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ORIGINAL RESEARCH—EPIDEMIOLOGY Age, Quality, and Context of First Sex: Associations With Sexual Difficulties Charlene M. Rapsey, PhD, PGDipClPsy Department of Psychological Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand DOI: 10.1111/jsm.12690
ABSTRACT
Introduction. Research consistently indicates an association between a younger age at first sex and poorer sexual health outcomes. However, research addressing associations between age at first sex and sexual difficulties has produced mixed findings. Moreover, little is known about links between the context and quality of first sex and subsequent sexual difficulties. Aims. The aims of this study are to examine whether (i) age and (ii) context and quality at first sex are associated with sexual difficulties; (iii) examine whether age at first sex and context and quality variables are independently associated (after mutual adjustment) with sexual difficulties; and (iv) examine whether age at first sex has an indirect effect on sexual difficulties through an effect on context or quality. Methods. Data from 388 questionnaires were gathered from students aged 17–21 living in accommodation halls and by postal invitation to adults aged 25–35. Main Outcome Measures. The main outcome measure was the Golombok–Rust Inventory of Sexual Satisfaction (GRISS), which assesses sexual difficulties via an overall score and seven subscales. Results. Appraising first sex as emotionally negative was associated with the majority of sexual difficulties. A less stable relationship at first sex was associated with sexual communication problems and dissatisfaction. Greater enjoyment and using substances were associated with a lower likelihood of anorgasmia for women. Age at first sex was directly associated with reduced sexual frequency only. A younger age at first sex was associated with a greater likelihood of negative appraisal and lower likelihood of a stable relationship and thereby indirectly associated with several sexual difficulties. Conclusions. Experiencing first sex as emotionally negative was consistently associated with later sexual difficulties. When attending to sexual difficulties, understanding the quality and context of first sex may be more useful than knowing the age at first sex. This research is limited by the retrospective nature of the reports of first sex. Rapsey C. Age, quality, and context of first sex: Associations with sexual difficulties. J Sex Med 2014;11:2873–2881. Key Words. Sexual Difficulties; Sexual Function; Age at First Sex; Sexual Debut; Context of First Sex
Introduction
M
ore is known about the significance of age than about any other factors in association with first sex [1]. A young age at first sex has been associated with a number of adverse outcomes, including increased risk of unwanted pregnancy, increased risk of sexually transmitted infection, health risk behaviours such as alcohol and drug use [2], a greater likelihood that sex will be regretted © 2014 International Society for Sexual Medicine
[3–5], and decreased sexual satisfaction at the time of first sex [6]. Evidence for an association between age at first sex and later sexual difficulties, however, has been mixed. Specifically, in two studies with university students (mean age 21 years), a younger age at first sex was associated with fewer sexual difficulties [7,8]. These studies were limited by the narrow age range of participants. It may be that the association between an older age at first sex and a greater J Sex Med 2014;11:2873–2881
2874 likelihood of currently experiencing sexual difficulties can be explained by the short time period between first sex and current sex and thus a relative lack of sexual experience of the older-age initiators. In another study with a wider age range of participants that controlled for the effects of age at time of study, Sandfort et al. [9] investigated the effects of a younger- or older-than-normative age at first sex. For men, late and early first sex were associated with an increased risk of arousal problems, erectile difficulties, and orgasm problems, whereas for women an older age at first sex was associated with a reduced risk of sexual arousal difficulties. In contrast, Else-Quest et al. [10], using nationally representative data from the United States, found no evidence for an association between early or late age at first sex and sexual difficulties for men or women. Although Else-Quest et al. [10] found no association between age at first sex and current sexual difficulties, they provided evidence for an association between a negative context at first sex and sexual difficulties. A negative context was defined as sex that was forced, with a relative, with someone who paid, or primarily motivated by peer pressure or substance use; a history of sexual abuse; or, for women, sex with someone they knew but not well. Else-Quest et al.’s findings contribute to a strong literature connecting coerced sex with poor outcomes [11,12]. However, less is known about the other elements of context at first sex that were included in their composite measure of a negative context. In another study, university-age participants who reported a negative subjective evaluation of first sex, that is, stronger negative emotions and weaker positive emotions, were more likely to report current difficulties [8]. Further, Mercer et al. [13], using nationally representative data from a large UK sample, found that sexual competence at first sex (defined as using hormonal or barrier contraception, not using alcohol, being willing, and engaging in sex for autonomous reasons such as love rather than because of peer pressure) predicted a lower likelihood of experiencing later sexual difficulties. Thus, there is evidence that subjective evaluation and context of first sex can have implications for later sexual experience. In sum, it is not clear whether age at first sex is associated with a greater or lesser likelihood of sexual difficulties, which specific elements of the context of first sex are associated with later sexual difficulties, and whether age at first sex influences J Sex Med 2014;11:2873–2881
Rapsey context and subjective evaluation of first sex. Understanding these elements may better inform our understanding of the development of sexual difficulties. Investigation of the quality and context of first sex allows for more information regarding the mechanisms or processes that may link first sex with later sexual experience. Thus the current study investigates associations between sexual difficulties and age at first sex, context at first sex, and appraisal of first sex.
Aims This study aimed to examine (i) whether age at first sex is associated with sexual difficulties, (ii) whether any of a series of context variables are associated with sexual difficulties, (iii) whether any of a series of context variables are independently associated (after mutual adjustment) with sexual difficulties, and (iv) indirect pathways between age at first sex, each context variable, and sexual difficulties. Methods
The University of Otago Ethics Committee granted approval for the research. Data were collected from late-adolescent students aged 17–21 years and adults aged 25–35 years. Late-adolescent participants were recruited from accommodation halls for students enrolled at university, polytechnic (an institution offering tertiary-degree and below-degree certification), or a teacher training school in a single New Zealand city. Participants aged 25–35 years were randomly selected from the electoral roll to ensure selection of participants from a developmental period following emergent adulthood/late adolescence. Late-adolescent participants provided written consent before being given a questionnaire to complete in supervised study rooms at their accommodation hall. Three female researchers were available to assist if needed. Participants were informed that their answers were confidential, and no identifying information was collected. Surveys were returned in a plain envelope to a closed box. Compensation was with a movie or phone voucher to the value of NZ$10.00. At one hall, students also entered into a draw to win an MP3 player. Participation was on an opt-in basis, with a maximum of 250 students being able to participate; representation of the participating halls ranged from 19–53%. To recruit adult participants, invitations to complete a self-report questionnaire via the internet or
First Sex and Later Sexual Difficulties hard copy were posted to 660 addresses, and 179 replies were received. Three reminder letters were sent along with a postage-paid envelope for participants to return their questionnaires. Participants were informed that completion of the questionnaire implied consent and that all responses were anonymous.
Dependent Variable Current Sexual Difficulties The Golombok–Rust Inventory of Sexual Satisfaction (GRISS) [14] was used to assess current sexual difficulties. In this way, direct comparison with an earlier study addressing age at first sex and sexual difficulties using the GRISS [7] was made possible. The GRISS has a male and a female version, each with 28 items. A main overall score is calculated along with seven subscales assessing frequency of sexual activity (infrequency), dissatisfaction with one’s sex life (dissatisfaction), extent of communication about sex (noncommunication), extent of nongenital physical contact (nonsensuality), avoidance of sexual intimacy (avoidance), male difficulties (early ejaculation, erectile difficulties), and female difficulties (anorgasmia, vaginismus). The original scale was adapted slightly to be more acceptable to individuals of all sexual orientations. Participants responded to items using a five-point scale. Following reverse scoring of some items, subscale and overall scores were summed and then transformed to fit a standardized scale ranging from 1 to 9 [14]. Independent Variables Negative Emotional Appraisal of First Sex Seven items from the First Coital Affective Reaction Scale (FCARS) [15] assessed degree of negative emotional response to first sex. The scale consisted of seven adjectives (e.g., confused, embarrassed, anxious). Scores ranged from 7 to 49, measured using a Likert scale ranging from 1 (not experiencing the feeling) to 7 (strongly experiencing the feeling). Good internal consistency was demonstrated, with Cronbach’s alpha coefficient of 0.85. Enjoyment at First Sex Four items from the FCARS [15] and two global indicators were used to assess sexual enjoyment. FCARS items were adjectives describing responses to first sex (e.g., satisfied and pleasurable) measured using a 7-point scale. The two global indicator questions were “How satisfied were you with your sexual relationship with your partner? and “How
2875 satisfied were you with the amount of emotional closeness during sex with your partner?” Participants reported their experience on a Likert scale from 1 (very dissatisfied) to 5 (very satisfied). A higher score indicated higher enjoyment (α = 0.89).
