Health Psychology: Theory, Research and Practice - David F. Marks 2010

Sexual Health
Theories, Models and Interventions for Health Behaviour Change

’Sexual health is a state of physical, mental and social well-being in relation to sexuality. It requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence.’

World Health Organization (2002)

Outline

In this chapter, we review some significant aspects of sexual health. In particular, we examine sexual health concerns of men and women, unwanted pregnancy, illness prevention and stigma, victimization, and other issues of current concern. Sexual health issues can have profound and long-lasting impacts on people’s lives, their families and communities. There has been progress in reducing teenage births over recent decades. However, sexually transmitted infections are showing increasing prevalence in several areas with high levels of stigma, particularly for the LBGTQ community. Social and health care systems are failing to adequately protect children’s sexual safety and well-being. We review key findings and suggest new lines of inquiry.

Box 9.1 Hypothetical Scenario: ’Jack the Lad and Jill the Ladette’*

* We have chosen this vignette because it highlights two key issues for this chapter: unprotected sexual intercourse and unintended teenage pregnancy. For a sociological discussion of ’lads’ and ’ladettes’, see Jackson (2006).

It is Jack’s birthday. He is 18. He’s a man! Jack goes out with his mates for a night on the town to celebrate. They hit the city centre and go on a pub crawl. The ’lads’ egg Jack on to drink as much as possible. They are having a great time with many jokes and pranks, as is customary on these occasions all over England (and most other places, one can assume). Suddenly it’s 1 am, most of the bars are closing, and so they hit a night club, the El Dorado, which stays open until 3 am. They smoke a ’spliff’ or two in a nearby alley and take a few ’uppers’ to keep them going. Inside El Dorado they meet a group of girls on a ’hen night’. They too are feeling ’worse for wear’. Encouraged by his riotous mates, Jack goes to the dance floor with one of the ’hens’, Jill. Jill is 17, she is wearing clothes showing generous amounts of her midriff. Jill is all over Jack ’like a rash’ and he reciprocates. They dance up close, hands wander and they have a long ’snog’. Jack tells Jill proudly that it’s his birthday and says, ’What do I get for my present?’ Jill grabs Jack’s hand and leads him to the intersex washrooms. Jack and Jill enter a booth, lock the door, and have penetrative vaginal sex …

As the dishevelled couple re-enter the clubroom, there’s a loud cheer and applause from the ’lads’ and the ’ladettes’. After a few more cocktails, and a fair amount of gavorting around the dance floor, the lights come on and the patrons are asked to leave by the security staff. The groups head off in their own separate directions. Before they know it, the party is over. No time to exchange contact details.

The next morning Jack remembers very little. Later, he notices a rash on his penis. Over the next few days he finds urination becoming increasingly uncomfortable and a sticky liquid leaks out from his penis. He visits the GUM clinic and is diagnosed with gonorrhoea. With a prescription of antibiotics, the symptoms are quickly gone.

Jill’s period was due two weeks after the ’hen night’. This month she misses. Jill waits a few more days and buys a pregnancy kit from the local pharmacy. It’s positive. Jill is unsure what to do. She talks to her mother, to her doctor, and to a few close friends. Two of her single friends already have babies. Jill thinks long and hard about having an abortion. At first, she thinks she should have one. Ultimately, however, she decides that she does not want to have one.

Jill and Jack have no way of contacting each other. They don’t even remember each other’s names.

The baby, Peter, is born. Jill’s parents, who are retired, help to look after the baby when Jill is at work. Jill remains single for a few years. Eventually she forms a stable relationship with George and they marry. George has two children from a previous relationship. Jill, George and their three children become a family together.

The vignette of Jack and Jill is hypothetical. However, it is not far removed from scenarios that are replicated all over the world on a frequent basis. Jack-and-Jill encounters of this kind have consequences. The vignette contains a classic mix of biopsychosocial elements:

· in-group conformity

· cultural norms

· alcohol

· drugs

· sex after alcohol

· sex after drugs

· unprotected sexual intercourse

· sexually transmitted infection (STI)

· pregnancy

· childbirth

· single-parent family.

Jack and Jill’s story contains significant ’bio’, ’psycho’ and ’social’ elements and illustrates the medium- to long-term consequences that can follow a few minutes of inebriated ’sexual fun’. It is a very human story. What happened can happen in a million different ways. On the medical issue of the STI, Jack and Jill’s condition was easily treatable. Other STIs would not be so easily dealt with and could have serious complications, including infertility and disability. In this story Jill will be a single parent, at least for a while. She has the support of her parents, which is likely to be a benefit, but Jack has missed out on fatherhood. Perhaps Jack would have been ill-prepared for this, but so are many fathers or mothers, and he could have been a proud and good father to baby Peter. Before examining some of the issues this story raises in more depth, we outline a few of the pivotal domains that fall under the umbrella of sexual health psychology.

The Scope of Sexual Health Psychology

’Sexual health’ can be defined in different ways. In 1994, the United Nations (UN) defined sexual health as ’the enhancement of life and personal relations’, and the framing of rights was gender-neutral and cognizant of ’couples and individuals’ in terms of rights and responsibilities. The World Health Organization (WHO) defined sexual health as an integral part of overall health. The US Centers for Disease Control and Prevention (CDC) recommended a definition of sexual health in which sexuality is both an intrinsic part of individuals and their overall health and is interwoven with social connections (CDC, 2010). The common elements across the three definitions are that (1) sexuality or relationships with a sexual or romantic component have intrinsic value as a part of health and (2) healthy sexual relationships require positive experiences for individuals and their partners (Hogben et al., 2015).

We can see from this last statement that sexual health entails a number of key elements: sexual or romantic relationships are a valuable asset to health; these relationships need to be positive experiences to be healthy. The latter implies that there is choice and enjoyment. The field of sexual health is very broad and encompasses many topics. Examples are:

· The social, cultural and structural determinants of sexual health

· The sexual health of marginalized or oppressed identities (e.g., people with disabilities, transgender persons, refugees)

· Living a fulfilling sexual life when living with chronic conditions (e.g., HIV)

· Sexual coercion, discrimination and violence

· Sexual health and well-being

· Sexual health and sexual rights

· Critical approaches to sexual health

· The development of new interventions for sexual health

· The evaluation of interventions that improve sexual health.

A special issue of the Journal of Health Psychology encompassing the above topics is in press (Rohleder and Flowers, 2018). Box 9.2 lists some commonly cited specific sexual issues that can be perceived as problematic for men and/or women.

Box 9.2 Typical Sexual Health Concerns of Women and Men

Many of these concerns share common features for both genders.

It is impossible to discuss all of these topics in a single chapter. Instead, we highlight a few key topics: ’erectile dysfunction’, orgasm and ’anorgasmia’, teenage pregnancy, STI prevention, stigmatization, victimization and choice. In our discussion, we observe a tension between traditional biomedical explanations and a more nuanced approach that views sexual experience as a complex of biopsychosocial processes that normally includes the stimulation of anatomical structures.

Masculinity, the Penis and Erectile Dysfunction

One dominant narrative of masculinity gives primacy to the erect penis. In some ways, contemporary discourse on the penis is similar to ancient fertility cults. Men often perceive their sexual potency as the foundation stone of their identity as a masculine human being. The erect penis has an ’iconic’ status as a symbol of virility and masculinity, a qualification of potency in the ’if-a-man-can’t-get-a-hard-on, he’s-not-fit-to-call-himself-a-man’ school of thought. Having a penis and the ability to have it erect when required are necessary but not sufficient conditions of virility or masculinity, however. There is another preferred condition: the penis should ideally also be large — or even ’huge’.

The penis lends power and potency to male identity, especially if the penis is not small. The media equate a man’s penis size with power and masculinity. Some women’s magazines convey that a large penis is beneficial to female sexual enjoyment, e.g., ’My best sex ever was … with a guy who was HUGE’ (Cosmopolitan headline, 7 July 2016). Men reporting a larger-than-average penis rate their appearance most favourably, suggesting an effect on male confidence of perceived large penis size (Lever et al., 2006).

A recent systematic review of studies with up to 15,521 men computed an average penis size of 9.16 cm (3.61 inches) with an SD of 1.57 cm when flaccid and 13.12 cm (5.17 inches) with an SD of 1.66 cm when erect, with an average erect circumference of 11.66 cm (4.59 inches) (Veale et al., 2015). Veale et al. reported a significant positive correlation between men’s erect penis length (PL) and their height, which ranged from r = 0.2 to 0.6. Above average height with above average PL would thus give a man the best of two worlds.

