Determinants of sexual and reproductive behaviour
R.H.W. van Lunsen, L.P. van Dalen
Department of Sexology & Psychosomatic Ob/Gyn, Academic Medical Centre, University of Amsterdam, The Netherlands
Sexuality and procreation in western societies have become more and more dissociated. Whereas in traditional Christian normative beliefs sexuality only existed in service of procreation it is estimated that approximately 95% of all human sexual encounters take place because of hedonistic motives while reproductive consequences would be an unwanted result of these sexual acts. The longer the period of sexual activity preceding family building is and the later attempts to conceive start, the lower are chances to conceive spontaneously in due course when a pregnancy is desired and the higher will be the need for assisted reproduction. Moreover sexually transmitted diseases that might be the result of hedonistic sexual activity endanger future fertility.
Determinants that on an individual level predict wether or not a women will be able to protect herself against unwanted pregnancy and STD and will preserve her fertilty as well as determinants that make her decide to discontinue contraception because of childwish are both of an intrinsic and extrinsic nature.
Choices with regard to contraception, STD prevention and reproduction however often are seen as unidimensional processes within the individual. In the most commonly used models such as the theory of planned behaviour (Ajzen) and the health belief model (Becker) subjective norms and values of the individual are used to predict whether or not a preventive method will be used.
These models however only give an indication of the intention of the individual to use a preventive method leaving out contextual factors like communication with the partner and situational factors - like for instance the use of alcohol - that are in between intended and actual sexual behaviour. It are mainly these factors that for instance explain discordances between knowledge about contraception and STD prevention of teenagers, their intended behaviour and the fact that unwantend pregnancies and STD transmission do occur more often than expected.
At least two extrinsic factors, other than the intrinsic subjective wishes,norms and values of the individual, are of great importance in predicting preventive and reproductive behaviour:
Interactional factors. When the partner is not effectively involved in the the decision making process this can lead to discontinuation or improper use of a chosen preventive method. A method that is more the choice of the prescriber than of the user will be used less successfully.
Situational influences. If a method is to expensive or not easily accessible, someone will have to resort to other means of prevention that may not be as suitable as the method he or she would have chosen if it were available.
Negative publicity resulting in distorted health beliefs may also cause someone to decide not to use a method that in the given situation would be the most suitable.
A lack of social possibilities to combine career and raising of a family might lead to postponement of reproduction to an age that diminishes reproductive chances.
The choice of oral contraceptives for instance is greatly influenced by the individuals subjective ideas on health related risks, whereas condom use has more interactional aspects.
The actual quality of preventive behaviour (compliance) depends on the number and severity of concerns about the chosen method. The more concerns, the more ambivalence and the more ambivalence, the more user failures and/or discontinuations. Data from an ongoing research project will be used to illustrate the complexity of factors influencing sexual ad reproductive health. Recommendations for innovative counseling strategies will be presented.