Anal heterosex among young people and implications for health promotion: a qualitative study in the UK

"What Is Normal?": A Qualitative Exploration of Health Practitioners' Reports of Treating Patients Presenting with Unpleasant Sexual Experiences

Sexual health, including sexual pleasure, is fundamental to holistic health and well-being, and is considered an area of priority health in Australia. Despite the importance of sexual functioning, women experience significant gaps in sexual well-being compared to men and often do not seek medical care or treatment. Health practitioners are central to the identification and treatment of sexual dysfunction, including fostering sexual well-being for patients. Despite this, minimal research has explored health practitioners' experiences in treating reports of unpleasant sex. This study aimed to explore health practitioners' experiences, responses, and confidence in treating patients presenting for unpleasant sexual experiences. An online, mixed-methods survey was completed by 96 participants. Thematic analysis identified 11 core themes. These themes included five patient centred themes (health risks, diverse sex acts, painful vaginal intercourse, relationship breakdown and violence, unwanted sex) and six health practitioner centred themes (communication and counselling, what is normal, ongoing care and follow up, emotional response, limited practical training, and highly prevalent). Participants described a complex sexual health landscape, with social contexts impacting women's sexual experiences and engagement in treatment. Additionally, health practitioners reported the need for a biopsychosocial approach to understanding and responding to unpleasant sexual experiences for patients, while simultaneously reporting limited education in this area. Findings reflect the need for health practitioners to be cognisant of matters related to sexual function, consent, coercion, client engagement, and treatment pathways, identifying a need for greater education and holistic approaches to sexual healthcare across medical settings.

Pornography exposure and access among young Australians: a cross-sectional study

OBJECTIVE

This article aims to explore the extent and nature of Australian young people's pornography exposure and access.

METHODS

Cross-sectional online survey of 1,985 young Australians aged 15-20 years, nationally representative of a range of demographics.

RESULTS

Exposure to pornography was reported by 86% of male and 69% of female participants. Most exposure occurred when participants were alone and at home, regardless of gender. Young men were more likely than young women to seek pornography out and to view it frequently, with over half (54%) of male participants reporting weekly use compared with 14% of female participants. On average, boys and young men saw pornography 3.2 years before their first partnered sexual experience, and girls and young women saw it 2.0 years before theirs.

CONCLUSIONS

It is common for young people to see pornography years before their first partnered sexual experience.

IMPLICATIONS FOR PUBLIC HEALTH

Unintentional and deliberate exposure to pornography is common and frequent among young people. Public health strategies among young people are necessary to address the potential harms associated with pornography use, including gender-based violence and risky sexual practices.

Sexual Behaviors as a Mediator Between Pornography Use and Heterosexual Relationship Outcomes

This study seeks to build on previous research about how pornography use is associated with relationship outcomes. Using the 3AM model (Wright, 2011) as a theoretical guide, sexual behaviors were tested as a possible mediator of the association between pornography use and relationship well-being. Using a national data set of individuals in heterosexual relationships (n = 2519), associations between different types of pornography use (alone use vs. joint use), sexual behaviors, and relationship outcomes were analyzed. Results showed that pornography use with a partner is a distinct activity when compared to pornography use alone. Additionally, significant indirect relationships between pornography use and relationship outcomes were found through sexual behaviors. Both vaginal sex and oral sex had positive effects, while anal sex had a unique, negative effect (use of sex toys was not significantly related). Future research should continue to examine the context of pornography use and how it is related to behaviors and outcomes in relationships.

A Systematic Review Looking at Anodyspareunia Among Cisgender Men and Women

This systematic review aims to provide an up-to-date evaluation of the available literature on anodyspareunia and treatment interventions. It aims to identify research gaps and to evaluate treatment methods in psychosexual healthcare services. Electronic searches including PubMed, PsycINFO, Web of Science, and registered clinical trials yielded 8 studies. Research centered on men who have sex with men (MSM) and cisgender women with a 3:1 ratio. In terms of causes of anodyspareunia, correlates among both MSM and cisgender women included generalized anxiety, performance anxiety, compromised well-being, lack of stimulation, lack of lubrication, and lack of sexual arousal. While research has focused on anodyspareunia among cisgender gay men, limited research has targeted other genders or sexualities including heterosexual men and lesbian and bisexual women. No research was found on intersex, transgender, and gender nonconforming people. Similarly, there were no articles that discussed or evaluated treatment strategies. The findings of this review demonstrate the paucity of research on both the condition of anodyspareunia and its treatment across genders and sexually diverse groups. Both quantitative and qualitative research would not only develop our understanding of anodyspareunia but also contribute to public health through the development of suitable treatment interventions.

A qualitative exploration of perceptions of anal sex: implications for sex education and sexual health services in England

Existing research into anal sex has centred on androcentric, medicalised parameters that focus on risk and health implications, leading to a lack of focus on women's experiences. Research that has focused on women's experiences has centred on concern around young women's anal sex practices, with little exploration of why people participate in anal sex and neglect of its relational and pleasure-based dimensions. The present study sought to explore these concerns via data gathered using focus groups and individual interviews with a range of individuals including sexual health practitioners and young people. Data were thematically coded, with results centred on three themes: anal sex as deviance, anal sex as phallocentric, and anal sex as agentic. Results suggest a pattern of perceptions and narratives that has potential to undermine honest education, advice-giving and safer sex if they are not addressed and questioned in safe spaces, prior to work with young people. The implications of these findings for sexual health education are discussed.

