Special Article
Sexual Behavior of College Women in 1975, 1986, and 1989
N Engl J Med 1990; 322:821-825March 22, 1990
- Abstract
- Abstract
To compare sexual practices in college women before and after the start of the current epidemics of Chlamydia trachomatis, genital herpesvirus, and human immunodeficiency virus type 1 infection, we surveyed 486 college women who consulted gynecologists at a student health service in 1975,161 in 1986, and 132 in 1989 at the same university. There were no statistically significant differences in age, age at menarche, or reason for visiting the gynecologist. The percentages of women in this population who were sexually experienced were the same in all three years (88 percent in 1975, 87 percent in 1986, and 87 percent in 1989).
Oral contraceptives were used by 55 percent of the women in 1975, 34 percent in 1986, and 42 percent in 1989; the use of condoms as the usual method of birth control increased (6 percent in 1975, 14 percent in 1986, and 25 percent in 1989; P<0.001). In 1975, only 12 percent reported the regular use of condoms during sexual intercourse, in some cases in conjunction with other methods of contraception, as compared with 21 percent in 1986 and 41 percent in 1989 (P = 0.0014). No significant differences were found in the three surveys in the number of male sexual partners or the frequency of fellatio, cunnilingus, or anal intercourse. An additional sample of 189 college women who did not consult the health service was surveyed in 1989, and similar sexual behavior was reported by those who were sexually experienced (65 percent).
We conclude that in this population there has been little change in sexual practices in response to new and serious epidemics of sexually transmitted diseases, with the exception of an increase in the use of condoms (which still does not reach 50 percent). (N Engl J Med 1990; 322:821–5.)
Media in This Article
Table 1
Sexual Activity of College Women in 1975, 1986, and 1989.*Table 2
Sexual Practices of College Women in 1975, 1986, and 1989.*Article Activity
- Article
DURING the 1974–1975 academic year, 500 unselected college women who consulted gynecologists at a student health service were studied in order to relate sexual practices to the prevalence of sexually transmitted pathogens.1 2 3 4 Each participant completed an anonymous questionnaire about her sexual development, sexual experience, and gynecologic symptoms. To evaluate whether the current epidemic of sexually transmitted diseases, including infection with Chlamydia trachomatis, herpes simplex virus, and human immunodeficiency virus (HIV), and the advent of toxic shock syndrome had influenced the sexual behavior of college women, the same questionnaire was administered to 165 unselected women presenting for gynecologic examination at the same student health service during the 1985–1986 academic year and to 132 women in the spring of 1989. This report compares the results of the three surveys.
Methods
Women who visited the health service of a large private university in the Northeast for a gynecologic examination from October 1985 to June 1986 and from April to June 1989 were invited to participate. Each participant was asked to complete an anonymous questionnaire, place it in an unmarked, sealed envelope, and give it to a health-service nurse before being examined by a physician or other provider. To maintain complete anonymity, reading the instructions and completing the confidential questionnaire constituted informed consent. No names were used, and the questionnaires were coded by number. The investigators, gynecologists, and health-service nurses were unable to correlate code numbers with participants' names. No record of involvement in the study was made in the participants' medical charts. The questionnaire contained demographic questions about the woman and her parents, as well as questions about sexual development, sexual experiences, and gynecologic symptoms. No clinical assessments were recorded and no microbiologic studies were done.
In 1989, the questionnaire was also administered to 189 female students who did not visit the health-service gynecologist. These women were solicited by fellow students in dormitories, classrooms, and libraries, and their questionnaires were placed in sealed envelopes, as in the health-services group.
The questionnaire used in the 1986 and 1989 studies was identical to that used in 1975.1 The method used to recruit health-service participants was the same in the more recent studies, whereas written informed consent was obtained in the 1975 study.1 Statistical analysis was performed with chi-square and Fisher's exact tests for categorical data (EPISTAT and EISSTATS programs); for continuing data, Student's t-test was used. For statistical comparisons of birth-control methods, a filtered denominator was used in which the number of sexually inexperienced women was subtracted from the total number of respondents.
