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Women’s Use and Perceptions of Commercial Lubricants: Prevalence and Characteristics in a Nationally Representative Sample of American Adults Debby Herbenick, PhD, MPH,* Michael Reece, PhD, MPH,* Vanessa Schick, PhD,† Stephanie A. Sanders, PhD,‡§ and J. Dennis Fortenberry, MD, MS¶ *Center for Sexual Health Promotion, Indiana University, Bloomington, IN, USA; †University of Texas. Houston, TX, USA; ‡ The Kinsey Institute for Research on Sex, Gender, and Reproduction, Indiana University, Bloomington, IN, USA; § Department of Gender Studies, Indiana University, Bloomington, IN, USA; ¶Division of Adolescent Medicine, School of Medicine, Indiana University, Indianapolis, IN, USA DOI: 10.1111/jsm.12427
ABSTRACT
Introduction. Use of commercial lubricant is common in the United States among adult women. However, little is known about the sexual behaviors for which women use lubricant, women’s perceptions of lubricant, or reasons for use, particularly in a nationally representative sample. Aim. The aim of this study was to document the prevalence and characteristics of lubricant use among adult women in the United States and their perceptions of lubricants in relation to subjective sexual experiences. Methods. Data are from a subset of individuals who were sampled as part of the 2012 National Survey of Sexual Health and Behavior, which involved the administration of an online questionnaire to a nationally representative probability sample of U.S. adults ages 18 and older. Main Outcome Measures. Sociodemographic characteristics, recent and lifetime commercial lubricant use, lubricant use during specific sexual behaviors, frequency of lubricant use, and reasons for lubricant use of participants were studied for the article. Results. Of the women who participated in the study, 65.5% (n = 1,021) reported ever having used lubricant and 20% had used a lubricant within the past 30 days. Across age groups, lubricant was most commonly used during intercourse (58.3% of women) or partnered sexual play (49.6%). Common reasons for lubricant use included to make sex more comfortable, fun, and pleasurable and to decrease discomfort/pain. Conclusions. Most American women have used lubricant. Also, lubricant is more common as part of partnered intercourse and sexual play or foreplay compared with other solo and partnered sexual behaviors. Clinicians may find it helpful to broaden conversations with patients to include questions about their sexual behaviors, comfort and/or pain during sex, and lubricant use and to share, particularly with younger women, that lubricant use is prevalent and commonly used for reasons related to pleasure as well as comfort. Herbenick B, Reece M, Schick V, Sanders SA, and Fortenberry JD. Women’s use and perceptions of commercial lubricants: Prevalence and characteristics in a nationally representative sample of American adults. J Sex Med 2014;11:642–652. Key Words. Lubricant; Vaginal Lubrication; Sexual Pleasure
Introduction
C
ommercial lubricants are widely sold in the United States and are commonly used by women as part of their solo and partnered sexual experiences [1–3]. Data from 2008 suggest that J Sex Med 2014;11:642–652
most women ages 18 to 60 (up to 62%) report use of a commercial lubricant, with 25% having done so in the previous month [3], suggesting variation in commercial lubricant use, frequency of use, as well as variation in reasons for lubricant use. For example, 2009 data demonstrate that © 2014 International Society for Sexual Medicine
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Women’s Lubricant Use 28.9% of women used a lubricant during sex without a condom, compared with 21.7% of women who used a condom [2]. Many women choose lubricants to enhance the subjective positive experiences of sexual events. For example, more than two-thirds of women choose lubricants to make sex more pleasurable, and about one-third of women use lubricants for fun or due to a preference for feeling very wet during sex [4]. Data from a large convenience sample of about 2,400 sexually active women demonstrate that lubricant use is associated with significantly higher ratings of sexual pleasure and satisfaction compared with sexual events that occurred without the use of lubricant [1]. Indeed, in recent years, advertising for lubricant has focused on sexual enhancement, foreplay, and pleasure [5,6], which has perhaps contributed to changing perceptions of lubricants, away from being only for older women or those with certain medical conditions and toward perceptions that lubricants may contribute to more pleasurable sex for women and men of all ages. Although commonly used for reasons related to pleasure, lubricants also are commonly used to ameliorate negative experiences of sexual events and have long been associated with aging and menopause. Many women (about 54%) choose lubricants because they feel that their natural vaginal lubrication is insufficient [3]. Also, women—including postmenopausal women, lactating women, breast cancer survivors, and women experiencing vulvovaginal pain—use lubricants to help make sex less painful, more comfortable, or at least tolerable [7–10]. Given the role of partnered sex in reproduction as well as in relationship happiness and satisfaction, it is not surprising that people look for ways to manage sex even under difficult circumstances. This use of lubricants to decrease pain and/or to increase comfort during sex is important as about 30% of women in a U.S. national sample have reported some degree of pain during their most recent sexual experience with a partner and about one-third of women report difficulty with vaginal lubrication during their most recent sexual experience [11]. Although women commonly report pain during sex, many women engage in sexual behavior because they still find it pleasurable (even in the midst of pain), because it feels connecting to them and/or their partner, to please their partner, or because they feel that it is part of their duties as a girlfriend or wife [12–14]. These uses for lubricants—to enhance sexual pleasure and ameliorate sexual pain—exemplify
the complexities of incorporation of a sexual health perspective in clinical medicine. In keeping with widely cited definitions of sexual health, lubricants enhance the contributions of sex to overall wellbeing, beyond the simple absence of disease or dysfunction. In addition, women’s relatively autonomous use of pleasure-enhancing products (such as vibrators and lubricants) highlights a still prevalent sexual double standard that gives minimal importance—and in some cases even stigmatizes—women’s sexual pleasure, in adolescence as well as in adulthood [15,16]. The important role of lubricants for ameliorating temporary or more enduring sexual problems of pain, however, points to both the commercialization and medicalization of women’s sexual function. These roles played by lubricants in women’s sexual health suggest the importance of more detailed understanding of commercial lubricant use among contemporary adult women. As much of the existing data on women’s lubricant use are from convenience samples, sexually active samples, or clinical samples, nationally representative data on lubricant use would be particularly helpful for clinicians, educators, and other sexual health professionals who are routinely faced with questions about women’s lubricant use. Aim
The purpose of this study (a subset of the 2012 National Survey of Sexual Health and Behavior [2012 NSSHB]) was to assess: (i) the prevalence and characteristics of lubricant use among American adult women (age 18 years and older); (ii) the sexual behaviors with which women use lubricant; (iii) the reasons why women first began using lubricant; and (iv) women’s perceptions of lubricant use. Methods
Study protocols and measures were reviewed and approved by the Institutional Review Board at the first author’s institution. The 2012 NSSHB is a population-based cross-sectional survey of adult women and men in the United States. Data were collected during October and November 2012, via the KnowledgePanel of GfK Research (GfK) (Menlo Park, CA, USA). Research panels accessed through GfK are based on a national probability sample established using both random digit dialing and an address-based sampling (ABS) frame. ABS involves the probability sampling of a frame of residential addresses in the United States derived from the U.S. Postal Service’s Delivery Sequence J Sex Med 2014;11:642–652
644 File, a system which contains detailed information on every mail deliverable address in the United States. Collectively, the sampling frame from which participants are recruited covers approximately 98% of all U.S. households. Randomly selected addresses are recruited to the research panel through a series of mailings and subsequently by telephone follow-ups to nonresponders when possible. To further correct sources of sampling and non-sampling error, study samples are corrected with a post-stratification adjustment using demographic distributions from the most recent data available from the Current Population Survey, the monthly population survey conducted by the U.S. Bureau of the Census considered to be the standard for measuring demographic and other trends in the United States. These adjustments result in a panel base weight that was employed in a probability proportional to size selection method for establishing the samples for this study. Once the sample frame was established, all individuals within that frame received a recruitment message from GfK that provided a brief description of the NSSHB and invited them to participate. A total of 6,175 were included in the initial sampling frame, with 61.5% (n = 4,020) viewing the informed consent. Of those viewing the informed consent, 81.7% (n = 3,285) consented to participate, with a total of 3,138 of those individuals (95.5%) completing the survey. Of these participants, 49.6% identified their gender as female and data from these 1,559 women are included in this report. The survey was administered in either English or Spanish. All data were collected by GfK via the Internet; participants in a given KnowledgePanel were provided with access to the Internet and hardware if needed. Multiple researchers have used GfK’s KnowledgePanel for multiple health-related studies, substantiating the validity of such methods for obtaining data from nationally representative samples of the U.S. population [17–23], and additional details about this methodology as used in the NSSHB are described elsewhere [20–23]. Main Outcome Measures
Demographics Participants responded to questions about their age, education, race/ethnicity, sexual orientation, and relationship status. Commercial Lubricant Use Participants provided details about commercial lubricant use at varying points in their lifetime. J Sex Med 2014;11:642–652
Herbenick et al. Response options included that participants had used a lubricant within the 30 days prior to participating in the study, 90 days prior to the study, within the past 12 months, more than 1 year ago, or never. Participants were provided with a definition of lubricant that included “any personal lubricant or vaginal moisturizer that you can purchase in a store marketed to enhance the sexual experience and/or increase lubrication.”
Commercial Lubricant Use During Specific Sexual Behaviors and Other Product Use Participants were also asked (using the same response categories as above—past 30 days, 90 days, etc.) to indicate whether they had used a lubricant during specific sexual behaviors, including: while masturbating alone, during sexual play or foreplay with a partner, and during intercourse. Participants were also asked to respond similarly as to whether they had used a lubricant in conjunction with a condom, a vibrator, or a dildo. Reasons for Lubricant Use Women were asked to provide the main reasons for their initial use of a commercial lubricant, with 18 response options including: “to make sex feel more wet” to “to manage vaginal pain” and “to spice up my/our sex life,” among others. Perceptions of Commercial Lubricant Use Participants were asked to respond to the extent to which they agreed or disagreed with items related to their perceptions of the use of lubricant during sexual activities. These items ranged from those such as “lubricant use is embarrassing” to “lubricant makes sex feel better” to “lubricant is only for older people.” Response options included a fourpoint scale ranging from strongly disagree to strongly agree. Analyses In all analyses, post-stratification data weights were used to reduce variance and minimize bias due to non-sampling error. Distributions for age, race, sex, Hispanic ethnicity, education, and U.S. census region were used in post-stratification adjustments. Bivariate logistic regressions were used to investigate the relationship between sociodemographic characteristics (i.e., age, education, race/ethnicity, sexual orientation, relationship status) and lifetime lubricant use. Recency, frequency, perceptions, and reasons for lubricant use were explored using descriptive statistics (e.g., frequencies).
