Debby Herbenick

Sexual Behavior in the United States: Results from a National Probability Sample of Men and Women Ages 14–94

INTRODUCTION Despite a demonstrated relationship between sexual behaviors and health, including clinical risks, little is known about contemporary sexual behavior. AIMS To assess the rates of sexual behavior among adolescents and adults in the United States. METHODS We report the recent (past month, past year) and lifetime prevalence of sexual behaviors in a nationally representative probability sample of 5,865 men and women ages 14 to 94 in the United States (2,936 men, 2,929 women). MAIN OUTCOME MEASURES Behaviors assessed included solo masturbation, partnered masturbation, giving and receiving oral sex, vaginal intercourse, and anal intercourse. RESULTS Masturbation was common throughout the lifespan and more common than partnered sexual activities during adolescence and older age (70+). Although uncommon among 14- to 15-year olds, in the past year 18.3% of 16- to 17-year-old males and 22.4% of 16- to 17-year-old females performed oral sex with an other-sex partner. Also in the past year, more than half of women and men ages 18 to 49 engaged in oral sex. The proportion of adults who reported vaginal sex in the past year was highest among men ages 25-39 and for women ages 20-29, then progressively declined among older age groups. More than 20% of men ages 25-49 and women ages 20-39 reported anal sex in the past year. Same-sex sexual behaviors occurring in the past year were uncommonly reported. CONCLUSIONS Men and women engage in a diverse range of solo and partnered sexual behaviors throughout the life course. The rates of contemporary sexual behavior provided in this report will be valuable to those who develop, implement, and evaluate programs that seek to improve societal knowledge related to the prevalence of sexual behaviors and to sexual health clinicians whose work to improve sexual health among the population often requires such rates of behavior.

Condom Use Rates in a National Probability Sample of Males and Females Ages 14 to 94 in the United States

INTRODUCTION Given the efficacy of latex condoms for preventing pregnancy, HIV, and most STI, their promotion remains central to global sexual health efforts. To inform the development of accurate and appropriately-targeted interventions, there is a need for contemporary condom use rates among specific populations. AIMS The purpose of this study was to establish rates of condom use among sexually active individuals in the U.S. population. METHODS Data were collected via a national probability sample of 5,865 U.S. adolescents and adults aged 14 to 94 years. MAIN OUTCOME MEASURES Condom use was assessed during the most recent partnered vaginal or anal sexual event and over the past 10 vaginal and anal intercourse events. RESULTS Condom use by men during past 10 vaginal intercourse events was slightly higher (21.5%) than that reported by women (18.4%), and consistent with rates of condom use reported during most recent vaginal intercourse by men (24.7%) and women (21.8%). Adolescent men reported condom use during 79.1% of the past 10 vaginal intercourse events, adolescent women reported use during 58.1% of the same. Condom use during past 10 anal intercourse events was higher among men (25.8%) than women (13.2%); the same was observed for most recent anal intercourse event (26.5% for insertive men, 44.1% for receptive men, and 10.8% for receptive women). Generally, condom use was highest among unmarried adults, higher among adolescents than adults, and higher among black and Hispanic individuals when compared with other racial groups. CONCLUSION These data indicate clear trends in condom use across age, gender, relationship status, and race/ethnicity. These contemporary rates of condom use will be helpful to those who lead efforts to increase condom use among individuals who may be at risk for sexually transmitted infections or who desire to prevent pregnancy.

Sexual Behaviors, Condom Use, and Sexual Health of Americans Over 50: Implications for Sexual Health Promotion for Older Adults

