Sexual and reproductive health in Britain during the first year of the COVID-19 pandemic: cross-sectional population survey (Natsal-COVID-Wave 2) and national surveillance data.

OBJECTIVES: To assess sexual behaviour, and sexual and reproductive health (SRH) outcomes, after 1 year of the COVID-19 pandemic in Britain. METHODS: 6658 participants aged 18-59 and resident in Britain completed a cross-sectional web-panel survey (Natsal-COVID-Wave 2, March-April 2021), 1 year after the first lockdown. Natsal-COVID-2 follows the Natsal-COVID-Wave 1 survey (July-August 2020) which captured impacts in the initial months. Quota-based sampling and weighting resulted in a quasi-representative population sample. Data were contextualised with reference to the most recent probability sample population data (Natsal-3; collected 2010-12; 15 162 participants aged 16-74) and national surveillance data on recorded sexually transmitted infection (STI) testing, conceptions, and abortions in England/Wales (2010-2020). The main outcomes were: sexual behaviour; SRH service use; pregnancy, abortion and fertility management; sexual dissatisfaction, distress and difficulties. RESULTS: In the year from the first lockdown, over two-thirds of participants reported one or more sexual partners (women 71.8%; men 69.9%), while fewer than 20.0% reported a new partner (women 10.4%; men 16.8%). Median occasions of sex per month was two. Compared with 2010-12 (Natsal-3), we found less sexual risk behaviour (lower reporting of multiple partners, new partners, and new condomless partners), including among younger participants and those reporting same-sex behaviour. One in 10 women reported a pregnancy; pregnancies were fewer than in 2010-12 and less likely to be scored as unplanned. 19.3% of women and 22.8% of men were distressed or worried about their sex life, significantly more than in 2010-12. Compared with surveillance trends from 2010 to 2019, we found lower than expected use of STI-related services and HIV testing, lower levels of chlamydia testing, and fewer conceptions and abortions. CONCLUSIONS: Our findings are consistent with significant changes in sexual behaviour, SRH, and service uptake in the year following the first lockdown in Britain. These data are foundational to SRH recovery and policy planning.

How did the COVID-19 pandemic affect access to condoms, chlamydia and HIV testing, and cervical cancer screening at a population level in Britain? (Natsal-COVID).

OBJECTIVES: To investigate how differential access to key interventions to reduce STIs, HIV and their sequelae changed during the COVID-19 pandemic. METHODS: British participants (18-59 years) completed a cross-sectional web survey 1 year (March-April 2021) after the initial lockdown in Britain. Quota-based sampling and weighting resulted in a quasi-representative population sample. We compared Natsal-COVID data with Natsal-3, a household-based probability sample cross-sectional survey (16-74 years) conducted in 2010-2012. Reported unmet need for condoms because of the pandemic and uptake of chlamydia testing/HIV testing/cervical cancer screening were analysed among sexually experienced participants (18-44 years) (n=3869, Natsal-COVID; n=8551, Natsal-3). ORs adjusted for age and other potential confounders describe associations with demographic and behavioural factors. RESULTS: In 2021, 6.9% of women and 16.2% of men reported unmet need for condoms because of the pandemic. This was more likely among participants: aged 18-24 years, of black or black British ethnicity, and reporting same-sex sex (past 5 years) or one or more new relationships (past year). Chlamydia and HIV testing were more commonly reported by younger participants, those reporting condomless sex with new sexual partners and men reporting same-sex partners; a very similar distribution to 10 years previously (Natsal-3). However, there were differences during the pandemic, including stronger associations with chlamydia testing for men reporting same-sex partners; with HIV testing for women reporting new sexual partners and with cervical screening among smokers. CONCLUSIONS: Our study suggests differential access to key primary and secondary STI/HIV prevention interventions continued during the first year of the COVID-19 pandemic. However, there was not strong evidence that differential access has changed during the pandemic when compared with 2010-2012. While the pandemic might not have exacerbated inequalities in access to primary and secondary prevention, it is clear that large inequalities persisted, typically among those at greatest STI/HIV risk.

Sexual consent norms in a cross-sectional national sample of the UK.

