A Comparison of the Sexual Knowledge , Attitudes , and Behaviors of Korean College Students Studying in Korea and in the United States

The number of Korean students enrolling in universities overseas is rapidly growing. However, these populations are underrepresented in sexuality related research, despite the possibility of sexually risky behavior in overseas university students. We examined the sexual knowledge, attitudes, and behaviors of university students in Korea and studying in the United States. Data were collected—131 Korean students in Korea and in the US using a web-based self-report questionnaire system. Students in the US showed greater total sexual knowledge than students studied in Korea. There were differences in the sexual knowledge, attitude and behaviors according to general characteristics between both groups. Although students in the USA had a higher level of sexual knowledge, both students in the USA and in Korea had a low level of sexual knowledge overall.


Introduction
There is no doubt that sexual values are influenced by disparate cultural, political, historical, and socioeconomic factors.In Western cultures, sexual behavior is often considered as a recreational activity, whereas Asian cultures view it as primarily procreative [1] [2].Asians tend to have relatively more conservative sexual attitudes than other ethnic groups, such as Euro-Americans [3].These culture-specific sexual values have a long history, We announced the project on the school board of each university to recruit participants from March to April, 2014.A total of 142 students in Korea or in the USA logged in the website and completed the questionnaire.However, 11 participants were excluded because they did not complete the survey.All students who completed the questionnaire were give 10-dollar gift coupon.

Measures
We used a web-based self-report instrument measuring sexual knowledge, sexual attitudes, and sexual behaviors, and also collected socio-demographic information such as age, gender, grade, living arrangements, and economic status.

Sexual Knowledge
For sexual knowledge assessment, we used a sexual knowledge scale developed by Woo [19].This scale consists of 39 items pertaining four domains: eight items pertaining to sexual organs, nine items for pregnancy and delivery, 15 items for sexual health issues, and seven items for sexual acts.Each question was evaluated as true or false, and scores were created by adding the number of correct answers.The total number of correct answers to these 39 sexual knowledge questions reflected the degree of knowledge, with higher scores indicating greater knowledge.The internal consistency reliability for this scale was 0.87 (Cronbach's alpha).

Sexual Attitudes
A modified version of the sexual attitudes scale developed by Woo [19] was used for sexual attitude measurement.After deletion of items pertaining to prostitution, the following 51 items, in six domains were included in the study: 13 items regarding awareness of marriage and sex, nine items for abortion, nine items for marriage and delivery, nine items for virginal purity, and 11 items for contraception.Each item was rated on a 5-point Likert scale with labels at each scale point (from 1 = strongly disagree to 5 = strongly agree).Higher scores indicated less conservative sexual attitudes.The internal consistency reliability for this scale was 0.72 (Cronbach's alpha).

Sexual Behaviors
To measure sexual behaviors, the students were asked about their experience of sexual acts, including friendship, kissing/embracing, petting, sexual relationships, pregnancy, abortion, childbirth, sexually transmitted disease, sexual violence, shameful sexual acts during childhood, sexual acts caused by alcohol, sexual acts occurring through ignorance, pornographic magazine/video contact, and phone sex.We used the sexual behavior and impulse scales developed by Woo [19].The sexual behavior scales consisted of 14 items, with each item rated on a five-point scale, labeled at each scale point (from 1 = never to 5 = always).Higher scores reflected a tendency toward more unrestricted and less conservative sexual behavior.The internal consistency reliability for this scale was 0.82 (Cronbach's alpha).

Statistical Analysis
Data were analyzed using SPSS version 21.0 (IBM SPSS Inc., Chicago, IL).To examine the differences between group variables, t-tests, ANOVAs, and Scheffé tests were performed.The Pearson correlation coefficient was used to analyze the relationships among sexual knowledge, attitudes, and behaviors.A p value of <0.05 was considered significant.

Results
The participants were 131 Korean students including 64 students studying in the U.S. and 67 students studying in Korea.For students in the US 59.4% were over 21 years old, 51.6% were female, 48.4% were freshmen, and 56.3% were cohabiting.Additionally, 68.7% reported a "medium" economic status.For the students in Korea, 43.3% were 19 years old, 56.7% were male, 52.2% were freshmen, and 67.2% were cohabiting.Additionally, 59.7% of this group reported a "medium" economic status.
There were no statistically significant differences between students in the Korea and in the U.S. in gender (t = −0.94,p = 0.347), grade (χ 2 = 3.88, p = 0.274), living arrangements (t = 1.65, p = 0.199), and economic status (t = 1.16, p = 0.362), but there was in age (χ 2 = 18.78, p < 0.001).To adjust for age we used analysis of covariance to determine whether there were any differences in the scores of sexual knowledge, attitudes, and behaviors between students in the U.S.A. and in Korea.

