Sexual behaviour and HIV/AIDS infection in Portugal

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2 Sexual behaviour and HIV/AIDS infection in Portugal Manuel Villaverde Cabral, Pedro Moura Ferreira, Sofia Aboim, Duarte Vilar e Raquel Lucas Project background Portugal has one of the most worrying levels of HIV/AIDS infection in the EU, not only because the number of people infected is high but also because, unlike most countries, these numbers do not show clear signs of stabilising. Despite all the prevention campaigns, the infection still needs to be kept permanently under surveillance. Albeit scarce, existing information on sexual risk behaviour associated with the transmission of HIV contributes to the opacity of reasons underlying the prevalence of the infection in Portuguese society. Is the sexuality of the Portuguese far too careless? If this is the case, why is it so? Or are we simply facing a phase-shift likely to be corrected through proper protection practices among the younger generations? The project should provide answers to these types of questions and, at the same time, provide indicators that permit the implementation of the Declaration of Commitment on HIV/AIDS, which establishes the need for countries to implement a system to monitor and control the HIV/AIDS epidemic. The global aim of the project is to analyse the relationships between sexual behaviour and risk behaviour associated with the transmission of HIV among those living in Portugal, and its methods are grounded on a survey based on a representative sample of individuals. The main instrument of research will therefore be the questionnaire. The general outline of the questionnaire is divided into four parts. The first part explores and characterises aspects of the sexual culture of the Portuguese. This culture is perceived in several ways. The first aspect is sexual activity described in terms of various practices, frequency and partners. The second refers to the representations which are reflected in the attitudes towards different fields of sexuality (faithfulness, love feelings, homosexuality, pre-marital sex and adolescents, etc.). The third identifies the normative aspects of the social networks in which the individual takes part. Lastly, the issue of sexual identities is also dealt with by resorting to the self-definition of identity. The second part identifies the relationship between sexuality and the individual s wellbeing. We aim to analyse the way sexuality is subjectively experienced. In this context, the issue of sexual and reproductive health becomes more relevant. We seek to assess the relationship between the individual s state of health and sexual activity and the satisfaction derived thereof. The role of contraception in the activity and in satisfaction is also studied. In terms of sexual problems, we highlight abortion, sexually transmitted diseases and sexual dysfunctions. The third part seeks to assess the impact that HIV/AIDS have on sexual behaviour associated with transmission. We explore both the protected sexual practices, in particular the use of condoms, and the preventive attitude in its wider sense. This includes the assessment of knowledge on HIV transmission, taking the HIV test, how condoms are represented, preventive strategies and the awareness campaigns for sexual prevention. Lastly, the survey includes a sociographic module. The project aims to characterise the main sexual trends of the population and to identify the groups in which the risk behaviour associated with HIV transmission are more noticeable. Naturally, the interpretation of this information will allow us to draw and explore hypotheses relating sexual trends to characteristics of the population and to risk behaviour. With the aim of providing monitoring indicators on the HIV/AIDS epidemic, this project also seeks to explore the reasons that may justify the epidemic situation seen in Portugal and to eventually pinpoint new targets for the guidelines governing the campaigns and the preventive measures to fight HIV/AIDS infection. Methodology The target population covers individuals between 18 and 65 years old, living in mainland Portugal. The random multistage-area sampling takes into account the following elements: Choice of location: The parishes of mainland Portugal have been divided into 12 strata, defined according to two stratification variables: a) Residence of population aged 18-65, by region. 1