BACKGROUND: Sexual assault is a pervasive problem in the UK, and young women are disproportionately affected. We sought to provide an initial account of sexual consent norms in the UK and whether they differ by gender and age. METHOD: The present study was a secondary analysis of data collected by the Family Planning Association, which conducted an online survey (N = 2003) to assess experiences with, knowledge of, and attitudes toward consent. The sample represented all regions of the UK and spanned ages 14-55. RESULTS: Definitions of sexual consent endorsed by women and older age groups more closely aligned with the tenets of affirmative consent compared with men and younger age groups. Women and older age groups were also more likely to perceive that various nonverbal cues may be used to interpret sexual consent or refusal and were more supportive of people being able to withdraw their sexual consent. CONCLUSION: Maladaptive sexual consent norms seemed to be prevalent among men and young people in the UK, which may contribute to young women's elevated risk of experiencing sexual assault. Our findings support the UK's recent relationships and sex education curriculum that actively promotes healthy sexual consent norms.

Effects of Typical and Binge Drinking on Sexual Consent Perceptions and Communication.

Young adults frequently engage in sexual activity after consuming alcohol and, consequently, may try to communicate sexual consent while intoxicated. We aimed to assess how people's drinking behaviors relate to their consent perceptions and communication with their current sexual partners. Using aggregated data from a 30-day daily diary study, young adults (n = 86, 77.9% women, 86% in a monogamous relationship) reported instances of partnered sexual activity and their perceptions of whether that activity was consensual. For each partnered sexual event, participants reported what they said or did to perceive the sexual activity as consensual. Responses were coded as active consent communication (i.e., using verbal or nonverbal cues) or tacit knowledge (i.e., using context to understand consent). During an exit survey, participants retrospectively reported how many days they drank (i.e., typical drinking) during the 30-day study and whether they binge drank. Typical and binge drinking were associated with identifying sexual experiences as consensual. Participants who binge drank relied less on active consent communication and more on context compared with those who did not binge drink. Young adults who binge drink may rely more on tacit knowledge because alcohol impedes their ability to process complex stimuli-such as active consent cues.

Momentary versus Retrospective Sexual Consent Perceptions.

Perceiving potential indicators of a person's willingness is an integral component of sexual consent. Preliminary qualitative evidence using vignettes suggested that consent perceptions can change over the course of a sexual scenario. In the present study, we extended previous research by directly comparing momentary and retrospective sexual consent perceptions using a quantitative study design. Employing a staggered vignette protocol, we examined participants' (n = 962; 72.0% female) momentary perceptions of fictional characters' sexual consent and compared them with participants' retrospective perceptions of the characters' consent. We hypothesized that participants would demonstrate a hindsight bias in that they would retrospectively indicate they thought the fictional characters were first willing to engage in sexual behavior earlier than when they did momentarily. We found that differences in participants' momentary versus retrospective perceptions of characters' sexual consent varied by the type of behavior. As we expected, participants demonstrated a hindsight bias for making out. Contrary to our hypothesis, participants were hesitant to retrospectively report that the characters were willing to engage in the other sexual behaviors (e.g., oral, vaginal, anal sex) at a point earlier than their momentary perceptions. That momentary and retrospective sexual consent perceptions significantly differ corroborates previous recommendations that sexual consent be conceptualized as an ongoing process.

Sexual Consent Perceptions of a Fictional Vignette: A Latent Growth Curve Model.

Sexual consent can be conceptualized as a process of accumulating cues that build toward and continue throughout a consensual sexual encounter. How people perceive the cues of others during this process is an important aspect of consent. However, previous research has not investigated the trajectories of people's consent perceptions throughout such a process. Using a novel staggered vignette protocol, we examined participants' (N = 1218; 64.4% female) perceptions of fictional targets' sexual consent at 11 time points. We tested latent growth curve models using multilevel structural equation modeling to examine trajectories in consent perceptions over the course of the vignette. We hypothesized that mean differences and rates of change would be associated with several constructs relevant to sexual consent. We found that initial consent perceptions and trends over the course of the vignette varied by whether the participant was a university student, by an alcohol manipulation in the vignette, by the fictional target's sex, and by type of sexual behavior. Researchers should examine whether our findings on consent perceptions of a fictional vignette extend to people's actual sexual encounters, including potential associations between the three primary aspects of sexual consent: perceptions, feelings, and communication.

Development of a Measure to Assess What Young Heterosexual Adults Say They Learn About Sex from Pornography.

This study involved the development of two new measures to assess what some young heterosexual-identifying adults report learning about sex from pornography. Inventory items were generated from an extensive literature review and six qualitative focus group sessions with young adults (N = 54) aged 18-29 which explored how pornography could be used as a source of sexual information. A total of 135 items pertaining to sexual learning from pornography were produced, reviewed and categorized by a sample of young adults (n = 9), and finally reviewed for item and construct relevance by a panel of pornography, sex education and scale development experts (n = 6). Inventory items were administered to a sample of young adult university students (n = 1306). Two separate exploratory factor analyses were conducted for the female and male datasets. The final factors were reviewed by a panel of young adults = 8) to identify the theme of each factor. Both the SIPI-F and SIPI-M yielded three factors: (1) How to be a good sexual partner, (2) Body aesthetic, and (3) Sexual exploration. Results show that pornography provides information about a range of sex-related topics. Findings also show that more frequent female pornography users reported learning more about how to be a good sexual partner and body aesthetic than less frequent pornography users. The SIPI-F and SIPI-M can be useful for examining a variety of questions regarding the use of pornography as an informal source of sexual information and its correlates.

