9.3.3. Sexual health
Human sexual behavior encompasses the search for a partner or partners,
interactions between individuals, physical or emotional intimacy, and sexual
contact. Sexual behaviours are
expressed in a variety of ways and are influenced by many factors including
age, gender, religion, family, friends, culture, ethnicity, economics, sexual
orientation and past experiences - both positive
relational experiences and experiences of abuse, discrimination and
The ability of individuals or couples to pursue a
fulfilling and safe sex life is central to achievements of sexual health.
Sexual behaviour usually analysed from adolescent age till the end of
reproductive age of women directly influences different aspects of health, from
sexual and reproductive health to mental health and injuries. The WHO estimates
unsafe sex to be the second most important global risk factor for health and
has included “promoting sexual health” as one of the five core elements of the
WHO first global Reproductive Health Strategy adopted by the 57th
World Health Assembly (WHO, 2004)
Risky sexual behaviour is directly linked to other health
determinants such as alcohol consumption, drugs and substance abuse and
socioeconomic factors. Adolescents and young people are one of the vulnerable
groups for what concerns sexual health, with sexual debut occurring most
frequently at this life stage.
Sexual behaviour changes in response to both secular and
non-secular social forces. Recent decades have seen large socioeconomic changes
in poverty, education and employment. Demographic changes have taken place, in
the age structure of populations, in the timing of marriage and in the scale of
mobility and migration between and within countries. Worldwide communications,
including internet, have had a bearing on social norms, transporting sexual
images from more liberal to more conservative societies (Cameron et al, 2005).
Therefore, information about sexual behaviour is essential to the design and
assessment of interventions to improve sexual health.
Several EU Member States observe an
increasing prevalence of high-risk sexual behaviours such as occasional sex
with multiple partners without use of a condom. The
average age at the first intercourse declined somewhat from the older generation
to the younger in several European countries, but more among males than
females. Risk reduction strategies need to be
strengthened and improved.
220.127.116.11. Data sources
Still little is known about patterns of sexual behaviour
in Europe; not all countries have conducted population surveys and available
data is usually non-comparable. The main information sources for the present
European Concerted Action on sexual behaviour and the risk of HIV infection that presents cross-national
analyses of key data on sexual behaviour from surveys carried out in 11
European countries between 1989 and 1993 in the 18-49 age group (Hubert M et al, 1998).
(Wellings et al, 2006) analyzing data on sexual behaviour from 59 countries
worldwide and including data from the UK (Johnson A et al, 2001), France
(Beltzer N et al, 2005) and an EU-sponsored series of surveys in England,
Finland, France, Germany, Greece, Italy, Norway, Portugal, Slovenia, Spain and
Swizerland (Facultes Universitaires Saint-Louis, 2006).
Council of Europe supported publication of study on teenage sexual and
reproductive behaviour and its consequences in Europe including five main
indicators: sexual behaviour, teenage fertility, contraceptive practices,
abortion and STIs/HIV/AIDS (Bajos et al, 2003). The study
data are based on national surveys on sexual behaviour and fertility conducted
in European countries, statistics and results of the related European studies
published in scientific journals.
from national sexual attitude and lifestyle surveys and reported
comparisons from Denmark (Kangas et al, 2004), France (Gremy and Beltzer,
2004), Finland (Haavio-Mannila and Kontula, 2001) and other countries of the
Baltic area (Haavio-Mannila and Kontula, 2003; Nikula et al, 2007), Portugal
(Amaro et al, 2004), Slovenia (Klavs et al, 2005), Sweden (Herlitz et al,
2005), Britain (Wellingset al, 2001), UK (Johnson et al, 2001) and Switzerland
(Dubois-Arber et al, 1997). Some data from the national survey carried out
recently in Germany (Hessling, 2006), Italy (Signorelli et al, 2006), Ireland
(Layte R et al, 2006) were used, however, in general data for EU countries are
difficult to obtain and compare because surveys are not standardized and are
done by many different groups.
data on health of adolescents in 31 countries and regions is presented in the Health
Behaviour in School-aged Children (HBSC) study that is a cross-national
research conducted by an international network of research teams in
collaboration with the WHO Regional Office for Europe (Currie et al, 2004).
HBSC surveys have started in 1983 and in the 1989/1990 protocol included
optional package of questions about relationships and sexual behaviour.
Countries and regions mainly used the data for their own purposes, and
cross-national comparisons were not published. In the 1997/1998 HBSC survey, a
number of countries and regions included questions about sexual health, but
these varied in scope and content. This lack of comparability enabled only
limited cross-national comparison. Questions included in the 2001/2002 protocol
were revised, but reliability testing was not undertaken in European countries.
