The Sexual Acceptability of Contraception: Reviewing the Literature and Building a New Concept

Figures & data

Figure 1. Conceptual model of the sexual acceptability of contraception.

TABLE 1. SUMMARY OF STUDIES REVIEWED IN PART 2: Positive and negative sexual aspects of contraception documented by peer-reviewed research, 2005-2015

Methods	Citations	Select Positive Sexual Impacts	Select Negative Sexual Impacts	Comments and Commonalities
Male Condom ^1 (n=54 identified in the review) Reviewed here: Male condom research that addresses women’s experiences (n=21)	(Bolton et al., 2010) (Braun, 2013) (Crosby et al., 2008) (Crosby et al., 2013) (Crosby et al., 2010) (Deardorff, Tschann, et al., 2013) (Fennell, 2014) (Free et al., 2007) (Garcia et al., 2006) (Gebhardt et al., 2006) (Higgins et al., 2009) (Higgins & Wang, 2015a) (Kaneko, 2007) (Randolph et al., 2007) (Sanders et al., 2010) (Sunmola, 2005) (Træen & Gravningen, 2011) (Tung et al., 2012) (Versteeg & Murray, 2008) (Wang, 2013) (Widdice et al., 2006)	Among women, condom use was positively associated with feeling comfortable communicating about sex and about sex in general. Young women expressing higher levels of sexual self-acceptance were less likely to report a dislike of condoms as a strategy to avoid using them (Deardorff, Tschann, et al., 2013). Female sex workers described skills in applying condoms in sexually arousing ways in order to increase client acceptance of condom use (Free et al., 2007). Men and women perceived condoms as hygienic and as providing sense of security and protection (Garcia et al., 2006). Among women who always used condoms, 28% agreed that condoms reduce sexual sensation; this figure was significantly larger (53%) among women who did not always use condoms (Kaneko, 2007). In a nationally representative survey of young adults in Norway, of the 20% who used a condom at most recent sex, 15% of men and 9% of women reported they did so to feel more clean; 18% of men and 23% of women reported a condom was used to avoid mess; 2% of both men and women stated they used a condom for fun; 9% of men and 7% of women used a condom to make sex last longer; and 2% of men and 7% of women reported using a condom to facilitate more penetration (Træen & Gravningen, 2011).	Many participants in a qualitative study invoked a narrative of how “natural” or “proper” heterosex does not involve condoms and use of a common metaphor of “condom-as-killer” highlighted the tension between condoms and sexual pleasure (Braun, 2013). Identifying the most common condom “turn-offs”, Crosby et al. (2008) found: 75% of men and 40% of women reported that decreased sexual sensation was a major turn-off in using the male condom. The disruption of sex with putting on the condom was a turn-off listed by 43% of men and 30% of women. Approximately one-third of both men and women declared that the smell of condoms was a turn-off. More than half of women and over one-third of men reported that condoms decreased their partners’ sensations during sex. 20% (Crosby et al., 2008) to 34% (Higgins et al., 2009) of both men and women reported loss of arousal and orgasm difficulties with male condom use. Almost one-third of both women and men reported problems with condom “feel” during sex (Crosby et al., 2013). For both young women and men, pleasure-related attitudes were more strongly associated with lack of condom use at last PVI than all other socio-demographic or sexual history variables (Higgins & Wang, 2015a).	Research overwhelmingly associated condoms (versus other methods) with reduced physical pleasure (Fennell, 2014). Though popular discourses about “proper” sex may mean that many young adults find condoms sexually unacceptable, one author argued that common anti-condom sentiments are socially constructed and thus possible to change (Braun, 2013). Pleasure-related reasons and feelings of increased intimacy with skin-to-skin contact influence condom discontinuation and non-use among women (Bolton et al., 2010). Studies including both women and men suggest a number of commonalities by gender. For example, the most common turn-offs relate to loss of pleasure for both men and women (Crosby et al., 2008) . Both women and men report condoms can reduce sexual spontaneity. Associations between women’s and men’s pleasure attitudes and their use/non-use patterns are similar if not identical (Higgins & Wang, 2015a). However, some findings illustrate gender-specific findings. Women were more likely than men to report that their partner experienced sexual discomfort with condom use. Many women also report an inability to negotiate condoms with partners due to reduced pleasure for their male partners, perceived and/or actualized side effects, and trust (Versteeg & Murray, 2008). Findings suggest that more emotional, affective motivations for sex can undermine condom use. More research is needed on how to normalize condom use within sexual contexts of expressing love and pleasing one’s partner (Gebhardt et al., 2006).
