Women's sexual experiences as a side effect of contraception in low- and middle-income countries: evidence from a systematic scoping review

Contraception is essential to preventing unintended pregnancy. While contraceptive use has increased significantly over the past decade, discontinuation and gaps in use remain common. Although women cite side effects as the reason for discontinuing or stopping methods, little is known about the specific ways in which contraception affects women's sexual experiences. This systematic scoping review aimed to understand how contraceptive-induced side effects relating to women's sexual experiences have been measured, classified, and explored in the literature, specifically in low- and middle-income countries (LMICs). Studies were eligible for inclusion if they were peer-reviewed, English-language articles published between 2003 and 2018 that examined women's sexual experiences related to their use of modern contraception, including sexual satisfaction, arousal, sexual dysfunction, discomfort, vaginal dryness, sexual frequency, and relationship or partner dynamics. Study populations were restricted to women of reproductive age in LMICs. Twenty-two studies were deemed eligible for inclusion, comprising a range of methods and geographies. Emergent sexual experience themes included: menstrual issues impacting sexual experience; libido; lubrication; sexual pleasure; dyspareunia; and female sexual function. Results highlight the variability in measures used, lack of a women-centred perspective, and void in research outside of high-income countries to study the influence of contraception on women's sexual experiences. Very few studies focused on women's sexual experiences as the primary outcome or predictor. Providers should adopt woman-centred contraceptive counselling that considers women's relationships. Further research is needed to disentangle the nuanced effects of contraception on women's sex lives, contraceptive decision-making, and method continuation.

Increasing condom use in heterosexual men: development of a theory-based interactive digital intervention

Increasing condom use to prevent sexually transmitted infections is a key public health goal. Interventions are more likely to be effective if they are theory- and evidence-based. The Behaviour Change Wheel (BCW) provides a framework for intervention development. To provide an example of how the BCW was used to develop an intervention to increase condom use in heterosexual men (the MenSS website), the steps of the BCW intervention development process were followed, incorporating evidence from the research literature and views of experts and the target population. Capability (e.g. knowledge) and motivation (e.g. beliefs about pleasure) were identified as important targets of the intervention. We devised ways to address each intervention target, including selecting interactive features and behaviour change techniques. The BCW provides a useful framework for integrating sources of evidence to inform intervention content and deciding which influences on behaviour to target.

Arousability as a predictor of sexual risk behaviours in African-American adolescent women

This study examined the impact of sexual excitation (arousability) on sexual risk-taking behaviours in a community sample of African-American adolescent women. A sample of 701 African-American adolescent women completed measures examining their propensity for sexual arousal, impulsivity and sexual behaviour. Compared with women with a lower propensity for sexual arousability, women with a higher propensity reported a greater number of sexual partners, more inconsistent condom use, a greater likelihood of having engaged in sexual intercourse with 'risky' partners, and sex while high on alcohol or drugs. These results indicate that women who have a greater propensity to become sexually aroused in a variety of situations may be at a greater risk for contracting HIV or sexually transmissible infections relative to women with a lower propensity for arousal. This suggests that individual differences in the propensity to become sexually aroused should be considered when developing intervention approaches targeting young African-American women.

Positive sexuality and its impact on overall well-being

Historically, the issue of sexual health has been largely considered with respect to the associated negative health outcomes. The dangers of sexual activity such as sexually transmitted infections (STIs), HIV/AIDS, unintended pregnancy, sexual coercion, and sexual violence have dominated the attention of those working in the field. Over the last 20 years, and particularly in the last decade, an increasing number of people from a variety disciplines that address issues of sexual health have developed a new discourse concerning the positive aspects of sexuality. This review of the literature explores this emerging discourse. The results indicate that sexual health, physical health, mental health, and overall well-being are all positively associated with sexual satisfaction, sexual self-esteem, and sexual pleasure. The beneficial effects of sexual satisfaction should be integrated into programs that seek to improve these diverse health outcomes through service delivery, prevention, and sexuality education.