3 b) Number of residents aged by parish (around 3, individuals). Stratification variables measured according to the Census 21 data. With the initial aim of conducting the same number of interviews in each parish, we selected in each stratum the number of parishes needed so that the number of respondents by stratum was proportional to the distribution of the target population in the strata. To achieve the same number of interviews per parish, these were randomly selected, with the probability proportionate to their size. A total of 3,643 interviews were conducted, in four versions (two female and two male). The criterion for alternating between the versions was systematic and random. All interviews were divided into two parts, one with questions posed by the interviewer and the other to be completed by the respondent. The respondent would place the second part of the questionnaire in an envelope, annexing it to to the general questionnaire. Both parts of the questionnaire were then placed in a second envelope and made anonymous. We attempted to contact 8,781 individuals in home addresses selected, based on the systematic procedures in each parish. The result was as follows: a) 3,643 valid questionnaires; b) 2,357 refusals, withdrawals or incomplete questionnaires; c) 2,781 failed contact attempts or impossible to contact the last resident that is 18 years old or older celebrating his/her birthday, after two attempts. Sexual indicators Sexual frequency In terms of annual frequency, the Portuguese population favours weekly sexual periodicity. Almost half of the population (47.6%) reports having sexual intercourse a few times a week. Above this frequency, the daily or almost daily sexual activities are reported. A total of 7.4% are in this category, which is slightly lower than those who abstained from sexual activity in the previous year (9.6%). A general interpretation of the distribution of results shows that the most visible differences between men and women are related to sexual inactivity. The breakdown by gender shows that women are far more representative (14.4% compared to 5% of men). Whatever the underlying reason, it is inevitable that the gap between men and women in terms of sexual inactivity influences the frequency categories. However, this influence is revealed in rather different ways. The direct consequence of the unequal rate of sexual inactivity according to gender is that men are more represented in the other frequency categories. Yet, this need not be the acknowledgement that men are particularly more represented in the categories of higher frequencies. In fact, in the every day or almost every day category, men represent 8.9% and women 5.9%, and for a few times a week, the contrast is of 5.8% against 44.2%. These differences show that on the issue of sexual frequency, women stand out in terms of inactivity whilst men do in terms of more intense activity. The number of partners Sexual relations are described according to type and are based on a divide between single partners and multiple partners, focusing on three moments in time: throughout life, five years ago and in the previous year. As to type, this is formed by five categories: one single partner throughout life; one single partner in the last five years (but having multiple partners before that); one single partner in the previous year (but having multiple partners before that); current multiple partners; no partner for one year (but having multiple partners before that). 2

4 The first category refers to the respondents who mentioned having had only one single partner throughout their lives and represents a little over one third of the total number of respondents (34.1%). The female predominance is three times higher than the male (52.% against 16.1%). The following category corresponds to the second in terms of frequency, with 28.3%, and reflects a monogamic trajectory of at least five years, having one single partner. Any number of partners is possible before that period, and this is where the difference lies compared to the first category. Here, the representation of men is higher (35.6%, against 21% for women). The third category could apparently be considered a special case of the previous category, in that the monogamic period is now measured taking into consideration only the previous year. However, the difference between these two categories is that in the period between the five years and the previous year, there may have been other relationships, and therefore this is marked by the multiple partner criterion. The single partners of less than one year represent 16.8% of the respondents. The intersexual differences are not particularly relevant. The fourth category includes the respondents who mentioned having more than one partner in the previous year. This is what distinguishes them from those of the previous category. As to the remaining characteristics, they converge. The category of the current multiple partners stands at 15.4%. are clearly represented here, with a percentage three times higher than that of women (23.6%) and 7.2% respectively). Representing only 5.4% of the population, the basis for the last category is grounded on two criteria: on the one hand, the characteristic of having no partner in the previous year, and on the other hand the reference to having several partners in the other periods. If we take into account the group of five final categories, in other words the current relationships of the individuals, we can state that there are more categories that follow the logic of a single partner than of multiple partners. If we calculate the influence of the latter using a relatively large time span (last five years), we can say that it affects around one in every three respondents. This difference can be interpreted in a contradictory way. For some it might be high and a sign of sexual dysfunction whilst for others it is less than expected within the context of a society that places few obstacles regarding sexual relationships. It is obvious that these two interpretations involve value judgements regarding what should be desirable, and given that there is a growing tendency towards the logic of multiple partners. From this point of view, it is important to understand the dynamics of how this logic disseminates in society, identifying the social categories which are more receptive to it. Another important aspect in terms of number of partners is the distribution according to age group. If we analyse the situation in the previous year, we see that one single partner is the main situation (85.4%). The population mentioning more than one sexual relationship represents only 14.7%, and a little over a half (8.6%) is in the higher frequency range (three or more partners). The results of the breakdown by gender are not unexpected, and there is a difference of gender in the number of partners mentioned, which is even higher in the range of three or more partners (14.2% and 2.8% respectively, in men and women). If we consider the age breakdown, there is a tendency for the number of partners to decrease as individuals grow older, which 3

