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1.  Secular trends in self reported sexual activity and satisfaction in Swedish 70 year olds: cross sectional survey of four populations, 1971-2001 
BMJ : British Medical Journal  2008;337(7662):151-154.
Objective To study secular trends in self reported sexual behaviour among 70 year olds.
Design Cross sectional survey.
Settings Four samples representative of the general population in Gothenburg, Sweden.
Participants 1506 adults (946 women, 560 men) examined in 1971-2, 1976-7, 1992-3, and 2000-1.
Main outcome measures Sexual intercourse, attitudes to sexuality in later life, sexual dysfunctions, and marital satisfaction.
Results From 1971 to 2000 the proportion of 70 year olds reporting sexual intercourse increased among all groups: married men from 52% to 68% (P=0.002), married women from 38% to 56% (P=0.001), unmarried men from 30% to 54% (P=0.016), and unmarried women from 0.8% to 12% (P<0.001). Men and women from later birth cohorts reported higher satisfaction with sexuality, fewer sexual dysfunctions, and more positive attitudes to sexuality in later life than those from earlier birth cohorts. A larger proportion of men (57% v 40%, P<0.001) and women (52% v 35%, P<0.001) reported very happy relationships in 2000-1 compared with those in 1971-2. Sexual debut before age 20 increased in both sexes: in men from 52% to 77% (P<0.001) and in women from 19% to 64% (P<0.001).
Conclusion Self reported quantity and quality of sexual experiences among Swedish 70 year olds has improved over a 30 year period.
PMCID: PMC2483873  PMID: 18614505
2.  Behaviours and expectations in relation to sexual intercourse among 18-20 year old Asians and non-Asians 
Sexually Transmitted Infections  1999;75(3):162-167.
OBJECTIVES: To begin to map the reported behaviours and attitudes of young Britons of south Asian origin that may have implications for sexual health. "South Asian" refers to people able to trace their ancestry from the Indian subcontinent (that is, India, Pakistan, and Bangladesh), henceforth referred to as "Asian". DESIGN: A cross sectional study of sexual behaviour using self report measures in a self complete section of a social survey administered by trained interviewers in 1996. SETTING: Greater Glasgow, Scotland. SUBJECTS: Sample (n = 824) originally recruited aged 14-15 in 1992 in secondary schools in Greater Glasgow and subsequently traced through general practitioner registration for 1996 survey. 492 Asians and non-Asians aged 18-20 years old eventually interviewed in their own homes. MAIN OUTCOME MEASURES: Self reported experience of sexual intercourse, age at first intercourse, and contraceptive practice over year before interview. METHODS: Measures of sexual behaviour and attitudes were elicited through a self complete questionnaire filled out in the presence of, and returned to, a trained social interviewer. RESULTS: Asians, and particularly Asian women, were far less likely to report having had heterosexual intercourse. Those Asian women who had had intercourse were likely to do so for the first time at an older age, and with an older partner, than the non-Asian women. Asian women were less likely to report using the pill than non-Asian women, irrespective of their marital status, and Asian men were less likely than non-Asian men to report using condoms. Asian sexual abstinence was reported to be for religious reasons, which were not important for non-Asians. In contrast with non-Asians, Asians saw themselves as likely to be married with children within the next 5 years. Asian men considered the ideal age to marry for men and women to be younger than the non-Asian men's average estimate. Asian and non-Asian women suggested a similar ideal age for men to marry, but Asian women considered a younger age appropriate for women than did non-Asian women. CONCLUSIONS: The higher level of sexual abstinence among Asians, and particularly women, has implications for the delivery of sexual health services to the minority who are sexually active before marriage. The underreporting of condom use by Asian men compared with their non-Asian counterparts, suggests a failure of the existing sexual health education and health services to reach minority ethnic young men which may be remedied by collaborative work with institutions currently used by the Asian community. 

PMCID: PMC1758202  PMID: 10448393
3.  Sex, health, and years of sexually active life gained due to good health: evidence from two US population based cross sectional surveys of ageing 
Objectives To examine the relation between health and several dimensions of sexuality and to estimate years of sexually active life across sex and health groups in middle aged and older adults.
Design Cross sectional study.
Setting Two samples representative of the US population: MIDUS (the national survey of midlife development in the United States, 1995-6) and NSHAP (the national social life, health and ageing project, 2005-6).
Participants 3032 adults aged 25 to 74 (1561 women, 1471 men) from the midlife cohort (MIDUS) and 3005 adults aged 57 to 85 (1550 women, 1455 men) from the later life cohort (NSHAP).
Main outcome measures Sexual activity, quality of sexual life, interest in sex, and average remaining years of sexually active life, referred to as sexually active life expectancy.
Results Overall, men were more likely than women to be sexually active, report a good quality sex life, and be interested in sex. These gender differences increased with age and were greatest among the 75 to 85 year old group: 38.9% of men compared with 16.8% of women were sexually active, 70.8% versus 50.9% of those who were sexually active had a good quality sex life, and 41.2% versus 11.4% were interested in sex. Men and women reporting very good or excellent health were more likely to be sexually active compared with their peers in poor or fair health: age adjusted odds ratio 2.2 (P<0.01) for men and 1.6 (P<0.05) for women in the midlife study and 4.6 (P<0.001) for men and 2.8 (P<0.001) for women in the later life study. Among sexually active people, good health was also significantly associated with frequent sex (once or more weekly) in men (adjusted odds ratio 1.6 to 2.1), with a good quality sex life among men and women in the midlife cohort (adjusted odds ratio 1.7), and with interest in sex. People in very good or excellent health were 1.5 to 1.8 times more likely to report an interest in sex than those in poorer health. At age 30, sexually active life expectancy was 34.7 years for men and 30.7 years for women compared with 14.9 to 15.3 years for men and 10.6 years for women at age 55. This gender disparity attenuated for people with a spouse or other intimate partner. At age 55, men in very good or excellent health on average gained 5-7 years of sexually active life compared with their peers in poor or fair health. Women in very good or excellent health gained 3-6 years compared with women in poor or fair health.
Conclusion Sexual activity, good quality sexual life, and interest in sex were higher for men than for women and this gender gap widened with age. Sexual activity, quality of sexual life, and interest in sex were positively associated with health in middle age and later life. Sexually active life expectancy was longer for men, but men lost more years of sexually active life as a result of poor health than women.
PMCID: PMC2835854  PMID: 20215365
4.  Long-Term Biological and Behavioural Impact of an Adolescent Sexual Health Intervention in Tanzania: Follow-up Survey of the Community-Based MEMA kwa Vijana Trial 
PLoS Medicine  2010;7(6):e1000287.
David Ross and colleagues conduct a follow-up survey of the community-based MEMA kwa Vijana (“Good things for young people”) trial in rural Tanzania to assess the long-term behavioral and biological impact of an adolescent sexual health intervention.
The ability of specific behaviour-change interventions to reduce HIV infection in young people remains questionable. Since January 1999, an adolescent sexual and reproductive health (SRH) intervention has been implemented in ten randomly chosen intervention communities in rural Tanzania, within a community randomised trial (see below; NCT00248469). The intervention consisted of teacher-led, peer-assisted in-school education, youth-friendly health services, community activities, and youth condom promotion and distribution. Process evaluation in 1999–2002 showed high intervention quality and coverage. A 2001/2 intervention impact evaluation showed no impact on the primary outcomes of HIV seroincidence and herpes simplex virus type 2 (HSV-2) seroprevalence but found substantial improvements in SRH knowledge, reported attitudes, and some reported sexual behaviours. It was postulated that the impact on “upstream” knowledge, attitude, and reported behaviour outcomes seen at the 3-year follow-up would, in the longer term, lead to a reduction in HIV and HSV-2 infection rates and other biological outcomes. A further impact evaluation survey in 2007/8 (∼9 years post-intervention) tested this hypothesis.
Methods and Findings
This is a cross-sectional survey (June 2007 through July 2008) of 13,814 young people aged 15–30 y who had attended trial schools during the first phase of the MEMA kwa Vijana intervention trial (1999–2002). Prevalences of the primary outcomes HIV and HSV-2 were 1.8% and 25.9% in males and 4.0% and 41.4% in females, respectively. The intervention did not significantly reduce risk of HIV (males adjusted prevalence ratio [aPR] 0.91, 95%CI 0.50–1.65; females aPR 1.07, 95%CI 0.68–1.67) or HSV-2 (males aPR 0.94, 95%CI 0.77–1.15; females aPR 0.96, 95%CI 0.87–1.06). The intervention was associated with a reduction in the proportion of males reporting more than four sexual partners in their lifetime (aPR 0.87, 95%CI 0.78–0.97) and an increase in reported condom use at last sex with a non-regular partner among females (aPR 1.34, 95%CI 1.07–1.69). There was a clear and consistent beneficial impact on knowledge, but no significant impact on reported attitudes to sexual risk, reported pregnancies, or other reported sexual behaviours. The study population was likely to have been, on average, at lower risk of HIV and other sexually transmitted infections compared to other rural populations, as only youth who had reached year five of primary school were eligible.
SRH knowledge can be improved and retained long-term, but this intervention had only a limited effect on reported behaviour and no significant effect on HIV/STI prevalence. Youth interventions integrated within intensive, community-wide risk reduction programmes may be more successful and should be evaluated.