An internet survey of 52,031 heterosexual men and women by Lever et al. (2006) showed that a majority of men (66%) rated their PL as average, 22% as large and 12% as small. A total of 85% of women were satisfied with their partner’s PL, but only 55% of men were satisfied with their PL, with 45% wanting a larger PL and only 0.2% wanting a smaller one. Given its primal role in the psyche, it is important to know in detail the anatomy of the penis and the neighbouring structures.

The penis is the external male organ that serves the dual function of a urinal duct and for the delivery of sperm. The human male urethra passes through the prostate gland, where it is joined by the ejaculatory duct, and then through the penis (Figure 9.1). The urethra traverses the corpus spongiosum, and its opening, the meatus, lies on the tip of the glans penis. It is a passage both for urination and ejaculation of semen.

Much of the penis develops from the same embryonic tissue as the clitoris in females; the skin around the penis and the urethra come from the same embryonic tissue from which develops the labia minora in females. The stiffening and rising of the penis, which occurs in erection during sexual arousal, also can happen in non-sexual situations. The most common genital alteration is circumcision, the removal of part or all of the foreskin for cultural, religious or medical reasons.

Figure 9.1 Penis and surrounding structures and tissues (lateral cross-section)

Source: Carl Fredrik (2017). Public domain (https://en.wikipedia.org/wiki/Human_penis#/media/File:Penis_lateral_cross_section.jpg)

A major issue in sexual satisfaction is the production of an erection. In so-called ’erectile dysfunction’ (ED), this does not happen. ED is defined as the ’inability to achieve or maintain an erection sufficient for satisfactory sexual performance’ and it is is estimated to affect as many as 30 million men in the USA (National Institutes of Health, 2017). ED is age-related, with a two- to three-fold increase in prevalence of moderate to severe ED between the ages of 40 and 70 years. It has been estimated that by 2025, the worldwide incidence of ED will approach 322 million, more than double the estimated 1995 incidence rate of approximately 152 million (Newton et al., 2012). When a man ceases to obtain an erection, he will tend to reach out for the little blue pills (Viagra, sildenafil citrate) or the little yellow pills (Cialis, tadalafil). Aids and devices for men with ED are a multibillion dollar industry, giving the hyped obsession with erections and penises in magazines a new meaning.

ED can impact negatively on self-esteem, quality of life and interpersonal relationships in heterosexual (Rosen et al., 1997), gay and bisexual men (Ussher et al., 2016). In her feminist deconstruction, Potts (2000) states that the fully erect penis is given an ’executive position in sex’. Potts suggests that ED or ’impotence’ places a ’coital imperative onto male bodies’ such that ED implies ’a dysfunctional nonpenetrative male (hetero)sexuality. The impotent man embodies this cultural narrative; his perceived failure to erect his penis and perform (with it) according to dominant phallocratic notions of healthy male heterosexuality infiltrates his flesh, actions, and thoughts’ (Potts, 2000).

Feelings of sexual disqualification as a consequence of ED are, of course, not restricted to heterosexual men. Ussher et al. (2016) explored the impact of ED on 46 gay and bisexual men in one-to-one interviews. ED was associated with emotional distress, a negative impact on gay identities, and feelings of sexual disqualification. Other concerns included loss of libido, climacturia, loss of sensitivity or pain during anal sex, non-ejaculatory orgasms and reduced penis size. Such changes can have particular significance to gay sex and gay identities, and can result in feelings of exclusion from a sexual community that can be central to gay or bisexual men’s lives. However, Ussher et al. reported that other men were reconciled to their sexual changes, did not experience a challenge to identity, and engaged in sexual re-negotiation.

A variety of medical, psychological and lifestyle factors have been implicated in ED. There is an association between ED and cardiovascular disease, notably coronary heart disease (Shamloul and Ghanem, 2013). Causes of erectile dysfunction include diabetes mellitus and hypertension, and also factors such as limited physical exercise. Lower urinary tract symptoms also have been linked to the development of ED.

How can ED be assessed for clinical purposes or research? The assessment of ED is based on questionnaire measures such as the International Index of Erectile Function Questionnaire (Rosen et al., 1997, described in Box 9.3).

The primary treatment for ED has been the phosphodiesterase type 5 (PDE5) inhibitors such as Viagra (sildenafil), Cialis (tadalafil) and Levitra (vardenafil). This class of drugs was the first effective oral treatment for ED and has made billions for the companies holding the patents. The PDE5 inhibitors are effective solutions for ED. McCabe and Althof (2014) analysed published findings from randomized controlled trials (RCTs) for (1) the psychosocial outcomes associated with erectile dysfunction (ED) before treatment with a PDE5 inhibitor, and (2) the change in psychosocial outcomes after the use of a PDE5 inhibitor in men with ED. The main outcome measures were scores on psychosocial measures before and after treatment. From a total of 1,714 publications, 40 (32 RCTs) were retained. Before treatment, men reported relatively good quality of life and overall relationships, but poor sexual relationships and sexual satisfaction, diminished confidence, low self-esteem and symptoms of depression. After treatment, there were significant improvements from baseline in most of these measures, except for overall life satisfaction and overall relationship satisfaction. The authors concluded: ’ED and the treatment of ED are associated with substantially broader aspects of a man’s life than just erectile functioning. This review demonstrates the importance of evaluating the psychosocial factors associated with ED and its treatment, and the importance of using standardized scales to conduct this evaluation’ (McCabe and Althof, 2014: 347).

A narrative review by Schmidt et al. (2014) suggested that psychological intervention combined with a PDE5 inhibitor is more effective than a PDE5 inhibitor alone, although larger-scale RCTs are needed to confirm this finding. Certainly, the PDE5 inhibitors have had a revolutionary impact on improving sexual satisfaction in both men and women.

We turn now to consider the concept and role of the orgasm in human sexual experience.

The Clitoris, Orgasm and Anorgasmia

If the penis is the epitome of masculinity, then the clitoris must be considered the epitome of female sexuality, and the orgasm the epitome of sexual relations. Fortunately, or unfortunately, depending upon how you look at it and where you’re looking from, human sexuality is far more complicated. Sexual behaviour is a complex interaction of biopsychosocial factors involving the central and peripheral nervous systems, modified by emotional, social and physical factors. One of best known classification systems of the human sexual response suggested four phases: desire, excitement, orgasm and resolution (Masters and Johnson, 1966; Kaplan, 1975). Sexual relationship concerns (or ’dysfunctions’ according to medical terminology) can stem from psychological and communication issues within a relationship.

Box 9.3 Selected Items from the International Index of Erectile Function Questionnaire and Response Options (US Version)

Over the past 4 weeks:

· Q1: How often were you able to get an erection during sexual activity? 0 = No sexual activity 1 = Almost never/never 2 = A few times (much less than half the time) 3 = Sometimes (about half the time) 4 = Most times (much more than half the time) 5 = Almost always/always

· Q2: When you had erections with sexual stimulation, how often were your erections hard enough for penetration? 0 = Did not attempt intercourse 1 = Almost never/never 2 = A few times (much less than half the time) 3 = Sometimes (about half the time) 4 = Most times (much more than half the time) 5 = Almost always/always

· Q3: When you attempted sexual intercourse, how often were you able to penetrate (enter) your partner? 0 = Did not attempt intercourse 1 = Extremely difficult 2 = Very difficult 3 = Difficult 4 = Slightly difficult 5 = Not difficult

· Q4: During sexual intercourse, how often were you able to maintain your erection after you had penetrated (entered) your partner? 0 = Did not attempt intercourse 1 = Extremely difficult 2 = Very difficult 3 = Difficult 4 = Slightly difficult 5 = Not difficult

· Q5: During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse? 0 = Did not attempt intercourse 1 = Extremely difficult 2 = Very difficult 3 = Difficult 4 = Slightly difficult 5 = Not difficult

· …

· Q14: How satisfied have you been with your sexual relationship with your partner? 1 = Very dissatisfied 2 = Moderately dissatisfied 3 = About equally satisfied and dissatisfied 4 = Moderately satisfied 5 = Very satisfied

· Q15: How do you rate your confidence that you could get and keep an erection? 1 = Very low 2 = Low 3 = Moderate 4 = High 5 = Very high

Source: Rosen et al. (1997)

Rightly or wrongly, the discourse on this topic focuses on the clitoris. While sexual desire and excitement can be triggered by stimulation of erotogenic areas of the vulva, the clitoris and the anterior wall or outer one-third of the vagina, it can also be triggered by words, thoughts and daydreams (Stock and Geer, 1982; Leitenberg and Henning, 1995). We begin with the ’bio’ component of the biopsychosocial approach, focusing on the anatomy and physiology of the female erogenous zones.

