Sexting among British adults: a qualitative analysis of sexting as emotion work governed by 'feeling rules'.

Sexting has generated considerable public and professional interest with concerns centring on young people, and potential harms to mental and sexual health. Little research thus far has explored the practice among adults and none has focused on the cultural norms relating to the emotional experience of sexting across different ages and genders. We conducted 40 semi-structured interviews with a diverse sample of adults aged 18-59 years in Britain on the role of digital technologies in participants' sexual lives. In this paper, we draw on the accounts of 34 people with experience of sexting. We identified three main themes in participants' accounts related to the emotional aspects of sexting: (1) trust, (2) desire/intimacy and (3) shame. Under each theme, we identified motivations, 'feeling rules', and examples of 'emotion work' relating to the self, the other and the dyad. We conclude that there are shared cultural norms that constitute what appropriate sexting should feel like. Interventions aiming to minimise harms arising from sexting need to build on commonly held cultural conventions regarding the 'rules of the game' concerning feelings as well as behaviours.

Impacts of COVID-19 on sexual behaviour in Britain: findings from a large, quasi-representative survey (Natsal-COVID).

OBJECTIVES: Physical restrictions imposed to combat COVID-19 dramatically altered sexual lifestyles but the specific impacts on sexual behaviour are still emerging. We investigated physical and virtual sexual activities, sexual frequency and satisfaction in the 4 months following lockdown in Britain in March 2020 and compared with pre-lockdown. METHODS: Weighted analyses of web panel survey data collected July/August 2020 from a quota-based sample of 6654 people aged 18-59 years in Britain. Multivariable regression took account of participants' opportunity for partnered sex, gender and age, to examine their independent associations with perceived changes in sexual frequency and satisfaction. RESULTS: Most participants (86.7%) reported some form of sex following lockdown with physical activities more commonly reported than virtual activities (83.7% vs 52.6%). Altogether, 63.2% reported sex with someone ('partnered sex') since lockdown, three-quarters of whom were in steady cohabiting relationships. With decreasing relationship formality, partnered sex was less frequently reported, while masturbation, sex toy use and virtual activities were more frequently reported. Around half of all participants perceived no change in partnered sex frequency compared with the 3 months pre-lockdown, but this was only one-third among those not cohabiting, who were more likely to report increases in non-partnered activities than those cohabiting. Two-thirds of participants perceived no change in sexual satisfaction; declines were more common among those not cohabiting. Relationship informality and younger age were independently associated with perceiving change, often declines, in sexual frequency and satisfaction. CONCLUSIONS: Our quasi-representative study of the British population found a substantial minority reported significant shifts in sexual repertoires, frequency and satisfaction following the introduction of COVID-19 restrictions. However, these negative changes were perceived by some more than others; predominantly those not cohabiting and the young. As these groups are most likely to experience adverse sexual health, it is important to monitor behaviour as restrictions ease to understand the longer term consequences, including for health services.

Changes in conceptions in women younger than 18 years and the circumstances of young mothers in England in 2000-12: an observational study.

BACKGROUND: In 2000, a 10-year Teenage Pregnancy Strategy was launched in England to reduce conceptions in women younger than 18 years and social exclusion in young parents. We used routinely collected data and data from Britain's National Surveys of Sexual Attitudes and Lifestyles (Natsal) to examine progress towards these goals. METHODS: In this observational study, we used random-effects meta-regression to analyse the change in conception rates from 1994-98 to 2009-13 by top-tier local authorities in England, in relation to Teenage Pregnancy Strategy-related expenditure per head, socioeconomic deprivation, and region. Data from similar probability sample surveys: Natsal-1 (1990-91), Natsal-2 (1999-2001), and Natsal-3 (2010-12) were used to assess the prevalence of risk factors and their association with conception in women younger than 18 years in women aged 18-24 years; and the prevalence of participation in education, work, and training in young mothers. FINDINGS: Conception rates in women younger than 18 years declined steadily from their peak in 1996-98 and more rapidly from 2007 onwards. More deprived areas and those receiving greater Teenage Pregnancy Strategy-related investment had higher rates of conception in 1994-98 and had greater declines to 2009-13. Regression analyses assessing the association between Teenage Pregnancy Strategy funding and decline in conception rates in women younger than 18 years showed an estimated reduction in the conception rate of 11.4 conceptions (95% CI 9.6-13.2; p<0.0001) per 1000 women aged 15-17 years for every £100 Teenage Pregnancy Strategy spend per head and a reduction of 8.2 conceptions (5.8-10.5; p<0.0001) after adjustment for socioeconomic deprivation and region. The association between conception in women younger than 18 years and lower socioeconomic status weakened slightly between Natsal-2 and Natsal-3. The prevalence of participation in education, work, or training among young women with a child conceived before age 18 years was low, but the odds of them doing so doubled between Natsal-2 and Natsal-3 (odds ratio 1.99, 95% CI 0.99-4.00). INTERPRETATION: A sustained, multifaceted policy intervention involving health and education agencies, alongside other social and educational changes, has probably contributed to a substantial and accelerating decline in conceptions in women younger than 18 years in England since the late 1990s. FUNDING: Medical Research Council, Wellcome Trust, Economic and Social Research Council, and Department of Health.

