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This installment of Sex Research Update summarizes recent research on attitudes towards non-marital sex in 24 countries; perceptions of what behaviours constitute "having sex"; the prevalence and predictors of sexual dysfunction in the United States; gender differences in sexual risk behaviour after an STD diagnosis; a community-level HIV intervention in 5 cities; and the effectiveness of abstinence-based sexuality education.

Widmer, E.D., Treas, J., & Newcomb, R. (1998). Attitudes toward nonmarital sex in 24 countries. The Journal of Sex Research, 35, 349-358.

Although all cultures seek to regulate some aspects of sexual behaviour, particularly out of wedlock, they appear to vary in their moral attitudes toward premarital sex, extramarital sex, and homosexuality. It has been difficult to draw definitive conclusions about cultural differences on these issues because there has been little cross-cultural or cross-national research using identical questionnaire items and available studies have often not used nationally representative samples. Widmer, Treas, and Newcomb report on newly available survey findings on extramarital sex, homosexual sex, premarital sex, and teen sex from 24 countries. The nationally representative data were collected in 1994 as part of the International Social Survey Program. The total sample consisted of 33,590 people. Survey respondents were asked four questions about sexual morality: "Do you think it is wrong or not wrong for a man and woman to have sexual relations before marriage?"; "What if they are in their early teens, say under 16 years old?"; "What about a married person having sexual relations with someone other than his or her husband or wife?"; "What about sexual relations between two adults of the same sex?" For each item, respondents were asked to choose either "always wrong", "almost always wrong", "wrong only sometimes", or "not wrong at all".

For the entire sample of 24 countries, 61% of respondents believed that premarital sex is "not wrong at all". Sweden was the most accepting of premarital sex with 89% saying that it was not wrong whereas the Philippines was the least accepting with only 11% saying premarital sex was OK. In Canada, 69% of respondents believed that premarital sex was not wrong at all while only 41% of respondents from the U.S.A. held this view. Overall, 58% of respondents felt that sex before age 16 was always wrong. Northern Ireland was the least accepting of sex before age 16 with 81% saying it was always wrong whereas East Germany was the most accepting with only 27% saying it was wrong. In Canada, 55% felt it was always wrong compared to 71% in the U.S.A. Overall, 66% of respondents said that extramarital sex is always wrong. For this item, the Philippines was least accepting with 88% saying it was always wrong whereas Russia was most accepting with only 36% saying it was wrong. In Canada, 68% felt extramarital sex was always wrong compared to 80% in the U.S.A. Overall, 59% of respondents said that sexual relations between people of the same sex was always wrong. Once again, the Philippines was the least accepting with 84% saying it was always wrong and the Netherlands was the most accepting with only 19% saying it was always wrong. In Canada, 39% said it was always wrong compared to 70% in the U.S.A.

The authors use their findings to place each country into one of six clusters characterizing the countries' moral standards related to sexuality. The authors note that although countries with conservative moral standards toward sexuality tended to have a large proportion of people who are religiously conservative, not all countries with large populations of religious conservatives were conservative with respect to sexual norms (e.g., Italy). The results also indicate that with respect to the issues under investigation formerly communist countries do not have uniform moral standards related to sexuality.

In their concluding comments the authors suggest that:
 Because our analysis focuses on a relatively homogeneous subset of largely
 industrialized and Western nations in an increasingly globalized world, the
 potential for overlap in moral judgements about sex is undoubtedly high. In
 general, these 24 nations take a cautious stance toward all types of
 nonmarital sex except premarital relations among adults (p. 357).

Sanders, S.A., & Reiniseh, J.M. (1999). Would you say you "had sex" if ...? Journal of the American Medical Association, 281, 275-277.

Although the question of what behaviours constitute "having sex" or "sexual relations" has recently been the subject of intense media and public discussion, Sanders and Reinisch point out that "...empirical exploration of what is included in definitions of having 'had sex' for the general public in the United States remains scant" (p. 275). Aside from the current discussion of socio-sexual mores, ambiguity over what defines "having sex" has important ramifications for health professionals and researchers with respect to sexual history taking. For example, misunderstandings about what it means to "have sex" may lead to an inaccurate assessment of an individual's risk of infection with sexually transmitted diseases. It was for this purpose that Sanders and Reinisch conducted their study in 1991.