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Women’s Lubricant Use Results
Sociodemographic Characteristics Participants ranged in age from 18 to 91 with a mean age of 46.8 (standard deviation = 16.6). Over half of the participants reported attending or graduating from college (Table 1). Most reported living with a spouse (51.6%, n = 835) with the second largest group being single and not dating (21.2%, n = 343). Participants were primarily white, non-Hispanic (66.5%, n = 1,082) and identified as heterosexual (93.6%, n = 1,498). Commercial Lubricant Use Rates Lifetime lubricant use significantly varied based upon the age, education, race/ethnicity, and relationship status (Table 1). Lubricant use was significantly higher among women who were aged 25 and older (P < 0.001), white (P < 0.01), and/or college educated (P < 0.01). Participants who were
in a relationship but not living together (odds ratio [OR] = 1.70, P < 0.01) and those who were married and living together (OR = 2.60, P < 0.001) were significantly more likely to use lubricants than those who were currently single and not dating. Overall, 65.5% (n = 1,021) of women reported lifetime lubricant use (Table 2) and over 20% had used a lubricant within the past 30 days. In all age groups, the most common context of lubricant use was during partnered intercourse (58.3%, n = 904) or partnered sexual play (49.6%, n = 768). While less commonly reported, approximately one-third of the participants (29.8%, n = 461) reported using lubricant during solo masturbation. Between 20% and 30% of women reported using a lubricant with a condom (32.8%), vibrator (26.8%), or dildo (20.8%). Of those who reported using a lubricant with a condom, most indicated they used the lubricant on the outside of the condom (84.0%,
Table 1 Participant sociodemographic distribution by lifetime lubricant use history using post-stratification weights (N = 1,559) Lubricant use
No lubricant use
Lubricant use vs. no lubricant use
Characteristics
% (n)
%
Odds ratio (95% CI)
Age 18–24 (ref) 25–29 30–39 40–49 50–59 60–69 70+
9.3 (151) 11.3 (184) 17.2 (281) 15.8 (258) 19.6 (320) 18.4 (300) 8.2 (134)
45.5 72.5 71.5 68.7 62.5 70.8 55.0
54.5 27.5 28.5 31.3 37.5 29.2 45.0
3.15**** 2.99**** 2.63**** 1.99**** 2.90**** 1.44
(1.98–5.02) (1.96–4.57) (1.72–4.02) (1.33–2.97) (1.91–4.40) (0.89–2.32)
Education Less than high school (ref) High school or GED Some college or associates degree College degree or higher
11.3 (184) 29.5 (480) 30.4 (495) 28.8 (469)
54.7 61.9 68.6 70.3
45.3 38.1 31.4 29.7
1.34 1.80**** 1.94****
(0.95–1.90) (1.26–2.55) (1.36–2.78)
Race/ethnicity White, non-Hispanic (ref) Black, non-Hispanic Other, non-Hispanic Hispanic More than two races, non-Hispanic
66.5 (1,082) 12.3 (200) 6.1 (99) 13.9 (226) 1.3 (20)
70.2 59.1 54.0 52.1 80.0
29.8 40.9 46.0 47.9 20.0
0.61** 0.50** 0.46**** 1.60
(0.44–0.84) (0.32–0.77) (0.34–0.62) (0.55–4.70)
Sexual orientation Heterosexual (ref) Homosexual/gay Bisexual Asexual Other
93.6 (1,498) 1.4 (22) 3.4 (54) 1.1 (18) 0.5 (8)
66.2% 63.6% 66.0% 44.4% 75.0%
33.8 36.4 34.0 55.6 25.0
0.88 1.00 0.45 1.84
(0.37–2.11) (0.56–1.79) (0.18–1.15) (0.33–10.29)
Relationship status Single and not dating (ref) Single and dating In a relationship but not living together Living with relationship partner Married and living together Married but not living together
21.2 (343) 4.7 (77) 9.9 (160) 10.3 (167) 51.6 (835) 2.3 (37)
51.4% 61.8% 64.3% 57.9% 73.3% 67.6%
48.6 38.2 35.7 42.1 26.7 32.4
1.56 1.70** 1.30 2.60*** 2.00
(0.93–2.59) (1.15–2.52) (0.89–1.91) (1.99–3.39) (0.97–4.16)
**P ≤ 0.01, ***P ≤ 0.005, ****P ≤ 0.001 CI = confidence interval; GED = General Educational Development
J Sex Med 2014;11:642–652
J Sex Med 2014;11:642–652 65.5 (1,021) 22.3 (348) 8.7 (136) 9.9 (155) 24.5 (382)
Ever used Past 30 days Past 90 days Past 12 months (year) More than a year ago
Ever used Past 30 days Past 90 days Past 12 months (year) More than a year ago
Ever used Past 30 days Past 90 days Past 12 months (year) More than a year ago
Ever used Past 30 days Past 90 days Past 12 months (year) More than a year ago
Ever used Past 30 days Past 90 days Past 12 months (year) More than a year ago
Ever used Past 30 days Past 90 days Past 12 months (year) More than a year ago
Ever used Past 30 days Past 90 days Past 12 months (year) More than a year ago
Used a lubricant
Used a lubricant during solo masturbation
Used a lubricant during partnered sexual play
Used a lubricant during partnered intercourse
Used a lubricant with a condom
Used a lubricant with a vibrator
Used a lubricant with a dildo
20.8 (323) 3.6 (56) 2.2 (34) 3.1 (48) 11.9 (185)
26.8 (414) 5.5 (85) 2.8 (42) 5.1 (79) 13.4 (207)
32.8 (508) 3.6 (56) 2.0 (32) 3.8 (59) 23.4 (362)
58.3 (904) 16.8 (260) 7.2 (112) 9.3 (144) 25.0 (387)
49.6 (768) 11.4 (177) 5.6 (86) 8.5 (132) 24.1 (373)
29.8 (461) 7.8 (121) 4.2 (65) 5.1 (78) 12.7 (197)
% (n)
Total sample
13.9 (20) 4.7 (7) 1.8 (3) 3.1 (4) 4.3 (6)
20.4 (29) 3.4 (5) 3.7 (5) 4.2 (6) 9.1 (13)
30.3 (43) 5.6 (8) 2.5 (4) 11.3 (16) 10.9 (15)
42.5 (61) 14.4 (21) 4.3 (6) 15.7 (22) 8.2 (12)
35.2 (50) 8.8 (13) 2.1 (3) 11.4 (16) 12.9 (18)
16.8 (24) 5.5 (8) 4.8 (7) 1.2 (2) 5.3 (8)
45.6 (65) 16.7 (24) 7.3 (10) 13.6 (19) 7.9 (11)
% (n)
18–24
21.4 (38) 1.9 (3) 6.4 (11) 2.3 (4) 10.7 (19)
32.2 (57) 3.9 (7) 4.2 (7) 13.2 (23) 10.9 (19)
40.8 (73) 3.2 (6) 4.7 (8) 9.4 (17) 23.5 (42)
62.9 (112) 15.9 (28) 17.1 (30) 11.3 (20) 18.6 (33)
56.5 (100) 12.2 (22) 10.6 (19) 14.6 (26) 19.1 (34)
31.6 (56) 2.6 (5) 7.3 (13) 5.8 (10) 15.9 (28)
72.5 (129) 22.5 (40) 17.4 (31) 14.8 (26) 17.8 (32)
25–29
Weighted lifetime prevalence and recency of lubricant use during various sexual contexts
Recency of Lubricant Use
Table 2
23.8 (63) 3.1 (8) 2.8 (7) 4.7 (12) 13.2 (35)
31.6 (82) 4.7 (12) 2.6 (7) 8.6 (22) 15.7 (41)
47.4 (125) 6.0 (16) 2.3 (6) 4.5 (12) 34.6 (91)
65.4 (170) 14.7 (38) 9.0 (23) 13.7 (36) 28.0 (73)
53.6 (141) 9.8 (26) 7.8 (20) 7.8 (20) 28.2 (74)
30.4 (80) 8.1 (21) 2.9 (8) 7.6 (20) 11.8 (31)
71.5 (188) 19.2 (51) 10.3 (27) 12.2 (32) 29.7 (78)
30–39
22.0 (54) 5.3 (13) 0.8 (2) 4.7 (12) 11.2 (28)
27.5 (69) 8.0 (20) 3.5 (9) 5.6 (14) 10.4 (26)
34.7 (87) 3.7 (9) 1.7 (4) 3.4 (9) 25.9 (65)
57.1 (143) 21.7 (54) 5.7 (14) 6.9 (17) 22.8 (57)
53.7 (134) 14.0 (35) 6.6 (16) 8.6 (21) 24.5 (61)
34.2 (84) 9.3 (23) 5.6 (14) 6.1 (15) 13.2 (32)
68.8 (171) 24.9 (62) 8.3 (21) 8.2 (20) 27.4 (68)
40–49
25.4 (77) 5.6 (17) 1.8 (6) 3.4 (10) 14.4 (44)
28.2 (85) 7.7 (23) 2.9 (9) 2.5 (7) 15.2 (46)
30.4 (90) 3.6 (11) 2.4 (7) 0.5 (1) 23.9 (71)
54.6 (165) 22.4 (68) 6.9 (21) 6.2 (19) 19.0 (58)
50.7 (153) 14.2 (43) 7.3 (22) 5.6 (17) 23.6 (71)
29.7 (90) 8.8 (27) 2.5 (8) 4.8 (14) 13.5 (41)
62.5 (192) 27.8 (85) 8.1 (25) 5.9 (18) 20.7 (64)
50–59
18.8 (54) 2.1 (6) 1.0 (3) 1.5 (4) 14.2 (41)
27.1 (78) 5.1 (15) 1.1 (3) 1.6 (5) 19.3 (55)
21.8 (63) 1.6 (5) 0.8 (2) 1.6 (5) 17.8 (51)
67.3 (191) 13.2 (38) 5.5 (16) 8.4 (24) 40.2 (114)
50.8 (145) 10.0 (28) 1.6 (4) 8.2 (23) 31.0 (88)
36.1 (103) 11.3 (32) 4.6 (13) 5.3 (15) 14.9 (43)
70.8 (204) 23.7 (68) 6.0 (17) 9.0 (26) 32.2 (92)
60–69
13.3 (17) 1.2 (2) 1.9 (3) 0.7 (1) 9.5 (12)
11.6 (15) 2.7 (3) 2.1 (3) 1.1 (1) 5.7 (7)
21.4 (28) 1.4 (2) 0.0 (0) 0.0 (0) 20.0 (26)
47.0 (62) 10.3 (14) 0.9 (1) 4.8 (6) 30.9 (41)
35.1 (46) 8.1 (11) 0.9 (1) 6.1 (8) 20.0 (26)
19.1 (25) 4.4 (6) 2.5 (3) 1.4 (2) 10.8 (14)
54.7 (72) 14.0 (18) 3.7 (5) 9.4 (12) 27.5 (36)
70+
646 Herbenick et al.
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Women’s Lubricant Use n = 121), with fewer participants reporting that they used the lubricant on the inside and outside of the condom (11.5%, n = 17) or only the inside of the condom (4.5%, n = 6).
with the respective product. Overall, older participants (with the exception of participants aged 70+) reported lubricant use more frequently than the younger participants.
Frequency of Commercial Lubricant Use Participants who reported using lubricant within the past 90 days were asked about their frequency of use during this time period. While many participants indicated lubricant use once or twice (39.6%) or three to five times (23.6%), over 20% of the participants reported lubricant use more than 10 times (Table 3). Lubricant use frequencies were similar for use during solo masturbation, partnered sexual play, and partnered intercourse. Participants who reported using lubricant with another product (i.e., condom, vibrator, or dildo) were asked about their frequency of lubricant use
Reasons for Lubricant Use The most commonly endorsed reason why women first started using lubricant was to “make sex more comfortable” (42.9%, n = 438). For women ages 18 to 39, however, the most commonly endorsed reason was “for fun” (Table 4). “To enhance foreplay” and “curiosity” were also commonly reported. When asked why they first started to use lubricant during sexual activities, the most commonly endorsed responses included: “my partner suggested we use a lubricant” (33.9%, n = 345), “I wanted to make sex more pleasurable” (33.0%, n = 337), and “I wanted to reduce discomfort or
Table 3 context
Weighted frequency of lubricant use for participants who reported lubricant during the past 90 days for each Total sample 18–24
Recency of lubricant use
25–29
30–39
40–49
50–59
60–69
11.6 (13) 26.8 (29) 26.2 (28) 12.4 (13) 23.0 (25)
8.0 (7) 37.6 (31) 22.2 (18) 13.8 (12) 18.4 (15)
