Widespread expectations around premarital ‘sexual purity’ through sexual innocence and abstinence as a sign of ‘good virtue’.

Seven articles explicitly described parental and societal disapproval of premarital sex as a common phenomenon experienced by most young people [44,46,47,49,53,55,58]. Young people across these studies reportedly perceived “sexual innocence” and premarital sexual abstinence as a way of signalling their “good virtue” to their parents and wider family members. While sexual abstinence before marriage was reported as a widespread expectation for young people, experiences of this norm varied by socioeconomic status, gender, and age.

Regarding socioeconomic status, in addition to sexual abstinence and not mixing with the opposite sex, middle class respectability required young people to focus on academic achievements, while young women living in slums were required to display “good virtue” through competence in household chores [44,46,47,49,53–55].

In the context of young women living in slums, two studies in India and Pakistan linked “sexual purity”–described as premarital sexual abstinence as well as “sexual innocence and ignorance” as a sign of virginity–very closely with being good daughters who take care of domestic duties [46,53]. For example, Bankar and colleagues identified modesty, respectfulness, proficiency in household chores, and “sexual purity” as traditional norms expected of young unmarried women. The authors explore how a sports-based program had given participants greater skills to negotiate restrictive mobility norms with parents [46]. In the absence of such interventions, a study based in Pakistan revealed young women engaged to be married had been “socialised into submissiveness” leading to them being more vulnerable to reproductive ill health in the future. The participants abided by rules to be “good daughters” as they trusted that continued family support would ensure security in future life [53].

A study of middle-class boys and girls in Dhaka, Bangladesh suggested that their parents saw sexual abstinence as a way of upholding the family’s respectability [49]. However, respondents in this study said they were able to navigate this norm by using silence around sexuality with their parents as a way of protecting good boy/girl image, be seen to respect parents’ values, and avoid mutual embarrassment [49].

Age was also a noteworthy factor in determining how young people perceived and experienced expectations around romance and sex. Iyer’s study with students aged 15–17 reported that sexual activity among participants appeared to be the exception rather than norm which could reflect “middle-class norms of premarital purity” as well as due to “the younger age range of participants in this study” [54]. Age-specific norms around romantic relationships were also explored in an article where participants of a Nepal-based study–aged 15–24 –believed the community viewed dating positively if practiced by “emerging adults” over the age of 18 rather than adolescents in their early teens [58].

Participants from the above study demonstrated a mostly positive attitude towards dating and sexual relationships. Young men and women shared their experiences of circumventing familial expectations of sexual abstinence by going out on dates rather than bringing partners home. The authors reported that unmarried young women challenged expectations of sexual abstinence and that considerations such as trust and opportunity were important in deciding whether to engage in sexual relations before marriage [58]. Likewise, a study based in India found that, despite social taboos against romantic interactions, adolescents were engaging in intimate relationships [47].

Additionally, Indian college students from another article reportedly believed that age and maturity–in terms of decision-making and responsibility–were also factors in deciding when to have sex for the first time [48]. The majority of respondents in Brahme et al.’s study in Pune, India said they believed that the “ideal age for initiation of sex” was between the age of 18 and 23 years as young people within this age range were better positioned to make responsible decisions compared to secondary school-aged youth [48].

Limited communication around sexuality between young people and parents due to embarrassment.

In addition to premarital sexual abstinence, nine articles specified a culture of silence around sexuality as a widespread norm [44,45,48,49,51–53,57,59]. Overall, young people felt embarrassed discussing sexual health with parents, elders, health professionals and friends of the opposite sex, and even sexual partners [45,52,53,57,59]. As a 24-year-old man in Bangladesh explained: “[Due to socio-cultural norms] people feel shy if we talk directly on sex” [44]. In addition to embarrassment, Farid-ul-Hasnain and colleagues suggested that the lack of intergenerational communication around sexuality was due to young people fearing harassment and violence from elders as a consequence of expressing sexual curiosity [51].

While most young people were curious, discussing sexuality was a taboo as it went against expectations of “good virtue” and sexual abstinence before marriage. As Khan and Raby [44] observed, the dominant discourse that sexuality is a private, shameful, and adult matter appeared to be reproduced through silence around the subject at home and educational institutions across all four countries. When parents did offer limited guidance, “this was only to tell them not to have sex until marriage, and to forbid girls from mixing with boys” [44]. The authors explore this silence or limited guidance as a way of exercising disciplinary power over young people to control their sexual behaviour and reproduce discourses like sexual abstinence before marriage.

