Abstract
Objective: This study aimed to examine differences in reporting sexual problems and distress among men and women with same-sex and opposite-sex sexual partners.
Methods: Multinomial regression was undertaken on risk of reporting sexual problems and/or distress using data from the third National Survey of Sexual Attitudes and Lifestyles.
Results: Differences were detected between men of different sexual behavior groups when considering the problems “lack of enjoyment in sex,” “felt anxious during sex,” “felt no excitement or arousal during sex,” “lack of interest in sex,” “did not reach/took a long time to reach climax,” and “getting or keeping an erection.” Fewer differences were detected among women.
Conclusions: Women reporting same sex sexual partners, and to a greater extent men reporting same sex sexual partners , have different sexual health needs and report sexual health problems and distress to a different extent than is the case for individuals who only have opposite-sex sexual partners
Introduction
An extensive body of literature exists that has explored differences in the reporting of sexual problems among men and women, with common patterns and conclusions emerging. Women are more likely to report experiencing one or more sexual problem in comparison to men (Laumann et al., Citation2005; Mercer et al., Citation2005; Mitchell et al., Citation2013; Mitchell, Geary, et al., Citation2016; Rosen, Citation2000). Moreover, among women, a lack of interest in sex and an inability to reach orgasm are the most frequently reported sexual problems, whilst among men a lack of interest in sex, early ejaculation and erectile difficulties are most commonly reported (Laumann et al., Citation2005; Mitchell et al., Citation2013).
Although the literature investigating gender differences in sexual problems is substantial, research has rarely considered differences related to sexual orientation. Variations in the frequency of orgasm have been reported in both single and partnered American populations, with gay and bisexual men showing similar patterns to heterosexual men, but lesbian women having higher rates of orgasm occurrence compared to heterosexual and bisexual women (Garcia, Lloyd, Wallen, & Fisher, Citation2014; Frederick, St. John, Garcia, & Lloyd, Citation2018). Among a sample of students in the United States, Breyer et al. (Citation2010) noted similarities and differences in sexual problems by sexual orientation. Although among men, rates of premature ejaculation were comparable among heterosexual and homosexual men, homosexual women were less likely to report difficulties associated with pain and orgasms compared to heterosexual women. Coleman, Hoon, and Hoon (Citation1983) and Beaber and Werner (Citation2009) also found evidence of higher levels of arousal for lesbians compared to heterosexual women, although Beaber and Werner (Citation2009) found no differences in terms of desire, vaginal lubrication or pain linked to sex.
A limitation of the literature on the relationship between sexual orientation and sexual problems is that it tends to conceptualize sexual orientation in terms of sexual identity (e.g., whether someone identifies as gay, lesbian, bisexual or straight). Samples collected on the basis of sexual identity do not provide a full picture of same-sex sexuality, which can be important depending on the research focus (Hoy & London, Citation2018). Sexual behavior and sexual attraction are also important dimensions of sexual orientation. Although sexual identity, behavior, and attraction are closely associated, it has been recognized that they are not the same and do not always neatly align (Hoy & London, Citation2018; Richters et al., Citation2014; Silva, Citation2018). Blair, Cappell, and Pukall (Citation2018, p. 721) argues that “individual’s self-identified sexual identity does not always accurately predict the gender of sexual partner.” Sexual identity, furthermore, can be more complex than simply the sex/gender of the partner; for example, pansexuals identify based on their attraction to individuals regardless of their sex or gender (Harper & Ginicola, Citation2017) Yet, the gender of sexual partners is important when it comes to sexual activities, and subsequently is likely to be an important consideration for sexual problems. The example given by Blair et al. (Citation2018) is that penile penetration happens less often in same-sex sexual activity (regardless of the gender of the sexual partners) compared to mixed-sex sexual activity. As men and women are more or less likely to experience an orgasm depending on the form of sexual activity that they engage in (e.g., penetrative activity, manual stimulation), the frequency with which individuals experience orgasm could depend on the gender of their sexual partners. This could also apply to other sexual problems. Lindley, Walsemann, and Carter’s (Citation2012) study of sexual orientation and young adults’ health outcomes, which uses three different measures of sexual orientation (identity, attraction, and behavior), demonstrates how research into these different dimensions can provide a more comprehensive picture. Because of relatively sparse research on same-sex behavior and sexual problems and distress, this research considers this dimension of sexuality.
