"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.

Pathways to help-seeking for sexual difficulties in older adults: qualitative findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3).

BACKGROUND: Older adults are at an increased risk of sexual difficulties due to ageing and chronic health conditions. While they experience barriers to seeking and receiving help for sexual difficulties there is a dearth of research about the help-seeking journey. OBJECTIVE: To explore decision-making in context; particularly, the reasons why older adults do, or do not, seek help for sexual difficulties. METHODS: Semi-structured interviews were conducted with 11 men and 12 women aged 58-75 who reported having a health condition, disability or medication that had affected their sex life in the last year. Participants were part of the third British National Survey of Sexual Attitudes and Lifestyles (Natsal-3). Data were analysed thematically. RESULTS: Help-seeking was rarely a predictable or linear process. Participants tended to wait and see if the sexual difficulty got better on its own or improved as a result of lifestyle changes. An often-lengthy period of thinking, researching and planning could end with a decision to seek professional help, to not seek help, or do nothing for now. A significant barrier was concern about the interaction of medicines prescribed for the sexual difficulty with those already taken for chronic health conditions. Patient fear of not being taken seriously and doctor reticence to ask thwarted potential conversations. Help-seeking journeys often ended without resolution, even when professional help was sought. CONCLUSIONS: To give patients and practitioners permission to raise the topic, suggestions include providing patients with a pre-consultation card which lists topics they would like to talk about, including sexual issues.

Navigating new sexual partnerships in midlife: a socioecological perspective on factors shaping STI risk perceptions and practices.

OBJECTIVE: Despite increases in STIs among those over 40, little is known about the social context of STI transmission among people experiencing relationship transition in midlife, and few sexual health promotion initiatives are targeted at this group. This study sought to identify factors shaping STI risk perceptions and practices among midlife individuals either contemplating or having sex with new partners following the end of a long-term relationship. METHODS: Participants were purposively selected from respondents to Britain's third National Survey of Sexual Attitudes and Lifestyles, using three eligibility criteria: aged 40-59, reported experience of the end of a marital or cohabiting relationship with an opposite-sex partner in the past 5 years, and willingness to participate in a qualitative interview. Qualitative data were generated via face-to-face interviews with 10 women and 9 men and analysed inductively using thematic analysis, with themes then organised using a socioecological framework. RESULTS: Participants' accounts of new sexual partnerships in midlife indicate that STI risk perceptions and practices are shaped by factors operating at multiple levels across the socioecological arena (individual, partnership, peers and communities, societal). Constraints on, and resources for, the navigation of sexual safety include self-perceived STI risk rooted in past rather than present circumstances; legacies of mistrust within former relationships; intersecting gender-age dynamics in negotiation of risk prevention strategies with new partners; peers and younger relatives' influences on understandings of sexual risk and safety; postrelationship change in social networks that increase or mitigate vulnerability to sexual risk; age-related barriers to accessing condoms; and disconnection from safer sex messaging and services culturally coded as for the young. CONCLUSIONS: Improving sexual health among midlife adults requires age-sensitive interventions designed to address multilevel constraints, and harness positive influences, on the navigation of sexual safety at this stage of life.

Help-seeking for genitourinary symptoms: a mixed methods study from Britain's Third National Survey of Sexual Attitudes and Lifestyles (Natsal-3).