5 obviously shows the impact of shifting marriage trends. The younger group is then the one which will most likely engage in new sexual relations as these individuals are less bound by emotional or long-lasting marital ties. For example, in the three or more partners class, the proportion of men shifts from 26.5%, in the age group, to 5.2%, in the age group; in women, the corresponding numbers are 8.2% and 2.2% respectively. Even if the numbers according to the gender gap are not similar, they nevertheless reflect the same tendency towards a fewer number of partners. Diversifying sexual practices The part dealing with diverse sexual activity focused on four practices: fellatio, cunnilingus, anal sex and sex without penetration (the latter is defined as mutual forms of excitement not involving penetration). The vaginal sex relation is not included as this is the baseline filter from which we selected the individuals who answered this part of the questionnaire. The listing of sexual practices from the highest to the lowest, places sex without penetration in the first position, with a predominance of 69.5%, followed closely by oral sex, that is, giving and receiving, 67.4% and 62.9% respectively, and ends with anal sex (37.2%). These figures show that non-penetrating and oral practices are quite widespread, while anal sex is not a common practice for most people, although more than one third of those questioned admitted having practised it. If we compare men and women, there is a systematic inconsistency which has nothing to do with the ranking of sexual practices but with the numbers which are reported: women mention them less. The intersexual differences vary according to practice, ranging more or less from 1% to 2%. If the different sexual practices reveal sexual diversity, it makes sense that they are related among themselves. In other words, the individuals more open to sexual diversification tend to accept several practices, whilst those who are less open to them tend to reject them. Therefore, sexual diversification could be represented along a straight line where at one end, we would have all the individuals who make no mention of any of these practices and at the other end, the individuals who mentioned all the practices. In the middle positions, we would have those who mention between one and three sexual practices. Basically, the diversification of the sexual activity can be broken down into three groups: those who reject sexual experimentation (21.7%), those who restrict experimentation to one or two practices (23.8%) and those with the all-encompassing portfolio (54.5%). This division is still valid when we consider the breakdown by gender, even if the relative weight of the frequency classes changes, particularly those at the top of the distribution. In effect, the intersexual differences only exist when there is no diversity or when it reaches its maximum. mention the absence of experimentation more often than men (26.7% and 16.9% respectively), while men exceed them in the four practices range (36.7%, against 2.8% for women). The prevalence throughout life seems to suggest that men have a far more extensive portfolio of sexual experiences and practices. Age at first intercourse The best way to compare the evolution of the age at which sexual activity starts, within several generations, is to compare the extreme 4

6 ends of the time span separating the younger generation (18-24 years old) from the older generation (55-65 years old). The comparison highlights some important differences. For males, there is a relatively limited evolution in that the age for starting sexual activity in the older generation is at 17.3 years old and in the younger generation it is at 16.5 years old. This means that over at least thirty years - the age span between the two generations - the average age men start their sexual activity has moved back less than one year. This evolution strongly contrasts with the female evolution, in which the average age has dropped from 21.2 to 17.2 years old, that is, a decrease of four years. Therefore, in this regard, women clearly stand out. partners they had had, but also to describe who these sexual partners were at different moments of their lives, starting with sexual initiation. Additionally, the last and the penultimate partner were also identified by respondents. As expected, gender differences are extremely marked and follow a quite linear pattern over time. The first partner with whom women had intercourse was described in the context of a regular relationship (normally with a boyfriend) in nearly 7% of the cases, which contrasts with the male profile. For men, the first partner was much more often described as an occasional one and nearly 1% of men had their sexual initiation with a prostitute ,7 Prostitute First partner 42,8 44,7 13,1 Occasional partner 69 Regular partner 2,9 17,8 Spouse As a result of this evolution, the age differences between men and women have gradually decreased over time. This difference is around four years in the older generation and of less than one year in the younger generation. It may well be that the downward tendency has yet to stabilise; therefore, we cannot exclude new decreases on the women s side. These data further suggest that there is a radical change in the conditions for starting sexual activities, clearly unlike the Mediterranean model in which the early development in men contrasts with the delay practiced by women, preferably until marriage takes place. It is possible that Portugal is shifting towards other European society models in which the average age for starting sexual activity is less marked by gender differences. Sexual partners over the life course The patterning of sexual behaviour over the life course was also a main objective of the study, thus allowing for the identification of diverse sexual life styles. and women were asked not only to estimate the number of sexual This traditional pattern of male sexual initiation is stronger in the older group of men: while a quarter of men between 55 and 65 reported a prostitute as first partner, within the younger group this percentage decreases to 3.3%. Overall, being sexually initiated in the context of a regular relationship is a pattern that clearly rises in the younger groups, which is also true in the case of women. But, differently from men, they substitute the traditional sexual initiation with the spouse for a relational pattern centred on the boyfriend. Younger men also tend to engage in this model, reducing the gender gap which was larger in older generations. However, in spite of these changes, differences concerning the proportion of occasional partners remain evident: in the group, more than one third of men were initiated by an occasional partner as against 12.3% of women. 5