Age at First Sex Participants indicated on a timeline how old they were the first time they had vaginal or anal sex. Substance Use Substance use at first sex was assessed by asking “The first time you had sex, had you been drinking or using drugs?” Responses included “no” (0), “a little” (1), and “a lot” (2). Relationship Status To assess relationship status, participants were asked about their relationship status at the time of first sex. Responses included “We had just met” (0), “We had met recently” (1), “We had known each other for a while but did not have a steady relationship at the time” (2), “We had a steady relationship” (3), “We were engaged” (4), and “We were married/civil union” (5). Mood An 11-item version of the Center for Epidemiological Studies Depression Scale (CES-D) [16] was used to assess symptoms of depression. Participants were asked to respond to the questions with reference to their past week using a scale with the following options: 0, never/rarely (less than 1 day); 1, sometimes (1–2 days); 2, occasionally (3–4 days); 3, mostly/always (5–7 days). Items focused on feelings of low mood, including feelings of sadness, depression, and “the blues”; tiredness; fear; loneliness; difficulty concentrating; and poor appetite. The 11-item version has shown good internal consistency in previous studies [17,18]. Statistical Analysis First, a series of univariate linear regression models were constructed examining the association between each independent variable (entered one at a time) and the overall GRISS score, controlling for current age and gender. The independent variables in these models were age at first sex and each of the context variables for first sex (negative emotional appraisal, enjoyment, substance use, and relationship status). Second, the quadratic term for age at first sex was included in all models to test for a linear association. J Sex Med 2014;11:2873–2881
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Third, an interaction term, gender × independent variable, was included in each of the models, testing for any variation in associations by gender. Fourth, multivariate regression models were tested that included age at first sex and all of the context variables. The multivariate models were run with the overall GRISS score and the subscales of the GRISS (e.g., infrequency, dissatisfaction, noncommunication, avoidance) as the dependent variables while controlling for current age and gender. Fifth, pathway analysis was conducted to investigate direct and indirect effects of age at first sex on context variables and sexual difficulties. Analyses were performed using Stata Version 11.2 [19] and IBM SPSS Amos 21 [20], with twosided P < 0.05 considered statistically significant. Results
Among the late-adolescent participants, 209 reported having had sex (116 females, 93 males). All 179 adult participants reported having had sex (103 females, 76 males). As can be seen in Table 1, in the adult sample, 85.3% had gained a qualification from a tertiary education; the majority of participants (92.5%) identified as being Pa¯keha¯ (New
Table 1
Demographic details of participants, % (n)
Gender Male Female Ethnicity† New Zealand European New Zealand Maori Asian Other Age 17–19 20–24 25–29 30–35 Sexual orientation Heterosexual Gay/lesbian Bisexual Other Highest academic qualification (adults only) Secondary school Bachelor’s Postgraduate Diploma/trade certificate Overseas qualification Tertiary institution (students only) University Teacher’s college Polytechnic †Values
43.6 (169) 56.4 (219) 92.5 (334) 2.8 (11) 2.2 (8) 4.5 (17) 53.0 (195) 2.7 (10) 16.6 (61) 27.7 (102) 96.5 (357) 1.4 (5) 1.6 (6) 0.5 (2) 14.6 (26) 38.8 (61) 28.2 (44) 16.9 (27) 2.4 (2) 67.9 (142) 23.4 (49) 8.6 (18)
do not add to 100 as some individuals reported more than one
ethnicity
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Zealand European) and labelled themselves as heterosexual (96.5%). There were no participants aged 22 or 24 years of age; however, two participants responding to the adult postal survey reported that they were 23 years of age. Mean age at first sex was 16.95 (SD = 2.52) with a range from 12 to 28 years.
Univariate Linear Regression Models Univariate linear regression models controlling for gender and current age indicated negative emotional appraisal of first sex was associated with high overall GRISS score (P < 0.001), infrequency (P = 0.030), dissatisfaction (P = 0.012), avoidance (P < 0.001), nonsensuality (P = 0.002), vaginismus (P = 0.023), erectile difficulties (P = 0.004), and early ejaculation (P = 0.038). A less committed relationship status was associated with higher scores on the infrequency (P = 0.038), dissatisfaction (P = 0.009), and noncommunication (P = 0.002) subscales. Lower enjoyment at first sex was associated with a higher overall GRISS score (P = 0.028). No evidence was found for an association between any of the GRISS scales and age at first sex or substance use at first sex. Quadratic Term for Age at First Sex There was no evidence that the quadratic term for age at first sex was significant in any of the models; therefore a linear association was assumed, and age at first sex was included in subsequent analyses as a continuous variable. Interactions With Gender Interactions with gender were not significant in any of the models tested, so data for males and females were analyzed together. Multivariate Linear Regression Models Multivariate linear regression models were tested relating the GRISS overall and domain scores as the outcome variables to all of the independent variables, adjusting for current age and gender. As in the univariate analysis, negative emotional appraisal was associated with a higher score on the majority of the GRISS domains, the exception being early ejaculation, which was not more significantly associated with negative emotional appraisal than with the other independent variables. Likewise, relationship status remained associated with several of the GRISS domains, with the exception of the infrequency. Enjoyment at first sex, although showing a significant association with the overall score in the univariate analysis,
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First Sex and Later Sexual Difficulties was no longer particularly significantly associated with any of the other variables. Some variables without evidence for an association with any of the independent variables in the univariate analysis showed evidence of an association in the multivariate analysis. Specifically, holding the other context variables constant, lower enjoyment and greater substance use at first sex were associated with anorgasmia. Thus, if the effect of enjoyment at first sex is controlled for, then substance use is associated with less risk of anorgasmia. In addition, an older age at first sex was associated with greater infrequency of sexual intercourse when the other variables were held constant.