Oral Contraception (n=24 here, n=38 in the table; please see “multiple methods” section below for more information)	(Avellanet et al., 2009) (Battaglia et al., 2012) (Bishop et al., 2009) (Caruso et al., 2011) (Caruso et al., 2013) (Caruso et al., 2009) (Davis et al., 2013) (Di Carlo, Gargano, et al., 2014) (Gardella et al., 2011) (Goldstein et al., 2010) (Goretzlehner et al., 2011) (Guzick et al., 2011) (Kucuk et al., 2012) (Lee et al., 2011) (Machado et al., 2012) (Nappi et al., 2014) (Pastor et al., 2013) (Shahnazi et al., 2015) (Skrzypulec & Drosdzol, 2008b) (Strufaldi et al., 2010) (Wallwiener, Wallwiener, Seeger, Muck, et al., 2010) (Warnock et al., 2006) (Wonglikhitpanya & Taneepanichskul, 2006) (Zimmerman et al., 2015)	Pooled results from a systematic review show that 85% of women using combined OCs reported an increase or no change in libido (Pastor et al., 2013). In a study of women using Klaira®, a combined multiphasic (4 phases) combined OC pill containing estradiol valerate (E2V)/dienogest (DNG), found significant improvements in Quality of Life (QoL), sexual enjoyment, desire, and pain after 3 and 6 cycles of OC use while adhering to a reduced hormone-free interval (26/2 regimen). This regimen was also associated with improvements in QoL, sexual function, PMS symptoms, and reduced bleeding (Caruso et al., 2011). Another study of Klaira® showed that after 6 months of use, younger women reported significant improvements in sexual pain and older women reported significant improvement in desire and overall sexual function compared to their baseline measures (Di Carlo, Gargano, et al., 2014). A study on continuous cycling regimens (OCs unspecified) reported positive sexual function (mainly improvement in orgasm, satisfaction, and pain) and QoL outcomes related to body pain, general health, and social function after 5 months (2 cycles of 72/4 regimen). Reports of desire, arousal, and lubrication did not change (Caruso et al., 2013). In a study of women diagnosed with PCOS, after 6-9 cycles of Belara® (combined OC containing 30 ug EE/2 mg chlormadinone acetate (CMA) used for 9 cycles), 81% reported significant increases in frequency of partnered sex, orgasm during intercourse, and a significant decrease in masturbation frequency (Caruso et al., 2009). A separate study of Belara® using an extended cycle regimen showed the pill was associated with improvement in: skin problems, symptoms of dysmenorrhea, headache, breast tenderness, withdrawal bleeding, bleeding duration, and libido (Goretzlehner et al., 2011). Results from a randomized, prospective study of women using either a combined OC containing 30 mcg EE/150 mcg LNG or a combined OC containing 20 mcg EE/100 mcg LNG, found significant increases in sexual desire, but this increase was statistically significant only for women using EE20/LNG100 (compared to EE30/LNG150) (Strufaldi et al., 2010).	Yasmin® use was related to increased pain during sex, decreased libido, issues with spontaneous arousal, and reductions in frequency of weekly sex and orgasm during sex. However, no women in this study met clinical criteria for sexual dysfunction (Battaglia et al., 2012). In a study assessing genetic biomarkers, women with the ll genotype were almost 8 times as likely to be classified as having sexual dysfunction if they used OC (OC type unspecified) (Bishop et al., 2009). Breast tenderness after 1 cycle of combined OC use ranged from 10% (Caruso et al., 2013) to 16% (Wonglikhitpanya & Taneepanichskul, 2006), with a majority reporting that the symptom had resolved by 6 months of use. One study of Italian women found that all 102 women reported a significant reduction in vaginal lubrication after 6 months of using Klaira® (Di Carlo, Gargano, et al., 2014). The use of combined OCs containing ethinylestradiol (EE) may have long-lasting effects on sex hormone binding globulin (SHBG) production even after method discontinuation. This may help explain why genital pain disorders do not always resolve with discontinued use of OCs (Goldstein et al., 2010). Pooled results from a systematic review show that 15% of women reported a decrease in sexual desire (libido) after OC use; decreased libido was significantly associated with using pills that containined 15ug ethinylestradiol (EE) (Pastor et al., 2013). Results from a large cross-sectional survey found no significant differences in sexual function based on women using combined OCs containing either androgenic or antiandrogenic progestins, or between different doses of EE. However, women using any type of combined OC reported significantly poorer sexual function scores compared to women not using combined OCs (Wallwiener, Wallwiener, Seeger, Muck, et al., 2010). One randomized, double-blind study provided good evidence that women who suffer from reduced desire and arousal attributed to their birth control pill may find significant improvement in sexual function if they switch to a different pill formulation, particularly those containing E2V/DNG or EE/levonorgestrel (LNG) (Davis et al., 2013).	