7.1 (2) 28.8 (6) 27.7 (6) 20.8 (5) 15.6 (3)
23.2 (7) 8.4 (3) 7.2 (2) 9.4 (4) 44.0 (13) 50.3 (18) 13.8 (5) 50.3 (23) 19.5 (6) 22.4 (8) 38.9 (13) 22.1 (10) 9.2 (3) 8.9 (3) 11.2 (4) 12.8 (6) 4.2 (1) 9.9 (4) 28.9 (10) 5.4 (2)
0.0 (0) 44.2 (4) 39.3 (3) 4.4 (0) 12.1 (1)
% (n)
% (n)
9.2 (44) 35.9 (172) 21.4 (103) 14.0 (67) 19.4 (93)
12.2 (4) 55.2 (19) 9.1 (3) 3.4 (1) 20.2 (7)
5.3 (4) 8.0 (6) 11.1 (9) 42.2 (30) 47.7 (37) 23.7 (20) 17.0 (12) 24.0 (18) 19.4 (16) 17.9 (13) 13.1 (10) 16.3 (13) 17.7 (13) 7.1 (5) 29.5 (24)
Used a lubricant during Not at all 11.5 (21) solo masturbation Once or twice 40.6 (75) 3–5 times 26.3 (49) 6–10 times 9.5 (18) More than 10 times 12.1 (22)
20.1 (3) 37.2 (5) 31.3 (5) 5.2 (1) 6.1 (1)
10.5 (2) 42.4 (7) 22.5 (4) 5.4 (1) 19.3 (3)
Used a lubricant during Not at all partnered sexual play Once or twice 3–5 times 6–10 times More than 10 times
8.6 (22) 27.8 (71) 25.4 (65) 16.6 (43) 21.6 (55)
6.6 (1) 20.6 (3) 20.9 (3) 13.4 (2) 38.6 (6)
4.6 (2) 9.9 (5) 14.6 (7) 33.9 (14) 39.7 (18) 13.8 (7) 16.3 (7) 39.8 (18) 23.4 (12) 22.0 (9) 6.9 (3) 24.5 (13) 23.1 (9) 3.7 (2) 23.8 (12)
Used a lubricant during Not at all partnered intercourse Once or twice 3–5 times 6–10 times More than 10 times
2.9 (11) 30.8 (114) 27.9 (103) 13.4 (50) 24.9 (92)
0.0 (0) 0.2 (0) 4.7 (3) 54.8 (15) 32.0 (19) 48.0 (30) 9.5 (3) 40.2 (24) 24.2 (15) 0.7 (1) 11.3 (7) 15.0 (9) 35.0 (9) 16.3 (10) 8.0 (5)
Used a lubricant with a condom
Not at all Once or twice 3–5 times 6–10 times More than 10 times
18.8 (16) 20.8 (18) 21.4 (18) 17.1 (15) 21.9 (19)
46.6 (5) 16.3 (2) 14.4 (2) 0.0 (0) 22.8 (3)
21.0 (3) 8.9 (1) 0.7 (0) 33.9 (5) 35.4 (5)
Used a lubricant with a vibrator
Not at all Once or twice 3–5 times 6–10 times More than 10 times
7.4 (9) 27.3 (34) 27.4 (34) 18.8 (24) 19.1 (24)
10.2 (1) 13.5 (1) 9.4 (1) 44.9 (5) 21.9 (2)
Used a lubricant with a dildo
Not at all Once or twice 3–5 times 6–10 times More than 10 times
12.4 (11) 29.6 (27) 20.9 (19) 18.4 (17) 18.6 (17)
35.2 (3) 1.1 (1) 8.6 (1) 11.4 (1) 43.7 (4)
Used a lubricant
Not at all Once or twice 3–5 times 6–10 times More than 10 times
70+
7.6 (4) 4.1 (1) 25.6 (15) 38.9 (13) 22.2 (13) 27.8 (9) 19.2 (11) 5.1 (2) 25.3 (15) 24.2 (8)
10.7 (1) 10.4 (1) 24.9 (3) 25.5 (3) 28.6 (3)
0.2 () 25.1 (17) 22.1 (15) 17.4 (12) 35.2 (24)
5.4 (5) 3.9 (2) 23.1 (21) 20.1 (10) 29.8 (26) 32.5 (17) 14.9 (13) 11.4 (6) 26.9 (24) 32.2 (17)
5.9 (1) 21.0 (3) 27.3 (4) 18.0 (3) 27.9 (4)
19.1 (4) 43.1 (9) 20.2 (4) 15.8 (3) 1.9 (1)
4.2 (1) 15.7 (2) 31.6 (4) 15.1 (2) 33.5 (5)
15.9 (3) 19.1 (3) 18.2 (3) 21.5 (3) 25.2 (4)
6.3 (1) 0.0 (0) 50.2 (4) 12.5 (1) 31.0 (2)
0.0 (0) 0.0 (0) 100.0 (1) 0.0 (0) 0.0 (0)
17.3 (2) 16.8 (2) 20.8 (3) 31.2 (4) 13.9 (2)
4.1 (1) 34.9 (7) 48.3 (9) 3.4 (1) 9.3 (2)
9.6 (3) 30.5 (9) 14.0 (4) 28.1 (8) 17.8 (5)
4.4 (1) 22.3 (7) 28.8 (9) 7.4 (2) 37.1 (11)
5.0 (1) 28.7 (5) 44.8 (8) 10.5 (2) 11.1 (2)
0.0 (0) 54.9 (3) 14.9 (1) 30.2 (2) 0.0 (0)
16.3 (2) 42.6 (6) 4.1 (1) 32.6 (5) 4.3 (1)
25.2 (4) 17.4 (3) 40.2 (6) 14.2 (2) 3.1 (1)
0.0 (0) 16.9 (3) 31.0 (5) 35.2 (5) 16.9 (3)
7.1 (2) 34.6 (8) 17.6 (4) 7.6 (2) 33.1 (8)
0.0 (0) 64.3 (6) 15.6 (1) 6.3 (1) 13.9 (1)
0.0 (0) 39.0 (2) 30.0 (1) 23.0 (1) 8.1 (0)
J Sex Med 2014;11:642–652
648 Table 4
Herbenick et al. Reasons for lubricant use by age using post-stratification weights
Reason for use Reason for first start of use To make sex more comfortable For fun To enhance foreplay Curiosity To add pleasurable sensations to sex To make sex feel more wet My partner wanted us to To spice up my/our sex life Approaching menopause To manage vaginal pain To comfortably have anal sex To reduce the risk of tearing My (or my partner’s) body changed during pregnancy Because of medication use/surgery Other reason A friend said it was fun to use While postpartum/nursing To reduce the risk of condom breakage
Total sample
18–24
% (n)
% (n)
42.9 (438) 32.1 (327) 27.0 (275) 26.4 (269) 21.6 (221) 21.5 (219) 16.7 (171) 14.9 (152) 14.3 (146) 14.1 (144) 11.0 (112) 8.0 (81) 4.5 (46) 4.3 (44) 4.2 (43) 3.8 (39) 3.7 (37) 1.2 (12)
Reason for first start of use during sexual activities My partner suggested we use lubricant 33.8 (345) I wanted to make sex more pleasurable 33.0 (337) I wanted to reduce discomfort or pain 31.6 (322) during sex I saw an advertisement for lubricant 13.8 (141) A doctor or nurse recommended lubricant 9.7 (99) A friend recommended lubricant 6.4 (66) I noticed that lubricated condoms felt more 6.4 (65) comfortable Other reason 4.8 (49) A health educator or sex educator 2.0 (20) recommended lubricant A family member recommended lubricant 0.9 (9)
25–29
30–39
40–49
50–59
60–69
70+
31.4 (20) 44.0 (29) 27.8 (18) 36.6 (24) 16.1 (10) 28.4 (18) 17.0 (11) 16.2 (11) 0.0 (0) 11.7 (8) 9.3 (6) 11.8 (8) 5.9 (4)
37.6 (48) 45.4 (58) 33.7 (43) 40.3 (52) 24.0 (31) 15.0 (19) 20.1 (26) 15.6 (20) 0.0 (0) 10.2 (13) 19.8 (25) 10.0 (13) 6.0 (8)
31.9 (60) 42.1 (79) 32.9 (62) 32.5 (61) 18.8 (35) 15.1 (29) 13.8 (26) 13.8 (26) 0.2 (1) 8.6 (16) 13.4 (25) 3.1 (6) 5.2 (10)
39.7 (68) 31.3 (54) 25.9 (44) 20.5 (35) 19.5 (33) 22.5 (39) 18.2 (31) 14.1 (24) 10.4 (18) 9.6 (16) 7.7 (13) 7.2 (12) 5.6 (10)
43.9 (84) 26.6 (51) 23.8 (46) 22.7 (44) 23.7 (45) 19.8 (38) 9.3 (18) 12.5 (24) 25.9 (50) 14.7 (28) 12.2 (23) 5.1 (10) 5.3 (10)
54.6 (111) 24.1 (49) 24.9 (51) 19.9 (41) 25.2 (51) 29.5 (60) 22.6 (46) 17.7 (36) 29.1 (59) 24.0 (49) 7.0 (14) 9.4 (19) 1.6 (3)
63.5 (45) 10.2 (7) 15.6 (11) 18.0 (13) 19.0 (14) 22.8 (16) 17.7 (13) 16.2 (12) 26.5 (19) 19.4 (14) 6.4 (5) 19.1 (14) 2.8 (2)
6.2 (4) 4.9 (3) 8.7 (6) 4.1 (3) 4.2 (3)
1.5 (2) 1.9 (2) 7.1 (9) 5.6 (7) 1.2 (2)
5.6 (11) 5.1 (10) 3.7 (7) 5.5 (10) 0.3 (1)
5.0 (9) 3.6 (6) 1.5 (3) 2.3 (4) 2.6 (4)
3.7 (7) 3.6 (7) 1.2 (2) 5.2 (10) 0.9 (2)
3.5 (7) 5.3 (11) 5.6 (11) 0.3 (1) 0.4 (1)
6.8 (5) 5.9 (4) 1.2 (1) 3.4 (2) 0.5 (1)
35.5 (23) 33.9 (22) 27.0 (18)
33.3 (43) 34.1 (44) 23.1 (30)
37.9 (71) 29.3 (55) 21.3 (40)
38.6 (66) 33.7 (58) 27.1 (46)
31.1 (60) 32.9 (63) 34.3 (66)
32.4 (66) 37.6 (77) 42.3 (86)
22.5 (16) 25.1 (18) 50.9 (37)
16.8 (11) 3.0 (2) 8.6 (6) 4.8 (3)
15.5 (20) 4.7 (6) 9.8 (13) 7.3 (9)
7.5 (14) 6.3 (12) 5.1 (10) 6.4 (12)
9.5 (16) 6.4 (11) 5.0 (9) 8.9 (15)
13.8 (26) 9.9 (19) 7.9 (15) 7.1 (14)
19.9 (41) 16.6 (34) 6.2 (13) 3.1 (6)
17.0 (12) 21.9 (16) 2.1 (1) 8.1 (6)
7.4 (5) 0.0 (0)
3.2 (4) 2.3 (3)
7.1 (13) 3.1 (6)
3.4 (6) 0.8 (1)
5.9 (11) 1.7 (3)
3.7 (8) 2.6 (5)
2.2 (2) 2.3 (2)
5.1 (3)
0.4 (0)
1.2 (2)
0.2 (1)
0.6 (1)
0.8 (2)
0.0 (0)
pain during sex” (31.6%, n = 322). These options were consistently the most frequently endorsed across age groups.
Perceptions of Lubricants Consistent with their reasons for use, the most commonly endorsed perception was that a lubricant “makes sex more comfortable” (85.1%, n = 839). Over half of the participants agreed that lubricant use during sexual activities “makes sex feel better” and “makes it easier to feel aroused.” Less than 15% of the participants reported that they perceived lubricants to be only for older people (Table 5). Discussion
Findings from the 2012 NSSHB demonstrate that most American women have used lubricant during solo or partnered sexual activities, with partnered intercourse and sexual play being the most J Sex Med 2014;11:642–652
common sexual events associated with lubricant use. Also, about one in three women in the United States has used a commercial lubricant with a condom, about one in four women has used lubricant with a vibrator, and about one in five women has used lubricant with a dildo. These data speak to the role that lubricants play in women’s sexual experiences, the contributions of lubricants to women’s sexual health, as well as the diverse ways that women engage in sexual activities (including the use of consumer products). That the most common reason women first started to use lubricant was to make sex feel more comfortable (endorsed by 43% of participants) is perhaps not surprising given other data demonstrating the high prevalence of pain and difficulty with vaginal lubrication experienced by women during sex [11]. However, it is notable that—for women aged 18 to 39—the most common reason for beginning lubricant use was “for fun,” followed closely by reasons related to curiosity and foreplay
649
61.4 (70) 44.4 (50) 66.8 (72) 19.8 (21) 72.3 (79) 38.6 (44) 55.6 (62) 33.2 (36) 80.2 (85) 27.7 (30)
% Disagree
62.5 (165) 55.8 (144) 69.0 (178) 16.8 (43) 80.1 (204) 37.5 (99) 44.2 (114) 31.0 (80) 83.2 (215) 19.9 (51)
% Disagree
52.6 (155) 46.5 (137) 53.7 (155) 13.0 (37) 66.2 (192) 47.4 (140) 53.5 (157) 46.3 (134) 87.0 (248) 33.8 (98)
% Disagree
57.3 (139) 41.9 (98) 63.3 (147) 8.9 (21) 73.5 (174) 42.7 (104) 58.1 (137) 36.7 (85) 91.1 (216) 26.5 (63)
% Disagree
52.7 (137) 41.2 (106) 61.8 (159) 8.6 (22) 67.4 (171) 47.3 (123) 58.8 (151) 38.2 (98) 91.4 (233) 32.6 (83)
% Disagree
57.8 (93) 38.6 (60) 60.9 (95) 12.9 (20) 67.3 (107)
% Agree
42.2 (68) 61.4 (95) 39.1 (61) 87.1 (134) 32.7 (52)
% Disagree
50.0 (67) 45.3 (60) 56.8 (77) 22.6 (30) 65.4 (86) 50.0 (67) 54.7 (72) 43.2 (58) 77.4 (103) 34.6 (45) 56.2 (825) 45.4 (654) 61.5 (883) 13.6 (195) 70.6 (1,014)
(n)
Makes sex more comfortable.
Is only for older people.
(n)
43.8 (644) 54.6 (788) 38.5 (553) 86.4 (1,235) 29.4 (423) Makes it easier to feel aroused. Makes it easier to have an orgasm. Makes sex feel better.
25–29
% Disagree
% Agree 18–24
% Disagree
% Agree Total
Using lubricant during sexual activities . . .