A further limitation of many studies on sexual problems is the use of the terminology sexual (dys)function without consideration of personal distress (Graham, Citation2010). This has the consequence of overestimating the prevalence of sexual dysfunction (Graham, Citation2010; Mitchell, Jones, et al., Citation2016; Moynihan, Citation2003) and pathologizing normal differences or variations (Bancroft, Citation2002; Basson, Citation2000). This medicalization of male and female sexuality has come under continued criticism in the research literature (e.g., Bass, Citation2011, Tiefer, Citation2010). The relatively small number of studies that assess associated distress, which has predominantly been focused on women in heterosexual relationships, reveal that reporting a sexual problem does not necessarily equate to a feeling of sexual distress (Bancroft, Loftus, & Long, Citation2003; King, Holt, & Nazareth, Citation2007; Mercer et al. Citation2005; Oberg, Fugl-Meyer & Fugl-Meyer, Citation2004; Witting et al., Citation2008). For example, among King et al.’s (Citation2007) sample of women aged 18–75 years old recruited from clinics in London, 38% self-reported sexual problems but only 6% self-reported both a sexual problem and feelings of distress linked to this issue.
Drawing on data from a nationally representative sample of Great Britain, this article explores patterns of sexual problems and distress. The specific research questions are (1) Do sexual orientation (as measured by sexual behavior) differences exist in the reporting of sexual problems and associated distress? and (2) Do gender differences exist in the reporting of sexual problems and distress across sexual orientation behavioral groups? Understanding prevalence and patterns of sexual problems is important in informing sexual health policy and practice, and experiences of those with same-sex sexual partners may differ to those with only opposite-sex sexual partners. Looking at how and whether such problems translate into sexual distress is of relevance from a clinical perspective and could aid in the improvement of sexual health services for different sexual behavior groups.
Methods
Data
We drew upon secondary data from Natsal-3 (Johnson et al., Citation2017), a national probability survey that collected information related to the sexual health of 15,162 men and women aged 16–74 years old living in Great Britain. This survey was conducted between 2010 and 2012 using a multistage stratified sampling approach with Postal Address Files (PAF) being the primary sampling unit. PAFs were stratified by region, population density, proportion of the population aged 60 years or above and the proportion of household heads in non-manual occupations (Erens et al., Citation2014). Between 30 to 36 addresses were randomly selected within each PAF, and one eligible individual selected from each household. Those aged 16–34 years were oversampled. The response rate for Natsal-3 was 57.7%, with a cooperation rate of 65.5%. The Natsal dataset is deposited on the U.K. data archive, with doi:10.5255/UKDA-SN-7799-2.
Measures
Definition of groups
Categorization of sexually active women and men was based on sexual behavior over their lifetime. Women who have sex exclusively with men (WSEM) and men who have sex exclusively with women (MSEW) were defined as any woman/man reporting at least one opposite-sex partner in their lifetime but no same-sex partners. WSW and MSM were defined as any woman/man reporting at least one same-sex sexual partner in their lifetime, regardless of the number of opposite-sex partners. For same sex partners, the Natsal questionnaire asked, “Altogether, in your life so far, how many (men/women–same sex) have you had sex with (that is oral [or anal] sex or other forms of genital contact)? Please type in the number in your life (so far), ‘0' if none.” For opposite sex partners, the questionnaire asked, “Altogether, in your life so far, how many (women/men) have you had sexual intercourse with (vaginal, oral or anal)? Please type in the number, ‘0' if none.” For both same sex and opposite sex partner questions, the display screen provided the sex of the partner according to the respondent’s description of their own sex.
