Procedimiento en la medida en escenarios

With reference to pregnancy outcomes, sex before 16 has been found to be associated with motherhood before 18, abortion before 18 (Wellings et al., 2001) and unplanned pregnancy (Wellings et al., 2013) in British population-based studies.

Despite the association found between younger age at first sex and subsequent sexual health, little is known about the potential mechanism which might explain these findings. The mechanism is important as it is unlikely that the act of having sex at a particular chronological age causes those people to be at greater risk of poor sexual health – though the way in which this research is drawn upon by studies identifying predictors of early sex implies a belief that in delaying first sex to an older age, the subsequent poorer sexual health will be avoided. A potential explanation of the associations observed is that unmeasured/unknown individual characteristics and/or background factors account for both the earlier transition into sexual activity and the subsequent engagement in behaviour that increase the risk of poor sexual health outcomes.

2.7 Research on the context of first sex

The experience of first sex and context in which it occurs has been explored in British qualitative studies, which are able to provide us with insights into which aspects of first sex are important to those young people engaging in it. Probably due to the open discussion arising in qualitative studies that are not constrained by survey questions, information relating to the context of first sex is abundant.

Reflections on the reasons for first sex are reported – particularly the pressure that comes from the perception that ‘everyone else was doing it’ (Hyde et al., 2008) or feeling that sexual intercourse is normal ‘natural progression’ within a relationship (Holland et al., 2000). Pressure from the partner, whether explicit or subtle, is also a common theme arising particularly in girls’

accounts of first sex, while men more commonly talk about pressure from friends (Hyde et al., 2008; Ingham et al., 1991).

How participants felt after their first sex was also a recurring topic. In a study which presented UK college students with hypothetical first sex scenarios in which no condom was used, the anxieties expressed by the young women related much more to their feelings and worries after sex about the relationship with the partner, as opposed to concerns about the threat to their physical sexual health (Bromnick and Swinburn, 2003). These findings were supported by other studies of young people living in Britain – with women more likely to express regret about how or with whom the intercourse took place, while men, in general, were more likely to just be happy that they had had sex (Ingham et al., 1991; Holland et al., 2000).

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Compared to those focused on age at first sex, there are relatively fewer quantitative British studies concerned with the context of sex. While contraceptive use is quite commonly measured, the social and emotional aspects of the encounter are often omitted, though it is evident from studies employing qualitative methodologies that these issues are of importance to young people when they are given the opportunity to talk freely about their first sex.

In Blenkinsop et al’s., (2004) evaluation of a package of work to improve the provision of Sex and Relationship Education in Schools - the APAUSE (Added Power and Understanding in Sex Education) programme – the outcomes of interest included not only age at first sex, but also contraceptive use, and regret about first sex – although no differences were observed in these between schools that implemented the APAUSE programme and those that did not.

Contraceptive use at first sex was more likely among respondents who expressed aspirations to attend university and those who had an ‘open’ relationship with their parents, and less likely among those with low self-esteem. Female respondents were more likely to express that they wished they had waited longer before having sex, compared with men.

Similarly, authors using data from the SHARE and RIPPLE sex education trial considered other contextual indicators alongside age at first sex – these included pressure at first sex (which was found to be more common among female participants and less so among participants who reported higher levels of parental supportiveness) and contraceptive use (which was associated with prior discussion about contraception with partner, less pressure from male partner, planned intercourse, stable relationships status, not being drunk, and greater reported parental supportiveness and monitoring) (Henderson et al., 2002; Parkes et al., 2011). Wight et al., (2008) also explored the distribution of the following factors relating to first sex in the sample: relative age of partner, relationship with partner, planning for sex, drunkenness/drug use, and regret.

A British study of an ethnically diverse sample of respondents in London also reports on contextual aspects of first sex, alongside age, based on the same questions asked in the Natsal surveys relating to relationship status, autonomy of decision, timing, relative willingness, and contraceptive use (Coleman and Testa, 2007). They found that a negative reason for first sex was most commonly given by male respondents, while women were generally more likely to report regret – particularly those of Black African ethnicity. The reporting of unequal willingness of partners was generally higher in the black and ethnic minority groups, compared to those of white ethnicity, and a similar pattern was observed for the non-use of contraception.