Although respondents across all nine articles mentioned feelings of embarrassment or shame, Indian college students in a 2020 study said that they still wanted active parental involvement and open discussions on sexuality [48]. Most students learned about sexual health from peers or internet searches but felt their parents were best positioned to provide reliable information. However, the article did not provide further details on which particular ‘sexual issues’ the participants wanted to discuss with parents [48]. Participants in Camellia et al.’s ethnographic study specified that they would have benefited from information around physical changes that occur during puberty but preferred not to talk about romance, love, or sex post-puberty because they felt awkward and uncomfortable. A 17-year-old focus group participant in the study explained: “The thought of speaking with parents about love or sex feels simply awkward. We are not even comfortable watching kissing scenes on television in the presence of our parents” [49].

Additionally, Camellia and colleagues [49] observed a temporal dimension of changes in youth-parent communication needs during and after puberty: as adolescents, participants wanted their parents to have open discussions about puberty but post-puberty they preferred to not communicate about sexual desire and dating. Likewise, a study of young men’s experiences of puberty in Karachi, Pakistan demonstrated that respondents wanted more guidance during this challenging period of transition but were unable to communicate this need to older relatives [45]. As one 21-year-old respondent said: “Our culture does not allow such communication with elders. That was the main barrier that I could not communicate regarding my puberty with elders” [45].

Despite this limited communication, young people were curious about their sexuality, and reiterated the need for sexual health education [44,45,48,49,51–53,57,58]. However, as with expectations of sexual abstinence, the ways young people navigated this limited guidance varied. For example, young women engaged to be married in Pakistan expressed curiosity about married life, but said they learned that talking about sexuality was a sign of having no shame as one 19-year-old respondent described [53]: “I am looking forward to my marriage and I want to ask questions but I do not talk about this with my mother…she doesn’t even know I menstruate. How can we talk about these things?”

Where possible, young people navigated this gap between curiosity and silence by looking for information around sexuality via the internet, media, pornography, and their peer groups. Five articles mentioned the importance of the internet/media as well as peers as alternative–and, most of the time, preferred–sources of sexual health information for young people [44,45,48,49,51,58]. Respondents with access to the internet found Google searches and YouTube to be a more effective resource than parents, as this 16-year-old student from Bangladesh explained: “In no way our parents can explain sex better than those videos. They will die out of shame” [49].

Young people were also routinely exposed to sexual content through the media without having to actively search for it. A 20-year-old woman from Nepal described how being inundated with such content affects young people [58]: “We watch TV and films, read papers and listen to the radio…It is all about sex. We become emotional and attempt to do such things.”

Access to, and reliability of, alternative resources varied across contexts. For example, young men in Bangladesh received information about sexuality from their peers but were of the view that peers were “unreliable sex educators” [44]. In another study, soon-to-be-married women of a slum in Pakistan had limited and vague information from contacts approved by respondents’ mothers, such as older cousins, sisters and aunts as a source of information about sexuality and childbearing near the time of their marriage [53]. For some, television adverts were the main source of information on contraception, although they lacked full understanding of how to use and access these [51].

Restrictive gender norms limit young women’s sexual and reproductive decision making.

The importance of gender norms was described in all included articles. Nine articles emphasized how underlying gender norms in South Asia meant that young women were often unable to exercise sexual consent and lacked control over their own reproductive health [44,46,50,53–56,58,59]. These articles primarily discussed three broad sub-themes stemming from the ideal of “good virtue”: gender narratives and a lack of sexual consent for girls and women; gendered mobility restrictions and limited access to sexual health information; and lack of decision making around contraception and its consequences.

Gender narratives and consent: Four articles referred to submissive/vulnerable femininity and heroic/hegemonic masculinity as dominant gender narratives in South Asia which contribute towards undermining women’s sexual consent [44,54,55,58]. For example, many boys in a Nepal-based study believed that most girls were “very soft and weakhearted in nature and cannot express their feelings of love” [58]. An unmarried FGD respondent from the same article further elaborated that young men also expected submissiveness in terms of making the first move regarding dating: “In most cases, boys act first. They always push for it [sex]” [58].