How is the clitoris structured and how does it function? The clitoris comprises an external glans and hood, and an internal body, root, crura and bulbs, and is richly supplied with nerve endings (Figure 9.2). The clitoris plays a role in the female orgasm but other factors are also important.

Figure 9.2 The clitoris

Source: Original artwork bu Amphis (2007). Public domain

The female orgasm is a complex and contended issue. Although stimulation of the clitoris can trigger orgasm, many factors and theories have been suggested for the female orgasm, clitoral stimulation being only one. The discourse tends to be medicalized. For example, orgasm has been described as ’a sensation of intense pleasure creating an altered consciousness state accompanied by pelvic striated circumvaginal musculature and uterine/anal contractions and myotonia that resolves sexually-induced vasocongestion and induces well-being/contentment’ (Meston et al., 2004: 66). Meston et al. (2004) reported a survey of 1,749 randomly-sampled US women, of whom 24% reported ’orgasmic dysfunction’. Working within a medical framework, they suggested that Female orgasmic disorder (FOD) is the second most frequently reported women’s sexual problem (the first being infertility). FOD was defined as ’the persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase that causes marked distress or interpersonal difficulty’ (American Psychiatric Association, 2000). Two treatment approaches for FOD have been suggested: cognitive behavioural therapy (CBT) and the pharmacological approach. CBT aims at promoting changes to attitudes and sexually-relevant thoughts and anxiety reduction using exercises such as directed masturbation, sensate focus and systematic desensitization, as well as sex education, communication skills training and Kegel exercises (simple clench-and-release exercises that can strengthen the muscles of the pelvic floor). Up to 2004 there had been no reported pharmacological trials (i.e., bupropion, granisetron, and sildenafil) with FOD.

Risk factors for FOD are classified as psychological, physiological, socio-demographic, hereditary, and with comorbid medical conditions (Cohen and Goldstein, 2016). These authors described multiple psychosocial conditions that can interfere with a woman’s ability to reach orgasm, including anxiety, depression, attention deficit disorder, body image, sexual abuse and negative religious views on sex. The relationship with the intimate partner is highly significant. For example, in one study the frequency of penile—vaginal intercourse correlated positively with dimensions of perceived relationship quality: Satisfaction, Intimacy, Trust, Passion, Love (all r ≥ .40) and Global Relationship Quality (r = .55) (Costa and Brody, 2007).

Salisbury and Fisher (2014) explored young adult Canadian heterosexual men’s and women’s experiences, beliefs and concerns regarding the occurrence or non-occurrence of orgasm during sexual interactions, with an emphasis on the absence of female orgasm during intercourse. Qualitative reports were obtained from five female focus groups (n = 24) and five male focus groups (n = 21) averaging 19 years of age. The results indicated that the most common concern regarding lack of female orgasm was the negative impact on the male partner’s ego. Both male and female participants agreed that ’men have the physical responsibility to stimulate their female partner to orgasm, while women have the psychological responsibility of being mentally prepared to experience the orgasm’ (Salisbury and Fisher, 2014: 616). Men and women tended to maintain different beliefs, however, regarding clitoral stimulation during intercourse, as well as the importance of female orgasm for a woman’s sexual satisfaction in a partnered context.

A qualitative study by Opperman et al. (2014) studied the meanings associated with orgasm and sexual pleasure during sex with a partner, to understand the social patterning of orgasm experience. The sample was 119 sexually experienced British young adults (81% women, mean age 20; 92% heterosexual). The five main themes were: (1) orgasm: the purpose and end of sex; (2) ’it’s more about my partner’s orgasm’; (3) orgasm: the ultimate pleasure?; (4) orgasm is not a simple physiological response; and (5) faking orgasm is not uncommon. The authors suggested that these themes demonstrate the existence of ’contextualized, complex and contradictory meanings’ around orgasm. However, the authors concluded that ’they do resonate strongly with widespread discourses of sexuality which prioritize heterosexual coitus, orgasm, and orgasm-reciprocity’ (Opperman et al., 2014: 503). It would appear that, to some degree, medical discourse has seeped into lay discourse about orgasm, in which the orgasm is seen as the ’holy grail’ of sexual intercourse such that it will be faked rather than be seen by a partner to be absent. The faking of an orgasm can serve a number of different purposes. To help unravel this complex topic, there is even a scale for measuring female faking of orgasm.

The Faking Orgasm Scale for Women

The Faking Orgasm Scale for Women (FOS) was designed to assess women’s self-reported motives for faking orgasm during oral sex and sexual intercourse (Cooper et al., 2014). There are two subscales, one for sexual intercourse and one for oral sex. A factor analysis on the responses of 481 heterosexual undergraduate females (M age = 20.33 years) revealed that the FOS—Sexual Intercourse Subscale was composed of four factors: ’(1) Altruistic Deceit, faking orgasm out of concern for a partner’s feelings; (2) Fear and Insecurity, faking orgasm to avoid negative emotions associated with the sexual experience; (3) Elevated Arousal, a woman’s attempt to increase her own arousal through faking orgasm; and (4) Sexual Adjournment, faking orgasm to end sex’ (Cooper et al., 2014: 423). The analysis of the FOS—Oral Sex Subscale also yielded four factors, the first three of which were similar to those for Sexual Intercourse. The fourth was ’Fear of Dysfunction’, faking orgasm to cope with concerns of being abnormal. This last factor is a serious indictment of the lack of authenticity in sexual relationships, faking it to appear and feel ’normal’.

Box 9.4 The Female Orgasm

There have been many competing hypotheses concerning the nature and function of the female orgasm. There is evidence supporting several hypotheses and it may be that more than one of them are helpful. A few of the main hypotheses suggest that the female orgasm:

encourages sexual behaviour more generally as a reward for, and reinforcement to continue, sexual behaviour that may result in conception;

promotes fertilization with chosen ’sires’, potentially of higher genetic quality;

attracts men of high genetic quality;

fosters pair bonds with chosen long-term partners at non-fertile points in the cycle, potentially via oxytocin release;

is a by-product that has been shaped as a secondary adaption over time;

or

that the female orgasm no longer functions in the capacity for which it was designed.

The medicalized model of women’s sexual problems, such as FSD and FOD, have been challenged in the light of qualitative studies of women’s desires and expectations. Nicolson and Burr (2003) interviewed 33 women aged between 19 and 60 years (mean age 28.6), focusing upon their perceptions and feelings about the nature of ’normal’ sexual satisfaction. They observed that these women’s desires and expectations differed from those reported in the clinical and sexological literature. The authors stated that their interviewees seemed less concerned with achieving orgasm through heterosexual intercourse for themselves than the literature suggested they might be. There was, however, evidence of a strong desire to experience orgasm in this way for the sake of their male partners. Thus, it is suggested that there is probably a closer relationship between popular beliefs about what is ’normal’ based upon the medical model, with women placing themselves in a dysfunctional category, than there is between the everyday enjoyment of sex and women identifying themselves as being sexually healthy. (Nicolson and Burr, 2003: 1735)

With so many theories and interests, it it true to say that the ’jury is still out’ on the nature and function of the female orgasm.

Source: Welling (2014)

The FOS should be helpful to improve understanding of the faking of orgasms and, to complement qualitative studies, provide a method for exploring sexual desire and satisfaction that goes beyond the medicalized discourse about anorgasmia, FSD and FOD. We turn now to consider the issue of female genital mutilation.

Female Genital Mutilation

Among those who practise it, female genital mutilation (FGM) is believed to be a way of reducing a woman’s libido to help her to resist ’illicit’ sexual acts. Although the WHO classification of FGM indicates that FGM can involve the complete removal of the clitoris, the clitoris is rarely fully removed, as erectile tissues for sexual arousal, orgasm and pleasure are preserved and normally developed in women with FGM (Okomo et al., 2017). However, any cutting of the clitoris in FGM can impair sexual responsivity and there is trauma with the procedure itself. Impaired sexual function, such as vaginal dryness during intercourse, increased pain, reduction in sexual satisfaction and desire, orgasmic delay and anorgasmia, have been reported among women living with all types of FGM. Scar formation, pain and traumatic memories associated with FGM can also lead to such problems.