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2.7.1 The association between context of first sex and age at first sex

Studies have generally found that younger age at first sex is associated with sexual debut occurring in a more negative context. Wellings et al. (2001) found that male and female respondents who were younger at first sex were more likely to wish that they had waited longer before having sex and were less likely to have used a reliable method of contraception. Among women only, younger age at first sex was also associated with an increased likelihood of reporting that their partner was ‘more willing’ and citing peer pressure as the main reason for engaging in sex. The associations between age at first sex and regret and contraceptive use were also identified in a study of Irish youth (Schubotz et al., 2004), while Wight et al., (2008) also found younger age at first sex to be associated with increased reporting of pressure at first sex and regret. In contrast to the majority of studies which focus on absolute age of the individual at first sex, Mercer et al., (2006) examined influence of pronounced age differences between the partners at first sex, finding that those who had a relatively older partner (above the 95th percentile of age difference) were more likely to have reported that their partner was more willing at first sex, to have given a non-autonomous reason for first sex, and were less likely to have used a condom.

The associations observed between younger age and negative contexts of first sex could be due to a number of factors. Being a younger teenager in a social context that is overtly disapproving of the idea of people engaging in sexual activities at younger ages, may limit teens’ real or perceived access to advice and services and the extent they are able to develop and demonstrate sexual autonomy (Aggleton and Campbell, 2000).

2.7.2 Subsequent sexual health and context of first sex

There seem to be relatively fewer studies attempting to explore the link between the context of first sex and subsequent sexual health, compared with those that focus on the predictive effect of age at first sex. The only British studies concerned with the association between the context of first sex and subsequent sexual health are those that analysed data from the Natsal surveys and used the measure of sexual competence at sexual debut – which are discussed in Section 2.8.2 below (Wellings et al., 2001; Mercer et al., 2005; Wellings et al., 2013; Mitchell et al., 2013).

The international research literature provides some evidence for an association between the context of first sex and subsequent sexual health and behaviour. In a Slovenian population-based study, men who reported condom use at sexual debut were 11 times more likely to report consistent condom use in the 4 weeks preceding the interview, and the equivalent odds ratio for women was 2.5 (Klavs et al., 2005).An analysis of the US National Longitudinal Study of Adolescent Health produced similar results of an association between condom use at sexual

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debut and condom use at most recent sex among 18-26 year olds (Shafii et al., 2007). One study attempted to explain the mechanism underlying the positive association between condom use at first sex and condom use at subsequent sexual encounters and found evidence supporting their hypothesis relating to habit formation (Stulhofer et al., 2010).

Regarding more emotional and social dimensions of first sex, a few studies have attempted to identify whether these are linked to subsequent health. In an analysis of the retrospective reports of 475 Canadian undergraduate students (age range: 18-29), Reissing et al (2012) found that positive current sexual adjustment was significantly associated with positive affective reaction to first sexual intercourse among both men and women. The respondents reaction to first intercourse was measured using the First Coital Affection Reaction Scale (FCARS), a measure consisting of thirteen items, including satisfaction and guilt, rated on a 7 point Likert scale with high scores indicating more negative experiences of first coitus (Schwartz, 1998) and their current sexual adjustment was measure using The Sexual Aversion Scale which assesses respondents on 30 items relating to their sexual fears and avoidant behaviours (Katz et al., 1989). Mediation analysis indicated that this relationship between affective reaction to first sex and current sexual adjustment was mediated by what the authors referred as ‘sexual self-efficacy’, among both genders. However, the measure of self-efficacy used was actually more reminiscent of a measure of sexual functioning: the Sexual Self-Efficacy Scale for Female Functioning/ Erectile Functioning (Bailes et al., 1998; Fichten et al., 1998). Therefore, it more accurate to conclude from this study that the relationship between positive current sexual adjustment and a positive affective reaction to first sexual intercourse observed was mediated by sexual functioning.