OBJECTIVES: Quantify non-attendance at sexual health clinics and explore help-seeking strategies for genitourinary symptoms. DESIGN: Sequential mixed methods using survey data and semistructured interviews. SETTING: General population in Britain. PARTICIPANTS: 1403 participants (1182 women) from Britain's Third National Survey of Sexual Attitudes and Lifestyles (Natsal-3; undertaken 2010-2012), aged 16-44 years who experienced specific genitourinary symptoms (past 4 weeks), of whom 27 (16 women) who reported they had never attended a sexual health clinic also participated in semistructured interviews, conducted May 2014-March 2015. PRIMARY AND SECONDARY OUTCOME MEASURES: From survey data, non-attendance at sexual health clinic (past year) and preferred service for STI care; semistructured interview domains were STI social representations, symptom experiences, help-seeking responses and STI stigma. RESULTS: Most women (85.9% (95% CI 83.7 to 87.9)) and men (87.6% (95% CI 82.3 to 91.5)) who reported genitourinary symptoms in Natsal-3 had not attended a sexual health clinic in the past year. Around half of these participants cited general practice (GP) as their preferred hypothetical service for STI care (women: 58.5% (95% CI 55.2% to 61.6%); men: 54.3% (95% CI 47.1% to 61.3%)). Semistructured interviews elucidated four main responses to symptoms: not seeking healthcare, seeking information to self-diagnose and self-treat, seeking care at non-specialist services and seeking care at sexual health clinics. Collectively, responses suggested individuals sought to gain control over their symptoms, and they prioritised emotional reassurance over accessing medical expertise. Integrating survey and interview data strengthened the evidence that participants preferred their general practitioner for STI care and extended understanding of help-seeking strategies. CONCLUSIONS: Help-seeking is important to access appropriate healthcare for genitourinary symptoms. Most participants did not attend a sexual health clinic but sought help from other sources. This study supports current service provision options in Britain, facilitating individual autonomy about where to seek help.

Health status, sexual activity and satisfaction among older people in Britain: A mixed methods study.

BACKGROUND: Men and women are increasingly likely to stay sexually active into later life, but research shows that sexual activity and satisfaction decrease with increasing age. Ill health and medical treatments may affect sexual activity but there is little research on why some older people with a health problem affecting their sexual activity are satisfied with their sex life, and others are not. METHODS: A mixed method study integrating data and analyses from the third British National Survey of Sexual Attitudes and Lifestyles (n = 3343 aged 55-74 years) and from follow-up in-depth interviews with 23 survey participants who reported having a health condition or taking medication affecting their sex life. RESULTS: Overall, 26.9% of men and 17.1% of women aged 55-74 reported having a health condition that affected their sex life. Among this group, women were less likely than men to be sexually active in the previous 6 months (54.3% vs 62.0%) but just as likely to be satisfied with their sex life (41.9% vs 42.1%). In follow-up interviews, participants sometimes struggled to tease out the effects of ill health from those of advancing age. Where effects of ill health were identified, they tended to operate through the inclination and capacity to be sexually active, the practical possibilities for doing so and the limits placed on forms of sexual expression. In close relationships partners worked to establish compensatory mechanisms, but in less close relationships ill health provided an excuse to stop sex or deterred attempts to resolve difficulties. Most fundamentally, ill health may influence whether individuals have a partner with whom to have sex. CONCLUSION: The data show complex interactions between health, lifestyle and relationship factors that affect sexual activity/satisfaction. When dealing with sexual problems in older people, practitioners need to take account of individual lifestyle, needs and preferences.

Awareness of and attitudes to sexually transmissible infections among gay men and other men who have sex with men in England: a qualitative study.

Background Rates of sexually transmissible infections (STIs) have increased over recent years among gay men and other men who have sex with men (MSM) in England and Wales. HIV diagnoses remain high in this group and men with diagnosed HIV are disproportionally affected by STIs. MSM are therefore a priority for health promotion efforts to reduce STIs. Understanding awareness of and attitudes towards STIs is essential in developing health promotion interventions to reduce prevalence. METHODS: Eight focus group discussions (FGDs) with a total of 61 MSM in four English cities included a ranking exercise to gauge how 'scary' participants thought 11 STIs are. The exercise sought insights into participants' awareness of, knowledge about and attitudes towards STIs and blood-borne viruses (BBVs). FGDs were audio-recorded, transcribed and data analysed thematically. RESULTS: All groups ranked HIV and Hepatitis C virus (HCV) as the scariest infections, and the majority ranked syphilis and herpes as highly scary. Scabies was ranked as the least scary by most groups. Rankings were dependent on how well informed participants felt about an infection, its transmission mechanisms, health affect and the availability of vaccines and treatment. Personal experience or that of friends influenced perceptions of particular infections, as did their prevalence, treatment options, visibility of symptoms and whether an STI could be cleared from the body. CONCLUSIONS: The study findings suggest that, although some MSM are well informed, there is widespread lack of knowledge about the prevalence, modes of transmission, health implications and treatment regimens of particular STIs.