The sample consisted of 599 undergraduates (mean age = 20.7) at a Midwestern university in the United States. Most participants labelled themselves as moderate to conservative politically and 32% were registered Republicans while 19% were registered Democrats. The survey questionnaire contained 104 items including one that read "Would you say that you 'had sex' with someone if the most intimate behaviour you engaged in was ..." (p. 276). Participants answered this question for 11 different behaviours including deep kissing, oral-breast contact, manual-genital contact, oral-genital contact, penile-vaginal intercourse, and penile-anal intercourse.

Almost all respondents (99.5%) agreed that penile-vaginal intercourse qualified as having "had sex". However, 19% did not consider penile-anal intercourse as having "had sex". "Only 40% indicated that they would say they `had sex' if oral genital contact was the most intimate behaviour in which they engaged (60% would not)" (p. 276). More males (43.9%) than females (37.7%) considered a partner having "oral contact with your genitals" as having "had sex" but this difference was not statistically significant. About the same percentages of males (43.9%) and females (37.3%) believed that "oral contact with other's genitals" constituted having "had sex". Significantly more males (19.2%) than females (12.2%) thought that a "person touches your genitals" qualified as having "had sex". Respondents beliefs about what constitutes "having sex" was, for some behaviours, related to their sexual experience. Those who had engaged in oral-genital contact but had never experienced penile-vaginal intercourse were less likely to consider oral-genital contact as "having sex".

The authors conclude their report by noting that:
 The lack of consensus with respect to what constitutes having "had sex"
 across the sexual behaviours examined herein provides empirical evidence of
 the need for behavioural specificity when collecting data on sexual
 histories and identifying sexual partners (p. 277).

Lauman, E.O., Paik, A., & Rosen, R.C. (1999). Sexual dysfunction in the United States: prevalence and predictors. Journal of the American Medical Association, 281, 537-544.

Sexual dysfunctions are generally defined as "... disturbances in sexual desire and in the psycho-physiological changes associated with the sexual response cycle in men and women" (p. 537). To date, for the United States, researchers have had to rely, almost exclusively, on clinical or community samples in order to estimate the prevalence of sexual dysfunctions in the general population. In addition, population-based data on the psychosocial and physical health predictors of sexual dysfunctions among men and women are lacking (Editors note: To date, no nationally representative surveys of sexual dysfunction have been conducted in Canada).

Lauman, Paik, and Rosen provide and analyze data on sexual dysfunction from the National Health and Social Life Survey of adult sexual behaviour in the United States conducted in 1992. The sample consisted of 1749 women and 1410 men aged 18 to 59 years. Survey respondents were asked if they had experienced any of seven sexual problems in the previous 12 months: lack of sexual desire, arousal difficulties, inability to climax or ejaculate, sexual performance anxiety, climaxing or ejaculating too quickly, physical pain during intercourse, and not finding sex pleasurable. Data on health, demographic, and lifestyle factors potentially associated with sexual dysfunction were also collected.

Overall, 43% of women and 31% of men reported experiencing one or more of these sexual problems in the previous 12 months. For women, 22% experienced problems related to low sexual desire, 14% had difficulties with arousal and 7% had experienced pain during sex. For men, 21% had experienced premature ejaculation, 5% reported erectile dysfunction, and 5% experienced low sexual desire. "For women, the prevalence of sexual problems tends to decrease with increasing age except for those who report trouble lubricating. Increasing age for men is positively associated with experience of erection problems and lacking desire for sex" (p. 544). For both men and women, emotional and stress related problems were associated with an increased risk of sexual dysfunctions. For men, poor health was associated with all categories of sexual dysfunction, whereas, for women, poor health was only associated with sexual pain.

Having had an STD and alcohol consumption were not associated with an increased risk of sexual dysfunction. Normative orientation toward sexuality did not increase the risk of sexual dysfunction except that men with liberal attitudes about sex were more likely to experience premature ejaculation. Falling household income was associated with a modest increase in all categories of sexual dysfunction among women and in erectile dysfunction among men. For both men and women, those who had experienced prior sexual victimization through adult-child contact or forced sexual contact were more likely to have experienced a sexual dysfunction in the previous 12 months. For women, prior sexual victimization was highly associated with sexual arousal disorders and men who had been sexually victimized were three times more likely to have experienced erectile dysfunction.

Married men and women were less likely to experience sexual dysfunction. People with higher levels of education were also less likely to have had sexual dysfunctions. For example, women who had graduated from college were half as likely to have experienced low sexual desire, problems achieving orgasm, sexual pain, and sexual anxiety as women who did not graduate from high school. For women in particular, sexual dysfunctions "... have strong positive associations low feelings of physical and emotional satisfaction and low feelings of happiness" (p. 542). Of those respondents who had experienced sexual dysfunctions in the previous 12 months, only 10% of men and 20% of women had sought a medical consultation for their sexual concerns.