Though some women report positive or negative sexual impacts in relation to their use of combined OC, the large majority of women report no impact in sexual function or frequency of sex related to their OC use. Nonetheless, women who do report decreases in sexual function may wish to switch to another OC formulation. Differences in aspects of sexual function such as experiences with sexual pain and levels of sexual desire vary by age and should be contextualized and accounted for in contraceptive research and clinical care. In terms of OCs and sexual pain, combined OCs may be a beneficial treatment for endometriosis-related pelvic pain (Guzick et al., 2011). However, the effects of OCs on experiences with genital pain and interstitial cystitis (Gardella et al., 2011) are not well understood. More research is needed on potential long-term, long-lasting impacts of OC use on women’s sexual pain. The sexual repercussions of seemingly non-sexual side effects of OC use should also be considered; examples include body/facial hair growth changes, and breast tenderness. Aesthetic changes, for example, may be related to improving women’s sexual and social self-esteem as evidenced by increased frequency of partnered sex and reductions in masturbation (Caruso et al., 2009). Genetic differences may influence experiences of depression and sexual function in women taking both SSRIs and OCs. More research is needed to better understand how genetics may play a role in sexual function, particularly in the context of hormonal contraception use (Bishop et al., 2009). Though results remain inconclusive as to the effects of a combined OC pill containing DHEA, the potential for positive sexual function improvements in some women with androgen-sensitivity and/or oral contraceptive-associated sexual dysfunction show promise and requires further investigation (Zimmerman et al., 2015). Women using 3^rd generation combined OCs (containing 0.03 mg EE/0.15 mg desogestrel) reported significantly better improvements in sexual function compared to women using 2^nd generation combined OCs (low-dose estrogen pills containing 0.03 mg EE/0.15 mg LNG); even though both groups demonstrated higher sexual function after 4 months compared to baseline (Shahnazi et al., 2015).
IUD/IUC/IUS (n=7 here, n=12 in the table; please see “multiple methods” section below for more information)	(Bastianelli et al., 2011) (Enzlin et al., 2012) (Gomez & Clark, 2014) (Gorgen et al., 2009) (Higgins et al., 2015) (Panchalee et al., 2014) (Skrzypulec & Drosdzol, 2008a)	In one study of the levonorgestrel (LNG) IUS, women reported a significant decrease in sexual pain and a significant increase in sexual desire after one year of use (Bastianelli et al., 2011). A cross-sectional study comparing women who had used either the LNG IUS or copper IUD for at least 6 months found that most women using both IUDs reported changes in menstrual bleeding after IUC placement, though LNG-IUS users were significantly more likely to report shorter menses and less blood flow. Women using either LNG IUS or copper IUD reported similar rates of self-perceived sexual satisfaction (58-60%), sex more than twice per week (48-49%), desire for sex more than twice per week (50-53%), ease in reaching physical arousal (47-54%), and ease in achieving orgasm (76-78%) (Enzlin et al., 2012). A qualitative study described both IUD users’ and non-users’ perceptions of the sexual aspects of IUDs. Sexual benefits included security, or enhanced sexual disinhibition thanks to IUDs’ efficacy, spontaneity, or improved sexual flow, and scarcity of hormones, which meant no/low hormonal influences on libido (Higgins et al. 2015).	Breast tenderness was reported by 35% of women using the LNG IUS, but resolved by 6 months of use (Bastianelli et al., 2011). Compared to women using copper IUDs, women using the LNG-IUS perceived their method to have a greater negative impact on aspects of their sex life (frequency of sex, arousal and desire); however, orgasm and overall satisfaction with sex did not change with LNG IUS use (Enzlin et al., 2012). One study reported that, after 6 months of use, 12% of women using the LNG IUS reported decreased libido and 35% reported no change in libido. 