Supplementary appendix

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1 Supplementary appendix This appendix formed part of the original submission and has been peer reviewed. We post it as supplied by the authors. Supplement to: Wayal S, Hughes G, Sonnenberg P, et al. Ethnic variations in sexual behaviours and sexual health markers: findings from the third British National Survey of Sexual Attitudes and Lifestyles (Natsal-3). Lancet Public Health 2017; 2: e

2 Page 1 of 14 Appendices Table 1: Definitions of key variables used in the analysis and how they were measured Variable Sexual health markers Sexual health clinic attendance Definition of variable used in the analysis Participants who had been to a clinic in the last 5 years. Time frame of variable used in the analysis In the last 5 years How the variable was measured Have you ever attended a sexual health clinic (GUM clinic)? 2. No STI diagnosis Participants with a diagnosis with any of the following STIs in the last 5 years: Trichomonas, Gonorrhoea, Chlamydia, Syphilis, NSU/NGU, Genital warts, Herpes In the last 5 years IF yes, then when was that? 1. Less than 1 year ago 2. Between 1 and 5 years ago 3. Between 5 and 10 years ago 4. More than 10 years ago Have you ever been told by a doctor or other healthcare professional that you had any of the following? 1. Chlamydia 2. Gonorrhoea 3. Genital Warts (venereal warts) 4. Syphilis 5. Trichomonas vaginalis (Trich, TV) 6. Herpes (genital herpes) 7. Pubic lice / crabs 8. Hepatitis B 9. (Men only:) NSU (Non Specific Urethritis), NGU (Non Gonococcal Urethritis) 10. (Men only:) Epididymitis 11. (Women only:) Pelvic Inflammatory Disease (PID, salpingitis) 12. (Women only:) Vaginal thrush (Candida, Yeast infection) 13. (Women only:) Bacterial vaginosis 14. Yes, but can't remember which 15. None of these Then for each infection that the participant had chosen they were asked: When were you last told by a doctor or healthcare professional that you had

3 Page 2 of 14 Emergency contraception use Low sexual function Explanatory variables Women who reported ever having used morning after pill and/or emergency intra-uterine device (IUD) were treated as users of emergency contraception. Participants were categorised as having low sexual function based on the lowest genderspecific quintile on the scores for the Natsal-SF. 1 (name of infection)? 1. Less than 1 year ago 2. Between 1 and 5 years ago 3. Between 5 and 10 years ago 4. More than 10 years ago Ever Participants were asked : First, from this list, could you tell me which you or any partner have ever used, together? (A) No method used ever (B) (Partner has been /I have been sterilized) (C) (I have been /partner has been sterilized (had vasectomy)) (D) The Pill (E) Male condom (F) Female condom (G) Morning after pill (H) Emergency intra-uterine device (IUD) (I) Coil/intra-uterine device (IUD) (J) Hormonal IUD - MIRENA (K) Cap/diaphragm (L) Injections (M) Spermicides (foams/gels/sprays/pessaries) (N) Natural family planning (safe period/rhythm method/persona) (O) Withdrawal (P) Implants (Q) Other method of protection (please say what) In the last year -Participants were asked to respond to a validated 17-item Natsal-SF scale 1 which takes into account problems with individual sexual response, sexual function in a relationship context, and self-appraisal of sex life. -Participants who were sexually active in the last year and were in a relationship that had lasted for all of the last year responded to all the 17 items. However for participants who had not been in a relationship, sophisticated modelling techniques were used to derive scores for these respondents. 1 Mitchell KR, Mercer CH, Ploubidis GB, et al. Sexual function in Britain: findings from the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3). Lancet (London, England) 2013; 382(9907):