INTRODUCTION In the contemporary U.S., men and women are living longer and healthier lives. As such, many people spend greater portions of their lives as sexually active individuals. Yet, little is known about the myriad of ways that older adults experience their sexual lives. AIM This study sought to assess the context and frequency of sexual behaviors, condom use, sexual pleasure, and sexual experience of men and women over age 50. METHODS Information regarding the sexual experiences of a nationally representative sample of men and women over age 50 within the past year was examined. MAIN OUTCOME MEASURES Sexual behavior over the past year was assessed in relation to several situational and contextual characteristics (e.g., event location, type of partner, health status, condom use). Participants were also asked about their experience (i.e., pleasure, arousal, pain, lubrication/erectile difficulties, and orgasm) during their most recent partnered sexual event. Bivariate or ordinal logistic regression models were used to investigate the relationship of age, health and partner status to sexual frequency and experience. RESULTS Although sizable proportions (20-30%) of both men and women remained sexually active well into their 80s age was related to a lower likelihood of solo and most partnered sexual behaviors. When controlling for age, relationship status, and health remained significant predictors of select sexual behaviors. The participants evaluation of their most recent sexual experience in terms of arousal, erectile difficulty, and orgasm all declined with age. Health status was related to mens evaluation of the experience. Relationship status was the most consistent predictor of womens evaluation of the experience. Condom use rates remained low for participants across age groups. CONCLUSION Many older adults continue be sexually active well into advanced age (80+). Thus, providers need to be attentive to the diverse sexual health needs of older adults.

Sexual Behaviors, Relationships, and Perceived Health Among Adult Men in the United States: Results from a National Probability Sample

INTRODUCTION To provide a foundation for those who provide sexual health services and programs to men in the United States, the need for population-based data that describes mens sexual behaviors and their correlates remains. AIMS The purpose of this study was to, in a national probability survey of men ages 18-94 years, assess the occurrence and frequency of sexual behaviors and their associations with relationship status and health status. METHODS A national probability sample of 2,522 men aged 18 to 94 completed a cross-sectional survey about their sexual behaviors, relationship status, and health. MAIN OUTCOME MEASURES Relationship status; health status; experience of solo masturbation, partnered masturbation, giving oral sex, receiving oral sex, vaginal intercourse and anal intercourse, in the past 90 days; frequency of solo masturbation, vaginal intercourse and anal intercourse in the past year. RESULTS Masturbation, oral intercourse, and vaginal intercourse are prevalent among men throughout most of their adult life, with both occurrence and frequency varying with age and as functions of relationship type and physical health status. Masturbation is prevalent and frequent across various stages of life and for both those with and without a relational partner, with fewer men with fair to poor health reporting recent masturbation. Patterns of giving oral sex to a female partner were similar to those for receiving oral sex. Vaginal intercourse in the past 90 days was more prevalent among men in their late 20s and 30s than in the other age groups, although being reported by approximately 50% of men in the sixth and seventh decades of life. Anal intercourse and sexual interactions with other men were less common than all other sexual behaviors. CONCLUSION Contemporary men in the United States engage in diverse solo and partnered sexual activities; however, sexual behavior is less common and more infrequent among older age cohorts.

Condom Use During Most Recent Vaginal Intercourse Event Among a Probability Sample of Adults in the United States

INTRODUCTION Correct and consistent condom use remains the most effective way to reduce sexually transmissible infection/HIV transmission during sex and is a highly effective contraceptive method. Understanding correlates of condom use is vital to public health programs. AIM To explore sociodemographic, event characteristics, and experiential correlates of condom use at last penile-vaginal intercourse (PVI). METHODS Survey data were collected from a nationally representative probability sample of adults in the United States as part of the National Survey of Sexual Health and Behavior. MAIN OUTCOME MEASURES Condom use/non-use at most recent PVI was the main outcome. Logistic regression analyses predicted condom use from sociodemographic variables (i.e., age, education, race/ethnicity, sexual orientation, health status, type of relationship with sexual partner) and event characteristics (i.e., location of sexual encounter, prior intercourse experience with partner, whether partner had other sex partners in the 6 months prior to sex with the participant; other contraceptive use, alcohol use, marijuana use, and for men, erection medication use). Logistic regression analyses examined evaluations of the sexual aspects of the experience (pleasure, arousal, erection/lubrication difficulty, participant orgasm, partner orgasm) in light of condom use. RESULTS Condom-protected PVI was significantly greater among younger people, blacks and Hispanics, and those having PVI with a nonrelationship partner. Statistically adjusting for these differences, condom use was significantly associated with fewer previous intercourse experiences with the partner and not using other forms of contraception. The sexual aspects of experience were evaluated similarly regardless of whether or not a condom was used. CONCLUSION Public health programs among youths and minorities may underlie higher condom use rates among these groups. Condom use may be further improved by continuing such programs and also expanding outreach to older persons and whites, suggesting prolonging use as relationships develop, and highlighting that condom use does not necessarily interfere with the sexual experience.