Adjustment for Depression Due to the link between a negative emotional appraisal of first sex and current sexual difficulties, the CES-D [16,21] was added to the models to test whether current depression could explain this association. That is, current depression may increase the likelihood of a negative emotional appraisal of sexual experience now and in the past. As displayed in Table 2, in all models except one, a negative emotional appraisal of first sex remained significantly associated with the outcome variable (overall GRISS score, infrequency, avoidance, nonsensuality, vaginismus, or erectile difficulties) after adjustment for current depression, with the exception of dissatisfaction. Pathway Analysis for Indirect Effects Pathway analysis was conducted to determine whether age at first sex had an indirect effect on sexual difficulties. Direct effects were observed for an older age at first sex with regard to less negative emotional appraisal (β = −0.490, P = 0.003), a more committed relationship status (β = 0.113, P < 0.001), and greater enjoyment (β = 0.314, P = 0.035). Following from these direct effects, older age at first sex had an indirect effect of lower scores on the infrequency, dissatisfaction, and nonsensuality scales and the overall score. Specifically, an older age at first sex reduced the severity of infrequency (β = −0.040, P = 0.004) and dissatisfaction (β = −0.029, P = 0.003) through an effect on relationship status and negative appraisal (Figure 1). An older age at first sex reduced the overall GRISS score (β = −0.033, P = 0.006) and nonsensuality score (β = −0.031, P = 0.019) through an effect on negative appraisal (Figure 2). Finally, an older age at first sex lowered the likelihood of noncommunication difficulties
Table 2 Age at first sex and context variables regressed on GRISS overall and subscales, controlling for age, gender and depression status GRISS domain Overall score (n = 328) Age at first sex Negative appraisal Enjoy Substance use Relationship status Infrequency (n = 331) Age at first sex Negative appraisal Enjoy Substance use Relationship status Dissatisfaction (n = 329) Age at first sex Negative appraisal Enjoy Substance use Relationship status Noncommunication (n = 333) Age at first sex Negative appraisal Enjoy Substance use Relationship status Avoidance (n = 326) Age at first sex Negative appraisal Enjoy Substance Use Relationship status Nonsensuality (n = 313) Age at first sex Negative appraisal Enjoy Substance use Relationship status Anorgasmia (n = 186) Age at first sex Negative appraisal Enjoy Substance use Relationship status Vaginismus (n = 185) Age at first sex Negative appraisal Enjoy Substance use Relationship status Erectile difficulties (n = 144) Age at first sex Negative appraisal Enjoy Substance use Relationship status Early ejaculation (n = 145) Age at first sex Negative appraisal Enjoy Substance use Relationship status
B
SE
t
P
0.04 0.04 −0.01 −0.01 −0.06
0.05 0.01 0.02 0.13 0.10
0.72 2.64 −0.60 −0.10 −0.65
0.473 0.009 0.549 0.923 0.515
0.18 0.02 −0.00 0.01 −0.19
0.05 0.02 0.02 0.14 0.11
3.28 1.54 −0.24 0.05 −1.79
0.001 0.125 0.812 0.962 0.075
0.08 0.02 −0.01 −0.03 −0.18
0.04 0.01 0.01 0.11 0.08
1.92 1.42 −0.39 −0.27 −2.31
0.056 0.158 0.696 0.784 0.021
0.09 −0.01 −0.01 0.05 −0.24
0.05 0.01 0.02 0.13 0.09
1.91 −0.71 −0.91 0.43 −2.60
0.056 0.476 0.366 0.669 0.010
0.00 0.05 0.02 0.21 0.14
0.05 0.01 0.02 0.13 0.10
0.09 3.85 1.13 1.60 1.52
0.928 0.000 0.258 0.110 0.130
−0.04 0.04 −0.00 −0.00 −0.08
0.06 0.02 0.02 0.15 0.11
−0.66 2.23 −0.24 −0.02 −0.72
0.511 0.027 0.808 0.983 0.471
−0.02 −0.00 −0.05 −0.44 0.02
0.07 0.02 0.02 0.18 0.14
−0.27 −0.07 −2.26 −2.43 0.12
0.786 0.944 0.025 0.016 0.901
0.05 0.04 0.04 −0.10 −0.07
0.07 0.02 0.02 0.18 0.13
0.67 2.39 1.78 −0.57 −0.50
0.504 0.018 0.077 0.571 0.621
0.04 0.06 0.03 −0.07 −0.09
0.06 0.02 0.02 0.17 0.12
0.70 2.62 1.10 −0.42 −0.75
0.485 0.010 0.275 0.676 0.457
−0.08 0.03 −0.01 0.31 0.13
0.07 0.02 0.03 0.18 0.13
−1.14 1.29 −0.31 1.70 1.02
0.258 0.198 0.758 0.091 0.311
GRISS = Golombok–Rust Inventory of Sexual Satisfaction
J Sex Med 2014;11:2873–2881
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Rapsey Alcohol
-0.49** Age at First Sex
NegaƟve Appraisal
0.02** DissaƟsfacƟon
0.31* Enjoyment -0.20**
0.11** RelaƟonship
(β = −0.034, P = 0.010) through an effect on relationship status (Figure 3). Discussion
Overall, our findings suggest that age at first sex was not directly associated with sexual difficulties; rather, the emotional quality of first sex was more relevant. For several sexual difficulties, age at first sex was important to the degree that it was associated with the context and quality of first sex. Specifically, a negative emotional appraisal of first sex was associated with a number of current sexual difficulties, and a negative appraisal was less likely if individuals were older when they first had sex. In addition to a negative emotional appraisal of first sex, a less committed relationship at first
Figure 1 Model of pathway analysis showing nonstandardized direct and indirect effects of age at first sex and context and quality of first sex on the dissatisfaction scale of the Golombok– Rust Inventory of Sexual Satisfaction. Dashed line = P not significant; *P < 0.05; **P < 0.01.
sex was associated with later dissatisfaction and noncommunication, and again, participants were more likely to have had first sex within a committed relationship when they were older at first sex. Age at first sex was not directly associated with any sexual difficulties except sexual infrequency, whereby those who first had sex when they were older were more likely to report high sexual infrequency. The findings of this study contribute to a mixed literature on the role of age of first sex and sexual difficulties. The results are consistent in one aspect with those of Woo and Brotto [7], who found that an older age at first sex was associated with a greater likelihood of infrequent sex; however, consistent with Else-Quest et al. [10], we did not find evidence that an older age at first sex was a risk
Alcohol
-0.49** Age at First Sex
-0.03 NegaƟve Appraisal GRISS Overall Score
-0.31* Enjoyment 0.11** RelaƟonship
Figure 2 Model of pathway analysis showing nonstandardized direct and indirect effects of age at first sex and context and quality of first sex on overall score on the Golombok–Rust Inventory of Sexual Satisfaction (GRISS). Dashed line = P not significant; *P < 0.05; **P < 0.01.
Alcohol
-0.49** NegaƟve Appraisal Age at First Sex
NoncommunicaƟon
0.31* Enjoyment 0.11**
-0.03 RelaƟonship
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Figure 3 Model of pathway analysis showing nonstandardized direct and indirect effects of age at first sex and context and quality of first sex on the noncommunication scale of the Golombok–Rust Inventory of Sexual Satisfaction. Dashed line = P not significant; *P < 0.05; **P < 0.01.