Table 5
Perceptions of lubricant use by age using post-stratification weights
30–39
% Agree
40–49
% Agree
50–59
% Agree
60–69
% Agree
70+
% Agree
Women’s Lubricant Use
enhancement (as well as increasing comfort). Fun-, curiosity- and pleasure-focused reasons echo reasons why women, in a 2008 nationally representative study of women aged 18 to 60, report use of vibrators and other sex toys [3]. A key difference, however, in these two studies has to do with recommendations from friends. In the earlier national study of vibrator use, 18% of women aged 18 to 60 indicated that they had first started using a vibrator because a friend had said that vibrators were fun to use [3]. In the present study, only 3.8% of women indicated that they had first started using lubricant due to a friend’s recommendation. Subsequent research might investigate this further as a means of understanding the kinds of conversations about sex and information-sharing women engage in with their friends. For example, subsequent research might examine whether it is more common for women to talk about sex toys or to discuss orgasms (e.g., which vibrators may be connected to in women’s perceptions or experiences) with their friends. What is it about lubricant use that perhaps makes it less likely to be talked about? And is that changing? For example, about 9% of 18–24-year-old women and 7% of 25–29-year-old women indicated that they first started using lubricant because a friend said lubricants were fun to use, whereas fewer women in older age groups endorsed this reason. That noted, more women—about 17%— indicated that they first started using lubricant because their partner wanted to (in comparison, 28% of women in the previous study first began using a vibrator for this reason). Partner suggestion was also the number one reason, in the total sample, given for why women first started using lubricant, specifically during sexual activities. Clinician recommendations were the fifth most common reason women began using lubricant during sexual activities (behind having seen an advertisement), with about 10% of women (mostly aged 60 and older) endorsing this reason for initial use. That so few women begin using lubricants because of clinician recommendations is notable. Given the large proportion of women who experience painful, uncomfortable sex, who feel that their vaginal lubrication is insufficient for the kinds of sex they are having, and/or who are postmenopausal, lactating, or experiencing vulvovaginal atrophy, it may be important for clinicians to incorporate questions about comfortable sex, vaginal lubrication, and/or the use of commercial lubricants when interacting with patients. Women may not report lubricants as among the topical J Sex Med 2014;11:642–652
650 products that they use, but given their potential for pleasure as well as irritation, it would be helpful for clinicians to have a more comprehensive understanding of the products women use on or in their genitals. Such conversations may also expand opportunities for clinicians and patients to discuss uncomfortable or painful sex, which appears to be a common experience for American women and one still not often talked about. Regarding women’s perceptions of lubricant use, about 85% of women agreed that lubricant makes sex more comfortable and over threequarters agreed that it makes sex feel better. Very few women felt that lubricant was only for older people (12%), and sizable proportions of women felt that lubricant use made it easier to feel aroused (69%) or easier to have an orgasm (56%). Subsequent research might explore more closely how women feel sex is better (or not better) with lubricant use and how lubricant does or does not contribute to their experiences of arousal and/or orgasm. About 30% of American women surveyed reported having used a lubricant during solo masturbation. Aside from the fact that many women masturbate at some point during their lives, and that masturbation is common among women across age, sexual orientation, and relationship status [22,24], little is known about the details of women’s solo masturbation experiences, perhaps because of a long-standing taboo about female masturbation. That nearly one-third of American women (and 8% of women just in the past 30 days) have used lubricant during solo masturbation contributes to our understanding of some aspects of female masturbation regardless of their relationship status. As with vibrators, using lubricant during masturbation may help women to masturbate more pleasurably, or more quickly or efficiently to orgasm. Some women may feel that this helps them to more easily incorporate masturbation into their busy lives that often involve paid or unpaid work, school, exercise, household chores, and/or caring for children, their partner, and/or aging parents [25,26]. This study had several strengths and limitations. A significant strength of the study is that sexual behavior and lubricant use were asked about in a nationally representative probability sample of Americans aged 18 and older. Participants completed the survey via the Internet, thus facilitating privacy and ease of access (as opposed to, say, having to travel to be interviewed or having to allow a stranger into their home to interview them J Sex Med 2014;11:642–652
Herbenick et al. about a sensitive topic) and, as noted earlier, were provided with computer hardware or Internet access if needed. Additionally, women are eligible to be part of the Knowledge Networks/GfK sample regardless of their Internet access or ownership of the hardware or software necessary to complete computer-based surveys on the Internet, as these are provided for participants if needed to facilitate their inclusion on the panel. Also, because participants are members of an ongoing active panel, they are familiar with the interface and did not require additional training regarding how to complete Internet-based questionnaires. The survey was also available in both English and Spanish languages. A limitation is that the sample was restricted to individuals who had a home address and who were community dwelling (e.g., not institutionalized). This may have limited the sample, particularly for much older individuals and/or those experiencing health conditions that warrant inpatient care. It is also possible that some people may not have felt comfortable answering questions about their sexual experiences or lubricant use, even in spite of being able to do so in the privacy of their own homes and via the Internet. Additionally, although we tried to clearly identify what we meant by a “lubricant” at various points throughout the survey, it is possible that some participants had different definitions in mind; however, we expect that this number would be small enough so as to not have a significant influence on our findings. Subsequent research might also explore differences in lubricant use behaviors and/or perceptions based on type of lubricant used (e.g., lubricants marketed for sensations vs. those marketed for increasing comfort). Given how rapidly sexual enhancement products have become more mainstream and more widely available, we feel that more attention should be paid to how women and men use these consumer products as part of their sexual experiences. For too long, taboos related to sexuality have perhaps contributed to the lack of research on these topics. Just as adult retail stores have become mainstream, it is our hope that scientific research related to sexual health and sexual enhancement product use will become more commonplace, thus contributing to scientific and clinical knowledge, and potentially, people’s quality of life. In the case of lubricants, a number of lubricants are available in the marketplace and women use them for a variety of solo and partnered sexual experiences, sometimes in combination with other products
651
Women’s Lubricant Use (e.g., condoms, vibrators, dildos, and other sex toys), and—because of the sex acts they are used as part of—lubricants are likely to be applied to a variety of body sites and orifices including the vulva, vagina, mouth, and anus. A greater understanding of these sexual practices can only serve to enhance clinicians’ understanding of their patients’ lives, including what they are doing and why (e.g., to improve comfort, to reduce pain, to enhance pleasure)—all of which may open communication and conversation among clinicians and patients. Given the high rates of self-reported pain during sex and difficulties with vaginal lubrication during sex, as well as a general human desire for sexual pleasure and enhancement as part of sex, clinicians may find it helpful to ask women more often about their comfort during sex and their lubricant use behaviors. Conclusions
Findings from this study demonstrate that most American women have used lubricant and that lubricant is more common as part of partnered intercourse and sexual play or foreplay compared with other solo and partnered sexual behaviors. Common reasons for lubricant use cited include to make sex more comfortable, for fun, due to curiosity, to enhance foreplay, and to add pleasurable sensations to sex (the latter reasons being particularly common among younger women). Clinicians may find it helpful and important to broaden conversations with patients to include questions about their sexual behaviors, comfort during sex, vaginal lubrication, and lubricant use. Acknowledgment
This study was partially funded by Church & Dwight, Co., Inc. Corresponding Author: Debby Herbenick, PhD, MPH, Center for Sexual Health Promotion, Indiana University, Bloomington, IN 47405, USA. Tel: 8123223777; Fax: 812 855 3936; E-mail: debby@ indiana.edu Conflict of Interest: Michael Reece is a member of the sexual health advisory council of Church & Dwight Co., Inc. Statement of Authorship
Category 1 (a) Conception and Design Debby Herbenick; Michael Reece; Stephanie A. Sanders; Vanessa Schick; J. Dennis Fortenberry
(b) Acquisition of Data Debby Herbenick; Michael Reece; Stephanie A. Sanders; J. Dennis Fortenberry; Vanessa Schick (c) Analysis and Interpretation of Data Vanessa Schick; Debby Herbenick
Category 2 (a) Drafting the Article Debby Herbenick; Vanessa Schick (b) Revising It for Intellectual Content Debby Herbenick; Vanessa Schick; Stephanie A. Sanders; J. Dennis Fortenberry; Michael Reece
Category 3 (a) Final Approval of the Completed Article Debby Herbenick; Vanessa Schick; Stephanie A. Sanders; J. Dennis Fortenberry; Michael Reece
References 1 Herbenick D, Reece M, Hensel D, Sanders SA, Jozkowski K, Fortenberry JD. Association of lubricant use with women’s sexual pleasure, sexual satisfaction, and genital symptoms: A prospective daily diary study. J Sex Med 2011;8:202–12. 2 Herbenick D, Schick V, Reece M, Sanders SA, Smith N, Dodge B, Fortenberry JD. Characteristics of condom and lubricant use among a nationally representative sample of adults ages 18–50 in the United States. J Sex Med 2013;10: 474–83. 3 Herbenick D, Reece M, Sanders SA, Dodge B, Ghassemi A, Fortenberry JD. Women’s vibrator use in romantic relationships: Results from a nationally representative survey in the United States. J Sex Marital Ther 2010;36:49–65. 4 Jozkowski KN, Herbenick D, Schick V, Reece M, Sanders SA, Fortenberry JD. Women’s perceptions about lubricant use and vaginal wetness during sexual activities. J Sex Med 2013;10: 484–92. 5 Schrobsdorff S. Red-light specials. Newsweek 2008. Available at: http://www.newsweek.com/id/110965 (accessed July 16, 2013). 6 Butler E. Steaming up the aisles. 2006. Available at: http:// www.crainsnewyork.com/article/20061029/FREE/61028016 (accessed July 16, 2013). 7 Sutton KS, Boyer SC, Goldfinger C, Ezer P, Pukall CF. To lube or not to lube: Experiences with perceptions of lubricant use in women with and without dyspareunia. J Sex Med 2012;9:240–50. 8 Emilee G, Ussher JM, Perz J. Sexuality after breast cancer: A review. Maturitas 2010;66:397–407. 9 Tan O, Bradshaw K, Carr B. Management of vulvovaginal atrophy-related sexual dysfunction in postmenopausal women: An up-to-date review. Menopause 2012;19:109–17. 10 Katz A. Sexual changes during and after pregnancy. Am J Nurs 2010;110:50–2. 11 Herbenick D, Reece M, Schich V, Sanders SA, Dodge B, Fortenberry JD. An event-level analysis of the sexual characteristics and composition among adults ages 18 to 59: Results from a national probability sample in the United States. J Sex Med 2010;7(5 suppl):346–61. 12 Meson CM, Buss DM. Why humans have sex. Arch Sex Behav 2007;36:477–507. 13 Ayling K, Ussher JM. “If sex hurts, am I still a woman?” The subjective experience of vulvodynia in hetero-sexual woman. Arch Sex Behav 2008;37:294–304.
J Sex Med 2014;11:642–652
652 14 Andersen BL, Hacker NF. Psychosexual adjustment after vulvar surgery. Obstet Gynecol 1983;62:457–62. 15 Jackson SM, Cram F. Disrupting the sexual double standard: Young women’s talk about heterosexuality. Brit J Soc Psychol 2003;42:113–27. 16 Tolman D. Female adolescent sexuality: An argument for a developmental perspective on the new view of women’s sexual problems. Women Ther 2002;24:1–2, 195–209. 17 Baker L, Wagner TH, Singer S, Bundorf MK. Use of the Internet and e-mail for health care information: Results from a national survey. JAMA 2003;289:2400–6. 18 Heiss F, McFadden D, Winter J. Who failed to enroll in Medicare Part D, and why? Early results. Health Aff 2006;25:344–54. 19 Silver RC, Holman EA, McIntosh DN, Poulin M, Gil-Rivas V. Nationwide longitudinal study of psychological responses to September 11. JAMA 2002;288:1235. 20 Sanders SA, Reece M, Herbenick D, Schick V, Dodge B, Fortenberry JD. Condom use during most recent vaginal intercourse event among a probability sample of adults in the United States. J Sex Med 2010;7(5 suppl):362– 73.
J Sex Med 2014;11:642–652
Herbenick et al. 21 Reece M, Herbenick D, Schick V, Sanders SA, Dodge B, Fortenberry JD. Sexual behaviors, relationships, and perceived health among adult men in the United States: Results from a national probability sample. J Sex Med 2010;7(5 suppl):291– 304. 22 Herbenick D, Reece M, Schick V, Sanders SA, Dodge B, Fortenberry JD. Sexual behaviors, relationships, and perceived health among adult women in the United States: Results from a national probability sample. J Sex Med 2010;7(5 suppl):277–90. 23 Herbenick D, Reece M, Sanders SA, Dodge B, Ghassemi A, Fortenberry JD. Prevalence and characteristics of vibrator use by women in the United States: Results from a nationality representative study. J Sex Med 2009;6:1857–66. 24 Gerressu M, Mercer CH, Graham CA, Wellings K, Johnson AM. Prevalence of masturbation and associated factors in a British national probability survey. Arch Sex Behav 2008;37: 266–78. 25 Pierret CR. The “sandwich generation”: Women caring for parents and children. Mon Labor Rev 2006;3–9. 26 Lachance-Grzela M, Bouchard G. Why do women do the lion’s share of housework? A decade of research. Sex Roles 2010;63:767–80.
