Jessica Datta

Changes in sexual attitudes and lifestyles in Britain through the life course and over time: findings from the National Surveys of Sexual Attitudes and Lifestyles (Natsal)

Summary Background Sexual behaviour and relationships are key components of wellbeing and are affected by social norms, attitudes, and health. We present data on sexual behaviours and attitudes in Britain (England, Scotland, and Wales) from the three National Surveys of Sexual Attitudes and Lifestyles (Natsal). Methods We used a multistage, clustered, and stratified probability sample design. Within each of the 1727 sampled postcode sectors for Natsal-3, 30 or 36 addresses were randomly selected and then assigned to interviewers. To oversample individuals aged 16–34 years, we randomly allocated addresses to either the core sample (in which individuals aged 16–74 years were eligible) or the boost sample (in which only individuals aged 16–34 years were eligible). Interviewers visited all sampled addresses between Sept 6, 2010, and Aug 31, 2012, and randomly selected one eligible individual from each household to be invited to participate. Participants completed the survey in their own homes through computer-assisted face-to-face interviews and self-interview. We analysed data from this survey, weighted to account for unequal selection probabilities and non-response to correct for differences in sex, age group, and region according to 2011 Census figures. We then compared data from participants aged 16–44 years from Natsal-1 (1990–91), Natsal-2 (1999–2001), and Natsal-3. Findings Interviews were completed with 15 162 participants (6293 men, 8869 women) from 26 274 eligible addresses (57·7%). 82·1% (95% CI 81·0–83·1%) of men and 77·7% (76·7–78·7%) of women reported at least one sexual partner of the opposite sex in the past year. The proportion generally decreased with age, as did the range of sexual practices with partners of the opposite sex, especially in women. The increased sexual activity and diversity reported in Natsal-2 in individuals aged 16–44 years when compared with Natsal-1 has generally been sustained in Natsal-3, but in men has generally not risen further. However, in women, the number of male sexual partners over the lifetime (age-adjusted odds ratio 1·18, 95% CI 1·08–1·28), proportion reporting ever having had a sexual experience with genital contact with another woman (1·69, 1·43–2·00), and proportion reporting at least one female sexual partner in the past 5 years (2·00, 1·59–2·51) increased in Natsal-3 compared with Natsal-2. While reported number of occasions of heterosexual intercourse in the past 4 weeks had reduced since Natsal-2, we recorded an expansion of heterosexual repertoires—particularly in oral and anal sex—over time. Acceptance of same-sex partnerships and intolerance of non-exclusivity in marriage increased in men and women in Natsal-3. Interpretation Sexual lifestyles in Britain have changed substantially in the past 60 years, with changes in behaviour seeming greater in women than men. The continuation of sexual activity into later life—albeit reduced in range and frequency—emphasises that attention to sexual health and wellbeing is needed throughout the life course. Funding Grants from the UK Medical Research Council and the Wellcome Trust, with support from the Economic and Social Research Council and the Department of Health.

The prevalence of unplanned pregnancy and associated factors in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3)