Trial Registration NCT00248469
Please see later in the article for the Editors' Summary
Editors' Summary
Every year, about 2.5 million people become infected with the human immunodeficiency virus (HIV), the virus that causes AIDS. HIV is most often spread through unprotected sex with an infected partner, so individuals can reduce their risk of HIV infection by abstaining from sex, by delaying first sex, by having few partners, and by always using a condom. And, because nearly half of new HIV infections occur among youths (15- to 24-year-olds), programs targeted at adolescents that encourage these protective behaviors could have a substantial impact on the HIV epidemic. One such program is the MEMA kwa Vijana (“Good things for young people”) program in rural Tanzania. This program includes in-school sexual and reproductive health (SRH) education for pupils in their last three years of primary education (12- to 15-year-olds) that provides them with the knowledge and skills needed to delay sexual debut and to reduce sexual risk taking. Between 1999 and 2002, the program was trialed in ten randomly chosen rural communities in the Mwanza Region of Tanzania; ten similar communities that did not receive the intervention acted as controls. Since 2004, the program has been scaled up to cover more communities.
Why Was This Study Done?
Although the quality and coverage of the MEMA kwa Vijana program was good, a 2001/2002 evaluation found no evidence that the intervention had reduced the incidence of HIV (the proportion of the young people in the trial who became HIV positive during the follow-up period) or the prevalence (the proportion of the young people in the trial who were HIV positive at the end of the follow-up period) of herpes simplex virus 2 (HSV-2, another sexually transmitted virus). However, the evaluation found improvements in SRH knowledge, in reported sexual attitudes, and in some reported sexual behaviors. Evaluations of other HIV prevention programs in other developing countries have also failed to provide strong evidence that such programs decrease the risk of HIV infection or other biological outcomes such as the frequency of other sexually transmitted infections or pregnancies, even when SRH knowledge improves. One possibility is that it takes some time for improved SRH knowledge to be reflected in true changes in sexual behavior and in HIV prevalence. In this follow-up study, therefore, researchers investigate the long-term impact of the MEMA kwa Vijana program on HIV and HSV-2 prevalence and ask whether the improvement in knowledge, reported attitudes and sexual risk behaviours seen at the 3-year follow up has persisted.
What Did the Researchers Do and Find?
In 2007/8, the researchers surveyed nearly 14,000 young people who had attended the trial schools between 1999 and 2002. Each participant had their HIV and HSV-2 status determined and answered questions (for example, “can HIV be caught by sexual intercourse (making love) with someone,” and “if a girl accepts a gift from a boy, must she agree to have sexual intercourse (make love) with him?”) to provide three composite sexual knowledge scores and one composite attitude score. 1.8% of the male and 4.0% of the female participants were HIV positive; 25.9% and 41.4% of the male and female participants, respectively, were HSV-2 positive. The prevalences were similar among the young people whose trial communities had been randomly allocated to receive the MEMA kwa Vijana Program and those whose communities had not received it, indicating that the MEMA kwa Vijana intervention program had not reduced the risk of HIV or HSV-2. The intervention program was associated, however, with a reduction in the proportion of men reporting more than four sexual partners in their lifetime and with an increase in reported condom use at last sex with a non-regular partner among women. Finally, although the intervention had still increased SRH knowledge, it now had had no impact on reported attitudes to sexual risk, reported pregnancies, or other reported risky sexual behaviors beyond what might have happened due to chance.
What Do These Findings Mean?
These findings indicate that, in the MEMA kwa Vijana trial, SRH knowledge improved and that this improved knowledge was retained for many years. Disappointingly, however, this intervention program had only a limited effect on reported sexual behaviors and no effect on HIV and HSV-2 prevalence at the 9-year follow-up. Although these findings may not be generalizable to other adolescent populations, they suggest that intervention programs that target only adolescents might not be particularly effective. Young people might find it hard to put their improved skills and knowledge into action when challenged, for example, by widespread community attitudes such as acceptance of older male–younger female relationships. Thus, the researchers suggest that the integration of youth HIV prevention programs within risk reduction programs that tackle sexual norms and expectations in all age groups might be a more successful approach and should be evaluated.
Additional Information
Please access these Web sites via the online version of this summary at
This study is further discussed in a PLoS Medicine Perspective by Rachel Jewkes
More information about the MEMA kwa Vijana program is available at their Web site
Information is available from the Programme for Research and Capacity Building in Sexual and Reproductive Health and HIV in Developing Countries on recent and ongoing research on HIV infection and other STIs
Information is available from the World Health Organization on HIV and on the health of young people
Information on HIV is available from UNAIDS
Information on HIV in children and adolescents is available from UNICEF
Information on HIV prevention interventions in the education sector is available from UNESCO
Information on HIV infection and AIDS is available from the US National Institute of Allergy and Infectious Diseases
The US Centers for Disease Control and Prevention provide information on HIV/AIDS and on HIV/AIDS among youth (in English and Spanish)
HIV InSitehas comprehensive information on all aspects of HIV/AIDS, including links to information on the prevention of HIV/AIDS
Information is available from Avert, an international AIDS charity, on many aspects of HIV/AIDS, including information on HIV and AIDS prevention and AIDS and sex education (in English and Spanish)
PMCID: PMC2882431  PMID: 20543994
5.  Prevalence of Consensual Male–Male Sex and Sexual Violence, and Associations with HIV in South Africa: A Population-Based Cross-Sectional Study 
PLoS Medicine  2013;10(6):e1001472.
Using a method that offered complete privacy to participants, Rachel Jewkes and colleagues conducted a survey among South African men about their lifetime same-sex experiences.
Please see later in the article for the Editors' Summary
In sub-Saharan Africa the population prevalence of men who have sex with men (MSM) is unknown, as is the population prevalence of male-on-male sexual violence, and whether male-on-male sexual violence may relate to HIV risk. This paper describes lifetime prevalence of consensual male–male sexual behavior and male-on-male sexual violence (victimization and perpetration) in two South African provinces, socio-demographic factors associated with these experiences, and associations with HIV serostatus.
Methods and Findings
In a cross-sectional study conducted in 2008, men aged 18–49 y from randomly selected households in the Eastern Cape and KwaZulu-Natal provinces provided anonymous survey data and dried blood spots for HIV serostatus assessment. Interviews were completed in 1,737 of 2,298 (75.6%) of enumerated and eligible households. From these households, 1,705 men (97.1%) provided data on lifetime history of same-sex experiences, and 1,220 (70.2%) also provided dried blood spots for HIV testing. 5.4% (n = 92) of participants reported a lifetime history of any consensual sexual activity with another man; 9.6% (n = 164) reported any sexual victimization by a man, and 3.0% (n = 51) reported perpetrating sexual violence against another man. 85.0% (n = 79) of men with a history of consensual sex with men reported having a current female partner, and 27.7% (n = 26) reported having a current male partner. Of the latter, 80.6% (n = 21/26) also reported having a female partner. Men reporting a history of consensual male–male sexual behavior are more likely to have been a victim of male-on-male sexual violence (adjusted odds ratio [aOR] = 7.24; 95% CI 4.26–12.3), and to have perpetrated sexual violence against another man (aOR = 3.10; 95% CI 1.22–7.90). Men reporting consensual oral/anal sex with a man were more likely to be HIV+ than men with no such history (aOR = 3.11; 95% CI 1.24–7.80). Men who had raped a man were more likely to be HIV+ than non-perpetrators (aOR = 3.58; 95% CI 1.17–10.9).
In this sample, one in 20 men (5.4%) reported lifetime consensual sexual contact with a man, while about one in ten (9.6%) reported experience of male-on-male sexual violence victimization. Men who reported having had sex with men were more likely to be HIV+, as were men who reported perpetrating sexual violence towards other men. Whilst there was no direct measure of male–female concurrency (having overlapping sexual relationships with men and women), the data suggest that this may have been common. These findings suggest that HIV prevention messages regarding male–male sex in South Africa should be mainstreamed with prevention messages for the general population, and sexual health interventions and HIV prevention interventions for South African men should explicitly address male-on-male sexual violence.
Please see later in the article for the Editors' Summary
Editors' Summary
AIDS first emerged in the early 1980s among gay men living in the US, but it soon became clear that AIDS also infects heterosexual men and women. Now, three decades on, globally, 34 million people (two-thirds of whom live in sub-Saharan Africa and half of whom are women) are infected with HIV, the virus that causes AIDS, and 2.5 million people become infected every year. HIV is most often spread by having unprotected sex with an infected partner, and most sexual transmission of HIV now occurs during heterosexual sex. However, 5%–10% of all new HIV infections still occur in men who have sex with men (MSM; homosexual, bisexual, and transgender men, and heterosexual men who sometimes have consensual sex with men). Moreover, in the concentrated HIV epidemics of high-income countries (epidemics in which the prevalence of HIV infection is more than 5% in at-risk populations such as sex workers but less than 1% in the general population), male-to-male sexual contact remains the most important transmission route, and MSM often have a higher prevalence of HIV infection than heterosexual men.
Why Was This Study Done?