Okomo et al. (2017) suggest that orgasmic difficulties may not be seen as a problem if the girl underwent the procedure before becoming sexually active, or if her peers are anorgasmic. Such difficulties are more likely to be reported in groups that undergo the procedure after a period of adolescent sexual activity or before childbirth. Sexual issues for men can be caused by physical discomfort when attempting intercourse with a partner with FGM as well as causing pain for the woman.

FGM has been illegal in the UK since 1985, and since 2003 anyone taking a child out of the UK for FGM faces 14 years in prison. However, enforcement has been lacking and not one successful prosecution of an FGM case had occurred in the UK to the date of this publication.

Teenage Pregnancy

Teenage pregnancy usually refers to cases of unintended pregnancy during adolescence. Approximately 750,000 of 15- to 19-year-olds in the USA become pregnant each year (American Congress of Obstetricians and Gynecologists, 2015). Somewhat bizarrely, teenagers often do not believe that they will get pregnant if they engage in unprotected sexual activity. This fact may seem a little weird, but it possibly stems from the well-established tendency of humans to indulge in unrealistic optimism: the almost universal ’I didn’t think this would ever happen to me’ syndrome (Weinstein, 1980). Most people also rarely appreciate the moderate-sized probability that they are themselves the result of an unintended pregnancy. You and me both! Sedgh et al. (2014) reported that 85 million pregnancies, which is 40% of all pregnancies worldwide, were unintended in 2012. Of these, 50% ended in abortion, 13% ended in miscarriage and 38% resulted in an unplanned birth. If reliable, this statistic means that 15.2% of all births in 2012 were unintended.

A large quantity of research has looked for social and psychological predictors of teenage pregnancy and examined the typical outcomes of teen births for babies and mothers. The good news is that teen pregnancy rates have significantly declined over the last few decades in both the UK and the USA (Lindberg et al., 2016; Office for National Statistics, 2016; Figures 9.3 and 9.4). These statistical reductions could possibly be attributed to improved methods of contraception, or teenagers becoming more intelligent (probably not) (Flynn, 2007; Marks, 2010), or, as ’digital natives’, teenagers exposing themselves less to pregnancy risk by spending more time on the internet using Facebook, SnapChat and other media and less time experimenting with sex. More research is needed to answer this question.

One of the most commonly cited reasons for teenage pregnancy is peer pressure. Teenagers believe that having sex is ’cool’. More than 29% of US pregnant teens reported that they felt pressured to have sex, and 33% of pregnant teens stated that they felt that they were not ready for a sexual relationship, but proceeded anyway because they feared ridicule or rejection (Kaiser Family Foundation, 2016). Another factor is the absence of parents. Teenage girls are more likely to get pregnant if they have received limited or no guidance from parents. If a teenager feels unable to talk to her parents about sex, her only source of guidance will be friends, social media, TV and print publications, resulting in misinformation.

Figure 9.3 Reduction in pregnancy risk among females 15—19 years in the USA from 1991—2014

Source: Martin et al. (2014)

Figure 9.4 Teenage pregnancies in England and Wales

Source: Office for National Statistics (2016)

Father absence has been another significant predictor. Ellis et al. (2003) investigated the impact of father absence on early sexual activity and teenage pregnancy in longitudinal studies in the USA and New Zealand. Community samples of girls were followed prospectively from early in life (5 years) to approximately age 18. The findings showed that greater exposure to father absence was strongly associated with risk for early sexual activity and adolescent pregnancy. This elevated risk was not explained (in the USA) or only partly explained (in New Zealand) by family, ecological and personal disadvantages associated with the father’s absence. There were stronger, more consistent effects of father absence on early sexual activity and teenage pregnancy than on other problems, including academic achievement.

It is often alleged that the movies and media contribute to teen pregnancy by glamorizing it. However, the evidence on glamorization is mixed and some evidence even contradicts the notion. Kearney and Levine (2014) obtained evidence that MTV’s 16 and Pregnant has had a positive effect on reducing teen childbearing in the USA. 16 and Pregnant is a reality TV series which follows the lives of pregnant teenagers at the end of their pregnancy and in the early days of motherhood. Kearney and Levine (2014) investigated whether the show influenced teens’ interest in contraceptive use or abortion, and whether it ultimately altered teen childbearing outcomes. They used data from Google Trends and Twitter to document changes in searches and tweets resulting from the show, Nielsen ratings data to capture geographic variation in viewership, and Vital Statistics birth data to measure changes in teen birth rates. They found that 16 and Pregnant led to more searches and tweets regarding birth control and abortion, and ultimately to a 5.7% reduction in teen births in the 18 months following its introduction. The authors claim that this reduction accounted for around one-third of the overall decline in teen births in the USA during that period. If real, this finding would be a progressive step towards the improvement of society.

Around 5% of teens become pregnant as a consequence of rape (Holmes et al., 1996). The Guttmacher Institute (2016) stated that around 50% of teens say that they had been impregnated by an adult male, and two-thirds report that their babies’ fathers are as old as 27.

Alcohol drinking is associated with unexpected pregnancy. Drinking lowers a teen’s ability to control her impulses, contributing to 75% of pregnancies that occur between the ages 14 and 21. Approximately 91% of pregnant teens reported that although they were drinking at the time, they did not originally plan to have sex when they conceived (Guttmacher Institute, 2016).

The stereotyping of young single mothers has been evident for many decades, going back to the Victorian era. Accepted professional opinion in the 1990s was that adverse birth outcomes with teenage pregnancy are attributable to low socio-economic status, inadequate prenatal care and inadequate weight gain during pregnancy. Empirical research has proved this thinking to be wrong. Chen et al. (2007) studied whether teenage pregnancy is associated with increased adverse birth outcomes independent of known confounding factors. They used a retrospective cohort design with 3.886 M. pregnant women under 25 years of age with a first live singleton birth during 1995 and 2000 in the USA. Chen et al. found all teenage groups were associated with increased risks for pre-term delivery, low birthweight and neonatal mortality. Infants born to teenage mothers aged 17 or younger were at an even higher risk. The sub-sample of white married mothers with an age-appropriate education level and adequate prenatal care, and without smoking and alcohol use during pregnancy, yielded similar results. Chen et al. concluded that ’teenage pregnancy increases the risk of adverse birth outcomes independent of important known confounders. This finding challenged the accepted opinion that adverse birth outcome associated with teenage pregnancy is attributable to low socioeconomic status, inadequate prenatal care and inadequate weight gain during pregnancy’ (Chen et al., 2007: 368).

Teenage mothers have been stereotyped and stigmatized in UK media, especially the ’red-top’ newspapers, as unmotivated, irresponsible and incompetent (SmithBattle, 2013). Stigmatization is a contributing factor to teenage mothers’ difficulties and their health and social disparities. Marginalized youth, unemployed young men and teenage mothers tend to be stereotyped and stigmatized in the UK through labels such as ’chav’ and ’pramface’ (Nayak and Kehily, 2014). Working-class young men and teenage mothers must learn to manage social class stigma and ’speak back to these markers of abjection’ (Nayak and Kehily, 2014: 1330). Stigma and stereotyping are impediments to effective clinical care and contribute to teenage mothers’ challenges. Improvements to training with advocacy for services and policies to reduce the stigmatization and marginalization are one way to lessen the negative experiences of teenage mothers.

Unsafe Abortion

The World Health Organization defines unsafe abortion as ’a procedure for terminating an unintended pregnancy either by individuals without the necessary skills or in an environment that does not conform to minimum medical standards, or both’ (World Health Organization (WHO), 2011). In a review by Grimes et al. (2006), unsafe abortion was described as ’a persistent, preventable pandemic’. Unsafe abortion mainly occurs in developing countries where abortion is highly restricted by law and in countries where, although legally permitted, safe abortion is not easily accessible. Women dealing with an unintended pregnancy often self-induce abortions or obtain clandestine abortions from medical practitioners, paramedical workers or traditional healers. The risks of infection and/or incorrect and potentially life-threatening procedures are high.

The WHO (2011) reported that unsafe abortion remains a major public health problem in many countries. It estimated that a woman dies every eighth minute somewhere in a developing country due to complications arising from unsafe abortion. These women were likely to have had little or no money to procure safe services. An estimated 74% of abortions in developing countries, excluding China, were unsafe in 2008, with Africa having a 97% rate of unsafe abortions (Sedgh et al., 2012).

As with HIV infection and AIDS, the disparities between the health of women in developed and developing countries is extreme. Unsafe abortion remains one of the most neglected sexual and reproductive health problems.