According to authors of a 2019 study in Bangladesh, some young men observed pornography as ‘brutally’ reinforcing sexual submissiveness of women. A 23-year-old participant pointed out that, “A boy is always a hero in pornography, a female is subordinate. A woman is treated like an animal” [44].

Similarly, Iyer’s [55] article about young people’s understandings of gender sexual violence identified Bollywood films as a source for dominant discourses in gender. The combination of fighting and pursuing heterosexual romance reinforced both narratives of heroic masculinity as well as vulnerable femininity. In such cases, the author asserts, girls were inevitably cast as passive and helpless, with boys fighting to determine who will “win” her hand. The article further revealed that in the aftermath of Delhi gang rape case, vulnerable femininity held influence at home and at school through the emphasis of being alert in public spaces. As a consequence of these dominant gender discourses, boys often conflated ideas of respecting and protecting girls, thereby undermining the latter’s agency [44,55]. There was also confusion over what constituted legitimate sexual attraction as opposed to predatory sexual behaviour as boys attempted to distinguish themselves from male predator stereotypes. Within a context where sex was frequently discussed in terms of sexual violence, many boys struggled to conceptualize sexual desire in positive terms [55].

Findings from the above study also suggested that “girls’ expectations of greater freedoms can lead them to vociferously challenge attempts at restriction” [55]. One way girls in this study challenged the narrative of vulnerable femininity was by aspiring to independent “can-do” narratives of girlhood–high-achieving, independent femininity–in India:

I think being self-dependent is the most important thing as a girl. If I get married, I don’t want to get married without working in any office or–because I–don’t completely want to depend on my husband, and on my family.

- Girl (age not reported), India, FGD [55]

Restricted mobility: Six articles highlighted mobility restrictions–imposed by parents or husbands/in-laws–as one of the main constraints in everyday life of both married and unmarried young women. Public space was identified primarily from a gendered viewpoint as young women’s access to public space was restricted due to safety concerns and fear of harassment and abuse from men [46,55]. Respondents explained that despite changing attitudes towards women in India, concern over safety still led to parents placing restrictions on their daughters [55].

As well as safety concerns–which were reported across all four countries–women’s presence in public spaces was also seen as departing from the ideals of “good virtue” and, therefore, raised suspicion about sexual chastity [46,55]. A 19-year-old respondent from Pakistan gave the example of being afraid that mistrust from her future spouse could lead to restrictions after marriage and suggested that she was “afraid of what will happen after my marriage” [53].

Overall, young women felt frustration, fear, and anger at having to abide by these restrictions [46]. In terms of consequences, restricting girls’ movement in public spaces contributes to school dropout and early marriage, and negatively affects girls’ health and wellbeing [46]. Moreover, Hamid et al. [53] argued that unlike their male counterparts, young women had limited access to different types of media because of their restricted mobility and fewer opportunities from which to choose [53].

Despite this, findings from included articles also demonstrated that young women–of different ages, and educational and socioeconomic backgrounds–challenged mobility restrictions in different ways. For example, most urban participants in a Nepali study about dating and sex mentioned having some dating experience and accessing places such as restaurants, inns, hotels, cinemas, parks, and public transport on dates [58]. While there appeared to be gender segregation in the home–with opposite-sex peers often discouraged from visiting each other’s homes–participants said it was commonplace for young people to form romantic partnerships through school or in their community [58]. For instance, a young woman was able to meet her boyfriend because of frequent opportunities to meet at his shop: “I used to get food and other items from his store…later on we became closer and started to love each other” [58].

Gendered reproductive health decision making: Six articles which included experiences of married or engaged participants from urban areas–particularly slums–in India, Nepal, and Pakistan and touched on young women’s lack of control over their own reproductive health [46,50,51,53,56,59]. Husbands and mothers-in-law appeared to be the main decision makers in contraceptive use and childbearing, with the majority of women across the four studies saying that condom use was dependent on their husbands. Conversely, young married men from a study in Karachi, Pakistan stated that the prime responsibility of avoiding unintended pregnancies lay with their partners, although the men themselves also generally avoided using contraception [56]. Young women identified unequal gender dynamics and hierarchy within the marital household as underlying reasons why they could not exercise autonomy over family planning [51,56,59].