"You Feel Like Normal Sex is not Enough Anymore": Women's Experiences of Coercive and Unwanted Anal Sex with Men

In this article, we explore the gendered dynamics of coercion described by 18 women we interviewed about their experiences of unwanted and nonconsensual heterosexual anal sex. Several women referred to what they believed to be the normative status of heterosexual anal sex. In many cases, the socially coercive effects of perceived norms intertwined with threads of interpersonal coercion, leaving women feeling pressured to agree to, or little room to refuse, anal sex they did not want. We discuss the ways that new sexual norms can translate into new pressures for women within the gendered framework of heterosexual relationships.

Representations of heterosexual anal sex in Cosmopolitan magazine

Anal sex has been the object of unprecedented recent media visibility; however, media discourses of anal sex are still largely unstudied. This study explores the representations of anal sex in Cosmopolitan, available online on the magazine's website. Anal sex, mostly equated with heterosexual anal intercourse, is presented as trendy and popular, as well as potentially pleasurable and intimate. The articles pervasively characterise anal sex as a sexual activity that demands preparation, providing women with tips and techniques allegedly indispensable for a safe and pleasurable (or at least painless) practice of anal sex. The discourses offered are deeply gendered, however, picturing anal sex as a male obsession, and sometimes an expression of power and male conquest. Women's own experiences are portrayed in a more nuanced and heterogeneous way, combining narratives of pleasure and pain, personal initiative and coercion. Although women's individual right to refuse anal sex is often stressed, male pressure is naturalised, and certain dimensions of constraint in heterosexual interaction are normalised.

Intimate Partner Sexual Violence Among Canadian University Students: Incidence, Context, and Perpetrators' Perceptions

Men's sexual violence against women is pervasive and is commonly committed against young women by intimate partners. Limited research has examined occurrence rates of intimate partner sexual violence among university students separated by various tactics and sexual acts. Using surveys with convenience samples of 142 Canadian university women and 441 Canadian university men, we examined women's self-reported intimate partner sexual violence victimization and men's self-reported perpetration rates in their most recent heterosexual intimate relationship in the past year. We examined a detailed breakdown across different tactics (i.e., verbal coercion, intoxication, and threats of harm/physical force) and sexual acts (i.e., nonpenetrative sexual contact; oral, vaginal, and anal penetration). Thirty-three percent of women reported at least one victimization experience, and 16% of men reported at least one perpetration experience. The most common tactic reported was verbal coercion for both women's victimization and men's perpetration, and the most common sexual act reported was vaginal penetration for women's victimization and oral sex for men's perpetration. We also examined contextual features and perceptions of the effects of perpetrators' most memorable incidents. These most memorable incidents often occurred either in their own or their partner's home and involved alcohol consumption. Most men reported no significant effects of their sexual violence on their relationships and sometimes normalized their behavior. We briefly discuss the implications of our results for future research and interventions.

A peer-led intervention to promote sexual health in secondary schools: the STASH feasibility study

Background

Young people report higher levels of unsafe sex and have higher rates of sexually transmitted infections than any other age group. Schools are well placed to facilitate early intervention, but more effective approaches are required. Peer-led approaches can augment school-based education, but often fail to capitalise on mechanisms of social influence. The potential of using social media in sexual health has not been tested in school settings.

Objectives

Finalise the design of the Sexually Transmitted infections And Sexual Health (STASH) intervention; assess the recruitment and retention of peer supporters, and acceptability to participants and stakeholders; assess the fidelity and reach, in addition to the barriers to and facilitators of, implementation; refine programme theory; understand the potential of social media; determine design parameters for a future randomised controlled trial, including economic evaluation; and establish whether or not progression criteria were met.

Design

This was a feasibility study comprising intervention development and refinement of the STASH pilot and non-randomised feasibility trial in six schools. Control data were provided by students in the year above the intervention group.

Setting

Secondary schools in Scotland.

Participants

Students aged 14–16 years, teachers and intervention delivery partners.

Interventions

The STASH intervention was adapted from A Stop Smoking In Schools Trial (ASSIST) (an effective peer-led smoking intervention). Based on diffusion of innovation theory, the STASH study involves peer nomination to identify the most influential students, with the aim of recruiting and training 15% of the year group as peer supporters. The peer supporters deliver sexual health messages to friends in their year group via conversations and use of Facebook (www.facebook.com; Facebook, Inc., Menlo Park, CA, USA) to share varied content from a curated set of web-based resources. Peer supporters are given support themselves via follow-up sessions and via trainer membership of Facebook groups.

Main outcome measures

The primary outcome was whether or not progression criteria were met in relation to intervention acceptability and feasibility. The study also piloted indicative primary outcomes for a full-scale evaluation.

Data sources

Peer supporter questionnaire; observations of activities; interviews with trainers, teachers, peer supporters and students; monitoring log of peer supporter activities (including on Facebook and meeting attendance); questionnaire to control year group (baseline characteristics, social networks, mediators and sexual health outcomes); baseline and follow-up questionnaire (approximately 6 months later) for intervention year group.

