Contraceptive researchers and practitioners rarely assess sexual acceptability, or how contraception affects women's sexual experiences.1–3 Research on male-based contraceptives4–6 demonstrates that sexual acceptability influences men's uptake and use of these methods. Building evidence suggests sexual acceptability shapes women's contraceptive practices as well.7–10 However, more studies are needed—especially for long-acting reversible contraception (LARC), the most effective contraceptive methods currently available.11,12
Two major measurement gaps hinder the research to date. First, most studies are cross-sectional,13 preventing evaluation of sexual experiences over time.14 Second, most extant research takes a solely physiologic approach to sexual acceptability, primarily through sexual libido13,14 or the Female Sexual Function Index.15 However, sexual acceptability includes other key domains, including psychologic factors such as sexual disinhibition, sexual aspects of side effects such as bleeding and cramping, and women's perceptions of whether their methods affect sexuality.7,9,16,17
A 2014 review examined 11 LARC studies that included sexuality measures.18 Use of the intrauterine device (IUD) was more commonly associated with positive or neutral sexual effects than negative ones; however, the review identified mixed results, a lack of U.S. studies, and potential methodologic limitations. A 2016 U.S. study found copper IUD users significantly less likely than depot medroxyprogesterone acetate users to report lack of sexual desire in the previous 6 months13; however, it did not include baseline sexuality measures, which could have affected study results. This prospective study addresses these gaps by documenting sexual acceptability using a variety of sexuality measures among women initiating a LARC method.
MATERIALS AND METHODS
In this prospective, observational cohort study, participants were 18- to 44-year-old women seeking contraceptive services at one of four Planned Parenthood Association of Utah clinics from December 2014 to April 2015. The study was reviewed and approved by University of Utah's institutional review board. Per standard care protocols, patients received shared decision-making counseling from a clinic staff member and then selected the contraceptive method of their choice. All patients who selected a currently available LARC method (copper IUD, levonorgestrel IUD, or contraceptive implant) were informed by the counselor of the current study on sexuality and contraception. Study eligibility included a desire to prevent pregnancy for at least 1 year, fluency in English or Spanish, and a working phone number. Women who were sterilized, pregnant, or trying to get pregnant were ineligible. If eligible and willing to participate, patients provided informed consent and enrolled in the study during the same clinic visit. Participants received their devices free of charge, which they were informed about after contraceptive counseling and before completing the informed consent process.
Initial data collection took place before device insertion through use of the Research Electronic Data Capture, a secure, web-based research application. (See Appendix 1, available online at https://links.lww.com/AOG/A870, for the clinic intake form.) At 1 and 3 months, postdevice placement participants were prompted by their preferred method of communication (phone, text, or e-mail) to complete Research Electronic Data Capture follow-up questionnaires. Surveys took approximately 15 minutes, and respondents received a small amount gift card credit for each completed round.
Baseline surveys collected information on variables that can influence both contraceptive choice and sexual outcomes and would later serve as control variables: sociodemographic information, obstetric history, relationship status and length, and health status (as captured by the WHO-5,19 a five-item measure of functional health and well-being). Women were also asked, “How important are each of the following characteristics to you when you decide which birth control method to use?” Based on qualitative7,17 and theoretical research,20 we included two sexual acceptability criteria (“it doesn't reduce my libido” and “it doesn't interrupt sex”) alongside the other more common criteria21 such as efficacy, hormonal content, and friend recommendation.
Our primary objective was to assess sexual outcomes among new LARC users over time while controlling for relevant baseline factors. Three measures contributing to the primary outcome were as follows: 1) the Female Sexual Function Index-6,22 a validated, six-question measure including items on sexual desire and interest, arousal, lubrication, orgasm, pain, and satisfaction; 2) the New Sexual Satisfaction Scale,23 a validated, 20-question measure with some functioning items but additional sexual domains such as partner-oriented items and the ability to “let go” during sex; and 3) a question devised and piloted by the research team about participants' perceptions of their contraceptive method's sexual effects, if any (“In the last 4 weeks, would you say your contraceptive method: made my sex life better, made it worse, or had no effect on my sex life?”).