A Psychometric Comparison of Three Scales and a Single-Item Measure to Assess Sexual Satisfaction

This study was designed to systematically compare and contrast the psychometric properties of three scales developed to measure sexual satisfaction and a single-item measure of sexual satisfaction. The Index of Sexual Satisfaction (ISS), Global Measure of Sexual Satisfaction (GMSEX), and the New Sexual Satisfaction Scale–Short (NSSS-S) were compared to one another and to a single-item measure of sexual satisfaction. Conceptualization of the constructs, distribution of scores, internal consistency, convergent validity, test-retest reliability, and factor structure were compared between the measures. A total of 211 men and 214 women completed the scales and a measure of relationship satisfaction, with 33% (n = 139) of the sample reassessed two months later. All scales demonstrated appropriate distribution of scores and adequate internal consistency. The GMSEX, NSSS-S, and the single-item measure demonstrated convergent validity. Test-retest reliability was demonstrated by the ISS, GMSEX, and NSSS-S, but not the single-item measure. Taken together, the GMSEX received the strongest psychometric support in this sample for a unidimensional measure of sexual satisfaction and the NSSS-S received the strongest psychometric support in this sample for a bidimensional measure of sexual satisfaction.

Relations between sexually transmitted infection diagnosis and sexual compulsivity in a community-based sample of men who have sex with men

Objective: To assess relations between sexual compulsivity and a history of sexually transmitted infection (STI) diagnosis and testing among a community-based sample of men who have sex with men (MSM) in a mid-size urban area of the midwestern United States. Methods: Sexual health data were collected from 504 MSM in the metropolitan area of Indianapolis, Indiana, using a community-based participatory research approach. Sexual compulsivity scores were assessed using the Sexual Compulsivity Scale (SCS). Results: The reliability and construct validity of the SCS were determined to be high in the total study sample. Men who scored high on the SCS reported higher levels of sexual risk behaviour with both male and female partners and were significantly more likely to have been diagnosed with STI (including chlamydia, gonorrhoea, both hepatitis A and B, and syphilis) than other men. Men who scored high on the SCS were not more likely than other men to have been tested for STI, despite higher levels of sexual risk. Conclusions: The SCS may be useful as a supplemental instrument in public health programmes and healthcare settings that encourage men to assess their sexual behaviours and make decisions to pursue STI or HIV screening. For those already diagnosed with an STI, the SCS may help providers to identify the cognitive and affective components of sexual behaviours that increase the likelihood that an STI will be transmitted to a sexual partner.

Experiences of condom fit and feel among African-American men who have sex with men

Objective: To offer an empirical understanding of characteristics associated with the fit and feel of condoms among African-American men who have sex with men (MSM), a particularly high-risk group for HIV and other sexually transmitted infections (STI) in the United States. Methods: Survey data were collected from 178 adult African-American MSM attending a community event in Atlanta, Georgia. Results: Although the majority of participants reported that condoms generally fit properly and felt comfortable, a substantial number of men reported a variety of problems with the fit and feel of condoms. Specifically, 21% reported that condoms felt too tight, 18% reported that condoms felt too short, 10% reported that condoms felt too loose, and 7% reported that condoms felt too long. There were significant associations between men’s reports of condom breakage and slippage, and their perceptions of condom fit and feel. Perceptions of condom fit and feel were also related to men’s reports of seeking condoms for their size-specific properties. Conclusions: The fit and feel issues that men in this sample identified may be among those that contribute to their likelihood of using, or not using, condoms consistently and correctly. A better understanding of these factors will be beneficial to both condom manufacturers and sexual health professionals who share a common goal of increasing consistent and correct condom use and reducing the incidence of HIV and other STI among this and other communities.