Denmark, Ireland, and Norway did not include any sexual health questions.
to the European Health Interview and Health Examination Surveys
database, 24 surveys in 17 EU and accession countries included questions on
sexual behaviour (European health interview and health surveys database, 2007).
review conducted by REPROSTAT 2 group on factors associated with teenage
pregnancy in the EU countries including 20 quantitative studies (1995- May
2005) on individual level factors associated with pregnancy in the age group
13-19 years (Imamura M et al, 2007).
deriving from the ECHI recommended indicators (http://www.healthindicators.org/ICHI/(3zcnmm55nymjooej2ccntca3)/General/Searchindicator.aspx).
Countries have also the obligation to provide data to UNAIDS concerning HIV/AIDS
and following defined indicators Some of them concern sexual behaviour and are
clearly defined in a guideline on core indicators ( http://www,unaids.org/en/AboutUNAIDS/Goals/UNGASS/2008_UNGASS_Reporting.asp).
Majority of sexual behaviour surveys include both men and
women. Some surveys collect partner-specific details, which provide additional
information useful in analysing sexual behaviour, such as: coital frequency in
last 30 days, duration of relationship, age of the partner and others. However,
the definition of some indicators differs country from country, for example,
definition of multiple partners in the countries of EU have several
interpretations: “>= 2 partners”, “> 2 partners” and “>= 2 new
partners”. Since 1980, six studies on youth sexuality in the age group of 14 to
17 year olds and their parents have been carried out in Germany (results from
1980 are based on data from West Germany only, all studies since 1994 include
East Germany) and present detailed information on sex education and advice,
sexual experiences, contraception, pregnancy and desire for children and sexual
violence, however, due to the chosen age group it is difficult to compare it
with data from other European countries (Hessling, 2006).
All survey data based on self reports are susceptible to
error. Sexual behaviour survey might suffer more than others in this respect,
since they are especially prone to a social desirability bias – the tendency
for participants to respond according to social expectations of what is right.
Many surveys find that the number of partners reported by men greatly exceeds
that reported by women (Wellings et al, 2006) that may be caused by women
under-report and/or men over report and many other causes.
presentation and analysis
Mean age at first sexual intercourse
Almost everywhere in Europe sexual activity begins for
most men and women at around 15-19 years of age, but age variations between men
and women in different countries are substantial. In Western Europe, the mean
age varied typically from 17 to 18. The lowest mean age for sexual initiation
among women was found in the UK, at 16.2 (Bajos et al, 2003); the increase in
the proportion of women reporting first intercourse before the age of 16 does
not appear to have increased throughout the past decade (Wellings et al, 2001).
Among males, the age at first sexual intercourse did not
vary much from country to country in Western Europe. The average age at first
intercourse declined somewhat from the older generation to the younger in
several European countries, but much less than among women. Particularly in
Southern countries, male sexual initiation was very stable for the different
generations in their teenage years from the 1950s to the 1990s (Bajos et al,
2003). At variance, in Ireland the median age of first intercourse proved to
fall steadily across age cohorts. The median age for men currently aged 60 to
64 was 22, while for those currently under 25, it is 17 (Layte R et al, 2006).
For what concerns older and younger female generations, the age at first
intercourse fell from the 1960s by at least two years in all Western European
countries where surveys were conducted. In the North, the changes started in
the ‘60s, whereas in the South the new trend dates back only to the ‘80s (Bajos
et al, 2003). In all of these Countries, a dramatic fall was observed in the
percentage of women who had had their first sexual intercourse at or after the
age of twenty.
Young people who have had sexual intercourse, 15 year olds
The percentage of 15-year-olds who report having had
sexual intercourse in the countries that are in the scope of this report and
were participating in the HBSC study range from 15% in Poland to 38% in England
(Fig. 1) (Currie et al, 2004). The gender differences are wide. Among boys,
positive responses range from 18% in Spain to 35.7% in England. Among girls, positive responses range from 9.2 in Poland to 40.4% in England. From a gender perspective, there are two distinct profiles. The average
age at first intercourse is much higher among women compared to men, especially
in Southern Europe. On the other hand, in Nordic countries the age at
initiation tends to be slightly earlier for women than for men in the youngest
cohorts (Bajos et al, 2003; Nikula et al, 2007). Also the HBSC study indicates
that in several North European Countries and regions more 15-year-old girls
than boys declare having had sexual intercourse (England, Finland, Germany,
Scotland, Sweden, Wales); however, in most of the countries a more traditional
pattern prevails with more boys than girls having had sexual intercourse at the
age of 15 (Currie at al, 2004). In Romania (Serbanescu et al, 2001) the medium
age at first intercourse for women still remains close to 20, while for men it
is around 18. Men were more than twice as likely as women to have had
premarital intercourse. The mean age at first intercourse in the Czech
Republic remained quite stable between 1993 and 2003 at 18 years of
age for both males and females (Weiss, 2008).