Summary Background Unplanned pregnancy is a key public health indicator. We describe the prevalence of unplanned pregnancy, and associated factors, in a general population sample in Britain (England, Scotland, and Wales). Method We did a probability sample survey, the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3), of 15 162 men and women aged 16–74 years in Britain, including 5686 women of child-bearing age (16–44 years) who were included in the pregnancy analysis, between Sept 6, 2010, and Aug 31, 2012. We describe the planning status of pregnancies with known outcomes in the past year, and report the annual population prevalence of unplanned pregnancy, using a validated, multicriteria, multi-outcome measure (the London Measure of Unplanned Pregnancy). We set the findings in the context of secular trends in reproductive health-related events, and patterns across the life course. Findings 9·7% of women aged 16–44 years had pregnancies with known outcome in the year before interview, of which 16·2% (95% CI 13·1–19·9) scored as unplanned, 29·0% (25·2–33·2) as ambivalent, and 54·8% (50·3–59·2) as planned, giving an annual prevalence estimate for unplanned pregnancy of 1·5% (1·2–1·9). Pregnancies in women aged 16–19 years were most commonly unplanned (45·2% [30·8–60·5]). However, most unplanned pregnancies were in women aged 20–34 years (62·4% [50·2–73·2]). Factors strongly associated with unplanned pregnancy were first sexual intercourse before 16 years of age (age-adjusted odds ratio 2·85 [95% CI 1·77–4·57], current smoking (2·47 [1·46–4·18]), recent use of drugs other than cannabis (3·41 [1·64–7·11]), and lower educational attainment. Unplanned pregnancy was also associated with lack of sexual competence at first sexual intercourse (1·90 [1·14–3·08]), reporting higher frequency of sex (2·11 [1·25–3·57] for five or more times in the past 4 weeks), receiving sex education mainly from a non-school-based source (1·84 [1·12–3·00]), and current depression (1·96 [1·10–3·47]). Interpretation The increasing intervals between first sexual intercourse, cohabitation, and childbearing means that, on average, women in Britain spend about 30 years of their life needing to avert an unplanned pregnancy. Our data offer scope for primary prevention aimed at reducing the rate of unplanned conceptions, and secondary prevention aimed at modification of health behaviours and health disorders in unplanned pregnancy that might be harmful for mother and child. Funding Grants from the UK Medical Research Council and the Wellcome Trust, with support from the Economic and Social Research Council and the Department of Health.

Sexual function in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3).

Summary Background Despite its importance to sexual health and wellbeing, sexual function is given little attention in sexual health policy. Population-based studies are needed to understand sexual function across the life course. Methods We undertook a probability sample survey (the third National Survey of Sexual Attitudes and Lifestyles [Natsal-3]) of 15 162 individuals aged 16–74 years who lived in Britain (England, Scotland, and Wales). Interviews were done between Sept 6, 2010, and Aug 31, 2012. We assessed the distribution of sexual function by use of a novel validated measure (the Natsal-SF), which assessed problems with individual sexual response, sexual function in a relationship context, and self-appraisal of sex life (17 items; 16 items per gender). We assess factors associated with low sexual function (defined as the lowest quintile of distribution of Natsal-SF scores) and the distribution of components of the measure. Participants reporting one or more sexual partner in the past year were given a score on the Natsal-SF (11 690 participants). 4122 of these participants were not in a relationship for all of the past year and we employed the full information maximum likelihood method to handle missing data on four relationship items. Findings We obtained data for 4913 men and 6777 women for the Natsal-SF. For men and women, low sexual function was associated with increased age, and, after age-adjustment, with depression (adjusted odds ratio 3·70 [95% CI 2·90–4·72] for men and 4·11 [3·36–5·04] for women) and self-reported poor health status (2·63 [1·73–3·98] and 2·41 [1·72–3·39]). Low sexual function was also associated with experiencing the end of a relationship (1·52 [1·18–1·95] and 1·77 [1·44–2·17]), inability to talk easily about sex with a partner (2·36 [1·94–2·88] and 2·82 [2·28–3·48]), and not being happy in the relationship (2·89 [2·32–3·61] and 4·10 [3·39–4·97]). Associations were also noted with engaging in fewer than four sex acts in the past 4 weeks (3·13 [2·58–3·79] and 3·38 [2·80–4·09]), having had same sex partners (2·28 [1·56–3·35] and 1·60 [1·16–2·20]), paying for sex (in men only; 2·62 [1·46–4·71]), and higher numbers of lifetime sexual partners (in women only; 2·12 [1·68–2·67] for ten or more partners). Low sexual function was also associated with negative sexual health outcomes such as experience of non-volitional sex (1·98 [1·14–3·43] and 2·18 [1·79–2·66]) and STI diagnosis (1·50 [1·06–2·11] and 1·83 [1·35–2·47]). Among individuals reporting sex in the past year, problems with sexual response were common (41·6% of men and 51·2% of women reported one or more problem) but self-reported distress about sex lives was much less common (9·9% and 10·9%). For individuals in a sexual relationship for the past year, 23·4% of men and 27·4% of women reported an imbalance in level of interest in sex between partners, and 18·0% of men and 17·1% of women said that their partner had had sexual difficulties. Most participants who did not have sex in the past year were not dissatisfied, distressed, or avoiding sex because of sexual difficulties. Interpretation Wide variability exists in the distribution of sexual function scores. Low sexual function is associated with negative sexual health outcomes, supporting calls for a greater emphasis on sexual function in sexual health policy and interventions. Funding Grants from the UK Medical Research Council and the Wellcome Trust, with support from the Economic and Social Research Council and the Department of Health.