7 's first partner by age groups ,4 41,5 27,1 5, ,5 42, ,3 42,9 45,1 1, ,4 46,2 48,4 1, ,3 36,7 58,9 1, Prostitute Occasional partner Regular partner Spouse ,2 4,7 Occasional partner Last partner 2,2 21 Regular partner 's last partner by age groups 74,3 63,6 Spouse 's first partner by age groups ,14,3 85, ,7 18,7 13,7 48,8 6,8 75,8 46,5 2,5 1, ,5 8,2 12,4 12,4 17,8 33,3 79,3 75,1 48, ,5 78,8 7, ,2 52,8 11, ,3 84,6 3, Occasional partner Regular partner Spouse Occasional partner Regular partner Spouse 's last partner by age groups The gender contrast in sexual life styles endures over the life course and applies also to the last partner s profile. Although there is a clear effect of the transition to conjugal life, men s sexuality remains, nonetheless, more oriented towards occasional relationships: 16.2% of men had an occasional last partner as against only 4.7% of women. This fact is to some extent validated by an analysis of age groups, as the effect of the conjugalization of sexuality (above age 25 more than half of respondents had intercourse with the spouse) is stronger among women. In the older group (55-65), one tenth of men are engaged in occasional sex, whereas women seem not to have occasional partners at all. In the younger age group (18-24), which is mostly constituted by unmarried respondents, women (69%) still have more regular partners than men (52.8%). In reverse, the percentage of young men (36.2%) with an occasional last partner more than doubles that of women (15.2%) ,7 6, ,61, ,2 6,2 15,2 27,4 92, ,1 81,8 66,4 15, Occasional partner Regular partner Spouse The characterization of the penultimate sexual partner adds interesting information, allowing us to understand the sexual practices of multipartners men and women: within the sexually active population, 81.8% of men and 44.3% of women had at least two sexual partners in their lifetime. The sexual life styles of multi-partner individuals are, in this context, of great importance to identify and evaluate risk-taking sexual behaviour. 6

8 Penultimate partner (multi-partner 52,8 respondants) 45, ,8 22,4 17,4 Occasional Regular partner Spouse partner (61.8%), two regular partners. Only 3.2% had both a regular and an occasional partner and even fewer (just 8%) reported two occasional partners. In the case of men, these proportions are quite different: almost half of these men declared having both regular and occasional partners and almost a fifth identified only occasional sexual partners. In the overall reckoning, occasional partners seem to have importance in individual s sexual styles. Moreover, the transition between regular and occasional partners appears to be quite frequent, particularly in the case of men. In more than half of the cases, the penultimate partner men have identified was described as an occasional relationship. For women, the links between sexual practice and relationships still tend to prevail, although more than one third of these multi-partner women have also described an occasional partner. Overall, the multi-partner sexual dynamics are further associated with non-regular and non-conjugal relationships. Among these individuals, occasional sex is reported in a significant number of cases. Partners profile among multi-partner individuals Male partners' profile (last two partners) by 36,2 28,3 37,4 34,8 44,6 age groups 42,5 43,5 46,5 48, ,1 2,3 16,2 14,4 16, Regular partners Regular and occasional partners Occasional partners The combination of the information collected on both the last and the penultimate partners enabled us to identify three different dynamics: that of individuals who reported two regular partners, either married, cohabiting or dating; that of those who had both a regular and an occasional partner; and, thirdly, that of men and women who declared having had just occasional partners Partners' profile (last two partners) 61,8 Regular partners 45 3,2 Regular and occasional partners 19 8 Occasional partners Once again gender is a key variable. Multipartner women reported, in their majority Female partners' profile (last two partners) by 5 61,9 61,9 age groups 7 78,4 33,8 3,2 32,7 3 16,2 16,2 5,4 7,9 5, Regular partners Regular and occasional partners Occasional partners These multi-partner dynamics are affected by age, for both men and women. In the case of the latter, the pattern is quite linear according to age: younger women (particularly in the group) tend more often to combine regular and occasional partners or simply to have just occasional relationships. The male pattern shows the increase of occasional partners both among younger (29.1%) and older men (2.3%). 7