Preventing STIs: Knowledge, Awareness and Condom Use

Worldwide, the WHO estimated that 499 million new cases of curable STIs occurred in 2008 among 15—49-year-olds globally: 106 million cases of chlamydia, 106 million cases of gonorrhea, 11 million cases of syphilis, and 276 million cases of trichomoniasis (WHO, 2008). More than 30 identified pathogens are known to be transmitted sexually, eight of which have been clearly linked to the greatest amount of morbidity. Three bacterial STIs, Chlamydia trachomatis (chlamydia), Neisseria gonorrhoeae (gonorrhea) and Treponema pallidum (syphilis), and one parasitic STI, Trichomonas vaginalis (trichomoniasis), are currently curable. Four viral STIs — HIV, human papillomavirus (HPV), herpes simplex virus (HSV) and hepatitis B virus (HBV) — can be chronic or life-long, although medications can modify disease course or symptoms (Gottlieb et al., 2014).

The Centers for Disease Control and Prevention (CDC, 2016a) reported that there are more than 110 million STIs among men and women across the nation and 20 million new STIs each year in the USA, costing the American health care system nearly $16 billion in direct medical costs alone. The CDC estimated that half of all new STIs in the USA occur among young men and women.

Research on sexual behaviour is procedurally complex. People do not feel comfortable sharing information with strangers carrying clip boards about their intimate experiences. There is an understandable tendency to over-report prudent and wise actions and to under-report casual indulgences, leading to biased data. The reliability and validity of self-report measures of condom use must be questioned because self-reported behaviour is likely to be influenced by self-presentation, social desirability or memory biases. Young people in general often also believe an incorrect and potentially fatal idea: they think that bad things won’t happen to them (’optimistic bias’; Weinstein, 1980). They are chronic under-reporters of sexual risk taking. There are also gender-based ’double standards’ in which males over-report and females under-report sexual activity (e.g., Rudman et al., 2016).

Adolescents have high rates of STIs. Adolescents consuming alcohol and using drugs have markedly greater HIV/STI risk and are a priority for intervention. Recent advances in microbiology, such as the use of less invasive specimen collection for DNA assays, can provide validation of adolescents’ self-reported sexual risk behaviour (DiClemente, 2016). However, the majority of studies of adolescents’ sexual risk rely solely on self-reports.

Among young adults who use condoms, incomplete condom use (putting a condom on after beginning or taking a condom off before finishing sex) and condom failure (condom breaking or slipping off during sex) are common. Therefore, surveys that only ask whether a condom was used are likely to underestimate the actual prevalence of unprotected sex. Dolezal et al. (2014) used data from 135 sexually active perinatally HIV-infected (PHIV+) youth and perinatally exposed but uninfected (PHIV−) youth aged 13—24. Participants were asked whether they used a condom on their first and their most recent occasion of vaginal sex. Dolezal et al. asked youth who reported using a condom a follow-up question about whether there was any time during that occasion when sex was not protected by a condom. This simple follow-up question identified almost double the proportion who initially said they did not use a condom as having had unprotected sex.

Communication between partners can be another barrier or a facilitator of safe sexual relations. Lack of communication between partners could help to explain why many adolescents fail to use condoms consistently. Widman et al. (2014) synthesized research linking adolescents’ sexual communication to condom use and examined several potential moderators of this association. A total of 41 independent effect sizes from 34 studies with 15,046 adolescent participants were meta-analysed. Their results revealed a modest but statistically significant weighted mean effect size of the sexual communication—condom use relationship of r = .24, p < .001. Communication topic and communication format were statistically significant moderators (p < .001). Larger effect sizes were found for communication about condom use (r = .34) than for communication about sexual history (r = .15) or general safer sex topics (r = .14). Effect sizes were also larger for communication behaviour formats (r = .27) and self-efficacy formats (r = .28) than for fear/concern (r = .18), future intention (r = .15) or communication comfort (r = −.15) formats. Widman et al.’s results highlight the need for communication skills, particularly about condom use, in HIV/STI prevention work for youth.

Sheeran et al. (1999) conducted a herculean systematic review of correlates of condom use among heterosexual samples. Altogether, 660 correlations distributed across 44 variables were derived from 121 empirical studies. The findings showed that demographic, personality and labelling stage variables showed small average correlations with condom use. The correlations ranged from −.18 (frequency of intercourse) to .10 (had an HIV test), suggesting that the variables were accounting for only 1—2% of the variability in reported condom usage rates.

Bearing in mind that there were 660 different correlations, then 1 in 20 of the 660 correlations would be significant at the 5% level owing to Type I error. That means there were in the region of 33 p < .05 coefficients from Type I errors, i.e., false positives. Applying the Bonferroni correction to the p level requires any individual correlation coefficient to be significant at p < .05/660 or p = .0000757. For n = 100, 200 and 1,000 respectively, r would need to be .37,.27 and .12 to be statistically significant. Table 2 in Sheeran et al. (1999) suggests that few correlations reached the corrected level of significance.

Another factor is publication bias, in which studies reporting statistically significant results and those supporting the investigator’s hypotheses are more likely to be published than null or negative findings. Dwan et al. (2013) found strong evidence of an association between significant results and publication. Publications also have been found to be inconsistent with their protocols. Dwan et al. (2013: 1) concluded: ’Researchers need to be aware of the problems of both types of bias and efforts should be concentrated on improving the reporting of trials.’

Sheeran et al. (1999: 90) concluded that their ’findings support a social psychological model of condom use highlighting the importance of behaviour-specific cognitions, social interaction, and preparatory behaviors rather than knowledge and beliefs about the threat of infection’. However, the support offered to the socio-cognitive model of condom use was limited to explaining a maximum of 18.5% in intention to use condoms. Setting aside the slippery problem of good intentions never being carried out, the published figure left 81.5% of the variation in intention to use condoms unaccounted for. Bearing in mind that no corrections were made for publication bias or multiple p values, the 18.5% figure must be assumed to be highly inflated compared to the true figure. Yet this low 18.5% figure is representative for what has been offered as the epitome of the best results offered by socio-cognitive theory. The findings of the best research from health psychology illustrated by the above studies suggest a huge gap between theoretical predictions and real-world sexual behaviour, an issue we highlight in the following in-depth analysis of a recent intervention study.

Intervention Study

The gap between psychological theory and actual sexual behaviour can be illustrated by an evaluation of an intervention to reduce sexual risk behaviours in Spanish adolescents (Morales et al., 2017). We chose this study as a representative example from a huge literature. This study is in many respects above the prevailing average in its well-crafted theoretical underpinnings and attention to detail.

The evaluated intervention is called ’Cuídate’, an adaptation for Latino youth of Be Proud! Be Responsible (Jemmott et al., 1994). The Spanish term cuídate means ’take care of yourself’. The intervention was designed originally to reduce HIV infection in black inner-city youth in the USA. It has been evaluated in RCTs with modest outcomes (O’Leary et al., 1992; Jemmott et al., 1999, 2010). Like many others, the intervention is based on constructs drawn from the theory of planned behaviour (TPB).

The goals and content of Cuídate were stated by the authors as follows: to influence attitudes, normative and behavioral beliefs, and self efficacy to have safe sex, in addition to highlighting cultural values that support safer sex practices, and discussing barriers to safer sex. It is based on the Social Learning Theory (Bandura, 1986) and TPB (Ajzen, 1991). Cuídate consists of six 1-hour modules delivered over 6 weeks (one session per week).

[The six-hour duration of the intervention is relatively modest. Perhaps the investigators were being optimistic in thinking that six hours of instruction might achieve significant and lasting changes in adolescent sexual risk taking?]

To continue with the authors’ description: The curriculum includes six modules: 1) Introduction and overview: this introduces the Cuídate program, provides knowledge about HIV transmission and prevention, and works on attitudes and beliefs of participants about risk behaviors and consequences; 2) Building knowledge about HIV, STIs, and pregnancy: this increases knowledge regarding the transmission, cause, and prevention of HIV, and trains adolescents to differentiate between myths and facts about HIV and AIDS; 3) Understanding vulnerability to pregnancy, STIs, and HIV infection: this promotes vulnerability to HIV infection, and trains communication and negotiation techniques to promote safer sexual behaviors; 4) Attitudes and beliefs about pregnancy, STIs, HIV, and safer sex: this promotes favorable attitudes about HIV and AIDS and safer sex and trains adolescents on condom use skills; …

[It is noteworthy that up to this point there are four modules dedicated to information, knowledge and beliefs about STIs, HIV and AIDS. It is a didactic exercise consisting of four lessons in a classroom course of sex education. Only in the following modules 5 and 6 are students offered practical training in skills relevant to condom use. Perhaps the intervention could be given more potential impact on actual behaviour change if the entire six sessions were devoted to condom-relevant skill acquisition?]