13% reported experiences with pelvic pain (Gorgen et al., 2009). A qualitative study described both IUD users’ and non-users’ perceptions of the sexual aspects of IUDs. Sexual detractions included string, or negative sexual effects on partner, and sexual aspects of bleeding and cramping, which could affect sexual experiences (Higgins et al., 2015).	In general, women using copper IUDs reported neither positive nor negative changes in sexual function related to their method. Women who reported existing sexual distress while using either type of IUD were more likely to attribute negative sexual function changes to their IUD usage rather than to other factors in their lives (Enzlin et al., 2012). Most studies show sexual improvements and/or no sexual changes among women using IUC. Studies indicate potential improvements to women’s sexual well-being through IUD/IUS use. For example, decreases in bleeding associated with IUDs for many users are likely to increase sexual acceptability of these methods. Young women also report psycho-sexual benefits of the IUC’s efficacy and no/low hormones (Higgins et al., 2015). Prospective research is needed to better understand the extent to which positive sexual function outcomes in women using a hormonal IUS can be attributed to the method itself versus particular characteristics of the women who choose to use this method (Witting, Santtila, Jern, et al., 2008).
Vaginal Ring (n=4 here n=12 in the table; please see “multiple methods” section below for more information)	(Caruso et al., 2014) (Merkatz et al., 2014) (Roumen, 2008) (Terrell et al., 2011)	One study found that women reported an increase in desire, arousal, lubrication, orgasm, satisfaction, and improvement in dyspareunia during 2 extended use cycles (approximately 4.5 months of use). No changes in sexual frequency were observed. FSFI scores increased and sexual distress (FSDS) scores decreased at both follow-up assessments (after 63 days and 126 days of use) (Caruso et al., 2014). In one study, male partners reported never feeling the ring during sex (72%), no change in sexual sensations (92%), and never feeling the ring move during coitus (87%). Though 16% of male partners experienced ring expulsion during sex, only 2 men found this experience disruptive. Most women and their partners found the ring to be highly sexually acceptable and women using the ring expressed fewer issues with vaginal dryness compared to combined OC users. (Roumen, 2008). Adolescent women most willing to try the ring reported more comfort with their genitals and greater knowledge of positive ring attributes (month-long protection, covert use) (Terrell et al., 2011). In one study, over 91% of women using the ring reported a steady increase or no change in sexual desire over 12 cycles (Sabatini & Cagiano, 2006) (see citation in “Multiple Methods” section).	2% of women using ring reported vaginal discomfort and 4% reported device-related events such as ring slipping out. The most common sexual “problems” with this method pertain to the mechanics of the ring during sexual activity and discomfort with touching their own genitals. Ring-related events (feeling the ring inside vagina, interference with sex, and expulsion) were associated with higher rates of discontinuation (Roumen, 2008). Women less willing to try the ring reported concerns of the ring getting lost inside or falling out of the vagina (Terrell et al., 2011). Mild adverse outcomes included bleeding, nausea, headache, and breast tenderness (Caruso et al., 2014; Roumen, 2008).	Some women using the ring have reported improvements in sexual function and quality of life and decreases in sexual distress. A small minority of users have reported adverse sexual outcomes such as vaginal discomfort. Higher user satisfaction with the ring is related to ease of removal, not being able to feel the ring during normal use, and either no change or an increase in sexual pleasure and/or sexual frequency. Women who were more satisfied with the method (including positive sexual attributes of the method) were more likely to adhere to correct use and to continue use over time (Merkatz et al., 2014). Among women less comfortable touching own genitals, providing alternative strategies such as wearing gloves or using an applicator to insert/remove the ring may facilitate willingness to try the method (Terrell et al., 2011). The extent to which ring users enjoy and/or find bothersome vaginal wetness associated with use should be explored to better understand sexual acceptability (Battaglia et al., 2014) (see citation in “Multiple Methods” section).