By contrast to high-income countries, HIV epidemics in sub-Saharan Africa are generalized—the prevalence of HIV infection is 1% or more in the general population. Because male-to-male sexual behavior is criminalized in many African countries and because homosexuality is widely stigmatized, little is known about the prevalence of consensual male–male sexual behavior in sub-Saharan Africa. This information and a better understanding of male–female sexual concurrency (having overlapping sexual relationships with men and women) and of how male-to-male transmission contributes to generalized HIV epidemics is needed to inform the design of HIV prevention strategies for use in sub-Saharan Africa. In addition, very little is known about male-on-male sexual violence. Such violence is potentially important to study because we know that male-on-female violence is associated with increased HIV risk for both victims and perpetrators. In this cross-sectional study (an investigation that measures population characteristics at a single time point), the researchers use data from a population-based household survey to investigate the lifetime prevalence of consensual male–male sexual behavior and male-on-male sexual violence (victimization and perpetration) among men in South Africa and the association of these experiences with HIV infection.
What Did the Researchers Do and Find?
About 1,700 adult men from randomly selected households in the Eastern Cape and KwaZulu-Natal provinces of South Africa self-completed a survey that included questions about their lifetime history of same-sex experiences using audio-enhanced personal digital assistants, a data collection method that provided a totally private and anonymous environment for the disclosure of illegal and stigmatized behavior; 1,220 of them also provided dried blood spots for HIV testing. Ninety-two men (5.4% of the participants) reported consensual sexual activity (for example, anal or oral sex) with another man at some time during their life; 9.6% of the men reported that they had been forced to have sex with another man (sexual victimization), and 3% reported that they had perpetrated sexual violence against another man. Most of the men who reported consensual sex with men, including those with current male partners, reported that they had a current female partner. Men with a history of consensual male–male sexual behavior were more likely to have been a victim or perpetrator of male-on-male sexual violence than men without a history of such experiences. Finally, men who reported consensual oral or anal sex with a man were more likely to be HIV+ than men without such a history, and perpetrators of male-on-male sexual violence were more likely to be HIV+ than non-perpetrators.
What Do These Findings Mean?
These findings provide new information about male–male sexual behaviors, male-on-male sexual violence, male–female concurrency, and HIV prevalence among men in two South African provinces. The precision of these findings is likely to be affected by the small numbers of men reporting a history of consensual male–male sexual behavior and of male-on-male sexual violence. Importantly, because the study was cross-sectional, these findings cannot indicate whether the association between consensual male–male sexual behaviors and increased risk of male-on-male sexual violence is causal. Moreover, these findings may not be generalizable to other regions of South Africa or to other African countries. Nevertheless, these findings suggest that information about the risks of male–male sexual behaviors should be included in HIV prevention strategies targeted at the general population in South Africa and that HIV prevention interventions for South African men should explicitly address male-on-male sexual violence. Similar HIV prevention strategies may also be suitable for other African countries, but are likely to succeed only in countries that have, like South Africa, decriminalized consensual homosexual behavior.
Additional Information
Please access these websites via the online version of this summary at
This study is further discussed in a PLOS Medicine Perspective by Jerome Singh
Information is available from the US National Institute of Allergy and Infectious Diseases on HIV infection and AIDS
NAM/aidsmap provides basic information about HIV/AIDS, including summaries of recent research findings on HIV care and treatment
Information is available from Avert, an international AIDS charity, on many aspects of HIV/AIDS, including information on HIV and men who have sex with men, on HIV prevention, and on AIDS in Africa (in English and Spanish)
The US Centers for Disease Control and Prevention also has information about HIV/AIDS among men who have sex with men (in English and Spanish)
Patient stories about living with HIV/AIDS are available through Avert; the charity website Healthtalkonline also provides personal stories about living with HIV
PMCID: PMC3708702  PMID: 23853554
6.  Is Food Insecurity Associated with HIV Risk? Cross-Sectional Evidence from Sexually Active Women in Brazil 
PLoS Medicine  2012;9(4):e1001203.
Alexander Tsai and colleagues show that in sexually active women in Brazil severe food insecurity with hunger was positively associated with symptoms potentially indicative of sexually transmitted infection and with reduced odds of condom use.
Understanding how food insecurity among women gives rise to differential patterning in HIV risks is critical for policy and programming in resource-limited settings. This is particularly the case in Brazil, which has undergone successive changes in the gender and socio-geographic composition of its complex epidemic over the past three decades. We used data from a national survey of Brazilian women to estimate the relationship between food insecurity and HIV risk.
Methods and Findings
We used data on 12,684 sexually active women from a national survey conducted in Brazil in 2006–2007. Self-reported outcomes were (a) consistent condom use, defined as using a condom at each occasion of sexual intercourse in the previous 12 mo; (b) recent condom use, less stringently defined as using a condom with the most recent sexual partner; and (c) itchy vaginal discharge in the previous 30 d, possibly indicating presence of a sexually transmitted infection. The primary explanatory variable of interest was food insecurity, measured using the culturally adapted and validated Escala Brasiliera de Segurança Alimentar. In multivariable logistic regression models, severe food insecurity with hunger was associated with a reduced odds of consistent condom use in the past 12 mo (adjusted odds ratio [AOR] = 0.67; 95% CI, 0.48–0.92) and condom use at last sexual intercourse (AOR = 0.75; 95% CI, 0.57–0.98). Self-reported itchy vaginal discharge was associated with all categories of food insecurity (with AORs ranging from 1.46 to 1.94). In absolute terms, the effect sizes were large in magnitude across all outcomes. Underweight and/or lack of control in sexual relations did not appear to mediate the observed associations.
Severe food insecurity with hunger was associated with reduced odds of condom use and increased odds of itchy vaginal discharge, which is potentially indicative of sexually transmitted infection, among sexually active women in Brazil. Interventions targeting food insecurity may have beneficial implications for HIV prevention in resource-limited settings.
Please see later in the article for the Editors' Summary
Editors' Summary
At the beginning of the AIDS epidemic, more men than women were infected with HIV, the virus that causes AIDS, but currently half of all HIV-positive adults are women. Most women become infected with HIV through unprotected sexual intercourse with an infected male partner. Biologically, women are twice as likely to become infected through unprotected heterosexual intercourse as men. Moreover, women are often unable to negotiate condom use because of unequal gender relations—men can insist on unprotected sexual intercourse in many relationships. Another factor often related to unequal gender relations that may shape women's risk of exposure to HIV is food insecurity—limited or uncertain access to enough nutritionally adequate and safe food for an active, healthy life. Recent studies done in sub-Saharan Africa suggest that food insecurity can affect women's engagement in risky sexual behaviors such as unprotected sex, transactional sex (sexual relationships that involve the giving of goods or services such as free lodgings), and commercial sex work.
Why Was This Study Done?
Policymakers planning HIV prevention strategies in resource-limited settings need to know whether food insecurity affects sexual risk taking among women. If it increases risk taking, then interventions that target food insecurity should improve the effectiveness of HIV prevention strategies. However, little is known about food insecurity and sexual risk taking outside sub-Saharan Africa. In this cross-sectional study (a study that characterizes a population at a single point in time), the researchers investigate whether food insecurity is associated with risky sexual behavior among sexually active women in Brazil, a country where the number of new heterosexually transmitted HIV infections among women is increasing. Condom promotion is the mainstay of Brazil's HIV prevention strategy, but less than half of the population reports the use of a condom whenever sexual intercourse occurs (consistent condom use) or at last sexual intercourse (recent condom use), and a greater proportion of men than women report condom use, possibly because of unequal power relations between men and women.
What Did the Researchers Do and Find?
The researchers obtained data on consistent condom use, recent condom use, and self-reported itchy vaginal discharge in the previous 30 days (used here as an indication that a woman may have a sexually transmitted infection) for 12,684 sexually active women from a national survey conducted in Brazil in 2006–2007. They then used multivariable logistic regression (a statistical method) to investigate the association between these outcomes and food insecurity, which was measured using the Escala Brasiliera de Insegurança Alimentar, an 18-item questionnaire that asks people to recall information about the quantity and quality of food available to them over the previous three months. Severe food insecurity with hunger (the most extreme category of food insecurity) was associated with an adjusted odds ratio (AOR) for consistent condom use of 0.67. That is, women who reported severe food insecurity were two-thirds as likely to use a condom whenever they had sexual intercourse as women who were food secure, after adjustment for other factors that might have affected condom use. The probability of consistent condom use was 15% among women who were food secure but only 10.5% among women who had the worst food security. Severe food insecurity with hunger was also associated with a reduced odds of recent condom use (AOR = 0.75), whereas all categories of food insecurity increased the odds of a recent itchy vaginal discharge.
What Do These Findings Mean?
These findings indicate that severe food insecurity with hunger is associated with reduced condom use and with increased occurrence of symptoms that may indicate sexually transmitted disease among sexually active women in Brazil. Because the study looked at women at only a single time point, these findings do not show that food insecurity causes risky sexual behavior. Moreover, these findings may not be generalizable to other settings, and they do not distinguish between regular condom use with a regular partner and regular condom use with casual partners. Also, although the researchers investigated two hypothesized explanations—lack of control in sexual relations and chronic energy deficiency—neither of these factors could explain why food insecurity is associated with risky sexual behavior. Nevertheless, these findings suggest that interventions that target sexual risk reduction behaviors are unlikely to be optimally effective if food insecurity is not taken into account, and, thus, the researchers conclude, HIV prevention strategies in Brazil should include interventions that target food insecurity.