Results

A total of 104 students were trained as peer supporters (just over half of those nominated for the role by their peers). Role retention was very high (97%). Of 611 students completing the follow-up questionnaire, 58% reported exposure to STASH study activities. Intervention acceptability was high among students and stakeholders. Activities were delivered with good fidelity. The peer supporters were active, representative of their year group and well connected within their social network. Carefully managed social media use by peer supporters augmented conversations. A primary outcome of ‘always safer sex’ was identified, measured as no sex or always condom use for vaginal or anal sex in the last 6 months. The intervention cost £42 per student. Six progression criteria were met. A seventh criterion (regarding uptake of role by peer supporters) was not.

Limitations

Small feasibility study that cannot comment on effectiveness.

Conclusions

The STASH intervention is feasible and acceptable within the context of Scottish secondary schools. The results support continuation to a full-scale evaluation.

Future work

Small-scale improvements to the intervention, refinement to programme theory and funding sought for full-scale evaluation.

Trial registration

Current Controlled Trials ISRCTN97369178.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 8, No. 15. See the NIHR Journals Library website for further project information.

Receptive anal sex contributes substantially to heterosexually acquired HIV infections among at-risk women in twenty US cities: Results from a modelling analysis

PROBLEM

Receptive anal intercourse (RAI) is more efficient than receptive vaginal intercourse (RVI) at transmitting HIV, but its contribution to heterosexually acquired HIV infections among at-risk women in the USA is unclear.

METHOD OF STUDY

We analysed sexual behaviour data from surveys of 9152 low-income heterosexual women living in 20 cities with high rates of HIV conducted in 2010 and 2013 as part of US National HIV Behavioral Surveillance. We estimated RAI prevalence (past-year RAI) and RAI fraction (fraction of all sex acts (RVI and RAI) at the last sexual episode that were RAI among those reporting past-year RAI) overall and by key demographic characteristics. These results and HIV incidence were used to calibrate a risk equation model to estimate the population attributable fraction of new HIV infections due to RAI (PAF_RAI ) accounting for uncertainty in parameter assumptions.

RESULTS

Receptive anal intercourse prevalence (overall: 32%, city range: 19%-60%) and RAI fraction (overall: 27%, city range: 18%-34%) were high overall and across cities, and positively associated with exchange sex. RAI accounted for an estimated 41% (uncertainty range: 18%-55%) of new infections overall (city range: 21%-57%). Variability in PAF_RAI estimates was most influenced by uncertainty in the estimate of the per-act increased risk of RAI relative to RVI and the number of sex acts.

CONCLUSION

Receptive anal intercourse may contribute disproportionately to new heterosexually acquired HIV infections among at-risk low-income women in the USA, meaning that tools to prevent HIV transmission during RAI are warranted. The number of RVI and RAI acts should also be collected to monitor heterosexually acquired HIV infections.

A qualitative study of heterosexual men's attitudes toward and practices of receiving anal stimulation

This study examines the practice of and attitudes toward anal sexual stimulation among 30 heterosexual undergraduate men attending a UK university. While scientific and popular belief throughout the twentieth century has considered anal pleasure to be only for gay or gender non-conforming men, we find participants discuss such pleasure openly, and some have explored physically receiving anal pleasure. Participants did not stigmatise sexual pleasure derived from anal play, challenging cultural narratives that conflate anal receptivity with being gay. We document how ignorance around the best practices for anal sex may impede pleasure and the further exploration of sexual pleasure and highlight areas where sexual health and education interventions may be beneficial.

Sexual Behaviors and Violence in Pornography: Systematic Review and Narrative Synthesis of Video Content Analyses

Background

Owing to increasing access to Web-based pornography and concerns about its impact on viewers, many researchers have attempted to systematically analyze the content of pornography.

Objective

We aimed to systematically review the results of quantitative content analyses of video-based pornography and identify the degree to which the following behaviors are depicted: (1) sexual behaviors and themes, (2) condom use during sexual behaviors, and (3) aggression and violence.

Methods

Inclusion criteria for article eligibility were (1) peer-reviewed publications, (2) articles in the English language, (3) articles describing a quantitative content analysis of video pornography, and (4) articles quantitatively examining at least one variable of interest.

Results

A total of 23 studies met the eligibility criteria. Studies varied in scope and definitions of behavioral variables. Condom use was rare, although more commonly depicted in gay male pornography (36%-64% videos) compared with heterosexual pornography (2%-3% videos). Normative sexual behaviors were most frequently depicted in pornography samples (eg, vaginal intercourse in 48%-90% and fellatio in 52%-90% of heterosexual videos; fellatio in 66%-100% and anal intercourse in 70%-80% of gay male videos). Extreme acts of violence (1%-3% videos) and rape (0%-6% videos) were relatively rare. However, more subtle forms of aggression, such as spanking (5%-75% videos), were more common, and unequal sexual relations (eg, domination) were also common. Although estimates varied by study, dominating and violent behaviors were nearly always directed toward women.

Conclusions

Condom nonuse and gender inequalities are common in pornography, which has implications for the development of healthy sexual relationships among pornography viewers. Higher quality research, including study replication and consistent methodological choices, is needed.