First Sex and Later Sexual Difficulties factor for any other sexual difficulties. Extending Else-Quest et al.’s findings of the influence of a negative context (forced sex, incest, sex work, peer pressure, substance use, history of sexual abuse, and, for women, weak relationship status), we are able to comment on the particular elements of the context at first sex that are associated with reports of sexual difficulties; that is, weak relationship status at first sex was associated with sexual difficulties, but substance use was not. In fact, we found evidence suggesting that substance use may be associated with a lower likelihood of anorgasmia in a particular context, that is, when adjustment is made for sexual enjoyment. Further, we found that the relationship context was as important for men as for women, which has not previously been investigated. Sandfort et al. [9] reported early and late first sex to be risk factors for sexual difficulties, particularly for men, whereas we found no direct or indirect effects of age at first sex on gender-specific difficulties (i.e., anorgasmia, vaginismus, early ejaculation, erectile dysfunction). Possible associations between first sex and later sexual experience may be explained by several mechanisms. It may be that there is a direct relationship whereby low enjoyment at first sex indicates the presence of sexual difficulties, and those sexual difficulties persist. For example, Landry and Bergeron [22] found a high prevalence of primary, chronic dyspareunia in their large adolescent sample; it is likely that without treatment, such difficulties contribute to immediate and long-term suffering. In particular, the finding that lower sexual enjoyment at first sex was associated with anorgasmia for women may be consistent with this theory. Another explanation is that a negative experience at first sex is associated with later sexual difficulties due to a common third factor. For example, a depressive disorder present during first sex and also present during subsequent sexual relationships would increase the likelihood of sexual dissatisfaction at each time period. In this study, current depression status did not account for associations between a negative emotional appraisal and sexual difficulties, and thus it is unlikely that depression status explains this association. It is also unlikely that depressions status was a confounding factor affecting recall of past sex or perception of current difficulties. Similarly, quality of first sex and quality of later sexual experience may be connected through a common factor such as attachment style, which is
2879 also associated with timing of first sex. That is, those with a more secure attachment style may be more likely to have sex when they are in an established relationship, which is more likely when they are older, and a secure attachment style may reduce the likelihood of sexual difficulties [23,24]. The finding that a more committed relationship status at first sex was associated with an older age at first sex and with fewer noncommunication difficulties appears to lend support to this theory, particularly as communication difficulties may reflect relationship processes. Thus, participants who initially have sex in less intimate relationships may continue to have sex in less intimate relationships, in which communication and sexual satisfaction are compromised. In addition, sexual self-schema theory predicts that the context of first sex contributes to consequent sexual experience in a formative manner [25,26]. Thus, a negative appraisal of first sex or lack of enjoyment may lead to negative expectations and assumptions about subsequent sexual relationships, which reduces the likelihood of experiencing more positive sexual relationships. Finally, timing of sexual experience may interact with the context of first sexual experience; for example, first sexual experience in young adulthood may take place in a context of greater emotional, relational, and cognitive skills than first sexual experience in early adolescence [23]. The finding that substance use at first sex was associated with a lower likelihood of anorgasmia when adjusting for context and quality of first sex was surprising. Alcohol use has been associated with lower pleasure at first sex [27], which was also found in the current study (results available on request). Alcohol use at first sex has also been associated with sexual risk taking and with nonconsensual sex [28]. More generally, there is some evidence that alcohol reduces objective arousal but increases subjective arousal [29]. Taking into account the extant research linking alcohol and sexual experience, we could speculate that once the potential negative associations between substance and first sex are accounted for, then, in some contexts for some people, substance use is not problematic and in fact marks a positive trajectory of sexual enjoyment for women.
Limitations The findings from this study must be understood in the context of several limitations. A crosssectional design cannot show causal relations. The study relied on retrospective report; perspectives J Sex Med 2014;11:2873–2881
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of first sex will be affected by memory and confounded by preceding sexual experiences. An adult age group was chosen to allow for the accrual of sexual experience that typically occurs with time; however, adults are likely to have more poorly recollected first sex. It may have been valuable to have included a greater number of participants in the 21–24 age group, as this age group may have had clear memories of first sex as well as accrued sexual experience. Memory errors could be expected to weaken actual associations between first sex and current experience, and thus our findings could be seen to be conservative. In addition, it may be that participants who are currently experiencing sexual difficulties are more inclined to remember previous sexual experiences negatively, generating the opposite of the “rosecolored glasses” effect. Current mood did not seem to account for the association between a negative emotional appraisal at first sex and current sexual difficulties; however, there may be other confounding variables that do explain the relationship. This study only controlled for a limited number of potential confounding variables, and thus the potential for residual confounding remains. In addition, first sex may not be the most reliable sample incident for assessing the quality of emergent sexuality. It may also be informative to assess the quality and context of a wider range of sexual experience. Moreover, qualitative research would allow for the voices of young people themselves to be heard. Such research may allow for the development of more appropriate measures of the quality of emergent sexuality. Sexuality and relationship constructs are culturally bound. The findings of this study may not generalize to other countries or cultures where different values and meanings are associated with sexuality and intimacy. Further, the participants in this study do not comprise a representative sample. Participants were predominantly Pa¯keha¯ (New Zealand European) and were either enrolled in tertiary education or had completed tertiary education. It may be that the participants who opted to take part in this study were different from those who did not opt to take part. Thus, associations between variables may differ between different groups even within a New Zealand context.
In particular, a negative emotional response to first sex was associated with several different types of sexual problem. This is relevant information for clinicians who routinely ask about an individual’s or couple’s sexual history. Future research should use a longitudinal methodology to aid understanding of the trajectory of sexual difficulties across time and different relationships. To improve strategies for intervention, it will be valuable to understand trajectories of sexual experience and the mechanisms linking first sex with subsequent sexual experiences.
Conclusions
References
This study provides evidence that experiences at first sex are associated with later sexual experience. J Sex Med 2014;11:2873–2881
Acknowledgments
The late Associate Professor Oliver Davidson, the late Dr. Tamar Murachver, Dr. Elizabeth Schaughency, Amy Smith, Katie Ryan, Andrew Gray, Associate Professor Kate Scott, and Dr. Nic Swain are thanked for their contribution to this research. This research was supported by scholarships from the University of Otago and the Dunedin School of Medicine, University of Otago. Corresponding Author: Charlene M. Rapsey, PhD, PGDipClPsy, Department of Psychological Medicine, University of Otago, PO Box 913, Fraser Building, 464 Cumberland Street, Dunedin 9016, New Zealand. Tel: (+64) 3-470-9451; Fax: (+64) 3-474-7934; E-mail: [email protected] Conflict of Interest: The authors report no conflicts of interest. Statement of Authorship
Category 1 (a) Conception and Design Charlene M. Rapsey (b) Acquisition of Data Charlene M. Rapsey (c) Analysis and Interpretation of Data Charlene M. Rapsey
Category 2 (a) Drafting Charlene (b) Revising Charlene
the Article M. Rapsey It for Intellectual Content M. Rapsey
Category 3 (a) Final Approval of the Completed Article Charlene M. Rapsey
1 Hawes ZC, Wellings K, Stephenson J. First heterosexual intercourse in the United Kingdom: A review of the literature. J Sex Res 2010;47:137–52.
First Sex and Later Sexual Difficulties 2 Albert B, Brown S, Flanigan C, eds. 14 and younger: The sexual behavior of young adolescents. Washington, DC: National Campaign to Prevent Teen Pregnancy, 2003. 3 Cotton S, Mills L, Succop PA, Biro FM, Rosenthal SL. Adolescent girls’ perceptions of the timing of their sexual initiation: “Too young” or “just right”? J Adolesc Health 2004;34:453–8. 4 Dickson N, Paul C, Herbison P, Silva P. First sexual intercourse: Age, coercion, and later regrets reported by a birth cohort. Br Med J 1998;316:29–33. 5 Wight D, Henderson M, Raab G, Abraham C, Buston K, Scott S, Hart G. Extent of regretted sexual intercourse among young teenagers in Scotland: A cross sectional survey. Br Med J 2000;320:1243–4. 6 Higgins JA, Trussell J, Moore NB, Davidson JK. Virginity lost, satisfaction gained? Physiological and psychological sexual satisfaction at heterosexual debut. J Sex Res 2010;47:384–94. 7 Woo JST, Brotto LA. Age of first sexual intercourse and acculturation: Effects on adult sexual responding. J Sex Med 2008;5:571–82. 8 Koch PB. The relationship of first intercourse to later sexual functioning concerns of adolescents. J Adolesc Res 1988;3:345–62. 9 Sandfort TGM, Orr M, Hirsch JS, Santelli J. Long-term health correlates of timing of sexual debut: Results from a national US study. Am J Public Health 2008;98:155–61. 10 Else-Quest NM, Hyde JS, DeLamater JD. Context counts: Long-term sequelae of premarital intercourse or abstinence. J Sex Res 2005;42:102–12. 11 Howard DE, Wang MQ. Psychosocial correlates of U.S. adolescents who report a history of forced sexual intercourse. J Adolesc Health 2005;36:372–9. 12 De Visser RO, Rissel CE, Richters J, Smith AMA. The impact of sexual coercion on psychological, physical, and sexual wellbeing in a representative sample of Australian women. Arch Sex Behav 2007;36:676–86. 13 Mercer CH, Fenton KA, Johnson AM, Copas AJ, Macdowall W, Erens B, Wellings K. Who reports sexual function problems? Empirical evidence from Britain’s 2000 National Survey of sexual attitudes and lifestyles. Sex Transm Infect 2005;81:394–9. 14 Rust J, Golombok S. Golombok–Rust Inventory of Sexual Satisfaction (GRISS) manual. 2007. London: Harcourt Assessment.
