Sexual Behavior in Germany

Sexual health is �a state of physical, emotional, mental and social wellbeing in relation to sexuality, and not merely the absence of disease, dysfunction or infirmity� (1). According to the World Health Organization (2), sexual health is closely linked to wellbeing and quality of life. To consider sexual health in the setting of health policy and identify risks in the healthcare system, representative data on the sexual behavior over the lifespan are crucial. With regard to German people�s sexual lives, only very few scientific studies are available, and these focus mostly on specific subgroups�among others, homosexual men (e1), adolescents (e2), and students (e3). For the general German population, data on sexual behavior based on a representative sample have thus far not been collected. Such studies have, however, been conducted in other countries (for example, the US, the UK, Australia, Sweden) (3�5, e4, e5). In the age group 25�44 years, vaginal intercourse was reported to be the most common practice (98% of women, 97% of men (3). Rates of oral intercourse were 89% in women versus 90%) in men (3), and rates of anal intercourse 36% in women and 44% in men (3). Reported rates of same-sex contacts were 12% in women and 6% in men (3). According to German-language cohort studies, 15�26% of women and 17�32% of men reported sexual contacts outside their current steady relationship (see [6] for an overview). An online survey found rates of 4% for homosexual women and 34% for homosexual men, 29% for heterosexual women and 49% for heterosexual men (7). Such studies, however, are subject to several biases (for example, as a result of the sampling and self-selection).

Box

Cinical Implications

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Sexually transmitted infections (STIs) present an interdisciplinary challenge. Incidence rates of the human immunodeficiency virus (HIV: 3200 incident infections in 2015, 95% confidence interval [3000; 3400]) and non-notifiable STIs (Chlamydia trachomatis, gonorrhea) have remained constant in Germany in recent years (8, 9), whereas the incidence of syphilis has steadily risen since 2010 (8.5 cases per 100 000 population in 2015) (10). The rise in new cases of infection is based primarily on increased numbers of reports of men who have sex with men (MSM) (10). Since no current epidemiological data are available, it is not possible to estimate the incidence rates of genital herpes (Herpes simplex viruses, HSV-1, HSV-2) and HPV infections (human papillomaviruses). Due to the increasing uptake of the HPV vaccine, it may be assumed that the prevalence rates of these STIs have fallen in recent years (e6�e8). STIs can cause neonatal harms (for example, owing to genital herpes), lead to genital and extragenital neoplasms (for example, as a result of HPV infection), or cause infertility (as a result of infection with Chlamydia trachomatis) (11, 12).

Transmission routes of STIs include unprotected vaginal, anal, and oral intercourse (13). Because of inconsistent use of condoms during sexual contacts outside the main relationship while simultaneously dispensing with condoms within the relationship, clandestine sexual contacts outside the relationship are seen as a transmission route for STIs to spread (14, 15). Similarly, unwanted pregnancies in the context of unprotected sexual intercourse are of relevance: in addition to contraceptive failure and non-compliance, unprotected sexual intercourse is the reason why interceptive drugs are prescribed. About 13% of women have used an interceptive at least once (16).

The aim of this study is to provide an overview of different sexual behaviors on the basis of a sample that is representative for age and sex. This furnishes persons working in the healthcare system with an information base that may be useful when taking a sexual history, preventing and treating STIs, treating sexual dysfunctions, or delivering sex education.

Methods

Sociodemographic data were collected nationwide by means of face to face interviews on site. Subsequently, study subjects were given a questionnaire to complete independently, which asked questions on sexual orientation, relationships, contraception, sexual behavior, and sexual contacts outside existing relationships. A total of 2524 persons were interviewed, 45% of these were men and 55% women (Table 1). Before the data evaluation, the researchers conducted plausibility tests on the basis of the complete data sets. By using weighted adjustments, each case was weighted; consequently the sample matched the German population for the combination of characteristics �age and sex� and �place of residence by federal state.� A detailed description of the data collection, measuring instruments, and evaluation can be found in the Supplementary material.

Results

Sexual orientation

Most women (82%) and men (86%) described themselves as exclusively heterosexual (Table 1). Heterosexual attraction (men: mean = 3.78; 95% confidence interval [3.71; 3.86]; women: mean = 3.25 [3.17; 3.33]) was much more common than attraction to a person of the same sex (men: mean = 1.16 [1.11; 1.20]; women: mean = 1.25 [1.20; 1.29]; as measured on a 5-point Likert scale: 1 = never/not at all, 5 = very strongly). Most men (83%) and women (78%) when asked for the number of sexual partners during their lives to date (lifetime sexual partners) reported heterosexual sexual contacts. Only 5% of men and 8% of women reported having had sexual contacts with the same sex.