Implant (n=5 here n=7 in the table; please see “multiple methods” section below for more information)	(Aisien & Enosolease, 2010) (Di Carlo, Sansone, et al., 2014) (Duvan et al., 2010) (Gezginc et al., 2007b) (Visconti et al., 2012)	Participants in one study exhibited significantly increased FSFI scores at 3 months, showing improvement in domains measuring arousal, orgasm, satisfaction and pain; no changes were observed at 6 months compared to 3 months (Di Carlo, Sansone, et al., 2014). Visconti et al. (2012) found that by 3 months, women reported statistically significant improvements in frequency and intensity of orgasm, better sexual satisfaction, and less sexual anxiety. By 6 months, scores measuring sexual pleasure, personal initiative, orgasm frequency, sexual satisfaction, discomfort and anxiousness had all improved significantly from baseline. Weekly frequency of sex increased significantly by 6 months compared to baseline (Visconti et al., 2012).	A small minority (2%-9%) of women using the implant reported reduced libido (Aisien & Enosolease, 2010) (Duvan et al., 2010) (Gezginc et al., 2007b). Bleeding profiles associated with implant use after one year of use were variable. The range from several studies is as follows: amenorrhea: 32% - 41% infrequent bleeding: 3% - 24% frequent bleeding: 7% - 18% prolonged bleeding: 10% - 21% Other reported side effects that may have sexual repercussions included the following: weight gain: 16% anxiety: 10% breast tenderness: 7% - 19% headaches: 4% - 13% depressed mood: 4% hirsutism: 3% acne: 2% - 10% pelvic pain: 3% (Aisien & Enosolease, 2010) (Duvan et al., 2010) (Gezginc et al., 2007b) (Visconti et al., 2012)	Several studies indicate improvements in women’s sexual functioning and satisfaction with implant use. The authors of one study (Visconti et al., 2012) attributed an increased sense of security from pregnancy as leading factor in increased frequency of sex and improvements in sexual function associated with this method. A minority (<10%) of users report libido reductions. A minority of women also report a number of bleeding changes and/or side effects such as breast tenderness, weight gain, or headaches that could decrease women’s sexual well-being. 88% of women in one study reported no negative feelings about the method (Aisien & Enosolease, 2010), though 25% of women in another study discontinued Implanon® within the first year of use; 35% discontinued due to bleeding irregularities and 10% stopped due to interference with sexual function (Gezginc et al., 2007b). Tolerability of irregular bleeding patterns associated with the implant should be further explored in regards to sexual acceptability.
Injectable (n=2 here, n=8 in the table; please see “multiple methods” section below for more information)	(Gubrium, 2011) (Wanyonyi et al., 2011)	After 6 months of Depo® use, women reported marginally significant improvements in physical health, which could have sexual repercussions. Women reported no significant changes in either mental health or sexual function after 6 months of use of injectable contraception (Wanyonyi et al., 2011).	Results from a qualitative study illustrate decreased libido (sexual desire) as a key theme associated with Depo® use. Participants linked this libido decrease with emotional and body image changes (Gubrium, 2011). 33% of women reported menstrual irregularities. Main reasons for discontinuation in one study included: menstrual irregularity (27%); reduced libido (13%); and weight gain (20%) (Wanyonyi et al., 2011).	Few studies report improvements to women’s sexual well-being with use of injectable contraception. Studies suggest that a minority of women experience libido reductions on this method, which may also be related to factors such as weight gain and changes in body image, unpredictable bleeding, and emotionality. Side effects associated with the shot are not experienced singly, but as a constellation of factors (examples: weight gain leads to changes that, taken together, contribute to the sex-acceptability of the method).