All over Europe, men and women graduates have their sexual
initiation later than early school-leavers (Bozon and Kontula, 1998). The gap
between the proportions of early school-leavers and graduates who had
intercourse before the age of eighteen was more marked (a difference of 20% or
more) in Finland, Greece (Athens), Great Britain and among Dutch and German
women. The difference was smaller in France, Norway and among Dutch and German
men. In Portugal, graduates did not behave differently from non-graduates.
The time between first intercourse and marriage or
cohabitation differs between genders and countries, but has a general tendency
to increase. This time period became six years for men and four for women in
the 1990s (Bajos et al, 2003). As a consequence of the increased difference
between the age of first sexual intercourse and marriage or cohabitation, young
people in the EU have more casual sexual relationships than in the previous
Number of partners and casual sex
Partnering patterns have been studied in many national
surveys. According to the data from the “New encounter module” (NEM) survey
countries, on average, one in three men in the 20-24 age group had more than
one partner during the last year. The highest proportion was found in Norway
(50%) and the lowest in Italy (10%) (Hubert et al, 1998). The proportion of
women who had more than one partner during the last year was in the 1990s close
to 25% in France and Greece, around 15% in Norway, Portugal and Spain and 3% in
Italy. In Ireland, around a third of men and over a half of women in the 18-64
age group have had a single sexual partner in their life so far (Layte et al,
2006), while a quarter of men and 6% of women have had 10 or more partners. International
comparisons show that Irish people tend to have fewer partners on average than
in other countries, but this varies substantially with age. Young Irish people
have as many partners as their peers in other countries. In the Czech
Republic, the number of sexual partners during lifetime has decreased
from 1993 to 2003 from about 11 to about 9 for men and has slightly increased
for women from 5.1 to 5.5 .
Besides higher prevalence of multiple partners, men also
report casual sex contacts more often than women (Bajos et al, 2003; Nikula et
al, 2007), but there is diversity even within one country. For example,
occasional sexual intercourses seem more frequent among those living in urban
areas of Italy and less frequent among people living in rural
areas, with a moderately higher proportion in Central and Southern
Italy (Signorelli et al, 2006). About two-thirds of those experiencing
occasional sex reported that they did not always use condom in these occasions.
Recent surveys in Finland notice a higher prevalence of
multiple partners than the Finnish sex study made in 1999 (Nikula et al,
2007).Studies comparing behaviour over time have found that there has been a
stronger increase in the number of sexual partners and the prevalence of casual
sex among women than among men.
The proportion of sexually-active young people who report
using a condom for the most recent sexual intercourse is higher for men than
According to the most recent HBSC survey data (Currie et
al, 2004) the proportion of sexually active 15-year-old people who report using
condom the last time they had sexual intercourse ranges from 68.5% in Portugal
to 91% in Greece for boys, and from 58% in Sweden to 89% in Spain for girls
(Figure 18.104.22.168). In almost all countries and regions, boys are more likely
than girls to report condom use. The gender difference can sometimes be quite
large, as in Belgium (Flemish).
Young people who used condom during their last sexual intercourse,15-year-olds
There is lack of data for the consistency with which
condoms are used. So, in Portugal, on the subject of condom usage during the
past year, 22.4% of one thousand individuals from the age group 18-69 mentioned
that they had always or almost always used condom but only 19.5% reported using
it in their last sexual relation (Amaro et al, 2004). Another study in Finland
reported that both genders showed relatively high and concordant rates of
condom use; however, in casual sexual contacts a condom was used only by less than
half of both sexes (Nikula et al, 2007).
