Sexual Difficulties, Problems, and Help-Seeking in a National Representative Sample: The Second Australian Study of Health and Relationships.

The Australian Study of Health and Relationships is a large national population-representative survey of sexual behavior and attitudes conducted every decade. We describe experiences of sexual difficulties lasting at least a month among Australians surveyed in 2012-2013 and identify changes since the previous survey in 2001-2002. Computer-assisted telephone interviews were completed by 20,091 people aged 16-69 years (participation rate 66%) of whom 16,897 people had had sex with a partner in the previous year. We asked how long each difficulty lasted, whether it was a problem, and whether they sought treatment. Half (48%) the men and 68% of women reported at least one difficulty. Lack of interest in having sex was common (28% men, 52% women); 21% of men reported coming to orgasm "too quickly" and women reported inability to reach orgasm (25%) and trouble with vaginal dryness (22%). Women were more likely than men not to find sex pleasurable and to have physical pain during intercourse. Some differences by age group were also apparent. Many difficulties were not seen as problems, especially lacking interest and reaching orgasm too quickly. People with erection/dryness problems, or with pain in intercourse, were more likely to seek treatment, as were people with multiple difficulties. Between 2001-2002 and 2012-2013, there was little change for men, but among women rates of all sexual difficulties fell by 4-10 percentage points. This change accompanied a drop in frequency of sex among people in ongoing relationships and an increase in masturbation and use of pornography. One explanation might be that, over time, fewer women were agreeing to "service sex" when they were not in the mood. Overall, the drop in prevalence of women's sexual difficulties since a decade earlier suggests a change towards more egalitarian sexual relations.

Identifying gaps in dual protection from sexually transmissible infections and unintended pregnancies among Australian women: an observational study.

Background Dual protection refers to the simultaneous prevention of sexually transmissible infection (STI) and unintended pregnancies. Optimal contraception and STI prevention strategies sometimes fail to align. Methods Using data from a large nationally representative population-based survey, we analysed the contraception and STI prevention behaviours at the last vaginal intercourse among 2420 heterosexually active women aged 16-34years who had participated in the Second Australian Study of Health and Relationships, 2012-13. Results At their last vaginal intercourse, most women (95%) used contraception and half (49%) used condoms, either as a sole multipurpose method or in conjunction with another type of contraception. Condom use was highest (72%) among women whose most recent partner was a casual or occasional partner, followed by women with a regular partner (59%) and women with a cohabiting regular partner (40%). One-third of the women (34%) used condoms as a sole method, and 14% used oral contraceptives together with a condom. Few women used implants or intrauterine devices (8%) and, among them, very few women also used condoms (<1%). Among the women who used a condom at their last vaginal intercourse, 49% reported both the correct use for STI prevention and consistent condom use during the previous 6months. Among women using condoms, correct and consistent use was also highest among women whose most recent partner was a casual or occasional partner (76%). Conclusions Although almost all women used contraception and half used dual protection, few benefited from the protective effects of using condoms together with highly effective contraception.

Reproductive experiences and outcomes among a representative sample of women: the Second Australian Study of Health and Relationships.

OBJECTIVE: To enumerate pregnancy outcomes for a representative sample of women in Australia surveyed in 2012-2013 (primary aim) and compare these with women surveyed in 2001-2002 (secondary aim). METHODS: Computer-assisted telephone interviews with over 10,000 women aged 16-69 years (participation rate 68.4%). Results are weighted for chance of selection and to reflect the population as a whole. RESULTS: Of women with experience of vaginal intercourse, 75.1% had ever been pregnant, 18.4% reported difficulties getting pregnant and 10.0% had had fertility treatment. Of those who had been pregnant, 91.3% had ever had a live birth, 34.3% a miscarriage, 22.8% an abortion and 2.3% a stillbirth; 0.9% had relinquished a child for adoption. The proportion first pregnant in their 30s was 11% among women aged 60-69 and 26% among those aged 40-49. Fewer older women reported difficulties getting pregnant. Of the 21,882 pregnancies reported, 70% led to live births and 10% were terminated. Compared with our 2001-2002 survey, fewer women reported ever having been pregnant. Giving up newborns for adoption has become very rare. CONCLUSIONS: Falling fertility since the 1960s reflects greater access to contraception and abortion and higher opportunity costs of childbearing. Implications for public health: These findings on women's lifetime reproductive experiences complement routine annual data collections.