Women’s Use and Perceptions of Commercial Lubricants: Prevalence and Characteristics in a Nationally Representative Sample of American Adults Debby Herbenick, PhD, MPH,* Michael Reece, PhD, MPH,* Vanessa Schick, PhD,† Stephanie A. Sanders, PhD,‡§ and J. Dennis Fortenberry, MD, MS¶ *Center for Sexual Health Promotion, Indiana University, Bloomington, IN, USA; †University of Texas. Houston, TX, USA; ‡ The Kinsey Institute for Research on Sex, Gender, and Reproduction, Indiana University, Bloomington, IN, USA; § Department of Gender Studies, Indiana University, Bloomington, IN, USA; ¶Division of Adolescent Medicine, School of Medicine, Indiana University, Indianapolis, IN, USA DOI: 10.1111/jsm.12427
ABSTRACT
Introduction. Use of commercial lubricant is common in the United States among adult women. However, little is known about the sexual behaviors for which women use lubricant, women’s perceptions of lubricant, or reasons for use, particularly in a nationally representative sample. Aim. The aim of this study was to document the prevalence and characteristics of lubricant use among adult women in the United States and their perceptions of lubricants in relation to subjective sexual experiences. Methods. Data are from a subset of individuals who were sampled as part of the 2012 National Survey of Sexual Health and Behavior, which involved the administration of an online questionnaire to a nationally representative probability sample of U.S. adults ages 18 and older. Main Outcome Measures. Sociodemographic characteristics, recent and lifetime commercial lubricant use, lubricant use during specific sexual behaviors, frequency of lubricant use, and reasons for lubricant use of participants were studied for the article. Results. Of the women who participated in the study, 65.5% (n = 1,021) reported ever having used lubricant and 20% had used a lubricant within the past 30 days. Across age groups, lubricant was most commonly used during intercourse (58.3% of women) or partnered sexual play (49.6%). Common reasons for lubricant use included to make sex more comfortable, fun, and pleasurable and to decrease discomfort/pain. Conclusions. Most American women have used lubricant. Also, lubricant is more common as part of partnered intercourse and sexual play or foreplay compared with other solo and partnered sexual behaviors. Clinicians may find it helpful to broaden conversations with patients to include questions about their sexual behaviors, comfort and/or pain during sex, and lubricant use and to share, particularly with younger women, that lubricant use is prevalent and commonly used for reasons related to pleasure as well as comfort. Herbenick B, Reece M, Schick V, Sanders SA, and Fortenberry JD. Women’s use and perceptions of commercial lubricants: Prevalence and characteristics in a nationally representative sample of American adults. J Sex Med 2014;11:642–652. Key Words. Lubricant; Vaginal Lubrication; Sexual Pleasure
Introduction
C
ommercial lubricants are widely sold in the United States and are commonly used by women as part of their solo and partnered sexual experiences [1–3]. Data from 2008 suggest that J Sex Med 2014;11:642–652
most women ages 18 to 60 (up to 62%) report use of a commercial lubricant, with 25% having done so in the previous month [3], suggesting variation in commercial lubricant use, frequency of use, as well as variation in reasons for lubricant use. For example, 2009 data demonstrate that © 2014 International Society for Sexual Medicine
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Women’s Lubricant Use 28.9% of women used a lubricant during sex without a condom, compared with 21.7% of women who used a condom [2]. Many women choose lubricants to enhance the subjective positive experiences of sexual events. For example, more than two-thirds of women choose lubricants to make sex more pleasurable, and about one-third of women use lubricants for fun or due to a preference for feeling very wet during sex [4]. Data from a large convenience sample of about 2,400 sexually active women demonstrate that lubricant use is associated with significantly higher ratings of sexual pleasure and satisfaction compared with sexual events that occurred without the use of lubricant [1]. Indeed, in recent years, advertising for lubricant has focused on sexual enhancement, foreplay, and pleasure [5,6], which has perhaps contributed to changing perceptions of lubricants, away from being only for older women or those with certain medical conditions and toward perceptions that lubricants may contribute to more pleasurable sex for women and men of all ages. Although commonly used for reasons related to pleasure, lubricants also are commonly used to ameliorate negative experiences of sexual events and have long been associated with aging and menopause. Many women (about 54%) choose lubricants because they feel that their natural vaginal lubrication is insufficient [3]. Also, women—including postmenopausal women, lactating women, breast cancer survivors, and women experiencing vulvovaginal pain—use lubricants to help make sex less painful, more comfortable, or at least tolerable [7–10]. Given the role of partnered sex in reproduction as well as in relationship happiness and satisfaction, it is not surprising that people look for ways to manage sex even under difficult circumstances. This use of lubricants to decrease pain and/or to increase comfort during sex is important as about 30% of women in a U.S. national sample have reported some degree of pain during their most recent sexual experience with a partner and about one-third of women report difficulty with vaginal lubrication during their most recent sexual experience [11]. Although women commonly report pain during sex, many women engage in sexual behavior because they still find it pleasurable (even in the midst of pain), because it feels connecting to them and/or their partner, to please their partner, or because they feel that it is part of their duties as a girlfriend or wife [12–14]. These uses for lubricants—to enhance sexual pleasure and ameliorate sexual pain—exemplify
the complexities of incorporation of a sexual health perspective in clinical medicine. In keeping with widely cited definitions of sexual health, lubricants enhance the contributions of sex to overall wellbeing, beyond the simple absence of disease or dysfunction. In addition, women’s relatively autonomous use of pleasure-enhancing products (such as vibrators and lubricants) highlights a still prevalent sexual double standard that gives minimal importance—and in some cases even stigmatizes—women’s sexual pleasure, in adolescence as well as in adulthood [15,16]. The important role of lubricants for ameliorating temporary or more enduring sexual problems of pain, however, points to both the commercialization and medicalization of women’s sexual function. These roles played by lubricants in women’s sexual health suggest the importance of more detailed understanding of commercial lubricant use among contemporary adult women. As much of the existing data on women’s lubricant use are from convenience samples, sexually active samples, or clinical samples, nationally representative data on lubricant use would be particularly helpful for clinicians, educators, and other sexual health professionals who are routinely faced with questions about women’s lubricant use. Aim
The purpose of this study (a subset of the 2012 National Survey of Sexual Health and Behavior [2012 NSSHB]) was to assess: (i) the prevalence and characteristics of lubricant use among American adult women (age 18 years and older); (ii) the sexual behaviors with which women use lubricant; (iii) the reasons why women first began using lubricant; and (iv) women’s perceptions of lubricant use. Methods
Study protocols and measures were reviewed and approved by the Institutional Review Board at the first author’s institution. The 2012 NSSHB is a population-based cross-sectional survey of adult women and men in the United States. Data were collected during October and November 2012, via the KnowledgePanel of GfK Research (GfK) (Menlo Park, CA, USA). Research panels accessed through GfK are based on a national probability sample established using both random digit dialing and an address-based sampling (ABS) frame. ABS involves the probability sampling of a frame of residential addresses in the United States derived from the U.S. Postal Service’s Delivery Sequence J Sex Med 2014;11:642–652
644 File, a system which contains detailed information on every mail deliverable address in the United States. Collectively, the sampling frame from which participants are recruited covers approximately 98% of all U.S. households. Randomly selected addresses are recruited to the research panel through a series of mailings and subsequently by telephone follow-ups to nonresponders when possible. To further correct sources of sampling and non-sampling error, study samples are corrected with a post-stratification adjustment using demographic distributions from the most recent data available from the Current Population Survey, the monthly population survey conducted by the U.S. Bureau of the Census considered to be the standard for measuring demographic and other trends in the United States. These adjustments result in a panel base weight that was employed in a probability proportional to size selection method for establishing the samples for this study. Once the sample frame was established, all individuals within that frame received a recruitment message from GfK that provided a brief description of the NSSHB and invited them to participate. A total of 6,175 were included in the initial sampling frame, with 61.5% (n = 4,020) viewing the informed consent. Of those viewing the informed consent, 81.7% (n = 3,285) consented to participate, with a total of 3,138 of those individuals (95.5%) completing the survey. Of these participants, 49.6% identified their gender as female and data from these 1,559 women are included in this report. The survey was administered in either English or Spanish. All data were collected by GfK via the Internet; participants in a given KnowledgePanel were provided with access to the Internet and hardware if needed. Multiple researchers have used GfK’s KnowledgePanel for multiple health-related studies, substantiating the validity of such methods for obtaining data from nationally representative samples of the U.S. population [17–23], and additional details about this methodology as used in the NSSHB are described elsewhere [20–23]. Main Outcome Measures
Demographics Participants responded to questions about their age, education, race/ethnicity, sexual orientation, and relationship status. Commercial Lubricant Use Participants provided details about commercial lubricant use at varying points in their lifetime. J Sex Med 2014;11:642–652
Herbenick et al. Response options included that participants had used a lubricant within the 30 days prior to participating in the study, 90 days prior to the study, within the past 12 months, more than 1 year ago, or never. Participants were provided with a definition of lubricant that included “any personal lubricant or vaginal moisturizer that you can purchase in a store marketed to enhance the sexual experience and/or increase lubrication.”
Commercial Lubricant Use During Specific Sexual Behaviors and Other Product Use Participants were also asked (using the same response categories as above—past 30 days, 90 days, etc.) to indicate whether they had used a lubricant during specific sexual behaviors, including: while masturbating alone, during sexual play or foreplay with a partner, and during intercourse. Participants were also asked to respond similarly as to whether they had used a lubricant in conjunction with a condom, a vibrator, or a dildo. Reasons for Lubricant Use Women were asked to provide the main reasons for their initial use of a commercial lubricant, with 18 response options including: “to make sex feel more wet” to “to manage vaginal pain” and “to spice up my/our sex life,” among others. Perceptions of Commercial Lubricant Use Participants were asked to respond to the extent to which they agreed or disagreed with items related to their perceptions of the use of lubricant during sexual activities. These items ranged from those such as “lubricant use is embarrassing” to “lubricant makes sex feel better” to “lubricant is only for older people.” Response options included a fourpoint scale ranging from strongly disagree to strongly agree. Analyses In all analyses, post-stratification data weights were used to reduce variance and minimize bias due to non-sampling error. Distributions for age, race, sex, Hispanic ethnicity, education, and U.S. census region were used in post-stratification adjustments. Bivariate logistic regressions were used to investigate the relationship between sociodemographic characteristics (i.e., age, education, race/ethnicity, sexual orientation, relationship status) and lifetime lubricant use. Recency, frequency, perceptions, and reasons for lubricant use were explored using descriptive statistics (e.g., frequencies).