Sexual problems
The second part of the Natsal-3 survey consisted of a self-completed computer assisted interview and collected information about sexual problems. Respondents who had had sex in the year preceding the survey, were asked “In the last year, have you experienced any of the following for a period of 3 months or longer?” Sexual problems asked about were “lacked interest in having sex,” “lacked enjoyment in sex,” “felt anxious during sex,” “felt physical pain as a result of sex,” “felt no excitement or arousal during sex,” “did not reach a climax (experience an orgasm) or took a long time to reach a climax despite feeling excited/aroused,” “reached a climax (experienced an orgasm) more quickly than you would like,” “had an uncomfortably dry vagina (asked of women only),” and “had trouble getting or keeping an erection (asked of men only).”
Sexual distress
For each sexual problem, respondents were asked, “And how do you feel about this?” with possible responses being “not at all distressed,” “a little distressed,” “fairly distressed,” and “very distressed.”. We categorized respondents as either reporting no problem, reporting a problem and “no or a little” distress, or reporting a problem and being “fairly or very distressed.”
Confounders
The sociodemographic and health profiles of the sample of men and women were considered. Characteristics studied included age at the time of interview, ethnicity, area deprivation level, relationship status, and the number of sexual partners in the year preceding the survey. Ethnicity was coded as “White” and “non-White” using the answers to the question “to which of the ethnic groups on this card do you consider you belong?,” with available options of “White, mixed, Asian or Asian British, Black or Black British, and Chinese or other ethnic group.” Because of small numbers for each of the ethnicity categories, the variable was recoded into binary format. The number of sexual partners in the past year was calculated in response to the questions on opposite-sex partners (“Altogether in the last year, how many women/men have you had sexual intercourse with?”) and same-sex partners (“Altogether in the last year, how many women/men have you had sex with?”). These questions were worded according to whether the participant had specified they were male or female at the beginning of the questionnaire. Those who were calculated as having two or more sexual partners in the year preceding the survey were collapsed into a single category. Natsal-3 measures area deprivation using the Index of Deprivation (IMD), which classifies areas by their level of relative deprivation as indicated by factors such as income, employment, housing, health and crime. IMD scores for England, Scotland, and Wales were combined and assigned into quintiles (Payne & Abel, Citation2012).
Statistical analysis
For the purpose of this article, the analysis was restricted to individuals who were sexually active in the year preceding the survey, and for whom complete data for all variables of interest were available resulting in a final sample size of 11,450. When complex survey weights were applied, this equated to 77.0% of the 15,162 Natsal respondents. The reason for this inclusion criterion was that questions on sexual function problems in Natsal-3 were only asked to those sexually active in the year preceding the survey. We derived this sub-sample from self-reports of number of sexual partners (same-sex and/or opposite-sex) in the year preceding the survey.
Multinomial regression was undertaken to examine differences in the reporting of one or more sexual response problems. For each model, the outcome was considered to be the response given to the sexual problem/distress question, and the exposure was considered to be the sexual behavior group. Comparison is made between those with same-sex sexual partners and those with exclusively opposite-sex sexual partners (considering men and women separately). Relative risk ratios (RRR) are presented with 95% confidence intervals. For each sexual behavior group, individuals were placed into one of three categories: reporting no sexual function problem, reporting a problem but no or little distress, or reporting a sexual function problem and fair or a large amount of distress. The reference category was reporting no problem. Relative risks were then obtained for having a problem and no or a small amount of distress compared to no problem and for having a problem and a fair or large amount of distress compared to no problem. These relative risks were obtained for MSM/WSW, and for MSEW/WSEM and RRR’s obtained showing the RRR for MSM compared to MSEW, and for WSW compared to WSEM. A subanalysis was also undertaken to assess whether the effect of age on sexual function reporting differed according to sexual behavior group using the sexual problem/distress variable as the outcome, and age as the independent covariate. The analysis was stratified by behavior group. Complex survey weights were applied to the data so distributions of key characteristics, including sex and age distributions, were reflective of the population of Great Britain as recorded in the 2011 census. All statistical analyses were conducted using STATA software version 14 (Stata Corp. Inc., College Station, TX).