Sexual Consent in Committed Relationships: A Dyadic Study.

Sexual consent is a multidimensional construct that requires the participation of all involved in a sexual encounter; however, previous research has almost exclusively relied on one person's perspective. To address this, we collected open- and closed-ended data on sexual consent from 37 dyads in committed sexual relationships (N = 74). We found that relationship length was associated with sexual consent and couples who accurately perceived each other's consent communication cues reported elevated levels of internal consent feelings. Communicating willingness to engage in sexual activity remains important even within committed relationships. Preliminary findings suggest that further investigations of dyadic nuances of sexual consent are warranted.

Internal and external sexual consent during events that involved alcohol, cannabis, or both.

Background Substance-involved sexual activity is common. Even though people recognise that substance-related impairment can be a barrier to people's ability to consent to sexual activity, most do not believe that substance use automatically negates sexual consent. We extended previous work on substance-related effects on internal and external consent by investigating sexual events that involved alcohol, cannabis, or both. METHODS: For 28 days, 113 participants (MAge = 29.2 years, 57.5% women, 70.8% White) responded to three surveys per day on their personal devices. At time points when participants reported having engaged in partnered sexual activity, they were asked to report their alcohol use, cannabis use, internal consent feelings, and external consent communication. RESULTS: Across 1189 partnered sexual events, 31.5% involved alcohol, cannabis, or both. Sexual events that involved combined use were associated with diminished feelings of safety/comfort and feelings that the sexual act was consensual, compared with events that involved neither substance. Greater levels of alcohol consumption were descriptively associated with lower ratings of internal sexual consent. CONCLUSIONS: We found that combined use of alcohol and cannabis may lead to lower internal sexual consent than using either substance alone - potentially due to greater levels of impairment associated with polysubstance use. Sexual health education programs should consider more nuanced approaches to teaching people how to navigate substance use and sexual consent.

Sexual Precedent's Effect on Sexual Consent Communication.

Sexual consent is one's voluntary, sober, and conscious willingness to engage in a particular sexual behavior with a particular person within a particular context. Sexual precedent theory posits that people believe that engaging in consensual sex at one point in time implies consent to later sexual encounters with that person. By assuming consent once a sexual precedent is set, people may rely less on communication cues. We sought to provide quantitative support for the claim that sexual precedent influences sexual consent in people's sexual relationships. To capture variability across sexual experiences, we collected daily sexual behavior data from each participant (n = 84) over a period of 30 days. We found a curvilinear relationship between sexual history with a partner and how people perceived consent during sexual activity with that partner (p = .003, ∆R2 = .089). A piecewise regression revealed that participants were less likely to report consent communication cues as sexual precedent increased until about 575 previous sexual behaviors (p = .003, R2 = .122); after this point, participants were more likely to report consent communication cues as sexual precedent increased (p = .028, R2 = .179). Overall, we provide the first quantitative evidence that consent conceptualization varies both within the person and across relationships regarding sexual precedent. In our discussion, we emphasize that sexual consent is contextual and cannot be assumed even after previous sexual encounters.

Are Women's Orgasms Hindered by Phallocentric Imperatives?

Women who have sex with women (WSW) are more likely to report experiencing an orgasm during partnered sex, compared to women who have sex with men (WSM). We investigated whether this difference can be partially accounted for by phallocentric imperatives-gendered sexual scripts that prioritize men's sexual experience. For example, these imperatives emphasize vaginal-penile intercourse (i.e., the coital imperative) and men's physical pleasure (i.e., the male orgasm imperative). We reasoned that a larger variety of sexual behaviors indicates less adherence to the coital imperative and that more self-oriented orgasm goals for women indicate less adherence to the male orgasm imperative. Consistent with previous work, we expected WSW to report higher rates of orgasm than WSM when taking frequency of sex into account. We also hypothesized that this difference in orgasm rates would dissipate when controlling for variety of sexual behavior and women's self-oriented orgasm goals. In a sample of 1988 WSM and 308 WSW, we found that WSW were 1.33 times (p < .001) more likely to report experiencing an orgasm than WSM, controlling for frequency of sex. This incidence rate ratio was reduced to 1.16 (p < .001) after taking into account variety of sexual behavior and self-oriented orgasm goals. Our findings indicate that certain sexual scripts (e.g., phallocentric imperatives) help explain the orgasm discrepancy between WSW and WSM. We discuss masturbation as another male-centered practice that may be relevant to this gap, as well as implications for intervention and future research.

