Sex Surveys in Europe: Reflections on over Four Decades of Sexual Behavior and Sexual Health Surveillance.

Sexual expression is fundamental to human existence and an important topic of enquiry in its own right. Understanding sexual behavior is also essential to establish effective sexual health prevention activities (e.g., education), services and policies, and to assess the progress of policies and action plans. Questions on sexual health are rarely included in general health surveys, and therefore dedicated population studies are required. Many countries lack both funding and sociopolitical support to conduct such surveys. A tradition of periodic population sexual health surveys exists in Europe but the methods used (e.g., in questionnaire construction, recruiting methods or interview format) vary from one survey to another. This is because the researchers within each country are confronted with conceptual, methodological, sociocultural and budgetary challenges, for which they find different solutions. These differences limit comparison across countries and pooling of estimates, but the variation in approaches provides a rich source of learning on population survey research. In this review, survey leads from 11 European countries discuss how their surveys evolved during the past four decades in response to sociohistorical and political context, and the challenges they encountered. The review discusses the solutions they identified and shows that it is possible to create well designed surveys which collect high quality data on a range of aspects of sexual health, despite the sensitivity of the topic. Herewith, we hope to support the research community in their perennial quest for political support and funding, and ongoing drive to advance methodology in future national sex surveys.

History of national sex surveys in Europe.

The historical background of European national sex surveys dates back to the late 1960s and early 1970s when the first such surveys were conducted in Europe. That was an era of Western sexual revolution, a time of increasing openness to discussion and debate of sexual issues, and legal reforms in many countries. During this period, there was a growing interest in understanding sexual behaviour, attitudes, and modern contraceptive use in the general population. Evidence was also needed for sexuality education that was emerging in some European countries. Despite this need for evidence, only a few countries (Sweden, Finland, France) conducted national surveys on the topic in the early 1970's, becoming pioneers in national sex surveys in Europe and in the world. It was the HIV and AIDS epidemic of the 1980s that gave more researchers and funders the impetus to conduct sex studies in many European countries. As a result, medical perspectives on sexuality became prioritised around Europe. Balancing the perspectives of the diverse disciplines (including public health, sociology, psychology) that use the data from national sex surveys remains a challenge for the modern surveys. The European Sexual Medicine Network (ESMN) is a part of European cooperation in science and technology (COST), which includes a strand of work on national sex surveys among the adult population. Since 2021, a subgroup of nationally representative sex surveys, co-chaired by Osmo Kontula and Hanneke de Graaf have worked together to further the field. This submission is based on a review of the literature, combined with Kontula's personal reflections following a history of participation in European collaboration in this field since the early 1990s.

Development of an international sexual and reproductive health survey instrument: results from a pilot WHO/HRP consultative Delphi process.

Population health surveys are rarely comprehensive in addressing sexual health, and population-representative surveys often lack standardised measures for collecting comparable data across countries. We present a sexual health survey instrument and implementation considerations for population-level sexual health research. The brief, comprehensive sexual health survey and consensus statement was developed via a multi-step process (an open call, a hackathon, and a modified Delphi process). The survey items, domains, entire instruments, and implementation considerations to develop a sexual health survey were solicited via a global crowdsourcing open call. The open call received 175 contributions from 49 countries. Following review of submissions from the open call, 18 finalists and eight facilitators with expertise in sexual health research, especially in low- and middle-income countries (LMICs), were invited to a 3-day hackathon to harmonise a survey instrument. Consensus was achieved through an iterative, modified Delphi process that included three rounds of online surveys. The entire process resulted in a 19-item consensus statement and a brief sexual health survey instrument. This is the first global consensus on a sexual and reproductive health survey instrument that can be used to generate cross-national comparative data in both high-income and LMICs. The inclusive process identified priority domains for improvement and can inform the design of sexual and reproductive health programs and contextually relevant data for comparable research across countries.

Contraceptive use among migrant women with a history of induced abortion in Finland.

BACKGROUND: Women's contraceptive choices may change after an induced abortion, due to contraceptive counselling or a behavioural change prompted by the experience. The effect may vary between women; sociocultural background, for example, may affect their subsequent reproductive choices. OBJECTIVE: We examined whether women's current contraceptive use was differently associated with a history of induced abortion among immigrant groups in Finland (Russian, Kurdish and Somali) and the general Finnish population. METHODS: We analysed data from two surveys, the Migrant Health and Wellbeing study and the Health 2011 study, linked to the Finnish register of induced abortions. Propensity score weighted logistic regression was used to analyse the data. RESULTS: The likelihood of using contraceptives after an abortion varied depending on women's sociocultural background. A history of induced abortion increased contraceptive use among all groups, except Russian women, in whom there was no effect. The effect was particularly strong for Kurdish women. CONCLUSION: Sociocultural background was an important determinant of post-abortion contraceptive use. Some immigrants may struggle to navigate the Finnish health care system due to language or literacy issues. Attention should be paid to improving access to family planning among these groups.

Determinants of female sexual orgasms.