Results
Sample characteristics
presents the characteristics of the sample. The participants in our sample were 49.1% female and 51.0% male. Among women, 517 (6.7%) reported they had ever had sex with a woman involving genital contact, whereas among men 273 (5.3%) reported they had ever had sex with a man. Sexual identity was not included in our analysis, but descriptives were obtained to explore the overlap and differences in terms of sexual behavior and identity of the sample. In terms of sexual identity, over half of MSM identified as heterosexual, whereas one-quarter identified as gay and 16% as bisexual. Over two-thirds of WSW identified as heterosexual, whereas 16% identified as gay or lesbian and 17% as bisexual.
Table 1. Demographic and Socioeconomic Characteristics of the Sample, by Sex and Sexual Orientation.
Differences in the most common sexual problems reported
presents the characteristics of the sample in terms of their reported sexual problems and associated distress. Among women, regardless of sexual orientation, the most commonly reported sexual problem was lack of interest in sex (34% WSEM vs 35.6% WSW). Among men differences exist. For MSM, trouble keeping an erection was the most commonly reported problem (25.2%), while among MSEW reaching a climax more quickly than would have liked was the most commonly reported problem (14.9%).
Table 2. Distribution of Reporting of Specified Sexual Problems and Distress Related to Problems, by Sex and Sexual Orientation.
The correspondence between the reporting of a sexual problem and associated distress
indicates that not all individuals who report a problem also experience considerable distress related to the sexual problem. Among MSEW, for example, 12.5% reported that they lacked an interest in sex and this caused no or little distress, whereas 2.1% reported this problem as associated with a fair or large amount of distress.
Comparison of sexual problems and distress reporting across behavior groups (men)
and present results of the unadjusted and adjusted multinomial models. Focusing first on differences among men, when considering the problems of “lack of enjoyment in sex,” “felt anxious during sex,” “felt no excitement or arousal during sex,” “did not reach/took a long time to reach climax,” “getting or keeping an erection,” MSM are significantly more likely than MSEW to report experiencing the problem and no or little associated distress and experiencing the problem and fair or high distress compared to reporting they did not experience the problem. Considering the problem of “lack of interest in sex” MSM are significantly more likely than MSEW to report the problem and experiencing little or no associated distress compared to reporting they did not experience the problem. With regards to the reporting of premature orgasm and the experience of pain during sex, MSM are significantly more likely than MSEW to report experiencing the problem and fair or high distress compared to reporting they did not experience the problem.
Table 3. Unadjusted Multinomial Regression Models for Specified Sexual Problems and Associated Distress.
Table 4. Adjusted Multinomial Regression Models for Specified Sexual Problems and Associated Distress.
Comparison of sexual problems and distress reporting across behavior groups (women)
Fewer significant differences were detected among women. When considering the problems “lack of enjoyment in sex” and premature orgasm, WSW are significantly more likely than WSEM to report the problem and experiencing little or no associated distress compared to reporting they did not experience the problem. With regards to reporting of “felt anxious during sex,” “felt pain during sex,” and “did not or took a long time to reach a climax,” WSW are significantly more likely than WSEM to report the problem and experiencing fair or high distress compared to reporting they did not experience the problem.
The impact of age on the reporting of sexual problems and distress
The subanalysis examining whether age differentially impacted on the outcome of reporting sexual problems and associated distress according to sexual behavior group showed no statistically significant effects of age aside from problems getting or maintaining an erection for both MSM and MSEW. For women, age increased the likelihood of reporting a problem or distress relating to having an uncomfortably dry vagina and decreased likelihood of reporting anxiety related to sex for WSEM. For WSW, age did not seem to impact on the likelihood of reporting any sexual problem or distress (data not shown).
Discussion
This study examined sexual problems and the consideration of sexual problems as distressing among sexually active men and women in Great Britain, providing new information on differences by sexual behavior group (as defined by the reporting of same-sex sexual partners).