Background and Considerations on the National Survey of Sexual Health and Behavior (NSSHB) from the Investigators

A we enter the second decade of the 21st century, the United States continues to face significant challenges in terms of the sexual and reproductive health of its population. With the Human Immunodeficiency Virus (HIV) continuing to have considerable and disproportionate impacts on diverse communities, high rates of other sexually transmissible infections and high numbers of unintended pregnancies each year, those on the front lines of public health and medicine are challenged to implement appropriate and effective strategies in response. While sexual health problems such as these have driven much of the nation’s social and health priorities and research agendas in the past, it remains the case that sexual behaviors, and the associated behaviors that occur within the context of a sexual event (e.g., condom use), continue to garner significant interest among both scientific and lay communities. However, the delivery of sexual health services and the conduct of sexual health research remain challenging and, at times, controversial. Just over 60 years ago, Dr. Alfred Kinsey and his research teammade available, to both scientists and the general public, the first large-scale systematic studies of human sexual behavior [1–2]. For decades, much of what was known about human sexual behaviors was based upon the thousands of interviews conducted by Kinsey and his team, most of which were collected during the 1930s and 1940s. Later on, in the 1980s, the realities of the epidemics of HIV and Acquired Immune Deficiency Syndrome (AIDS) made clear how little was known about contemporary human sexual interactions, how they had changed over time, and the manner in which individuals and couples make decisions to protect themselves from infection and pregnancy. In 1994, a team of researchers had a profound impact on our understanding of these issues with the results from the first nationally representative probability study of sex and sexuality-related behavior in theU.S. (theNational Health and Social Life Survey-NHSLS), which they had conducted two years earlier [3–4]. Since that time, there have been thousands of studies focusing on specific sexuality and health-related topics among a diverse range of communities that have continued to advance scientific understanding of sexuality-related behaviors, condom and contraceptive use, and that have driven the development of increasingly effective public health interventions. There have been only a few nationally representative probability samples of sexual behavior among specific age groups (e.g., Youth Risk Behavior Survey;National Social Life, Health, and Aging Project) or of sexual concerns or distress. Studies specific to condom use have been more frequent, with a great deal of effort being expended to document trends in cond om use both across the general population and within specific communities disproportionately impacted by sexual health problems for which the latex condom is an accessible and efficacious solution. Studies such as these have clear relevance for the development and delivery of social service and health programs that address issues related to sexuality and sexual health. They are also central to those individuals whose scientific interests are grounded within areas related to human sexuality, and over the past two decades, such scientists have discussed and debated the need for, and the possible mechanisms for conducting, a contemporary 243

Pubic Hair Removal and Sexual Behavior: Findings from a Prospective Daily Diary Study of Sexually Active Women in the United States

INTRODUCTION Pubic hair removal is prevalent among women in the United States. However, most studies related to pubic hair removal are based on cross-sectional surveys and retrospective recall. AIM The purpose of this research was to, in a prospective event-level daily diary study, assess demographic, affective, relational, situational, and behavioral factors related to womens pubic hair removal. METHOD Data collection occurred as part of a 5-week prospective, Internet-based daily diary study. MAIN OUTCOME MEASURES Age; Affective predictors (positive mood, negative mood, feeling interested in sex, feeling in love); Relational predictors (partner support, partner negativity, partner type, partner gender); Situational predictors (any vaginal symptoms, use of any vaginal hygiene products; having applied any creams to the genitals); Behavioral variables (penile-vaginal sex, penile-anal sex, had finger inserted into vagina, had clitoris stimulated with fingers, inserted toy into vagina, used vibrator on clitoris, inserted finger into anus, inserted toy into anus, duration of penetration, intensity of penetration). RESULTS A total of 2,453 women ages 18 to 68 (mean age 32.69) completed the study, contributing 49,287 total diaries (mean per person 24.5; standard deviation 10.3, median 30); 15.2% of all days (N = 7,362) involved pubic hair waxing or shaving, with the vast majority of hair removal days involving shaving (N = 7,302; 99%). Pubic hair removal was significantly associated with younger age, a greater interest in sex, vaginal fingering, finger-clitoral stimulation, having a casual sex partner, using vaginal hygiene products, and applying cream to the genitals. Hair removal was marginally associated with longer duration of vaginal penetration. CONCLUSIONS These findings provide greater insight into the factors associated with womens pubic hair removal and their sexual experiences on a day-to-day level. Clinical and educational implications are discussed.