Sexual Knowledge
Differences in sexual knowledge between students in the U.S.A. and in Korea are shown in Table 1.The total score of sexual knowledge for students in the U.S.A. was significantly higher than for those in Korea (F = 4.16, p = 0.044).Among the subcategories, students in the U.S.A. scored significantly higher in the category of knowledge about sexual acts than those in Korea (F = 4.16, p = 0.044).

Sexual Attitudes
Differences in sexual attitudes between students in the USA and in Korea are shown in Table 2.Although students in the USA had a lower total sexual attitude score than students in Korea, the difference was not significant (F = 1.86, p = 0.175).

Sexual Behaviors
Differences in sexual behaviors between students in the USA and in Korea are shown in Table 3.There was no significant difference in the total sexual behavior score (F = 0.03, p = 0.868).However, for the subcategories, students in the USA scored significantly lower than those in Korea for the items related to sexually transmitted disease (F = 7.12, p = 0.009), sexual violence (F = 6.03, p = 0.015), and sexual acts caused through ignorance (F = 6.25, p = 0.014).Shameful sexual acts scored higher for students in the USA versus those in Korea (F = 5.93, p = 0.016).

Differences in Sexual Knowledge, Attitudes, and Behaviors According to General Characteristics of Students in Korea
Scores of sexual knowledge, attitudes, and behaviors according to general characteristics, including correlations among sexual knowledge, attitudes, and behaviors for students in Korea are shown in Table 4. Sexual knowledge was significantly different according to school grade.The scores of seniors were highest of all (F = 3.21, p = 0.029), while there were no significant differences according to the Scheffé test (p > 0.05).There were no correlations among sexual attitudes according to general characteristics.Sexual behavior differed according to economic status (F = 2.69, p = 0.009).There were no correlations among sexual knowledge, attitudes, and behaviors in Korea.

Differences in Sexual Knowledge, Attitudes, and Behaviors According to General Characteristics of Students in the USA
Scores of sexual knowledge, attitudes, and behaviors according to general characteristics, including correlations among sexual knowledge, attitudes, and behaviors in the USA are shown in Table 5.There were no correlations among sexual knowledge according to general characteristics.Sexual attitude differed significantly according to school grade (F = 3.87, p = 0.013).Based on a Scheffé test, the scores of seniors were significantly higher than those of freshmen (p < 0.05).There was a significant difference in sexual behavior according to school grade (F = 6.57, p = 0.001).Based on a Scheffé test, the scores of senior were significantly higher than those of freshmen and sophomores (p < 0.05).A significant positive correlation was shown between sexual knowledge and behavior (r = 0.39, p = 0.002).