The authors conclude their report by noting that their findings,
 ....indicate that sexual problems are widespread in society and are
 influenced by both health-related and psychosocial factors.... With the
 strong association between sexual dysfunction and impaired quality of life,
 this problem warrants recognition as a significant public health concern
 (p. 544).

Warszawski, J., Meyer, L., & ACSF Investigators. (1998). Gender difference in persistent at-risk sexual behaviour after a diagnosed sexually transmitted disease. Sexually Transmitted Diseases, 25, 437-442.

Research has clearly documented that a self-reported history of STD infection is strongly correlated with past high-risk sexual behaviour. However, very little research has investigated the relationship between a prior history of STD infection and current sexual behaviour. In other words, does being diagnosed with an STD lead people to become more cautious in their subsequent sexual behaviour? To investigate this issue, Warszawski and colleagues used data from the Analyse des Comportements Sexuels en France, a nationally representative telephone survey of 18 to 69 year-old residents of France. From the data, the authors were able to examine the relationship between a history of STD in the four years prior to the last year before the survey among a subsample of heterosexual respondents (n = 2572) and their sexual behaviour in the twelve months prior to the interview. High-risk sexual behaviour was defined as having three or more partners in a year and/or the occurrence of unprotected penetrative sex with new or multiple partners.

As in other studies, the frequency of STD varied with age, educational level, marital status, and, in particular, number of sexual partners. For those with a history of STD infection the patterns of past sexual risk behaviours for men and women were similar. However, the link between a history of STD infection and current sexual risk behaviour was different for men and women. For example, compared with men who did not report a previous STD history, men who had had an STD in the past were 2.8 times more likely to report high risk unprotected sex in the past year. These men were also more likely to report a larger number of sexual partners in the previous year. "The pattern was very different among women. Women who reported an STD and those who did not had similar percentages of each current risk indicator" (p. 439). In contrast to men, for women, a previous STD was significantly associated with reporting behaviour changes. In sum, the authors conclude that "... a history of STD is a marker of current high-risk sexual behaviour among heterosexual men, whereas it may be associated in women with subsequent adoption of STD and HIV risk reduction strategies" (p. 442). In addition, the authors suggest that their findings indicate a need to improve STD prevention counselling for men after they have been diagnosed with an STD.

The CDC AIDS Community Demonstration Projects Research Group. (1999). Community-level HIV intervention in 5 cities: final outcome data from the CDC AIDS community demonstration projects. American Journal of Public Health, 89, 336-345.

Community-level HIV risk reduction interventions seek to change community wide norms and practices in a way that will support individuals efforts to change their HIV risk behaviours. Although community-level HIV risk reduction interventions have had some success in preventing HIV infections, most studies evaluating these programs have focused on behaviour changes among individuals rather than assessing levels of change at the community level.

The CDC research group evaluated the results of a 5-city trial to assess the effects of a community-level intervention for underserved populations at risk for HIV infection. The five cities were Dallas, Denver, Long Beach, New York and Seattle. For the purposes of the study, a community was defined as "... an at-risk population in a specific geographic region" (p. 336) and the populations that the study focused on were active injection drug users, female sex partners of male injection drug users, female commercial sex workers and other women who trade sex for money or drugs, youth in high-risk situations, non-gay-identified men who have sex with men, and residents of census areas where STD rates were high. Each intervention community was matched to a no-intervention comparison community. The intervention consisted of three main components. First, small media materials (e.g., newsletters, pamphlets, baseball cards) containing theory-based prevention messages in the form of role model stories were created. Second, community members were mobilized to distribute and verbally reinforce prevention materials and messages among their peers. Third, the availability of condoms and bleach kits was increased.

The intervention, including its evaluation component, was based on a continuum of 5 behaviour change stages. With respect to condom use, the continuum of five stages was as follows:
 1 = Precontemplation: has little or no intention to always use condoms in
 the future. 2 = Contemplation: does not use condoms but intends to begin
 using them every time in the future. 3 = Preparation: almost always or
 sometimes uses condoms and intends to use condoms every time in the future.
 4 = Action: has used condoms every time for less than 6 months. 5 =
 Maintenance: has used condoms every time for 6 or more months (p. 338).