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Women’s Lubricant Use Results
Sociodemographic Characteristics Participants ranged in age from 18 to 91 with a mean age of 46.8 (standard deviation = 16.6). Over half of the participants reported attending or graduating from college (Table 1). Most reported living with a spouse (51.6%, n = 835) with the second largest group being single and not dating (21.2%, n = 343). Participants were primarily white, non-Hispanic (66.5%, n = 1,082) and identified as heterosexual (93.6%, n = 1,498). Commercial Lubricant Use Rates Lifetime lubricant use significantly varied based upon the age, education, race/ethnicity, and relationship status (Table 1). Lubricant use was significantly higher among women who were aged 25 and older (P < 0.001), white (P < 0.01), and/or college educated (P < 0.01). Participants who were
in a relationship but not living together (odds ratio [OR] = 1.70, P < 0.01) and those who were married and living together (OR = 2.60, P < 0.001) were significantly more likely to use lubricants than those who were currently single and not dating. Overall, 65.5% (n = 1,021) of women reported lifetime lubricant use (Table 2) and over 20% had used a lubricant within the past 30 days. In all age groups, the most common context of lubricant use was during partnered intercourse (58.3%, n = 904) or partnered sexual play (49.6%, n = 768). While less commonly reported, approximately one-third of the participants (29.8%, n = 461) reported using lubricant during solo masturbation. Between 20% and 30% of women reported using a lubricant with a condom (32.8%), vibrator (26.8%), or dildo (20.8%). Of those who reported using a lubricant with a condom, most indicated they used the lubricant on the outside of the condom (84.0%,
Table 1 Participant sociodemographic distribution by lifetime lubricant use history using post-stratification weights (N = 1,559) Lubricant use
No lubricant use
Lubricant use vs. no lubricant use
Characteristics
% (n)
%
Odds ratio (95% CI)
Age 18–24 (ref) 25–29 30–39 40–49 50–59 60–69 70+
9.3 (151) 11.3 (184) 17.2 (281) 15.8 (258) 19.6 (320) 18.4 (300) 8.2 (134)
45.5 72.5 71.5 68.7 62.5 70.8 55.0
54.5 27.5 28.5 31.3 37.5 29.2 45.0
3.15**** 2.99**** 2.63**** 1.99**** 2.90**** 1.44
(1.98–5.02) (1.96–4.57) (1.72–4.02) (1.33–2.97) (1.91–4.40) (0.89–2.32)
Education Less than high school (ref) High school or GED Some college or associates degree College degree or higher
11.3 (184) 29.5 (480) 30.4 (495) 28.8 (469)
54.7 61.9 68.6 70.3
45.3 38.1 31.4 29.7
1.34 1.80**** 1.94****
(0.95–1.90) (1.26–2.55) (1.36–2.78)
Race/ethnicity White, non-Hispanic (ref) Black, non-Hispanic Other, non-Hispanic Hispanic More than two races, non-Hispanic
66.5 (1,082) 12.3 (200) 6.1 (99) 13.9 (226) 1.3 (20)
70.2 59.1 54.0 52.1 80.0
29.8 40.9 46.0 47.9 20.0
0.61** 0.50** 0.46**** 1.60
(0.44–0.84) (0.32–0.77) (0.34–0.62) (0.55–4.70)
Sexual orientation Heterosexual (ref) Homosexual/gay Bisexual Asexual Other
93.6 (1,498) 1.4 (22) 3.4 (54) 1.1 (18) 0.5 (8)
66.2% 63.6% 66.0% 44.4% 75.0%
33.8 36.4 34.0 55.6 25.0
0.88 1.00 0.45 1.84
(0.37–2.11) (0.56–1.79) (0.18–1.15) (0.33–10.29)
Relationship status Single and not dating (ref) Single and dating In a relationship but not living together Living with relationship partner Married and living together Married but not living together
21.2 (343) 4.7 (77) 9.9 (160) 10.3 (167) 51.6 (835) 2.3 (37)
51.4% 61.8% 64.3% 57.9% 73.3% 67.6%
48.6 38.2 35.7 42.1 26.7 32.4
1.56 1.70** 1.30 2.60*** 2.00
(0.93–2.59) (1.15–2.52) (0.89–1.91) (1.99–3.39) (0.97–4.16)
**P ≤ 0.01, ***P ≤ 0.005, ****P ≤ 0.001 CI = confidence interval; GED = General Educational Development
J Sex Med 2014;11:642–652
J Sex Med 2014;11:642–652 65.5 (1,021) 22.3 (348) 8.7 (136) 9.9 (155) 24.5 (382)
Ever used Past 30 days Past 90 days Past 12 months (year) More than a year ago
Ever used Past 30 days Past 90 days Past 12 months (year) More than a year ago
Ever used Past 30 days Past 90 days Past 12 months (year) More than a year ago
Ever used Past 30 days Past 90 days Past 12 months (year) More than a year ago
Ever used Past 30 days Past 90 days Past 12 months (year) More than a year ago
Ever used Past 30 days Past 90 days Past 12 months (year) More than a year ago
Ever used Past 30 days Past 90 days Past 12 months (year) More than a year ago
Used a lubricant
Used a lubricant during solo masturbation
Used a lubricant during partnered sexual play
Used a lubricant during partnered intercourse
Used a lubricant with a condom
Used a lubricant with a vibrator
Used a lubricant with a dildo
20.8 (323) 3.6 (56) 2.2 (34) 3.1 (48) 11.9 (185)
26.8 (414) 5.5 (85) 2.8 (42) 5.1 (79) 13.4 (207)
32.8 (508) 3.6 (56) 2.0 (32) 3.8 (59) 23.4 (362)
58.3 (904) 16.8 (260) 7.2 (112) 9.3 (144) 25.0 (387)
49.6 (768) 11.4 (177) 5.6 (86) 8.5 (132) 24.1 (373)
29.8 (461) 7.8 (121) 4.2 (65) 5.1 (78) 12.7 (197)
% (n)
Total sample
13.9 (20) 4.7 (7) 1.8 (3) 3.1 (4) 4.3 (6)
20.4 (29) 3.4 (5) 3.7 (5) 4.2 (6) 9.1 (13)
30.3 (43) 5.6 (8) 2.5 (4) 11.3 (16) 10.9 (15)
42.5 (61) 14.4 (21) 4.3 (6) 15.7 (22) 8.2 (12)
35.2 (50) 8.8 (13) 2.1 (3) 11.4 (16) 12.9 (18)
16.8 (24) 5.5 (8) 4.8 (7) 1.2 (2) 5.3 (8)
45.6 (65) 16.7 (24) 7.3 (10) 13.6 (19) 7.9 (11)
% (n)
18–24
21.4 (38) 1.9 (3) 6.4 (11) 2.3 (4) 10.7 (19)
32.2 (57) 3.9 (7) 4.2 (7) 13.2 (23) 10.9 (19)
40.8 (73) 3.2 (6) 4.7 (8) 9.4 (17) 23.5 (42)
62.9 (112) 15.9 (28) 17.1 (30) 11.3 (20) 18.6 (33)
56.5 (100) 12.2 (22) 10.6 (19) 14.6 (26) 19.1 (34)
31.6 (56) 2.6 (5) 7.3 (13) 5.8 (10) 15.9 (28)
72.5 (129) 22.5 (40) 17.4 (31) 14.8 (26) 17.8 (32)
25–29
Weighted lifetime prevalence and recency of lubricant use during various sexual contexts
Recency of Lubricant Use
Table 2
23.8 (63) 3.1 (8) 2.8 (7) 4.7 (12) 13.2 (35)
31.6 (82) 4.7 (12) 2.6 (7) 8.6 (22) 15.7 (41)
47.4 (125) 6.0 (16) 2.3 (6) 4.5 (12) 34.6 (91)
65.4 (170) 14.7 (38) 9.0 (23) 13.7 (36) 28.0 (73)
53.6 (141) 9.8 (26) 7.8 (20) 7.8 (20) 28.2 (74)
30.4 (80) 8.1 (21) 2.9 (8) 7.6 (20) 11.8 (31)
71.5 (188) 19.2 (51) 10.3 (27) 12.2 (32) 29.7 (78)
30–39
22.0 (54) 5.3 (13) 0.8 (2) 4.7 (12) 11.2 (28)
27.5 (69) 8.0 (20) 3.5 (9) 5.6 (14) 10.4 (26)
34.7 (87) 3.7 (9) 1.7 (4) 3.4 (9) 25.9 (65)
57.1 (143) 21.7 (54) 5.7 (14) 6.9 (17) 22.8 (57)
53.7 (134) 14.0 (35) 6.6 (16) 8.6 (21) 24.5 (61)
34.2 (84) 9.3 (23) 5.6 (14) 6.1 (15) 13.2 (32)
68.8 (171) 24.9 (62) 8.3 (21) 8.2 (20) 27.4 (68)
40–49
25.4 (77) 5.6 (17) 1.8 (6) 3.4 (10) 14.4 (44)
28.2 (85) 7.7 (23) 2.9 (9) 2.5 (7) 15.2 (46)
30.4 (90) 3.6 (11) 2.4 (7) 0.5 (1) 23.9 (71)
54.6 (165) 22.4 (68) 6.9 (21) 6.2 (19) 19.0 (58)
50.7 (153) 14.2 (43) 7.3 (22) 5.6 (17) 23.6 (71)
29.7 (90) 8.8 (27) 2.5 (8) 4.8 (14) 13.5 (41)
62.5 (192) 27.8 (85) 8.1 (25) 5.9 (18) 20.7 (64)
50–59
18.8 (54) 2.1 (6) 1.0 (3) 1.5 (4) 14.2 (41)
27.1 (78) 5.1 (15) 1.1 (3) 1.6 (5) 19.3 (55)
21.8 (63) 1.6 (5) 0.8 (2) 1.6 (5) 17.8 (51)
67.3 (191) 13.2 (38) 5.5 (16) 8.4 (24) 40.2 (114)
50.8 (145) 10.0 (28) 1.6 (4) 8.2 (23) 31.0 (88)
36.1 (103) 11.3 (32) 4.6 (13) 5.3 (15) 14.9 (43)
70.8 (204) 23.7 (68) 6.0 (17) 9.0 (26) 32.2 (92)
60–69
13.3 (17) 1.2 (2) 1.9 (3) 0.7 (1) 9.5 (12)
11.6 (15) 2.7 (3) 2.1 (3) 1.1 (1) 5.7 (7)
21.4 (28) 1.4 (2) 0.0 (0) 0.0 (0) 20.0 (26)
47.0 (62) 10.3 (14) 0.9 (1) 4.8 (6) 30.9 (41)
35.1 (46) 8.1 (11) 0.9 (1) 6.1 (8) 20.0 (26)
19.1 (25) 4.4 (6) 2.5 (3) 1.4 (2) 10.8 (14)
54.7 (72) 14.0 (18) 3.7 (5) 9.4 (12) 27.5 (36)
70+
646 Herbenick et al.
647
Women’s Lubricant Use n = 121), with fewer participants reporting that they used the lubricant on the inside and outside of the condom (11.5%, n = 17) or only the inside of the condom (4.5%, n = 6).
with the respective product. Overall, older participants (with the exception of participants aged 70+) reported lubricant use more frequently than the younger participants.
Frequency of Commercial Lubricant Use Participants who reported using lubricant within the past 90 days were asked about their frequency of use during this time period. While many participants indicated lubricant use once or twice (39.6%) or three to five times (23.6%), over 20% of the participants reported lubricant use more than 10 times (Table 3). Lubricant use frequencies were similar for use during solo masturbation, partnered sexual play, and partnered intercourse. Participants who reported using lubricant with another product (i.e., condom, vibrator, or dildo) were asked about their frequency of lubricant use
Reasons for Lubricant Use The most commonly endorsed reason why women first started using lubricant was to “make sex more comfortable” (42.9%, n = 438). For women ages 18 to 39, however, the most commonly endorsed reason was “for fun” (Table 4). “To enhance foreplay” and “curiosity” were also commonly reported. When asked why they first started to use lubricant during sexual activities, the most commonly endorsed responses included: “my partner suggested we use a lubricant” (33.9%, n = 345), “I wanted to make sex more pleasurable” (33.0%, n = 337), and “I wanted to reduce discomfort or
Table 3 context
Weighted frequency of lubricant use for participants who reported lubricant during the past 90 days for each Total sample 18–24
Recency of lubricant use
25–29
30–39
40–49
50–59
60–69
11.6 (13) 26.8 (29) 26.2 (28) 12.4 (13) 23.0 (25)
8.0 (7) 37.6 (31) 22.2 (18) 13.8 (12) 18.4 (15)
7.1 (2) 28.8 (6) 27.7 (6) 20.8 (5) 15.6 (3)
