Framing sexual health research: adopting a broader perspective
The results of the third British National Survey of Sexual Attitudes and Lifestyles (Natsal-3), in The Lancet, provide extensive data from a large, representative population sample collected with the aim of better understanding sexual lifestyles and improving sexual health.1Mercer CH Tanton C Prah P et al.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; (published online Nov 26.)http://dx.doi.org/10.1016/S0140-6736(13)62035-8Google Scholar, 2Sonnenberg P Clifton S Beddows S et al.Prevalence, risk factors, and uptake of interventions for sexually transmitted infections in Britain: findings from the National Surveys of Sexual Attitudes and Lifestyles (Natsal).Lancet. 2013; (published online Nov 26.)http://dx.doi.org/10.1016/S0140-6736(13)61947-9Google Scholar, 3Wellings K Jones KG Mercer CH et al.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; (published online Nov 26.)http://dx.doi.org/10.1016/S0140-6736(13)62071-1Google Scholar, 4Mitchell KR Mercer CH Ploubidis GB et al.Sexual function in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3).Lancet. 2013; (published online Nov 26.)http://dx.doi.org/10.1016/S0140-6736(13)62366-1Google Scholar, 5Field N Mercer CH Sonnenberg P et al.Associations between health and sexual lifestyles in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3).Lancet. 2013; (published online Nov 26.)http://dx.doi.org/10.1016/S0140-6736(13)62222-9Google Scholar, 6Macdowall W Gibson LJ Tanton C et al.Lifetime prevalence, associated factors, and circumstances of non-volitional sex in women and men in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3).Lancet. 2013; (published online Nov 26.)http://dx.doi.org/10.1016/S0140-6736(13)62300-4Google Scholar Major advances in research on sexuality and sexual lifestyles have been made in the past 25 years. When the first large-scale surveys of sexual behaviour were undertaken in the 1980s—the impetus provided by the emergence of the HIV epidemic—they were politically controversial in the UK and elsewhere.7Maddox J Sexual behaviour unsurveyed.Nature. 1989; 341: 181Crossref PubMed Scopus (1) Google Scholar Since then, sexual behaviour has been surveyed worldwide;8Wellings K Collumbien M Slaymaker E et al.Sexual behaviour in context: a global perspective.Lancet. 2006; 368: 1706-1728Summary Full Text Full Text PDF PubMed Scopus (622) Google Scholar sampling strategies, question standardisation, and computer-assisted methods of data collection have improved data quality, and biological measures, such as prevalence of sexually transmitted infections (STI) and hormonal status, have been added to behavioural measures.9Wellings K Cleland J Surveys on sexual health: recent developments and future directions.Sex Transm Infect. 2001; 77: 238-241Crossref PubMed Scopus (21) Google Scholar These studies have documented the extraordinary changes in sexual behaviour that have occurred in the latter half of the 20th century, characterised, at least in wealthier nations, by a fall in age at first intercourse, increasing numbers of lifetime sexual partners, and changes in patterns of partnership formation and childbearing. Natsal-1 charted not only generational changes in sexual behaviour, but also changes in HIV risk behaviour during the 1980s. Natsal-2 captured the resurgence in risk characterised by increasing numbers of sexual partners, increasing proportions of men paying for sex, and increases in risk behaviour among men who have sex with men since 1990 as treatments for HIV became available and the widespread fear of AIDS in the 1980s diminished.10Johnson AM Wadsworth J Wellings K Bradshaw S Field J Sexual lifestyles and HIV risk.Nature. 1992; 360: 4100-4102Crossref Scopus (189) Google Scholar Just as sexual behaviour is shaped by its social and historical context, so too is research in this specialty. The aims and content of Natsal and other sexual behaviour studies have evolved as the lens through which we view sexual health has changed. Natsal-3 used WHO's definition of sexual health to frame the design, analysis, and interpretation of the study; this approach views sexual health as not merely the absence of disease but recognises the importance of having pleasurable and safe sexual experiences that are free of coercion, discrimination, and violence.11WHODefining sexual health: report of a technical consultation on sexual health, 28–31 January 2002, Geneva. World Health Organization, Geneva2006Google Scholar This comprehensive formulation avoids framing sexual health exclusively in terms of the prevention of adverse sexual health outcomes, and