Effects of Pornography Use and Demographic Parameters on Sexual Response during Masturbation and Partnered Sex in Women

The effect of pornography on sexual response is understudied, particularly among women. A multinational, community-based sample of 2433 women at least 18 years of age completed a 42-item, opt-in questionnaire collecting information on demographic and sexual history characteristics, use of pornography during masturbation, frequency of pornography use, and sexual response parameters. Pornography use and average frequency were compared across demographic variables. We also examined how pornography frequency predicted differences in self-reported arousal difficulty; orgasmic difficulty, latency, and pleasure; and the percent of sexual activities ending in orgasm during both masturbation and partnered sex. On average, women using pornography were younger, and reported more interest in sex. Pornography frequency differed significantly by menopausal status, sexual orientation, anxiety/depression status, number of sexual partners, and origin of data collection. During masturbation, more frequent pornography use predicted lower arousal difficulty and orgasmic difficulty, greater pleasure, and a higher percentage of masturbatory events leading to orgasm. Frequency of pornography use predicted only lower arousal difficulty and longer orgasmic latencies during partnered sex, having no effect on the other outcome variables. Pornography use frequency did not predict overall relationship satisfaction or sexual relationship satisfaction. Overall, more frequent pornography use was generally associated with more favorable sexual response outcomes during masturbation, while not affecting most partnered sex parameters. Several demographic and relationship covariates appear to more consistently and strongly predict orgasmic problems during partnered sexual activity than pornography use.

I (Dis)Like it Like That: Gender, Pornography, and Liking Sex

Rates of pornography consumption in the U.S. are high and increasing. With exploratory aims, this study addresses the questions: What is the association between pornography consumption and liking of sexual behaviors commonly depicted in pornography, and is enjoyment moderated by gender? Sexual scripts theory suggests that increased pornography consumption is associated with increased engagement in pornographic sex acts, but it does not speak to enjoyment of the acts when engaged. The current study seeks to fill that gap. Based on data collected from a larger sample of 1,883 heterosexual men and women (predominantly, 86.6%, college or university students) in the U.S., and comparing correlations between pornography consumption (frequency of use) and reported enjoyment of a range of sexual behaviors by gender using Fisher's z transformations (α value set at <.0025), analysis revealed that pornography consumption, overall, was not significantly correlated with increased enjoyment of the sexual acts that comprise the pornographic sexual script. However, gender was a significant moderating factor in the enjoyment, specifically, of degrading and/or uncommon acts. Male respondents were significantly more likely to report enjoying these acts than their female counterparts. These findings have possible implications for consumers, educators, and mental health professionals.

Does Stigma Toward Anal Sexuality Impede HIV Prevention Among Men Who Have Sex With Men in the United States? A Structural Equation Modeling Assessment

INTRODUCTION

Men who have sex with men (MSM) are suboptimally engaged in efficacious HIV interventions, due in part to stigma.

AIM

We sought to validate the Anal Health Stigma Model, developed based on theory and prior qualitative data, by testing the magnitude of associations between measures of anal sex stigma and engagement in HIV prevention practices, while adjusting for covariates.

METHODS

We conducted a cross-sectional online survey of 1,263 cisgender MSM living in the United States and analyzed data with structural equation modeling. We tested a direct path from Anal Sex Stigma to Engagement in HIV Prevention alongside 2 indirect paths, 1 through Anal Sex Concerns and another through Comfort Discussing Anal Sexuality with Health Workers. The model adjusted for Social Support, Everyday Discrimination, and Sociodemographics.

MAIN OUTCOME MEASURE

Engagement in HIV Prevention comprised an ad hoc measure of (i) lifetime exposure to a behavioral intervention, (ii) current adherence to biomedical intervention, and (iii) consistent use of a prevention strategy during recent penile-anal intercourse.

RESULTS

In the final model, anal sex stigma was associated with less engagement (β = -0.22, P < .001), mediated by participants' comfort talking about anal sex practices with health workers (β = -0.52; β = 0.44; both P < .001), adjusting for covariates (R2 = 67%; χ2/df = 2.98, root mean square error of approximation = 0.040, comparative fit index = 0.99 and Tucker-Lewis index = 0.99). Sex-related concerns partially mediated the association between stigma and comfort (β = 0.55; β = 0.14, both P < .001). Modification indices also supported total effects of social support on increased comfort discussing anal sex (β = 0.35, P < .001) and, to a lesser degree, on decreased sex-related concerns (β = -0.10; P < .001).

CLINICAL IMPLICATIONS

Higher stigma toward anal sexuality is associated with less engagement in HIV prevention, largely due to discomfort discussing anal sex practices with health workers.

STRENGTH & LIMITATIONS

Adjustment for mediation in a cross-sectional design cannot establish temporal causality. Self-report is vulnerable to social desirability and recall bias. Online samples may not represent cisgender MSM in general. However, findings place HIV- and health-related behaviors within a social and relational context and may suggest points for intervention in health-care settings.

CONCLUSION

Providers' willingness to engage in discussion about anal sexuality, for example, by responding to questions related to sexual well-being, may function as social support and thereby bolster comfort and improve engagement in HIV prevention. Kutner BA, Simoni JM, King KM, et al. Does Stigma Toward Anal Sexuality Impede HIV Prevention Among Men Who Have Sex With Men in the United States? A Structural Equation Modeling Assessment. J Sex Med 2020;17:477-490.

Childhood Traumatic Experiences and Receptive Anal Intercourse Among Women

CONTEXT

Receptive anal intercourse (RAI), which has become increasingly common among U.S. heterosexual women, is associated with STDs, including HIV, when it is unprotected and coercive. Childhood traumatic experiences may increase sexual risk behavior, but the relationship between childhood trauma and RAI among women has not been examined.