2881 15 Schwartz IM. First Coital Affective Reaction Scale. In: Davis C, Yarber WL, Bauserman R, Schreer GE, Davis SL, eds Handbook of sexuality-related measures. Thousand Oaks, CA: Sage Publications; 1998:127–8. 16 Radloff LS. The CES-D scale: A self-report depression scale for research in the general population. Appl Psychol Meas 1977;1:385–401. 17 Joyner K, Udry JR. You don’t bring me anything but down: Adolescent romance and depression. J Health Soc Behav 2000;41:369–91. 18 Longmore MA, Manning WD, Giordano PC, Rudolph JL. Self-esteem, depressive symptoms, and adolescents’ sexual onset. Soc Psychol Q 2004;67:279–95. 19 Statacorp. Stata Statistical Software: Release 12. College Station, TX: Statacorp LP, 2011. 20 Arbuckle JL. Amos (Version 21.0). Chicago: IBM SPSS, 2012. 21 Radloff LS. The use of the Center for Epidemiologic Studies Depression Scale in adolescents and young adults. J Youth Adolesc 1991;20:149–66. 22 Landry T, Bergeron S. How young does vulvo-vaginal pain begin? Prevalence and characteristics of dyspareunia in adolescents. J Sex Med 2009;6:927–35. 23 Harden KP. True love waits? A sibling-comparison study of age at first sexual intercourse and romantic relationships in young adulthood. Psychol Sci 2012;23:1324–36. 24 Stefanou C, McCabe MP. Adult attachment and sexual functioning: A review of past research. J Sex Med 2012;9: 2499–507. 25 Andersen BL, Cyranowski JM. Women’s sexual self-schema. J Pers Soc Psychol 1994;67:1079–100. 26 Andersen BL, Cyranowski JM, Espindle D. Men’s sexual selfschema. J Pers Soc Psychol 1999;76:645–61. 27 Sprecher S, Barbee A, Schwartz P. “Was it good for you, too?” Gender differences in first sexual intercourse experiences. J Sex Res 1995;32:3–15. 28 Cashell-Smith ML, Connor JL, Kypri K. Harmful effects of alcohol on sexual behaviour in a New Zealand university community. Drug Alcohol Rev 2007;26:645–51. 29 George WH, Stoner SA. Understanding acute alcohol effects on sexual behavior. Annu Rev Sex Res 2000;11:92–124.
J Sex Med 2014;11:2873–2881
ORIGINAL RESEARCH—EPIDEMIOLOGY Age, Quality, and Context of First Sex: Associations With Sexual Difficulties Charlene M. Rapsey, PhD, PGDipClPsy Department of Psychological Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand DOI: 10.1111/jsm.12690
ABSTRACT
Introduction. Research consistently indicates an association between a younger age at first sex and poorer sexual health outcomes. However, research addressing associations between age at first sex and sexual difficulties has produced mixed findings. Moreover, little is known about links between the context and quality of first sex and subsequent sexual difficulties. Aims. The aims of this study are to examine whether (i) age and (ii) context and quality at first sex are associated with sexual difficulties; (iii) examine whether age at first sex and context and quality variables are independently associated (after mutual adjustment) with sexual difficulties; and (iv) examine whether age at first sex has an indirect effect on sexual difficulties through an effect on context or quality. Methods. Data from 388 questionnaires were gathered from students aged 17–21 living in accommodation halls and by postal invitation to adults aged 25–35. Main Outcome Measures. The main outcome measure was the Golombok–Rust Inventory of Sexual Satisfaction (GRISS), which assesses sexual difficulties via an overall score and seven subscales. Results. Appraising first sex as emotionally negative was associated with the majority of sexual difficulties. A less stable relationship at first sex was associated with sexual communication problems and dissatisfaction. Greater enjoyment and using substances were associated with a lower likelihood of anorgasmia for women. Age at first sex was directly associated with reduced sexual frequency only. A younger age at first sex was associated with a greater likelihood of negative appraisal and lower likelihood of a stable relationship and thereby indirectly associated with several sexual difficulties. Conclusions. Experiencing first sex as emotionally negative was consistently associated with later sexual difficulties. When attending to sexual difficulties, understanding the quality and context of first sex may be more useful than knowing the age at first sex. This research is limited by the retrospective nature of the reports of first sex. Rapsey C. Age, quality, and context of first sex: Associations with sexual difficulties. J Sex Med 2014;11:2873–2881. Key Words. Sexual Difficulties; Sexual Function; Age at First Sex; Sexual Debut; Context of First Sex
Introduction
M
ore is known about the significance of age than about any other factors in association with first sex [1]. A young age at first sex has been associated with a number of adverse outcomes, including increased risk of unwanted pregnancy, increased risk of sexually transmitted infection, health risk behaviours such as alcohol and drug use [2], a greater likelihood that sex will be regretted © 2014 International Society for Sexual Medicine
[3–5], and decreased sexual satisfaction at the time of first sex [6]. Evidence for an association between age at first sex and later sexual difficulties, however, has been mixed. Specifically, in two studies with university students (mean age 21 years), a younger age at first sex was associated with fewer sexual difficulties [7,8]. These studies were limited by the narrow age range of participants. It may be that the association between an older age at first sex and a greater J Sex Med 2014;11:2873–2881
2874 likelihood of currently experiencing sexual difficulties can be explained by the short time period between first sex and current sex and thus a relative lack of sexual experience of the older-age initiators. In another study with a wider age range of participants that controlled for the effects of age at time of study, Sandfort et al. [9] investigated the effects of a younger- or older-than-normative age at first sex. For men, late and early first sex were associated with an increased risk of arousal problems, erectile difficulties, and orgasm problems, whereas for women an older age at first sex was associated with a reduced risk of sexual arousal difficulties. In contrast, Else-Quest et al. [10], using nationally representative data from the United States, found no evidence for an association between early or late age at first sex and sexual difficulties for men or women. Although Else-Quest et al. [10] found no association between age at first sex and current sexual difficulties, they provided evidence for an association between a negative context at first sex and sexual difficulties. A negative context was defined as sex that was forced, with a relative, with someone who paid, or primarily motivated by peer pressure or substance use; a history of sexual abuse; or, for women, sex with someone they knew but not well. Else-Quest et al.’s findings contribute to a strong literature connecting coerced sex with poor outcomes [11,12]. However, less is known about the other elements of context at first sex that were included in their composite measure of a negative context. In another study, university-age participants who reported a negative subjective evaluation of first sex, that is, stronger negative emotions and weaker positive emotions, were more likely to report current difficulties [8]. Further, Mercer et al. [13], using nationally representative data from a large UK sample, found that sexual competence at first sex (defined as using hormonal or barrier contraception, not using alcohol, being willing, and engaging in sex for autonomous reasons such as love rather than because of peer pressure) predicted a lower likelihood of experiencing later sexual difficulties. Thus, there is evidence that subjective evaluation and context of first sex can have implications for later sexual experience. In sum, it is not clear whether age at first sex is associated with a greater or lesser likelihood of sexual difficulties, which specific elements of the context of first sex are associated with later sexual difficulties, and whether age at first sex influences J Sex Med 2014;11:2873–2881
Rapsey context and subjective evaluation of first sex. Understanding these elements may better inform our understanding of the development of sexual difficulties. Investigation of the quality and context of first sex allows for more information regarding the mechanisms or processes that may link first sex with later sexual experience. Thus the current study investigates associations between sexual difficulties and age at first sex, context at first sex, and appraisal of first sex.