Where do women and men in Britain obtain contraception? Findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3).

INTRODUCTION: To estimate the prevalence of use of different sources of contraceptive supplies in Britain and its variation by key demographic and behavioural characteristics. METHODS: Cross-sectional probability sample survey of women and men aged 16-74 years, resident in Britain, interviewed between 2010 and 2012. Analyses reported here were of 4571 women and 3142 men aged 16-44 years who reported having vaginal sex in the past year. Those relying exclusively on sterilisation (including hysterectomy) were excluded. Sources of contraceptive supplies were categorised as: general practice, community clinic, retail and other. Prevalence of use of these sources was estimated, and associated factors examined. RESULTS: Some 87.0% of women and 73.8% of men accessed at least one source of contraceptive supplies in the previous year. Most women (59.1%) used general practice and most men (54.6%) used retail outlets. Community clinics were less commonly used, by 23.0% of women and 21.3% of men, but these users were younger and at greater sexual health risk. These associations were also observed among the 27.3% of women and 30.6% of men who used more than one source category (general practice, community clinic or retail) for contraceptive supplies. CONCLUSIONS: People in Britain use a variety of sources to obtain contraceptive supplies and some sources are more commonly used by those more vulnerable to poorer sexual health. Our findings suggest that national policy changes to increase access to contraceptive methods have had an effect on the diversity of services used.

Sexual behaviours and sexual health outcomes among young adults with limiting disabilities: findings from third British National Survey of Sexual Attitudes and Lifestyles (Natsal-3).

OBJECTIVE: To explore whether the sexual behaviours and sexual health outcomes of young adults with self-reported disabilities that they perceive limit their activities ('limiting disability') differ from those without disability. DESIGN: Complex survey analyses of cross-sectional probability sample survey data collected between September 2010 and August 2012 using computer-assisted personal interviewing and computer-assisted self-interview. SETTING: British general population. PARTICIPANTS: 7435 women and men aged 17-34 years, resident in private households in Britain, interviewed for the third National Survey of Sexual Attitudes and Lifestyles. MAIN OUTCOME MEASURES: Self-reported sexual behaviour and sexual health outcomes. RESULTS: Approximately 1 in 10 participants reported having a limiting disability. Sexual behaviours were similar between those with limiting disability and those without, with a few exceptions. Women and men with limiting disability were less likely to report having sexual partner(s) (past year, adjusted ORs (AORs) for age and social class: AORs: 0.71, 0.75, respectively). Women with limiting disability were more likely to report having same-sex partner(s) in the past 5 years (AOR: 2.39). Differences were seen in sexual health outcomes, especially among women; those with limiting disability were more likely to report having experienced non-volitional sex (ever, AOR: 3.08), STI diagnoses (ever, AOR: 1.43) and sought help/advice regarding their sex life (past year, AOR: 1.56). Women with limiting disability were also more likely to feel distressed/worried about their sex life than those without limiting disability (AORs: 1.61). None of these associations were seen in men. CONCLUSIONS: Young adults with limiting disability, especially women, are more likely to report adverse sexual health outcomes than those without, despite comparatively few behavioural differences. It is important to ensure that people with disabilities are included in sexual health promotion and service planning, and targeted policy and programme interventions are needed to address negative sexual health outcomes disproportionally experienced by people with disabilities.

Sexual identity, attraction and behaviour in Britain: The implications of using different dimensions of sexual orientation to estimate the size of sexual minority populations and inform public health interventions.

BACKGROUND: Sexual orientation encompasses three dimensions: sexual identity, attraction and behaviour. There is increasing demand for data on sexual orientation to meet equality legislation, monitor potential inequalities and address public health needs. We present estimates of all three dimensions and their overlap in British men and women, and consider the implications for health services, research and the development and evaluation of public health interventions. METHODS: Analyses of data from Britain's third National Survey of Sexual Attitudes and Lifestyles, a probability sample survey (15,162 people aged 16-74 years) undertaken in 2010-2012. FINDINGS: A lesbian, gay or bisexual (LGB) identity was reported by 2·5% of men and 2·4% of women, whilst 6·5% of men and 11·5% of women reported any same-sex attraction and 5·5% of men and 6·1% of women reported ever experience of same-sex sex. This equates to approximately 547,000 men and 546,000 women aged 16-74 in Britain self-identifying as LGB and 1,204,000 men and 1,389,000 women ever having experience of same-sex sex. Of those reporting same-sex sex in the past 5 years, 28% of men and 45% of women identified as heterosexual. INTERPRETATION: There is large variation in the size of sexual minority populations depending on the dimension applied, with implications for the design of epidemiological studies, targeting and monitoring of public health interventions and estimating population-based denominators. There is also substantial diversity on an individual level between identity, behaviour and attraction, adding to the complexity of delivering appropriate services and interventions.