METHODS

Data from 4,876 female participants in Waves 1 (1994-1995), 3 (2001-2002) and 4 (2007-2008) of the National Longitudinal Study of Adolescent to Adult Health were used to examine associations between nine self-reported childhood traumas (neglect; emotional, physical and sexual abuse; parental binge drinking and incarceration; and witnessing, being threatened with and experiencing violence) and RAI during adulthood using modified Poisson regression analysis. Whether depression, low self-esteem, drug use, relationship characteristics or sex trade involvement mediated the relationship between trauma and RAI was also explored.

RESULTS

Forty percent of the sample reported having engaged in receptive anal intercourse. After adjustment for sociodemographic characteristics, eight of the nine childhood traumas were associated with increased risk of RAI (adjusted prevalence ratios, 1.2-1.5); the strongest association was with experience of violence. Each unit increase in the number of traumas yielded a 16% increase in RAI prevalence. In mediation analyses, only drug use and relationship factors slightly attenuated the association between childhood trauma and RAI (1.2 for each).

CONCLUSIONS

Women with a history of childhood trauma may be at increased risk of engaging in RAI, highlighting the importance of screening and trauma-informed education in sexual health settings. Pathways linking childhood trauma and RAI among women are complex and warrant further research.

How men and women learn about sex: multi-generational perspectives on insufficient preparedness and prevailing gender norms in Scotland

Attitudes towards sexual health and relationships are learned from a young age, and there is an ongoing need for innovative and comprehensive approaches to sex education that keep pace with rapidly changing contexts of people's lives. We used thematic analysis of data from two qualitative studies in Scotland to explore learning contexts from a multi-generational perspective, as well as the influence of different socio-cultural factors on provision, access to and experience of sex education. The importance, but inadequacy, of school as a source of learning, was a persistent theme over time. Participants' strategies to address perceived gaps in knowledge included experience, conversations, vicarious and online learning. Gender and age differences emerged, with younger participants more likely to go online for information, and prevailing gender norms shaping attitudes and behaviours across both study groups. Participants who identified as gay, lesbian or bisexual described feeling particularly unprepared for sex and relationships due to the narrow, heteronormative content received. Although schools continue to be a common source of information, it appears that they fail to equip young people for their post-school sexual life-course. We recommend the mandatory provision of comprehensive, positive, inclusive and skills-based learning to improve people's chances of forming and building healthy, positive relationships across the lifespan.

Psychosexual history-taking in the 21st century: new terminology, new technology and new risks

Sexual and relationships difficulties are not uncommon among psychiatric patients. A presenting complaint of anxiety or depression may relate to an underlying sexual or relationship difficulty; commonly used psychotropic medications cause sexual side-effects that can have a significant impact quality of life, relationship maintenance and treatment adherence; patients may exhibit unusual or excessive sexual behaviours when acutely unwell, including risky use of apps to meet sexual partners and accessing online pornography in unsafe ways; patients may have used technology such as the internet to harm others or they may be victims of such harm; the internet and social media might even be influencing sexual expression, for example gender identity. Therefore, psychosexual history-taking remains a key competency for psychiatrists. They must also understand the new language used to describe sexuality, sexual behaviours and the use of social media, apps and so on to form relationships. This article outlines the key areas to consider in carrying out a structured psychosexual assessment. It also gives an overview of current sexual terminology, observed influences of the internet on sexuality and sexual behaviour, and its implications for mental health and potential sexual offending.

LEARNING OBJECTIVES

After reading this article you will be able to: •

DECLARATION OF INTEREST

None.

Kissing, Cuddling, and Massage at Most Recent Sexual Event: Findings From a U.S. Nationally Representative Probability Sample

Using data from the 2014 National Survey of Sexual Health and Behavior, a probability survey of Americans aged 14+, we assessed the prevalence and correlates of kissing, cuddling, and massage during 1,493 individuals' most recent sexual event from the past year. Most respondents reported kissing (87%) and cuddling (70%); fewer (23%) reported massage. Each was significantly associated with age, education, and relationship structure. Respondents younger than 30 were significantly more likely to indicate they did not kiss because kissing would have been too intimate with their partner. Only cuddling was significantly associated with event-level emotional intimacy and sexual pleasure.

Does per-act HIV-1 transmission risk through anal sex vary by gender? An updated systematic review and meta-analysis

Quantifying HIV-1 transmission risk per-act of anal intercourse (AI) is important for HIV-1 prevention. We updated previous reviews by searching Medline and Embase to 02/2018. We derived pooled estimates of receptive AI (URAI) and insertive AI (UIAI) risk unprotected by condoms using random-effects models. Subgroup analyses were conducted by gender, study design, and whether antiretroviral treatment (ART) had been introduced by the time of the study. Two new relevant studies were identified, one of which met inclusion criteria, adding three new cohorts and increasing number of individuals/partnerships included from 1869 to 14 277. Four studies, all from high-income countries, were included. Pooled HIV-1 risk was higher for URAI (1.25%, 95% CI 0.55%-2.23%, N = 5, I²  = 87%) than UIAI (0.17%, 95 % CI 0.09%-0.26%, N = 3, I²  = 0%). The sole heterosexual URAI estimate (3.38%, 95% CI 1.85%-4.91%), from a study of 72 women published in a peer-reviewed journal, was significantly higher than the men-who-have-sex-with-men (MSM) pooled estimate (0.75%, 95% CI 0.56%-0.98%, N = 4, P < 0.0001) and higher than the only other heterosexual estimate identified (0.4%, 95% CI 0.08%-2.0%, based on 59 women, excluded for being a pre-2013 abstract). Pooled per-act URAI risk varied by study design (retrospective-partner studies: 2.56%, 95% CI 1.20%-4.42%, N = 2 (one MSM, one heterosexual); prospective studies: 0.71%, 95% CI 0.51%-0.93%, N = 3 MSM, P < 0.0001). URAI risk was lower for studies conducted in the ART era (0.75%, 95% CI 0.52%-1.03%) than pre-ART (1.67%, 95% CI 0.44%-3.67%) but not significantly so (P = 0.537). Prevention messages must emphasize that HIV-1 infectiousness through AI remains high, even in the ART era. Further studies, particularly among heterosexual populations and in resource-limited settings, are required to elucidate whether AI risk differs by gender, region and following population-level ART scale-up.