9 Interestingly, the combination of regular and occasional sexual partners shows similar proportions across generations, especially among men. The time gap between the last and the penultimate partner is also an important indicator from the viewpoint of risk-taking behaviour, as several studies have shown. The shorter the time-gap between partners the greater the lack of control concerning possible risks of infection. In the Portuguese sample, there is a clear trend, among multi-partner individuals, to have simultaneous sexual partners, namely when these are not regular relationships. Roughly, half of the men follow this pattern, which although less marked among women, also applies to a significant percentage of females: 42.9% of women who have had regular and occasional partners were involved in simultaneous sexual relationships Male partners' profile and time gap between partners 16,8 15,9 28,4 2 34,7 Regular partners 16,7 19,7 2,2 16, ,7 52,7 Regular and occasional Occasional Simultaneously Same year but not simultaneasly One year 2 or more years Female partners' profile and time gap between partners 21,4 33,3 18,7 26,7 Regular partners 5,2 1 27, ,7 42,9 Regular and occasional 35 3 Occasional Simultaneously Same year but not simultaneasly One year 2 or more years The use of condoms in sexual relationships depends on the sexual life styles of individuals, which is an important conclusion emerging from our data. Individuals who reported having had two occasional partners in a row are also those who more often used condoms with all of their sex partners in the last year (48.4% of men and 43.5% of women). On the other hand, a significant part of these individuals shows an inconsistent use of condoms: 32.8% of men and 39.1% of women used condoms only with some partners, thus showing some lack of preventive strategies Male partners' profile and condom use in the last year 2,7 3,1 2, , ,3 43,6 48,4 32,8 16,4 Regular partners Regular and occasional Occasional Did not have sex Used condoms with all sexual partners Used condoms only with some partners Never used condoms Female partners' profile and condom use 42,1 in the last year 8,6 4,9 8,7 32,2 34,1 17,1 28 Regular partners 32,9 Regular and occasional 43,5 39,1 8,7 Occasional Did not have sex Used condoms with all sexual partners Used condoms only with some partners Never used condoms The group of those having both regular and occasional partners is even more inconsistent in their use of condoms: only a fifth of men and a third of women used condoms with all sexual partners. A very high percentage, particularly among men (43.6%), never used condoms in the last year. In sum, individuals with more frequent occasional sex seem, in spite of some irregularity, keener to take on preventive sexual behaviour when compared to those who mix regular with occasional relationships. The 8

10 latter seem to be less aware or less concerned about potential risks of unprotected sex involving multiple partners ,6 2,8 who never used condoms with sexual partners in the last year 2,8 37,5 31,1 13,9 63,8 57,4 58,7 52,8 5 9,5 91,7 79, Regular partners Regular and ocasional partners Ocasional partners 35,7 However, these general trends are strongly affected by age. Among men, the impact of age follows a quite linear pattern, indicating higher levels of unsafe sex among older individuals and inversely. If we compare the younger and the older groups of men who had two unprotected experiences of occasional sex, the conclusion is striking. In the group, 35.7% of men never used condoms, whereas among those aged between 18 and 24 this percentage falls to just 2.8%. In sum, our findings reveal that among older men not only is there a significant proportion of multi-partner occasional behaviour, but also that the levels of protection from sexually transmitted diseases are much lower, when compared to those of younger generations. Same gender sex, homosexuality and bisexuality Following major guidelines in the quantitative approach of sexuality, the Portuguese survey included a module of questions related to the experience of same gender sex. and women were firstly asked about their contacts (both genital and non genital) with same gender individuals over their life courses and only afterwards were they invited to report their sexual preferences and to define themselves as hetero, homo or bisexual. The percentage of individuals who declared either having had homosexual practices or to have a non-heterosexual orientation is a minority, as could be anticipated on the basis of previous findings. However, the Portuguese numbers are similar to those obtained in France, Great Britain or the U.S ,7 Same gender sex; behaviour and orientation 5,5 Non Genital contact 3 2,5 Genital contact 3,7 2,9 2,9 2,4 Same-sex atraction Homo/bisexual orientation 5,2 6,3 Total % of respondents with at least an affirmative answer The proportion of men and women who experienced some type of same gender nongenital contact in their lifetimes is roughly 5%. Comparatively, the percentage of those who declared having had genital contact decreases significantly, particularly in the case of women. Overall, it comprises no more than 3% of the sample. The other two indicators sexual attraction and self-orientation have a similar range, although more men (3.7%) define themselves as homo or bisexuals when compared to women (2.9%). However, if we consider the three indicators altogether, we may conclude that the amount of individuals who gave a positive answer to at least one of them is higher, thus raising the proportion of population with non-heterosexual experiences, whether related to practices or merely to desire and identity Partner's gender across the lifetime 95,2 94,3 Only other gender partners,9,5 3,9 Only same gender partners 5,2 Both gender partners 9

