Nathalie Bajos

Sexual behaviour in context: a global perspective.

Although Claudia Garcia-Moreno and colleagues acknowledge that intimate-partner violence is a global health-care problem they report that educational status does not explain differences in the prevalence of intimate-partner violence between the countries the research team visited. However other studies suggest conflicting results. Thompson and colleagues studied 3568 women aged 18--64 years in the USA and showed that the rates of intimatepartner violence were higher for women with less education. In another study Maziak reported that poor education was one important correlate of physical abuse in 412 Syrian women. The association between female educational status and intimate-partner violence is also documented in a review article by Jewkes. According to this study high educational status of women was associated with low levels of violence in some countries whereas in others the aforementioned relation followed an inverted U-shape pattern with low violence rates at the lowest and highest educational levels. (excerpt)Research aimed at investigating sexual behaviour and assessing interventions to improve sexual health has increased in recent decades. The resulting data, despite regional differences in quantity and quality, provide a historically unique opportunity to describe patterns of sexual behaviour and their implications for attempts to protect sexual health at the beginning of the 21st century. In this paper we present original analyses of sexual behaviour data from 59 countries for which they were available. The data show substantial diversity in sexual behaviour by region and sex. No universal trend towards earlier sexual intercourse has occurred, but the shift towards later marriage in most countries has led to an increase in premarital sex, the prevalence of which is generally higher in developed countries than in developing countries, and is higher in men than in women. Monogamy is the dominant pattern everywhere, but having had two or more sexual partners in the past year is more common in men than in women, and reported rates are higher in industrialised than in non-industrialised countries. Condom use has increased in prevalence almost everywhere, but rates remain low in many developing countries. The huge regional variation indicates mainly social and economic determinants of sexual behaviour, which have implications for intervention. Although individual behaviour change is central to improving sexual health, efforts are also needed to address the broader determinants of sexual behaviour, particularly those that relate to the social context. The evidence from behavioural interventions is that no general approach to sexual-health promotion will work everywhere and no single-component intervention will work anywhere. Comprehensive behavioural interventions are needed that take account of the social context in mounting individual-level programmes, attempt to modify social norms to support uptake and maintenance of behaviour change, and tackle the structural factors that contribute to risky sexual behaviour.

Sexuality and obesity, a gender perspective: results from French national random probability survey of sexual behaviours

Objectives To analyse the association between body mass index (BMI) and sexual activity, sexual satisfaction, unintended pregnancies, and abortions in obese people and to discuss the implications for public health practices, taking into account the respondents’ and their partners’ BMI. Design Random probability survey of sexual behaviours. Setting National population based survey of 12 364 men and women aged 18-69 living in France in 2006. Participants Random selection of 5535 women and 4635 men, of whom 3651 women and 2725 men were normal weight (BMI 18.5-<25), 1010 women and 1488 men were overweight (BMI 25-<30), and 411 women and 350 men were obese (BMI >30). Results Obese women were less likely than normal weight women to report having a sexual partner in the past 12 months (odds ratio 0.71, 95% confidence interval 0.51 to 0.97). Obese men were less likely than normal weight men to report more than one sexual partner in the same period (0.31, 0.17 to 0.57, P<0.001) and more likely to report erectile dysfunction (2.58, 1.09 to 6.11, P<0.05). Sexual dysfunction was not associated with BMI among women. Obese women aged under 30 were less likely to seek healthcare services for contraception (0.37, 0.18 to 0.76) or to use oral contraceptives (0.34, 0.15 to 0.78). They were also more likely to report an unintended pregnancy (4.26, 2.21 to 8.23). Conclusion There is a link between BMI and sexual behaviour and adverse sexual health outcomes, with obese women less likely to access contraceptive healthcare services and having more unplanned pregnancies. Prevention of unintended pregnancies among these women is a major reproductive health challenge. Healthcare professionals need to be aware of sensitivities related to weight and gender in the provision of sexual health services.

Remedicalizing an epidemic: from HIV treatment as prevention to HIV treatment is prevention.

Bold claims of a ‘paradigm shift’ at the recentWorld AIDS Conference signal a striking remedicalization of our approach to the HIV epidemic and a return to the early 1980s view of the epidemic as a medical problem best addressed by purely technical, biomedical solutions whose management should be left to biomedical professionals and scientists [1]. This is reflected in the assertion by the outgoing President of the International AIDS Society that aggressive diagnosis and treatment of HIV should emerge as the most significant theme of the conference, ‘over and above the human rights issue’ [2]. Studies were presented to demonstrate that antiretroviral drugs and microbicides should now be included alongside male circumcision in the biomedical armamentarium of ‘new HIV prevention technologies’ (NPTs). ‘NPTs’ were even touted as potentially more effective than ‘old’ prevention technologies of condoms [3] based on misleading comparisons between data from randomized controlled trials of simple interventions and observational studies – even though other studies have demonstrated that combined prevention (NPTsþ condoms) were more effective than NPTs only. Despite impressive evidence that ‘old’ prevention has resulted in declining incidence in youth in the most affected countries [4], the enthusiasm for NPTs made it seem as though more classical approaches do not work. Concerns that prevention efforts might be undermined by such biomedical triumphalism cannot be dismissed in light of evidence that prevention efforts are already compromised by the growing emphasis on treatment. Increased investment in treatment is welcomed, but it is profoundly disturbing that prevention remains grossly underfunded even as treatment budgets explode [5]. Nowhere are the dangers of this remedicalization clearer than in the case of ‘treatment-as-prevention’ (TASP), widely trumpeted as a ‘game-changer’ and a ‘paradigm shift’ in the battle against HIV/AIDS.