To continue the description: 5) Building condom use skills: this teaches how to manage barriers to condom use, the ability to reduce these barriers, and the ability and knowledge to use condoms correctly and effectively, as well as condom use skills; and 6) Building negotiation and refusal skills: this teaches how to manage sexual risk situations by training communication skills, the ability to negotiate condom use, and how to refuse unsafe sex. (Morales et al., 2017)

[These last two modules get down to the ’nitty-gritty’ — training in actual skills helpful to the desired outcome of employing a condom before sexual intercourse.]

The intervention included group discussions, games, role-playing, demonstrations, brainstorming, skill-building activities, and a talking circle to begin and end each session. The original US version was culturally adapted to adolescents in Spain. This process involved several stages, including three focus groups: experts in reducing sexual risk in adolescents, psychology graduate students and Spanish adolescents. Content specific to US Latino adolescents was removed if it was regarded as unsuitable for adolescents in Spain. For example, the context, music and vocabulary of the videos were not appropriate and were not used in this study.

[Given the appeal of music and videos to teenagers, the removal of this content, without substitution of equivalent Spanish content, was not ideal. However, the authors adapted the vocabulary and Latino expressions to Spanish culture, and cultural discrepancies were addressed.]

The sample was 626 adolescents aged 14—16 enrolled in ninth and tenth grades at 12 high schools in the north, east and south of Spain. The main outcome was consistent condom use reported at the 24-month follow-up. This binary variable indicated whether a person reported using a condom every time he/she had penetrative sex. It was computed from responses to the item ’What percentage of the time do you use a condom in your sexual relations?’, with a scale ranging from 0 (Never) to 100 (Always).

Precursors of the outcome measure were evaluated in accordance with the TPB as knowledge, attitudes, self-efficacy and perceived norms, and these were analysed as potential mediators (M1). Intention of using condoms at the 12-month follow-up was also included as mediator 2 (M2). Condom use intention was assessed with the statement ’I will use a condom during the upcoming 12 months if I have sexual relations’.

The results indicated that there were significant short-term increases in the level of knowledge on HIV and STIs, including about male and female condoms (t = 5.62; p < .00001). However, the results of mediation analysis did not support the TPB. Only knowledge on HIV and STIs was a mediator of the efficacy of Cuídate to promote condom use at the 24-month follow-up. Compared to the control group, adolescents who received Cuídate were found to present a higher level of knowledge on HIV and STIs at the post-test, which influenced their intention to use condoms positively at the 12-month follow-up, and consequently they reported more consistent condom use at the 24-month follow-up: up from 35% to 41% for the Cuídate group (+6%) versus down from 33% to 25% (-8%) in the controls. The net effect of the study on consistent condom use across the intervention and control groups was minus 2%.

Knowledge about HIV and STIs did not have a direct relationship to consistent condom use; however, it positively affected the intention to use condoms. Attitudes towards condom use, attitudes towards condom use when barriers exist, self-efficacy and perceived norms — the precursors of condom use intention in the TPB — were not mediators of the efficacy of the intervention to promote long-term condom use.

Condom use intention at the 12-month follow-up was positively related to consistent condom use at the 24-month follow-up. However, intention at 12 months was not a direct mediator of the efficacy of the intervention on long-term, consistent condom use. The authors concluded that the TPB was not able to explain the long-term effects and also that their evidence did not support relevant relationships among variables postulated by the TPB.

As we have seen in Chapter 8, a number of investigators have criticized the TPB for its low predictive validity for health behaviours. A meta-analysis, including 237 independent prospective tests, that examined the efficacy of the TPB to predict health behaviour found that the TPB only accounted for between 13.8% and 15.3% of the explained variance in health behaviours such as safer sex and abstinence from drugs (McEachan et al., 2011). This suggests that more than 80% of sexual health behaviour is unexplained by the TPB.

Many variables that are related to sexual behaviour, such as gender and religiosity, are not included in the TPB. For example, in a sample of 126 teenagers aged 15—18 in London, Sinha et al. (2007) found that gender, religiosity and youth were mediators of sexual behaviour. In an editorial entitled ’Time to retire the theory of planned behaviour’, Sniehotta et al. (2014) argued that the TPB is too simple and rationality-based, with measures that do not account for the majority of observed behaviour. Sexual behaviour cannot be considered ’rational’. In spite of its application in multiple studies, the evidence suggests that the TPB is not an appropriate theoretical approach for the prediction of condom use in heterosexual sex.

As already discussed in Chapter 8, the disappointing outcome of 50 years of modelling is that health psychologists must return to the drawing board to look for a theory that actually does explain the decision-making of humans in the act of sexual intercourse and potential procreation.

Social Media, Pornography and Cybersex

One approach to improving sexual health, awareness and knowledge has been to use digital technology. Information and communications technologies (ICTs) of the internet, text messaging and social networking increasingly are being used in sexual health promotion and risk reduction. Billions of people worldwide actively use social media, yet only a few dozen publications on the use of social media for promoting sexual health could be identified. Gabarron and Wynn (2016) reported that about a quarter identified promising results, and the evidence base is increasing. They concluded there is a need for a theoretical framework and stronger research designs.

Some have suggested the idea of ’internet addiction’. Starcevic and Aboujaoude (2017: 13) find this concept inadequate for several reasons: ’Internet addiction is conceptually too heterogeneous because it pertains to a variety of very different behaviours. Internet addiction should be replaced by terms that refer to the specific behaviours (e.g., gaming, gambling, or sexual activity), regardless of whether these are performed online or offline.’

Unquestionably, access to internet pornography and cybersex are on the rise. In 2008, it was estimated that up to 90% or more of US youth aged between 12 and 18 years had access to pornography on the internet (Sabina et al., 2008). Concerns that such high accessibility may lead to a rise in pornography-seeking among children and adolescents would have implications for adolescent sexual development. Seekers of pornography, online or offline, were in 2008 more likely to be male, with only 5% of self-identified seekers being female. The vast majority (87%) of youth who reported looking for sexual images online were 14 years of age or older.

Accessibility to pornography today is approaching or has already reached 100% of the population. Researchers with both adolescents and adults have suggested evidence of ’pornography addiction’, although this idea is controversial. In partial support of the addiction idea, it has been estimated that 17% of individuals who view internet pornography meet criteria for problematic sexual compulsivity (Cooper et al., 2000). One study examined pornography use and well-being, including feelings of addiction, with a cross-sectional sample of 713 adults (Grubbs et al., 2015). A one-year, longitudinal follow-up with a subset of undergraduates found an association over time between perceived addiction to internet pornography and psychological distress.

With increasing use of ICTs across societies worldwide, social, sexual and psychological development of young people is a new focus for health psychology research. The risk of negative sexual experience and victimization online is likely to have real-world consequences for young people. DeMarco et al. (2017) explored adolescent risk-taking online behaviour from a group of young adults in different European countries using a retrospective survey of 18—25-year-olds in higher education. The sample were asked about their online experiences between the ages of 12 and 16. Risky behaviour online and offline, types of victimization (online and offline) and sexual solicitation requests online were analysed together with help-seeking behaviour. Four profiles concerning adolescent risky behaviours were identified using cluster analysis. Two were considered normative (adapted adolescents and inquisitive online) and two high risk (risk-taking aggressive and sexually inquisitive online).

Chang et al. (2014) studied predictors of unwanted exposure to online pornography and sexual solicitation with 2,315 students from 26 high schools in Taiwan. They were assessed in the tenth grade, with follow-up in the eleventh grade using self-administered questionnaires. High levels of online game use, pornography media exposure, internet risk behaviours, depression and cyber-bullying experiences were associated with online sexual solicitation, victimization and perpetration. It may well be the case that frequent and habitual users of online pornography become more risk-averse and bully, victimize or groom unsuspecting ’friends’ on Facebook.

The majority of studies in this field are cross-sectional surveys of low quality. Prospective studies are fairly rare, owing to the newness of the field. In spite of the issue of definitions, this field is likely to expand over the next five to ten years.

Sexual Violence and Abuse

A substantial proportion of female and male adults report having experienced some form of sexual violence, stalking or intimate partner violence at least once during their lifetime in the USA (Breiding, 2014) and in Europe (Krahé et al., 2015). Both women and men are affected by these types of violence over their lifetime, including sexual violence, stalking and physical violence by an intimate partner.