Forming new sex partnerships while overseas: findings from the third British National Survey of Sexual Attitudes & Lifestyles (Natsal-3).

OBJECTIVES: Travelling away from home presents opportunities for new sexual partnerships, which may be associated with sexually transmitted infection (STI) risk. We examined the prevalence of, and factors associated with, reporting new sexual partner(s) while overseas, and whether this differed by partners' region of residence. METHODS: We analysed data from 12 530 men and women aged 16-74 years reporting ≥1 sexual partner(s) in the past 5 years in Britain's third National Survey of Sexual Attitudes and Lifestyles (Natsal-3), a probability survey undertaken 2010-2012. RESULTS: 9.2% (95% CI 8.3% to 10.1%) of men and 5.3% (4.8% to 5.8%) of women reported new sexual partner(s) while overseas in the past 5 years. This was strongly associated with higher partner numbers and other sexual and health risk behaviours. Among those with new partners while overseas, 72% of men and 58% of women reported partner(s) who were not UK residents. Compared with those having only UK partners while abroad, these people were more likely to identify as 'White Other' or 'Non-White' (vs White British ethnicity), report higher partner numbers, new partners from outside the UK while in the UK and paying for sex (men only) all in the past 5 years. There was no difference in reporting STI diagnosis/es during this time period. CONCLUSIONS: Reporting new partners while overseas was associated with a range of sexual risk behaviours. Advice on sexual health should be included as part of holistic health advice for all travellers, regardless of age, destination or reason for travel.

Medicated sex in Britain: evidence from the third National Survey of Sexual Attitudes and Lifestyles.

OBJECTIVES: To describe the prevalence of medication use to assist sexual performance in Britain and to identify associated factors. METHODS: Cross-sectional probability sample, undertaken in 2010-2012, of 15 162 people aged 16-74 years, resident in Britain, of whom, 5617 men and 8095 women reported sexual experience (ever) and 4817 men were sexually-active (reported sex in the last year). RESULTS: Ever use of medication to assist sexual performance (medicated sex) was more commonly reported by men than women (12.9% (95% CI 11.9% to 13.9%) vs 1.9% (95% CI 1.7% to 2.3%)) and associated with older age in men and younger age in women. It was associated with reporting smoking, and use of alcohol and recreational drugs, as well as unsafe sex (≥2 partners and no condom use in the last year) in both men and women. Among men, the proportion reporting medicated sex in the last year was higher among those reporting erectile difficulties (ED) than those not doing so (28.4% (95% CI 24.4% to 32.8%) vs 4.1% (95% CI 3.4% to 4.9%)). In all men, medicated sex was associated with more frequent sexual activity, meeting a partner on the internet, unsafe sex and recent sexually transmitted infections diagnosis; associations that persisted after adjusting for same-sex behaviour and ED. However, there were significant interactions with reporting ED, indicating that among men with ED, medicated sex is not associated with same-sex behaviour and ever use of recreational drugs. CONCLUSIONS: A substantial minority of people in Britain report medicated sex, and the association between medicated sex and risky sexual behaviour is not confined to high-risk groups.

The health and well-being of men who have sex with men (MSM) in Britain: Evidence from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3).