Heterosexual Practices Among Young People in Britain: Evidence From Three National Surveys of Sexual Attitudes and Lifestyles

PURPOSE

To describe time trends and current patterns in sexual practices with opposite-sex partners among men and women aged 16-24 years in Britain.

METHODS

Complex survey analyses of cross-sectional probability survey data from three British National Surveys of Sexual Attitudes and Lifestyles (Natsal), conducted approximately decennially 1990-2012, involving interviews with 45,199 people in total.

RESULTS

Birth cohort analysis showed a decline in the median age at first sexual experience and first intercourse since the midtwentieth century and a narrowing of the interval between these events. Comparison of data from Natsals 1, 2, and 3 showed increases in the prevalence of ever experience of oral and anal sex among 16- to 24-year-olds, which were more marked among older respondents in this age group between Natsals 1 and 2, and among younger respondents between Natsals 2 and 3. Among the sexually active, vaginal and oral sex remained the most common combination of practices reported in the past year. The proportion reporting a past-year repertoire of vaginal, oral, and anal sex rose from approximately one in 10 in 1990-1991 to approximately one in four men and one in five women in 2010-2012. In the latest survey, heterosexual experience of practices was positively associated with bisexual attraction among women.

CONCLUSIONS

Recent decades have seen an earlier age at initiation of partnered sexual experiences and increased diversity in heterosexual practices among young people. Keeping pace with trends in sexual practices is necessary to safeguard young people's health and to support them in increasing their sexual well-being.

Early sexual experiences of teenage heterosexual males in Australia: a cross-sectional survey

OBJECTIVE

There are limited data on the patterns of early sexual behaviours among Australian teenage heterosexual boys. This study describes the nature and onset of early sexual experiences in this population through a cross-sectional survey.

DESIGN

A cross-sectional survey between 2014 and 2015 SETTING: Major sexual health clinics and community sources across Australia PARTICIPANTS: Heterosexual men aged 17-19 years RESULTS: There were 191 men in the study with a median age of 19.1 years. Median age at first oral sex was 16.4 years (IQR: 15.5-17.7) and 16.9 years (IQR: 16.0-18.0) for first vaginal sex. Most men had engaged in oral sex (89.5%) and vaginal sex (91.6%) in the previous 12 months with 32.6% reporting condom use at last vaginal sex. Of the total lifetime female partners for vaginal sex reported by men as a group (n=1187): 54.3% (n=645) were the same age as the man, 28.3% (n=336) were a year or more younger and 17.4% (n=206) were a year or more older. Prior anal sex with females was reported by 22% with 47% reporting condom use at last anal sex. Median age at first anal sex was 18.2 years (IQR: 17.3-18.8). Anal sex with a female was associated with having five or more lifetime female sexual partners for oral and vaginal sex.

CONCLUSIONS

These data provide insights into the trajectory of sexual behaviours experienced by teenage heterosexual boys following sexual debut, findings which can inform programme promoting sexual health among teenage boys.

What is best practice in sex and relationship education? A synthesis of evidence, including stakeholders' views

OBJECTIVES

Sex and relationship education (SRE) is regarded as vital to improving young people's sexual health, but a third of schools in England lacks good SRE and government guidance is outdated. We aimed to identify what makes SRE programmes effective, acceptable, sustainable and capable of faithful implementation.

DESIGN

This is a synthesis of findings from five research packages that we conducted (practitioner interviews, case study investigation, National Survey of Sexual Attitudes and Lifestyles, review of reviews and qualitative synthesis). We also gained feedback on our research from stakeholder consultations.

SETTINGS

Primary research and stakeholder consultations were conducted in the UK. Secondary research draws on studies worldwide.

RESULTS

Our findings indicate that school-based SRE and school-linked sexual health services can be effective at improving sexual health. We found professional consensus that good programmes start in primary school. Professionals and young people agreed that good programmes are age-appropriate, interactive and take place in a safe environment. Some young women reported preferring single-sex classes, but young men appeared to want mixed classes. Young people and professionals agreed that SRE should take a 'life skills' approach and not focus on abstinence. Young people advocated a 'sex-positive' approach but reported this was lacking. Young people and professionals agreed that SRE should discuss risks, but young people indicated that approaches to risk need revising. Professionals felt teachers should be involved in SRE delivery, but many young people reported disliking having their teachers deliver SRE and we found that key messages could become lost when interpreted by teachers. The divergence between young people and professionals was echoed by stakeholders. We developed criteria for best practice based on the evidence.