Children

Over the last decade, media revelations of childhood victimization reached epic levels. Seemingly, there are no boundaries to this problem within the established religious organizations, such as the Roman Catholic Church, media organizations such as the BBC, child protection organizations, and sports clubs in athletics and football. The concern is that the child sexual abuse (CSA) that has surfaced to date is the tip of a large iceberg. It has been empirically demonstrated since the 1990s that childhood victimization is detrimental to the well-being of victims. Victimization has been shown to be a risk factor for promiscuity, prostitution and teenage pregnancy. However, the CSA area is replete with statistics and moral panic, while theory and explanation are thin on the ground.

The prevalence of child sexual abuse is difficult to estimate exactly because it is often unreported. However, studies in the USA by Finkelhor (1994, 2008) and Finkelhor et al. (2014) show that:

· one in five girls and one in 20 boys is a victim of child sexual abuse;

· 20% of adult females and 5—10% of adult males recall a childhood sexual assault or sexual abuse incident;

· during a one-year period, 16% of youth aged 14—17 had been sexually victimized;

· over the course of their lifetime, 28% of youth aged 14—17 had been sexually victimized;

· children are most vulnerable to CSA between the ages of 7 and 13.

The US Department of Health and Human Services’ Children’s Bureau (2010) reported that 9.2% of victimized children were sexually assaulted. The National Institute of Justice (2003) statistics suggested that three out of four sexually assaulted adolescents were victimized by someone they knew well. A child who is the victim of prolonged sexual abuse usually develops low self-esteem, a feeling of worthlessness and an abnormal or distorted view of sex. The child may become withdrawn and mistrustful of adults, and can become suicidal. Children who do not live with both parents, as well as children living in homes marked by parental discord, divorce or domestic violence, have a higher risk of being sexually abused. In the vast majority of cases where there is credible evidence that a child has been penetrated, only between 5% and 15% of those children will have genital injuries consistent with sexual abuse. CSA is not restricted to physical contact; it can include exposure, voyeurism and child pornography. Compared to those with no history of sexual abuse, young sexually abused males were five times more likely to cause teen pregnancy, three times more likely to have multiple sexual partners and two times more likely to have unprotected sex (e.g., Beitchman et al., 1992).

Widom and Kuhns (1996) examined the extent to which being abused and/or neglected in childhood increases a person’s risk for promiscuity, prostitution and teenage pregnancy. They employed a prospective cohorts design to match age, race, sex and social class in cohorts of abused and/or neglected children from 1967 to 1971. Widom and Kuhns followed participants into young adulthood. Early childhood abuse and/or neglect was a significant predictor of prostitution for females. However, childhood abuse and neglect were not associated with increased risk for promiscuity or teenage pregnancy.

In an open-ended survey question to European 9- to 16-year-olds, some 10,000 children reported a range of risks that concern them on the internet (Livingstone et al., 2014). Pornography (22% of children who mentioned risks), conduct risk such as cyber-bullying (19%), and violent content (18%) were the three main children’s concerns. Livingstone et al. observed that many children expressed shock and disgust on witnessing ’violent, aggressive or gory’ online content, especially that which graphically depicts realistic violence against vulnerable victims, including from the news. The video-sharing website YouTube was a primary source of violent and pornographic content.

The exploitation and lack of protection of children in both public and private organizations have been a particular weakness of contemporary social, judiciary and systems of care. These systems themselves are in need of radical treatment and reform to reduce harm to children resulting from sexual exploitation.

Adults

Sexual violence is a sexual act committed against someone without that person’s freely given consent. The person did not offer their informed consent. Sexual violence can be divided into the following categories:

· Completed or attempted forced penetration of a victim.

· Completed or attempted alcohol/drug-facilitated penetration of a victim.

· Completed or attempted forced acts in which a victim is made to penetrate a perpetrator or someone else.

· Completed or attempted alcohol/drug-facilitated acts in which a victim is made to penetrate a perpetrator or someone else.

· Non-physically forced penetration which occurs after a person is pressured verbally or through intimidation or misuse of authority to consent or acquiesce.

· Unwanted sexual contact.

· Non-contact unwanted sexual experiences. (CDC, 2017c)

Using a definition of rape that includes forced vaginal, oral and anal intercourse, an interview survey of 8,000 women and 8,000 men in the USA found that one in six women had experienced an attempted rape or a completed rape (Tjaden and Thoennes, 1998). At the time they were raped 22% were under the age of 12, 54% were under the age of 18 and 83% were under the age of 25. In the same study, one in 33 men had experienced a sexual assault.

A large proportion of rape occurs as intimate partner violence (IPV). In the USA, nearly one in 10 women have been raped by an intimate partner, while an estimated 16.9% of women and 8% of men have experienced sexual violence other than rape (Breiding et al., 2014). Women have a higher lifetime prevalence of severe physical violence compared to men, 24.3% and 13.8%, respectively. Almost half of men and women have experienced at least one occurrence of psychologically aggressive behaviour by an intimate partner during their lifetime. Black non-Hispanic women and multiracial non-Hispanic women had significantly higher lifetime prevalence of rape, physical violence and stalking compared to white, non-Hispanic women, while bisexual women had a significantly higher prevalence of lifetime rape, physical violence or stalking by an intimate partner compared to lesbian women.

The poor quality of the processes of law enforcement and the justice system in dealing with rape cases has been widely publicized for decades. Many rape victims suffer secondary victimization after reporting the crime to the authorities. In the USA, for every 100 rape cases reported to law enforcement, 33 on average would be referred to prosecutors, 16 would be charged and moved into the court system, 12 would end in a successful conviction, and seven would end in a prison sentence (Campbell, 2008). Successful prosecution is more likely for those from privileged backgrounds and those who experienced assaults that fit stereotypic notions of what constitutes rape. Younger women, ethnic minority women and women of lower SES are more likely to have their cases rejected by the criminal justice system (Campbell, 2008). Cases of stranger rape (where the suspect was later identified) and rape with the use of a weapon and/or physical injuries to victims are more likely to be prosecuted. Also, alcohol and drug use by the victim significantly increases the likelihood that a case will be dropped.

In a review, 43—52% of victims who had contact with the legal system rated their experience as unhelpful and/or hurtful (Campbell, 2008). Survivors have described their contact with the legal system as a ’dehumanizing’ experience, by being interrogated, intimidated and blamed, and many say they would not have reported the rape had they known what the experience would be like (Logan et al., 2005).

Experiences of secondary victimization take a toll on victims’ mental health. In self-reports of their psychological health, rape survivors indicated that as a result of their contact with legal system personnel, they felt bad about themselves (87%), depressed (71%), violated (89%), distrustful of others (53%) and reluctant to seek further help (80%) (Campbell, 2008). The harm of secondary victimization is evident in objective measures of PTSD symptoms. Contact with formal help systems, including the police, is likely to result in negative social reactions associated with increased PTSD outcomes (Ullman et al., 2005).

Hogben et al. (2015) reviewed sexual health interventions for adults. They summarized data from 58 studies (1996—2011) by population (adults, parents, sexual minorities, vulnerable populations) across domains. Interventions were found to be predominantly individual and small-group designs that addressed sexual behaviours (72%) and attitudes/norms (55%). Of these interventions, 98% reported a positive finding in at least one domain, while 50% also reported null effects. With vulnerable populations, the results suggested that interventions were more effective in changing sexual behaviour in terms of risk per act than in changing the amount of sexual behaviour. Interventions were found to be successful in increasing contraceptive use, increasing condom use or decreasing the amount of unprotected sex, but only sometimes affected numbers of partners.

The highly positive findings (98% of studies!) in the Hogben et al. (2015) review indicate a very strong publication bias. The bulk of studies focused heavily on heterosexual women and, among LGBT populations, focused heavily on gay men and MSM. Well-controlled, larger-scale studies with more diverse population groups are needed.

Recent research has explored the psychological correlates of male sexual fantasies about raping women. Bartels et al. (2017) examined the link between imaginal ability and the use of aggressive sexual fantasies, including their link with rape-supportive cognition. They proposed that men who hold hostile beliefs towards women use aggressive sexual fantasies more often if they possess a ’rich fantasy life’. Operationally, they argued that this involves: (1) a proneness to fantasize in general; (2) an ability to vividly envision mental imagery (Marks, 1973); and (3) frequent experiences of dissociation. They hypothesized that a ’Rich Fantasy Life’ mediated by ’Hostile Beliefs about Women’ influences the use of ’Aggressive Sexual Fantasies’. A sample of 159 community males completed measures of fantasy proneness, dissociation and vividness of mental imagery, along with two measures that assess hostile beliefs about women. Structural equation modelling (along with bootstrapping procedures) indicated that the data had a very good fit with the hypothesized model.