Research on HIV sexual risk: Social relations-based approach in a cross-cultural perspective

In opposition to individual-oriented approaches to sexual risk taking, new theoretical approaches have emerged that strive to encompass all of the social relations--that is to say, the connections that structure the components of relations between groups and go beyond simple adaptations to a given interaction--that prevail in a sexual relationship. This paper examines the strengths and weaknesses of such an approach for understanding HIV risk-related behaviour. The analysis is based on data from European surveys of sexual behaviour in the general population, with special attention paid to the data from the Belgian survey, which used a relation-based approach to risk-related behaviour. The analysis shows that sexual behaviour and preventive behaviour patterns of men and women appear to be linked to womens status in a given society. The data also tend to show that the social and preventive contexts also help structure the relations that develop between partners when it comes to negotiating about using a condom. Finally, the same people behave differently depending on the relationships context. In particular, the balance of power within the couple, which is strongly interconnected with gender relations issues, and even characteristics of the former relationship help explain these behaviour differences.

Changes in sexual behaviours: from secular trends to public health policies.

Objective:To explore the relative contribution of secular trends and public health policies to changes in sexual behaviour. Design:Three random probability surveys of the sexual behaviour of people aged 18–69 years were conducted in 1970, 1992 and 2006 in France. Methods:Data of the 2006 survey (n = 12 364) were compared with those from two surveys carried out in 1970 (n = 2625) and 1992 (n = 20 055). Results:Over the last decades, median age at first intercourse has decreased by 4 years for women (22.0 in the 1930s vs. 17.6 in the 2000s) and 1 year for men (18.1 vs. 17.2). Lifetime number of sexual partners increased for women (1.8 in 1970 vs. 4.4 in 2006), but not for men (11.8 vs. 11.6). At the same time, the proportion of respondents, especially women, who reported nonpenetrative sexual practices and considered sexual intercourse essential to well being was on the increase. These changes are mainly attributed to an increase in womens social status. A marked increase in condom use was observed following the first AIDS/HIV prevention campaigns in the 1980s. Conclusion:Public health interventions that are synergistic with trends in social norms are likely to be more effective than those that run counter to them. In France, sexual health and HIV prevention policies aimed at harm limitation appear to have chimed with secular trends. The evidence of greater diversification of sexual practices offers potential to increase the range of safer sex messages used in public health interventions.

Frequency of discontinuation of contraceptive use: results from a French population-based cohort

BACKGROUND Despite the widespread use of highly effective contraceptive methods in France, one in every three pregnancies is unintended. Among women experiencing an unintended pregnancy leading to an abortion, half had changed their contraceptive method in the 6 months preceding the abortion, in most cases switching to a less-effective method or to no method at all. This study provides estimates of method-specific contraceptive discontinuation rates for any reason and for method-related reasons among French women. METHODS The data were drawn from the COCON survey (2000-2004), a population-based French prospective cohort, comprising a representative sample of 2863 women aged 18-44. We estimated Kaplan-Meier life-table probabilities of contraceptive discontinuation during the 4 years of follow-up and tested for differences by intrauterine device (IUD) type and pill composition. RESULTS Probabilities of contraceptive discontinuation for method-related reasons varied widely by method: IUDs were associated with the lowest probabilities of discontinuation (11% within 12 months, 30% within 4 years), followed by the pill (22% and 48%, respectively). Discontinuation rates were significantly higher for all other methods (condoms, withdrawal, fertility awareness methods and spermicides). We found no differences in discontinuation rates by the type of IUD (levonorgestrel-IUD versus copper-IUD) and increasing rates of pill discontinuation with decreasing dosage in estrogen. CONCLUSIONS Contraceptive discontinuation rates among French women are substantially lower than those reported for US women. Comparing the determinants of contraceptive discontinuation and the role of healthcare providers in helping women make these changes would improve our understanding of the reasons for such variation.

Patterns of contraceptive use before and after an abortion: results from a nationally representative survey of women undergoing an abortion in France.