Places and people: the perceptions of men who have sex with men concerning STI testing: a qualitative study.

OBJECTIVES: To explore the experiences and views of men who have sex with men (MSM) on attending clinical sexual health services and their preferences regarding service characteristics in the context of the disproportionate burden of STIs experienced by this group. The wider study aim was to develop a risk assessment tool for use in sexual health clinics. METHODS: Qualitative study comprising eight focus group discussions with 61 MSM in four English cities. Topics included: experience of attending sexual health services, perceptions of norms of attendance among MSM, knowledge of, and attitudes towards, STIs and views on 'being researched.' Discussions were audio-recorded and transcribed and a thematic data analysis conducted. RESULTS: Attending sexual health services for STI testing was described as embarrassing by some and some clinic procedures were thought to compromise confidentiality. Young men seeking STI testing were particularly sensitive to feelings of awkwardness and self-consciousness. Black and ethnic minority men were concerned about being exposed in their communities. The personal qualities of staff were seen as key features of sexual health services. Participants wanted staff to be friendly, professional, discreet, knowledgeable and non-judgemental. CONCLUSIONS: A range of opinion on the type of STI service men preferred was expressed with some favouring generic sexual and reproductive health clinics and others favouring specialist community-based services. There was consensus on the qualities they would like to see in healthcare staff. The knowledge, conduct and demeanour of staff could exacerbate or ameliorate unease associated with attending for STI testing.

Where do women and men in Britain obtain contraception? Findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3).

INTRODUCTION: To estimate the prevalence of use of different sources of contraceptive supplies in Britain and its variation by key demographic and behavioural characteristics. METHODS: Cross-sectional probability sample survey of women and men aged 16-74 years, resident in Britain, interviewed between 2010 and 2012. Analyses reported here were of 4571 women and 3142 men aged 16-44 years who reported having vaginal sex in the past year. Those relying exclusively on sterilisation (including hysterectomy) were excluded. Sources of contraceptive supplies were categorised as: general practice, community clinic, retail and other. Prevalence of use of these sources was estimated, and associated factors examined. RESULTS: Some 87.0% of women and 73.8% of men accessed at least one source of contraceptive supplies in the previous year. Most women (59.1%) used general practice and most men (54.6%) used retail outlets. Community clinics were less commonly used, by 23.0% of women and 21.3% of men, but these users were younger and at greater sexual health risk. These associations were also observed among the 27.3% of women and 30.6% of men who used more than one source category (general practice, community clinic or retail) for contraceptive supplies. CONCLUSIONS: People in Britain use a variety of sources to obtain contraceptive supplies and some sources are more commonly used by those more vulnerable to poorer sexual health. Our findings suggest that national policy changes to increase access to contraceptive methods have had an effect on the diversity of services used.

A Mixed-Methods Evaluation of a Community-Based Glaucoma Check Service in Hackney, London, UK.