widens the remit to include enhancement of the quality of sexual experience and relationships. Despite being widely cited, however, this definition of sexual health has yet to be incorporated into public health practice. Unplanned pregnancy, HIV, and STIs have to date been the staple endpoints of interventions to improve sexual health, whereas sexual violence has received attention only recently and sexual wellbeing and satisfaction are rarely considered. The case for adopting a more holistic approach to sexual health has generally been made on the grounds of the benefits for control and prevention of STIs, HIV, and unplanned pregnancy.12Philpott A Knerr W Maher D Promoting protection and pleasure: amplifying the effectiveness of barriers against sexually transmitted infections and pregnancy.Lancet. 2006; 368: 2028-2031Summary Full Text Full Text PDF PubMed Scopus (97) Google Scholar, 13Dixon-Mueller R The sexuality connection in reproductive health.Stud Fam Plann. 1993; 24: 262-282Crossref Scopus (151) Google Scholar Evidence that lends support to such claims is growing. For example, studies have reported associations between sexual violence against women and risk factors for acquisition of HIV and STIs14Sareen J Pagura G Grant B Is intimate partner violence associated with HIV infection among women in the United States?.Gen Hosp Psychiatry. 2009; 31: 274-278Summary Full Text Full Text PDF PubMed Scopus (90) Google Scholar, 15Pettifor A O'Brien K Macphail C Miller WC Rees H Early coital debut and associated HIV risk factors among young women and men in South Africa.Int Perspect Sex Reprod Health. 2009; 35: 82-90Crossref PubMed Scopus (92) Google Scholar and unplanned pregnancy.16Miller E Jordan B Levenson R Silverman JG Reproductive coercion: connecting the dots between partner violence and unintended pregnancy.Contraception. 2010; 81: 457-459Summary Full Text Full Text PDF PubMed Scopus (141) Google Scholar Mechanisms to explain these associations are both direct (forced sex is likely to be unprotected)14Sareen J Pagura G Grant B Is intimate partner violence associated with HIV infection among women in the United States?.Gen Hosp Psychiatry. 2009; 31: 274-278Summary Full Text Full Text PDF PubMed Scopus (90) Google Scholar and indirect (repeated abuse might lead to a reduced sense of self-worth and acceptance of high risk practices). And the links are bidirectional: sexual violence might lead to increased risk of unintended pregnancy and STIs, and disclosure of unintended pregnancy or infection to an intimate partner might trigger abuse.16Miller E Jordan B Levenson R Silverman JG Reproductive coercion: connecting the dots between partner violence and unintended pregnancy.Contraception. 2010; 81: 457-459Summary Full Text Full Text PDF PubMed Scopus (141) Google Scholar There has been limited research on the relation between the quality of sexual experience and risk of unplanned pregnancy and STIs. What evidence there is shows that goals relating to sexual satisfaction shape both risk taking and the adoption of risk-reduction practices, including use of condoms and choice of contraceptive method and whether it is continued.17Higgins JA Hirsch JS Pleasure, power, and inequality: incorporating sexuality into research on contraceptive use.Am J Public Health. 2008; 98: 1803-1813Crossref PubMed Scopus (139) Google Scholar, 18Smit J McFadyen L Zuma K Preston-Whyte E Vaginal wetness: an underestimated problem experienced by progestogen injectable contraceptive users in South Africa.Soc Sci Med. 2002; 55: 1511-1522Crossref PubMed Scopus (32) Google Scholar, 19Khan SI Hudson-Rodd N Saggers S Bhuiyan MI Bhuiya A Safer sex or pleasurable sex? Rethinking condom use in the AIDS era.Sex Health. 2004; 1: 217-225Crossref PubMed Scopus (45) Google Scholar Calls to incorporate pleasure into sexual health programmes have cited evidence of the increased effectiveness of interventions which do so.12Philpott A Knerr W Maher D Promoting protection and pleasure: amplifying the effectiveness of barriers against sexually transmitted infections and pregnancy.Lancet. 