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The main outcome measures for this study are sexual behaviors including age at sexual initiation, number of sexual partners, vaginal and anal intercourse, and oral sex, among others. Data from a population-based cross-sectional study in PR — was analyzed.
The prevalence of sexual behaviors and characteristics was described by age-group and gender during the lifetime and in the past 12 months. In both genders, the prevalence of oral and anal sex was also lower in the older age cohorts.
This study provides essential information than can help health professionals understand the sexual practices and needs of the population of PR. Sexual rights, including access to sexual and reproductive healthcare services, sexuality education, respect for bodily integrity, and choice of partners, are a basic component of human rights and are fundamental to the achievement and maintenance of sexual health [ 2 ].
Even though sexual behaviors are a fundamental part of human relationships, closely related to physical and mental health [ 1 ], high-risk sexual practices can increase the risk of unintended pregnancies, promote violent behavior, and increase the risk of sexually transmitted infections STIs [ 1 , 3 — 5 ].
Studies of sexual health and behavior are of great interest in Puerto Rico PR , as statistics for this U. In the Unites States, changes in sexual behaviors and norms have occurred in the past decades, partially influenced by the media, Internet, and sexual dysfunction medication, some of which may be related to increased incidence rates of some STIs in the population [ 11 ].
Population-based data on the prevalence of sexual practices among Puerto Rican adults are lacking. This information is essential to further characterize sexual practices in this population, the size and characteristics of populations at elevated risk for STIs and other sexuality-related problems, and the recognized need to develop and implement targeted interventions for these populations [ 16 , 17 ].
Thus, this study described, for the first time, patterns of sexual behaviors and characteristics among sexually active adults in PR. Data were collected as part of the household cross-sectional survey that estimated the prevalence of antibodies to hepatitis C and other viral infections hepatitis A [HAV], HBV, HIV and HSV-2 in the adult population of PR using a stratified cluster probability sample of households [ 10 , 18 , 19 ]. The target population comprised non-institutionalized adults residing in PR at the time of the survey.
The study population consisted of 1, individuals aged 21—64 years randomly selected, from which, 1, individuals The study data collection methodology has been described in detail elsewhere [ 10 , 18 , 19 ].
In brief, eligible individuals that agreed to participate were provided with appointments to visit a mobile examination unit located in the vicinity of their homes where they completed the informed consent procedures. Private face-to-face interviews collected standard sociodemographic characteristics plus extensive information on medical history and other health-related habits.
We modeled our questionnaires after those used in previous Spanish household surveys conducted in PR [ 18 ]. The overall participation rate of the study was Demographic characteristics included gender male, female , age in years 21—34, 35—49, 50—64 , marital status, educational attainment in years, employment status, and annual family income below poverty level: Lifetime and past month history of the following sex practices were collected: The question that addressed anal intercourse among all respondents was the following: The number of lifetime sexual partners, number of lifetime male and female sexual partners, and information on age at sexual initiation was also assessed.
Other characteristics collected included: The overall and age- and gender-specific prevalence of sexual behaviors and characteristics were described. Overall prevalence of each sexual practice was weighted to match the age and gender distribution according to the Census estimated population aged 21—64 years in PR. Logistic regression models were employed to evaluate the interaction effect of age and gender in the behavior of relevant sexual practices using the likelihood ratio test.
The prevalence lifetime and past 12 months of each sexual item was age-adjusted by the direct method based on the U. Also, logistic regression models were employed to evaluate the age- and gender-adjusted association of selected sexual practices with positivity to STIs antibodies.
The study population of this project has been described in detail elsewhere [ 10 , 18 , 19 ]. Among sexually active adults, At the time of interview, Overall and gender specific lifetime sexual behaviors are described in Table 1. In this population, 9. Several sexual behaviors were also assessed during the 12 months preceding the interview Table 2. No differences were observed in the prevalence of vaginal, oral, or anal sexual practices by gender.
These gender differences persisted after persons who had ever been forced to have sex were excluded from the analysis data not shown. A similar pattern was also seen for history of sexual partners who had ever injected drugs; in older cohorts, the prevalence was higher among men and lower among women.
Although no significant interactions were seen in the prevalence of other sexual risk behaviors by gender and age, interesting patterns were observed. For instance, the prevalence of history of anal intercourse was lower in older cohorts while the history of forced sexual intercourse was more common in younger cohorts. Finally, in both genders, the use of sex toys was more common among the youngest age group 7. Meanwhile, in both men and women, the prevalence of oral and anal sexual activities 12 months previous to the interview also decreased with age, with lower prevalence observed in persons from older cohorts.
Although sex under the influence of drugs was a practice reported in the past 12 months by participants of all age groups, these were most common in the youngest age cohort The specific prevalence of seropositivity was 0.
Table 5 shows the age-and gender-adjusted prevalence odds ratio for selected STIs according to sexual practices. Significantly higher odds of STIs were observed for early age at sexual initiation, increased number of sexual partners and history of anal sex.
In addition, persons who engaged in sex with both men and women, those who engaged in sex under the influence of drugs, and those who had a sexual partner with a history of injection drug use had increased odds of STIs. This is the first population-based study that describes multiple sexual behaviors and characteristics among a representative sample of adults aged 21—64 years in PR. The prevalence of early age at sexual initiation is much higher in men This result is of relevance as early age of sexual initiation was positively associated with STIs in our study, an association that is well established in the scientific literature [ 22 ], and that may partially explain the high burden of STIs in PR, including HIV and HSV-2 [ 7 , 10 ].