Female Condom (n=7 here, n=8 in the table; please see “multiple methods” section below for more information)	(Latka et al., 2008) (Mack et al., 2010) (Mathenjwa & Maharaj, 2012) (Okunlola et al., 2006) (Sobze Sanou et al., 2013) (Telles Dias et al., 2006) (van Dijk et al., 2013)	Studies have documented a number of positive sexual aspects of the female condom, including the following: high level of sexual comfort due to sufficient lubricant and better lubrication compared to male condom; low risk of breakage, especially during rough sex; ability to accommodate all penis sizes; reduced interruption of sexual encounter due to ability to insert before intercourse; greater protection of the outer labia; preferred the smell to the male condom; lack of side effects; increased protection from pregnancy & STIs/HIV; female-controlled use; lower likelihood of allergic reaction compared to male condom; increased ability to relax and enjoy sex; increased sensation; clitoral stimulation through external ring; and massage of head of penis with internal ring (Latka et al., 2008) (Mack et al., 2010) (Mathenjwa & Maharaj, 2012) (Telles Dias et al., 2006) (van Dijk et al., 2013).	Initially, women in one study reported that the method’s design, particularly the internal ring, made it difficult (and painful) to insert and remove. However, after several uses, more than half of participants preferred the female to the male condom (Mack et al., 2010). Among female condom users, the most common complaint (30%) was poor sexual satisfaction associated with use. 22% reported difficulties with insertion, and 5% experienced pain during intercourse when using the female condom (Okunlola et al., 2006). Common complaints included noise during intercourse, stiffness of internal ring, resistance of partners to use, and excessive lubrication (Telles Dias et al., 2006).	The preconceived notion that female condoms decrease sexual pleasure can be a barrier to use among both men and women (Sobze Sanou et al., 2013). Women in a number of studies discussed difficulties with insertion and/or aesthetic detractions such as noise and stiffness of the internal ring. However, women in a variety of studies reported myriad sexual advantages to female condoms, especially compared to male condoms. Pleasure-related aspects experienced by both men and women increased acceptability and long-term use of this method. Though women’s first impressions of the female condom may be negative, particularly regarding insertion and large size, perceptions are likely to improve with time and practice. Women with greater personal autonomy were more likely to report sustained use (Telles Dias et al., 2006).
Female Sterilization (n=3 here, n=7 in the table; please see “multiple methods” section below for more information)	(Dias et al., 2014) (Schaffir, Fleming, et al., 2010) (Smith et al., 2010)	92% of women were satisfied with the procedure and would recommend it to friends (Dias et al., 2014). After controlling for age and other socio-demographic characteristics, women with a tubal ligation were significantly less likely than non-sterilized women to experience negative sexual outcomes such as a lack in sexual desire, issues with vaginal lubrication, or taking too long to orgasm. Sterilized women reported significantly higher levels of sexual and relationship satisfaction and sexual pleasure compared to non-sterilized women (Smith et al., 2010).	After tubal ligation, women reported significantly more bleeding, premenstrual symptoms, dysmenorrhea, and noncyclic pelvic pain; they also reported significantly reduced libido and fewer sex acts per week (Dias et al., 2014). 37% of women undergoing sterilization agreed with a statement that they would have less sexual desire after procedure (Schaffir, Fleming, et al., 2010).	Studies report both positive and negative impacts of sterilization on aspects of sexual function, yet women report overwhelmingly high rates of satisfaction with the method, highlighting the aspect of safety and freedom from pregnancy as important aspects of method acceptability. Many women report sexual concerns in anticipation of gynecological procedures. We recommend that physicians address sexual concerns with women in more detail before surgery and continue to address concerns as needed post-procedure.
Vasectomy (n=3 here, n=5 in the table, please see “multiple methods” section below for more information)	(Al-Ali et al., 2014) (Bunce et al., 2007) (Shih et al., 2013)	Female partners in one study reported significantly more positive sexual function after vasectomy. No significant changes were reported in men’s sexual function (Al-Ali et al., 2014). Men often cited seeking vasectomy to allow their female partners to discontinue hormonal methods (Bunce et al., 2007).	Loss of manhood and misconceptions around negative impacts on men’s sexual function, desire, and performance were cited by men and their partners as reasons for not selecting vasectomy. Both male and female participants cited potential for infidelity as both a positive and negative aspect of vasectomy (Shih et al., 2013). Partner influence, including partner’s approval, was an important factor in men seeking vasectomy (or not) (Bunce et al., 2007).	Though vasectomies are performed on male bodies, women may experience positive sexual effects from this method, potentially related to security against unwanted pregnancy and/or no longer having to take contraceptive responsibility. Cultural constructions of gender relating to infidelity and manhood and sexuality may deter some men and their partners from vasectomy. Highlighting the rapid return to prior sexual function is an important component in vasectomy counseling and could increase knowledge and acceptability of the procedure (Shih et al., 2013).