2006; 368: 2028-2031Summary Full Text Full Text PDF PubMed Scopus (97) Google Scholar The logic is simple. People have sex for various reasons, but mostly because it is pleasurable, and interventions that safeguard pleasure are more likely to work than those that do not. The benefits in terms of infection and fertility control that result from improving the quality of sexual relationships could be regarded as justification enough for adopting a broader approach to sexual health. But the argument for including sexual wellbeing in a concept of sexual health is not merely that it can be harnessed to goals for the prevention of HIV, STIs, and unplanned pregnancy. Improving the quality of sexual experience and relationships is important in its own right. Positive sexual experience is good for us. Regular sexual activity contributes to health20Charnetski CJ Brennan FX Sexual frequency and salivary immunoglobulin A (IgA).Psychol Rep. 2004; 94: 839-844Crossref PubMed Scopus (24) Google Scholar, 21Ebrahim S May M Ben Shlomo Y et al.Sexual intercourse and risk of ischaemic stroke and coronary heart disease: the Caerphilly study.J Epidemiol Community Health. 2002; 56: 99-102Crossref PubMed Scopus (81) Google Scholar, 22Light KC Grewen KM Amico JA More frequent partner hugs and higher oxytocin levels are linked to lower blood pressure and heart rate in premenopausal women.Biol Psychol. 2005; 69: 5-21Crossref PubMed Scopus (319) Google Scholar and quality of life. Men and women who enjoy an active sex life are fitter, have lower rates of depressive symptoms, and improved cardiovascular health as compared with those who do not,23Davey Smith G Frankel S Yarnell J Sex and death: are they related? Findings from the Caerphilly cohort study.BMJ. 1997; 315: 1641Crossref PubMed Scopus (151) Google Scholar although the causal directions of these associations are not always clear. By contrast, negative sexual experience is bad for us. The physical and psychological pain that results from acts of non-consensual sex, the effects on self-esteem of exploitative sex, and the effects on mental health of sexual dysfunction are considerable. Sexual violence is linked to a raft of negative health outcomes that can last a lifetime. The link between sexual satisfaction and the stability of relationships is well documented,24Sprecher S Cate RM Sexual satisfaction and sexual expression as predictors of relationship satisfaction and stability.in: Harvey JH Wenzel A Sprecher S The handbook of sexuality in close relationships. Lawrence Erlbaum Associates, Mahwah, NJ2004: 235-256Google Scholar, 25Yeh H-C Lorenz FO Wickrama KAS Conger RD Elder J Glen H Relationships among sexual satisfaction, marital quality, and marital instability at midlife.J Fam Psychol. 2006; 20: 339-343Crossref PubMed Scopus (235) Google Scholar and has health and social consequences—the implications of divorce and separation are of profound public health significance. A life course approach is another important part of a broader perspective on sexual health. A narrow conceptualisation of sexual health excludes the sexual health needs of large subgroups of the population. The sexual health of young people is under constant scrutiny, but the emphasis is usually on preventing unintended pregnancy and STIs. Yet the research reported in Natsal-36Macdowall W Gibson LJ Tanton C et al.Lifetime prevalence, associated factors, and circumstances of non-volitional sex in women and men in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3).Lancet. 2013; (published online Nov 26.)http://dx.doi.org/10.1016/S0140-6736(13)62300-4Google Scholar and elsewhere shows that unwanted sex is most likely to occur at an early age, and that sexual problems are not exclusive to older people, but affect young people too.4Mitchell KR Mercer CH Ploubidis GB et al.Sexual function in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3).Lancet. 2013; (published online Nov 26.)http://dx.doi.org/10.1016/S0140-6736(13)62366-1Google Scholar The sexual expression of older people has, until recently, been a neglected issue. The incidence of STIs and adverse reproductive health events is lower in older people than in younger people. Although the advent of pharmacological treatments has stimulated research in this area, its predominantly biomedical perspective has perpetuated the view that sex is problematic in later life. Sexual activity in later life is also neglected in the policy arena. Sexual health is not included in policy documents concerned with the health of older people,26Department of HealthUK National Service Framework for Older People. Department of Health, London2001Google Scholar, 27US National Institute of AgingNational Institutes of HealthUS Department of Health and Human ServicesLiving long and well in the 21st century: strategic directions for research on aging. US Department of Health and Human Services, Washington, DC2007Google Scholar whilst older people are paid scant attention in policy relating to sexual health.28WHODeveloping sexual health programmes: a framework for action. World Health Organization, Geneva2010Google Scholar, 29Department of HealthNational sexual health and HIV strategy. Department of