Our secondary objective was to assess other sexual factors potentially involved in the sexual acceptability of these contraceptive methods, including the sexual-related selection criteria measures mentioned previously. Other secondary sexual measures were based on recent qualitative research on the sexual acceptability of IUDs in the United States.17 The potential sexual effects of bleeding changes were captured with a question about vaginal bleeding in the previous 4 weeks (no bleeding, less bleeding than before the device, no change, more bleeding). To capture the potential sexual effects of sexual disinhibition by way of feeling extremely protected against pregnancy, we used two questions: 1) the “surrender” question of the New Sexual Satisfaction Scale, in which women ranked their satisfaction with their “ability to let go and ‘surrender’ to sexual pleasure during sex”; and 2) women's responses (from strongly disagree to strongly agree) to an item phrased “I feel I have control over whether I get pregnant.”
All analyses were conducted with SAS 9.4.24 Descriptive statistics came from means (standard deviations) and percentages. F-tests (for continuous variables) and Pearson χ2 tests (for categorical variables) compared baseline characteristics across contraceptive groups. To assess trends in sexual outcomes over time, mixed-effects models were fit for continuous outcomes with time trend, random intercept, and random slope across time—separately for each contraceptive method and then with all the method groups combined. Interaction effects between contraceptive methods and time trend tested whether methods differed in their effect. Perceived effect of contraceptive method on sex life over time was compared across time points through robust Wald χ2 tests and conditional logistic regression. Models were fit both with and without adjustment for self-reported health as a time-varying factor. Finally, we performed overall χ2 tests to document associations between perceived sexual changes (grouped as better, unchanged, and worse) and both vaginal bleeding and sexual disinhibition (ie, the “surrender” question and the control-over-pregnancy question).
The primary aim of this study was to assess three sexual outcome measures in three groups of LARC users. However, given its prominence in the sexual acceptability literature, we based the sample size calculation on the Female Sexual Function Index and informed this with the method mix from historical data at the participating sites (12% implant, 60% levonorgestrel IUD, and 28% copper T IUD). Based on prior research, we assumed baseline average Female Sexual Function Index total scores of 31 (standard deviation=5).25 We assumed the implant would lead to no change in Female Sexual Function Index and both IUDs would lead to a five-unit improvement in Female Sexual Function Index total score over 3 months. With 125 participants, we were powered at 90% at 5% significance to compare changes over time in total Female Sexual Function Index score among the three method groups—the equivalent of an effect size of 0.33. With an anticipated retention rate of 83%, we planned to recruit 150 participants (18 implant, 90 levonorgestrel IUD, and 48 copper T IUD).
RESULTS
A total of 195 women consented to participate in the study and had successful insertions. Of 195 enrollees, 159 original study participants (32 copper IUD users, 73 levonorgestrel users, and 54 contraceptive implant users) completed the 3-month follow-up, indicating a retention rate of 82% (Fig. 1). In the month before study enrollment, participants had used the following methods, either by themselves or in conjunction with other methods (not shown): 45% condoms (n=86 for male condoms, n=1 for female condom), 28% withdrawal (n=54), 19% oral contraceptives (n=36), 12% no method, 10% 3-month injection (n=20), 7% emergency contraception (n=14), 4% vaginal ring (n=8), 2% contraceptive patch (n=4), 3% fertility awareness methods (n=5), 1% spermicide (n=2), and 1% copper IUD.
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Fig. 1.: Participant flow diagram. IUD, intrauterine device.Higgins. New IUD and Implant Users' Sexual Outcomes. Obstet Gynecol 2016.
Table 1 displays baseline characteristics of participants by method selected. Participants had a mean age of 27 years, the majority were unmarried (80%, n=120) and had at least some college or vocational training (64%, n=97), and one third were women of color (23% [n=35] Hispanic nonwhite and 10% [n=15] non-Hispanic other). There were few significant sociodemographic differences between method groups save for age with contraceptive implant users slightly younger in years.