Results
One hundred sixty-five women were asked to complete the confidential questionnaire between October 1985 and June 1986; 161 completed questionnaires were collected (97.5 percent), and four women turned in blank questionnaires. In 1989, 132 questionnaires were administered and turned in (although some questions were unanswered). These figures compare with the 486 of 500 completed questionnaires obtained in 1975. The larger numbers recruited in 1975 reflect the availability of a larger study team and a full-time, on-site recruiter; they do not imply a lower utilization of gynecological services in 1986 or 1989. Most of the participants in all three surveys were visiting the health service to obtain contraceptives, an annual cervical cytologic examination, or both.
In the 1989 survey a total of 189 questionnaires were completed by the women who did not visit the health-service gynecologist. Only two students refused to participate.
The mean age of those in our survey who consulted the health service was 21.4 years (range, 17 to 30) in 1986 and 21.6 years (range, 17 to 37) in 1989 —not significantly different from each other or from the mean age in 1975. More nonwhite women were included in 1989 (28 [21 percent]) than in 1986 (20 [12 percent]; P<0.01) or 1975 (53 [11 percent]; P = 0.009). All but 33 (20 percent) in 1986 and 28 (21 percent) in 1989 were undergraduates. The mean age at menarche was 12.7 years in both 1986 and 1989. There were no statistically significant differences in mean age, level of education, marital status, or mean age at menarche in the three survey years. However, the educational levels of the respondents' parents were significantly higher in the two more recent years than in 1975. For example, the mothers of 42 and 43 percent of the 1986 and 1989 respondents, respectively, had 17 or more years of formal education, as compared with the mothers of 27 percent in 1975 (P<0.05).
In the 1989 survey the women who did not consult the health service were younger (19.7 years) and more likely to be sexually inexperienced (66 [35 percent] were virgins) than those who did (17 [13 percent]; P<0.001). For our analyses of the responses to questions about sexual activity and the use of condoms, we excluded sexually inexperienced women from both populations.
Among those who visited the health service there was a slight decline in the use of tampons over the 14-year period. In 1975, 466 of 488 women (95 percent) used tampons, as compared with 145 of 161 (90 percent) in 1986 (P<0.05); however, in 1989, 124 of 132 women (94 percent) reported using tampons (P not significant). Sexually experienced respondents who did not consult the health service reported a similar frequency of tampon use (115 of 123 [93 percent]), but sexually inexperienced women used tampons less frequently (42 of 66 [64 percent]; P<0.001). Sixteen of 127 respondents (12.6 percent) in 1989, 7 of 161 (4.3 percent) in 1986, and 48 of 486 (9.9 percent) in 1975 had been pregnant.
Two women in 1989 (1.5 percent) and none in 1986 had a history of gonorrhea, as compared with 11 women (2.3 percent) in the 1975 study (χ2 = 4.94, P<0.08). No women had a history of syphilis.
Of the 132 respondents in 1989, 115 (87 percent) were sexually experienced, as compared with 140 of 161 (87 percent) in 1986 and 427 of 486 (88 percent) in 1975 (P not significant). With regard to the groups that consulted the health service, the proportions of women who had had sexual intercourse with six or more men were not different in the three surveys, nor were the proportions of women who had had sexual intercourse with three or more partners in the year before the study (Table 1Table 1
Sexual Activity of College Women in 1975, 1986, and 1989.*). The proportions of women engaging in fellatio, cunnilingus, and anal intercourse were not significantly different in the three studies. For example, 12 women (9.1 percent) in 1989 and 12 women (7.5 percent) in 1986 had engaged in anal intercourse, as compared with 50 women (10.3 percent) in 1975 (Table 2Table 2Sexual Practices of College Women in 1975, 1986, and 1989.*). The numbers of women who had ever had a lesbian relationship did not differ in the three studies.Among the women surveyed in 1989, those who did not visit the health service reported similar sexual practices, although fewer were sexually experienced. Of the 121 nonvirgins who responded, 28 (23 percent) had had six or more male sexual partners, as had 28 of 113 women who did visit the health service (25 percent). Also, the numbers of sexually active women who reported two or more male sexual partners in the previous year were similar among those who visited the health service and those who did not (51 of 109 [47 percent] vs. 60 of 115 [52 percent]; P = 0.5). Similar responses were found in the two groups of sexually experienced women with respect to the frequency of sexual intercourse in the week before the survey, and the proportions of women who practiced fellatio (36 percent regularly and 49 percent occasionally), cunnilingus (24 percent regularly and 40 percent occasionally), and anal intercourse (11 percent occasionally) were similar. The proportions of sexually experienced women who had had lesbian relations were also similar (7.3 percent of those who did not visit the health service vs. 8.7 percent of those who did).