CONCLUSIONS

We identified key features of effective and acceptable SRE. Our best practice criteria can be used to evaluate existing programmes, contribute to the development of new programmes and inform consultations around statutory SRE.

The physiology of adolescent sexual behaviour: A systematic review

Objectives: To examine physiological influences of adolescent sexual behaviour, including associated psychosocial factors. Methods: Systematic review. Results: Thirteen studies met the inclusion criteria relating to adolescents, physiology and sexual behaviour. We excluded studies relating to abnormal development. Findings highlighted hormonal and gender differences. Females appear to be more influenced by psychosocial aspects, including the effects of peers, than males. Males may be more inclined to engage in unprotected sex with a greater number of partners. Early maturing adolescents are more likely to be sexually active at an early age. Conclusions: Hormonal, psychosocial context, and sexual preference need to be acknowledged in intervention development. Stage of readiness to receive information may differ according to gender and physiological maturity.

Sexual Function in 16- to 21-Year-Olds in Britain

PURPOSE

Concern about young people's sexuality is focused on the need to prevent harmful outcomes such as sexually transmitted infections and unplanned pregnancy. Although the benefit of a broader perspective is recognized, data on other aspects of sexuality, particularly sexual function, are scant. We sought to address this gap by measuring the population prevalence of sexual function problems, help seeking, and avoidance of sex in young people.

METHODS

A cross-sectional stratified probability sample survey (Natsal-3) of 15,162 women and men in Britain (response rate: 57.7%), using computer-assisted self-interviews. Data come from 1875 (71.9%) sexually active, and 517 sexually inactive (18.7%), participants aged 16-21 years. Measures were single items from a validated measure of sexual function (the Natsal-SF).

RESULTS

Among sexually active 16- to 21-year-old participants, 9.1% of men and 13.4% of women reported a distressing sexual problem lasting 3 months or more in the last year. Most common among men was reaching a climax too quickly (4.5%), and among women was difficulty in reaching climax (6.3%). Just over a third (35.5%) of men and 42.3% of women reporting a problem had sought help, but rarely from professional sources. Among those who had not had sex in the last year, just >10% of young men and women said they had avoided sex because of sexual difficulties.

CONCLUSIONS

Distressing sexual function problems are reported by a sizeable minority of sexually active young people. Education is required, and counseling should be available, to prevent lack of knowledge, anxiety, and shame progressing into lifelong sexual difficulties.

Adult Pornography and Violence Against Women in the Heartland: Results From a Rural Southeast Ohio Study

Many rural parts of the United States are now "pornified." There is growing quantitative evidence revealing that rural women are at higher risk of being victimized by intimate violence than their urban and suburban counterparts. In-depth interviews with 55 rural southeast Ohio women who wanted to leave, were trying to leave, or were in the process of leaving, or who have left their male marital/cohabiting partners reveal that pornography is a major component of the problem of rural woman abuse. The main objective of this article is twofold: (a) to present the results of our qualitative study, and (b) to suggest future directions in theoretical and empirical work.

Adolescents and Pornography: A Review of 20 Years of Research

The goal of this review was to systematize empirical research that was published in peer-reviewed English-language journals between 1995 and 2015 on the prevalence, predictors, and implications of adolescents' use of pornography. This research showed that adolescents use pornography, but prevalence rates varied greatly. Adolescents who used pornography more frequently were male, at a more advanced pubertal stage, sensation seekers, and had weak or troubled family relations. Pornography use was associated with more permissive sexual attitudes and tended to be linked with stronger gender-stereotypical sexual beliefs. It also seemed to be related to the occurrence of sexual intercourse, greater experience with casual sex behavior, and more sexual aggression, both in terms of perpetration and victimization. The findings of this review need to be seen against the background of various methodological and theoretical shortcomings, as well as several biases in the literature, which currently precludes internally valid causal conclusions about effects of pornography on adolescents.

Condoms, Lubricants and Rectal Cleansing: Practices Associated with Heterosexual Penile-Anal Intercourse Amongst Participants in an HIV Prevention Trial in South Africa, Uganda and Zimbabwe

We investigated condom and lubricant use, rectal cleansing and rectal gel use for penile-anal intercourse (PAI), during in-depth interviews with women from South Africa, Uganda and Zimbabwe who formerly participated in VOICE, a five-arm HIV prevention trial of two antiretroviral tablets and a vaginal gel. Few studies have addressed practices related to PAI among women; existing data from Africa on condom and lubricant use for PAI, as well as preparatory practices of PAI such as rectal cleansing, are limited to men who have sex with men. Women demonstrated a lack of awareness of HIV transmission risks of PAI and none of the participants reported using condom-compatible lubricants for PAI. Participants described a variety of preparatory rectal cleansing practices. Some participants disclosed rectal use of the vaginal study gel. Understanding practices related to PAI in Africa is critical to microbicide development, as these practices are likely to influence the acceptability, feasibility, and use of both vaginal and rectal microbicide products.