Using data from the National Health and Social Life Survey conducted in the United States in 1992 with 3432 participants aged 18-59, Else-Quest et al. (2005) classified their participants as having had their first sexual experience in a negative context if any of the following criteria applied: first intercourse was forced; was with a blood relative; was with someone who paid the participant to have sex; the main reason the participant chose to have first intercourse was peer pressure or the influence of drugs or alcohol; or the participant reported having been touched sexually by an adult prior to puberty. Additionally, female respondents were also classified as having had a negative first sexual experience if first intercourse occurred with a stranger;

someone they had just met; or with someone who they did not know well. Analyses found that a negative context of first sexual experience was associated with sexual dysfunction, more sex guilt, poorer general health, experience of STIs, and poorer life satisfaction.

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A study of 331 US undergraduate students also found evidence that the experience of first sexual intercourse has implications for subsequent sexual functioning (Smith and Shaffer, 2013).

Respondents were asked to fill in an online diary within in eight hours of any intimate interaction (defined as an intimate interaction in which the purpose was sexual arousal, not limited to sexual intercourse). The online diary asked respondents to rate how they felt during and after the interaction on 23 dimensions, which were reduced down to four factors using factor analysis:

positivity during interaction (feeling intimate, desired, respected, loved, capable, and aroused), negativity during interaction (feeling pressured, incompetent, anxious, and detached), positivity after the interaction (feeling relaxed, good, and exhilarated), and negativity after interaction (regret, guilty, disappointed, and ashamed). In addition, questions related to physical and emotional satisfaction were asked. Similarly, participants were asked to rate how they felt during and after their first ever sexual intercourse on 26 dimensions, which were reduced down to four factors: anxiety (scared, nervousness during, nervousness after), afterglow (relaxed, content, good, excited, confident, proud, relieved), negativity (pressured, confused, detached, regret, guilt, disappointment, ashamed), and connection (intimate, desired, in control, respected, loved, capable, and aroused). Participants were also asked to rate their emotional and physical satisfaction at first sex.

Analyses found that those who experienced greater physical satisfaction at first sex have current sexual interactions characterised by greater physical satisfaction. Similarly, emotional satisfaction at first sex was predictive of greater emotional satisfaction with current sexual interactions. Associations were also identified between the four derived factors: first sex negativity predicted current negativity during and after sexual interactions, while first time

‘afterglow’ was associated with positivity after the current interactions. In general, this study found that even when controlling for overall sexual satisfaction, the experience and feelings about first sex had implications for the experiences of subsequent sexual interactions, with negative experiences of first intercourse being associated with negative feelings about current sexual encounters, and positive accounts of first intercourse being predictive of more positive experiences in current sexual interactions. These findings prompted the authors to speculate that “first-time sexual experience is so salient that it is related to future sexual satisfaction and functioning, specifically through long-lasting sexual schemas[....]any schemas and scripts developed during the first time may continue to influence sexual intercourse later in life” (Smith and Shaffer, 2013)(p.107-108).

Moore and Davidson’s (1997) study of 570 never-married college women identified that feelings of guilt about their first sexual intercourse experience were significantly associated with a greater likelihood of current psychological sexual dissatisfaction and guilt feelings about current

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intercourse. However, these findings should be interpreted cautiously – the study identified a number of family-related factors that were predictive of guilt feelings about first intercourse – though these were not adjusted for in the analysis of the relationship between first sex guilt and current sexual adjustment.

A study of 899 Greek women aged 19-44 years found that experiencing less pleasure than expected at first sex, and first sex being painful, were both associated with their emotional and behavioural reactions to subsequent sexual relationships – whereby they were more likely to experience fear and sexual unresponsiveness in later sexual encounters (Papaharitou et al., 2011). However – again this study was methodologically flawed, with no statistical adjustment for potential confounders to the relationships observed.

These studies provide evidence that the experience and context of first sexual intercourse, and not just age at occurrence, may have implications for subsequent sexual health and functioning.

However, it should be noted that they all rely on retrospective reporting, so that the associations observed may be a product of recall bias; respondents who currently enjoy a positive and well-adjusted sex life may be more inclined to recall their first sexual experiences in a more positive light.