Young Danes’ experiences with unsafe sex

Risky sexual behaviour may affect general health, especially in younger persons. Over the past ten years, the number of sexually transmitted infections (STIs) has increased. The number of detected Chlamydia trachomatis infections has almost doubled (reaching a total of 27,932 detected cases in 2010) [1], and the numbers of gonorrhoea (n = 484) and syphilis (n = 377) cases have tripled [2, 3]. Furthermore, 15-20% of sexually active young Danes are infected with herpes simplex [4], and the lifetime risk of human papillomavirus (HPV) infection is considered to be approximately 80% [5]. From 2003 to 2009, the number of abortions has also doubled among adolescents aged 15-19 years (from 8.5 to 16.9 per 1,000 women), and an 85% increase was reported in the same period among young women aged 20-24 years (from 13.8 to 25.2 per 1,000 women) [6]. This finding indicates a high risk of unwanted pregnancy despite a decrease in the number of abortions in the general population. In summary, unsafe sex in relation to both the risk of infection and unwanted pregnancy seems to be an increasing public health problem in Denmark, and interventions are needed to stimulate healthy sexual behaviour. Detailed knowledge about sexual behaviour is essential both to enable targeted prevention and to conduct a valid continuous survey of status and changes over time in sexual attitudes and behaviour. However, although several small surveys have been conducted, a standardized measurement tool has not yet been developed in Denmark, [7-9]. Critical points suitable for targeted interventions and validated questionnaires describing sexual behaviour can only to some extent be adapted from other countries as contextual and cultural issues may influence sex behaviour. As a supplement to the international literature, it is therefore necessary to attain detailed qualitative insights into current Danish attitudes and behaviours before implementing targeted interventions and developing national surveys and instruments to monitor preventive efforts. In the present qualitative study we therefore aimed to explore categories of sexual behaviour experiences for the prevention of unsafe sex as perceived by young Danes.

MATERIAL AND METHODS

Sample and setting

The participants were recruited in January 2010 from a Danish folk high school, which is generally open to individuals from all social classes above 17.5 years of age. Interviews were supported by the school’s principal and the purpose was presented to the students by the first author (MJJ) prior to the first interview. All students who had had their sexual debut at the time of the interview were considered for inclusion. The strategic sample consisted of young adults (> 18 years of age) with different social, geographical and educational backgrounds and an open attitude towards the topic. A total of 19 students aged 18-23 years agreed to participate (11 women, eight men). Men and women were interviewed separately. The two interview groups with women comprised five and six participants and the two groups of men each comprised four participants.

Focus group interviews

MJJ (registered nurse and researcher) conducted semi-structured interviews of approximately one hour’s duration, and the second author (BA, doctor and researcher) attended as a supervisor. The interviews were structured by an interview guide covering topics related to sexual behaviour among the Danish youth (Table 1). The guide was developed based on literature studies supplemented with clinical experience and experiences from research in the topic among the group of authors. We used open-ended questions, and the informants were encouraged to speak freely based on their experiences, attitudes, and general knowledge from their network and to raise issues of importance to them, even if the issues went beyond the themes of the interview guide. Thus, the interview guide was only used as a template that could be deviated from during and between the interviews and not as closed-ended questions to the participants.

Data analysis

First, the focus group interviews were transcribed verbatim by a trained professional secretary. The transcripts were then read simultaneously with the tapes by MJJ to ensure correctness of the transcription and to get an overall impression of the material before the initial coding. All meaningful text units related to the issues of the interview guide (Table 1) were then coded and grouped into relevant categories [10] using the software package NVivo (ed. 8). A qualitative description approach was used for the analyses [11]. We enhanced the rigour of the analysis by paying attention to the informants’ voices, staying true to the topic under investigation, being reflective and critical of both the results and the decisions made throughout the research process, and by ongoing reflection and self-criticality of the researcher [12].

Ethical approval

The study was approved by the Danish Data Protection Agency (J. No. 2009-41-4220). The Central Denmark Regional Committees on Biomedical Research (J. No. 162/2010) did not consider approval of the project necessary as there was no biomedical intervention.