Negative perceptions about condom use in a clinic population: comparisons by gender, race and age

We sought to elucidate the associations of 13 items assessing negative perceptions about condom use with gender, age and race in a sample of clinic attendees. Patients from four clinics, in three US cities, were recruited (N = 928). Data were collected using audio-computer-assisted self-interviewing. The primary measure was a 13-item adapted version of the Condom Barriers Scale. Logistic regression and chi-square tests were employed to relate the 13 items to gender, age and race. Gender, race and age all had significant associations with negative perceptions of condoms and their use. A primary finding was a large number of significant differences between men and women, with negative perceptions more common among women than among men. For African Americans, especially women, negative perceptions were more common among older participants than among younger participants. In conclusion, important demographic differences regarding negative perceptions may inform the tailoring of intervention efforts that seek to rectify negative perceptions about condoms and thus promote condom use among individuals at risk for sexually transmitted infections (STIs) in the USA. On the other hand, our findings also suggest that the majority of STI clinic attendees may hold positive perceptions about condoms and their use; maintaining and building upon these positive perceptions via education, counselling, and access is also important.

Condom use in the context of sex research: a commentary

This commentary highlights some recent trends in sex research that have particular relevance for research on condom use, including studies investigating the meaning of sexual arousal, desire and pleasure; a focus on couple-level investigations; and the relevance of individual differences and personality characteristics to sexual risk-taking. Although historically, sexuality-related issues have received little systematic attention in the field of public health, researchers are now paying more attention to the role of pleasure and sexual arousal in condom use. It is argued that a better integration of findings from the area of sex research into the HIV and sexually transmissible infection (STI) field is needed to develop and improve programs to reduce the risk of STIs and unintended pregnancy.

Condom 'turn offs' among adults: an exploratory study

An exploratory study compared the prevalence of multiple types of condom-associated 'turn offs' in men and women. Nearly 2000 people completed a web-based questionnaire. Data were analysed from 464 men and women who reported that condoms had turned them off the last time they were used. Gender differences were not observed for the majority (9) of 15 turn offs. The most common turn offs related to loss of pleasure. For example, more than three-quarters of the men and nearly 40% of the women reported decreased sexual sensation (P = 0.0001). Putting on condoms was reported by 43.2% of the men versus 30.2% of the women (P = 0.02). Smell was a relatively frequent turn off, with about one-third indicating this issue and no significant gender difference (P = 0.32). Turn offs pertaining to arousal and orgasm were also common. Findings suggest that numerous physical and psychological condom turn offs may be experienced by men and women while using male condoms. Although some turn offs differed as a function of gender, there was remarkable similarity between men and women.

Predictors of unprotected sex among young sexually active African American, Hispanic, and White MSM: the importance of ethnicity and culture

Despite the recognized need for culturally tailored HIV prevention interventions for gay, bisexual, and questioning youth, few studies have examined if predictors of unprotected sex vary for youth from different ethnic groups. This study reports on a sample of 189 gay, bisexual, and questioning youth (age 15-22) from three racial/ethnic backgrounds (African American, Hispanic, and White) recruited in Chicago, IL and Miami-Dade and Broward Counties, Florida. For African American youth, being in a long-term relationship, having been kicked out of the home for having sex with men, and younger age at initiation of sexual behavior were associated with unprotected sex. For Hispanic youth, higher ethnic identification and older age at initiation of sexual behavior were associated with unprotected sex. For White youth, no predictors were associated with unprotected sex. Our findings point to the importance of understanding the varying predictors of unprotected sex and integrating them into tailored prevention interventions.

Longitudinal test of a multiple domain model of adolescent condom use

A comprehensive multiple domain model (MDM) to understand condom use in adolescents was proposed and tested using structural equation modeling of data at three time points. The proposed model integrates social psychological theory, demographic and personality factors, social environment, and situational/contextual variables. Adolescents who were sexually active at time 2 (6 months after baseline) and time 3 (1 year after time 2) and completed surveys at all three time points were included in the analyses (N = 511). An iterative process of model testing resulted in a structural equation model that provided a good fit to the data (CFI = .92, RMSEA = .04). Models comparing gender and race as moderators also were calculated and supported the generalizability of the model. Results provide support for an MDM that goes beyond traditional social psychological models for a broader understanding of condom use in adolescents. Implications for further theory testing and safer sexual interventions are discussed.

Eroticizing creates safer sex: a research synthesis

This meta-analytic review examined the effectiveness of sexual risk reduction interventions in 21 studies (N=5,015) that integrated a safer sex eroticization component. Compared to controls, intervention participants exhibited lower sexual risk on 6 dimensions: HIV-related knowledge, attitudes toward condoms, condom use, overall behavioral risk, communication with sexual partners, and sexual frequency. Additional analyses examined pre- to post-test outcomes and showed significant improvement in condom use in the intervention compared to the control groups. Overall, findings suggest that eroticizing safer sex leads to more risk-preventive attitudes, which in turn facilitates less risky sexual behavior.