PURPOSE: To evaluate the uptake, feasibility and acceptability of a general practice-based optometrist-led glaucoma check service. The service targeted people of black Caribbean and black African descent aged 40-65 years, resident in Hackney, London, United Kingdom. METHODS: The study used a mixed-method design, including analysis of service data, prospective audit of secondary care referrals patient survey, cost-consequence analysis, and interviews with staff involved in developing and implementing the service. RESULTS: A total of 3040 patients were invited to undergo the free check; 595 (19.6%) booked an appointment and 461 (15.2%) attended. Overall, 31 patients (6.8%) were referred to secondary care, of whom 22 attended and were assessed for glaucoma. Four were diagnosed with glaucoma and eight with suspected glaucoma, i.e. 2.6% of patients who underwent the check. The cost per patient identified with suspected or confirmed glaucoma was £9,013. Staff who were interviewed suggested that patients who attended might be those who routinely attended optometrist appointments, however only 62.4% of survey respondents reported having had an eye examination in the previous two years, and 11.4% of women and 16.0% of men reported never having had an eye examination. CONCLUSION: This study represents one possible configuration for a glaucoma case-finding service, and it contributes to a wider debate about whether screening, targeted or otherwise, should be offered in the UK. Our findings suggest that general practice is an acceptable setting and that such a service may reach some people not previously engaged with primary eye care services.

Actual and preferred contraceptive sources among young people: findings from the British National Survey of Sexual Attitudes and Lifestyles.

OBJECTIVE: To describe actual and preferred contraceptive sources among young people in Britain and whether discordance between these is associated with markers of sexual risk behaviour or poor sexual health. DESIGN: Cross-sectional probability sample survey. SETTING: British general population. PARTICIPANTS: 3869 men and women aged 16-24 years interviewed for the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3) between 2010 and 2012. MAIN OUTCOME MEASURES: Reported source of contraceptive method(s) and preferred source if all were available and easily accessible. RESULTS: Of the 75% of young people (aged 16-24) who were heterosexually active (1619 women, 1233 men), >86% reported obtaining contraceptives in the past year. Most common sources were general practice (women, 63%) and retail (men, 60%): using multiple sources was common (women 40%, men 45%). Healthcare sources were preferred by 81% of women and 57% of men. Overall, 32% of women and 39% of men had not used their preferred source. This discordance was most common among men who preferred general practice (69%) and women who preferred retail (52%). Likelihood of discordance was higher among women who usually used a less effective contraceptive method or had an abortion. It was less likely among men who usually used a less effective method of contraception and men who were not in a steady relationship. CONCLUSIONS: Most young people in Britain obtained contraception in the past year but one-third had not used their preferred source. Healthcare sources were preferred. Discordance was associated with using less effective contraception and abortion among young women. Meeting young people's preference for obtaining contraception from healthcare sources could improve uptake of effective contraception to reduce unwanted pregnancies.

Sexual Function in 16- to 21-Year-Olds in Britain.

PURPOSE: Concern about young people's sexuality is focused on the need to prevent harmful outcomes such as sexually transmitted infections and unplanned pregnancy. Although the benefit of a broader perspective is recognized, data on other aspects of sexuality, particularly sexual function, are scant. We sought to address this gap by measuring the population prevalence of sexual function problems, help seeking, and avoidance of sex in young people. METHODS: A cross-sectional stratified probability sample survey (Natsal-3) of 15,162 women and men in Britain (response rate: 57.7%), using computer-assisted self-interviews. Data come from 1875 (71.9%) sexually active, and 517 sexually inactive (18.7%), participants aged 16-21 years. Measures were single items from a validated measure of sexual function (the Natsal-SF). RESULTS: Among sexually active 16- to 21-year-old participants, 9.1% of men and 13.4% of women reported a distressing sexual problem lasting 3 months or more in the last year. Most common among men was reaching a climax too quickly (4.5%), and among women was difficulty in reaching climax (6.3%). Just over a third (35.5%) of men and 42.3% of women reporting a problem had sought help, but rarely from professional sources. Among those who had not had sex in the last year, just >10% of young men and women said they had avoided sex because of sexual difficulties. CONCLUSIONS: Distressing sexual function problems are reported by a sizeable minority of sexually active young people. Education is required, and counseling should be available, to prevent lack of knowledge, anxiety, and shame progressing into lifelong sexual difficulties.

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.

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.

Are depression and poor sexual health neglected comorbidities? Evidence from a population sample.