Methodology of the third British National Survey of Sexual Attitudes and Lifestyles (Natsal-3)

Background Data from the first two National Surveys of Sexual Attitudes and Lifestyles, carried out in 1990–1991 (Natsal-1) and 1999–2001 (Natsal-2), have been extensively used to inform sexual health policy in Britain over the past two decades. Natsal-3 was carried out from September 2010 to August 2012 in order to provide up-to-date measures of sexual lifestyles and to extend the scope of the previous studies by including an older age group (up to 74 years), an extended range of topics and biological measures. Methods We describe the methods used in Natsal-3, which surveyed the general population in Britain aged 16–74 years (with oversampling of younger adults aged 16–34 years). Results Overall, 15 162 interviews were completed, with a response rate of 57.7% and a cooperation rate of 65.8%. The response rate for the boost sample of ages 16–34 years was 64.8%, only marginally lower than the 65.4% achieved for Natsal-2, which surveyed a similar age range (16–44). The data were weighted by age, gender and region to reduce possible bias. Comparisons with census data show the weighted sample to provide good representation on a range of respondent characteristics. The interview involved a combination of face-to-face and self-completion components, both carried out on computer. Urine samples from 4550 sexually-experienced participants aged 16–44 years were tested for a range of STIs. Saliva samples from 4128 participants aged 18–74 years were tested for testosterone. Conclusions Natsal-3 provides a high quality dataset that can be used to examine trends in sexual attitudes and behaviours over the past 20 years.

Challenges to evaluating complex interventions: a content analysis of published papers.

BackgroundThere is continuing interest among practitioners, policymakers and researchers in the evaluation of complex interventions stemming from the need to further develop the evidence base on the effectiveness of healthcare and public health interventions, and an awareness that evaluation becomes more challenging if interventions are complex.We undertook an analysis of published journal articles in order to identify aspects of complexity described by writers, the fields in which complex interventions are being evaluated and the challenges experienced in design, implementation and evaluation. This paper outlines the findings of this documentary analysis.MethodsThe PubMed electronic database was searched for the ten year period, January 2002 to December 2011, using the term “complex intervention*” in the title and/or abstract of a paper. We extracted text from papers to a table and carried out a thematic analysis to identify authors’ descriptions of challenges faced in developing, implementing and evaluating complex interventions.ResultsThe search resulted in a sample of 221 papers of which full text of 216 was obtained and 207 were included in the analysis. The 207 papers broadly cover clinical, public health and methodological topics. Challenges described included the content and standardisation of interventions, the impact of the people involved (staff and patients), the organisational context of implementation, the development of outcome measures, and evaluation.ConclusionsOur analysis of these papers suggests that more detailed reporting of information on outcomes, context and intervention is required for complex interventions. Future revisions to reporting guidelines for both primary and secondary research may need to take aspects of complexity into account to enhance their value to both researchers and users of research.

Associations between health and sexual lifestyles in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3)