Trial registration: not relevant.

RESULTS

Nine categories of sexual behaviour experiences leading to unsafe sex were identified and grouped into four main categories: one-night stands, alcohol consumption, low self-esteem, and increased sexual experience (Figure 1).

One-night stand

First, the analyses in our study revealed that, in general, young Danes do intend to use a condom when they have sex. However, if the partners met during a night out partying, at festivals, or on vacation, the sexual act will often result in a one-night stand without the use of condoms (Table 2, quotations 1-3). Situations like these gave the informants a feeling of freedom to be a bit wilder and more experimental because they were not likely to meet the person again (Table 2, quotations 4-5). In contrast, meeting a potential sex partner at school, through hobbies, or even from contact on the internet were not likely to result in one-night stands, but in a long-term relationship not involving unsafe sex unless they were both tested for STIs and/or the girl was taking the pill as a contraceptive device (Table 2, quotations 6-7).

Alcohol consumption

Second, all of the informants considered alcohol consumption a major category leading to unsafe sex, whereas drug abuse did not seem to have the same influence among the informants (Table 2, quotations 8-9). Alcohol consumption influenced the ability to make rational decisions and made it harder to keep one’s promise of not having unprotected sex (Table 2, quotations 10-12).

Low self-esteem

Third, the interviews made clear that low self-esteem often leads to unsafe sex. According to the informants, low self-esteem could easily influence the person’s ability to accept one’s boundaries being crossed. For example, acceptance of having a sexual debut too early, having unprotected sex, or another sexual experience they did not feel ready for, but where they did not have the courage to tell their partner about their feelings (Table 3, quotations 1-2). In contrast to low self-esteem, high self-esteem gives the young adults the courage to believe in themselves, to trust their feelings and to inform their partner, and thereby avoid that their boundaries are being overstepped (Table 3, quotation 3).

Increased sexual experience

Fourth, the analyses revealed that even though the informants found self-esteem to improve with age, unsafe sex would still occur. The reason seemed to be an association between increased sexual experience and lack of condom use; the more experience, the less likely they were to use a condom whenever they engaged in sexual activity. The informants explained that when women are older, they tend to use the pill as birth control, and young adults are generally more concerned with becoming pregnant than being infected with an STI. Therefore, whenever the woman is taking the pill, the informants believed that young Danes tend to forget about condoms and engage in unhealthy sexual behaviour (Table 3, quotations 4-6).

DISCUSSION

This study identified one-night stands, alcohol consumption, low self-esteem and increased sexual experience as important categories for future interventions that aim to create a safer sexual behaviour among young Danes. The significance of one-night stands and alcohol was similar to findings in previous studies of sexual risk among youths [7, 9, 13-15]. Identifying alcohol as a category may have even more meaning for the Danish youth as they have been found to drink more alcohol than youths in other European countries [16]. Furthermore, 40-50% of women with unwanted pregnancy admit to isolated episodes of binge drinking, particularly before realizing that they had become pregnant [17], which supports the identification of alcohol as a factor that leads to unsafe sex.

Another major finding made in this study was the association between unsafe sex and low self-esteem. Obesity was previously found to be associated with unsafe sex in a French study [18]. Obesity could be assumed to correlate with low self-esteem [19] and, as such, our results are in agreement with the French study. However, low self-esteem is a broad concept that may contain multiple dimensions, and further research to confirm the impact of self-esteem should be done before including this category into a prevention programme.

In contrast to our expectations, “meeting a partner on the internet” or “the use of drugs prior to the sexual act” was not found to be among the factors leading to unsafe sex. According to our informants, meeting a sexual partner online was most likely associated with a long-term relationship, not a one-night stand, because they got to know each other through intensive communication before engaging in sexual intercourse. The informants also explained that using drugs would often increase sexual arousal, but the ability to perform would decrease. However, a previous study found drugs to be related to unsafe sex [20], and this subject should be included when planning future preventive programmes.