23.2 (7) 8.4 (3) 7.2 (2) 9.4 (4) 44.0 (13) 50.3 (18) 13.8 (5) 50.3 (23) 19.5 (6) 22.4 (8) 38.9 (13) 22.1 (10) 9.2 (3) 8.9 (3) 11.2 (4) 12.8 (6) 4.2 (1) 9.9 (4) 28.9 (10) 5.4 (2)
0.0 (0) 44.2 (4) 39.3 (3) 4.4 (0) 12.1 (1)
% (n)
% (n)
9.2 (44) 35.9 (172) 21.4 (103) 14.0 (67) 19.4 (93)
12.2 (4) 55.2 (19) 9.1 (3) 3.4 (1) 20.2 (7)
5.3 (4) 8.0 (6) 11.1 (9) 42.2 (30) 47.7 (37) 23.7 (20) 17.0 (12) 24.0 (18) 19.4 (16) 17.9 (13) 13.1 (10) 16.3 (13) 17.7 (13) 7.1 (5) 29.5 (24)
Used a lubricant during Not at all 11.5 (21) solo masturbation Once or twice 40.6 (75) 3–5 times 26.3 (49) 6–10 times 9.5 (18) More than 10 times 12.1 (22)
20.1 (3) 37.2 (5) 31.3 (5) 5.2 (1) 6.1 (1)
10.5 (2) 42.4 (7) 22.5 (4) 5.4 (1) 19.3 (3)
Used a lubricant during Not at all partnered sexual play Once or twice 3–5 times 6–10 times More than 10 times
8.6 (22) 27.8 (71) 25.4 (65) 16.6 (43) 21.6 (55)
6.6 (1) 20.6 (3) 20.9 (3) 13.4 (2) 38.6 (6)
4.6 (2) 9.9 (5) 14.6 (7) 33.9 (14) 39.7 (18) 13.8 (7) 16.3 (7) 39.8 (18) 23.4 (12) 22.0 (9) 6.9 (3) 24.5 (13) 23.1 (9) 3.7 (2) 23.8 (12)
Used a lubricant during Not at all partnered intercourse Once or twice 3–5 times 6–10 times More than 10 times
2.9 (11) 30.8 (114) 27.9 (103) 13.4 (50) 24.9 (92)
0.0 (0) 0.2 (0) 4.7 (3) 54.8 (15) 32.0 (19) 48.0 (30) 9.5 (3) 40.2 (24) 24.2 (15) 0.7 (1) 11.3 (7) 15.0 (9) 35.0 (9) 16.3 (10) 8.0 (5)
Used a lubricant with a condom
Not at all Once or twice 3–5 times 6–10 times More than 10 times
18.8 (16) 20.8 (18) 21.4 (18) 17.1 (15) 21.9 (19)
46.6 (5) 16.3 (2) 14.4 (2) 0.0 (0) 22.8 (3)
21.0 (3) 8.9 (1) 0.7 (0) 33.9 (5) 35.4 (5)
Used a lubricant with a vibrator
Not at all Once or twice 3–5 times 6–10 times More than 10 times
7.4 (9) 27.3 (34) 27.4 (34) 18.8 (24) 19.1 (24)
10.2 (1) 13.5 (1) 9.4 (1) 44.9 (5) 21.9 (2)
Used a lubricant with a dildo
Not at all Once or twice 3–5 times 6–10 times More than 10 times
12.4 (11) 29.6 (27) 20.9 (19) 18.4 (17) 18.6 (17)
35.2 (3) 1.1 (1) 8.6 (1) 11.4 (1) 43.7 (4)
Used a lubricant
Not at all Once or twice 3–5 times 6–10 times More than 10 times
70+
7.6 (4) 4.1 (1) 25.6 (15) 38.9 (13) 22.2 (13) 27.8 (9) 19.2 (11) 5.1 (2) 25.3 (15) 24.2 (8)
10.7 (1) 10.4 (1) 24.9 (3) 25.5 (3) 28.6 (3)
0.2 () 25.1 (17) 22.1 (15) 17.4 (12) 35.2 (24)
5.4 (5) 3.9 (2) 23.1 (21) 20.1 (10) 29.8 (26) 32.5 (17) 14.9 (13) 11.4 (6) 26.9 (24) 32.2 (17)
5.9 (1) 21.0 (3) 27.3 (4) 18.0 (3) 27.9 (4)
19.1 (4) 43.1 (9) 20.2 (4) 15.8 (3) 1.9 (1)
4.2 (1) 15.7 (2) 31.6 (4) 15.1 (2) 33.5 (5)
15.9 (3) 19.1 (3) 18.2 (3) 21.5 (3) 25.2 (4)
6.3 (1) 0.0 (0) 50.2 (4) 12.5 (1) 31.0 (2)
0.0 (0) 0.0 (0) 100.0 (1) 0.0 (0) 0.0 (0)
17.3 (2) 16.8 (2) 20.8 (3) 31.2 (4) 13.9 (2)
4.1 (1) 34.9 (7) 48.3 (9) 3.4 (1) 9.3 (2)
9.6 (3) 30.5 (9) 14.0 (4) 28.1 (8) 17.8 (5)
4.4 (1) 22.3 (7) 28.8 (9) 7.4 (2) 37.1 (11)
5.0 (1) 28.7 (5) 44.8 (8) 10.5 (2) 11.1 (2)
0.0 (0) 54.9 (3) 14.9 (1) 30.2 (2) 0.0 (0)
16.3 (2) 42.6 (6) 4.1 (1) 32.6 (5) 4.3 (1)
25.2 (4) 17.4 (3) 40.2 (6) 14.2 (2) 3.1 (1)
0.0 (0) 16.9 (3) 31.0 (5) 35.2 (5) 16.9 (3)
7.1 (2) 34.6 (8) 17.6 (4) 7.6 (2) 33.1 (8)
0.0 (0) 64.3 (6) 15.6 (1) 6.3 (1) 13.9 (1)
0.0 (0) 39.0 (2) 30.0 (1) 23.0 (1) 8.1 (0)
J Sex Med 2014;11:642–652
648 Table 4
Herbenick et al. Reasons for lubricant use by age using post-stratification weights
Reason for use Reason for first start of use To make sex more comfortable For fun To enhance foreplay Curiosity To add pleasurable sensations to sex To make sex feel more wet My partner wanted us to To spice up my/our sex life Approaching menopause To manage vaginal pain To comfortably have anal sex To reduce the risk of tearing My (or my partner’s) body changed during pregnancy Because of medication use/surgery Other reason A friend said it was fun to use While postpartum/nursing To reduce the risk of condom breakage
Total sample
18–24
% (n)
% (n)
42.9 (438) 32.1 (327) 27.0 (275) 26.4 (269) 21.6 (221) 21.5 (219) 16.7 (171) 14.9 (152) 14.3 (146) 14.1 (144) 11.0 (112) 8.0 (81) 4.5 (46) 4.3 (44) 4.2 (43) 3.8 (39) 3.7 (37) 1.2 (12)
Reason for first start of use during sexual activities My partner suggested we use lubricant 33.8 (345) I wanted to make sex more pleasurable 33.0 (337) I wanted to reduce discomfort or pain 31.6 (322) during sex I saw an advertisement for lubricant 13.8 (141) A doctor or nurse recommended lubricant 9.7 (99) A friend recommended lubricant 6.4 (66) I noticed that lubricated condoms felt more 6.4 (65) comfortable Other reason 4.8 (49) A health educator or sex educator 2.0 (20) recommended lubricant A family member recommended lubricant 0.9 (9)
25–29
30–39
40–49
50–59
60–69
70+
31.4 (20) 44.0 (29) 27.8 (18) 36.6 (24) 16.1 (10) 28.4 (18) 17.0 (11) 16.2 (11) 0.0 (0) 11.7 (8) 9.3 (6) 11.8 (8) 5.9 (4)
37.6 (48) 45.4 (58) 33.7 (43) 40.3 (52) 24.0 (31) 15.0 (19) 20.1 (26) 15.6 (20) 0.0 (0) 10.2 (13) 19.8 (25) 10.0 (13) 6.0 (8)
31.9 (60) 42.1 (79) 32.9 (62) 32.5 (61) 18.8 (35) 15.1 (29) 13.8 (26) 13.8 (26) 0.2 (1) 8.6 (16) 13.4 (25) 3.1 (6) 5.2 (10)
39.7 (68) 31.3 (54) 25.9 (44) 20.5 (35) 19.5 (33) 22.5 (39) 18.2 (31) 14.1 (24) 10.4 (18) 9.6 (16) 7.7 (13) 7.2 (12) 5.6 (10)
43.9 (84) 26.6 (51) 23.8 (46) 22.7 (44) 23.7 (45) 19.8 (38) 9.3 (18) 12.5 (24) 25.9 (50) 14.7 (28) 12.2 (23) 5.1 (10) 5.3 (10)
54.6 (111) 24.1 (49) 24.9 (51) 19.9 (41) 25.2 (51) 29.5 (60) 22.6 (46) 17.7 (36) 29.1 (59) 24.0 (49) 7.0 (14) 9.4 (19) 1.6 (3)
63.5 (45) 10.2 (7) 15.6 (11) 18.0 (13) 19.0 (14) 22.8 (16) 17.7 (13) 16.2 (12) 26.5 (19) 19.4 (14) 6.4 (5) 19.1 (14) 2.8 (2)
6.2 (4) 4.9 (3) 8.7 (6) 4.1 (3) 4.2 (3)
1.5 (2) 1.9 (2) 7.1 (9) 5.6 (7) 1.2 (2)
5.6 (11) 5.1 (10) 3.7 (7) 5.5 (10) 0.3 (1)
5.0 (9) 3.6 (6) 1.5 (3) 2.3 (4) 2.6 (4)
3.7 (7) 3.6 (7) 1.2 (2) 5.2 (10) 0.9 (2)
3.5 (7) 5.3 (11) 5.6 (11) 0.3 (1) 0.4 (1)
6.8 (5) 5.9 (4) 1.2 (1) 3.4 (2) 0.5 (1)
35.5 (23) 33.9 (22) 27.0 (18)
33.3 (43) 34.1 (44) 23.1 (30)
37.9 (71) 29.3 (55) 21.3 (40)
38.6 (66) 33.7 (58) 27.1 (46)
31.1 (60) 32.9 (63) 34.3 (66)
32.4 (66) 37.6 (77) 42.3 (86)
22.5 (16) 25.1 (18) 50.9 (37)
16.8 (11) 3.0 (2) 8.6 (6) 4.8 (3)
15.5 (20) 4.7 (6) 9.8 (13) 7.3 (9)
7.5 (14) 6.3 (12) 5.1 (10) 6.4 (12)
9.5 (16) 6.4 (11) 5.0 (9) 8.9 (15)
13.8 (26) 9.9 (19) 7.9 (15) 7.1 (14)
19.9 (41) 16.6 (34) 6.2 (13) 3.1 (6)
17.0 (12) 21.9 (16) 2.1 (1) 8.1 (6)
7.4 (5) 0.0 (0)
3.2 (4) 2.3 (3)
7.1 (13) 3.1 (6)
3.4 (6) 0.8 (1)
5.9 (11) 1.7 (3)
3.7 (8) 2.6 (5)
2.2 (2) 2.3 (2)
5.1 (3)
0.4 (0)
1.2 (2)
0.2 (1)
0.6 (1)
0.8 (2)
0.0 (0)
pain during sex” (31.6%, n = 322). These options were consistently the most frequently endorsed across age groups.
Perceptions of Lubricants Consistent with their reasons for use, the most commonly endorsed perception was that a lubricant “makes sex more comfortable” (85.1%, n = 839). Over half of the participants agreed that lubricant use during sexual activities “makes sex feel better” and “makes it easier to feel aroused.” Less than 15% of the participants reported that they perceived lubricants to be only for older people (Table 5). Discussion
Findings from the 2012 NSSHB demonstrate that most American women have used lubricant during solo or partnered sexual activities, with partnered intercourse and sexual play being the most J Sex Med 2014;11:642–652
common sexual events associated with lubricant use. Also, about one in three women in the United States has used a commercial lubricant with a condom, about one in four women has used lubricant with a vibrator, and about one in five women has used lubricant with a dildo. These data speak to the role that lubricants play in women’s sexual experiences, the contributions of lubricants to women’s sexual health, as well as the diverse ways that women engage in sexual activities (including the use of consumer products). That the most common reason women first started to use lubricant was to make sex feel more comfortable (endorsed by 43% of participants) is perhaps not surprising given other data demonstrating the high prevalence of pain and difficulty with vaginal lubrication experienced by women during sex [11]. However, it is notable that—for women aged 18 to 39—the most common reason for beginning lubricant use was “for fun,” followed closely by reasons related to curiosity and foreplay
649
61.4 (70) 44.4 (50) 66.8 (72) 19.8 (21) 72.3 (79) 38.6 (44) 55.6 (62) 33.2 (36) 80.2 (85) 27.7 (30)
% Disagree
62.5 (165) 55.8 (144) 69.0 (178) 16.8 (43) 80.1 (204) 37.5 (99) 44.2 (114) 31.0 (80) 83.2 (215) 19.9 (51)
% Disagree
52.6 (155) 46.5 (137) 53.7 (155) 13.0 (37) 66.2 (192) 47.4 (140) 53.5 (157) 46.3 (134) 87.0 (248) 33.8 (98)
% Disagree
57.3 (139) 41.9 (98) 63.3 (147) 8.9 (21) 73.5 (174) 42.7 (104) 58.1 (137) 36.7 (85) 91.1 (216) 26.5 (63)
% Disagree
52.7 (137) 41.2 (106) 61.8 (159) 8.6 (22) 67.4 (171) 47.3 (123) 58.8 (151) 38.2 (98) 91.4 (233) 32.6 (83)
% Disagree
57.8 (93) 38.6 (60) 60.9 (95) 12.9 (20) 67.3 (107)
% Agree
42.2 (68) 61.4 (95) 39.1 (61) 87.1 (134) 32.7 (52)
% Disagree
50.0 (67) 45.3 (60) 56.8 (77) 22.6 (30) 65.4 (86) 50.0 (67) 54.7 (72) 43.2 (58) 77.4 (103) 34.6 (45) 56.2 (825) 45.4 (654) 61.5 (883) 13.6 (195) 70.6 (1,014)
(n)
Makes sex more comfortable.
Is only for older people.
(n)
43.8 (644) 54.6 (788) 38.5 (553) 86.4 (1,235) 29.4 (423) Makes it easier to feel aroused. Makes it easier to have an orgasm. Makes sex feel better.
25–29
% Disagree
% Agree 18–24
% Disagree
% Agree Total
Using lubricant during sexual activities . . .