Summary Background Physical and mental health could greatly affect sexual activity and fulfilment, but the nature of associations at a population level is poorly understood. We used data from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3) to explore associations between health and sexual lifestyles in Britain (England, Scotland, and Wales). Methods Men and women aged 16–74 years who were resident in households in Britain were interviewed between Sept 6, 2010, and Aug 31, 2012. Participants completed the survey in their own homes through computer-assisted face-to-face interviews and self-interview. We analysed data for self-reported health status, chronic conditions, and sexual lifestyles, weighted to account for unequal selection probabilities and non-response to correct for differences in sex, age group, and region according to 2011 Census figures. Findings Interviews were done with 15 162 participants (6293 men, 8869 women). The proportion reporting recent sexual activity (one or more occasion of vaginal, oral, or anal sex with a partner of the opposite sex, or oral or anal sex or genital contact with a partner of the same sex in the past 4 weeks) decreased with age after the age of 45 years in men and after the age of 35 years in women, while the proportion in poorer health categories increased with age. Recent sexual activity was less common in participants reporting bad or very bad health than in those reporting very good health (men: 35·7% [95% CI 28·6–43·5] vs 74·8% [72·7–76·7]; women: 34·0% [28·6–39·9] vs 67·4% [65·4–69·3]), and this association remained after adjusting for age and relationship status (men: adjusted odds ratio [AOR] 0·29 [95% CI 0·19–0·44]; women: 0·43 [0·31–0·61]). Sexual satisfaction generally decreased with age, and was significantly lower in those reporting bad or very bad health than in those reporting very good health (men: 45·4% [38·4–52·7] vs 69·5% [67·3–71·6], AOR 0·51 [0·36–0·72]; women: 48·6% [42·9–54·3] vs 65·6% [63·6–67·4], AOR 0·69 [0·53–0·91]). In both sexes, reduced sexual activity and reduced satisfaction were associated with limiting disability and depressive symptoms, and reduced sexual activity was associated with chronic airways disease and difficulty walking up the stairs because of a health problem. 16·6% (95% CI 15·4–17·7) of men and 17·2% (16·3–18·2) of women reported that their health had affected their sex life in the past year, increasing to about 60% in those reporting bad or very bad health. 23·5% (20·3–26·9) of men and 18·4% (16·0–20·9) of women who reported that their health affected their sex life reported that they had sought clinical help (>80% from general practitioners; <10% from specialist services). Interpretation Poor health is independently associated with decreased sexual activity and satisfaction at all ages in Britain. Many people in poor health report an effect on their sex life, but few seek clinical help. Sexual lifestyle advice should be a component of holistic health care for patients with chronic ill health. Funding Grants from the UK Medical Research Council and the Wellcome Trust, with support from the Economic and Social Research Council and Department of Health.

Lifetime prevalence, associated factors, and circumstances of non-volitional sex in women and men in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3)

Summary Background Sexual violence is increasingly recognised as a public health issue. Information about prevalence, associated factors, and consequences for health in the population of Britain (England, Scotland, and Wales) is scarce. The third National Survey of Sexual Health Attitudes and Lifestyles (Natsal-3) is the first of the Natsal surveys to include questions about sexual violence and the first population-based survey in Britain to explore the issue outside the context of crime. Methods Between Sept 6, 2010, and Aug 31, 2012, we did a probability sample survey of women and men aged 16–74 years living in Britain. We asked participants about their experience of sex against their will since age 13 years and the circumstances surrounding the most recent occurrence. We explored associations between ever experiencing non-volitional sex and a range of sociodemographic, health, and behavioural factors. We used logistic regression to estimate age-adjusted odds ratios to analyse factors associated with the occurrence of completed non-volitional sex in women and men. Findings We interviewed 15 162 people. Completed non-volitional sex was reported by 9·8% (95% CI 9·0–10·5) of women and 1·4% (1·1–1·7) of men. Median age (interdecile range) at most recent occurrence was 18 years (14–32) for women and 16 years (13–30) for men. Completed non-volitional sex varied by family structure and, in women, by age, education, and area-level deprivation. It was associated with poor health, longstanding illness or disability, and treatment for mental health conditions, smoking, and use of non-prescription drugs in the past year in both sexes, and with binge drinking in women. Completed non-volitional sex was also associated with reporting of first heterosexual intercourse before 16 years of age, same-sex experience, more lifetime sexual partners, ever being diagnosed with a sexually transmitted infection, and low sexual function in both sexes, and, in women, with abortion and pregnancy outcome before 18 years of age. In most cases, the person responsible was known to the individual, although the nature of the relationship differed by age at most recent occurrence. Participants who were younger at interview were more likely to have told someone about the event and to have reported it to the police than were older participants. Interpretation These data provide the first population prevalence estimates of non-volitional sex in Britain. We showed it to be mainly an experience of young age and strongly associated with a range of adverse health outcomes in both women and men. Funding Grants from the UK Medical Research Council and the Wellcome Trust, with support from the Economic and Social Research Council and the Department of Health.