Withdrawal (n=4 here, n=5 in the table, please see “multiple methods” section below for more information)	(Higgins & Wang, 2015b) (Ortayli et al., 2005) (Rahnama et al., 2010) (Sirkeci & Cindoglu, 2012)	For both women and men, those who felt condoms could diminish sexual pleasure were significantly more likely to have used any/only withdrawal at last sexual intercourse (Higgins & Wang, 2015b). Iranian women who use withdrawal cited dissatisfaction with sexual sensation associated with condom use and partners’ unwillingness as reasons for not using modern (more highly effective) methods of contraception (Rahnama et al., 2010)	Turkish men who did not use withdrawal reported anxiety, decreased sexual pleasure, and dislike of coital-dependent methods as reasons for non-use. Almost all current withdrawal users cited reductions in sexual pleasure with the method, but less so than with male condom use (Ortayli et al., 2005). 34% of women reported decreased sexual enjoyment when using withdrawal; 42% perceived their partner to experience decreased enjoyment as well (Rahnama et al., 2010). Participants acknowledged female sexual pleasure as a consideration for using withdrawal as well as difficulties with climax control for some men (Ortayli et al., 2005).	Findings suggest that sexual acceptability issues may play a larger role in shaping withdrawal and other contraceptive practices than acknowledged by prior research. Withdrawal reduced both women’s and men’s sexual well-being in a number of studies; other studies suggested that couples were more likely to use withdrawal when they experienced pleasure-reductions with other methods (e.g., male condoms). Authors acknowledge the need for climax awareness and control for male partners in order for withdrawal to work successfully (Freundl et al., 2010).
Diaphragm (n=2)	(Sahin-Hodoglugil et al., 2011) (Thorburn et al., 2006)	Current users described the diaphragm as valuable to women’s autonomy with a female-initiated method and the ability to use covertly. Women and men enjoyed the increased sexual pleasure when using the diaphragm with a gel (Sahin-Hodoglugil et al., 2011). 66% of women who had never used a diaphragm perceived that it “does not decrease sexual pleasure” (Thorburn et al., 2006).	Less than 25% of women in one study felt confident in using the method correctly when sexually excited or in the heat of the moment. 17% of women preferred methods that require no genital touching (Thorburn et al., 2006). Current diaphragm users reported the need for partner negotiation as an attribute that contributed to overall acceptability (Sahin-Hodoglugil et al., 2011).	Few study participants reported negative sexual attributes of diaphragms, though (like condoms and other coitus-dependent methods) this method may hinder sexual flow and spontaneity. Women acknowledge the difficulty of stopping to insert one’s diaphragm in the heat of the sexual moment. The ability to insert the diaphragm before sexual activity increased its acceptability. Along these lines, comfort with genital touching will impact acceptability.
Natural Family Planning (NFP) (n=1 here, n=3 in the table; please see “multiple methods” section below for more information)	(Freundl et al., 2010)	Results from a systematic literature review highlighted sexual self-control and increased body awareness as positive attributes of NFP reported by users (Freundl et al., 2010).	Natural family planning methods may disallow spontaneity as most methods require abstaining from PVI during peak periods of fertility (Freundl et al., 2010).	Couple-focused research may enlighten effective sexual communication strategies of couples who successfully use NFP or other methods negotiated by both partners. Highlighting and promoting strategies for intimacy and other sexual activities that don’t involve PVI may increase the sexual acceptability of NFP methods; more research is needed.
EC Pills (n=1)	(Escajadillo-Vargas et al., 2011)	N/A	Regression analyses from a nested case-control study indicate that women using oral EC in the past 3 months had significantly greater odds for increased risk of sexual dysfunction (Escajadillo-Vargas et al., 2011).	More research is needed to better understand the characteristics of women who use EC and how oral EC use might be related to sexual function.