4 Page 3 of 14 examined the analysis Marital status Academic qualification Participants were grouped as: 1: Married / civil partnership if response was 1,or 2 2: Cohabiting if response was 3 3: In a steady relationship but not living together if response was 4 4: Not in a steady relationship if response was 5, 6, 7 or 8 Participants aged 16 years were not classified for this question. Those with foreign qualifications are coded as not answered as we do not have information on what level these qualifications were. Those aged 17+ were classified into 3 groups according to their highest academic qualification. 1: no academic qualifications 2. academic qualifications typically gained at age 16 if gave one of qualifications 5-15 and were no longer in full-time education 3. Studying for/attained further academic qualifications if gave one of qualifications 5-15 and were still in full-time education or if gave one of qualifications 1-4. At the time of interview At the time of the interview At present are you 1. single, that is never married and never registered in a same-sex civil partnership 2. married and living with husband/wife 3. in a registered same-sex civil partnership and living with your partner 4. separated, but still legally married 5. divorced 6. widowed 7. [spontaneous only] separated, but still legally in a same-sex civil partnership 8. [spontaneous only] formerly a same sex civil partner, the civil partnership now legally dissolved 9. [spontaneous only] a surviving civil partner: his/her partner having since died -At what age did you complete your continuous full-time education? If you had a 'gap' year between school and university or college please include it as continuous. -Have you passed any exams or got any of the qualifications? 2. No, none IF Yes THEN Please read down the list and tell me the highest qualification that you have, that is, the first one you come to. INTERVIEWER: Code one only. 1. Degree level qualification 2. A-levels 3. AS level 4. SLC Higher Grade, etc 5. O-level, 1975 or earlier 6. O-level, after 1975 A-C 7. O-level, after 1975 D-E 8. GCSE grades A*-C 9. GCSE grades D-G 10. CSE grade 1, etc 11. CSE grades 2-5, etc

5 Page 4 of 14 Ethnicity Index of Multiple Deprivation Participants were grouped as: 1.White British if their response was A:1 2.Black Caribbean if their response was D:12 3.Black African if their response was D:13 4. Indian: if their response was C:8 5. Pakistani if their response was D:9 6. White other if their response was A: 2 or 3 7.Mixed if their response was B:4,5,6,or 7 Participants who were in the highest quintile were treated as living in a most deprived area. NA At the time of the interview 12. CSE Ungraded 13. SLC Lower 14. SUPE Lower or Ordinary 15. School Certificate 16. Foreign qualification Participants were asked about which ethnic group they belong to. They could choose: A. White 1. British 2. Irish 3. Any Other White background B. Mixed 4. White and Black Caribbean 5. White and Black African 6. White and Asian 7. Any Other Mixed background C. Asian or Asian British 8. Indian 9. Pakistani 10. Bangladeshi 11. Any Other Asian background D. Black or British Black 12. Caribbean 13. African 14. Any Other Black background E. Chinese or other ethnic group 15. Chinese 16. Any Other Postcodes were used to obtain IMD scores. The adjusted IMD score was generated using a method by Payne and Abel. 2 It is based on the income and employment of the individual country IMD scores combined with the co-efficients and residual values from a linear regression of income and employment on the overall IMD score for each country. The combined scores were generated using the most up-to-date scores for each country at the time. These were IMD 2010 for England, IMD 2011 for Wales, and IMD 2009 for Scotland. 2 Payne R, Abel G. UK indices of multiple deprivation a way to make comparisons across constituent countries easier. Health Statistics Quately 2012; Spring 2012.

6 Page 5 of 14 National Statistics Socio- Economic Classification Binge drinking Participants responses were classified as: 1: managerial & professional occupations 2: intermediate occupations 3: small employers and own account workers 4: lower supervisory and technical occupations 5: semi-routine and routine occupations 6: never worked or long term unemployed 7: no job of 10+ hours/week or not in the last 10 years 8: student in full-time education Participants reporting drinking 6 units of alcohol at least on one occasion in a month were treated as binge drinkers At the time of the interview In the last year Several questions based on the International Standard occupation codes were asked: See the following website for the International Standard Occupation Codes (SOC) for details: classifications/standard-occupational-classification-2000/index.html How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year? 1. Never 2. Less than monthly 3. Monthly 4. Weekly 5. Daily or almost daily Smoking (current smoker) Recreational drug use Participants who said yes to smoking cigarettes at all nowadays were treated as current smokers Participants who reported using any of the listed recreational drugs including injecting drugs in the last 12 months were treated as recreational drug users in the last year Current In the last year Do you ever smoke cigarettes at all nowadays?" (Includes roll-ups but excludes cigars). 2. No If they had ever used taken: 1. cannabis (marijuana, grass, hash, ganja, draw, skunk, weed, spliff); 2. amphetamines (speed, whizz, uppers, billy); 3. cocaine or coke (charlie), crack (rock, stones, white); 4. ecstasy (E); heroin that was not injected (smack, skag, H, brown, gear, horse); 5. acid or LSD (tabs, trips) or magic mushrooms; 6. crystal Meth; 7. amyl Nitrates (poppers, liquid gold, rush);