Additional Information
Please access these web sites via the online version of this summary at
Information is available from the US National Institute of Allergy and Infectious Diseases on all aspects of HIV infection and AIDS
NAM/aidsmap provides basic information about HIV/AIDS, and summaries of recent research findings on HIV care and treatment (in several languages)
Information is available from Avert, an international AIDS charity on many aspects of HIV/AIDS, including detailed information on HIV and AIDS prevention, women, HIV, and AIDS, and HIV and AIDS in Brazil (in English and Spanish); personal stories of women living with HIV are available
HIV InSite provides comprehensive and up-to-date information on all aspects of HIV/AIDS from the University of California at San Francisco
Additional patient stories about living with HIV/AIDS are available through the charity website Healthtalkonline
A primer on food security from the Food and Agriculture Organization of the United Nations is available
Information about the 2006–2007 Brazilian national survey on health in women and children is available in Portuguese; a profile of food security in Brazil is also available (some information in English but mainly in Portuguese)
PMCID: PMC3323512  PMID: 22505852
7.  Sexual dysfunction among married couples living in Kumasi metropolis, Ghana 
BMC Urology  2011;11:3.
Sexuality and its manifestation constitute some of the most complex of human behaviour and its disorders are encountered in community. Sexual dysfunction is more prevalent in women than in men. While studies examining sexual dysfunction among males and females in Ghana exist, there are no studies relating sexual problems in males and females as dyadic units. This study therefore investigated the prevalence and type of sexual disorders among married couples.
The study participants consisted of married couples between the ages of 19 and 66 living in the province of Kumasi, Ghana. Socio-demographic information and Golombok-Rust Inventory of Sexual Satisfaction (GRISS) questionnaires were administered to 200 couples who consented to take part in the study. All 28 questions of the GRISS are answered on a five-point (Likert type) scale from "always", through "usually', "sometimes", and "hardly ever", to "never". Responses are summed up to give a total raw score ranging from 28-140. The total score and subscale scores are transformed using a standard nine point scale, with high scores indicating greater problems. Scores of five or more are considered to indicate SD. The study was conducted between July and September 2010.
Out of a total of 200 married couples, 179 completed their questionnaires resulting in a response rate of 89.5%. The mean age of the participating couples as well as the mean duration of marriage was 34.8 ± 8.6 years and 7.8 ± 7.6 years respectively. The husbands (37.1 ± 8.6) were significantly older (p < 0.0001) than their corresponding wives (32.5 ± 7.9). After adjusting for age, 13-18 years of marriage life poses about 10 times significant risk of developing SD compared to 1-6 years of married life among the wives (OR: 10.8; CI: 1.1 - 49.1; p = 0.04). The total scores (6.0) as well as the percentage above the cut-off (59.2) obtained by the husbands compared to the total score (6.2) and the percentage above cut-off (61.5) obtained by the wives, indicates the likely presence of sexual dysfunction. The prevalence of impotence and premature ejaculation were 60.9% and 65.4% respectively from this study and the prevalence of vaginismus and anorgasmia were 69.3% and 74.9% respectively. The highest prevalence of SD subscales among the men was dissatisfaction with sexual act followed by infrequency, whereas the highest among the women was infrequency followed by anorgasmia. Dissatisfaction with sexual intercourse among men correlated positively with anorgasmia and wife's non-sensuality and infrequency of sex.
The prevalence of sexual dysfunction in married couples is comparable to prevalence rates in the general male and female population and is further worsened by duration of marriage. This could impact significantly on a couple's self-esteem and overall quality of life.
PMCID: PMC3058113  PMID: 21366917
8.  Attitudes and sexual behaviours of unmarried people with HIV/AIDS living in the Niger Delta region of Nigeria 
Mental Health in Family Medicine  2012;9(4):225-232.
Background Increasing morbidity and mortality associated with HIV/AIDS may be attributable to the lifestyle of individuals. Appropriate sexual behaviour and lifestyle modification may be helpful strategies for prevention and control of HIV/AIDS in many countries.
Aim The study was designed to assess the impact of attitudes and sexual behaviour on control of HIV/AIDS among unmarried people living with HIV/AIDS in Uyo, a community in the Niger Delta region of Nigeria.
Method A total of 365 unmarried individuals living with HIV/AIDS were assessed at the HIV clinic of the University of Uyo Teaching Hospital. Attitudes and sexual behaviour were evaluated using the Attitude and Sexual Behaviour Questionnaire adapted from previous studies.
Results Of the 365 individuals living with HIV/AIDS, 142 (38.9%) were male and 223 (61.1%) were female. The majority of the subjects were below 50 years of age. The mean ages (± SD) of men and women were 36.8 ± 3.9 and 29.2 ± 1.7 years, respectively. Sexual attitudes and behaviours were variable. There was no change in the partner's reaction to sex for 28.9% of men and 27.8% of women, abstinence in 7.7% of men and 8.1% of women, and breakdown of the relationship with the partner for 4.9% of men and 7.2% of women. More women than men agreed to undergo testing after their partners had tested positive for HIV. Sexual activity was higher in women than men, with 4.9% of men and 10.3% of women reporting daily sexual intercourse, 16.2% of men and 15.7% of women reporting weekly intercourse, and occasional sexual intercourse being reported by 44.4% of both men and women. After testing positive, 58.4% of male partners and 56.9% of female partners were persuaded to use condoms during sexual intercourse.
Conclusion This study has demonstrated unhealthy attitudes and sexual behaviour among individuals living with HIV/AIDS in the Niger Delta region of Nigeria. This can potentially limit efforts and investment in controlling HIV/AIDS in this region. Therefore there is a need to initiate concrete policies and programmes that would encourage people living with HIV/AIDS in the Niger Delta region to adopt a healthy lifestyle.
PMCID: PMC3721916  PMID: 24294297
behaviour; HIV/AIDS; Nigeria; sexual attitudes; unmarried people
9.  Changes in human immunodeficiency virus and sexually transmitted infections-related sexual risk taking among young Croatian adults: findings from the 2005 and 2010 population-based surveys 
Croatian Medical Journal  2011;52(4):458-468.
To determine changes in sexual behaviors and other relevant characteristics related to human immunodeficiency virus (HIV) and sexually transmitted infection (STI) risks among young Croatian adults.
We surveyed adults aged 18-24 in 2005 (n = 1092) and 18-25 in 2010 (n = 1005). Both samples were probabilistic and stratified by county, settlement size, age, and gender. The samples were non-matched. Trained interviewers conducted structured face-to-face interviews in participants’ households. The part of the questionnaire assessing sensitive information was self-administered.
A majority of participants at both survey points (85.2%-86.2%) were sexually active. Median age at sexual debut (17 years) remained unchanged. Lifetime number of sexual partners was also stable. More women than men reported only one lifetime sexual partner. The prevalence of condom use at first intercourse increased (from 62.6 to 70%, P = 0.002), while the prevalence of condom use at most recent sexual intercourse remained stable (54% in 2005 and 54.7% in 2010). Consistent condom use also remained unchanged. About one fifth of participants (19.2% in 2005 and 20% in 2010) reported consistent condom use in the past year. At both survey points for both genders, consistent condom use was associated with age (odds ratio [OR] Women2005 = 0.74, P = 0.004; ORWomen2010 = 0.72, P < 0.001; ORMen2005 = 0.73, P < 0.001; ORMen2010 = 0.80, P = 0.006), negative attitudes toward condom use (ORWomen2005 = 0.84, P = 0.001; ORWomen2010 = 0.90, P = 0.026; ORMen2005 = 0.92, P = 0.032; ORMen2010 = 0.90, P = 0.011)), and condom use at first intercourse (ORWomen2005 = 3.87, P < 0.001; ORWomen2010 = 4.64, P < 0.001; ORMen2005 = 5.85, P < 0.001; ORMen2010 = 4.03, P < 0.001). In the observed period, HIV/AIDS knowledge was stable.
Risky sexual practices remain common among young Croatian adults. Given the recently reported STI prevalence rates in this age cohort, introduction of school-based sex education that would focus on protective behavioral and communication skills seems to be of crucial epidemiological importance.
PMCID: PMC3160693  PMID: 21853540
10.  Determinants of sexual habits in Italian females. 
Genitourinary Medicine  1992;68(6):394-398.
OBJECTIVE--To identify characteristics of women reporting multiple sexual partners and early age at first intercourse in Italy. METHOD--Information on 1139 control women (median age 54 years) interviewed as part of a case-control study of cervical neoplasia conducted in the greater Milan area, Northern Italy were analysed using stratified analysis and multiple logistic regression. RESULTS--Overall, 81% of the study sample reported no more than one sexual partner, 10% two and 9% three or more. The proportion reporting multiple sexual partners tended to be higher among younger and more educated women (4% vs 19% of women with respectively less than 7 and 12 or more years of education reported three or more partners). Ever smokers reported a higher number of sexual partners than never smokers. The proportion of nulliparae reporting three or more sexual partners was higher than that of parous women. These findings were confirmed after taking into account in a multivariate analysis the role of potential confounding factors. Furthermore similar findings emerged from an analysis restricted to women aged 40 years or less. Always considering number of sexual partners, no relationship emerged with marital status, spontaneous or induced abortions, lifetime number of reported Pap smears and contraceptive habits. With reference to age at first intercourse, 25% of the study population reported their first intercourse at age 18 or before, 34% between 19 and 22 years, and 41% at age 23 or later. Younger women (that is, more recent cohorts) more frequently reported earlier age at first intercourse and the proportion of never married women reporting early intercourse was higher (51% vs 22% of never married vs married women). No relationship emerged between education, smoking habits, parity, history of spontaneous or induced abortions, number of Pap smears, contraceptive habits, and age at first intercourse. CONCLUSION--This study documents conservative sexual habits in Northern Italian females (at least on the basis of self reporting) but indicates that any educational compaigns towards safe sex should be focused towards younger women, particularly smokers, unmarried and nulliparae.
