Sexual wellbeing

Introduction

Preventing STIs and unwanted pregnancies are important aspects of the strategies currently being pursued to improve sexual health outcomes in Scotland. However, it is increasingly recognised that positive sexual health and wellbeing outcomes span a broader range of areas beyond disease prevention and contraception. For example, the Sexual Health and Blood Borne Viruses Framework 2015-2020 highlights the importance of relationships free from coercion or harm, the impact of sexual dysfunction on wellbeing, and the harmful role wider social stigma and homophobia can play in preventing people from accessing sexual health services. 

Data sources

Data on these kinds of wider sexual health and wellbeing issues are not available from the routine administrative sources that provide data on outcomes such as STIs and pregnancies. However, population surveys such as the National Surveys of Sexual Attitudes and Lifestyles (NATSAL) series (conduced in 1990, 2000 and 2010-12), the Scottish Government’s Sexual Health and Wellbeing Survey, and the Scottish Social Attitudes (SSA) survey provide such data. NATSAL also provides useful contextual information about behaviours and attitudes that can help inform public health policies about issues such as STI prevention and contraception (for example, the age at which people first have sex, number of partners in the past year, and the frequency of having sex with new partners without condoms). 

The information reported here comes from the following sources:

• The NATSAL-3 Scottish report published in March 2015 (behavioural indicators, sexual function, coercion and harm).
• The 2015 Scottish Social Attitudes (SSA) survey discrimination report  published  in 2016 (which reports on trends in attitudes to same-sex relationships since 2000).

Contextual information on risk behaviours

The table below presents data for a small selection of indicators of risky sexual behaviour of potential interest to sexual health service planners and policy makers. A wider range of information is available in the NATSAL-3 Scottish report and in the main UK-wide reports. Generational differences are evident in the age at which people had their first heterosexual intercourse (people aged 16-45 years are more likely to report having had intercourse before the age of 16 years than those aged 45-74 years). Recent sexual behaviour also shows generational differences: people aged 16-29 years are the most likely to have had multiple sexual partners in the past year, and to have had intercourse with two or more partners without a condom in the past year. Note that the sample size is too small to be able to present equivalent figures for same-sex experiences.

Table 2. Risk behaviours (adults aged 16-74 years) (2010-12)
Risk behaviour	Gender	16-29 years (%)	30-44 years (%)	45-74 years (%)	Total 16-74 years (%)
% who had sex with someone of opposite sex before age of 16	Men	31	30	19	25
	Women	29	19	6	15
2 or more opposite sex partners in the past year	Men	31	12	7	15
	Women	23	8	2	9
Sex without a condom with >1 partner in past year	Men	19	10	4	10
	Women	11	6	2	5

Sexual function

Sexual function can be defined as “the extent to which an individual is able to participate in and enjoy a sexual relationship” (Mitchell et al 2013). NATSAL-3 measured sexual function using a 17-item scale that asked people to assess three components of their sexual lives: their own sexual difficulties (physiological or psychological), sexual difficulties within relationships, and a broader appraisal of satisfaction and difficulties in their sex life (full details available here). Total scores were used to identify people with scores in the lowest fifth of the overall distribution. In Scotland, 18% of men and 21% of women had low sexual function. Low sexual function did not vary by age among men, but it doubled from 16% in women aged 16-29 years to 29% for women aged 45-74 years. One item within the sexual function scale asked people to rate their overall satisfaction with their sex life. Among those with at least one sexual partner in the previous year, 17% of men and 12% of women reported dissatisfaction with their sex life. Levels of dissatisfaction did not vary by age.

Analysis of the GB-wide data showed that 39% of people with bad or very bad self-assessed health had low sexual function compared with 18% of those with very good or good health. Around one in six adults in Scotland reported a health problem or disability that affected their sex life (14% of men, 15% of women) (Natsal 3: Key Findings from Scotland, 2015).

Coercion and harm

NATSAL can be used to identify the prevalence of adults in Scotland who have experienced someone attempting to have sex with them against their will since the age of 13 years (attempted non-volitional sex), and those who have experienced someone having sex with them against their will (completed non-volitional sex). Women were five times as likely as men to have experienced attempted non-volitional sex (19% versus 4%) and completed non-volitional sex (10% versus 2%). More detailed analysis of the GB-wide data showed that the groups most at risk of these experiences included younger people and men who have sex with men.

Experiencing attempted and completed non-volitional sex was associated with a range of other adverse outcomes, such as poor mental health, substance misuse, early pregnancy or terminations (in women), multiple sexual partners, STI diagnoses and low sexual function. These associations were not necessarily causal, but they do highlight the extent that these adverse outcomes cluster.

Attitudes to same-sex relationships

The Scottish Social Attitudes survey reports that the proportion of adults aged 18 years and over in Scotland who say that sexual relationships between people of the same sex are always or mostly wrong declined from 48% in 2000, to 40% in 2005, 28% in 2010 and 18% in 2015. At the same time, the proportion saying such relationships are rarely wrong or not wrong at all increased from 37% in 2005 to 69% in 2015. Other measures of attitudes towards same-sex relationships have seen similar changes. Between 2005 and 2015, the proportion of adults in Scotland saying they would be unhappy if a close relative married or formed a long-term relationship with someone of the same sex halved from 33% to 16%.