7 Page 6 of 14 Depressive symptoms Participants who had an overall score of 3 were treated as having current depression Depressive symptoms in the last two weeks. 8. other non-prescribed drugs or none of these. If yes to any of these they were asked: Have you taken (name of drug) in the last 12 months? 2. No Patient Health Questionnaire (PHQ)-2 was used to measure current depression. Higher score indicates current depressive symptoms. Over the last 2 weeks, how often have you been bothered by any of the following problems? Give answers as 0 to 3, using this scale:0=not at all; 1=Several days; 2=More than half the days; 3=Nearly every day 1. Little interest or pleasure in doing things Sexual behaviours Age at sexual debut Sexual competence at sexual debut Participant s age at the time of sexual debut. First intercourse was classified as competent if there was absence of duress and regret about timing; if there was autonomy of decision; and if a reliable form of contraception was used. (i.e., if participants responses were those that are highlighted in bold then they At the time of sexual debut At the time of sexual debut 2. Feeling down, depressed, or hopeless Participants were asked How old were you when you first had sexual intercourse with someone of the opposite sex, or hasn't this happened? Those who were unsure of their age were asked to estimate. If the participant reported an age <13 years, they were asked Has this happened with anybody else since you turned 13? Constructed variable to capture readiness, combining consensuality, autonomy of decision making, timing, and use of effective contraception. Would you say that you were both equally willing to have intercourse that first time, or was one of you more willing than the other? IF ONE MORE WILLING: Who was more willing? 1. Both equally willing 2. Respondent more willing 3. Partner more willing

8 Page 7 of 14 were treated as being sexually competent at first intercourse.) Did you or your partner use any form of contraception or take any precautions that first time, or not? (Code all that apply) 1. Condom (Sheath/Durex) 2. The Pill 3. Emergency contraception 4. Other contraception 5. (partner) withdrew 6. Made sure it was a safe period 7. No precautions by me, don't know about partner 8. No precautions by either of us Looking back now to the first time you had sexual intercourse, do you think 1....you should have waited longer before having sex with anyone, 2. or, that you should not have waited so long, 3. or, was it about the right time? Ever same-sex experience Any same-sex experience involving genital contact Participants who reported yes to same sex experience, not necessarily involving genital contact, were treated as having had ever same-sex experience Participants who responded as yes were treated as having had any same-sex experience involving genital contact Ever Ever Which of these things applied to you at the time? (Code all that apply). 1. I was curious about what it would be like 2. I was carried away by my feelings 3. Most people in my age group seemed to be doing it 4. It seemed like a natural 'follow on' in the relationship 5. I was a bit drunk at the time 6. I had smoked some cannabis 7. I had taken some other drugs 8. I wanted to lose my virginity 9. I was in love 10. Other particular factor (SPECIFY AT NEXT QUESTION) 11. Can't remember Have you ever had any kind of sexual experience or sexual contact with a (same sex partner mentioned depending on sex of the participant)? Even if it was a long time ago or did not involve contact with the (genitalarea/penis/vagina). 1 Yes 2 No Have you had sex with a (same sex partner mentioned depending on sex of the participant) involving (genital area/penis/vaginal) contact? (That is oral (or anal) sex or any other contact involving the genital area.) 1 Yes 2 No

9 Page 8 of 14 Lifetime partnerships The total number of lifetime opposite sex and same sex partners participant reported. Lifetime 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. And 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. Partnerships in 5 years The total number of opposite sex and same sex partners participant reported in the last five years. In the last 5 years Answers to these two questions were added together to give total lifetime partners. Altogether, in the last 5 years, how many (women/men) have you had sexual intercourse with? Please type in the number in the last 5 years, '0' if none. And Altogether, in the last 5 YEARS, how many (men/women) have you had sex with? Please type in the number in the last 5 years, '0' if none. Concurrency New partners while outside of the UK Paid for sex Participants who responded yes were treated has being in a concurrent partnership Participants who reported having new partners abroad i.e., yes Participants who reported paying for sex i.e., yes In the last 5 years In the last 5 years In the last 5 years Answers to these two questions were added together to give total partners in the past 5 years. Thinking about all of the people you have had sex with in the last five years, did any of them overlap in time? In other words did you have sex with someone (person A) then have sex with someone else (person B) then have sex with the first person (person A) again? 2.No In the last 5 years, have you had sex with anyone for the first time while you were in any country outside the UK? Include UK citizens and/or others you first had sex with while in another country. 2. No Have you ever paid money for sex with a (man/woman opposite sex)?" 1. "Yes" 2. "No" IF Yes THEN