Finally, we found an association between increased sexual experience and unsafe sex. The more experience the young Danes had, the more likely the young women were to use the pill as contraception, which would lead both young men and women to forget or to ignore condom use and thereby cause an increased risk of getting an STI. According to our informants, the main reason for contraception use is a general concern of becoming pregnant rather than a concern of being infected with an STI. This finding indicates a need for special focus on the prevention of STIs among more sexually experienced young Danes.

The present qualitative, descriptive study provides an updated insight into current sexual experiences as well as sexual behaviour among young Danes, and provides in-depth descriptions of categories leading to unsafe sex according to their perception. Thus, it gives a solid ground for targeted interventions and for the development of a questionnaire and for quantitative mapping of changes in sexual behaviour over time.

We are confident that this study is a broad elaboration of the topic and that it allowed for new themes and aspects to emerge from the focus group interviews. The interaction within the group seemed to make it less awkward and difficult to discuss the sensitive subject of sexual behaviour compared with what might have been expected. Thus, focus group interviews were utilized as the underlying basis for the development of new views and descriptions among the informants [10].

Some informants may have been reluctant to disclose their sexual experiences, and we invited them to talk about the topic as if they were describing a third party, but no participants chose to make use of this option. The group setting gave the informants a valuable feeling of sharing experiences and supporting each other.

The presence of the interviewer (MJJ) and supervisor (BA) could have influenced the informants. However, they expressed that they felt that it was completely uncomplicated to talk about their sexual experien- ces and behaviour: “I think it has been relaxing and totally down to earth” (informant 9). The support of the school’s principal, the introduction given in advance, and the educational background of both the interviewer and supervisor may have given the informants a feeling of confidence and safety. The fact that we aimed to use the same terminology as the informants (or not being offended by their terminology) regarding sexual behaviour may also have given them a feeling of confidence.

We aimed to achieve credibility, reliability and generalizability in order to ensure validity [10]. No new themes emerged at the fourth interview in this study, why saturation was likely obtained within the group setting. The informants in our focus group interviews volunteered to participate; thus, these students may have been more interested in contributing with their opinions and experiences than their fellow students. One could argue that the group setting was socially skewed and the informants did not represent all social groups. This may question the credibility of the findings. However, due to the diversity in social, geographical and educational backgrounds and the recommendation to express general knowledge, attitudes and experiences from their network, we assume that the topics were covered from many different angles and areas, and that this ensured credibility. Thorough transcription by a professional secretary and thorough coding and discussion of all topics by the authors helped ensure reliability.

An essential question concerns the external validity of our findings. These are in line with findings in previous studies with few additional amendments [7, 9, 13-15]; and since our informants had very different backgrounds and talked both in general and personal terms, we assume they represent both personal and general attitudes from their network; thus data can be assumed to be both qualitatively valid and applicable. Denmark is assumed to have a very homogenous population with small differences between different parts of the country, which improves the external validity of our findings. A deeper insight into the distribution within gender, age groups and Danish youth in general requires a larger quantitative study.

CONCLUSION

In conclusion, young Danes find one-night stands, alcohol consumption, low self-esteem and increased sexual experience to be important categories leading to unsafe sex. These findings should be taken into consideration when designing preventive programmes and developing and initiating national surveys and instruments to describe and monitor preventive efforts in order to reduce the number of STIs and unwanted pregnancies among the Danish youth.

Correspondence: Marianne J. Jørgensen, Afdeling for Folkeundersøgelser, Regionshospitalet Randers, 8930 Randers NØ, Denmark. E-mail: mjj@alm.au.dk

Accepted: 6 November 2012

Conflicts of interest:None. Disclosure forms provided by the authors are available with the full text of this article at www.danmedj.dk.

Acknowledgement: We would like to express our profound gratitude to all our informants for their participation. Informants were recruited from a Danish folk high school in the Central Region of Denmark. Also, we express our gratitude to the temporary principal of a Danish folk high school in the Central Region of Denmark for helping identify potential informants. Finally, we are indebted to Mette Asbjørn Neergaard, The Palliative Care Team, Aarhus University Hospital for her contributions and ideas in the initial phase.

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