Table 1

Sociodemographic data

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Relationships

57% of those interviewed reported being in a stable relationship at the time of the survey. Altogether, subjects tended to be satisfied with their relationships. Of the 57% of subjects in stable relationships, 40% had a monogamous relationship, 2% an open relationship, and 1% had agreed to have relationships including a third partner. 56% had not negotiated any agreement regarding contacts with third partners.

Contraception

Of the 57% of subjects in stable relationships, 76% reported that they never used condoms within their relationship, 12% reported occasional condom use, 3% frequent condom use, and 6% reported that they always used a condom. 4% did not answer the question. Of the women of childbearing age (≤ 50 years), 51% reported that they were taking oral contraceptives, 17% used other kinds of contraception. 5% did not use any contraception as they wanted to have children; 27% reported that they did not think about using contraception. 7% had taken interceptives for the purpose of postcoital contraception; 3% had taken an interceptive more than once. 8% did not answer the question.

Sexual behaviors

Table 2, Figure 1, and eTable 1 provide an overview of reported sexual behaviors in men and women. Detailed reported rates of sexual practices by sex and age are shown in eTables 1�5.

Figure 1

Frequency of sexual practices

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Table 2

Frequency of sexual practices in the past year

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eTable 1

Frequency of sexual practices

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eTable 2

Response rates

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eTable 3

Sociodemographic data

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eTable 4a

Age specific data on the sexual practices of men

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eTable 4b

Age specific data on the sexual practices of men

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eTable 5a

Age specific data on the sexual practices of women

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eTable 5b

Age specific data on the sexual practices of women

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Sexual contacts outside relationships

17% of those interviewed reported ever having had sexual intercourse with someone other than their partner while being in a steady relationship. 5% did not did not answer the question. More men (21%) than women (15%) answered in the affirmative when asked if they had had sexual contacts outside their relationships (χ² [2] = 17 972, p = 0.001). Persons who had had sexual contacts outside their relationships reported a mean of 3.65 other sexual partners (range = 1�199; 95% confidence interval [2.51; 4.79]) in addition to their primary partners; 40 persons did not answer the question. 7% reported having had sex outside their current relationship; 4% did not answer the question. Differences between the sexes reached significance (χ² [2] = 4724, p = 0.030): more men (8%) than women (6%) reported having sexual contacts outside their current primary relationships. Persons who had had sexual contacts outside their current relationships reported a mean of 2.71 other sexual partners (range = 1�20 [2.06; 3.36]) during that relationship; 10 persons did not give an answer regarding the number. 8% of men (n = 89) reported contacts with a mean of 4.06 [2.15; 5.97] female prostitutes. Very few men (0.01%; n = 8) reported sexual contacts outside their relationships with a mean of 2.38 [0.72; 4.04] male prostitutes. Women were not asked for sexual contacts with prostitutes as the researchers were wary of the risk of dropouts from the study as a result of such questions.

Unprotected sexual intercourse

82% of study participants reported never having had unprotected sex outside their primary relationship, 5% reported having had unprotected sex once, and 8% reported more than one occurrence. Of those who had had unprotected sex outside their relationship, 16% had sought out a subsequent medical examination for fear of having contracted an STI once and 9% more than once; 74% reported that they had not had any examination; 1% did not answer the question. Only 2% of those who had had unprotected sex outside their relationships always used condoms during sex with their steady partner. 38% reported never using condoms in their primary relationship, and 7% reported using condoms occasionally; 3% reported using condoms often.

On the basis of the assumption that STIs may be associated with the number of lifetime sexual partners, we determined a subgroup with an increased risk for STIs (n = 35 men, n = 27 women), who had reported sexual contacts outside their current relationship, unprotected sexual intercourse outside, and inconsistent condom use within, their relationship. Men from this high-risk group reported a mean of 38 female sexual partners, women reported a mean of 17 male sexual partners (Figure 2). The number of sexual partners in the high-risk group was three times as high as in persons who did not meet all the listed criteria (normal population). Of those persons who had reported sexual contacts with prostitutes (n = 93), 36% reported never using condoms with their primary partners. Only 4% each reported using condoms occasionally, often, or always. Half of those who reported sexual contact with prostitutes reported having had unprotected sex outside their relationship (once: 18%; more than once: 33%). The data do not convey any information on the occurrence or frequency of unprotected sex with prostitutes.