Associations Between Recent Contraceptive Use and First Sex Behaviors of Scottish Adolescents: A Brief Report.

Objectives: We examined associations between recent contraceptive use and first-sex behaviors (early initiation, substance use, contraceptive use) among adolescents in Scotland. Methods: We used data from the Health Behavior in School-aged Children study. Results: Controlling for early initiation and substance use, girls and boys who used contraceptives at first sex were 7.5 and 12.3 times more likely to use contraceptives at most recent sexual intercourse than adolescents who did not (p < .001). We also present preliminary evidence on contraceptive use of Scottish adolescents in 2022. Conclusions: Experiences during adolescents' first sex may have lasting implications for later sexual behavior.

The Effects of Alcohol Intoxication on Perceptions of Consent and Refusal Indicators in a Fictional Alcohol-Involved Sexual Encounter.

Alcohol intoxication may influence how bystanders interpret other people's consent and refusal cues. We examined the effects of alcohol intoxication on participants' perceptions of characters' consent and refusal indicators in a fictional vignette depicting an alcohol-involved sexual encounter. Young adults (n = 119, 52% women) participated in an alcohol administration experiment examining the influence of acute intoxication on bystander perceptions during a vignette depicting a character who is intoxicated and declines a sexual advance from another character, who ignores her refusal and continues to pursue sexual activity. Participants were randomly assigned to an alcohol or non-alcohol condition and then guided through a semi-structured interview in which we asked about the characters' consent and refusal cues. Interviews were analyzed using both inductive and deductive coding. Most participants eventually indicated the encounter was nonconsensual, but approximately 9% of participants described the encounter as entirely consensual and another 42% of participants described the interaction as initially consensual and then nonconsensual. Participants discussed nuanced accounts of consent and refusal cues, including indicators related to alcohol consumption. Disregarding intoxication and gender, participants eventually recognized the situation as nonconsensual and thus potentially risky. However, some participants recognized this risk earlier in the encounter than others. Consequently, bystanders who recognize risk later in a situation may have fewer opportunities to intervene before a situation escalates. We recommend sexual assault prevention educators take a more nuanced approach when discussing consent and refusal indicators, emphasizing contextual factors that may indicate risk.

Pornography Use and Sexual Objectification of Others.

Researchers have demonstrated associations between use of pornography and sexual objectification of women. We examine whether self-reported preference for degrading pornography moderated the relation between use frequency and sexual objectification of others. Participants were 1,342 heterosexual women and men residing in the United States. In women and men, pornography use frequency was associated with the sexual objectification of others, even after controlling for interest in generally explicit content. In men, interest in degrading pornography content significantly predicted sexual objectification of women. Our results suggest greater pornography use is associated with greater sexual objectification of others, across a variety of content categories.

Prevention of, and response to, sexual harassment at secondary school: A system map.

BACKGROUND: Sexual harassment in secondary school is common but only recently acknowledged as a widespread problem in the United Kingdom. There is limited research on how schools respond to incidents of sexual harassment. The aim of this study was to understand how school systems shape the dynamics of disclosure, reporting and handling of sexual harassment in school (including behaviours, processes, norms), and to identify opportunities for effecting systems change. METHODS: We used participatory systems mapping to elicit school stakeholders' perspectives on systems factors and their connections. Researchers built the map based on in-person workshops with students (n = 18) and staff (n = 4) from three schools in Scotland. Survey data (n = 638 students; n = 119 staff) was used to augment participant perspectives. The map was validated via three workshops (two online, one in-person) involving students and staff from seven schools. RESULTS: The final map (causal loop diagram) represents a hypothesised system of 25 causally connected factors and three feedback loops shaping the disclosure, reporting and handling of sexual harassment. We grouped these factors into four interlinked themes: 1] Knowledge and confidence; 2] Trust in reporting system and processes; 3] Communication, confidentiality and safeguarding; and, 4] Prioritisation of sexual harassment. CONCLUSIONS AND IMPLICATIONS: This study highlights the interconnectedness of factors shaping disclosure, reporting and handling of sexual harassment within secondary schools. The map surfaces key challenges for schools and provides a foundation for learning and discussions on where to focus efforts in future.