Multiple Methods Measured in the Same Study (n=19)	(Battaglia et al., 2014) (Davison et al., 2008) (Elaut et al., 2012) (Fataneh et al., 2013) (Gabalci & Terzioglu, 2010) (Guida et al., 2014) (Halmesmaki et al., 2007) (Higgins, Hoffman, et al., 2008) (Mohamed et al., 2011) (Nishtar et al., 2013) (Ott et al., 2008) (Roumen, 2007) (Sabatini & Cagiano, 2006) (Sanders, Smith, et al., 2014) (Schaffir, Isley, et al., 2010) (Smith et al., 2014) (Stewart et al., 2007) (Tabari et al., 2012) (Witting, Santtila, Jern, et al., 2008)	In a genetic study using a within-subject, crossover study design with random-order use of 3 contraceptive methods (combined OCs, progestin-only pills, and the ring), both partners’ level of sexual desire was statistically significantly higher among women using the vaginal ring (Elaut et al., 2012). Compared to women using the ring, pill, or no method (control group), after 6 months, implant users reported the most significant improvements in sexual discomfort, anxiousness, personal initiative, and fantasy. All method users reported significantly more sexual pleasure, satisfaction and higher orgasm frequency at 6 months compared to controls (Guida et al., 2014) Women reported that the ring was more likely to interfere with sex compared to the pill and significantly more women reported that their sex partners preferred the pill (Stewart et al., 2007). A systematic review found either improvement or no change in sexual function and sexual experience in women using both implants and IUD/IUS (Sanders, Smith, et al., 2014).	Results from a prospective study found that women using drospirenone-containing OC (Yasmin®) reported significant reductions in sexual frequency and orgasm during sex, and reported more pain during sex after 6 months of use compared to baseline measures. After 6 months of use, women using Yasmin® and vaginal ring demonstrated significant decreases in sexual function scores compared to baseline assessment (Battaglia et al., 2014). Results from a case-controlled study found that, compared to controls, women using any contraceptive method reported significantly poorer scores in the domains measuring desire, arousal, lubrication, orgasm, pain, and satisfaction (Fataneh et al., 2013). Controlling for a number of socio-demographic and relationship characteristics, results of one cross-sectional study demonstrated that male condoms, either used alone or in conjunction with hormonal methods (dual use), were most strongly associated with decreased sexual pleasure (Higgins, Hoffman, et al., 2008). In a randomized, prospective trial conducted from method initiation to 12 months or method discontinuation, findings show that, compared to pill users, ring users reported significantly more experiences with vaginitis, decreased libido, and ring-related problems. Conversely, compared to ring users, women using combined OCs reported significantly more experiences with increased weight, acne, and emotional lability (Mohamed et al., 2011). Results from a large cross-sectional study show that a regression controlling for a number of socio-demographic and relationship characteristics indicated that women using hormonal contraception experienced significantly less frequent sex, and significantly more problems with arousal, pleasure, orgasm, and vaginal lubrication compared to women using non-hormonal methods (Smith et al., 2014).	Studies comparing sexual outcomes for multiple methods show mixed findings. However, studies of multiple methods do highlight that contraceptives can affect a wide range of sexual domains for women, from inference with sexual flow to partner preference to sexual functioning and pleasure to more general sexual satisfaction. Most studies of multiple methods compare and contrast various formulations of hormonal methods. Studies with sufficient sample sizes to compare a wider range of methods are warranted. Researchers have paid especially little attention to women’s sexual experiences with long-acting reversible contraception, or LARC (implants and IUDs) in the past 10 years. With the recent public health focus on LARC, more research is needed, especially in the US context (Sanders, Smith, et al., 2014). In one study, the authors note that dual users are likely “erotizing safety” associated with doubling up on pregnancy and STI prevention methods. (This group reported higher sexual satisfaction levels than pill-only or condom-only users (Higgins, Hoffman, et al, 2008).) Adolescents and young women often report frequent method switching, starting, and stopping, all of which reflect their dynamic lives and intimate experiences. More research is needed on how mood influences interest in sex and reasons for method switching or discontinuation among young women (Ott, Shew et al, 2008).

¹ Methods are presented in descending order per number of citations, with those methods most commonly cited appearing first and articles assessing multiple methods (n=19) located at the end of the table.

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