PMCID: PMC1194978  PMID: 1487262
11.  The Safety of Adult Male Circumcision in HIV-Infected and Uninfected Men in Rakai, Uganda 
PLoS Medicine  2008;5(6):e116.
The objective of the study was to compare rates of adverse events (AEs) related to male circumcision (MC) in HIV-positive and HIV-negative men in order to provide guidance for MC programs that may provide services to HIV-infected and uninfected men.
Methods and Findings
A total of 2,326 HIV-negative and 420 HIV-positive men (World Health Organization [WHO] stage I or II and CD4 counts > 350 cells/mm3) were circumcised in two separate but procedurally identical trials of MC for HIV and/or sexually transmitted infection prevention in rural Rakai, Uganda. Participants were followed at 1–2 d and 5–9 d, and at 4–6 wk, to assess surgery-related AEs, wound healing, and resumption of intercourse. AE risks and wound healing were compared in HIV-positive and HIV-negative men. Adjusted odds ratios (AdjORs) were estimated by multiple logistic regression, adjusting for baseline characteristics and postoperative resumption of sex. At enrollment, HIV-positive men were older, more likely to be married, reported more sexual partners, less condom use, and higher rates of sexually transmitted disease symptoms than HIV-negative men. Risks of moderate or severe AEs were 3.1/100 and 3.5/100 in HIV-positive and HIV-negative participants, respectively (AdjOR 0.91, 95% confidence interval [CI] 0.47–1.74). Infections were the most common AEs (2.6/100 in HIV-positive versus 3.0/100 in HIV-negative men). Risks of other complications were similar in the two groups. The proportion with completed healing by 6 wk postsurgery was 92.7% in HIV-positive men and 95.8% in HIV-negative men (p = 0.007). AEs were more common in men who resumed intercourse before wound healing compared to those who waited (AdjOR 1.56, 95% CI 1.05–2.33).
Overall, the safety of MC was comparable in asymptomatic HIV-positive and HIV-negative men, although healing was somewhat slower among the HIV infected. All men should be strongly counseled to refrain from intercourse until full wound healing is achieved.
Trial registration:; for HIV-negative men, #NCT00047073 and for HIV-positive men, #NCT00047073.
Ron Gray and colleagues report on complications of circumcision in HIV-infected and HIV-uninfected men from two related trials in Uganda, finding increased risk with intercourse before wound healing.
Editors' Summary
Worldwide over 33 million people are thought to be living with HIV, and in the absence of a vaccine, preventing its spread is a major health issue. The World Health Organization (WHO) and the Joint United Nations Programme on HIV/AIDS (UNAIDS) estimate that 68% of 2.5 million new infections worldwide in 2007 took place in sub-Saharan Africa, where 76% of 2.1 million AIDS-related deaths also took place.
One of the principal means of person-to-person transmission of HIV is through sex without the protection of a condom. In parts of Africa, male circumcision is performed in infancy or childhood for religious or cultural reasons or is a traditional rite of passage that marks the transition from child to man. Three trials, in South Africa, Kenya, and Uganda, each found that circumcised men were around half as likely as uncircumcised men to contract HIV from HIV-positive female partners. After reviewing the results, WHO and UNAIDS issued joint advice that male circumcision should be promoted for preventing HIV infection in heterosexual men. As male circumcision does not provide complete protection against HIV infection, they advised that it should be promoted in addition to existing strategies of promoting condom use, abstinence, and a reduction in the number of sexual partners.
Why Was This Study Done?
Although earlier studies had shown that adult male circumcision, when performed in Africa under optimal conditions, is a safe procedure for HIV-negative men, it was not known whether it would also be a safe procedure for HIV-positive men. WHO guidelines recommend that HIV-positive men who request the procedure or have a medical need and no contraindications for it should be circumcised. Also, exclusion of HIV-positive men from circumcision programs may result in stigmatization of these men, and discourage participation by men who do not wish to be tested for HIV. Therefore, it is important to know whether the procedure is safe for HIV-positive men.
What Did the Researchers Do and Find?
The authors compared results from two separate clinical trials carried out with identical procedures in rural Rakai, Uganda. The first, which compared the effect of circumcision with no circumcision in HIV-negative men, was one of the three trials that persuaded the WHO and UNAIDS to promote male circumcision as an HIV prevention strategy. The second Rakai trial did the same comparison but in men who were HIV positive and without symptoms. In this present study, the authors used data from both trials to compare the likelihood of surgery-related complications following circumcision for HIV-negative and HIV-positive men.
The trials recruited men aged 15–49, who were randomly assigned to be circumcised either on enrollment or two years later and were followed up to monitor complications related to the procedure, such as infections, as well as wound healing and when the participant first had sex after the operation. Condom use was recorded at enrollment and six months after enrollment.
The researchers found that most complications were infrequent, mild, and comparable in both groups, with moderate-to-severe complications occurring in only 3%–4% of men in each group. However, delayed wound healing was more frequent in HIV-positive men. Complications were more likely among men who had sex before healing was complete; such men were more likely to be HIV-positive and/or married. Similarly, moderate or severe complications were more likely where men had symptoms of sexually transmitted disease at enrollment, although these were treated before surgery, and these men were more likely to be HIV-positive. Six months after enrollment, similar proportions of HIV-positive and HIV-negative men used condoms consistently, but HIV-positive men were more likely to report using condoms inconsistently than HIV-negative men. However, consistent use of a condom increased among the HIV-positive men compared to when they enrolled.
What Do these Findings Mean?
Circumcision in HIV-positive men without symptoms of AIDS has a low rate of complications, although healing is slower than in HIV-negative men. Because of the greater risk of complications if sex is resumed before full healing, both men and their women partners should be advised to have no sex for at least six weeks after the operation. A separately reported analysis from one of these studies found that women partners are more likely to become HIV infected by HIV-positive men who resume sex prior to complete wound healing. Therefore, for protection of both men and their female partners, it is essential to refrain from intercourse after circumcision until the wound has completely healed.
Because the study found no increased risk of surgical complications in HIV-positive men who undergo circumcision, it should not be necessary to screen men with no symptoms of HIV in future circumcision programs. This should reduce the complexity of implementing such programs and reduce any stigma resulting from exclusion, making it likely that more men will be willing to be circumcised. The rise in consistent condom use among HIV-positive men suggests that messages of safe sex are reaching an important target group and changing their behavior, and that circumcision does not make men less likely to use a condom.
The authors also noted that the rates of complications they observed were low compared with those following traditional circumcision procedures. Others have found that circumcision carried out under unsafe conditions has a high rate of complications. The authors of this study comment that the resources and standards of surgery during the trial represented best practice and that to attain similarly low rates of complications—and the confidence of men in the safety of the procedure—there is a need to ensure sufficient resources and high standards of training.
Additional Information.
Please access these Web sites via the online version of this summary at
WHO and the UNAIDS issued a joint report recommending male circumcision for HIV prevention and another on the HIV epidemic worldwide in December 2007
An information pack here on male circumcision and HIV prevention has also been developed jointly by WHO/UNAIDS, the United Nations International Children's Emergency Fund (UNICEF), the United Nations Population Fund (UNFPA), and the World Bank
The University of California San Francisco's HIV InSite provides information on HIV prevention, treatment, and policy
AEGIS is the world's largest searchable database on HIV and AIDS
The National AIDS Trust provides information on HIV prevention
PMCID: PMC2408615  PMID: 18532873
12.  Self-Esteem, Confidence, and Relationships in Men Treated with Sildenafil Citrate for Erectile Dysfunction 
Journal of General Internal Medicine  2006;21(10):1069-1074.
Men with erectile dysfunction (ED) often have low self-esteem, confidence, and sexual relationship satisfaction.
We evaluated the impact of sildenafil citrate and its generalizability across cultures on self-esteem, confidence, and sexual relationship satisfaction in men with ED using the Self-Esteem And Relationship (SEAR) questionnaire.
Pooled analysis of 2 double-blind, placebo-controlled, flexible-dose trials of sildenafil with identical protocols: 1 was conducted in the United States and the other in Mexico, Brazil, Australia, and Japan.
Men ≥18 years old with ED.
The impact of treatment on psychosocial factors associated with ED was determined by patient responses to the SEAR questionnaire. Erectile function was determined using the International Index of Erectile Function (IIEF) and a global efficacy question. Successful sexual intercourse attempts were derived from event logs of sexual activity. Treatment effect sizes were calculated for all study outcomes.
Compared with patients who received placebo (n = 274), patients who received sildenafil (n = 279) reported significantly greater improvements (P<.0001) in self-esteem, confidence, sexual relationship satisfaction, and in all sexual function domains of the IIEF. Treatment effect sizes were large (range, 0.7 to 1.2) for all SEAR components, and improvement in psychosocial measures showed moderate to high correlations (range, 0.50 to 0.83, P<.0001) with improvement in erectile function, percentage of successful intercourse attempts, and global efficacy.
In men with ED from 5 different nations, sildenafil produced substantial improvements in self-esteem, confidence, and sexual relationship satisfaction. Improvements in these psychosocial factors were observed crossculturally and correlated significantly and tangibly with improvements in erectile function.