The methods of contraception differed in the three study years. Fewer women in 1989 and 1986 than in 1975 stated that their usual method of birth control was the use of oral contraceptives (42 and 34 percent vs. 55 percent; χ2 = 20.8, P<0.001). The use of a diaphragm (with or without foam) was reported by 15 women (13 percent) in 1989, 42 (30 percent) in 1986, and 90 (21 percent) in 1975 (χ2 for trend = 0.93, P = 0.4). Condoms were reported as the usual method of contraception in 29 women (25 percent) in 1989, 19 (14 percent) in 1986, and 29 (7 percent) in 1975 (χ2 for trend = 29.99, P<0.001). Forty-eight of 123 sexually experienced women who did not visit the health service (39 percent) reported the use of condoms for contraception — a proportion significantly different from that of sexually experienced women who did consult the health service (P = 0.03). There were no statistically significant differences in the use of intrauterine devices, rhythm, or combination methods in the three study years. Only 1 woman (0.9 percent) in 1989, but 11 women (7.9 percent) in 1986, used no method of contraception, as compared with 6 women (1.4 percent) in the 1975 study.
To the question "When you have intercourse how often does your partner use a condom?" 49 of 408 sexually active women (12 percent) responded "always" or "almost always" in 1975, as compared with 30 of 140 (21 percent) in 1986 and 46 of 113 (41 percent) in 1989 (χ2 for trend = 53.98, P<0.0001) (Table 3Table 3
Frequency of Condom Use during Sexual Intercourse in College Women in 1975, 1986, and 1989.*). Conversely, in 1975, 370 (87 percent) stated that their partners seldom or never used a condom, as compared with 99 (71 percent) in 1986 and 66 (58 percent) in 1989 (χ2 for trend = 70.73, P<0.001). Of 122 sexually experienced women who did not consult the health service, 62 (51 percent) reported regular ("always" or "almost always") condom use, as compared with 46 of the sexually experienced women who visited the health service (41 percent) (χ2 = 2.03, P = 0.15).Discussion
The years between 1975 and 1989 have seen the emergence of genital herpes simplex virus infection, chlamydial infection, toxic shock syndrome, and the acquired immunodeficiency syndrome (AIDS). There has also been a heightened awareness of the value of maintaining a healthy lifestyle, including the avoidance of products containing nicotine. Public health messages during this period have included recommendations to stop smoking and, for women, to alter methods of menstrual absorption. Other recommendations have included limiting the number of one's sexual partners, discriminating in one's choice of sexual partners and practices (avoiding, for example, anal intercourse), and using barrier methods of contraception to restrict the spread of sexually transmitted diseases.5 6 7
Data supporting the validity of these public health messages for college-aged women emerged from the microbiologic analysis of cultures from the group studied in 1975.1 2 3 4 For example, having an increased number of sexual partners was predictive of chlamydial infection among women who did not use barrier methods of contraception, but no such relation was detected among sexually experienced women who used barrier methods.2
The groups examined in all study years were highly educated, as were their parents. The parents were more highly educated in the later surveys than in the study conducted 15 years ago.
The influence of public health messages on the habits of these women has varied. Considerably fewer women in the recent studies than in 1975 smoked (21 of 130 [16 percent] in 1989, 20 of 161 [12 percent] in 1986, and 136 of 486 [28 percent] in 1975; χ2 = 20.5, P<0.001). Also, habits related to the absorption of menstrual flow and the use of tampons shifted over the 11-year period, with fewer women using tampons in 1986 than in 1975. Although the strong public health messages that emanated from the well-publicized epidemiologic link between the use of tampons and toxic shock syndrome are likely to have played a part in the trend toward lower tampon use in this group, 90 percent of the respondents in 1986 still reported using tampons.8 9 10 The use of tampons increased to 94 percent in 1989, possibly because there was less publicity about toxic shock syndrome.