11 An approach focused on practices is, however, interestingly revealing. If we look at the gender of all the partners with whom individuals have said to have had sexual contact (genital and non-genital) in their lifetime, we conclude that bisexual behaviour is much more frequent than the strict homosexual pattern: 3.9% of men and 5.2% of women reported sexual contact with both genders, whereas only less than 1% of respondents declared having had only same gender partners across the life course Occasional sex without using condoms in the last year 9,3 5,3 17,9 2,5 Only other gender partners Only same gender partners Both gender partners 11,4 Bisexual behaviour has been analysed in several studies and has often emerged as more unprotected, thus unsafe, than strict same gender sex. Our findings seem to point to a similar result, as revealed by the analysis of individuals who had occasional sex without using condoms in the last year. While this percentage is the lowest among men who had only male partners (5.3%), it rises quite clearly among those who had both male and female partners. This last group is probably less aware of infection risks, which may result in more risktaking behaviour. Contraception, pregnancy and miscarriage Use of contraceptives 81.4% of the interviewees who are sexually active, who are not pregnant or whose partner is not pregnant and don t want to be pregnant, use a contraceptive method. This figure is below those referred to in the 4 th National Health Survey of 27. However, it is important to remember that the age limits of this study are larger that those of the NHS 27, and they include older participants. When we consider this aspect, and consider only the participants under 55, the use of contraceptives rises to 86% which is much closer to the values found in the NHS of %. Thus, our research confirms, once more, a very high use of contraception in line with the very low fertility and birth rates existent in the country. Very small differences exist between men and women on this question: women refer more to the use of contraceptives than their partners. As we will confirm later, the values of each contraceptive method in women are always higher than those referred to by men, with the exception of condom use which is more referred to by men than by women. Age is obviously a factor that influences the use of contraception. Firstly, older people have less sexual activity; secondly the belief of not being fertile anymore is higher at these ages. It is at the ages between 18 and 35 years that the use of contraceptives is higher, which corresponds to the period where conception is also more frequent. Saying this, the high use of contraception reconfirms the strong birth control attitude that prevails among Portuguese couples. But age also allows comparisons between different generations and in this context, research reconfirms that the older generations are also those who were reached later by the changes in contraceptive use, having less access to contraception and education as well to reproductive health care. 1

12 These two factors combined mean that the use of contraception decreases very significantly after 45 years and, after 55 only 3% of the subjects use contraceptives. The non use of contraception The reasons referred to for not using contraception are diverse and we also found significant differences between men and women. Analysing only the group of participants that don t use contraceptives, 53.4% of the men do not mention a specific reason for the non use and 23% state that they don t use contraception because they don t currently have sexual intercourse; 7.8 % of the men have a pregnant partner or are planning a pregnancy. The main reason given by women is sexual inactivity (41.7%) followed by other unspecific reasons (38%). We also verified that the justification given for not using contraceptives because of infertility increases with age reaching highly significant levels between 45 and 54 years 13.7% - and after 55 almost 2%. However, it is important to remember that this belief of being infertile is often not based on any medical observation or examination. Therefore, in these age groups there are also risks of unintended pregnancies. In contrast, a current pregnancy or the wish for pregnancy obviously implies the non use of contraceptives. This situation is more frequent in the more educated groups (that are also the younger groups) and in the younger groups mainly between 25 and 35, which corresponds to the age groups where births are actually more frequent in Portugal. The use of different contraceptive methods We also studied the use of the different contraceptive methods, now just using the participants that practise any one of the contraceptive methods. It s important to stress that these unspecific reasons constitute a significant exposure to the risk of an unwanted pregnancy given the fact that these people are, in principle, sexually active. They are not pregnant or waiting to become pregnant but, at the same time, they are not using any kind of contraception. Moral reasons are rarely given 2.4% as motives for the non use of contraceptives and they are more expressive in men than in women. The reasons for not using contraception also vary according to the different age groups. In the younger group (18-24) and in the older group (over 45), the non use because of sexual inactivity is higher, which corresponds, respectively, to age groups where a significant percentage still didn t initiate sexual intercourse or have stopped having sexual intercourse. According to this group, the method most used is the contraceptive pill, which is mentioned by 51% of the users. This is followed by the condom, referred to by 35.9% of the users. The IUD is mentioned by 4.3%, female sterilization by 3.8% and withdrawal by 1%. All the other methods are mentioned by less than 1% of the subjects. These figures reconfirm a situation already described in other national researches: a very high concentration of contraceptive usage around the pill and a very modest use of any of the other contraceptive methods. They also reconfirm a much higher contraceptive prevalence among women than men. These figures also confirm that the traditional methods, such as withdrawal are actually very rarely used. On the other hand, the figures show that the use of the most recent contraceptive methods 11