Figure 2

Mean lifetime number of sexual partners

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Discussion

Subjects aged 25�29 were the most sexually active age group, as was also shown by a previous study (4). Increasing age was observed to be accompanied by a decreased frequency in sexual activity; the causes may be the length of the relationship (17) as well as aging (for example, as a result of falling testosterone concentrations) (e9). Similar to the results from research from the US and the UK to date (3, 5), the responses from men and women differed regarding the numbers of their sexual partners. Self-serving biases and gender-specific responding behavior may have contributed to the differing responses. As far as we know the reasons for these differing responses have not been investigated to date. Data from questionnaire surveys have also not been validated on the basis of behavioral data. Compared with earlier, non-representative studies, fewer subjects reported active or passive oral intercourse, and the same was true for insertive and receptive anal intercourse. This may be because of cultural differences (3, 4) or online based data collections (18).

The proportion of persons who reported having sexual contacts outside their relationship was low compared with earlier studies (6, 7). Many partners therefore seemed to be true to the widespread desire for faithful relationships (e10). Because of the random selection of the sample and the independent completion of the questionnaires it can be assumed that the data are less prone to biases and the rates shown are more reliable than in other studies.

It is of particular relevance that participants reported having had unprotected sex outside their primary relationships, and of these, only 2% reported using condoms at all times within their relationship. In a scenario of changing sexual partners and inconsistent condom use, regular sexual medical examinations are recommended, because STIs will otherwise remain undetected at first (19). Only one in four of those who answered in the affirmative about having unprotected sexual intercourse outside their steady relationship had undergone a relevant medical examination. Simultaneously, some persons displayed behaviors (external contacts, unprotected sexual intercourse outside their relationships, inconsistent condom use, a higher lifetime number of sexual partners) that are to be considered as at risk with regard to STIs. If one considers that more than 80% of 18- to 40-year-olds reported in another survey that they had never been comprehensively asked about their sexuality when they had contact with physicians (Brenk-Franz K, Strau� B [in preparation]: The medical care of persons with sexual dysfunction), our results underline the necessity of exploring in detail high-risk behaviors and of providing factual and structured education for the prevention of STIs. In addition, the guideline (20) recommends that the HPV (types 16 and 18) vaccine be given to girls for cancer prevention as early as possible.

Whether vaccination at a later date�especially after the start of sexual activity�is indicated should be decided on an individual basis (20). A detailed sexual history is helpful and required in this setting.

The results should be viewed while considering the composition of the sample. Participants mainly reported being heterosexual. The proportion of homosexual subjects was consistent with the proportions reported in other German-language publications (21). The proportion of those who reported same-sex sexual partners (5�8%) was lower than in studies from the US (10%; [e11]) and UK (7�16%; [5]). Because of the small subsample sizes, no conclusions were possible with regard to specific subgroups (for example, those with a homosexual identity). To this end, a disproportional number of such subgroups compared with the total population would have been required in the sample (oversampling). For reasons of economy we also dispensed with capturing data on body image and satisfaction with the reported sexual behaviors. Similarly we were not able to find out which factors (for example, consumption of pornography) affect the sexual practices undertaken. And neither did we focus on contraceptive use in specific sexual behaviors. For example, in orogenital sexual encounters, protective measures were used notably less often, even in case of multiple partners, because of ignorance vis-�-vis the risk of infection (22). Certain criteria (age, sex, place of residence) were weighted during recruitment, so that the sample largely matched the total population of Germany. However, individual reports of frequencies may be subject to bias because the willingness to answer a question varied by the subject of the question. Although a recommended computer aided self interview was used to capture sensitive data, we found many missing values (17�43%). We decided against estimating the missing data and reported confidence intervals. Self-serving memory biases and self-portrayals have to be assumed as a matter of principle in the setting of reporting sexual behaviors. As self-reported sexual behaviors are also subject to biases when using other data collection methods (e12), in future, partners should be interviewed about the behaviors and experiences of their significant other, in order to validate their responses. A longitudinal study design would help identify predictors for high-risk sexual behaviors.

eMethods

Methods

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Conflict of interest statement

The authors declare that no conflict of interest exists.

Manuscript received on 28 November 2016, revised version accepted on
7 June 2017.

Translated from the original German by Birte Twisselmann, PhD.

Corresponding author
Prof. Dr. phil. Christoph Kr�ger
Universit�t Hildesheim
Universit�tsplatz 1, 3114 Hildesheim
kroegerc@uni-hildesheim.de

Supplementary material
For eReferences please refer to:
www.aerzteblatt-international.de/ref3317

eMethods, eTables:
www.aerzteblatt-international.de/17m0545