However, although smoking habits and tampon use changed, the sexual behavior and practices of these college-aged women did not. In all three study years, an equal proportion of women had had six or more male sexual partners and had had three or more male sexual partners in the year before the study. Similarly, the proportion of women who engaged in oral and anal sex, although low, was unchanged. Studies examining the association of human immunodeficiency virus (HIV) infection with sexual behavior in various cohorts have demonstrated an association between HIV infection and both anal intercourse and having multiple sexual partners.11 12 13 Reducing the number of sexual partners and avoiding anal intercourse are two of several safer-sex practices that have been advocated for all sexually active adults.5 Our data indicate little change in the sexual practices of these groups of college women.
The methods of birth control used by college women who participated in the study reflect a significant decrease in the use of oral contraceptives. Again, publicity about the side effects and potential dangers of oral contraceptives may have influenced these women, at least in 1986.
Data from the original study that link chlamydial infection with the use of nonbarrier methods of contraception demonstrate that sexually active college women are at risk for sexually transmitted diseases, and these must now include HIV infection. Condoms have been shown to protect against sexually transmissible agents such as Ureaplasma urealyticum and Neisseria gonorrhoeae 14 , 15 and may also provide protection against HIV (particularly latex condoms).16 The relatively low frequency of condom use in 1986 (21 percent) suggested that recommendations for the prevention of AIDS and sexually transmitted disease had not had a major influence on the women studied. However, the use of condoms rose significantly in 1989 (to 41 percent) among sexually active women who visited the health service and was reported by 51 percent of the sexually experienced women surveyed who did not consult the health service. This suggests that safer-sex messages have influenced the choice of contraceptive method in women currently of college age.
The cohorts of women studied in the health service in all three surveys were probably representative of other women on this university campus. The cohort of women drawn from other university sites (dormitories, libraries, and classrooms) was younger and less sexually experienced than the women visiting a gynecologist at the student health service. However, the sexual practices of the sexually experienced women in the group that did not visit the health service (65 percent) did not differ significantly from those of the sexually experienced women who did consult the health-service gynecologist in 1989 or in the earlier survey years. The data we present are likely to be relatively representative of sexually experienced women attending this university. In a survey of 500 students performed at this university in 1985, 424 of 477 respondents (89 percent) reported using the health service during their years at school (Hoffman S: personal communication).
One might have expected that in the years since the first survey in 1975, concern about sexually transmitted diseases would have resulted in substantial changes in sexual behavior that would have been reflected in the number of lifetime or recent sexual partners. The data in this study do not support this expectation. Rather, these data comparing the sexual behavior of three cohorts of college women at the same university over a 14-year period indicate that public health campaigns have not had a substantial influence on the habits and behavior of these well-educated young adults.
It is encouraging that the regular use of condoms during intercourse is reported by 41 to 51 percent of the sexually active women surveyed in 1989. However, the majority of sexually active college women surveyed do not report the use of condoms during sexual intercourse. In answer to questions asked only of the 1989 respondents, 68 sexually experienced women who consulted the health service (60 percent) and 58 who did not (49 percent) said that they worried about being infected with HIV. Similarly, 52 (45 percent) and 49 (41 percent) of these women, respectively, thought that their partners might be at risk for HIV infection. Moreover, when asked about changes in sexual practices when they were seriously involved with a partner, 25 (22 percent) and 24 (21 percent) of these women, respectively, reported that they engaged in more risky sexual behavior.
These data suggest that despite the existence of major new infectious diseases, sexual practices among these college women did not change markedly in 14 years with respect to the number of sexual partners or specific sexual acts. Although the use of condoms increased, the majority of sexually active women surveyed did not report their regular use. New educational approaches may be necessary to translate knowledge about the current epidemics of sexually transmitted diseases into more protective sexual behavior.
We are indebted to Sumner Hoffman, M.D., Marlene Eckerle, M.D., Dolores Norton, R.N., Toby Simon, M.Ed., Barry Smith, P.A.-C, Samantha Levy, Victoria Sams, and the entire healthservice staff for their valued assistance.
Source Information
From the Department of Medicine, Brown University, and Roger Williams General Hospital, Providence (B.A.D., S.H.Z., M.D.); and the Departments of Medicine and Obstetrics and Gynecology, State University of New York Health Science Center, Brooklyn (W.M.M.). Address reprint requests to Dr. Zinner at the Department of Medicine, Roger Williams General Hospital, 825 Chalkstone Ave., Providence, RI 02908.
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