EUGLOREH project
THE STATUS OF HEALTH IN THE EUROPEAN UNION:
TOWARDS A HEALTHIER EUROPE

FULL REPORT

PART II - HEALTH CONDITIONS

9. MAIN HEALTH ISSUES AND TRENDS FOR DIFFERENT AGE AND GENDER POPULATION GROUPS

9.3. Adults

9.3.3. Sexual health

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9.3.3. Sexual health

 

9.3.3.1. Introduction

 

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 oppression.

 

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 includedpromoting 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.

 

9.3.3.. 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 chapter are:

 

·          The 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).

·          Global sex survey (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).

·          The 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.

·          Data 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.

·          Comparative 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.

·          According 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).

·          Systematic 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).

·          Information deriving from the ECHI recommended indicators (http://www.healthindicators.org/ICHI/(3zcnmm55nymjooej2ccntca3)/General/Searchindicator.aspx).

·          European 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.

 

 

 

9.3.3.3. Data 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.

 

Figure 9.3.3.1. 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 decades.

 

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.

 

Condom use

 

The proportion of sexually-active young people who report using a condom for the most recent sexual intercourse is higher for men than for women

 

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 9.3.3.2). 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).

 

Figure 9.3.3.2. 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 points1982, 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 (Weiss,2008).

 

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.

 

Sexual orientation

 

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 lifetime (Weiss,2008).

 

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, 1994).

 

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 is associated 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).

 

9.3.3.4. Control 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):

 

·          percentage of men and women who have experienced coercive or forced sex;

·          percentage of adolescents who have ever had sexual intercourse, subdivided per sex;

·          percentage of sexually initiated adolescents who used contraception at first/last sexual intercourse, subdivided per sex;

·          percentage of sexually active, unmarried adolescents who consistently use condoms, subdivided per sex;

·          age at marriage (for men and women);

·          age at first intercourse (for men and women);

·          percentage of women who have undergone female genital mutilation; and

·          type(s) 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:

 

·          type of partner (spouse or cohabitant, commercial, or other non-regular);

·          number of partners (during the last year, lifetime);

·          condom use at most recent coital act during the last 12 months;

·          percentage of men who had sex with a commercial sex worker in the last year;

·          age 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);

·          sexual orientation;

·          sexual 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, 2000).

 

9.3.3.5. Future developments

 

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.

 

9.3.3.6. References

 

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Bochow M, Chiarotti F, davies P, Dubois-Arber F, Dür W, Fouchard J, Gruet F, McManus T, Markert S, Sandfort T, et al (1994) : Sexual behaviour of gay and bisexual men in eight European countries. AIDS Care 6(5) :533-49.

Bozon M, Kontula O (1998): Sexual initiation and gender : a cross-cultural analysis of trends in the 20th century. In Sexual behaviour and HIV/AIDS in Europe: comparisons of national surveys. (Edited by:Hubert M, Bajos N, Sandroft T) London: UCL Press; p37-67.

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Layte R, McGee H, Qual A, Rundle K, Cousins G, Donnelly C, Mulcahy F, Conroy R (2006): The Irish Study of Sexual Health and Relationships. Summary Report. Crisis Pregnancy Agency and the Department of Health and Children. 62 p. [http://www.crisispregnancy.ie]

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Serbanescu F, Morris L, Marin M (2001): Reproductive health survey Romania, 1999, Final report. Atlanta. GA. Centres for Disease Control and Prevention.

Shepherd J, Weston R, Peersman G, Napuli IZ, Interventions for encouraging sexual lifestyles and behaviours intended to prevent cervical cancer. Cochrane Database Syst Rev 2:CD001035.

Signorelli C, Pasquarella C, Limina RM, Cozani E, Fanti M, Cielo A, Greco M, de Somenzi CP, Chironna M, Quarto M (2006): Third Italian national survey on knowledge, attitudes, and sexual behaviour in relation to HIV/AIDS risk and the role of health education campaigns. Eur J Public Health 16(5):498-504.

Thompson JC, Kao TC, Thomas RJ (2005): The relationship between alcohol use and risk-taking sexual behaviours in a large behavioural study. Prev Med 41:247-52.

Weiss,P.(2008) Trends and risk factors in the sexual behaviour and sexual approach oh inhabitants of the Czech Republic at the beginning of the 21st Century. (in press in Czech language). The study was carried out by administering about 2000 nameless questionnaires to boys and girls over 15 years of age addressing many topics ( e.g. first intercourse, number of sexual partners and contraception) in each year 1993, 1998 and 2003.

Wellings K, Nanchahak K, Macdowall W, McManus S, Erens B, Mercer CH, Johnson AM, Cpas AJ, Korovessis C, fenton KA, Fiels J (2001): Sexual behaviour in Britain: early heterosexual experience. Lancet 358(9296): 1843-1850.

Wellings K, Collumbien M, Slaymaker E, Singh S, Hodges Z, Patel D, Bajos N (2006): Sexual behaviour in context: a global perspective. Lancet Series: Sexual and Reproductive Health; October: 24-46. [http://www.thelancet.com]

World Health Organization (WHO) (2004): Reproductive Health Strategy to Accelerate Progress towards the Attainment of International Goals and Targets, Geneva, WHO. Available at: http://www.who.int/reproductive-health/publications/strategy.pdf

World Health Organization (WHO) (2006): Accelerating progress towards the attainment of international reproductive health goals. A framework for implementing the WHO Global Reproductive Health Strategy, Department of Reproductive Health and Research, World Health Organization. Available at: http://www.who.int/reproductive-health/publications/rhstrategyframework.pdf

World Health Organisation (WHO) (2006b): Sexuality education in Europe: A reference guide to policies and practices guide (2006). The SAFE project, IPPF European Network. Available at: http://www.euro.who.int/Document/RHP/SexEd_in_Europe.pdf

Wilkinson P, French R, Kane R, et al (2006) Teenage conceptions, abortions, and births in England, 1994-2003, and the national teenage pregnancy strategy: Lancet 368:1846-1848

 

 

9.3.3.7. Acronyms

 

BZgA

Bundeszentrale Für Gesundheitliche Aufklärung

FHI

Family Health International

HBSC

Health Behaviour in School-aged Children study

ISSHR

The Irish Study of Sexual Health and Relationships

MSM

Men having sex with men

NEM

New Encounter Module

UNECE

United Nations Economic Commission for Europe

UNFPA

United Nations Population Fund

WHO

World Health Organization