The role model stories were designed to move people along these stages of the continuum and the evaluation questionnaire assessed, using the 1 to 5 stage scale where people in the communities were at on the continuum before and after the intervention. For condom use a 1 to 5 stage of change score was calculated for each respondent who reported having vaginal sex in the past 30 days with a main or nonmain partner.

Results indicated that 27 months after the intervention had begun, 54% of respondents in the intervention communities reported that they had been exposed to the intervention. Before the intervention began, respondents in the intervention communities had a mean condom use stage of change score of 1.66 for condom use with main partners and 2.76 for condom use with nonmain partners compared to comparison community scores of 1.60 and 2.82 respectively. Thus, preintervention scores indicated that, on average, respondents were at the precontemplation stage for using condoms with main partners and at the contemplation stage for using condoms with nonmain partners. By the final wave of data collection about 3 years after the intervention had begun, the mean condom use stage of change score for the intervention communities had increased to 2.07 for condom use with main partners and 3.18 for condom use with nonmain partners compared to comparison community scores of 1.82 and 2.90 respectively. For condom use with nonmain partners, "The increase in the intervention communities was 5 times that in the comparison communities" (p. 340). In sum, the intervention resulted in mean scores moving from the precontemplation stage to the contemplation stage for condom use with main partners and from the contemplation stage to the preparation stage for condom use with nonmain partners. In their discussion of the findings, the authors note that the increases in the condom use scores
 ... were observed not only among individuals reached directly by the
 intervention but across the study communities as a whole. The ability of
 the intervention to reach and motivate change in these geographically and
 demographically diverse communities suggests the potential usefulness of
 this approach to HIV prevention (p. 341).

Denney, G., Young, M., & Spear, C. E. (1999). An evaluation of the Sex Can Wait abstinence education curriculum series. American Journal of Health Behavior, 23, 134-143.

The authors begin by noting that evaluation research literature assessing the impact of sexuality education programs emphasizing abstinence from sexual activity has not shown that these programs are effective in reducing sexual activity. Nevertheless, they add, over $500 million will be allocated each year, for the next five years, in U.S. federal spending for sexual abstinence education programs. In order to further research the potential effectiveness of abstinence-based sexuality education, the authors conducted an evaluation of the Sex Can Wait curriculum series for upper elementary (grades 5 + 6), middle school (grades 7 + 8), and high school (grades 9 - 12) students.

The study sample consisted of students from 15 different school districts in Arkansas. Students from eight of the school districts were assigned the Sex Can Wait curriculum (n = 1503) and students from the other 7 districts (n = 1104) served as a comparison group. The schools in the comparison group received their regular sexuality education programs. The Sex Can Wait curriculum consisted of 23 lessons at the upper elementary level and 24 lessons at the middle and high school levels delivered over a five week period. Students in both groups filled out questionnaires before the program and again after the program was completed. The upper elementary questionnaire assessed knowledge of information given in the Sex Can Wait curriculum and the degree to which students expressed positive attitudes towards sexual abstinence. The middle and high school questionnaires assessed knowledge of information given in the curriculum, self-esteem, decision-making behaviours, intentions to have sexual intercourse, and participation in sexual intercourse in the previous 30 days.

For the upper elementary students, at posttest, the Sex Can Wait students had higher knowledge and attitudes towards abstinence scores and "The Sex Can Wait group moved slightly, but not significantly, toward greater intent to remain abstinent" (p. 139). For the middle school students, the Sex Can Wait group had significantly higher scores at posttest for knowledge, attitudes, and decision making related to abstinence than did the comparison group. With respect to intentions to have sexual intercourse, both groups were less likely at posttest to say they would be abstinent in the future than they did at the beginning of the program and there were no statistically significant differences between the two groups in this regard. "Additionally, more students in both groups reported participating in sexual intercourse in the last month at posttest than had reported such activity at pretest" (p. 139). The increase in sexual activity was slightly less for the Sex Can Wait group but the difference compared to the comparison group was not statistically significant. For the high school students there were no significant differences between the Sex Can Wait group and the comparison group at posttest on any of the outcome variables. Both groups were less likely to report the intention to remain abstinent at posttest and more students in both groups reported that they had had sexual intercourse in the previous 30 days than at pretest. There were no statistically significant differences between the Sex Can Wait group and the comparison group with respect to middle and high school students participation in sexual intercourse at posttest.
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Article Details
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Title Annotation:Review
Author:McKay, Alexander
Publication:The Canadian Journal of Human Sexuality
Date:Dec 22, 1998

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