10 Page 9 of 14 When was the last time you paid money for sex with a (man/woman opposite sex)? 1. In the last 7 days 2. Between 7 days and 4 weeks ago 3. Between 4 weeks and 1 year ago 4. Between 1 year and 5 years ago 5. Longer than 5 years ago Men who had previously reported ever having had sexual experience with a man were then asked: Have you ever paid money for sex with a man? 2. No Condomless sex with two or more partners Answers to these questions were used to determine how many partners (opposite or same sex) a participant had had sex with without a condom in the past year. In the last year IF Yes THEN When was the last time you paid money for sex with a man? 1. In the last 7 days 2. Between 7 days and 4 weeks ago 3. Between 4 weeks and 1 year ago 4. Between 1 year and 5 years ago 5. Longer than 5 years ago In the last YEAR have you ever had vaginal (or anal) intercourse with a (woman/man) without using a condom? (have had intercourse without a condom in the past year) 2. No (have used a condom on all occasions of vaginal (or anal) intercourse in the past year) IF Yes THEN How many (women/men) have you had vaginal (or anal) intercourse with in the past year without using a condom? Men were asked: In the last year, when you've had anal sex, how often have you, or your partner, used a condom? 1. Every time 2. Most of the time 3. Occasionally 4. Not at all in the last year

11 Page 10 of 14 Attitudes Non-exclusivity in marriage Participants who responded as 1 were treated as considering non-exclusivity in marriage as always wrong Perceived concurrency of their most recent partner Participants who responded as 1 were considered to perceive their most recent partner has having been in concurrent partnership NA Most recent partner IF Most of the time to not at all in the past year THEN In the last year, with how many men have you had anal intercourse without using a condom? A married person having sexual relations with someone other than his or her partner?" 1. "Always wrong" 2. "Mostly wrong" 3. "Sometimes wrong" 4. "Rarely wrong" 5. "Not wrong at all//" 6. "Depends/Don't know" Participants were asked about their perception of their most recent partner s concurrency in the past 5 years. Questions were worded differently depending on the duration of their relationship and whether the relationship was ongoing (based on perception of participant and how long ago most recently reported sex with this partner was). IF first sex with partner was more than 5 years ago and partnership is ongoing: Do you think that (that person/name) has had sex with anyone else in the last 5 years? 2. Probably 3. Probably not 4. No 5. Prefer not to say IF first sex with this partner was more than 5 years ago AND most recent sex with this partner was in the last 5 years AND partnership is not ongoing THEN Do you think (that person/name) had sex with anyone other than you between (month and year 5 years ago) and the most recent occasion you had sex with him/her?. IF First sex with partner was less than 5 years ago AND partnership is ongoing THEN Do you think (that person/name) has had sex with anyone else since you first had sex together?

12 Page 11 of 14 One night stand Participants who responded as 2 to 5 were treated as considering one night stand as not wrong at all NA IF First sex with partner was less than 5 years ago AND partnership is not ongoing Do you think (that person/name) had sex with anyone else in the time between when you first and most recently had sex together? what is your opinion about a person having one night stands?" 1. "Always wrong" 2. "Mostly wrong" 3. "Sometimes wrong" 4. "Rarely wrong" 5. "Not wrong at all" 6. "Depends/Don't know"

13 Page 12 of 14 Appendix Table 2. Comparison of population distribution by ethnic group in the Census 2011 and Natsal-3 Ethnic group Census 2011 Natsal-3 Difference in ethnic distribution of population in the 2011 Census and Natsal-3 White British 80.5% 82.1% +1.6% Irish 0.9% 1.0% +0.1% Other White 4.4% 4.3% 0.1% Gypsy 0.1% - 0.1% Mixed White and Black Caribbean 0.7% 0.6% 0.1% Mixed White and Black African 0.3% 0.3% 0.0% Mixed White and Asian 0.6% 0.4% 0.2% Other Mixed 0.5% 0.5% 0.0% Indian 2.5% 2.5% 0.0% Pakistani 2.0% 1.4% 0.6% Bangladeshi 0.7% 0.6% 0.1% Chinese 0.6% 0.5% 0.1% Other Asian 1.5% 1.5% 0.0% Black African 1.7% 1.8% +0.1% Black Caribbean 1.1% 1.3% +0.2% Other Black 0.5% 0.3% 0.2% Arab 0.4% - 0.4% Other ethnic groups 1.0% 0.7% 0.3% Not answered - 0.3% +0.3%