Discussion
In spite of a high level of depression, anxiety, and stress related to acculturation or general life events, many international students do not use the available health services in their university or in the community [15].Based on the conservative attitudes toward sexuality in Asia, one would expect university students to be more hesitant before using health services for sex-related health problems.This could be a simple health problem for the international student him/herself but could result in a serious domestic health issue by, for example, spreading sexually transmitted disease.Thus, we compared the sexual knowledge, attitudes, and behaviors of Korean university students attending college in the USA with those doing so in Korea.We expected students in the USA would have a higher level of sexual knowledge, and less conservative sexual attitudes and behaviors than those in Korea because sexuality was more pervasive in US society than in Korea.Scores of total sexual knowledge for students in the USA were significantly higher than those in Korea, but there were no significant differences between students in the US and Korea in total scores for sexual attitudes and behaviors.Because of the lack of previous studies that have compared those sexual concepts among the same ethic population, living in different nations, we are limited in the comparisons we can make.One possible interpretation is related to the purpose of studying in the USA.In this study, we included Koreans who had student visa.We assumed that many of the students studying in the US would be the most able students, having strong academic motivations.To study in the US, they would have spent considerable effort, including learning English, as well as investing time in obtaining financial support.Therefore, students in the U.A would be expected to control their sexual impulses.
One interesting fact is that previous studies [20] [21] have reported that greater sexual knowledge leads to more frequent sexual intercourse, use of pornography, and nontraditional behavior, including drug usage, binge drinking, and failing to use birth control.Otherwise, Kim et al. [22] reported no correlation between sexual knowledge and behavior.In contrast, Woo et al. [23] showed a positive correlation between sexual knowledge and sexual behavior in American university students, but no correlation in Korean students.The results from the present study showed greater sexual knowledge was correlated with a higher level of sexual behavior among students in the U.S., but not in Korea.There is a need for further study to identify whether this is an influence of culture or ethnic characteristics.
Although the sexual knowledge scores of students in the USA were significantly higher than those in Korea, the scores showed but a moderate level of knowledge, with a mean of 46.2% -56.4% correct answers.Compared with a previous study [23] using the same knowledge scale as the present study, the level of sexual knowledge of students in this study was similar.In Korea, there are regulations regarding sexual education in high school.Fifteen class hours per year has been obligatory.However, routine sexual education is unlikely to reflect the specific educational needs of learners [24] [25].Because a low level of sexual health knowledge is related to the incidence of unexpected pregnancy or HIV/STI transmission [16] [26], health care providers and schoolteachers must strive to provide young adults with sufficient accurate knowledge of sexuality.This is not a domestic issue.Departments responsible for international students should also heed this point and improve sexual knowledge by the provision of suitable programs.Such programs should be on the basis of not only international students' own culture, but also specific national characteristics, such as common sexually transmitted diseases, homosexual culture, and so on.
In this study, Korean college students in the US demonstrated more conservative attitudes and behaviors than domestic students studying in Korea.What factors could influence such conservative sexual attitudes and behaviors?First, the elementary and middle school years are when students begin to establish a sexual identity and develop their primary and secondary sexual characteristics [27] [28].During high school and college, individuals continue to define and build their sexual profile from social interactions, family background, moral values, educational standards, and cultural settings.In effect, both student groups' sexual attitudes and behaviors could be hampered by conservative sociocultural influences, as they transit scholastically [29].This result is consistent with previous studies [23] [30] that compared North American to Asian university students; Asians possess lower sexual knowledge, and more conservative attitudes and behaviors than other student groups.
Further studies might highlight the lack of, and need for, sex education as Korean students enroll in college.Students' attitudes and behaviors related to promiscuity, dating, intercourse, and pregnancy could be skewed toward risky or unsafe actions because of their conservative sexual values.Further, adolescents born overseas, and living in the US six years or less, face increased peer pressures toward harmful, abnormal, or even violent sexual behavior [27] [31].Furthermore, these studies point out that students born overseas face a raised level of risky sexual behaviors, such as unprotected intercourse, preteen sex, anal sex, multiple or high-risk sex partners, sexually transmitted diseases, and sex for drugs or money.
According to previous studies [22] [32], economic status and social grade are significant in the development of a student's sexual identity.Their findings have revealed that students demonstrate improved overall sexual awareness if subject to financial and family stability.In addition, Franklin and Dotge [33] supported this point with a comparison of sexual environmental changes between Korean college freshman and upperclassmen.Consistent with our findings, upperclassmen have improved sexual knowledge, attitudes, and behavior.This is because senior graduates have had more time to establish and broaden their sexuality versus incoming students, through acculturation, social network orientation, and individualism or collectivism.
Our study has several limitations.First, the findings cannot be generalized to the whole population, despite our attempts to recruit Korean students through six different universities located in diverse cities in Korea and in the U.S. Second, we did not assess the motivation or purpose for studying overseas, that is, whether studying overseas was the student's own choice or whether he or she followed someone else's decision.This motivation could influence sexual behaviors even if the overseas students were exposed to attractive sexual-cultural environments.Future studies would benefit from diversity in the population investigated.Corresponding studies would be needed for Korean adolescents or younger adults studying in the USA, Europe, or other countries in Asia, to offer a more global perspective on sexual knowledge, attitudes, and behaviors.The role of additional factors should also be considered, including the motivation for studying overseas and social factors like the support and influence of domestic friends.
Although Korean university students in the US had greater sexual knowledge than those studying in Korea, there were no significant differences in total scores assessing sexual attitudes and behaviors between the two groups in the present study.Additional studies would be needed to consider other factors and cultural enculturation.Furthermore, because both students in the USA and in Korea demonstrated a low level of sexual knowledge, enhanced sexual health strategies should be formulated for Korea, and overseas where international students study.

Table 1 .
Sexual knowledge of Korean university students in the US and Korea (N = 131).

Table 2 .
Sexual attitudesof Korean university students in the US and Korea (N = 131).

Table 3 .
Sexual behaviorsof Korean university students in the US and Korea (N = 131).

Table 4 .
Differences in sexual knowledge, sexual attitudes and sexual behaviors according to general characteristics of the Korean university students in Korea (N = 67).

Table 5 .
Differences in sexual knowledge, sexual attitudes and sexual behaviors according to general characteristics of the Korean university students in the US (N = 64).