In contrast, the percentage of women in PR who reported this behavior Also, consistent with studies in the United States and in other Hispanic populations is the observation that men have more sexual partners than women [ 13 , 23 , 24 ], and that younger women have a higher prevalence of multiple sexual partners than older women [ 13 ].
This pattern is consistent with a study of adolescents in PR where the prevalence of sexual relations with intercourse was similar in both sexes, which contrasts with what has been traditionally reported and still prevails in many other countries higher prevalence of early age at sexual initiation among men than women. However, it parallels recent studies that demonstrate that gender differences in sexual practices are vanishing and could represent a future trend [ 25 ].
Anal intercourse appears to be more common in PR than in the United States. The prevalence of lifetime anal sex among men and women in our study sample Nonetheless, our prevalence estimates of oral sex were somewhat higher when we limited our comparison with men and women aged 21—44 years in our study population men: Similar to studies in the United States [ 15 , 27 ], both anal and oral sex practices were more frequently reported among men and women in younger age groups.
In the case of older individuals, although oral, anal, and vaginal sex is reported in the past 12 months across all age groups, our results are consistent with U. These results are comparable with data obtained from studies in the United States 6.
The fact that having had sexual practices with both men and women was more common in older male cohorts and in younger female cohorts warrants attention, as it documents an opposite cohort effect of this behavior by gender. Nonetheless, this finding is limited to the sexual practices and not to the sexual orientation of men or women in PR.
The higher prevalence of forced sexual encounters in our study among women 9. Violence Against Women Survey in women Given that victims of sexual abuse have been shown to be at increased risk of unwanted pregnancies, STIs, substance abuse, somatic disorders, posttraumatic stress disorders, and other mental health problems in other studies [ 1 , 34 — 37 ], funding should continue to support integrated public health interventions for sexual abuse victims in PR that are widely available to these groups.
These behaviors are of concern as persons who engage in these behaviors increase the risk of STIs [ 38 — 45 ]; our study results support these associations. Population-based data on the prevalence of participation in orgies or other group activities where sex is involved is limited.
This result could reflect a more conservative opinion about their use, an issue of availability or lack of willingness to document their use in PR as compared with the United States, while their higher use among the youngest cohort suggests a greater acceptability regarding their inclusion in sexual practices in this group as compared with older cohorts. Among the strengths of this study, the use of ACASI for the collection of information on sexual practices of participants reduces the potential for information bias, as it results in a more complete reporting of sensitive behaviors and avoids missing data often found on paper-and-pencil self-administered questionnaires of sensitive behaviors [ 47 , 48 ].
To assess the potential for selection bias, study participants were compared with those who refused to participate and to the population of PR according to the Census with regard to the age and gender distribution in each geographic stratum [ 18 ]. The age distribution of interviewed individuals was similar to those who were not interviewed and to residents of PR across all strata; however, higher participation of females was observed in some strata [ 18 ].
Nonetheless, the gender distribution of PR according to the U. Census was taken into account in the statistical estimation process. Among limitations, despite the use of ACASI, our study might be subject to social desirability bias, as there is a possibility of underreporting of some sexual practices, a common challenge when exploring sexual practices [ 49 ].
Finally, the low prevalence of certain sexual behaviors in the general population may have limited the power of our study to detect an association between these behaviors and STIs.
This population-based study shows a high prevalence of oral and anal sexual practices in PR in both genders, and particularly among younger cohorts. Nonetheless, sexual activity and high risk sexual behaviors showed to be present throughout the life span of the population, and in the case of older adults, these patterns have an impact on continued surveillance of sexual health issues in this group.
Public health interventions should focus on the development of age- and gender-specific comprehensive and evidence-based education initiatives to increase knowledge and awareness regarding sexual health, safe sexual practices, and prevention for STIs in PR.
Special emphasis should be given to interventions that target men, young adults, and persons with history of forced sexual intercourse. Continued research is needed to identify innovative, interdisciplinary approaches to modify risk behaviors that reduce the impact of STIs and promote sexual health in PR, with a focus on examining the causes of these behaviors and their implications for sexual health. Its contents are solely the responsibility of the authors and do not necessarily represent the official view of the National Institutes of Health.
The authors have no financial interest to disclose. National Center for Biotechnology Information , U. Author manuscript; available in PMC Oct Box , San Juan, Puerto Rico Author information Copyright and License information Disclaimer. The publisher's final edited version of this article is available at J Sex Med. See other articles in PMC that cite the published article. Main Outcome Measures The main outcome measures for this study are sexual behaviors including age at sexual initiation, number of sexual partners, vaginal and anal intercourse, and oral sex, among others.
Methods Data from a population-based cross-sectional study in PR — was analyzed. Conclusion This study provides essential information than can help health professionals understand the sexual practices and needs of the population of PR.
Study Variables Demographic characteristics included gender male, female , age in years 21—34, 35—49, 50—64 , marital status, educational attainment in years, employment status, and annual family income below poverty level: Statistical Analysis The overall and age- and gender-specific prevalence of sexual behaviors and characteristics were described.
Results Study Population The study population of this project has been described in detail elsewhere [ 10 , 18 , 19 ]. Open in a separate window. Age-Standardized Prevalence of Selected Sexual Practices in the Past 12 Months, by Gender Several sexual behaviors were also assessed during the 12 months preceding the interview Table 2.
Variables combined because of small numbers. Discussion This is the first population-based study that describes multiple sexual behaviors and characteristics among a representative sample of adults aged 21—64 years in PR.
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