13 namely the implant, the contraceptive patch or the vaginal ring is still very limited. Finally, they reconfirm the idea that almost all the participants use regular methods of contraception and, in consequence, the use of emergency contraception is very rarely mentioned. The pattern of contraceptive usage in Portugal is a product of the policies on Family Planning and Reproductive Health that have been followed. On the one hand, there has been an excessive integration of the family planning services within the context of women s health. Although this is justifiable because of the greater risks they have to face, it does not justify the complete absence of programmes or campaigns on male contraceptive methods. On the other hand, the pharmaceutical industry has strongly promoted the contraceptive pill (Portugal is one of the world s biggest users of the pill). The first campaigns on condoms only took place in the nineties. But this issue was approached not as a contraceptive method but as a method to prevent HIV/AIDS. Furthermore, these campaigns were systematically addressed to young people. However, and besides the contraceptive offer, this pattern, so centred on female contraception, also reveals the proactive attitude of Portuguese women in controlling their fertility. In contrast to other Portuguese studies, much higher levels of condom use are referred to in our research. For instance, the National Health Survey in 27 stated that only 13% of participants used condoms (against almost 36% in this research). When we compare the answers of men and women on the type of contraceptive that they use, very significant differences appear. These differences are always significant in relation to the methods most used but they are especially significant when we compare the answers on the condom use which is mentioned by 47.3% of men and for 23.7% of women. Of course, the men and women interviewed are not, in principle, partners (the sample was made up of individuals and not couples) but the answers of both sexes were not expected to be so different. It is also understandable that some female contraceptive methods are not visible. The pill is taken at any time and not during sexual intercourse; sterilization or IUD is not visible. But this doesn t happen with the condom, which is used and perceived during sexual intercourse. Therefore, these results and differences concerning condom use especially by the men must be seen carefully because they may partially represent a socially desirable answer in research promoted by the AIDS National Coordination. But beyond the interpretations that may be produced on these data, it is important to stress that those men and women have different perceptions of contraception usage and this fact has to be taken into account in the design and promotion of contraceptive education programmes and campaigns. Pregnancies Portugal has passed through a deep process of demographic changes characterized by low levels of fertility and also by a late fertility. This is also reflected in our research, where only 2.8% of the interviewees or their partners are pregnant. This situation is referred to more by men 3.8% than by women 1.8%. Miscarriages 25% of the women who have been pregnant declared that they have had a miscarriage. This situation is more frequent in the older groups which, beyond the cumulative effect, may also reflect the current better conditions in relation to the follow up and medical surveillance of pregnant women in Portugal. This situation is also more common in the less educated groups, who are also the older groups. Unwanted pregnancies Around one third of the women studied had, at least, one unintended pregnancy. Naturally, this fact is more frequent in older women because of cumulative effect and also because the older generation had less information and access to contraceptives. 12

14 This also happened more to women in cohabitation 43.1% - than in the group of the married women 37% and in the group of the single. Non use of contraception being the main factor in unintended pregnancies was mentioned by more than 4% of the women in this situation. Contraceptive failure is the second reason for this circumstance, referred to by more than 3% of the women. Induced abortion 27.2% of the women who had an intended pregnancy had an induced abortion (8.5% of the total of women). Taking into consideration that this was the first research after the referendum on abortion and the consequent changes in law, it is important to acknowledge that there were still many difficulties for the women studied in giving information on this issue. This can be seen from the high level of non responses to these particular questions (16.1%) referring to abortion practices and respective contexts. The low number of women that admitted an induced abortion around 12 and the significant level of non responses limited the possibility of a more detailed correlation analysis. In spite of this, it was possible to note that, in consonance of other research done in 26, the induced abortion is an event that crosses all social groups and all ages. This contradicts the common idea that induced abortion is mainly a problem of younger and poorer women. In conclusion, we have studied the motives why these women terminated their pregnancies. Economic difficulties were given by 25% of the women, followed by not wanting those particular pregnancies 2.1% and, finally, because of being too young. Having recently had a baby or couple instability were also mentioned by more than 1% of these women. Prevention of HIV transmission through sexual contact Our aims were to characterise the primary and secondary prevention of HIV transmission in the Portuguese general population aged between 18 and 65, by estimating the frequency and distribution of condom use and HIV testing, according to socio-demographic and behavioural characteristics, and representations and attitudes towards HIV/AIDS. Condom use According to the present survey, lifetime condom use was 67% among women and 83% in men. In the previous month condoms had been used by 22% of women and 35% of men. Condom use in the last sexual intercourse was reported by 19% of women and 3% of men. Lifetime condom use was more frequent in 3 to 34 year-old women and in 2 to 24 year-old men. Frequencies were also higher among participants who reported higher levels of formal education, reaching nearly 1% in those with college education. Regarding the first sexual intercourse, condom use was associated with the age at which this experience occurred, in both genders, and it was more frequent when the first intercourse was referred to have happened between 17 and 18 years-old and less frequent when the reported age was between 26 and 29 years-old. % 6, 5, 4, 3, 2, * 41,1 4,5 21,4 4,6 47,8 43,8 3,6 35,7 25,8 25,1 28,9 35,9 Mulheres Homens 1,, < Age at first sexual intercourse (years) * p<,5 Among participants whose first intercourse occurred before 15 years-old, women reported having used condom significantly more 13