PMCID: PMC1831645  PMID: 16836626
erectile dysfunction; impotence; self-esteem; confidence; quality of life; relationship; psychometrics
13.  The association of body image dissatisfaction and pain with reduced sexual function in women with systemic sclerosis 
Rheumatology (Oxford, England)  2011;50(6):1125-1130.
Objective. Pain and body image distress are common among women with SSc, but their relative associations with reduced sexual function have not been assessed. The objective of this study was to assess the independent associations of pain and body image distress with reduced sexual function in women with SSc.
Methods. Female SSc patients completed measures of sexual function (sexual relationships subscale of the Psychosocial Adjustment to Illness Scale–Self-Report), body image dissatisfaction (Satisfaction with Appearance Scale) and pain (visual analogue scale). Multiple regression analysis was used to assess the associations of body image dissatisfaction and pain with reduced sexual function, controlling for sociodemographic and disease variables.
Results. The sample included 117 female SSc patients [33 (28.2%) diffuse; mean age 51.4 (11.9) years; mean time since diagnosis 9.1 (8.5) years]. Unadjusted analyses found that reduced sexual function was associated with pain (r = 0.44, P < 0.001), body image dissatisfaction (r = 0.35, P < 0.001) and being married (r = 0.34, P < 0.001). In multivariate linear regression, disease duration (β = 0.17, P = 0.046), pain (β = 0.29, P = 0.001) and unmarried status (β = −0.23, P = 0.006) were independently associated with reduced sexual function. Dissatisfaction with appearance was not significantly associated with reduced sexual function (β = 0.16, P = 0.067).
Conclusion. Pain is an important indicator of sexual function among women with SSc. Body image dissatisfaction was not independently associated with sexual impairment and appears to be less important factor than pain in determining sexual function. Future research should focus on isolating specific sources of pain that may be amenable to intervention in order to improve sexual function.
PMCID: PMC3093929  PMID: 21278071
Systemic sclerosis; Sexual impairment; Women's health; Pain; Body image
14.  Socioeconomic, Anthropomorphic, and Demographic Predictors of Adult Sexual Activity in the United States: Data from the National Survey of Family Growth 
The journal of sexual medicine  2009;7(1 0 1):50-58.
Individuals who engage in regular sexual intercourse are more likely to report good overall quality of life. Studies of sexuality in adolescents have focused on high-risk behaviors whereas similar studies in older adults have focused on sexual dysfunction. Given a paucity of data on the sexual behaviors of young adults and the possibility of important relationships between sexuality and overall health, we sought to determine factors that influence the frequency of intercourse in adult men and women in the United States.
To identify factors related to coital frequency in young and middle-aged adults.
We analyzed data from the male and female sample of the 2002 National Survey of Family Growth to examine frequency of sexual intercourse among Americans aged 25–45 years (men: N = 2,469; women: N = 5,120).
Main Outcome Measures
Multivariable negative binomial regression modeling was used to test for independent associations between the frequency of sexual intercourse and demographic, socioeconomic, and anthropometric variables.
In this study, men and women between the ages of 25 and 45 have sex a mean 5.7 and 6.4 times per month, respectively. Being married significantly increased coital frequency for women but has no effect on male coital frequency. Increased height, less than high school education, and younger age were predictive of increased sexual frequency in men. Pregnancy was associated with significantly lower coital frequency for both men and women. No association was shown between self-reported health status and coital frequency on multivariable analysis.
Among young male adults, coital frequency is associated with specific socioeconomic, demographic, and anthropomorphic characteristics. Sexual frequency in women does not appear to be influenced by such factors. Self-reported health is not predictive of sexual activity in this age group.
PMCID: PMC4081028  PMID: 19796014
Sexual Behavior; Socioeconomic Factors; United States; Coitus; Body Height
15.  Changes in sexual attitudes and lifestyles in Britain through the life course and over time: findings from the National Surveys of Sexual Attitudes and Lifestyles (Natsal) 
Lancet  2013;382(9907):1781-1794.
Sexual behaviour and relationships are key components of wellbeing and are affected by social norms, attitudes, and health. We present data on sexual behaviours and attitudes in Britain (England, Scotland, and Wales) from the three National Surveys of Sexual Attitudes and Lifestyles (Natsal).
We used a multistage, clustered, and stratified probability sample design. Within each of the 1727 sampled postcode sectors for Natsal-3, 30 or 36 addresses were randomly selected and then assigned to interviewers. To oversample individuals aged 16–34 years, we randomly allocated addresses to either the core sample (in which individuals aged 16–74 years were eligible) or the boost sample (in which only individuals aged 16–34 years were eligible). Interviewers visited all sampled addresses between Sept 6, 2010, and Aug 31, 2012, and randomly selected one eligible individual from each household to be invited to participate. Participants completed the survey in their own homes through computer-assisted face-to-face interviews and self-interview. We analysed data from this survey, weighted to account for unequal selection probabilities and non-response to correct for differences in sex, age group, and region according to 2011 Census figures. We then compared data from participants aged 16–44 years from Natsal-1 (1990–91), Natsal-2 (1999–2001), and Natsal-3.
Interviews were completed with 15 162 participants (6293 men, 8869 women) from 26 274 eligible addresses (57·7%). 82·1% (95% CI 81·0–83·1%) of men and 77·7% (76·7–78·7%) of women reported at least one sexual partner of the opposite sex in the past year. The proportion generally decreased with age, as did the range of sexual practices with partners of the opposite sex, especially in women. The increased sexual activity and diversity reported in Natsal-2 in individuals aged 16–44 years when compared with Natsal-1 has generally been sustained in Natsal-3, but in men has generally not risen further. However, in women, the number of male sexual partners over the lifetime (age-adjusted odds ratio 1·18, 95% CI 1·08–1·28), proportion reporting ever having had a sexual experience with genital contact with another woman (1·69, 1·43–2·00), and proportion reporting at least one female sexual partner in the past 5 years (2·00, 1·59–2·51) increased in Natsal-3 compared with Natsal-2. While reported number of occasions of heterosexual intercourse in the past 4 weeks had reduced since Natsal-2, we recorded an expansion of heterosexual repertoires—particularly in oral and anal sex—over time. Acceptance of same-sex partnerships and intolerance of non-exclusivity in marriage increased in men and women in Natsal-3.
Sexual lifestyles in Britain have changed substantially in the past 60 years, with changes in behaviour seeming greater in women than men. The continuation of sexual activity into later life—albeit reduced in range and frequency—emphasises that attention to sexual health and wellbeing is needed throughout the life course.
Grants from the UK Medical Research Council and the Wellcome Trust, with support from the Economic and Social Research Council and the Department of Health.
PMCID: PMC3899021  PMID: 24286784
16.  Racial origin, sexual behaviour, and genital infection among heterosexual men attending a genitourinary medicine clinic in London (1993-4) 
OBJECTIVES: To compare variables of sexual behaviour and incidence of genital infections among heterosexual men of different racial origins. DESIGN: A prospective cross sectional study of sexual behaviour reported by a standardised self administered questionnaire in new patients who presented for screening and diagnosis. SETTING: A genitourinary medicine clinic in west London. SUBJECTS: 1212 consecutive heterosexual men newly attending in 1993-4. MAIN OUTCOME MEASURES: Variables relating to sociodemographic status, sexual behaviour, condom use, sexually transmitted diseases, and other genital infections stratified by racial origin. RESULTS: There were 941 evaluable heterosexual men of whom the majority were white (79%) and 17% were black. The black men comprised more teenagers (11% cf 2%; p < 0.00001), were more likely to be unemployed (26% cf 12%; p < 0.00001), to have commenced intercourse much earlier (45% cf 22% before aged 16: p < 0.0001), and to have had intercourse with an African woman (14% cf 6%; p < 0.001). Both fellatio (64% cf 96%; p < 0.00001) and cunnilingus (40% cf 92%; p < 0.00001) were practised less frequently by the black men and so too was anal intercourse (11% cf 27%; p < 0.00001). Similar proportions from both groups were non-smokers (53% cf 57%), but a significantly higher proportion of the black men did not drink alcohol (13% cf 5%; p < 0.001). Gonorrhoea (15% cf 1%; p < 0.00001), chlamydial infection (17% cf 8%; p < 0.001), and non-gonococcal urethritis (37% cf 24%; p = 0.001) were diagnosed more frequently in the black men. These findings remained significant after logistic regression and are therefore independently associated with black race. However, there was no significant difference in numbers of sexual partners in the preceding year (median 2), nor in condom use with regular and non-regular partners. The Asian men had commenced intercourse later (mean 19.1 years) than both the black men (mean 15.9 years) and the white men (mean 17.3 years). CONCLUSIONS: Compared with white men, black men attending a genitourinary medicine clinic were much more likely to be unemployed, to have commenced intercourse earlier and to have urethral infection. They were much less likely to practice fellatio, cunnilingus, or anal intercourse. However, there was no difference between the two racial groups in respect of numbers of sexual partners and condom use. 

PMCID: PMC1758075  PMID: 9634302
17.  Sexual function among married menopausal women in Amol (Iran) 
Journal of Mid-Life Health  2011;2(2):77-80.
Sexual activity is an important part of the human being's life but this instinct could be influenced by some factors such as diseases, drug using, aging, and menopause. But information about that is limited.