OBJECTIVE: To examine associations between sexual behaviour, sexual function and sexual health service use of individuals with depression in the British general population, to inform primary care and specialist services. SETTING: British general population. PARTICIPANTS: 15,162 men and women aged 16-74 years were interviewed for the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3), undertaken in 2010-2012. Using age-adjusted ORs (aAOR), relative to a comparator group reporting no treatment or symptoms, we compared the sexual health of those reporting treatment for depression in the past year. OUTCOME MEASURES: Sexual risk behaviour, sexual function, sexual satisfaction and sexual health service use. RESULTS: 1331 participants reported treatment for depression (5.2% men; 11.8% women). Relative to the comparator group, treatment for depression was associated with reporting 2 or more sexual partners without condoms (men aAOR 2.07 (95% CI 1.38 to 3.10); women 2.22 (1.68 to 2.92)), and concurrent partnerships (men 1.80 (1.18 to 2.76); women 2.06 (1.48 to 2.88)), in the past year. Those reporting depression treatment were more likely to be dissatisfied with their sex lives (men 2.32 (1.74 to 3.11); women 2.30 (1.89 to 2.79)), and to score in the lowest quintile on the Natsal-sexual function measure. They were also more likely to report a recent chlamydia test (men 1.92 (1.15 to 3.20)); women (1.27 (1.01 to 1.60)), and to have sought help regarding their sex life from a healthcare professional (men 2.92 (1.98 to 4.30); women (2.36 (1.83 to 3.04)), most commonly from a family doctor. Women only were more likely to report attending a sexual health clinic (1.91 (1.42 to 2.58)) and use of emergency contraception (1.98 (1.23 to 3.19)). Associations were broadly similar for individuals with depressive symptoms but not reporting treatment. CONCLUSIONS: Depression, measured by reported treatment, was strongly associated with sexual risk behaviours, reduced sexual function and increased use of sexual health services, with many people reporting help doing so from a family doctor. The sexual health of depressed people needs consideration in primary care, and mental health assessment might benefit people attending sexual health services.

Using the Web to Collect Data on Sensitive Behaviours: A Study Looking at Mode Effects on the British National Survey of Sexual Attitudes and Lifestyles.

BACKGROUND: Interviewer-administered surveys are an important method of collecting population-level epidemiological data, but suffer from declining response rates and increasing costs. Web surveys offer more rapid data collection and lower costs. There are concerns, however, about data quality from web surveys. Previous research has largely focused on selection biases, and few have explored measurement differences. This paper aims to assess the extent to which mode affects the responses given by the same respondents at two points in time, providing information on potential measurement error if web surveys are used in the future. METHODS: 527 participants from the third British National Survey of Sexual Attitudes and Lifestyles (Natsal-3), which uses computer assisted personal interview (CAPI) and self-interview (CASI) modes, subsequently responded to identically-worded questions in a web survey. McNemar tests assessed whether within-person differences in responses were at random or indicated a mode effect, i.e. higher reporting of more sensitive responses in one mode. An analysis of pooled responses by generalized estimating equations addressed the impact of gender and question type on change. RESULTS: Only 10% of responses changed between surveys. However mode effects were found for about a third of variables, with higher reporting of sensitive responses more commonly found on the web compared with Natsal-3. CONCLUSIONS: The web appears a promising mode for surveys of sensitive behaviours, most likely as part of a mixed-mode design. Our findings suggest that mode effects may vary by question type and content, and by the particular mix of modes used. Mixed-mode surveys need careful development to understand mode effects and how to account for them.

Estimating the Prevalence of Sexual Function Problems: The Impact of Morbidity Criteria.

Establishing the clinical significance of symptoms of sexual dysfunction is challenging. To address this, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) introduced two new morbidity criteria (duration and symptom severity) to the existing criteria of distress. This study sought to establish the impact of these three criteria on the population prevalence of sexual function problems. The data come from a national probability survey (Natsal-3) and are based on 11,509 male and female participants aged 16-74, reporting at least one sexual partner in the past year. The key outcomes were: proportion of individuals reporting proxy measures of DSM-5 problems, and the proportion of those meeting morbidity criteria. We found that among sexually active men, the prevalence of reporting one or more of four specific sexual problems was 38.2%, but 4.2% after applying the three morbidity criteria; corresponding figures for women reporting one or more of three specific sexual problems, were 22.8% and 3.6%. Just over a third of men and women reporting a problem meeting all three morbidity criteria had sought help in the last year. We conclude that the DSM-5 morbidity criteria impose a focus on clinically significant symptoms.