Views and experiences of men who have sex with men on the ban on blood donation: a cross sectional survey with qualitative interviews

Objective To explore compliance with the UK blood services’ criterion that excludes men who have had penetrative sex with a man from donating blood, and to assess the possible effects of revising this policy. Design A random location, cross sectional survey followed by qualitative interviews. Setting Britain. Participants 1028 of 32 373 men in the general population reporting any male sexual contact completed the survey. Additional questions were asked of a general population sample (n=3914). Thirty men who had had penetrative sex with a man participated in the qualitative interviews (19 who had complied with the blood services’ exclusion criterion and 11 who had not complied). Main outcome measure Compliance with the blood services’ lifetime exclusion criterion for men who have had penetrative sex with a man. Results 10.6% of men with experience of penetrative sex with a man reported having donated blood in Britain while ineligible under the exclusion criterion, and 2.5% had donated in the previous 12 months. Ineligible donation was less common among men who had had penetrative sex with a man recently (in previous 12 months) than among men for whom this last occurred longer ago. Reasons for non-compliance with the exclusion included self categorisation as low risk, discounting the sexual experience that barred donation, belief in the infallibility of blood screening, concerns about confidentiality, and misunderstanding or perceived inequity of the rule. Although blood donation was rarely viewed as a “right,” potential donors were seen as entitled to a considered assessment of risk. A one year deferral since last male penetrative sex was considered by study participants to be generally feasible, equitable, and acceptable. Conclusions A minority of men who have sex with men who are ineligible to donate blood under the current donor exclusion in Britain have nevertheless done so in the past 12 months. Many of the reasons identified for non-compliance seem amenable to intervention. A clearly rationalised and communicated one year donor deferral is likely to be welcomed by most men who have sex with men.

The Travelling Citizen: Emergent Discourses of Moral Mobility in a Study of Cycling in London

Drawing on accounts of travelling within London, this article explores the ways in which mobility discourses are tied to the responsibilities of ‘a good citizen’ and suggests that car-dominated automobility has been significantly fractured, at least in one urban setting. A consensus hierarchy of transport modes now configures driving as immoral, as well as dysfunctional, and cycling, in contrast, as particularly laudable. Within this new moral economy of transport, cycling holds the promise of conscientious automobility, enabling a number of explicit and implied citizenship responsibilities to be met. These include ecological responsibilities to the city and global ecosystem, but also responsibilities to enact the ‘new citizen’: a knowledgeable and alert risk-assessor competent to travel in ways that maximize independence, efficiency and health. However, cycling has its own contradictions: whilst enabling some to enact a new ‘moral’ citizenship, it simultaneously underlines the marginal citizenship of less mobile Londoners.

Patterns and trends in sources of information about sex among young people in Britain: evidence from three National Surveys of Sexual Attitudes and Lifestyles

Objective To assess progress in meeting young peoples sex education needs in Britain by examining the current situation and changes over the past 20 years in sources of information about sexual matters and unmet information needs. Design Cross-sectional probability sample surveys. Setting British general population. Participants 3869 men and women aged 16–24 years, interviewed 2010–2012 for the third National Survey of Sexual Attitudes & Lifestyles (Natsal-3), compared with 16–24 year-olds in Natsal-1 (1990–1991; 792 men and women) and Natsal-2 (1999–2001; 2673 men and women). Main outcome measures Reported source of information about sexual matters, unmet information needs and preferred source of additional information. Results Between 1990 and 2012, the proportion citing school lessons as their main source of information about sexual matters increased from 28.2% (95% CI 24.6 to 32.1) to 40.3% (95% CI 38.6 to 42.1). In 2010–2012, parents were reported as a main source by only 7.1% (95% CI 5.8 to 8.7) of men and 14.1% (95% CI 12.6 to 15.7) of women and, for women, were less commonly reported than in 1999–2001 (21.7%; 95% CI 19.6 to 24.0). Most young people reported not knowing enough when they first felt ready for sexual experience (68.1% men, 70.6% women), and this did not change substantially over time. They wanted more information about psychosexual matters (41.6% men, 46.8% women), as well as sexually transmitted infections (27.8% men, 29.8% women) and, for women, contraception (27.5%). Young people primarily wanted this information from school, parents or health professionals. Conclusions Over the past 20 years, young people have increasingly identified school lessons as their main source of information about sex, although they continue to report needing more information on a broad range of topics. The findings support the expressed need for improved sex and relationships education in schools alongside greater involvement of parents and health professionals.