The aim of this study is to determine the status of sexual activity among married menopausal women in Amol, Iran.
Materials and Methods:
This descriptive analytical study was conducted to describe the sexual activity and sexual dysfunction of women after menopause. Data were collected from health centers in Amol from 280 married women using a questionnaire (self-completed or by interview).
Mean age of subjects were 55.9 ± 6.02 years. 23.4% of subjects reported that their sexual intercourse had been low. 70% of subjects reported a decrease in their sexual activities after menopause. Sexual dysfunctions includes sexual desire disorder 80% arousal dysfunction 80%, orgasmic dysfunction 25%, dyspareunia 55.6%, and lack of sexual satisfaction 43.2%.
Findings revealed high percentage of sexual desire disorder and sexual arousal disorder in menopausal women. Therefore, we should have emphasis on counseling and education about sexual activities during the menopause period.
PMCID: PMC3296390  PMID: 22408336
Menopause; sexual function; women
18.  Associations between health and sexual lifestyles in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3) 
Lancet  2013;382(9907):1830-1844.
Physical and mental health could greatly affect sexual activity and fulfilment, but the nature of associations at a population level is poorly understood. We used data from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3) to explore associations between health and sexual lifestyles in Britain (England, Scotland, and Wales).
Men and women aged 16–74 years who were resident in households in Britain were interviewed between Sept 6, 2010, and Aug 31, 2012. Participants completed the survey in their own homes through computer-assisted face-to-face interviews and self-interview. We analysed data for self-reported health status, chronic conditions, and sexual lifestyles, weighted to account for unequal selection probabilities and non-response to correct for differences in sex, age group, and region according to 2011 Census figures.
Interviews were done with 15 162 participants (6293 men, 8869 women). The proportion reporting recent sexual activity (one or more occasion of vaginal, oral, or anal sex with a partner of the opposite sex, or oral or anal sex or genital contact with a partner of the same sex in the past 4 weeks) decreased with age after the age of 45 years in men and after the age of 35 years in women, while the proportion in poorer health categories increased with age. Recent sexual activity was less common in participants reporting bad or very bad health than in those reporting very good health (men: 35·7% [95% CI 28·6–43·5] vs 74·8% [72·7–76·7]; women: 34·0% [28·6–39·9] vs 67·4% [65·4–69·3]), and this association remained after adjusting for age and relationship status (men: adjusted odds ratio [AOR] 0·29 [95% CI 0·19–0·44]; women: 0·43 [0·31–0·61]). Sexual satisfaction generally decreased with age, and was significantly lower in those reporting bad or very bad health than in those reporting very good health (men: 45·4% [38·4–52·7] vs 69·5% [67·3–71·6], AOR 0·51 [0·36–0·72]; women: 48·6% [42·9–54·3] vs 65·6% [63·6–67·4], AOR 0·69 [0·53–0·91]). In both sexes, reduced sexual activity and reduced satisfaction were associated with limiting disability and depressive symptoms, and reduced sexual activity was associated with chronic airways disease and difficulty walking up the stairs because of a health problem. 16·6% (95% CI 15·4–17·7) of men and 17·2% (16·3–18·2) of women reported that their health had affected their sex life in the past year, increasing to about 60% in those reporting bad or very bad health. 23·5% (20·3–26·9) of men and 18·4% (16·0–20·9) of women who reported that their health affected their sex life reported that they had sought clinical help (>80% from general practitioners; <10% from specialist services).
Poor health is independently associated with decreased sexual activity and satisfaction at all ages in Britain. Many people in poor health report an effect on their sex life, but few seek clinical help. Sexual lifestyle advice should be a component of holistic health care for patients with chronic ill health.
Grants from the UK Medical Research Council and the Wellcome Trust, with support from the Economic and Social Research Council and Department of Health.
PMCID: PMC3898988  PMID: 24286788
19.  Sexual function in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3) 
Lancet  2013;382(9907):1817-1829.
Despite its importance to sexual health and wellbeing, sexual function is given little attention in sexual health policy. Population-based studies are needed to understand sexual function across the life course.
We undertook a probability sample survey (the third National Survey of Sexual Attitudes and Lifestyles [Natsal-3]) of 15 162 individuals aged 16–74 years who lived in Britain (England, Scotland, and Wales). Interviews were done between Sept 6, 2010, and Aug 31, 2012. We assessed the distribution of sexual function by use of a novel validated measure (the Natsal-SF), which assessed problems with individual sexual response, sexual function in a relationship context, and self-appraisal of sex life (17 items; 16 items per gender). We assess factors associated with low sexual function (defined as the lowest quintile of distribution of Natsal-SF scores) and the distribution of components of the measure. Participants reporting one or more sexual partner in the past year were given a score on the Natsal-SF (11 690 participants). 4122 of these participants were not in a relationship for all of the past year and we employed the full information maximum likelihood method to handle missing data on four relationship items.
We obtained data for 4913 men and 6777 women for the Natsal-SF. For men and women, low sexual function was associated with increased age, and, after age-adjustment, with depression (adjusted odds ratio 3·70 [95% CI 2·90–4·72] for men and 4·11 [3·36–5·04] for women) and self-reported poor health status (2·63 [1·73–3·98] and 2·41 [1·72–3·39]). Low sexual function was also associated with experiencing the end of a relationship (1·52 [1·18–1·95] and 1·77 [1·44–2·17]), inability to talk easily about sex with a partner (2·36 [1·94–2·88] and 2·82 [2·28–3·48]), and not being happy in the relationship (2·89 [2·32–3·61] and 4·10 [3·39–4·97]). Associations were also noted with engaging in fewer than four sex acts in the past 4 weeks (3·13 [2·58–3·79] and 3·38 [2·80–4·09]), having had same sex partners (2·28 [1·56–3·35] and 1·60 [1·16–2·20]), paying for sex (in men only; 2·62 [1·46–4·71]), and higher numbers of lifetime sexual partners (in women only; 2·12 [1·68–2·67] for ten or more partners). Low sexual function was also associated with negative sexual health outcomes such as experience of non-volitional sex (1·98 [1·14–3·43] and 2·18 [1·79–2·66]) and STI diagnosis (1·50 [1·06–2·11] and 1·83 [1·35–2·47]). Among individuals reporting sex in the past year, problems with sexual response were common (41·6% of men and 51·2% of women reported one or more problem) but self-reported distress about sex lives was much less common (9·9% and 10·9%). For individuals in a sexual relationship for the past year, 23·4% of men and 27·4% of women reported an imbalance in level of interest in sex between partners, and 18·0% of men and 17·1% of women said that their partner had had sexual difficulties. Most participants who did not have sex in the past year were not dissatisfied, distressed, or avoiding sex because of sexual difficulties.
Wide variability exists in the distribution of sexual function scores. Low sexual function is associated with negative sexual health outcomes, supporting calls for a greater emphasis on sexual function in sexual health policy and interventions.
Grants from the UK Medical Research Council and the Wellcome Trust, with support from the Economic and Social Research Council and the Department of Health.
PMCID: PMC3898902  PMID: 24286787
20.  Sociodemographic, Psychosocial, and Health Behavior Risk Factors Associated with Sexual Risk Behaviors among Southeastern US College Students 
We examined correlates of 1) being a virgin; 2) drug or alcohol use prior to the last intercourse; and 3) condom use during the last intercourse in a sample of college students.
We recruited 24,055 students at six colleges in the Southeast to complete an online survey, yielding 4840 responses (20.1% response rate), with complete data from 4514.
Logistic regression indicated that correlates of virginity included being younger (p < 0.001), male (p = 0.01), being White or other ethnicity (p < 0.001), attending a four-vs. two-year school (p < 0.001), being single/never married (p < 0.001), lower sensation seeking (p < 0.001), more regular religious service attendance (p < 0.001), lower likelihood of smoking (p < 0.001) and marijuana use (p = 0.002), and less frequentdrinking (p < 0.001). Correlates of alcohol or drug use prior to most recent intercourse including being older (p = 0.03), being White (p < 0.01), attending a four-year college (p < 0.001), being homosexual (p = 0.041) or bisexual (p = 0.011), having more lifetime sexual partners (p = 0.005), lower satisfaction with life (p = 0.004), greater likelihood of smoking (p < 0.001) and marijuana use (p < 0.001), and more frequent drinking (p < 0.001). Correlates of condom use during the last sexual intercourse including being older (p = 0.003), being female (p < 0.001), being White (p < 0.001), attending a two-year school (p = 0.04), being single/never married (p = 0.005), being homosexual or bisexual (p = 0.04), and a more frequent drinking (p = 0.001).
Four-year college attendees were more likely to be a virgin but, if sexually active, reported higher sexual risk behaviors. These nuances regarding sexual risk may provide targets for sexual health promotion programs and interventions.
PMCID: PMC4110725  PMID: 25068080
Sexual Risk; Substance Use; College Students
21.  Differences in sexual behaviour and sexual practices of adolescents in Nigeria based on sex and self-reported HIV status 
Reproductive Health  2014;11(1):83.
Sexual behaviour and sexual practices affect the risk for acquisition and transmission of HIV infection. This study tries to identify differences in sexual behaviour (condom use with non-marital partners, multiple sexual partnerships transactional sex and age mixing in sexual relationships), sexual practices (oral, anal and vagina sex), and forced sexual initiation based on sex and HIV status of adolescents in Nigeria.