LBGTQ Stigmatization

On 12 June 2016, Omar Mateen, a 29-year-old security guard, killed 49 people and wounded 53 others in an attack/hate crime inside Pulse, a gay nightclub in Orlando, Florida, USA. Mateen was shot and killed by Orlando Police Department (OPD) officers after a three-hour stand-off. This was the most lethal hate crime in the USA since the 2001 September 11 World Trade Center atrocity.

Historically, LBGTQ people typically have hidden their true selves from public view from pure fear of the social stigma that would inevitably follow a ’coming out’. It has been said that Oscar Wilde and Quentin Crisp each performed ’stigma management’, deflecting stigma for being gay by projecting the image of a dandy. The stigma attached to being LBGTQ is high.

LBGTQ is an acronym that collectively refers to individuals who are lesbian, gay, bisexual or transgender, with the ’Q’ representing queer or questioning. It is sometimes stated as ’GLBT’ (gay, lesbian, bi and transgender) or ’LBGT’. Terminology and vernacular change over time. ’Queer’ as a descriptor was in common usage in the 1950s and 1960s, as were other terms, such as the ’N word’, that today are proscribed, although they still may make occasional appearances as graffiti.

Fear of discrimination is a major concern for LBGTQ people throughout the world. In China, 61% of respondents in an LBGTQ survey reported they were afraid of being treated differently by doctors because of their sexual orientation or gender identity (Love Without Borders Foundation, 2016). Almost half of respondents experienced discrimination from health care workers after disclosing their sexual orientation or gender.

Almeida et al. (2009) evaluated emotional distress among ninth to twelth grade students to examine whether the association between LBGTQ status and emotional distress was mediated by perceptions of having been treated badly or discriminated against because others thought they were gay or lesbian. Data from a school-based survey in Boston, MA, were analysed. In this sample, 10% of a sample of more than 1,000 were LBGTQ, 58% were female and of a 13—19 year age range. About 45% were black, 31% were Hispanic and 14% were white. LBGTQ youth scored significantly higher on depressive symptomatology. They were also more likely than heterosexual, non-transgendered youth to report suicidal ideation (30% versus 6%) and self-harm (5% versus 3%). Perceived discrimination was observed to account for increased depressive symptomatology among LBGTQ males and females, and accounted for an elevated risk of self-harm and suicidal ideation among LBGTQ males.

Earnshaw et al. (2016a) noted that bullying of LBGTQ youth is prevalent in the USA, yet multiple studies have shown that bullying undermines the mental, behavioural and physical health of LBGTQ youth, with consequences lasting throughout life. Paediatricians can play a vital role in promoting the well-being of LBGTQ youth by preventing and identifying bullying, offering counselling to youth and their parents, and advocating for programmes and policies.

Box 9.5 LBGTQ Terminology

· Asexual: an individual who does not experience sexual attraction.

· Assigned sex: the sex that is assigned to an infant at birth based on the child’s visible sex organs, including genitalia and other physical characteristics.

· Biological sex: anatomical, physiological, genetic or physical attributes that define whether a person is male, female, or intersex. These include genitalia, gonads, hormone levels, hormone receptors, chromosomes, genes and secondary sex characteristics.

· Bisexual, or bi: a person who experiences romantic, emotional or sexual attraction to the same gender and other genders, whether to equal degrees or to varying degrees.

· Closeted: a person who is not open about their sexual orientation or gender identity, or an ally who is not open about their support for people who are LGBTQ.

· Gay: the adjective to describe people who are emotionally, romantically or physically attracted to people of the same gender.

· Gender: a set of social, psychological or emotional traits, often influenced by societal expectations, that classify an individual as male, female, a mixture of both, or neither.

· Gender Nonconforming, or GNC: a person whose identified gender is expansive beyond the binary of male or female.

· Homophobia: An aversion to lesbian or gay people that often manifests itself in the form of prejudice and bias.

· Lesbian: a woman who is emotionally, romantically and/or physically attracted to other women.

· Pansexual, or pan: a person who experiences romantic, emotional or sexual attraction to persons of all gender identities or sexes.

· Transgender, or trans: a person whose self-identified gender does not fully align with their physical sex as assigned at birth, and who may choose to take steps to medically alter the gendered features of their body.

Source: PFLAG (2017); www.pflag.org/about

Issues of masculinity are important to males’ self-esteem and to the well-being of boys and young men. The use of anabolic-androgenic steroids is a concern for adolescent boys. Parent and Bradstreet (2017) examined bullying based on being labelled gay/bisexual and steroid use among US adolescent boys, including sexual orientation disparities. They used data from 2,660 boys from the 2015 Youth Behaviour Risk Survey. Among heterosexual boys, Parent and Bradstreet reported that steroid use was higher among those who reported being bullied due to being labelled gay or bisexual. However, no such relationship was observed among non-heterosexual boys.

Meyer (2016) discussed the stigma regarding accessing STI prevention and treatment for the LBGTQ community, which can be a barrier towards accessing services. Meyer found that one in five LBGTQ individuals reported withholding information regarding their sexual history from a health care provider. A survey from the National Coalition for LBGTQ Health cited stigma in health care settings as a top concern. Over half of participants reported stigma and lack of cultural competency in health care.

While there is a tendency of mainstream media to focus on terrorism, drugs and crime, the commonplace existence of stigma and bullying in the everyday lives of millions of people within the LBGTQ community receives far less attention. A cultural change is necessary.

Discussion Topic: ’Live and Let Live’

It is a human right to have freedom of thought, expression and action within the law. If this is true, the scope for health psychology is limited to providing help and advice to those who seek such help and advice. People can choose to smoke, vape, eat unhealthily, have unprotected sex, acquire an STI or HIV infection, and become pregnant in so doing. Is this not their inalienable human right? In what ways can or should the health care professionals/health psychologists intervene?

Future Research

1. There are several neglected areas of sexual health, such as unsafe abortion, sexual abuse, paedophilia and sexual hate crime, that warrant more research.

2. The campaigns to reduce unwanted teenage pregnancies need to continue with groups and in areas that have not yet been reached.

3. Future sexual health research is needed to cover a greater diversity of population groups, including heterosexual men and a more diverse selection of sexual minorities.

4. The impact of increased access to ICT and the internet on sexual health is likely to be a major theme for research over the next decades.

Summary

1. The incidence and prevalence of sexually transmitted infections is increasing in most regions of the world. Improvements in education and greater access to ICTs may lead to global reductions in both the incidence and prevalence of STIs.

2. The World Health Organization estimates that a woman dies every eighth minute somewhere in a developing country due to complications arising from unsafe abortion.

3. Optimistic bias and lack of preparation contribute to unprotected sex. There is a high probability that the infected person will feel shame, anxiety and stigmatization.

4. Medicalized discourse on topics such as orgasm, erectile dysfunction and female orgasmic dysfunction indicate physical explanations. This oversimplified discourse is challenged by psychosocial studies of the quality and meaning of sexual relationships.

5. Sexuality and relationships with a sexual or romantic component have intrinsic value as an aspect of health, and healthy sexual relationships include positive experiences for individuals and their partners. Sexual activity is associated with dilemmas, disappointment and risks in the form of STIs, HIV infections and unplanned pregnancies.

6. Teenage pregnancy rates have fallen over the last few decades in both the USA and the UK. However, the precise cause of these reductions cannot be unambiguously attributed to improvements in contraception as there may have been a decrease in sexual intercourse among teenagers due to their habitual usage of social media.

7. Studies in the USA show that one in five girls and one in 20 boys is a victim of child sexual abuse, with 20% of adult females and 5—10% of adult males recalling a childhood sexual assault or sexual abuse incident.

8. In the USA, one in six women report experiencing an attempted or completed rape. At the time they were raped, 83% were under the age of 25. Only one in 33 men experience a sexual assault. Nearly one in 10 women have been raped by an intimate partner.

9. Stigma, harassment and bullying are commonly experienced by LBGTQ people.

10. ICTs, text messaging and social media are new tools for sexual health promotion and risk reduction. However, high internet access is leading to a rise in pornography-seeking among children and adolescents, with implications for adolescent sexual development. This needs to be monitored.