Health, London2001Google Scholar As men and women live longer, new stages of the later life course are emerging when sexual activity beyond the reproductive years remains important, and valued. Additionally, chronic health conditions and treatments for them might affect both sexual activity and satisfaction in older people, but this is seldom addressed in public or clinical discourse. Why is there such resistance to a broader approach to sexual health? One reason could be that a focus on adverse biomedical outcomes is more comfortable for practitioners and less controversial for policy makers. Clinicians and researchers alike find it easier to ask about matters that relate to safer sex than to raise sensitive issues of pleasure, power, and exploitation. The same is true of those who provide sex education. Pleasure rarely features in sex education curricula,30Ingham R “We didn't cover that at school”: education against pleasure or education for pleasure?.Sex Educ Sexual Soc Learning. 2005; 5: 375-388Crossref Scopus (140) Google Scholar and when it has, it has provoked outrage or derision.31AnonWarning: teenagers may view non-coital sex as a safe option.Contracept Technol Update. 2005; 26: 4Google Scholar Teaching young people how to achieve sexual enjoyment is unacceptable in most cultures. Instead, curricula typically focus on reproductive maturation and conception. Locating sex within the context of procreation might be easier to deal with, but sexual activity is not primarily, or even necessarily, about reproduction. Sex is more often recreational and communicational than procreational, and is increasingly recognised as such. In a growing number of contexts globally, the separation of sexual activity from reproduction is well under way as contraception, abortion, and assisted reproduction have weakened the natural link. Sexual behaviours that are not essential to conception have become easier to discuss and have gained greater acceptance; they include masturbation, oral and anal sex, same-sex practices, and sex in groups among whom reproduction may not be possible or might have conventionally been deemed inappropriate. In many cultural contexts, what was once seen as deviance or perversion is increasingly referred to as diversity. Public health research and practice has to adapt to these changes. Building sexual lifestyles and the quality of sexual experience and relationships into the overall framework of human wellbeing across the life course is an essential first step. Without this framework a vicious cycle is set up such that data on the interactions between sexual experience and health and wellbeing are not available to inform and guide policy agendas, and without the demand for data dictated by policy, research on the broader aspects of sexuality is neither commissioned nor undertaken. Sexual violence, pleasure, and satisfaction should be routinely incorporated in sexual health datasets, as both explanatory variables and outcomes in studies of sexual behaviour, and as endpoints in trials of the effectiveness of sexual health interventions. The HIV/AIDS epidemic was pivotal in stimulating and legitimising research into sexual health, but also constrained its scope to quantification of key drivers of transmission. The 21st century has begun with a new set of public health challenges. Sex has been described as the new lifestyle discovery, and new forces are shaping sexuality. The ubiquity of the internet as a source of sexual contacts and communication, the growth of sex tourism, and increased access to pornography are setting new expectations of sexual conduct. Moreover, media representations of sexual expression are helping to create new and sometimes unhelpful norms. An important, but generally unrecognised, function of sexual behaviour research is to correct myths and misinformation, and to counter unhelpful and unrealistic expectations by revealing normative ranges of behaviour. Inevitably, even in the 6 years since preparations for Natsal-3 began, new influences on sexuality have emerged that will to be addressed the Natsal is undertaken. 25 years on from the first Natsal we have a long way from the that the first to a in which sexual lifestyles are increasingly recognised as a and focus of public health policy, and that has of has been a of the since health, and an this the of the UK of Public Health, made the that have on to that the age of for sex be reduced to and for a public about the issue. the and But it was to they were because of what to about the age of or because of to in a public about sexual behaviour. 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