Unwanted Sex Due to Intoxication among Australians Aged 16-69 Years.

Intoxication can be a factor in unwanted sex, but research on the extent of the issue in both women and men is limited. We assessed the prevalence, correlates, and 10-year time-trends of unwanted sex due to intoxication among a representative sample of 4,279 women and 3,875 men aged 16-69 years in Australia and considered how these vary by gender. In 2012-13, 16% of women and 10% of men reported ever having had a sexual experience when they "did not want to because they were too drunk or high at the time." For both women and men, this was associated with younger age, bisexual activity, and reports of lifetime injection drug use, sexually transmitted infections, and forced sex. Among women only, it was associated with drinking above guideline levels and ever having terminated a pregnancy. Among men only, it was associated with current tobacco smoking, elevated psychosocial distress, and poor general health. Compared with 2001-02 data, fewer men reported unwanted intoxicated sex, while there were no changes for women as a whole. Interpreting these findings through an intersectional assemblage framework supports stronger understanding of the multiple factors influencing sexuality and substance use with implications for promoting equity, safety, and sexual health.

Romantic Jealousy: A Test of Social Cognitive and Evolutionary Models in A Population-Representative Sample of Adults.

Whereas sexually dimorphic evolutionary models argue for clear sex differences in responses to jealousy-evoking scenarios, social cognitive models emphasize the importance of other factors. This paper explores variables associated with responses to a commonly-used jealousy-evoking scenario in a population-representative sample. Data from 8,386 Australian men and women aged 16-69 were weighted to match the population. The results provided some support for evolutionary models among heterosexual respondents, but findings contrary to evolutionary models were found among non-heterosexual respondents. Support for social cognitive models was provided by the identification of six variables that had significant independent multivariate associations with jealousy: sex, age, education, lifetime number of partners, relationship status, and attitudes toward infidelity. The results suggest that although men and women may tend to respond differently to sexual or emotional infidelity scenarios, the anticipated experience of jealousy in each context is strongly influenced by biographical and cultural factors.

The Impact of Externally Worn Diabetes Technology on Sexual Behavior and Activity, Body Image, and Anxiety in Type 1 Diabetes.

BACKGROUND: We aimed to explore the impact of externally worn diabetes technologies on sexual behavior and activity, body image, and anxiety in adopters and nonadopters of these devices. METHODS: People with type 1 diabetes aged 16-60 years living in Western Australia were invited to complete an online survey. RESULTS: Of the 289 respondents (mean age 34.3 years), 45% used continuous subcutaneous insulin infusion (CSII) and 35% used continuous glucose monitoring (CGM). Approximately half of CSII users stated that the pump interferes with sex. Of these, 75% disconnect their pump during sexual activity to avoid this issue. Comfort during sex influenced the location of the CSII insertion site in 22% of respondents, with the abdomen being preferred. One in four non-CSII users cited sex-related concerns as a factor for not adopting the technology. CGM interfered with sexual activity in 20% of users, but did not commonly affect CGM placement (only 18%). Sexual activity was reported as a factor for not adopting the technology in 10% of non-CGM users. No differences in body dissatisfaction (P = .514) or anxiety (P = .304) between CSII and non-CSII users were observed. No differences in sexual activity and behavior between technology users and nontechnology users were observed. CONCLUSION: Wearable technologies impact upon sexual activity and this influences the decision to adopt the technology. Despite this, technology users are similar in terms of sexual behavior, anxiety, and body image compared to nontechnology users. Where appropriate, these data can be used to identify potential concerns, address strategies to mitigate them, and inform people with diabetes when considering adopting external technologies.

Disclosing sexuality: Gay and bisexual men's experiences of coming out, forced out, going back in and staying out of the 'closet' in prison.