14 Page 13 of 14 Appendix Table 3. Variables retained in final multivariable model (model 3) by sexual health marker, for men and women MEN WOMEN Sexual health marker: Sexual health clinic attendance STI diagnosis Low sexual function Sexual health clinic attendance STI diagnosis Low sexual function Emergency contraception use Adjusted odds ratio (95% CI) Adjusted odds ratio (95% CI) Adjusted odds ratio (95% CI) Adjusted odds ratio (95% CI) Adjusted odds ratio (95% CI) Adjusted odds ratio (95% CI) Adjusted odds ratio (95% CI) Age (continuous variable) $ Socioeconomic factors *** 0.94 ( ) *** 0.96 ( ) *** 1.02 ( ) *** 0.92 ( ) *** 0.95 ( ) *** 1.02 ( ) *** 0.94 ( ) Marital status Married/civil *** *** 1 ** 1 - ** 1 partnership Cohabiting 2.20 ( ) 1.46 ( ) 1.29 ( ) 2.39 ( ) 2.63 ( ) ( ) In a steady partnership 1.86 ( ) 1.44 ( ) 0.97 ( ) 3.21 ( ) 1.79 ( ) ( ) but not living together Not in a steady 1.68 ( ) 1.09 ( ) 1.29 ( ) 2.46 ( ) 1.82 ( ) ( ) partnership Academic qualification No academic qualification Academic qualification typically gained at 16 years ± Studying/attained further academic qualifications ** ( ) ( ) ( ) ( ) Index of Multiple ( ) ( ) Deprivation Least deprived * Else ( ) Most deprived ( ) - - National Statistics Socio-Economic - - *** 1

15 Page 14 of 14 Classification Managerial & ** 1 * 1 - * *** 1 professional occupations Intermediate 0.61 ( ) 0.77 ( ) ( ) 1.33 ( ) ( ) occupations Semi-routine and 0.61 ( ) 0.77 ( ) ( ) 1.09 ( ) ( ) routine occupations Never 0.68 ( ) 0.33 ( ) ( ) 0.93 ( ) ( ) worked/unemployed Full-time student 0.61 ( ) 0.44 ( ) ( ) 0.68 ( ) ( ) Substance use factors and depressive symptoms Binge drinking (yes) - - ** 0.80 ( ) 1.01 ( ) 1.04 ( ) - ** 1.19 ( ) Recreational drug user *** 1.61 ( ) *** 2.72 ( ) 1.28 ( ) * 1.36 ( ) 1.10 ( ) ** 1.38 ( ) *** 1.69 ( ) (last year) (yes) Current smoking (yes) ( ) Depressive symptoms *** 3.94 ( ) 1.17 ( ) (yes) Sexual behaviour - variables <16 years at sexual - * 0.69 ( ) ** 0.78 ( ) * 1.28 ( ) debut (yes) * Sexually competent at - * 0.69 ( ) ** 0.76 ( ) 0.84 ( ) - *** 0.64 ( ) * 0.81 ( ) sexual debut (yes) 10+ sexual partners in *** 2.04 ( ) *** 1.82 ( ) - *** 2.04 ( ) *** 2.16 ( ) - *** 1.26 ( ) last 5 years Reported concurrent ** 1.51 ( ) 1.30 ( ) - ** 1.47 ( ) ** 1.52 ( ) - *** 1.62 ( ) sex partners in last 5 years Paid for sex in last 5 - * 1.76 ( ) ** 1.86 ( ) ( ) years) Condomless sex with 2+ partners in last year (yes) ( ) - Model 3 included variables that were retained in model 1 ( $ socioeconomic factors) and model 2 ( substance use and depressive symptoms) along with the * sexual behaviour variables that were retained after backwards selection, using a p-value threshold of 0.10 *p-value 0.05; ** p-value<0.001; *** p-value<0.0001