BACKGROUND: To date, research on men who have sex with men (MSM) has largely focused on their sexual health needs and on men recruited from gay-orientated venues. National probability survey data provide a rare opportunity to examine the broader sociodemographic, behavioural, and health profiles of MSM, defined as men who reported ≥1 male sexual partner(s) in the past 5 years, and thus regardless of their sexual identity, in comparison to men reporting sex exclusively with women (MSEW) during this time, and also the extent that health inequalities cluster. METHODS: Britain's third National Survey of Sexual Attitudes and Lifestyles (Natsal-3), a probability sample survey, interviewed 15,162 people aged 16-74 years (6,293 men) during 2010-2012 using computer-assisted personal-interviewing with a computer-assisted self-interview. We used multivariable regression to compare MSM relative to MSEW in their reporting of variables, individually and collectively, corresponding to three domains: physical, mental, and sexual health. RESULTS: Among all men, 2.6 % (n = 190) were defined as MSM, of whom 52.5 % (95 % CI: 43.6 %-61.2 %) identified as gay. MSM were as likely as MSEW (n = 5,069) to perceive their health was 'bad'/'very bad', despite MSM being more likely to report a long-standing illness/disability/infirmity (adjusted odds ratio, AOR: 1.46, 95 % CI:1.02-2.09), treatment for depression/past year (2.75, 1.69-4.47), and substance use (e.g., recreational drug use/past year: 3.46, 2.22-5.40). MSM were more likely to report harmful sexual health behaviours, e.g., condomless sex with ≥2 partners/past year (3.52, 2.13-5.83), and poor sexual health outcomes, including STI diagnosis/es (5.67, 2.67-12.04), poorer sexual function (2.28, 1.57-3.33), both past year, and ever-experience of attempted non-volitional sex (6.51, 4.22-10.06). MSM were also more likely than MSEW to report poor health behaviours and outcomes both within and across the three health domains considered. Of all MSM, 8.4 % had experienced poor health outcomes in all three domains - physical, mental, and sexual health - in contrast to 1.5 % of all MSEW. CONCLUSIONS: MSM are disproportionately affected by a broad range of harmful health behaviours and poor health outcomes. Although often observed for a minority of MSM, many health inequalities were seen in combination such that policies and practices aimed at improving the health and well-being of MSM require a holistic approach, regardless of clinical specialty.

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).

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.

Prevalence, risk factors, and uptake of interventions for sexually transmitted infections in Britain: findings from the National Surveys of Sexual Attitudes and Lifestyles (Natsal).

BACKGROUND: Population-based estimates of prevalence, risk distribution, and intervention uptake inform delivery of control programmes for sexually transmitted infections (STIs). We undertook the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3) after implementation of national sexual health strategies, and describe the epidemiology of four STIs in Britain (England, Scotland, and Wales) and the uptake of interventions. METHODS: Between Sept 6, 2010 and Aug 31, 2012, we did a probability sample survey of 15,162 women and men aged 16-74 years in Britain. Participants were interviewed with computer-assisted face-to-face and self-completion questionnaires. Urine from a sample of participants aged 16-44 years who reported at least one sexual partner over the lifetime was tested for the presence of Chlamydia trachomatis, type-specific human papillomavirus (HPV), Neisseria gonorrhoeae, and HIV antibody. We describe age-specific and sex-specific prevalences of infection and intervention uptake, in relation to demographic and behavioural factors, and explore changes since Natsal-1 (1990-91) and Natsal-2 (1999-2001). FINDINGS: Of 8047 eligible participants invited to provide a urine sample, 4828 (60%) agreed. We excluded 278 samples, leaving 4550 (94%) participants with STI test results. Chlamydia prevalence was 1·5% (95% CI 1·1-2·0) in women and 1·1% (0·7-1·6) in men. Prevalences in individuals aged 16-24 years were 3·1% (2·2-4·3) in women and 2·3% (1·5-3·4) in men. Area-level deprivation and higher numbers of partners, especially without use of condoms, were risk factors. However, 60·4% (45·5-73·7) of chlamydia in women and 43·3% (25·9-62·5) in men was in individuals who had had one partner in the past year. Among sexually active 16-24-year-olds, 54·2% (51·4-56·9) of women and 34·6% (31·8-37·4) of men reported testing for chlamydia in the past year, with testing higher in those with more partners. High-risk HPV was detected in 15·9% (14·4-17·5) of women, similar to in Natsal-2. Coverage of HPV catch-up vaccination was 61·5% (58·2-64·7). Prevalence of HPV types 16 and 18 in women aged 18-20 years was lower in Natsal-3 than Natsal-2 (5·8% [3·9-8·6] vs 11·3% [6·8-18·2]; age-adjusted odds ratio 0·44 [0·21-0·94]). Gonorrhoea (<0·1% prevalence in women and men) and HIV (0·1% prevalence in women and 0·2% in men) were uncommon and restricted to participants with recognised high-risk factors. Since Natsal-2, substantial increases were noted in attendance at sexual health clinics (from 6·7% to 21·4% in women and from 7·7% to 19·6% in men) and HIV testing (from 8·7% to 27·6% in women and from 9·2% to 16·9% in men) in the past 5 years. INTERPRETATION: STIs were distributed heterogeneously, requiring general and infection-specific interventions. Increases in testing and attendance at sexual health clinics, especially in people at highest risk, are encouraging. However, STIs persist both in individuals accessing and those not accessing services. Our findings provide empirical evidence to inform future sexual health interventions and services. 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).