Table 1.: Participant Characteristics and Criteria for Choosing a New Contraceptive Method Selected by New-Start Contraceptive Users at Baseline by Method
Table 1-A.: Participant Characteristics and Criteria for Choosing a New Contraceptive Method Selected by New-Start Contraceptive Users at Baseline by Method
Table 1 also features information on method selection criteria. More than three fourths (76%, n=112) of women said method effectiveness is extremely important to them in choosing a method; just as many said it was extremely important that a method does not reduce libido (77%, n=109) and does not interrupt sex (73%, n=109). There were no significant differences across method groups. There were few differences in selection criteria by method group; although, as expected, women who selected the copper IUD were significantly more likely than the other two groups to say that “lack of hormones” was extremely important.
Table 2 shows the three primary sexuality measures by both method type and time period. Neither overall Female Sexual Function Index scores nor New Sexual Satisfaction Scale scores differed significantly between each of the three LARC groups at any time or between time periods. However, participants were significantly more likely to report perceived improvements to their sexual lives as a result of their contraceptive method (χ2P<.001). For example, at 1 month, 38% of women (n=60) indicated their new method had improved their sex life in the previous 4 weeks compared with 15% (n=24) reporting their method had made their sex life worse. By 3 months, 40% (n=64) of women reported positive changes and 17% (n=27) reported negative changes. Sexual outcomes showed few differences across the method groups.
Table 2.: Sexual Outcomes by Method Group Across Time
Table 2-A.: Sexual Outcomes by Method Group Across Time
The significance of women's perceived sexual improvements resulting from contraceptive method remained even after adjusting for all differences between individuals through conditional logistic regression (not shown in tables). This method compares individuals with themselves at different time points with respect to perceived effect of contraceptive method on sex life. Women remained significantly more likely to report positive changes at both 1 and 3 months with odds ratios of 4.64 (95% confidence interval [CI] 2.38–9.92) and 5.61 (95% CI 2.83–10.0), respectively.
To help explain reports of positive compared with negative method-related sexual changes, we performed χ2 tests between the measure of perceived sexual changes and the three secondary sexual outcomes: reports of vaginal bleeding changes, the surrender question of the New Sexual Satisfaction Scale, and the control-over-pregnancy variable (Table 3). Because there were few significant differences in sexuality outcomes by method, and to simplify data presentation, we combined the three contraceptive method groups into one for these analyses. All three variables were significantly associated with women's perceived sexual changes. For example, at 1 month, among those women who reported their method had made their sex life worse, the overwhelming majority (88%, n=21) reported increased vaginal bleeding compared with only 38% (n=23) of women reporting sexual improvements. In terms of sexual surrender, women reporting negative sexual changes resulting from their method in the previous month were significantly less likely to be satisfied with their ability to “let go” during sex. Finally, among women reporting positive sexual changes, a greater proportion reported the highest levels of perceived control over pregnancy.
Table 3.: Associations Between Perceived Sexual Changes Resulting From Method (Better, Unchanged, Worse) and Vaginal Bleeding, Sexual Surrender or Disinhibition, and Control Over Pregnancy by Time*
DISCUSSION
This study assessed 159 U.S. women's sexual experiences with IUDs and contraceptive implants while controlling for baseline sexuality factors. The overwhelming majority reported either no sexual changes or positive sexual changes after using a LARC method for 3 months. These findings align with European and Middle Eastern research showing sexual improvements in some women using IUDs.18,26–29 Although participants in the current study did not report significant changes in sexual functioning or satisfaction, more than half reported perceived sexual changes as a result of their method. Those few women who reported negative sexual changes were significantly more likely to have experienced increased vaginal bleeding.