Sexual scripting of heterosexual penile-anal intercourse amongst participants in an HIV prevention trial in South Africa, Uganda and Zimbabwe

Sexual risk-taking is influenced by individual, interpersonal and social factors. This paper presents findings from a qualitative follow-up study to a clinical trial evaluating biomedical HIV prevention products among African women, explored participants' perceptions and experiences of heterosexual penile-anal intercourse, as well as the gendered power dynamics and relationship contexts in which this sexual behaviour occurs. In-depth interviews were conducted with 88 women from South Africa, Uganda and Zimbabwe. Findings reveal that despite its social stigmatisation, women engage in penile-anal intercourse for reasons including male pleasure, relationship security, hiding infidelity, menstruation, vaginal infections, money and beliefs that it will prevent HIV transmission. In addition, participants described experiences of non-consensual penile-anal intercourse. We used sexual scripting theory as an analytical framework with which to describe the sociocultural and relationship contexts and gendered power dynamics in which these practices occur. These data on the distinct individual, dyadic and social contexts of heterosexual penile-anal intercourse, and the specific factors that may contribute to women's HIV risk, make a unique contribution to our understanding of heterosexual behaviour in these sub-Saharan countries, thereby helping to inform both current and future HIV prevention efforts for women in the region.

Gender Differences in Factors Associated With Anal Intercourse Among Heterosexual Adolescents in Singapore

Using a cross-sectional survey, we examined the gender differences in prevalence of and factors associated with anal sex among adolescents attending the only public STI clinic in Singapore. Data were collected from 1035 sexually active adolescents aged 14 to 19 and analyzed using Poisson regression. Prevalence of anal intercourse was 28%, with significantly more females (32%) than males (23%) ever engaged in it. On multivariate analysis, the factors associated with anal intercourse for both genders were oral sex and the nonuse of contraception at last sex. For males, anal intercourse was associated with younger age of sexual debut and greater perceived external control. Among females, it was associated with higher rebellious scores and lack of confidence to resist peer pressure to engage in sex. Consistent condom use for anal sex was 22% and 8% for males and females, respectively. STI prevention programs for adolescents should address anal sex, be gender-specific, and take into consideration individual personality characteristics.

Prevalence and Frequency of Heterosexual Anal Intercourse Among Young People: A Systematic Review and Meta-analysis

We aim to assess if heterosexual anal intercourse (AI) is commonly practiced and how frequently it is practiced by young people. We searched PubMed for articles published 1975 to July 2014 reporting data on the proportion of young people (mean age <25) practicing heterosexual AI (AI prevalence) and on number of AI acts (AI frequency). Stratified random-effects meta-analysis and meta-regression were used to produce summary estimates and assess the influence of participant and study characteristics on AI prevalence. Eighty-three and thirteen of the 136 included articles reported data on lifetime AI prevalence and monthly AI frequency, respectively. Estimates were heterogenous. Overall summary estimates of lifetime AI prevalence were 22 % (95 % confidence interval 20-24) among sexually active young people, with no statistically significant differences by gender, continent or age. Prevalence increased significantly with confidentiality of interview method and, among males and in Europe, by survey year. Prevalence did not significantly differ by recall period. An estimated 3-24 % of all reported sex acts were AI. Reported heterosexual AI is common but variable among young people worldwide. To fully understand its impact on STI spread, more and better quality data on frequency of unprotected AI, and trends over time are required.

Factors Associated With Exposure to Violent or Degrading Pornography Among High School Students

The purpose of this study was to analyze pornography exposure in a sample of 702 Italian adolescents (46% males; mean age = 18.2, SD = 0.8). Among male students, 11% were not exposed, 44.5% were exposed to nonviolent material, and 44.5% were exposed to violent/degrading material. Among female students, 60.8% were not exposed, 20.4% were exposed to nonviolent material, and 18.8% were exposed to violent/degrading material. Among males, adjusted odds ratio (AdjOR) of exposure to violent/degrading pornography were higher if using alcohol, having friends who sell/buy sex, and taking sexual pictures. Females who were victims of family violence, attending technical/vocational schools, and taking sexual pictures had higher AdjOR of watching violent pornography; smoking and having friends who sell/buy sex were associated with both nonviolent and violent/degrading exposure. Exposure to violent/degrading pornography is common among adolescents, associated with at-risk behaviors, and, for females, it correlates with a history of victimization. School nurses have a pivotal role in including discussions about pornography in interventions about relationships, sexuality, or violence.

"Without Porn … I Wouldn't Know Half the Things I Know Now": A Qualitative Study of Pornography Use Among a Sample of Urban, Low-Income, Black and Hispanic Youth

Information about the pornography-viewing habits of urban, low-income youth of color in the United States is lacking. This study was designed to answer the following using a sample of 16- to 18-year-old urban-residing, low-income Black or Hispanic youth: (1) What types of pornography do youth report watching; where and for what purpose? (2) Do youth feel that pornography exposure has an impact on their own sexual behaviors? and (3) How do parents react to their pornography use? The following themes emerged from interviews with 23 youth: (1) Youth primarily reported watching pornography that featured one-on-one sexual intercourse but also reported having seen extreme pornography (e.g., public humiliation, incest); (2) youth reported watching pornography on home computers or smartphones, and that pornography was frequently watched in school; (3) youth reported watching for entertainment, for sexual stimulation, instructional purposes, and to alleviate boredom; many copied what they saw in pornography during their own sexual encounters; (4) pressure to make or to imitate pornography was an element of some unhealthy dating relationships; and (5) parents were generally described as unsupportive of youth's use of pornography but underequipped to discuss it. Approximately one-fifth expressed a preference for pornography featuring actors of their same race/ethnicity.