In Denmark, the use of identical questionnaires and fixed
setting (a high school) in a stable population allowed to compare sexual
attitudes and behaviour at three different time points – 1982, 1996 and 2001
(Kangas et al, 2004). It was found that after a period of increased safe sex
practice, sexual behaviour among adolescents in the general population appears
to be returning to the levels seen in the early 1980s. Also in the Czech
Republic, it was noted that the percentage of men and women making
use of condom, after an increase from 1993 to 1998, decreased again in 2003
It has been asserted that in Western Europe, after two
decades of HIV, the perceived risk of the epidemic and also funding for large
sexuality studies are diminishing (Fenton et al, 2001). The increase in risky
sexual behaviours may be a consequence of the lower priority given to sexual
health on political agendas in the mid-1990s, and a new generation not exposed
to the heavy safe-sex messages of the 1980s when HIV emerged.
Condom use can be challenged by several social, cultural
and economic factors. One potential explanation for poor motivation in condom
use and decreased perception of risk may be alcohol consumption prior to having
sex. Numerous studies have reported the correlation of excessive drinking and
risky sexual behaviour (Thompson et al, 2005). Being away from home is also
associated to concurrency of partnerships and an increase in risky behaviours.
The socially censored nature of same-sex activity may lead
to under-reporting and might also account for the absence of such activity from
research agenda. The prevalence of same-sex activity in men is 6% in the UK
(Johnson A, 2001) and 5% in France (Bajos et al, 1995). In Portugal 4.2% of men
reported that during their lifetime they had experienced homosexual relations
at least once, and only 0.9% said they had sexual relations exclusively with
other men (Amaro et al, 2004).In the Czech Republic, 5% of
men and 6% of women reported occasional homosexual intercourses during their
Similar patterns of sexual behaviour of gay men in eight
European countries (Austria, Denmark, France, Germany, Great Britain, Italy,
the Netherlands and Switzerland) have been recognized, but strategies at risk
management vary widely. The proportion of men who during the last year were
engaged in unprotected intercourse with a partner with different or unknown
HIV-status ranged from 1/3 in East Germany to 1/6 in the UK (Bochow et al,
According to the Irish Study of Sexual Health and
Relationships, most men who currently have sex with men (MSM) have similar
numbers of partners as heterosexual men, but 32% of MSM have had 10 or more
partners in their life so far, compared to 21% of the general male population.
Women with homosexual experience tend to have lower numbers of partners than
the general population (Layte R et al, 2006).
Predictors of sexual behaviour
Marital status is the strongest predictor for sexual
behaviour and health outcomes in comparison to age or education (Del Amo et al,
2004; Herlitz and Ramstedt, 2005; Nikula et al, 2007). Being single isssociated to risky sexual behaviour and
adverse health outcomes for both genders.
Results from a survey in Britain show an increasing prominence of
the school in the sexual education of the young and the association between
school sex education and risk reduction and the fact that the variables which
emerge as most strongly associated with reducing risk (educational level and
source of information about sex) are those which are amenable to intervention
(Wellings et al, 2001).
The best predictors of having two or more partners in
Ireland are younger age, not being in a relationship and being in a casual
relationship, being in a higher social class, having a higher level of
education and age of first intercourse (Layte R et all, 2006). In Italy the
first sexual intercourse at a very young age is an indicator of a higher
probability of risky behaviours in adult life (Signorelli et al, 2006).
tools and policies
Obviously, risky sexual behaviours may be very dangerous
for health especially in relation to the transmission of infectious diseases.
Analysis of sexual behaviour in the era of HIV, hepatitis C and other
infections is directly linked to morbidity and mortality that are covered in other
chapters. Data related to sexual abuse and violence is included in the Chapter
dedicated to “Special gender-related issues” (e.g.violence).
On 3 July 2002, The European Parliament supported the
Resolution on Sexual and Reproductive Health and Rights in Europe that confirms
its intention to support the rights of all people to have healthy and
satisfying sex lives (European Parliament, 2003).
Individual-based interventions also need to be targeted in
order to be successful. Young people are most commonly targeted in schools
(WHO, 2006b) and the evidence is that curriculum-based sex education does not
increase risky sexual behaviour (Kirby et al, 2006). Systematic reviews have
shown school-based sex education to lead to improved awareness of risk and
knowledge of risk reduction strategies, increased self-effectiveness and
intention to adopt safer sex behaviours, and to delay the onset of sexual
activity. Techniques used in social marketing, which target individuals
according to their lifestyles, values, and risk status are an improvement
compared to conventional targeting approaches (Grier and Bryant, 2005).
Attitudes towards sexuality education differ among countries in the EU and
among different nationalities within the country (WHO, 2006b).