Differences in the most common reported sexual problems
Previous research has indicated gender differences in the reporting of sexual problems. The results of this study suggest that differences also exist by sexual behavior group but only when considering men. For MSM, the most frequently reported problem was trouble getting or keeping an erection, whereas amongst MSEW it was premature climax. It should be noted however that the percentages reporting reaching a climax more quickly than they would like was similar for MSM and MSEW. In comparison, a greater percentage of MSM reported erectile difficulties (25.2%) compared to MSEW (22.1%). This finding is only partially consistent with that of Bancroft et al. (Citation2005) who found the prevalence of erectile difficulties to be higher among gay men and rapid ejaculation to be more prevalent among heterosexual men. However, Bancroft’s sample is not directly comparable to that used in this study, and draws upon a convenience sample and defines sexual orientation based on identity. It is important to note that although 25.2% of MSM reported trouble getting or keeping an erection in our analysis, not all reported associated distress (11.9% reported problem and no or little distress versus 13.3% reported the problem and a fair or large amount of distress). For anally receptive MSM, it may not be expected or necessarily desired that they have an erection, which could make this question less relevant to the group of MSM who would not necessarily consider inability to get or maintain an erection as problematic or distressing. A limitation of the literature on sexual problems has been the predominant use of scales designed with heterosexual sex for reference. For women, the most commonly reported sexual problem did not differ according to sexual behavior group.
Differences in the reporting of sexual problems and associated distress
In response to the growing criticism of the medicalization of sexual response (Bancroft, Citation2002; Bass, Citation2011; Graham, Citation2010; Tiefer, Citation2010), we considered the reporting of distress in addition to the reporting of a sexual problem. In the adjusted multinomial models among men, MSM were more likely to report a range of sexual problems and higher levels of distress in comparison to MSEW. Documented differences in etiological factors between homosexual and heterosexual men (Sandfort & de Keizer, Citation2001) may explain differences in reported problems and distress found in this study, although it should be noted that over half our sample of MSM identified as heterosexual. Sandfort and de Keizer (Citation2001) outlined distinct factors such as alcohol and drug use, sexually transmitted diseases, and intrapsychic conflict as being associated with sexual problems. Depression has also been found to be a risk factor for sexual dysfunction (Atlantis & Sullivan, Citation2012). MSM are more likely to report substance use, are more likely to perceive their health as bad or very bad, and are more likely to report being treated for depression (Mercer et al., Citation2016).
In terms of distress, issues of gender and masculinity may be important. Fergus, Gray, and Fitch’s (2002) study of sexual dysfunction among men with prostate cancer found sex was seen as an expression of manhood and sexual dysfunction posing “a threat to who they were” (p. 310). Fergus et al. (Citation2002) noted that feelings of “relative lack” (p. 310) were more pronounced for gay men in the sample who could compare themselves more readily. Connected to this, Sandfort and de Keizer (Citation2001) discussed how sexual script being less readily available for same-sex interaction among men can promote sexual exploration but also create uncertainty.
Past research has also found diagnosis of sexually transmitted disease (STDs) to be associated with distress, which can continue after successful treatment (Bhugra & Wright, Citation2007). In our sample, a significantly (p < .001) greater percentage of MSEW reported never have been diagnosed with an STD (87.1%) compared to MSM (65.2%) which may contribute to MSM being more likely to report distress about certain problems compared to MSEW in our results.
For women in particular, some of the differences are not of particularly large magnitude. For example, outcomes including lacking interest in sex, and problems with excitement or arousal showed no statistically significant difference for WSW relative to WSEM. Other outcomes including lacking enjoyment, and time taken to reach an orgasm showed only minimal differences for WSW relative to WSEM. Overall, the number of outcomes shown to be statistically significant were fewer, and the magnitude of the difference generally smaller for the comparison between women than the comparison between men. The reasons why greater differences may exist between men compared to women in terms of sexual orientation, however, remains unclear. Women have been found to be more likely than men to endorse beliefs of sexual fluidity in which sexuality is believed to be changeable, perhaps indicating women are less reluctant, or have less psychological obstacles toward accepting attraction to and having sexual relations with someone of the same sex despite perhaps identifying as heterosexual (Katz-Wise & Hyde, Citation2015). This could in turn reduce feelings of sexual function problems or distress when having a partner of the same sex for women, relative to men who may be more likely to have fixed ideas about sexual identity and behaviors. Future qualitative research into sexual expectations and cultural and psychological norms that may influence how sexual problems are perceived and defined is recommended.