As mentioned earlier, Hamid and co-authors explored this lack of reproductive autonomy by interviewing engaged women living in slums in Islamabad, Pakistan. Their findings showed how young women were underprepared for marital life with very little access to sexual health information due to a culture of silence around sexuality and parental pressures to be obedient daughters. The authors concluded that this “socialisation into submissiveness” contributed to women’s lack of control over future reproductive health. Young women in this study reportedly abided by rules and trusted that family support would ensure security in future life. Unlike young people in other studies, these women did not seem to have access to resources outside of parent-approved sources such as older cousins, sisters, and aunts. As well as directing questions about sexuality and childbearing to these sources, young women also felt that television–in particular, contraceptive adverts–was akin to information from a peer from which they could learn about sexuality. Bankar et al. [46] and Sekine el al. [59] also found that young women’s restricted access to public space and resources persisted after marriage.

In their study of pregnant women aged 15 to 24 in Kathmandu, Nepal, Deuba et al. [50] identified a lack of women’s sexual consent and strong son preference among slum residents as contributing factors of prepartum intimate partner violence among participants. These young pregnant women were more likely to experience different forms of violence (psychological, physical, and sexual) if they refused to have sex with their husband, gave birth to a girl, or if their husband had alcohol use disorder. One of the main misconceptions around son preference was that having sex during pregnancy would result in a son. This misconception, coupled with a lack of women’s sexual consent, often led to experiences of sexual violence [50]. Additionally, most young women in Deuba et al’s [50] study reported (mis)information around son preference from their spouses and mothers-in-law. Similar misconceptions were also reported by middle-class respondents in Nepal [59].

In terms of coping with IPV, most of these young women reported tolerating and accepting abuse due to economic dependence on their husbands. In some cases, their in-laws interfered to prevent further escalation of physical abuse and sometimes women were able to seek informal support from close family members [50].

Heteronormativity presumed and implied in research through absence of sexual and gender diversity.

All included research appeared to be about (presumed) cisgender heterosexual and able-bodied individuals, with only two articles mentioning sexual diversity. A study about young men’s experiences of sex education in Bangladesh mentioned the lack of queer representation in their research as a limitation due to difficulties in accessing “a more diverse group of participants representing different sexualities in Bangladesh where such sexual diversity is not acknowledged socially or legally” [44]. A study exploring perceptions of sexuality and sexual health education among college students in Pune, India touched very briefly on the topic of “homosexuality and anal sex”. Authors reported “mixed reactions” on homosexuality from boys in the study–no data were presented on perceptions of girls. Boys from lower socioeconomic backgrounds were said to lack awareness about homosexuality while others described it as a “personal choice”. The findings finally stated that many explored homosexuality as “a different way of fun” although this was not elaborated any further. It was unclear how the authors defined homosexuality in this case or how the respondents themselves identified as this was not reported [48].

While participants in Khan and Raby’s study all self-identified as heterosexual, other articles did not explicitly report respondents’ sexual or gender identity. At the same time, the included articles did not present any findings specific to experiences of non-heterosexual and non-cisgender young people. Therefore, it was not within the scope of these included articles to explore, and provide recommendations, around sexual health implications of different sexual or gender identities. Findings from articles looking at sexual health needs and barriers, for instance, focussed on overall issues such as concerns around privacy and confidentiality of services, accessibility of services, and lack of sexual health knowledge [45,51,52,57].

The use of particular definitions also excluded young people who may not identify as heterosexual or cisgender. For example, a paper on perceptions around dating and sex in Nepal defined dating as “a meeting between young women and men for romantic and sexual purposes” without indicating that the study was concentrating only on heterosexual relationships [58]. Similarly, Iyer’s mixed methods study of middle-class students in India reflected heteronormativity as default by framing heterosocial (cross-sex) friendships as having potential for romance–and therefore being discouraged by educational institutions–while homosocial (same-sex) friendships were subsequently seen as only platonic. A study based on the puberty experiences of men in Pakistan also only referred to “societal norms encouraged them to exhibit opposite-sex attraction” without addressing the respondents’ sexual identities further [45].