Findings from this study expand how we define and measure the concept of contraception's sexual acceptability.20 The few contraceptive studies that have included any sexual measures tend to either use the Female Sexual Function Index15 or a single sexual functioning measure such as lack of interest in sex.13 However, such functioning measures were not designed for young, healthy, contraception-seeking women. They may also miss sexual domains such as psychologic factors, subjective perceptions, or sexual aspects of bleeding and cramping.17,20 In our study, sexual functioning and satisfaction did not change significantly with LARC use, whereas women's perceptions of their method's sexual effects did. Such perceptions are likely to influence contraceptive continuation. Moreover, we documented correlates of these perceived sexual improvements. For example, sexual improvements were strongly associated with the ability to “let go” in sex and one's sense of control over pregnancy prevention, suggesting that many women may be able to enjoy sexual activity more when the threat of pregnancy is reduced, a finding that corroborates qualitative research on the sexual acceptability of IUDs in the United States.17
A final important finding is that sexual-related criteria may influence women's selection of new contraceptive methods more than previously examined. Proportionally as many participants in this study valued efficacy as they did methods that neither reduce libido nor interrupt sex. These findings align with recent research by Gomez and Clark,21 who found that the most frequently selected contraceptive feature by potential IUD users was “does not interfere with the pleasure of sex,” thereby trumping features such as effectiveness. Sexual criteria should be better integrated into contraceptive counseling protocols and decision support tools.
Findings should be interpreted in light of study limitations. First and foremost, our study included LARC methods only and no control group. We therefore cannot determine whether LARC users are sexually or psychologically different compared with women who select hormonal methods or barrier methods nor whether LARC users have better sexual outcomes. Future studies should include a broader array of contraceptive methods, including condom-only users or another type of nonhormonal comparison group.
Secondary limitation are as follows. Our sexual measure regarding perceived sexual changes resulting from method only had three possible response categories (no change, better, or worse); a greater number of responses or a continuous scale may have picked up more nuance. Participants may have been using contraceptive method(s) in the month before the study that could have affected their sexual measures at baseline and over the course of the study. However, we used the study methodology described here as a result of its practicality and feasibility; moreover, a group of participants who have used no contraceptive method(s) in the month before the study would be sexually select compared with a more average contraceptive-seeking population. In addition, the clinical setting of this study offered a realistic compared with a laboratory environment, but one cost of this setting was the inability to collect data on all eligible participants who declined enrollment. Finally, because clinical assistants highlighted the sexual aspects of the study when enrolling potential participants, our sample may be select—that is, they may represent patients who care more about sexuality than the average contraceptive user. On the other hand, we argue that sexuality is of interest to most if not all women seeking contraception, a finding upheld in other studies.21
Study findings suggest at least two clinical implications. First, practitioners may wish to reassure patients that they are unlikely to experience declines in sexual function or satisfaction as a result of their LARC method. Moreover, they may wish to inform contraceptive users about the potentially sexual-enhancing aspects of LARC methods—that is, that a greater proportion of LARC users will perceive positive compared with negative sexual effects as a result of their method, and the overwhelming majority will experience either no sexual change or a positive sexual change. This information may improve LARC method uptake and satisfaction with potential positive public health benefits. Second, patients deserve upfront education and reassurances about the management of increased bleeding and cramping. The few women in this study reporting negative sexual changes were also likely to report increased vaginal bleeding—an effect that will typically improve for levonorgestrel IUD users and may be ameliorated for copper IUD users and contraceptive implant users.30
REFERENCES
1. Philpott A, Knerr W, Maher D. Promoting protection and pleasure: amplifying the effectiveness of barriers against sexually transmitted infections and pregnancy. Lancet 2006;368:2028–31.
2. Higgins JA, Hirsch JS. The pleasure deficit: revisiting the “sexuality connection” in reproductive health. Perspect Sex Reprod Health 2007;39:240–7.
3. Severy LJ, Newcomer S. Critical issues in contraceptive and STI acceptability research. J Social Issues 2005;61:45–65.
4. Hensel DJ, Stupiansky NW, Herbenick D, Dodge B, Reece M. Sexual pleasure during condom-protected vaginal sex among heterosexual men. J Sex Med 2012;9:1272–6.
5. Randolph ME, Pinkerton SD, Bogart LM, Cecil H, Abramson PR. Sexual pleasure and condom use. Arch Sex Behav 2007;36:844–8.
6. Hormonal contraception for men: acceptability and effects on sexuality. World Health Organization Task Force on Psychosocial Research in Family Planning, Special Programme of Research, Development and Research Training in Human Reproduction. Stud Fam Plann 1982;13:328–42.
7. Higgins JA, Hirsch JS. Pleasure and power: incorporating sexuality and inequality into research on contraceptive use and unintended pregnancy. Am J Public Health 2008;98:1803–13.