15 frequently than men (41% vs. 21%, respectively). Considering only participants who referred one or more sexual partners in the year preceding the survey, condom use was more frequent among those who had had 3 to 4 partners (89% in women and 87% in men), when compared to the period prevalence found in participants who reported a smaller number of partners. However, among women who referred more than 4 partners, 22% had used a condom in the previous year, which represents a substantially lower frequency than the one found in men, 73%. The proportion of participants who reported consistent condom use (with every partner in the previous year) increased with the number of partners, both in women and in men. Condom use in the last sexual intercourse was more frequent in men (3% vs. 19% in women) and in both genders the prevalence was higher among participants who referred having a relationship to which they did not feel committed (64% in women and 71% in men) and rarer in those who referred living as couple (9% in women and 16% in men) % 9,3 16,1 Vive Living em as casal a couple 29,6 Participants who reported the absence of religious practice also referred condom use in the last sexual intercourse more frequently, as well as men who defined their sexual orientation as homosexual (41%) and women who characterised theirs as bisexual (3%). Reference to problems when using condoms was not associated with their use in the last intercourse. Participants who agreed with the statement Condoms are very expensive had used this preventive method more frequently in the last intercourse. HIV/AIDS testing 45,2 Tem With uma relação a relationship, em que se sente comprometido(a) feeling committed In the present sample, the life prevalence of HIV/AIDS testing was 44%. Medical check-up or 63,6 71,1 Tem uma With relação a relationship, mas não se sente comprometido(a) not feeling committed 46,7 64,3 Não tem Without nenhuma a regular relação relationship regular Mulheres Homens hospital admission were the most frequently referred motives for the last HIV test (43%) and only 8% identified the reason for testing as a precaution measure related to personal or partner s risks. Among participants who had never been tested for HIV, 16% did not admit the possibility of a future test. Among these, 86% substantiated this attitude by not considering themselves at risk, and 5% by not knowing where to conduct a test respondents Yes: 44% No: 55% Which was the reason for your last test? Medical check-up or hospital admission: 43.1% Pregnancy: 18.5% Precaution related to personal/partner s risks 7.6% Have you ever taken a blood sample to conduct an HIV test? Yes: 54.1% Maybe: 23.5% Does not know: 6.2% Do you admit the possibility of a future test? No: 16,2% I do not consider myself to be at risk: 85.7% I do not know where to conduct a test: 5.1% Life prevalence of testing was higher in women between 3 and 34 years-old and in 35 to 39 year-old men. In both genders, there was a significant trend for an increase in the proportion of participants tested with increasing number of schooling years. and men who referred a present relationship to which they did not feel committed had conducted an HIV test more frequently than those who did not have a regular relationship. % Life prevalence of HIV testing Age group (years) Mulheres Homens Testing was more frequently referred by women who characterised their sexual orientation as bisexual (69% had had at least one test) and by men who defined themselves as homosexual (life prevalence: 78%) 47.1% 42,% 14

16 Participants who reported hearing about HIV/AIDS very often and those who referred having an acquaintance or a friend/family member who was HIV-positive or who had died from AIDS had more frequently had an HIV test themselves. Among respondents who reported asking every new partner to have an HIV test 62% of women and 48% of men had conducted one themselves. In both genders the probability of having had an HIV test in the previous year increased with the number of sexual partners referred in that period respondents years-old 1816 women 1717 men 7.2% with 2 or more partners in the previous year 22.3% with 2 or more partners in the previous year 4.% did not use condom with any of the patners 25.8% did not use condom with any of the patners 14.6% had an HIV test in the previous year 16.5% had an HIV test in the previous year Overall, considering all respondents, 7% of women and 22% of men reported two or more partners in the precedent year. Among these, 4% of women and 26% of men referred not having used a condom with any of the partners. In these, 15% of women and 16% of men had conducted and HIV test in that period. 15