Inequalities in health complaints: 20-year trends among adolescents in Scotland, 1998-2018.

This study examined trends in inequalities in health complaints among early adolescents in Scotland from 1998 to 2018. We analysed data from the Health Behaviour in School-aged Children (HBSC) survey conducted in Scotland in 1998, 2002, 2006, 2010, 2014 and 2018. A self-report questionnaire was administered in schools to a nationally representative sample of 11-, 13-, and 15-year-olds (n = 29,250). Health complaints were measured using a scale comprising four psychological symptoms (feeling low, feeling nervous, irritability and sleep difficulties) and four somatic symptoms (headache, backache, stomachache and dizziness). Socio-economic status was measured using the Family Affluence Scale. Between 1998 and 2018, there were significant increases in the proportion of girls and boys reporting feeling low, feeling nervous, sleep difficulties and backache. Prevalence of the eight individual health complaints was higher among girls and adolescents from lower affluence families. Socio-economic inequalities increased over time, such that declines in mental health were greatest among low affluence adolescents. The data show worsening trends in health complaints among Scottish adolescents between 1998 and 2018, particularly for girls and adolescents from low affluence families. Increasing inequalities in mental health highlight the need to address the underlying social and structural determinants of adolescent mental health.

Mental health and loneliness in Scottish schools: A multilevel analysis of data from the health behaviour in school-aged children study.

BACKGROUND: Adolescent loneliness and poor mental health represent dual public health concerns. Yet, associations between loneliness and mental health, and critically, how these associations vary in school settings are less understood. AIMS: Framed by social-ecological theory, we aimed to identify key predictors of adolescent mental health and examine school-level variation in the relationship between loneliness and mental health. SAMPLE: Cross-sectional data on adolescents from the 2018 wave of the Health Behaviour in School-aged Children study (HBSC) in Scotland were used (N = 5286). METHODS: Mental health was measured as a composite variable containing items assessing nervousness, irritability, sleep difficulties and feeling low. Loneliness was measured via a single item assessing how often adolescents felt 'left out'. Multilevel models were used to identify social-ecological predictors of mental health, associations with loneliness and between-school variation. RESULTS: Loneliness, as well as demographic, social and school factors, was found to be associated with mental health. Mental health varied across schools, with the between-school difference greater among adolescents with high levels of loneliness. Additionally, the negative effect of loneliness on mental health was stronger in schools with lower average mental health scores. CONCLUSIONS: The findings suggest that schools can play an important role in shaping adolescent mental health. Our study uniquely identifies that school-based interventions targeting mental health may be especially necessary among lonely adolescents, and programmes aimed at tackling loneliness may be more beneficial in schools with poorer mental health.

Contraceptive use and pregnancy planning in Britain during the first year of the COVID-19 pandemic: findings from a large, quasi-representative survey (Natsal-COVID).

BACKGROUND: Contraceptive services were significantly disrupted during the COVID-19 pandemic in Britain. We investigated contraception-related health inequalities in the first year of the pandemic. METHODS: Natsal-COVID Wave 2 surveyed 6658 adults aged 18-59 years between March and April 2021, using quotas and weighting to achieve quasi-representativeness. Our analysis included sexually active participants aged 18-44 years, described as female at birth. We analysed contraception use, contraceptive switching due to the pandemic, contraceptive service access, and pregnancy plannedness. RESULTS: Of 1488 participants, 1619 were at risk of unplanned pregnancy, of whom 54.1% (51.0%-57.1%) reported routinely using effective contraception in the past year. Among all participants, 14.3% (12.5%-16.3%) reported switching or stopping contraception due to the pandemic. 3.2% (2.0%-5.1%) of those using effective methods pre-pandemic switched to less effective methods, while 3.8% (2.5%-5.9%) stopped. 29.3% (26.9%-31.8%) of at-risk participants reported seeking contraceptive services, of whom 16.4% (13.0%-20.4%) reported difficulty accessing services. Clinic closures and cancelled appointments were commonly reported pandemic-related reasons for difficulty accessing services. This unmet need was associated with younger age, diverse sexual identities and anxiety symptoms. Of 199 pregnancies, 6.6% (3.9%-11.1%) scored as 'unplanned'; less planning was associated with younger age, lower social grade and unemployment. CONCLUSIONS: Just under a third of participants sought contraceptive services during the pandemic and most were successful, indicating resilience and adaptability of service delivery. However, one in six reported an unmet need due to the pandemic. COVID-induced inequalities in service access potentially exacerbated existing reproductive health inequalities. These should be addressed in the post-pandemic period and beyond.