Table 5
Perceptions of lubricant use by age using post-stratification weights
30–39
% Agree
40–49
% Agree
50–59
% Agree
60–69
% Agree
70+
% Agree
Women’s Lubricant Use
enhancement (as well as increasing comfort). Fun-, curiosity- and pleasure-focused reasons echo reasons why women, in a 2008 nationally representative study of women aged 18 to 60, report use of vibrators and other sex toys [3]. A key difference, however, in these two studies has to do with recommendations from friends. In the earlier national study of vibrator use, 18% of women aged 18 to 60 indicated that they had first started using a vibrator because a friend had said that vibrators were fun to use [3]. In the present study, only 3.8% of women indicated that they had first started using lubricant due to a friend’s recommendation. Subsequent research might investigate this further as a means of understanding the kinds of conversations about sex and information-sharing women engage in with their friends. For example, subsequent research might examine whether it is more common for women to talk about sex toys or to discuss orgasms (e.g., which vibrators may be connected to in women’s perceptions or experiences) with their friends. What is it about lubricant use that perhaps makes it less likely to be talked about? And is that changing? For example, about 9% of 18–24-year-old women and 7% of 25–29-year-old women indicated that they first started using lubricant because a friend said lubricants were fun to use, whereas fewer women in older age groups endorsed this reason. That noted, more women—about 17%— indicated that they first started using lubricant because their partner wanted to (in comparison, 28% of women in the previous study first began using a vibrator for this reason). Partner suggestion was also the number one reason, in the total sample, given for why women first started using lubricant, specifically during sexual activities. Clinician recommendations were the fifth most common reason women began using lubricant during sexual activities (behind having seen an advertisement), with about 10% of women (mostly aged 60 and older) endorsing this reason for initial use. That so few women begin using lubricants because of clinician recommendations is notable. Given the large proportion of women who experience painful, uncomfortable sex, who feel that their vaginal lubrication is insufficient for the kinds of sex they are having, and/or who are postmenopausal, lactating, or experiencing vulvovaginal atrophy, it may be important for clinicians to incorporate questions about comfortable sex, vaginal lubrication, and/or the use of commercial lubricants when interacting with patients. Women may not report lubricants as among the topical J Sex Med 2014;11:642–652
650 products that they use, but given their potential for pleasure as well as irritation, it would be helpful for clinicians to have a more comprehensive understanding of the products women use on or in their genitals. Such conversations may also expand opportunities for clinicians and patients to discuss uncomfortable or painful sex, which appears to be a common experience for American women and one still not often talked about. Regarding women’s perceptions of lubricant use, about 85% of women agreed that lubricant makes sex more comfortable and over threequarters agreed that it makes sex feel better. Very few women felt that lubricant was only for older people (12%), and sizable proportions of women felt that lubricant use made it easier to feel aroused (69%) or easier to have an orgasm (56%). Subsequent research might explore more closely how women feel sex is better (or not better) with lubricant use and how lubricant does or does not contribute to their experiences of arousal and/or orgasm. About 30% of American women surveyed reported having used a lubricant during solo masturbation. Aside from the fact that many women masturbate at some point during their lives, and that masturbation is common among women across age, sexual orientation, and relationship status [22,24], little is known about the details of women’s solo masturbation experiences, perhaps because of a long-standing taboo about female masturbation. That nearly one-third of American women (and 8% of women just in the past 30 days) have used lubricant during solo masturbation contributes to our understanding of some aspects of female masturbation regardless of their relationship status. As with vibrators, using lubricant during masturbation may help women to masturbate more pleasurably, or more quickly or efficiently to orgasm. Some women may feel that this helps them to more easily incorporate masturbation into their busy lives that often involve paid or unpaid work, school, exercise, household chores, and/or caring for children, their partner, and/or aging parents [25,26]. This study had several strengths and limitations. A significant strength of the study is that sexual behavior and lubricant use were asked about in a nationally representative probability sample of Americans aged 18 and older. Participants completed the survey via the Internet, thus facilitating privacy and ease of access (as opposed to, say, having to travel to be interviewed or having to allow a stranger into their home to interview them J Sex Med 2014;11:642–652
Herbenick et al. about a sensitive topic) and, as noted earlier, were provided with computer hardware or Internet access if needed. Additionally, women are eligible to be part of the Knowledge Networks/GfK sample regardless of their Internet access or ownership of the hardware or software necessary to complete computer-based surveys on the Internet, as these are provided for participants if needed to facilitate their inclusion on the panel. Also, because participants are members of an ongoing active panel, they are familiar with the interface and did not require additional training regarding how to complete Internet-based questionnaires. The survey was also available in both English and Spanish languages. A limitation is that the sample was restricted to individuals who had a home address and who were community dwelling (e.g., not institutionalized). This may have limited the sample, particularly for much older individuals and/or those experiencing health conditions that warrant inpatient care. It is also possible that some people may not have felt comfortable answering questions about their sexual experiences or lubricant use, even in spite of being able to do so in the privacy of their own homes and via the Internet. Additionally, although we tried to clearly identify what we meant by a “lubricant” at various points throughout the survey, it is possible that some participants had different definitions in mind; however, we expect that this number would be small enough so as to not have a significant influence on our findings. Subsequent research might also explore differences in lubricant use behaviors and/or perceptions based on type of lubricant used (e.g., lubricants marketed for sensations vs. those marketed for increasing comfort). Given how rapidly sexual enhancement products have become more mainstream and more widely available, we feel that more attention should be paid to how women and men use these consumer products as part of their sexual experiences. For too long, taboos related to sexuality have perhaps contributed to the lack of research on these topics. Just as adult retail stores have become mainstream, it is our hope that scientific research related to sexual health and sexual enhancement product use will become more commonplace, thus contributing to scientific and clinical knowledge, and potentially, people’s quality of life. In the case of lubricants, a number of lubricants are available in the marketplace and women use them for a variety of solo and partnered sexual experiences, sometimes in combination with other products
651
Women’s Lubricant Use (e.g., condoms, vibrators, dildos, and other sex toys), and—because of the sex acts they are used as part of—lubricants are likely to be applied to a variety of body sites and orifices including the vulva, vagina, mouth, and anus. A greater understanding of these sexual practices can only serve to enhance clinicians’ understanding of their patients’ lives, including what they are doing and why (e.g., to improve comfort, to reduce pain, to enhance pleasure)—all of which may open communication and conversation among clinicians and patients. Given the high rates of self-reported pain during sex and difficulties with vaginal lubrication during sex, as well as a general human desire for sexual pleasure and enhancement as part of sex, clinicians may find it helpful to ask women more often about their comfort during sex and their lubricant use behaviors. Conclusions
Findings from this study demonstrate that most American women have used lubricant and that lubricant is more common as part of partnered intercourse and sexual play or foreplay compared with other solo and partnered sexual behaviors. Common reasons for lubricant use cited include to make sex more comfortable, for fun, due to curiosity, to enhance foreplay, and to add pleasurable sensations to sex (the latter reasons being particularly common among younger women). Clinicians may find it helpful and important to broaden conversations with patients to include questions about their sexual behaviors, comfort during sex, vaginal lubrication, and lubricant use. Acknowledgment
This study was partially funded by Church & Dwight, Co., Inc. Corresponding Author: Debby Herbenick, PhD, MPH, Center for Sexual Health Promotion, Indiana University, Bloomington, IN 47405, USA. Tel: 8123223777; Fax: 812 855 3936; E-mail: debby@ indiana.edu Conflict of Interest: Michael Reece is a member of the sexual health advisory council of Church & Dwight Co., Inc. Statement of Authorship
Category 1 (a) Conception and Design Debby Herbenick; Michael Reece; Stephanie A. Sanders; Vanessa Schick; J. Dennis Fortenberry
(b) Acquisition of Data Debby Herbenick; Michael Reece; Stephanie A. Sanders; J. Dennis Fortenberry; Vanessa Schick (c) Analysis and Interpretation of Data Vanessa Schick; Debby Herbenick
Category 2 (a) Drafting the Article Debby Herbenick; Vanessa Schick (b) Revising It for Intellectual Content Debby Herbenick; Vanessa Schick; Stephanie A. Sanders; J. Dennis Fortenberry; Michael Reece
Category 3 (a) Final Approval of the Completed Article Debby Herbenick; Vanessa Schick; Stephanie A. Sanders; J. Dennis Fortenberry; Michael Reece
References 1 Herbenick D, Reece M, Hensel D, Sanders SA, Jozkowski K, Fortenberry JD. Association of lubricant use with women’s sexual pleasure, sexual satisfaction, and genital symptoms: A prospective daily diary study. J Sex Med 2011;8:202–12. 2 Herbenick D, Schick V, Reece M, Sanders SA, Smith N, Dodge B, Fortenberry JD. Characteristics of condom and lubricant use among a nationally representative sample of adults ages 18–50 in the United States. J Sex Med 2013;10: 474–83. 3 Herbenick D, Reece M, Sanders SA, Dodge B, Ghassemi A, Fortenberry JD. Women’s vibrator use in romantic relationships: Results from a nationally representative survey in the United States. J Sex Marital Ther 2010;36:49–65. 4 Jozkowski KN, Herbenick D, Schick V, Reece M, Sanders SA, Fortenberry JD. Women’s perceptions about lubricant use and vaginal wetness during sexual activities. J Sex Med 2013;10: 484–92. 5 Schrobsdorff S. Red-light specials. Newsweek 2008. Available at: http://www.newsweek.com/id/110965 (accessed July 16, 2013). 6 Butler E. Steaming up the aisles. 2006. Available at: http:// www.crainsnewyork.com/article/20061029/FREE/61028016 (accessed July 16, 2013). 7 Sutton KS, Boyer SC, Goldfinger C, Ezer P, Pukall CF. To lube or not to lube: Experiences with perceptions of lubricant use in women with and without dyspareunia. J Sex Med 2012;9:240–50. 8 Emilee G, Ussher JM, Perz J. Sexuality after breast cancer: A review. Maturitas 2010;66:397–407. 9 Tan O, Bradshaw K, Carr B. Management of vulvovaginal atrophy-related sexual dysfunction in postmenopausal women: An up-to-date review. Menopause 2012;19:109–17. 10 Katz A. Sexual changes during and after pregnancy. Am J Nurs 2010;110:50–2. 11 Herbenick D, Reece M, Schich V, Sanders SA, Dodge B, Fortenberry JD. An event-level analysis of the sexual characteristics and composition among adults ages 18 to 59: Results from a national probability sample in the United States. J Sex Med 2010;7(5 suppl):346–61. 12 Meson CM, Buss DM. Why humans have sex. Arch Sex Behav 2007;36:477–507. 13 Ayling K, Ussher JM. “If sex hurts, am I still a woman?” The subjective experience of vulvodynia in hetero-sexual woman. Arch Sex Behav 2008;37:294–304.
J Sex Med 2014;11:642–652
652 14 Andersen BL, Hacker NF. Psychosexual adjustment after vulvar surgery. Obstet Gynecol 1983;62:457–62. 15 Jackson SM, Cram F. Disrupting the sexual double standard: Young women’s talk about heterosexuality. Brit J Soc Psychol 2003;42:113–27. 16 Tolman D. Female adolescent sexuality: An argument for a developmental perspective on the new view of women’s sexual problems. Women Ther 2002;24:1–2, 195–209. 17 Baker L, Wagner TH, Singer S, Bundorf MK. Use of the Internet and e-mail for health care information: Results from a national survey. JAMA 2003;289:2400–6. 18 Heiss F, McFadden D, Winter J. Who failed to enroll in Medicare Part D, and why? Early results. Health Aff 2006;25:344–54. 19 Silver RC, Holman EA, McIntosh DN, Poulin M, Gil-Rivas V. Nationwide longitudinal study of psychological responses to September 11. JAMA 2002;288:1235. 20 Sanders SA, Reece M, Herbenick D, Schick V, Dodge B, Fortenberry JD. Condom use during most recent vaginal intercourse event among a probability sample of adults in the United States. J Sex Med 2010;7(5 suppl):362– 73.
J Sex Med 2014;11:642–652
Herbenick et al. 21 Reece M, Herbenick D, Schick V, Sanders SA, Dodge B, Fortenberry JD. Sexual behaviors, relationships, and perceived health among adult men in the United States: Results from a national probability sample. J Sex Med 2010;7(5 suppl):291– 304. 22 Herbenick D, Reece M, Schick V, Sanders SA, Dodge B, Fortenberry JD. Sexual behaviors, relationships, and perceived health among adult women in the United States: Results from a national probability sample. J Sex Med 2010;7(5 suppl):277–90. 23 Herbenick D, Reece M, Sanders SA, Dodge B, Ghassemi A, Fortenberry JD. Prevalence and characteristics of vibrator use by women in the United States: Results from a nationality representative study. J Sex Med 2009;6:1857–66. 24 Gerressu M, Mercer CH, Graham CA, Wellings K, Johnson AM. Prevalence of masturbation and associated factors in a British national probability survey. Arch Sex Behav 2008;37: 266–78. 25 Pierret CR. The “sandwich generation”: Women caring for parents and children. Mon Labor Rev 2006;3–9. 26 Lachance-Grzela M, Bouchard G. Why do women do the lion’s share of housework? A decade of research. Sex Roles 2010;63:767–80.