The evidence is that information gained through social
networks is more salient, and more likely to lead to behaviour change, than
that conveyed by more impersonal agencies (McIntyre, 2005). Addressing of
structural determinants demands the involvement of social as well as health
sectors, and thus requires co-ordination and collaboration across sectors and
agencies, as well as other social interventions. A way of ensuring that joint
action takes place is to make it not merely a generalised goal of intervention,
but an explicit element of the programme as in the case of the UK Teenage
Pregnancy Strategy (Wilkinson et al, 2006).
There are examples of national policies to face the
present situation with risky sexual behaviour including modernisation of
sexual-health services, reduced waiting times in genitourinary clinics,
organizing campaigns and many other activities. Strategies are not to focus on
one problem or disease, but should have the broad approach of promoting sexual
behaviour that is likely to protect against a host of adverse outcomes. There
needs to be reassurance that the policy will be followed through via a
multi-sectorial approach and the active involvement of the community.
Most of the national sexual health policies in the western
European countries are based on the principle that sexual behaviour belongs to
the sphere of individual choice and responsibility.
The WHO recommends the following outcome indicators to
monitor and evaluate the process for promoting sexual health (WHO, 2006a):
of men and women who have experienced coercive or forced sex;
of adolescents who have ever had sexual intercourse, subdivided per sex;
of sexually initiated adolescents who used contraception at first/last sexual
intercourse, subdivided per sex;
of sexually active, unmarried adolescents who consistently use condoms,
subdivided per sex;
at marriage (for men and women);
at first intercourse (for men and women);
of women who have undergone female genital mutilation; and
of female genital mutilation performed in the country.
Many countries are broadening the number of indicators
when surveys are carried out. The most common ones included in the studies are:
of partner (spouse or cohabitant, commercial, or other non-regular);
of partners (during the last year, lifetime);
use at most recent coital act during the last 12 months;
of men who had sex with a commercial sex worker in the last year;
mixing in sexual relationships (women aged 15-19 who had sex with a man to whom
they are not married and who is 10 or more years older);
orientation of partner/partners.
More research needs to be undertaken to investigate the
audience perspective and to understand what is driving sexual behaviour rather
than collecting data on post behaviour reporting.
Surveys historically have suggested that men and women may
have very different goals and attitudes related to sexual behaviour. However,
recently collected data supports the evidence that differences in attitudes and
behaviour around sexuality in Europe are diminishing between men and women.
Collection of empirical evidence is important to correct myths in the public
perception of behaviours. However, sexual habits are strongly regulated in
virtually every society, and the modification of sexual behaviours to improve
sexual health has proven to be difficult (Wellings et al, 2006).
The HBSC survey gives some possibility to evaluate the
dynamics of the change in time (Currie et al, 2004). Cross-national differences
undoubtedly reflect fundamental cultural, social, religious and educational
differences across countries, as well as differences in public policy. The most
important findings demonstrate variations across countries and regions in the
use of condoms. These findings have important policy implications and are to be
analysed in relation to other risk behaviours (especially drug and alcohol use),
school and community bonding, school performance and parental relations.
The increase of risky sexual behaviour has been high on
the agenda of many countries within the European Union. However, sex is a
private activity between free individuals, and improvements in sexual behaviour
depend on people being comfortable with, and absorbing, public-health messages.
With the diversity of sexual behaviour, a range of
preventive strategies are needed to protect sexual health. Interventions
encouraging the adoption of risk reduction practices remain a cornerstone of
sexual health promotion, but evidence shows that they need
to go beyond the mere provision of information to be effective (Kirby D et al,
2006). Systematic reviews have focused mainly on the assessment of
interventions to change individual behaviour and show increased effectiveness
where information is supplemented by life-skill building (Shepherd J et al,
Diversity of sexual behaviour needs to be respected in a
range of approaches tailored to whole societies, and to particular groups and
individuals within them.
Instead of issue-driven sexual health agenda, it is
necessary to promote sexual behaviours that are likely to protect against a
host of adverse outcomes and let people have a responsible, satisfying and safe
sexual life, which is positively enriching and enhancing personality,
communication and love.
The existing evidence that migration dynamics largely
determine sexual health in Europe calls for the systematic use of comparative
indicators for sexual behaviour and reproductive health outcomes for monitoring
trends and epidemics. Incorporation of sexual health as an integrated part of
general health surveys using comparative sexual health indicators will enable a
more effective monitoring of trends and the further development of strategies
and programs for a comprehensive approach towards sexual health. There are many
publications suggesting ways of monitoring sexual behaviour. However, most of
the indicators are directly linked to outcomes of unsafe sex rather than sexual
behaviour in general.
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