Many papers have been written on the process of coming out by individuals with predominantly same-sex sexual orientation but few of these papers have explored the concept of how people negotiate the idea of coming out in prison. We conducted in-depth interviews with 13 prisoners and one ex-prisoner in New South Wales, Australia, who self-identified as gay, homosexual or bisexual men. Data was collected and analysed using an inductive or grounded theory framework since very little was known on the sexual behaviours and identities of Australian prisoners prior to the study and elsewhere. We examined and discussed the lived experiences of prisoners whose disclosure stories were seen to fall under four thematic categories: 'coming out', 'forced out', 'going back in' and 'staying out of the closet' on entering prison. Respondents were required continuously and contextually to manage their sexual identities and disclosure to different audiences while incarcerated. Findings suggest that the prison environment and its attendant heteronormative values and hyper-masculine culture, apply significant pressure on gay and bisexual men on how to manage their sexual identities and disclose their sexuality in prison.

Enhancing use of emergency contraceptive pills: A systematic review of women's attitudes, beliefs, knowledge, and experiences in Australia.

Over a decade after emergency contraceptive pills (ECPs) became available without a prescription, the rate of unintended pregnancies remains high in many settings. Understanding women's experiences and perceptions of ECPs may provide insights into this underutilization. We systematically searched databases to identify qualitative and quantitative primary studies about women's beliefs, knowledge, and experiences of ECPs in Australia. Findings demonstrate persistent misunderstandings around access, how ECPs work, and a moral discourse around acceptable versus unacceptable use. Addressing knowledge and the stigma around ECPs use is fundamental to increasing the use of this medically safe and effective strategy.

Meeting Sexual Partners Through Internet Sites and Smartphone Apps in Australia: National Representative Study.

BACKGROUND: Studies have reported on the proportion of the population looking for potential sexual partners using internet sites and smartphone apps, but few have investigated those who have sex with these partners, arguably a more important target group for health promotion. OBJECTIVE: This study aimed to determine the proportion of people who have had sex with someone they met on an internet site or a smartphone app in the previous year. METHODS: We analyzed data from the 2012-2013 Second Australian Study of Health and Relationships, a nationally representative telephone survey of Australian residents aged 16-69 years (N=20,091). The participation rate for the telephone survey was 66.22%. The prevalence of looking for a potential partner, physically meeting, and having sex with someone first met through an internet site or a smartphone app was estimated. Multivariate logistic regression was used for men and women separately to determine demographic and behavioral factors associated with having had sex with someone met on an internet site or a smartphone app in the last year. RESULTS: Overall, 12.09% of respondents had looked for potential partners using these technologies and 5.40% had done so in the last year. In the last year, 2.98% had met someone in person and 1.95% reported having had sex with someone first met on an internet site or a smartphone app. The prevalence of all behaviors was greater in men than in women and in younger respondents than in older respondents. Among sexually active men, factors associated with having had sex with someone met using internet sites or smartphone apps included identifying as gay or bisexual (adjusted odds ratio, AOR: 15.37, 95% CI 8.34-28.35), having either 2-3 or >3 sexual partners in the last year (AOR: 9.20, 95% CI 9.20-34.68 and AOR: 35.77, 95% CI 18.04-70.94, respectively), having had a sexually transmissible infection (STI) test in the past year (AOR: 2.02, 95% CI 1.21-3.38), or an STI in the last year (AOR: 3.15, 95% CI 1.25-7.97). Among sexually active women, factors associated with having had sex with someone met on an internet site or a smartphone app were as follows: having either 2-3 or >3 sexual partners in the last year (AOR: 32.01, 95% CI 13.17-77.78 and AOR: 71:03, 95 % CI 27.48-183.57, respectively), very low and low income (vs very high AOR: 3.40, 95% CI 1.12-10.35), and identifying as lesbian or bisexual (AOR: 2.27, 95% CI 1.04-4.49). CONCLUSIONS: More than a third of adults who had looked for potential partners using websites and apps each year had sex with such partners, and those who had done so were more sexually active, suggesting that dating and hookup websites and applications are suitable settings for targeted sexual health interventions.

Tobacco smoking and sexual difficulties among Australian adults: a cross-sectional study.

