The results of our study demonstrated that SC did not correlate with UI among all 664 surveyed STI patients in Shanghai. However, SC was evidently a potential predictor for UI with casual sexual partners, especially among the male participants.
To our knowledge, this is the first research to focus on sexually active STI patients on mainland China, a population vulnerable to HIV and other STIs. The results demonstrated a difference between male/female gender and regular/casual sexual partners. Not surprisingly, greater sexual preoccupations and poorer control of sexual impulse were associated with a greater possibility of UI with casual sexual partners. The same result has also been reported for other sexually active populations, including homosexual males, lesbians, bisexual men and women, and HIV-positive populations (10, 16, 27). Regarding gender, we found a significant difference in SC between men and women, with men scoring higher than women in accordance with all previous studies (24–26). The results also showed that the association between SC and UI appeared to be different for males and females. While SC predicts the possibility of UI with a casual sexual partner among males, the association is not as obvious in females. Moreover, a significant difference also exists between regular and casual sexual partners. SC seemed to correlate only with increased UI in casual rather than regular sexual partners.
These two differences are the most intriguing takeaways from the results of this study. That female SC does not seem to directly affect the incidence of UI could be due to the fact that women tend to be in a disadvantaged position when it comes to applying protection. Female condoms are not as common and easily accessible as male condoms (28, 29), and persuading a casual sexual partner who is reluctant to use protection can be difficult. Men will have more control in this situation because their willingness to use condoms can be more directly transformed into action.
The difference between regular and casual sexual partners was also found in several previous studies among other sexually active populations (8, 10, 30), one of which was conducted in China (10). Chinese culture has a tendency to discourage people from expressing sexual drive, especially in front of people who are supposed to have a secularly appropriate relationship (31). It could be possible that our participants who had higher SC no longer seek sexual fulfillment with regular sexual partners but instead freely express their SC while engaging with casual partners, thus making them feel less shameful. It could also be possible that higher SC results in more intercourse with casual partners, which is a less controllable scenario in comparison with regular partners, thus resulting in greater possibility of UI (32).
According to the theory of planned behavior, perceived behavioral control is one of the most important predictors of an individual’s intention and behavior (33, 34). Evidence has shown that less perceived behavioral control over condom use is correlated with practicing UI. People who have poor impulse control also tend to have a higher anxiety and depression level (35–37), which could result in more risky behavior. The high prevalence of UI and the fact that our participants already had STIs together lead to a higher risk of acquiring HIV and other STIs as well as acting as a bridge to spread the diseases, although compared with university students, unmarried youth, migrant workers, and sex workers, STI patients are more likely to have already received more health education on this matter, possibly due to their familiarity with the diseases, the fear of progression, and contact with clinicians (38). The prevalence of UI is still high, which may be associated with the patients’ innate high SC in their personality.
The overall prevalence of sexual preoccupation and poor impulse control in Shanghai STD clinic cohorts supports a susceptibility for STIs among people of similar demographic characteristics with persistent and uncontrolled sexual thoughts and impulses. Traditional models of public health education and behavioral interventions will likely prove insufficient and ineffective for this population (39). If validated through further research, these STI results indicate an urgent need for preventive interventions targeted toward people who lack control of sexual thoughts, behaviors, and impulses. General health education may work poorly in this population because the overall education level was shown to be low, with only 3.46% reporting a highest education of college degree or above while 56.93% reported having a highest academic qualification of primary school level. Therefore, we urgently need to design new ways to intervene (40). The most promising intervention models for this population may be those that integrate elements of mental health, treatment of substance abuse, and reduction of sexual risk. For example, behavioral self-management approaches used in cognitive behavioral therapy for sexual preoccupations and poor impulse control can be adapted for inclusion in STI risk-reduction counseling (7). Public health clinics should also be prepared to refer their clients who express distress about feeling uncontrolled sexual desire and behavior for help that goes beyond services that an STD clinic can provide (41). STD clinics in Shanghai can work with psychiatric hospitals and establish a system that can effectively help the patients to manage their sexual impulse. Furthermore, the difference we found between males and females can provide a new approach to the prevention of UI that would include two different intervention procedures appropriate for males and females, respectively (42). If women’s disadvantaged position in applying protection prevents them from having protected intercourse according to their own will, we should establish a method that can somehow shift that disadvantage (43, 44). For example, STD clinics can recommend that their female patients prepare female condoms themselves so that they can be less passive when the situation arises. Also, health education can place more emphasis on the importance of having control in these situations, and how to communicate with the other party to achieve protection or refuse if the sexual partner cannot be persuaded, thus combining the management of SC with custom health education for each gender. Meanwhile, the reported difference between regular and casual sexual partners suggests that we should focus on the subpopulation with more casual partners when further studying this subject, not only because they show a stronger correlation between SC and UI but also because having more casual sexual partners equates to a higher possibility of spreading STIs and HIV (1, 2, 8). It is hoped that a more efficient and promotable method can be found, resulting in the reduction of risky sexual behavior and, ultimately, reduction of the prevalence of STIs and HIV in Shanghai.
4.1. Limitations and future research
Several limitations should be considered in interpreting the present results. First, cross-sectional surveys have difficulty determining causality; therefore, a prospective study would be beneficial. Second, although this research is a double-center cross-sectional study in a hospital specializing in STDs, the sample size was not especially large, so more multicenter research is needed. Third, there was selection bias: for example, those who experienced strong SC but felt bad about partaking in casual sexual activities may also have been more reluctant to participate in the study. Fourth, a self-reported binary scale was used to assess SC and UI, which potentially underestimated their prevalence. Also, the present study only focused on sexually active STI patients rather than the general STI population. Further follow-up research should target other high-risk groups or study whether the SCS can be used to identify healthy people who are prone to UI and STDs, and to intervene in advance.