8. Smith NK, Jozkowski KN, Sanders SA. Hormonal contraception and female pain, orgasm and sexual pleasure. J Sex Med 2013;11:462–70.
9. Higgins JA, Davis AR. Contraceptive sex acceptability: a commentary, synopsis and agenda for future research. Contraception 2014;90:4–10.
10. Sanders SA, Graham CA, Bass JL, Bancroft J. A prospective study of the effects of oral contraceptives on sexuality and well-being and their relationship to discontinuation. Contraception 2001;64:51–8.
11. Trussell J. Contraceptive failure in the United States. Contraception 2011;83:397–404.
12. Daniels K, Daugherty J, Jones J. Current contraceptive status among women aged 15–44: United States, 2011–2013. Hyattsville (MD): National Council for Health Statistics; 2014.
13. Boozalis A, Tutlam NT, Chrisman Robbins C, Peipert JF. Sexual desire and hormonal contraception. Obstet Gynecol 2016;127:563–72.
14. Davis AR, Castaño PM. Oral contraceptives and libido in women. Annu Rev Sex Res 2004;15:297–320.
15. Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R, et al. The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther 2000;26:191–208.
16. Higgins JA, Hoffman S, Graham CA, Sanders SA. Relationships between condoms, hormonal methods, and sexual pleasure and satisfaction: an exploratory analysis from the Women's Well-Being and Sexuality Study. Sex Health 2008;5:321–30.
17. Higgins JA, Ryder K, Skarda G, Koepsel E, Bennett EA. The sexual acceptability of intrauterine contraception: a qualitative study of young adult women. Perspect Sex Reprod Health 2015;47:115–22.
18. Sanders JN, Smith NK, Higgins JA. The intimate link: a systematic review of highly effective reversible contraception and women's sexual experience. Clin Obstet Gynecol 2014;57:777–89.
19. Primack BA. The WHO-5 Wellbeing Index performed the best in screening for depression in primary care. ACP J Club 2003;139:48.
20. Higgins JA, Smith NK. The sexual acceptability of contraception: reviewing the literature and building a new concept. J Sex Res 2016;53:417–56.
21. Gomez AM, Clark JB. The relationship between contraceptive features preferred by young women and interest in IUDs: an exploratory analysis. Perspect Sex Reprod Health 2014;46:157–63.
22. Isidori AM, Pozza C, Esposito K, Giugliano D, Morano S, Vignozzi L, et al. Development and validation of a 6-item version of the female sexual function index (FSFI) as a diagnostic tool for female sexual dysfunction. J Sex Med 2010;7:1139–46.
23. Stulhofer A, Busko V, Brouillard P. Development and bicultural validation of the new sexual satisfaction scale. J Sex Res 2010;47:257–68.
24. SAS software. Base SAS 9.4 procedures guide. Cary (NC): SAS Institute, Inc; 2015.
25. Wiegel M, Meston C, Rosen R. The female sexual function index (FSFI): cross-validation and development of clinical cutoff scores. J Sex Marital Ther 2005;31:1–20.
26. Oddens BJ. Women's satisfaction with birth control: a population survey of physical and psychological effects of oral contraceptives, intrauterine devices, condoms, natural family planning, and sterilization among 1466 women. Contraception 1999;59:277–86.
27. Skrzypulec V, Drosdzol A. Evaluation of quality of life and sexual functioning of women using levonorgestrel-releasing intrauterine contraceptive system–Mirena. Coll Antropol 2008;32:1059–68.
28. Gorgen H, Api M, Akça A, Cetin A. Use of the Levonorgestrel-IUS in the treatment of menorrhagia: assessment of quality of life in Turkish users. Arch Gynecol Obstet 2009;279:835–40.
29. Enzlin P, Weyers S, Janssens D, Poppe W, Eelen C, Pazmany E, et al. Sexual functioning in women using levonorgestrel-releasing intrauterine systems as compared to copper intrauterine devices. J Sex Med 2012;9:1065–73.
30. Centers for Disease Control and Prevention. US selected practice recommendations for contraceptive use, 2013. MMWR (Vol. 62, No. 5). Atlanta (GA): CDC; 2013.