Background Few studies have examined smoking and female sexual difficulties. The aim of this study was to investigate the association between current tobacco smoking and sexual difficulties in Australian men and women. METHODS: Data for this study came from the Second Australian Study of Health and Relationships (2012-13), which includes a representative sample of 18427 sexually active Australian adults (aged 16-69 years). The main study and outcome measures were tobacco smoking and sexual difficulties. A multiple logistic regression analysis was conducted to adjust for potential confounders. RESULTS: Male heavy smokers (>20 cigarettes per day) were significantly more likely than non-smokers to have trouble keeping an erection [adjusted odds ratio (AOR) 4.14, 95% confidence interval (CI) 1.87-9.20; P<0.0001], lack interest in having sex (AOR 2.18, 95% CI 1.20-3.97; P=0.011), have anxiety about performance (AOR 2.46, 95% CI 1.24-4.86; P=0.010) and be unable to come to orgasm (AOR=2.81, 95% CI 1.23-6.42; P=0.015). Female smokers were also significantly more likely than non-smokers to not find sex pleasurable (AOR 1.48, 95% CI 1.05-2.07; P=0.025); and light female smokers were significantly more likely than non-smokers to be unable to come to orgasm (AOR=1.44, 95% CI 1.05-1.98; P=0.025). CONCLUSIONS: Current tobacco smoking was associated with sexual difficulties in both men and women. For women, even light smoking was associated with not finding sex pleasurable and being unable to come to orgasm.

Sex education: findings from the Second Australian Study of Health and Relationships.

In a national telephone-based survey, information on sexual behaviour and outcomes were collected from 20091 randomly selected Australians in 2012-13. Data were weighted and analysed to determine the proportion of those who had received school-based sex education and to examine the associations between sex education and sexual health outcomes, specifically a history of a sexually transmissible infection (STI), early pregnancy, contraception use at first sex, and level of STI knowledge. Just over half the respondents (53%; n=19836) reported receiving sex education that included information about condoms and contraception. Using logistic regression analysis after adjusting for age, education and non-English-speaking background, we found that sex education was strongly associated with increased odds of using contraception at first vaginal intercourse (odds ratio (OR)=1.57; 95% confidence interval (CI) 1.44-1.71; P<0.001) and higher levels of STI knowledge (OR=1.75; 95% CI 1.46-2.12; P<0.001).

Australian women's attitudes towards and understandings of the subdermal contraceptive implant: a qualitative study of never-users.

OBJECTIVE: Few studies have explored Australian women's understandings of contraception. This study examined the attitudes towards, and understandings of, the subdermal contraceptive implant expressed by women living in New South Wales (NSW), Australia. STUDY DESIGN: As part of a larger qualitative study using in-depth, open-ended interviews in 2012-2013 with women aged 16-49 years who had ever used contraception (n=94), 65 interviews from women who discussed or mentioned the subdermal implant, but had not previously used the device, were examined and analysed using thematic analysis. RESULTS: The emergent themes were: satisfaction with current method; weak personal opinions and ambivalence; uncertainty due to specific concerns; and strong negative reactions - fear and dislike. Although there were a few positive perceptions expressed by women who had never used the subdermal implant, for the majority of women the perception was predominantly negative. DISCUSSION AND CONCLUSION: Women tended to form negative impressions from the stories of other women about the subdermal implant. Interventions to enhance evidence-informed awareness of the relative advantages and disadvantages of the implant - for example, improved access to supportive contraceptive counselling - need investigation in the Australian context. Avenues to improve women's perceived control over the device could also be usefully investigated.

Doctors' experience of the contraceptive consultation: a qualitative study in Australia.

BACKGROUND: Contraception is a field in which good doctor-patient communication is crucial and core to shared decision making. Despite the centrality of contraception to primary health care in Australia, little is known about how doctors manage the contraceptive consultation. In particular, little is known about how doctors discuss sexual issues related to contraception. METHODS: Fifteen contraceptive providers participated in qualitative interviews averaging 45 min. Interviews were audio recorded, transcribed verbatim, and analysed using an inductive thematic approach. RESULTS: We found doctors were aware that they had to modify their illness-based 'scripts' in consultations about contraception, and said it was challenging always to adhere to a shared model of decision making. Prescribing behaviour reflected personal preferences in relation to some forms of contraception, and doctors were enthusiastic about the levonorgestrel-releasing intrauterine system. Doctors identified gaps in training in relation to sexuality and reported feeling tentative in raising sexual issues, even within contraceptive consultations. CONCLUSIONS: A range of factors-including tendencies to use illness scripts, personal preferences, and discomfort with communications about sexuality-appear to influence doctors' approaches to contraceptive management. Medical training that enables doctors to move out of an illness-treating framework and to improve their understanding of and comfort in discussing sexuality issues will improve their management of healthy women seeking contraception.