The main strength of this data was its reliance on national probability data, which could be considered representative of WSW and MSM in Great Britain, and therefore present a more accurate picture of sexual problems and associated distress among these groups. Furthermore, the response rate for Natsal-3 is similar to other large-scale social surveys in Britain, and higher than other studies focused on sexual response (Mitchell et al., Citation2016b).
There were several caveats to this study. Questions on sexual problems and associated distress were asked only to those sexually active. This is likely to underestimate the prevalence of those experiencing sexual problems and associated distress by excluding those sexually inactive. Mitchell et al.’s (Citation2013) analysis of Natsal-3 data found that among those ever sexually active, 21% of men and 17% of women reported avoiding sex because of a sexual difficulty. Secondly, our groups of men and women who reported a same-sex sexual partner in their lifetime included both those who reported same-sex sexual partners exclusively and those who report both same-sex and opposite-sex partners. Further distinguishing WSW and MSM by exclusively same-sex partners or both same- and opposite-sex partners would have allowed for a more nuanced analysis, and an indication of whether the same outcomes are found among different categories of WSW and MSM, which would have aided in providing a fuller picture of sexual problems and distress. Small group sizes, however, made the further division of these groups difficult. Thirdly, here we have selected the term opposite-sex partners when considering those identifying as female having male partners, and those identifying as male having female partners. This term was selected due to the wording of the Natsal questionnaire; however, it is not clear how for example nonbinary partners are categorized. It is the choice of the respondent to select whether they believe their partners to be male or female; however, other options such as nonbinary are not currently available for selection when respondents complete the Natsal questionnaire. The opportunity to select additional gender categories, or for open text for the respondent to describe the gender of their partners, could prove informative and allow for a more nuanced categorization and analysis. In addition, the wording of the question for inclusion into the sexual problems section of the questionnaire asked about sex when referring to same-sex practices, but intercourse when asking about opposite-sex practices, meaning the definitions are not entirely parallel. Finally, the data was collected between 2010 and 2012. Comparison of Natsal-1 (1990), Natsal-2 (2000), and Natsal-3 (2010) reveals an increase in the reporting of at least one sexual partner of the same sex over time, particularly among women (Mercer et al., Citation2013). As far as we are aware, a population based survey on sexual lifestyles and attitudes has not been undertaken in the Great Britain since Natsal-3, so it is not easy to determine the extent to which there may have been an increase in the reporting of same-sex sexual behavior in the last decade, and the extent to which this may influence the results. In the last decade there has been rapid transformation in understandings of sexual identity and societal perceptions of same-sex behavior. Carrillo and Hoffman (Citation2018), for example, noted the emergence of the terms heteroflexible and bicurious, which they said reflect represent a shift in sexual attitudes. These shifts may impact on the experience and perceptions of those engaging in same-sex sexual behavior and have an impact on outcomes such as the experience of sexual problems and distress. Despite these limitations, Natsal-3 is a rich national data source for examining sexuality and sexual health.
Conclusion
To date, research on sexual response and associated distress has tended to focus on heterosexual women. Previous research, nonetheless, has revealed differences between men and women and differences in the reporting of sexual response problems according to sexual orientation. However, it is also important to include consideration of sexual distress about problems.
Research on sexual response problems commonly uses sexual identity as a measure of sexual orientation comparing gay/lesbian (and to a lesser extent bisexual) individuals with individuals identifying as heterosexual. Nonetheless, sexual attraction and same-sex sexual behavior are also important components of sexual orientation. As the size and composition of sexual minority populations vary based on definition of sexual orientation, research and services should consider which definition best serves their needs (Geary et al., Citation2018). This is especially the case with young women, where there is substantial difference in those reporting lesbian or bisexual identity and those reporting recent same-sex sexual behavior. Our findings show that to some extent WSW, and to a greater extent MSM, have different sexual health needs and report sexual health problems and distress to a different extent than is the case for individuals who only have opposite-sex sexual partners.
Acknowledgments
We would like to thank Mathijs Lucassen for proof reading the final draft of this paper.
Disclosure statement
The authors report no conflict of interest relevant for this manuscript.
Data availability
The data that support the findings of this study are openly available in the UK Data Service at http://doi.org/10.5255/ukda-sn-7799-2, Reference number: SN:7799
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