BACKGROUND: The pursuit of sexual pleasure is a key motivating factor in sexual activity. Many things can stand in the way of sexual orgasms and enjoyment, particularly among women. These are essential issues of sexual well-being and gender equality. OBJECTIVE: This study presents long-term trends and determinants of female orgasms in Finland. The aim is to analyze the roles of factors such as the personal importance of orgasms, sexual desire, masturbation, clitoral and vaginal stimulation, sexual self-esteem, communication with partner, and partner's sexual techniques. DESIGN: In Finland, five national sex surveys that are based on random samples from the central population register have been conducted. They are representative of the total population within the age range of 18-54 years in 1971 (N=2,152), 18-74 years in 1992 (N=2,250), 18-81 years in 1999 (N=1,496), 18-74 years in 2007 (N=2,590), and 18-79 years in 2015 (N=2,150). Another dataset of 2,049 women in the age group of 18-70 years was collected in 2015 via a national Internet panel. RESULTS: Contrary to expectations, women did not have orgasms that are more frequent by increasing their experience and practice of masturbation, or by experimenting with different partners in their lifetime. The keys to their more frequent orgasms lay in mental and relationship factors. These factors and capacities included orgasm importance, sexual desire, sexual self-esteem, and openness of sexual communication with partners. Women valued their partner's orgasm more than their own. In addition, positive determinants were the ability to concentrate, mutual sexual initiations, and partner's good sexual techniques. A relationship that felt good and worked well emotionally, and where sex was approached openly and appreciatively, promoted orgasms. CONCLUSION: The findings indicate that women differ greatly from one another in terms of their tendency and capacity to experience orgasms. The improvements in gender equality and sexual education since the 1970s have not helped women to become more orgasmic. Neither has the major increase in masturbation habits (among women in general). One challenge for future studies is to understand why women value their partner's orgasms more than their own.

[How does summer affect sexual desire?]. / Miten kesävaikuttaa seksuaaliseen haluun?

Sexual desire involves many different things such as sexual thoughts and images, excitement, expectation and orgasm. Mood has a strong association with sexual desire. Fatigue and depression in particular cause lack of sexual desire. By affecting the state of alertness and energy in humans, sunlight may increase sexual activity.

[Sex life of the elderly is active and satisfying]. / Ikäihmistenkin seksielämä on aktiivista ja tyydyttävää.

Sex life of the elderly has been investigated in Finland by three representative population surveys. The subject is topical as the large generations become aged. According to the survey the sexual activity of the elderly people remained quite high, if they were living in a steady relationship. In the survey the numbers of sexual intercourses decreased with age, whereas masturbation and use of pornography increased. Most felt that their relationship and sexual life were satisfying. The most common sexual problems were lack of sexual desire in women and inability to achieve orgasm in the intercourse. Male erection problems increased more significantly only at the age of 70.

The impact of aging on human sexual activity and sexual desire.

This article empirically studies how much aging modifies human sexual activity and sexual desire, and what the most important determinants in this change are. The analyses are based on 2 representative national sex surveys conducted in Finland in the 1990s. As a result of female widowhood, aging men had a higher incidence of sexual intercourse compared with aging women; and in relationships, women were more likely than men to report lack of sexual desire. In regression analysis, age was a predictor of sexual activity but not of sexual desire, when controlling for the impact of other factors. Relationship duration did not play an important role in sexual activity or sexual desire when controlling for a number of other variables. Sexual desire, valuing sexuality, and a healthy partner were important to female sexual activity; and high sexual self-esteem, good health, and active sexual history were important to male sexual activity. To keep up their sexual desire, both men and women needed good health, good sexual functioning, positive sexual self-esteem, and a sexually skilful partner.

Epidemiology of HPV 16 and cervical cancer in Finland and the potential impact of vaccination: mathematical modelling analyses.

BACKGROUND: Candidate human papillomavirus (HPV) vaccines have demonstrated almost 90%-100% efficacy in preventing persistent, type-specific HPV infection over 18 mo in clinical trials. If these vaccines go on to demonstrate prevention of precancerous lesions in phase III clinical trials, they will be licensed for public use in the near future. How these vaccines will be used in countries with national cervical cancer screening programmes is an important question. METHODS AND FINDINGS: We developed a transmission model of HPV 16 infection and progression to cervical cancer and calibrated it to Finnish HPV 16 seroprevalence over time. The model was used to estimate the transmission probability of the virus, to look at the effect of changes in patterns of sexual behaviour and smoking on age-specific trends in cancer incidence, and to explore the impact of HPV 16 vaccination. We estimated a high per-partnership transmission probability of HPV 16, of 0.6. The modelling analyses showed that changes in sexual behaviour and smoking accounted, in part, for the increase seen in cervical cancer incidence in 35- to 39-y-old women from 1990 to 1999. At both low (10% in opportunistic immunisation) and high (90% in a national immunisation programme) coverage of the adolescent population, vaccinating women and men had little benefit over vaccinating women alone. We estimate that vaccinating 90% of young women before sexual debut has the potential to decrease HPV type-specific (e.g., type 16) cervical cancer incidence by 91%. If older women are more likely to have persistent infections and progress to cancer, then vaccination with a duration of protection of less than 15 y could result in an older susceptible cohort and no decrease in cancer incidence. While vaccination has the potential to significantly reduce type-specific cancer incidence, its combination with screening further improves cancer prevention. CONCLUSIONS: HPV vaccination has the potential to significantly decrease HPV type-specific cervical cancer incidence. High vaccine coverage of women alone, sustained over many decades, with a long duration of vaccine-conferred protection, would have the greatest impact on type-specific cancer incidence. This level of coverage could be achieved through national coordinated programmes, with surveillance to detect cancers caused by nonvaccine oncogenic HPV types.

Single and double sexual standards in Finland, Estonia, and St. Petersburg.

The sexual revolution and fight for gender equality began in the West during the 1960s but did not reach the Soviet Union until the late 1980s. Using survey data from nationally representative samples from Finland in 1971, 1992, and 1999 and from two former Soviet areas, Estonia in 2000 and St. Petersburg in 1996, we investigated the following: (a) differences across decades and countries in acceptance of the sexual double standard (SDS) in attitudes toward marital infidelity and women's initiating sex; and (b) the relationship between the SDS and sexual satisfaction. Results show that Finland in the 1990s was more egalitarian than Finland in 1971, St. Petersburg in 1996, or Estonia in 2000. Egalitarian sexual attitudes were positively related to sexual satisfaction.