Aims This study aimed to examine (i) whether age at first sex is associated with sexual difficulties, (ii) whether any of a series of context variables are associated with sexual difficulties, (iii) whether any of a series of context variables are independently associated (after mutual adjustment) with sexual difficulties, and (iv) indirect pathways between age at first sex, each context variable, and sexual difficulties. Methods
The University of Otago Ethics Committee granted approval for the research. Data were collected from late-adolescent students aged 17–21 years and adults aged 25–35 years. Late-adolescent participants were recruited from accommodation halls for students enrolled at university, polytechnic (an institution offering tertiary-degree and below-degree certification), or a teacher training school in a single New Zealand city. Participants aged 25–35 years were randomly selected from the electoral roll to ensure selection of participants from a developmental period following emergent adulthood/late adolescence. Late-adolescent participants provided written consent before being given a questionnaire to complete in supervised study rooms at their accommodation hall. Three female researchers were available to assist if needed. Participants were informed that their answers were confidential, and no identifying information was collected. Surveys were returned in a plain envelope to a closed box. Compensation was with a movie or phone voucher to the value of NZ$10.00. At one hall, students also entered into a draw to win an MP3 player. Participation was on an opt-in basis, with a maximum of 250 students being able to participate; representation of the participating halls ranged from 19–53%. To recruit adult participants, invitations to complete a self-report questionnaire via the internet or
First Sex and Later Sexual Difficulties hard copy were posted to 660 addresses, and 179 replies were received. Three reminder letters were sent along with a postage-paid envelope for participants to return their questionnaires. Participants were informed that completion of the questionnaire implied consent and that all responses were anonymous.
Dependent Variable Current Sexual Difficulties The Golombok–Rust Inventory of Sexual Satisfaction (GRISS) [14] was used to assess current sexual difficulties. In this way, direct comparison with an earlier study addressing age at first sex and sexual difficulties using the GRISS [7] was made possible. The GRISS has a male and a female version, each with 28 items. A main overall score is calculated along with seven subscales assessing frequency of sexual activity (infrequency), dissatisfaction with one’s sex life (dissatisfaction), extent of communication about sex (noncommunication), extent of nongenital physical contact (nonsensuality), avoidance of sexual intimacy (avoidance), male difficulties (early ejaculation, erectile difficulties), and female difficulties (anorgasmia, vaginismus). The original scale was adapted slightly to be more acceptable to individuals of all sexual orientations. Participants responded to items using a five-point scale. Following reverse scoring of some items, subscale and overall scores were summed and then transformed to fit a standardized scale ranging from 1 to 9 [14]. Independent Variables Negative Emotional Appraisal of First Sex Seven items from the First Coital Affective Reaction Scale (FCARS) [15] assessed degree of negative emotional response to first sex. The scale consisted of seven adjectives (e.g., confused, embarrassed, anxious). Scores ranged from 7 to 49, measured using a Likert scale ranging from 1 (not experiencing the feeling) to 7 (strongly experiencing the feeling). Good internal consistency was demonstrated, with Cronbach’s alpha coefficient of 0.85. Enjoyment at First Sex Four items from the FCARS [15] and two global indicators were used to assess sexual enjoyment. FCARS items were adjectives describing responses to first sex (e.g., satisfied and pleasurable) measured using a 7-point scale. The two global indicator questions were “How satisfied were you with your sexual relationship with your partner? and “How
2875 satisfied were you with the amount of emotional closeness during sex with your partner?” Participants reported their experience on a Likert scale from 1 (very dissatisfied) to 5 (very satisfied). A higher score indicated higher enjoyment (α = 0.89).
Age at First Sex Participants indicated on a timeline how old they were the first time they had vaginal or anal sex. Substance Use Substance use at first sex was assessed by asking “The first time you had sex, had you been drinking or using drugs?” Responses included “no” (0), “a little” (1), and “a lot” (2). Relationship Status To assess relationship status, participants were asked about their relationship status at the time of first sex. Responses included “We had just met” (0), “We had met recently” (1), “We had known each other for a while but did not have a steady relationship at the time” (2), “We had a steady relationship” (3), “We were engaged” (4), and “We were married/civil union” (5). Mood An 11-item version of the Center for Epidemiological Studies Depression Scale (CES-D) [16] was used to assess symptoms of depression. Participants were asked to respond to the questions with reference to their past week using a scale with the following options: 0, never/rarely (less than 1 day); 1, sometimes (1–2 days); 2, occasionally (3–4 days); 3, mostly/always (5–7 days). Items focused on feelings of low mood, including feelings of sadness, depression, and “the blues”; tiredness; fear; loneliness; difficulty concentrating; and poor appetite. The 11-item version has shown good internal consistency in previous studies [17,18]. Statistical Analysis First, a series of univariate linear regression models were constructed examining the association between each independent variable (entered one at a time) and the overall GRISS score, controlling for current age and gender. The independent variables in these models were age at first sex and each of the context variables for first sex (negative emotional appraisal, enjoyment, substance use, and relationship status). Second, the quadratic term for age at first sex was included in all models to test for a linear association. J Sex Med 2014;11:2873–2881
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Third, an interaction term, gender × independent variable, was included in each of the models, testing for any variation in associations by gender. Fourth, multivariate regression models were tested that included age at first sex and all of the context variables. The multivariate models were run with the overall GRISS score and the subscales of the GRISS (e.g., infrequency, dissatisfaction, noncommunication, avoidance) as the dependent variables while controlling for current age and gender. Fifth, pathway analysis was conducted to investigate direct and indirect effects of age at first sex on context variables and sexual difficulties. Analyses were performed using Stata Version 11.2 [19] and IBM SPSS Amos 21 [20], with twosided P < 0.05 considered statistically significant. Results
Among the late-adolescent participants, 209 reported having had sex (116 females, 93 males). All 179 adult participants reported having had sex (103 females, 76 males). As can be seen in Table 1, in the adult sample, 85.3% had gained a qualification from a tertiary education; the majority of participants (92.5%) identified as being Pa¯keha¯ (New
Table 1
Demographic details of participants, % (n)
Gender Male Female Ethnicity† New Zealand European New Zealand Maori Asian Other Age 17–19 20–24 25–29 30–35 Sexual orientation Heterosexual Gay/lesbian Bisexual Other Highest academic qualification (adults only) Secondary school Bachelor’s Postgraduate Diploma/trade certificate Overseas qualification Tertiary institution (students only) University Teacher’s college Polytechnic †Values
43.6 (169) 56.4 (219) 92.5 (334) 2.8 (11) 2.2 (8) 4.5 (17) 53.0 (195) 2.7 (10) 16.6 (61) 27.7 (102) 96.5 (357) 1.4 (5) 1.6 (6) 0.5 (2) 14.6 (26) 38.8 (61) 28.2 (44) 16.9 (27) 2.4 (2) 67.9 (142) 23.4 (49) 8.6 (18)
do not add to 100 as some individuals reported more than one
ethnicity
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Zealand European) and labelled themselves as heterosexual (96.5%). There were no participants aged 22 or 24 years of age; however, two participants responding to the adult postal survey reported that they were 23 years of age. Mean age at first sex was 16.95 (SD = 2.52) with a range from 12 to 28 years.