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).

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.

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

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).

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.

Consistency in reporting sensitive sexual behaviours in Britain: change in reporting bias in the second and third National Surveys of Sexual Attitudes and Lifestyles (Natsal-2 and Natsal-3).

OBJECTIVES: Britain's second National Survey of Sexual Attitudes and Lifestyles (Natsal-2) was conducted in 1999-2001 and the third (Natsal-3) was conducted in 2010-2012 to update prevalence estimates of sexual behaviours and assess changes over time. We investigated whether there was a change in reporting bias between these two cross-sectional surveys. METHODS: We analysed data from the 'common birth cohort' of participants born during 1956-1983, who were eligible to take part in Natsal-2 (n=10 764) and Natsal-3 (n=6907). We compared estimates for outcomes that occurred before Natsal-2 and expected these to be consistent between surveys if no change in reporting bias had occurred. RESULTS: A greater proportion of non-white men and women were in Natsal-3 consistent with demographic changes in Britain. Reporting behaviours was largely consistent between surveys for men. Fewer women in Natsal-3 reported early first intercourse or having child(ren) before age 20; they were also more likely to report not discussing sex with their parents at age 14. Men and women in Natsal-3 were more likely to report tolerant attitudes towards same-sex partnerships but less tolerance towards unfaithfulness in marriage and one-night-stands. CONCLUSIONS: We found little evidence of change in reporting bias among men since Natsal-2. Among women, a modest change in reporting bias was observed for a small number of experiences, possibly due to changes in participation, social acceptability and methodological differences between surveys. Changes in the reporting of sexual behaviours and attitudes over time observed in the wider Natsal-3 study are therefore likely to largely reflect real changes in the population.

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.

"We're Just Tired": Influences on Sexual Activity Among Male-Partnered Women in Midlife; A Mixed Method Study.

Studies into decline in sexual activity among women in midlife produce equivocal findings, some implicating hormonal and physiological changes, others psycho-social and environmental factors. Women's perspectives rarely inform interpretation of the data. Associations between sexual satisfaction, activity and function, and health and lifestyle factors were explored using data from 2133 female participants in the third British National Survey of Sexual Attitudes and Lifestyles (2010-2012). Semi-structured interviews (2012-2015) with 23 women aged 45-59 reporting sexual dissatisfaction in Natsal-3 explored their perceptions of the influences on their sexual activity. Analysis of the survey data showed sexual dissatisfaction to be less common than low frequency and function. Neither menopausal stage nor age was independently associated with any of the dimensions of sexual experience. Only relationship unhappiness was independently associated with all three and communicational difficulty with two (dissatisfaction and lower function). In-depth interviews identified influences on sexual activity not captured in the survey. Tiredness attributed to contemporary challenges of midlife was a dominant theme. Relationship quality mediated its adverse impact. Sexual experience in midlife must be interpreted in light of both life-stage and era, notably, the increasing demands on women in contemporary society and their impact on vitality. Efforts to address sexual wellbeing should take account of the wider social context.

Initial Impacts of COVID-19 on Sex Life and Relationship Quality in Steady Relationships in Britain: Findings from a Large, Quasi-representative Survey (Natsal-COVID).

Intimate relationships are ubiquitous and exert a strong influence on health. Widespread disruption to them may impact wellbeing at a population level. We investigated the extent to which the first COVID-19 lockdown (March 2020) affected steady relationships in Britain. In total, 6,654 participants aged 18-59 years completed a web-panel survey (July-August 2020). Quasi-representativeness was achieved via quota sampling and weighting. We explored changes in sex life and relationship quality among participants in steady relationships (n = 4,271) by age, gender, and cohabitation status, and examined factors associated with deterioration to a lower-quality relationship. A total of 64.2% of participants were in a steady relationship (of whom 88.9% were cohabiting). A total of 22.1% perceived no change in their sex-life quality, and 59.5% no change in their relationship quality. Among those perceiving change, sex-life quality was more commonly reported to decrease and relationship quality to improve. There was significant variation by age; less often by gender or cohabitation. Overall, 10.6% reported sexual difficulties that started/worsened during lockdown. In total, 6.9% reported deterioration to a "lower quality" relationship, more commonly those: aged 18-24 and aged 35-44; not living with partner (women only); and reporting depression/anxiety and decrease in sex-life quality. In conclusion, intimate relationship quality is yet another way in which COVID-19 has led to divergence in experience.

Development and Validation of a Brief Measure of Sexual Wellbeing for Population Surveys: The Natsal Sexual Wellbeing Measure (Natsal-SW).