BACKGROUND Using a large national survey of women undergoing an abortion in France, we explore their contraceptive use surrounding an abortion. STUDY DESIGN The study comprised a representative sample of 7541 women undergoing an abortion in 2007. We compared their use of contraception before and after the abortion and examined the factors associated with the prescription of a very effective method (IUD, hormonal methods) after the procedure. RESULTS Sixty-six percent of women were using contraception in the month they conceived. A third of women reported the same use of contraception before and after the abortion, 54% were prescribed a more effective method, while 14% changed to a less effective or no method at all. After the abortion, 77% of women were prescribed a very effective contraceptive. CONCLUSIONS Abortion offers an opportunity to improve contraceptive uptake and a chance for providers to adjust their prescriptions according to the difficulties women experience in their use of contraceptives.

Oral contraceptive tolerance : Does the type of pill matter?

OBJECTIVE: To examine the frequencies of reported symptoms by oral contraceptive pill (OCP) composition among French women. METHODS: A population-based cohort of 2,863 women studied between 2000 and 2004 was used to compare the frequency of reported symptoms (weight gain, nausea, breast tenderness, lower frequency of menstrual periods, breakthrough bleeding, painful and heavy periods, swollen legs) by type of OCPs (classified by estrogen dosage, progestin component, and sequence of administration). RESULTS: Results show little variation in the frequency of symptoms by type of OCPs, with the exception of progestin-only pills being associated with higher frequencies of breakthrough bleeding and lower frequencies of menstrual periods. We found no decrease in the reporting of symptoms with the reduction of estrogen dosage, nor with the use of third-generation OCPs compared with second-generation OCPs. Likewise, we found little variation by sequence of administration of OCPs (monophasic versus triphasic). CONCLUSION: In the absence of sufficient evidence-based data to support the existence of differences in the tolerance profile of low-dose combined OCPs, future well-designed randomized trials are needed to guide providers in their choice of OCPs. However, research should also assess the effectiveness of counseling on the tolerance of OCPs, an intervention that may prove to be more rewarding than basing the choice of OCPs on their theoretical properties. LEVEL OF EVIDENCE: II

Social, Demographic and Situational Characteristics Associated with Inconsistent Use of Oral Contraceptives: Evidence from France

CONTEXT Oral contraceptives are the most popular form of reversible contraception used in developed countries. Their efficacy depends on how consistently and correctly they are used. METHODS The incidence of inconsistent pill use was estimated from data from a random sample of 1,234 pill users who participated in a French population-based survey in 2000. Multivariate logistic regressions were used to identify the social, demographic and situational characteristics associated with inconsistent use. RESULTS Twenty percent of women missed at least one pill during the four weeks prior to the interview, 7% missed two or more pills, and 10% missed at least one pill without using contraceptive backup during subsequent sexual intercourse. Inconsistent pill use was related to situational characteristics that are likely to change over time. The odds of having missed pills were elevated among women whose last intercourse had been with an occasional partner or who had small children. Women who did not have a daily pill-taking routine also had elevated odds of inconsistent use. The likelihood of having missed a pill and not used contraceptive backup was elevated among women who felt they had not been involved in the choice of contraceptive method prescribed by their physician. CONCLUSIONS Service providers may need to better address womens preferences and needs, to help them choose the contraceptive method that best fits their sexual, emotional.

Is hardship during migration a determinant of HIV infection? Results from the ANRS PARCOURS study of sub-Saharan African migrants in France

Objectives:In Europe, sub-Saharan African migrants are a key population for HIV infection. We analyse how social hardships during settlement in France shape sexual partnerships and HIV risk. Design:PARCOURS is a life-event survey conducted in 2012–2013 in 74 health-care facilities in the Paris region, among three groups of sub-Saharan migrants: 926 receiving HIV care (296 acquired HIV in France), 779 with chronic hepatitis B, and 763 with neither HIV nor hepatitis B (reference group). Methods:Hardships (lack of residence permit, economic resources and housing) and sexual partnerships were documented for each year since arrival in France. For each sex, reported sexual partnerships were compared by group and their associations with hardships each year analysed with mixed-effects logistic regression models. Results:Hardships were frequent: more than 40% had lived a year or longer without a residence permit, and more than 20% without stable housing. Most of the migrants had nonstable and concurrent partnerships, more frequent among those who acquired HIV in France compared with reference group, as were casual partnerships among men (76.7 vs. 54.2%; P = 0.004) and women (52.4 vs. 30.5%; P = 0.02), concurrent partnerships among men (69.9 vs. 45.8%; P = 0.02), and transactional partnerships among women (8.6 vs. 2.3%; P = 0.006). Hardship increased risky behaviours: in women, lacking a residence permit increased casual and transactional partnerships [resp. odds ratio (OR) = 2.01(1.48–2.72) and OR = 6.27(2.25–17.44)]. Same trends were observed for lacking stable housing [OR = 3.71(2.75–5.00) and OR = 10.58 (4.68–23.93)]. Conclusion:Hardships faced by migrants increase HIV risks. Women, especially during the period without stable housing, appear especially vulnerable.