Face to face interviewer-administered questionnaires were used to collect information from a nationally representative sample of 10–19 years old adolescents residing in Nigeria. Data included information on age of sexual debut, sexual behaviour and sexual practices. Association between HIV status, sex, sexual behaviour and sexual practices, and predictors of use of condoms during the last vaginal sexual intercourse were determined.
More self-reported HIV positive than HIV negative females had experienced forced sexual initiation (p = 0.008). Significantly more female than male adolescents had engaged in transactional sex (p < 0.001) and had sex with partners who were older than them by 10 years or more (p < 0.001). Vaginal (95.2%), oral (26.6%) and anal (7.8%) sex were practiced by male and females irrespective of HIV status. More females reported oral sex (p = 0.001). Being a female (p = 0.001), having genital itching in the last 12 months (p = 0.04)and having engaged in anal sex in the last 12 months (p = 0.009) reduced the odds of using a condom at last vaginal intercourse. Having a HIV positive or negative status did not significantly increase the odds of using a condom at last vaginal intercourse.
Differences in sexual behaviour and sexual practices of adolescents was observed based on sex and not on HIV status. History of forced sex initiation however differed by HIV status. Tailored interventions for male and female adolescents are required to reduce their risk of HIV infection. Tailored interventions are also required for adolescents living with HIV to improve their sexual and reproductive health.
PMCID: PMC4266967  PMID: 25481734
Adolescents; Nigeria; HIV; Sex; Practices; Behaviour
22.  Psychological Correlates of Sexual Dysfunction in Female Rectal and Anal Cancer Survivors: Analysis of Baseline Intervention Data 
The journal of sexual medicine  2013;10(10):2539-2548.
Sexual dysfunction represents a complex and multifactorial construct that can affect both men and women and has been noted to often deteriorate significantly after treatment for rectal and anal cancer. Despite this, it remains an understudied, underreported and undertreated issue in the field of cancer survivorship.
This study examined the characteristics of women enrolled in an intervention trial to treat sexual dysfunction, and explored the relationship between sexual functioning and psychological well-being.
Main Outcomes Measures
Quality of life (EORTC-QLQ-C30 & QLQ-CR38), sexual functioning (FSFI) and psychological well-being (BSI Depression/Anxiety, IES-R, CR-38 Body Image).
There were 70 female post-treatment anal or rectal cancer survivors assessed as part of the current study. Participants were enrolled in a randomized intervention trial to treat sexual dysfunction and completed outcome measures prior to randomization.
Women enrolled in the study intervention were on average 55 years old, predominantly Caucasian (79%), married (57%) and a median of 4 years post-primary treatment. For those reporting sexual activity at baseline (N=41), sexual dysfunction was associated with a range of specific measures of psychological well-being, all in the hypothesized direction. The Sexual/Relationship Satisfaction subscale was associated with all measures of psychological well-being (r=−.45 to −.70, all p<.01). Body image, anxiety and cancer-specific post-traumatic distress were notable in their association with subscales of sexual functioning, while a global quality of life measure was largely unrelated.
For sexually-active female rectal and anal cancer survivors enrolled in a sexual health intervention, sexual dysfunction was significantly and consistently associated with specific measures of psychological well-being, most notably Sexual/Relationship Satisfaction. These results suggest that sexual functioning may require focused assessment by providers, beyond broad quality of life assessments, and that attention to Sexual/Relationship Satisfaction may be critical in the development and implementation of interventions for this cohort of patients.
PMCID: PMC3706574  PMID: 23551928
Sexual Dysfunction; Sexual Health; Rectal Cancer; Psychological Distress
23.  Trends in sexual behaviour and HIV testing among women presenting at a genitourinary medicine clinic during the advent of AIDS. 
Genitourinary Medicine  1991;67(3):194-198.
Changes in female sexual behaviour with the advent of AIDS and safer sex campaigns were studied. Subjects were drawn from a wide social spectrum of women attending an STD clinic in West London where there is a high prevalence of HIV infection among homosexual men. Between 1982 and 1989, 4224 women answered a self-administered questionnaire: women who reported more than one sexual partner in the previous year fell from 56.9% in 1982 to 51.8% in 1989 (p = 0.003). Anal intercourse showed no change and was reported by 8.8% in 1982 and 9.4% in 1989 (p = 0.8). Oral intercourse increased from 36.9% in 1982 to 44.7% in 1989 (p = 0.001). Condom use for contraception increased from 3.6% in 1982 to 16.2% in 1989 (p less than 0.001). Between 1987 and 1989, 35.6% of 3199 women reported having non-regular partners with no significant trend over this period; these women had earlier coitarche (17.0 years cf 17.9 years), many more partners (p less than 0.0001) and more practised anal (p = 0.007) and oral (p less than 0.0001) intercourse. However, frequent use of condoms doubled from 23.6% in 1987 to 47.6% in 1989. During this period, the prevalence of antibody to HIV (anti-HIV) remained unchanged (0.27-0.37%), but more women declined to be tested. Anonymised testing showed that none of those who refused consent for named testing was anti-HIV positive. It is concluded that significant changes in female sexual behaviour have taken place with the advent of AIDS but there has been no evidence of heterosexual spread beyond the confines of well defined risk behaviours. Risks of the magnitude reported in homosexual men were not found in heterosexual women.
PMCID: PMC1194671  PMID: 2071120
24.  Sexual Knowledge, attitudes and behaviors among unmarried migrant female workers in China: a comparative analysis 
BMC Public Health  2011;11:917.
In recent years, many studies have focused on adolescent's sex-related issues in China. However, there have been few studies of unmarried migrant females' sexual knowledge, attitudes and behaviors, which is important for sexual health education and promotion.
A sample of 5156 unmarried migrant female workers was selected from three manufacturing factories, two located in Shenzhen and one in Guangzhou, China. Demographic data, sexual knowledge, attitudes and behaviors were assessed by self-administered questionnaires. Multivariate logistic regression analysis was conducted to examine the factors associated with premarital sexual intercourse.
The average age of the unmarried female workers included in the sample was 20.2 years, and majority of them showed a low level of sex-related knowledge. Females from the west of China demonstrated a significant lower level of sex-related knowledge than those from the eastern or central provinces (p < 0.05). Approximately 13% of participants held a favorable attitude towards premarital sexual intercourse, and youths from the east/central were more likely to have favorable attitudes compared with those from the west (p < 0.05). About 17.0% of the unmarried female workers reported having engaged in premarital sexual intercourse, and females from the east/central were more likely to have experienced premarital sexual intercourse than those from the west (p < 0.05). Multivariate analysis revealed that age, education, current residential type, dating, sexual knowledge, attitudes, and pattern of communication were significantly associated with premarital sexual intercourse.
The unmarried migrant female workers lack sexual knowledge and a substantial proportion of them are engaged in premarital sexual behaviors. Interventions aimed at improving their sexual knowledge and related skills are needed.
PMCID: PMC3259080  PMID: 22151661
25.  The prevalence of unplanned pregnancy and associated factors in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3) 
Lancet  2013;382(9907):1807-1816.
Unplanned pregnancy is a key public health indicator. We describe the prevalence of unplanned pregnancy, and associated factors, in a general population sample in Britain (England, Scotland, and Wales).
We did a probability sample survey, the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3), of 15 162 men and women aged 16–74 years in Britain, including 5686 women of child-bearing age (16–44 years) who were included in the pregnancy analysis, between Sept 6, 2010, and Aug 31, 2012. We describe the planning status of pregnancies with known outcomes in the past year, and report the annual population prevalence of unplanned pregnancy, using a validated, multicriteria, multi-outcome measure (the London Measure of Unplanned Pregnancy). We set the findings in the context of secular trends in reproductive health-related events, and patterns across the life course.
9·7% of women aged 16–44 years had pregnancies with known outcome in the year before interview, of which 16·2% (95% CI 13·1–19·9) scored as unplanned, 29·0% (25·2–33·2) as ambivalent, and 54·8% (50·3–59·2) as planned, giving an annual prevalence estimate for unplanned pregnancy of 1·5% (1·2–1·9). Pregnancies in women aged 16–19 years were most commonly unplanned (45·2% [30·8–60·5]). However, most unplanned pregnancies were in women aged 20–34 years (62·4% [50·2–73·2]). Factors strongly associated with unplanned pregnancy were first sexual intercourse before 16 years of age (age-adjusted odds ratio 2·85 [95% CI 1·77–4·57], current smoking (2·47 [1·46–4·18]), recent use of drugs other than cannabis (3·41 [1·64–7·11]), and lower educational attainment. Unplanned pregnancy was also associated with lack of sexual competence at first sexual intercourse (1·90 [1·14–3·08]), reporting higher frequency of sex (2·11 [1·25–3·57] for five or more times in the past 4 weeks), receiving sex education mainly from a non-school-based source (1·84 [1·12–3·00]), and current depression (1·96 [1·10–3·47]).
The increasing intervals between first sexual intercourse, cohabitation, and childbearing means that, on average, women in Britain spend about 30 years of their life needing to avert an unplanned pregnancy. Our data offer scope for primary prevention aimed at reducing the rate of unplanned conceptions, and secondary prevention aimed at modification of health behaviours and health disorders in unplanned pregnancy that might be harmful for mother and child.
Grants from the UK Medical Research Council and the Wellcome Trust, with support from the Economic and Social Research Council and the Department of Health.
PMCID: PMC3898922  PMID: 24286786

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