Sexual wellbeing is an important aspect of population health. Addressing and monitoring it as a distinct issue requires valid measures. Our previous conceptual work identified seven domains of sexual wellbeing: security; respect; self-esteem; resilience; forgiveness; self-determination; and comfort. Here, we describe the development and validation of a measure of sexual wellbeing reflecting these domains. Based on the analysis of 40 semi-structured interviews, we operationalized domains into items, and refined them via cognitive interviews, workshops, and expert review. We tested the items via two web-based surveys (n = 590; n = 814). Using data from the first survey, we carried out exploratory factor analysis to assess and eliminate poor performing items. Using data from the second survey, we carried out confirmatory factor analysis to examine model fit and associations between the item reduced measure and external variables hypothesized to correlate with sexual wellbeing (external validity). A sub-sample (n = 113) repeated the second survey after 2 weeks to evaluate test-retest reliability. Confirmatory factor analysis indicated that a "general specific model" had best fit (RMSEA: 0.064; CFI: 0.975, TLI: 0.962), and functioned equivalently across age group, gender, sexual orientation, and relationship status. The final Natsal-SW measure comprised 13 items (from an initial set of 25). It was associated with external variables in the directions hypothesized (all p < .001), including mental wellbeing (0.454), self-esteem (0.564), body image (0.232), depression (-0.384), anxiety (-0.340), sexual satisfaction (0.680) and sexual distress (-0.615), and demonstrated good test-retest reliability (ICC = 0.78). The measure enables sexual wellbeing to be quantified and understood within and across populations.

Online Sexual Partner Seeking as a Social Practice: Qualitative Evidence from the 4th British National Survey of Sexual Attitudes and Lifestyles (Natsal-4).

Once perceived as a means for those unsuccessful at traditional dating, online dating has become normalized as a way to seek sexual or romantic partners. In 2019, we interviewed 40 British adults on the role of digital technologies in their sexual lives; this paper draws on the accounts of 22 who had used such technologies for seeking partners. We analyzed qualitative accounts of online partner seeking as a social practice, drawing on a sample diverse in age, gender and sexual orientation, and informed by sexual script and social practice theory. Our theoretically informed analysis emphasized the multiple meanings and goals involved, the affordances of the technology and individuals' skills. Our study provided several novel contributions. Young heterosexual people commonly used general social media, rather than dating apps, to meet partners; meeting partners often involved complex interplays between online and offline networks and encounters. Risks were defined not merely in relation to "risky others" but in terms of one's own actions or attitudes. Participants deployed various skills in minimizing harms such as non-consensual sharing of intimate images, and used self-care skills such as setting limits to engagement.

Intimate physical contact between people from different households during the COVID-19 pandemic: a mixed-methods study from a large, quasi-representative survey (Natsal-COVID).

OBJECTIVES: Physical distancing as a non-pharmaceutical intervention aims to reduce interactions between people to prevent SARS-CoV-2 transmission. Intimate physical contact outside the household (IPCOH) may expand transmission networks by connecting households. We aimed to explore whether intimacy needs impacted adherence to physical distancing following lockdown in Britain in March 2020. METHODS: The Natsal-COVID web-panel survey (July-August 2020) used quota-sampling and weighting to achieve a quasi-representative population sample. We estimate reporting of IPCOH with a romantic/sexual partner in the 4 weeks prior to interview, describe the type of contact, identify demographic and behavioural factors associated with IPCOH and present age-adjusted ORs (aORs). Qualitative interviews (n=18) were conducted to understand the context, reasons and decision making around IPCOH. RESULTS: Of 6654 participants aged 18-59 years, 9.9% (95% CI 9.1% to 10.6%) reported IPCOH. IPCOH was highest in those aged 18-24 (17.7%), identifying as gay or lesbian (19.5%), and in steady non-cohabiting relationships (56.3%). IPCOH was associated with reporting risk behaviours (eg, condomless sex, higher alcohol consumption). IPCOH was less likely among those reporting bad/very bad health (aOR 0.54; 95% CI 0.32 to 0.93) but more likely among those with COVID-19 symptoms and/or diagnosis (aOR 1.34; 95% CI 1.10 to 1.65). Two-thirds (64.4%) of IPCOH was reported as being within a support bubble. Qualitative interviews found that people reporting IPCOH deliberated over, and made efforts to mitigate, the risks. CONCLUSIONS: Given 90% of people did not report IPCOH, this contact may not be a large additional contributor to SARS-CoV-2 transmission, although heterogeneity exists within the population. Public health messages need to recognise how single people and partners living apart balance sexual intimacy and relationship needs with adherence to control measures.