Univariate Linear Regression Models Univariate linear regression models controlling for gender and current age indicated negative emotional appraisal of first sex was associated with high overall GRISS score (P < 0.001), infrequency (P = 0.030), dissatisfaction (P = 0.012), avoidance (P < 0.001), nonsensuality (P = 0.002), vaginismus (P = 0.023), erectile difficulties (P = 0.004), and early ejaculation (P = 0.038). A less committed relationship status was associated with higher scores on the infrequency (P = 0.038), dissatisfaction (P = 0.009), and noncommunication (P = 0.002) subscales. Lower enjoyment at first sex was associated with a higher overall GRISS score (P = 0.028). No evidence was found for an association between any of the GRISS scales and age at first sex or substance use at first sex. Quadratic Term for Age at First Sex There was no evidence that the quadratic term for age at first sex was significant in any of the models; therefore a linear association was assumed, and age at first sex was included in subsequent analyses as a continuous variable. Interactions With Gender Interactions with gender were not significant in any of the models tested, so data for males and females were analyzed together. Multivariate Linear Regression Models Multivariate linear regression models were tested relating the GRISS overall and domain scores as the outcome variables to all of the independent variables, adjusting for current age and gender. As in the univariate analysis, negative emotional appraisal was associated with a higher score on the majority of the GRISS domains, the exception being early ejaculation, which was not more significantly associated with negative emotional appraisal than with the other independent variables. Likewise, relationship status remained associated with several of the GRISS domains, with the exception of the infrequency. Enjoyment at first sex, although showing a significant association with the overall score in the univariate analysis,
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First Sex and Later Sexual Difficulties was no longer particularly significantly associated with any of the other variables. Some variables without evidence for an association with any of the independent variables in the univariate analysis showed evidence of an association in the multivariate analysis. Specifically, holding the other context variables constant, lower enjoyment and greater substance use at first sex were associated with anorgasmia. Thus, if the effect of enjoyment at first sex is controlled for, then substance use is associated with less risk of anorgasmia. In addition, an older age at first sex was associated with greater infrequency of sexual intercourse when the other variables were held constant.
Adjustment for Depression Due to the link between a negative emotional appraisal of first sex and current sexual difficulties, the CES-D [16,21] was added to the models to test whether current depression could explain this association. That is, current depression may increase the likelihood of a negative emotional appraisal of sexual experience now and in the past. As displayed in Table 2, in all models except one, a negative emotional appraisal of first sex remained significantly associated with the outcome variable (overall GRISS score, infrequency, avoidance, nonsensuality, vaginismus, or erectile difficulties) after adjustment for current depression, with the exception of dissatisfaction. Pathway Analysis for Indirect Effects Pathway analysis was conducted to determine whether age at first sex had an indirect effect on sexual difficulties. Direct effects were observed for an older age at first sex with regard to less negative emotional appraisal (β = −0.490, P = 0.003), a more committed relationship status (β = 0.113, P < 0.001), and greater enjoyment (β = 0.314, P = 0.035). Following from these direct effects, older age at first sex had an indirect effect of lower scores on the infrequency, dissatisfaction, and nonsensuality scales and the overall score. Specifically, an older age at first sex reduced the severity of infrequency (β = −0.040, P = 0.004) and dissatisfaction (β = −0.029, P = 0.003) through an effect on relationship status and negative appraisal (Figure 1). An older age at first sex reduced the overall GRISS score (β = −0.033, P = 0.006) and nonsensuality score (β = −0.031, P = 0.019) through an effect on negative appraisal (Figure 2). Finally, an older age at first sex lowered the likelihood of noncommunication difficulties
Table 2 Age at first sex and context variables regressed on GRISS overall and subscales, controlling for age, gender and depression status GRISS domain Overall score (n = 328) Age at first sex Negative appraisal Enjoy Substance use Relationship status Infrequency (n = 331) Age at first sex Negative appraisal Enjoy Substance use Relationship status Dissatisfaction (n = 329) Age at first sex Negative appraisal Enjoy Substance use Relationship status Noncommunication (n = 333) Age at first sex Negative appraisal Enjoy Substance use Relationship status Avoidance (n = 326) Age at first sex Negative appraisal Enjoy Substance Use Relationship status Nonsensuality (n = 313) Age at first sex Negative appraisal Enjoy Substance use Relationship status Anorgasmia (n = 186) Age at first sex Negative appraisal Enjoy Substance use Relationship status Vaginismus (n = 185) Age at first sex Negative appraisal Enjoy Substance use Relationship status Erectile difficulties (n = 144) Age at first sex Negative appraisal Enjoy Substance use Relationship status Early ejaculation (n = 145) Age at first sex Negative appraisal Enjoy Substance use Relationship status
B
SE
t
P
0.04 0.04 −0.01 −0.01 −0.06
0.05 0.01 0.02 0.13 0.10
0.72 2.64 −0.60 −0.10 −0.65
0.473 0.009 0.549 0.923 0.515
0.18 0.02 −0.00 0.01 −0.19
0.05 0.02 0.02 0.14 0.11
3.28 1.54 −0.24 0.05 −1.79
0.001 0.125 0.812 0.962 0.075
0.08 0.02 −0.01 −0.03 −0.18
0.04 0.01 0.01 0.11 0.08
1.92 1.42 −0.39 −0.27 −2.31
0.056 0.158 0.696 0.784 0.021
0.09 −0.01 −0.01 0.05 −0.24
0.05 0.01 0.02 0.13 0.09
1.91 −0.71 −0.91 0.43 −2.60
0.056 0.476 0.366 0.669 0.010
0.00 0.05 0.02 0.21 0.14
0.05 0.01 0.02 0.13 0.10
0.09 3.85 1.13 1.60 1.52
0.928 0.000 0.258 0.110 0.130
−0.04 0.04 −0.00 −0.00 −0.08
0.06 0.02 0.02 0.15 0.11
−0.66 2.23 −0.24 −0.02 −0.72
0.511 0.027 0.808 0.983 0.471
−0.02 −0.00 −0.05 −0.44 0.02
0.07 0.02 0.02 0.18 0.14
−0.27 −0.07 −2.26 −2.43 0.12
0.786 0.944 0.025 0.016 0.901
0.05 0.04 0.04 −0.10 −0.07
0.07 0.02 0.02 0.18 0.13
0.67 2.39 1.78 −0.57 −0.50
0.504 0.018 0.077 0.571 0.621
0.04 0.06 0.03 −0.07 −0.09
0.06 0.02 0.02 0.17 0.12
0.70 2.62 1.10 −0.42 −0.75
0.485 0.010 0.275 0.676 0.457
−0.08 0.03 −0.01 0.31 0.13
0.07 0.02 0.03 0.18 0.13
−1.14 1.29 −0.31 1.70 1.02
0.258 0.198 0.758 0.091 0.311
GRISS = Golombok–Rust Inventory of Sexual Satisfaction
J Sex Med 2014;11:2873–2881
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Rapsey Alcohol
-0.49** Age at First Sex
NegaƟve Appraisal
0.02** DissaƟsfacƟon
0.31* Enjoyment -0.20**
0.11** RelaƟonship
(β = −0.034, P = 0.010) through an effect on relationship status (Figure 3). Discussion
Overall, our findings suggest that age at first sex was not directly associated with sexual difficulties; rather, the emotional quality of first sex was more relevant. For several sexual difficulties, age at first sex was important to the degree that it was associated with the context and quality of first sex. Specifically, a negative emotional appraisal of first sex was associated with a number of current sexual difficulties, and a negative appraisal was less likely if individuals were older when they first had sex. In addition to a negative emotional appraisal of first sex, a less committed relationship at first
Figure 1 Model of pathway analysis showing nonstandardized direct and indirect effects of age at first sex and context and quality of first sex on the dissatisfaction scale of the Golombok– Rust Inventory of Sexual Satisfaction. Dashed line = P not significant; *P < 0.05; **P < 0.01.
sex was associated with later dissatisfaction and noncommunication, and again, participants were more likely to have had first sex within a committed relationship when they were older at first sex. Age at first sex was not directly associated with any sexual difficulties except sexual infrequency, whereby those who first had sex when they were older were more likely to report high sexual infrequency. The findings of this study contribute to a mixed literature on the role of age of first sex and sexual difficulties. The results are consistent in one aspect with those of Woo and Brotto [7], who found that an older age at first sex was associated with a greater likelihood of infrequent sex; however, consistent with Else-Quest et al. [10], we did not find evidence that an older age at first sex was a risk
Alcohol
-0.49** Age at First Sex
-0.03 NegaƟve Appraisal GRISS Overall Score
-0.31* Enjoyment 0.11** RelaƟonship
Figure 2 Model of pathway analysis showing nonstandardized direct and indirect effects of age at first sex and context and quality of first sex on overall score on the Golombok–Rust Inventory of Sexual Satisfaction (GRISS). Dashed line = P not significant; *P < 0.05; **P < 0.01.