Differences Between Landline and Mobile Phone Users in Sexual Behavior Research.

This study investigated differences between the demographic characteristics, participation rates (i.e., agreeing to respond to questions about sexual behavior), and sexual behaviors of landline and mobile phone samples in Australia. A nationally representative sample of Australians aged 18 years and over was recruited via random digit dialing in December 2011 to collect data via computer-assisted telephone interviews. A total of 1012 people (370 men, 642 women) completed a landline interview and 1002 (524 men, 478 women) completed a mobile phone interview. Results revealed that telephone user status was significantly related to all demographic variables: gender, age, educational attainment, area of residence, country of birth, household composition, and current ongoing relationship status. In unadjusted analyses, telephone status was also associated with women's participation rates, participants' number of other-sex sexual partners in the previous year, and women's lifetime sexual experience. However, after controlling for significant demographic factors, telephone status was only independently related to women's participation rates. Post hoc analyses showed that significant, between-group differences for all other sexual behavior outcomes could be explained by demographic covariates. Results also suggested that telephone status may be associated with participation bias in research on sexual behavior. Taken together, these findings highlight the importance of sampling both landline and mobile phone users to improve the representativeness of sexual behavior data collected via telephone interviews.

Performing (heterosexual) femininity: female agency and role in sexual life and contraceptive use - a qualitative study in Australia.

Women's liberation and the sexual revolution have changed the social landscape for heterosexual women in the West over the past 50 years, but exploration of women's lived experiences of contraceptive use in the context of their sexual lives is comparatively recent. We conducted 94 in-depth open-ended interviews with women of reproductive age (16-49 years) living in New South Wales, Australia. Interviews were audio-recorded, transcribed verbatim and analysed using an inductive thematic approach. Four major themes are explored here: (1) what women do and do not do: unspoken gendered assumptions; (2) focus on partner's pleasure; (3) juggling responsibilities: sex as a chore; and (4) women's sexual motivations. Findings suggest sexual double standards and gender expectations continue to pervade women's sexual and contraceptive practices. We found that women performed their femininity by focusing on enabling their male partner's pleasure, while simultaneously ignoring their own sexual desires, wishes or interests. Accompanying new-found freedoms are new-found responsibilities, as women now add managing modern contraceptives and a good sex life to their list of tasks alongside paid employment, domestic labour and childrearing. Our research findings suggest that women may derive different pleasures from sex, including what we term 'connection pleasure'.

A Profile of Pornography Users in Australia: Findings From the Second Australian Study of Health and Relationships.

There are societal concerns that looking at pornography has adverse consequences among those exposed. However, looking at sexually explicit material could have educative and relationship benefits. This article identifies factors associated with looking at pornography ever or within the past 12 months for men and women in Australia, and the extent to which reporting an "addiction" to pornography is associated with reported bad effects. Data from the Second Australian Study of Health and Relationships (ASHR2) were used: computer-assisted telephone interviews (CASIs) completed by a representative sample of 9,963 men and 10,131 women aged 16 to 69 years from all Australian states and territories, with an overall participation rate of 66%. Most men (84%) and half of the women (54%) had ever looked at pornographic material. Three-quarters of these men (76%) and more than one-third of these women (41%) had looked at pornographic material in the past year. Very few respondents reported that they were addicted to pornography (men 4%, women 1%), and of those who said they were addicted about half also reported that using pornography had had a bad effect on them. Looking at pornographic material appears to be reasonably common in Australia, with adverse effects reported by a small minority.

Australian women's experiences of the subdermal contraceptive implant: A qualitative perspective.

BACKGROUND: The number of prescriptions for contraceptive implants has steadily increased in Australia, but implant use is still low. OBJECTIVE: The objectives of the study were to describe women's nuanced responses, and characterise their multidimensional and complex reasons for (dis)continuing use of the contraceptive implant. METHODS: A descriptive qualitative approach was used for this study. A larger qualitative study using in-depth, open-ended interviews, conducted in New South Wales between 2012 and 2013 with 94 women aged 16-49 years who had used contraception, included 10 interviews containing accounts of implant use. The 10 interviews were analysed thematically in the present study. RESULTS: The three main themes analysed from the 10 interviews were perceived benefits, undesirable experiences and perseverance. DISCUSSION: The participants were well informed about the benefits of the implant. Many persevered with it for a significant period of time before discontinuing it, despite experiencing side effects such as bleeding or mood changes. A decision to discontinue was often only made after an accumulation of multiple side effects.

Contraceptive choices and sexual health of Japanese women living in Australia: A brief report from a qualitative study.

BACKGROUND: There is a lack of research focused specifically on the contraceptive and sexual health practices of Japanese women living in Australia. OBJECTIVE: This paper reports findings from a cohort of migrant Japanese women who participated in a study of Australian women's understanding and experience of contraceptives. METHODS: In-depth, open-ended interviews were conducted between August 2012 and June 2013 in New South Wales. Audio-recorded interviews of seven Japanese women were transcribed verbatim and analysed thematically. RESULTS: The four prominent themes were the condom and withdrawal methods, varying attitudes to contraceptive practices, discussing contraception and sexual issues with general practitioners (GPs), and the unspoken topic of sexually transmissible infections (STIs). DISCUSSION: Japanese migrants tend to choose the condom and withdrawal methods, which they perceive to be 'standard practice' in Japan. A greater understanding by Australian GPs of Japanese women's attitudes to contraception and sexual health issues could enhance the sexual health of Japanese women.

Is sexual content in new media linked to sexual risk behaviour in young people? A systematic review and meta-analysis.

BACKGROUND: Social networking and digital media increasingly have an impact on the lives of young people. We undertook a systematic review and meta-analysis of studies that examined the relationship between exposure to sexually explicit websites (SEWs) and 'sexting' (i.e. sending semi-nude or nude photos from a mobile phone) and the sexual attitudes and practices of young people. METHODS: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta Analyses statement, Medline, EMBASE and PsycINFO were searched for papers that described the statistical association between viewing SEWs or sexting by young people (defined as 10-24 years) and their sexual attitudes and behaviours. RESULTS: Fourteen studies, all cross-sectional in design, met the inclusion criteria. Six studies (10352 participants) examined young people's exposure to SEWs and eight (10429 participants) examined sexting. There was substantial variation across studies in exposure and outcome definitions. Meta-analyses found that SEW exposure was correlated with condomless sexual intercourse (odds ratio (OR) 1.23, 95% confidence interval (CI): 1.08-1.38, two studies); sexting was correlated with ever having had sexual intercourse (OR 5.58, 95% CI: 4.46-6.71, five studies), recent sexual activity (OR 4.79, 95% CI: 3.55-6.04, two studies), alcohol and other drug use before sexual intercourse (OR 2.65, 95% CI: 1.99-3.32, two studies) and multiple recent sexual partners (OR 2.79, 95% CI: 1.95-3.63, two studies). Most studies had limited adjustment for important potential confounders. CONCLUSIONS: Cross-sectional studies show a strong association between self-reported exposure to sexual content in new media and sexual behaviours in young people. Longitudinal studies would provide a greater opportunity to adjust for confounding, and better insight into the causal pathways underlying the observed associations.

Contraceptive practices among women: the second Australian study of health and relationships.

OBJECTIVE: To document the use of contraception by a representative sample of Australian women aged 16-49 years and compare it with 2001-2002. METHODS: Women were asked about their use of contraception and method used or reason for non-use during computer-assisted telephone interviews in 2012-2013. Women were sampled by random digit dialling of landline and mobile phones (participation rate 67.2%). RESULTS: Of a weighted sample of 5654 heterosexually active women interviewed 81% were using a method of contraception including sterilisation; this amounts to 66% of all women aged 16-49. Of those who were not using a method, 42% were pregnant or wanted a baby, 25% said they or their partners were infertile, 5% were currently not having intercourse, 3% were past menopause and 25% were apparently at risk of unintended pregnancy. Of those who used a method, 33% used oral contraceptives, 30% condoms and 19% sterilisation as their primary method. Use of condoms, intrauterine devices, implants and emergency contraception has increased since 2002, and use of sterilisation has fallen. Method used varied by age group, location, occupational group, relationship status and parity. A third of women had ever used emergency contraception, with the highest rate among women in their 20s. CONCLUSION: Australian women have access to a wide range of effective contraceptive methods. IMPLICATIONS: Given the high levels of use, most unintended pregnancies in Australia are likely to be attributable to method failure or inconsistent use.