Alcohol
-0.49** NegaƟve Appraisal Age at First Sex
NoncommunicaƟon
0.31* Enjoyment 0.11**
-0.03 RelaƟonship
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Figure 3 Model of pathway analysis showing nonstandardized direct and indirect effects of age at first sex and context and quality of first sex on the noncommunication scale of the Golombok–Rust Inventory of Sexual Satisfaction. Dashed line = P not significant; *P < 0.05; **P < 0.01.
First Sex and Later Sexual Difficulties factor for any other sexual difficulties. Extending Else-Quest et al.’s findings of the influence of a negative context (forced sex, incest, sex work, peer pressure, substance use, history of sexual abuse, and, for women, weak relationship status), we are able to comment on the particular elements of the context at first sex that are associated with reports of sexual difficulties; that is, weak relationship status at first sex was associated with sexual difficulties, but substance use was not. In fact, we found evidence suggesting that substance use may be associated with a lower likelihood of anorgasmia in a particular context, that is, when adjustment is made for sexual enjoyment. Further, we found that the relationship context was as important for men as for women, which has not previously been investigated. Sandfort et al. [9] reported early and late first sex to be risk factors for sexual difficulties, particularly for men, whereas we found no direct or indirect effects of age at first sex on gender-specific difficulties (i.e., anorgasmia, vaginismus, early ejaculation, erectile dysfunction). Possible associations between first sex and later sexual experience may be explained by several mechanisms. It may be that there is a direct relationship whereby low enjoyment at first sex indicates the presence of sexual difficulties, and those sexual difficulties persist. For example, Landry and Bergeron [22] found a high prevalence of primary, chronic dyspareunia in their large adolescent sample; it is likely that without treatment, such difficulties contribute to immediate and long-term suffering. In particular, the finding that lower sexual enjoyment at first sex was associated with anorgasmia for women may be consistent with this theory. Another explanation is that a negative experience at first sex is associated with later sexual difficulties due to a common third factor. For example, a depressive disorder present during first sex and also present during subsequent sexual relationships would increase the likelihood of sexual dissatisfaction at each time period. In this study, current depression status did not account for associations between a negative emotional appraisal and sexual difficulties, and thus it is unlikely that depression status explains this association. It is also unlikely that depressions status was a confounding factor affecting recall of past sex or perception of current difficulties. Similarly, quality of first sex and quality of later sexual experience may be connected through a common factor such as attachment style, which is
2879 also associated with timing of first sex. That is, those with a more secure attachment style may be more likely to have sex when they are in an established relationship, which is more likely when they are older, and a secure attachment style may reduce the likelihood of sexual difficulties [23,24]. The finding that a more committed relationship status at first sex was associated with an older age at first sex and with fewer noncommunication difficulties appears to lend support to this theory, particularly as communication difficulties may reflect relationship processes. Thus, participants who initially have sex in less intimate relationships may continue to have sex in less intimate relationships, in which communication and sexual satisfaction are compromised. In addition, sexual self-schema theory predicts that the context of first sex contributes to consequent sexual experience in a formative manner [25,26]. Thus, a negative appraisal of first sex or lack of enjoyment may lead to negative expectations and assumptions about subsequent sexual relationships, which reduces the likelihood of experiencing more positive sexual relationships. Finally, timing of sexual experience may interact with the context of first sexual experience; for example, first sexual experience in young adulthood may take place in a context of greater emotional, relational, and cognitive skills than first sexual experience in early adolescence [23]. The finding that substance use at first sex was associated with a lower likelihood of anorgasmia when adjusting for context and quality of first sex was surprising. Alcohol use has been associated with lower pleasure at first sex [27], which was also found in the current study (results available on request). Alcohol use at first sex has also been associated with sexual risk taking and with nonconsensual sex [28]. More generally, there is some evidence that alcohol reduces objective arousal but increases subjective arousal [29]. Taking into account the extant research linking alcohol and sexual experience, we could speculate that once the potential negative associations between substance and first sex are accounted for, then, in some contexts for some people, substance use is not problematic and in fact marks a positive trajectory of sexual enjoyment for women.
Limitations The findings from this study must be understood in the context of several limitations. A crosssectional design cannot show causal relations. The study relied on retrospective report; perspectives J Sex Med 2014;11:2873–2881
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of first sex will be affected by memory and confounded by preceding sexual experiences. An adult age group was chosen to allow for the accrual of sexual experience that typically occurs with time; however, adults are likely to have more poorly recollected first sex. It may have been valuable to have included a greater number of participants in the 21–24 age group, as this age group may have had clear memories of first sex as well as accrued sexual experience. Memory errors could be expected to weaken actual associations between first sex and current experience, and thus our findings could be seen to be conservative. In addition, it may be that participants who are currently experiencing sexual difficulties are more inclined to remember previous sexual experiences negatively, generating the opposite of the “rosecolored glasses” effect. Current mood did not seem to account for the association between a negative emotional appraisal at first sex and current sexual difficulties; however, there may be other confounding variables that do explain the relationship. This study only controlled for a limited number of potential confounding variables, and thus the potential for residual confounding remains. In addition, first sex may not be the most reliable sample incident for assessing the quality of emergent sexuality. It may also be informative to assess the quality and context of a wider range of sexual experience. Moreover, qualitative research would allow for the voices of young people themselves to be heard. Such research may allow for the development of more appropriate measures of the quality of emergent sexuality. Sexuality and relationship constructs are culturally bound. The findings of this study may not generalize to other countries or cultures where different values and meanings are associated with sexuality and intimacy. Further, the participants in this study do not comprise a representative sample. Participants were predominantly Pa¯keha¯ (New Zealand European) and were either enrolled in tertiary education or had completed tertiary education. It may be that the participants who opted to take part in this study were different from those who did not opt to take part. Thus, associations between variables may differ between different groups even within a New Zealand context.
In particular, a negative emotional response to first sex was associated with several different types of sexual problem. This is relevant information for clinicians who routinely ask about an individual’s or couple’s sexual history. Future research should use a longitudinal methodology to aid understanding of the trajectory of sexual difficulties across time and different relationships. To improve strategies for intervention, it will be valuable to understand trajectories of sexual experience and the mechanisms linking first sex with subsequent sexual experiences.
Conclusions
References
This study provides evidence that experiences at first sex are associated with later sexual experience. J Sex Med 2014;11:2873–2881
Acknowledgments
The late Associate Professor Oliver Davidson, the late Dr. Tamar Murachver, Dr. Elizabeth Schaughency, Amy Smith, Katie Ryan, Andrew Gray, Associate Professor Kate Scott, and Dr. Nic Swain are thanked for their contribution to this research. This research was supported by scholarships from the University of Otago and the Dunedin School of Medicine, University of Otago. Corresponding Author: Charlene M. Rapsey, PhD, PGDipClPsy, Department of Psychological Medicine, University of Otago, PO Box 913, Fraser Building, 464 Cumberland Street, Dunedin 9016, New Zealand. Tel: (+64) 3-470-9451; Fax: (+64) 3-474-7934; E-mail: [email protected] Conflict of Interest: The authors report no conflicts of interest. Statement of Authorship
Category 1 (a) Conception and Design Charlene M. Rapsey (b) Acquisition of Data Charlene M. Rapsey (c) Analysis and Interpretation of Data Charlene M. Rapsey
Category 2 (a) Drafting Charlene (b) Revising Charlene
the Article M. Rapsey It for Intellectual Content M. Rapsey
Category 3 (a) Final Approval of the Completed Article Charlene M. Rapsey
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