7th September 2012, Volume 125 Number 1361

Rebecca Psutka, Jennie Connor, Kimberly Cousins, Kypros Kypri

There is little information on the sexual health and behaviour of young people in New Zealand (NZ). Indications from national statistics on prevalence of sexually transmitted infections and incidence of terminations are that furtherattention is required. In 2009, NZ had an estimated national chlamydia prevalence of 803 per 100,000 people, higher than in previous years and 3–4 times higher than in Australia and the UK.1

NZ has high termination of pregnancy (TOP) rates compared with most OECD countries. In 2008, there were 19.7 terminations per 1000 women aged 15–44 per year compared to 19.6 in the USA, 21.3 in Sweden, and 8.7 in the Netherlands and 7.3 in Germany.2 High levels of TOP may reflect good provision of abortion services, poor availability of contraceptive services, or greater sexual activity at younger ages.3

The only national survey of sexual behaviour in the general NZ population was the NZ Partner Relations Survey in 1991.4 Birth cohort studies from Dunedin and Christchurch collected some sexual health and behaviour data as the cohorts reached early adulthood 15 and 20 years ago, respectively.5,6

The Dunedin cohort study of individuals born in 1972/3 found that the median age of first intercourse was 17 in women and 16 in men in the late 1980s.5 The Christchurch 1977 birth cohort reported on risk behaviours. About 32% of those aged 20–21 reported unprotected sex in the past year, and that those aged 18–21 had an average of 5.5 sexual partners during that timeframe.7

University students are a large, relatively easy to reach subgroup who may serve as a sentinel population for young people more generally, notwithstanding some obvious differences. There is no contemporary information regarding the sexual health outcomes and experiences of tertiary students in NZ, but some recent information is available on sexual and other risk behaviour in younger adolescents.

The Youth Health Survey of a nationally representative sample of secondary students in NZ, completed in 2001,8 showed that by age 17, 50% of students had ever had sex, 15% of sexually active students didn’t use or only sometimes used condoms and/or contraception, and 63% used a condom last time they had sex. In the 2007 iteration, the authors reported no substantial change in behaviour since 2001.9

Motivation for a study of sexual health, risks, and experiences amongst tertiary students comes from both this lack of information on sexual health and increasing concern about the potential impact of high levels of risky drinking. A 2005 survey found that NZ university students frequently attributed unsafe, unhappy, and unwanted sexual experiences to drinking.

With reference to the preceding four weeks, 5% of women and 8% of men reported unsafe sex, 3% of women and 4% of men had sex they were not happy about at the time, and 8% of women and 9% of men had a sexual experience they later regretted that they attributed to their drinking.

Unwanted sexual advances due to another person’s drinking negatively affected 21% of women and 12% of men, and 0.5% of both genders reported sexual assault in those four weeks.10 This suggests adverse sexual experiences associated with drinking are fairly common on university campuses, and that the sexual health of university students is worthy of attention.

The aims of this study are to better understand the sexual health, risk behaviour, and experiences of the NZ university student population by investigating age of sexual debut, number of partners, choice of partners, condom use, and occurrence of unintended pregnancies and terminations.

Methods

Design—Cross-sectional data were collected as part of the 2009 Tertiary Student Health Survey, using a confidential online computerised questionnaire. A detailed description of the methods for the previous iterations of this survey has been published11 and is summarised here.
Participants—All 8 NZ universities were invited to participate and students from 8 campuses of 6 universities were eventually included. Enrolment lists provided by institutions were used as a sampling frame, from which random samples of full-time, intramural Māori and non-Māori students aged 17–24 years were invited by both letter and email, timed to arrive the same day, to visit a secure website and complete a questionnaire. Overall, 5770 randomly selected students were invited to participate in the 2009 survey.
Measures—Information was sought from study participants on their sexual behaviour and experiences through written questions with categorical responses in drop-down menus. The first question in the sexual health section of the questionnaire was: “Have you ever had sexual intercourse?” Those answering “yes” were presented with the rest of the questions.
  • Age at first sex: “How old were you when you first had sexual intercourse?” [<14, 14, 15, 16, 17, 18,19+]
  • Number of partners ever: “How many people have you had sexual intercourse with in your life?” [0,1,2,3,4,5,6,7,8,9,10,10–20, >20 ]
  • Number of partners in the last 12 months: “How many people have you had sexual intercourse with in the last 12 months?” [0,1,2,3,4,5,6,7,8,9,10, 10–20, >20]
  • Last sexual intercourse: “Did you use a condom last time you had sex?” [yes, no]
  • “Had you been drinking alcohol the last time you had sex?” [no, yes, a little, yes a lot]
  • “Thinking about the last time you had sex, which best describes you and your partner...” 
    [we had just met for the first time; we had met recently; we had known each other for a while but didn’t have a steady relationship; we had a steady relationship at the time; we were living together or engaged or married]
  • Unintended pregnancies: “Have you ever become pregnant unintentionally?” (women only) 
    “Have you ever got someone pregnant unintentionally” (men only)
    [no, once, twice, more than twice]
  • Terminations: “Did this result in a termination of pregnancy (abortion)?” (Those reporting unintended pregnancies only) 
    [no, once, twice, more than twice, don’t know]
  • Sexual attraction: “What best describes who you feel attracted to?” 
    [opposite sex only, opposite sex mainly, both sexes equally, same sex mainly, same sex only, no attraction]
Analysis—Analyses were conducted using survey procedures in Stata version 11 software12 and weighting was used to account for the oversampling of Māori students. Bivariate analyses used chi2 tests, comparisons between groups used two-sided Student’s t-tests, and p values < 0.05 were considered statistically significant.
Ethical approval—The study was approved by the New Zealand Multi-region Ethics Committee (MEC/05/01/013).

Results

Demographics—Of the 5770 students invited to participate, 2922 (50.6%) completed the survey while a further 226 (3.9%) began but did not complete the survey.

Participants had a median age of 20 and women were over-represented (61% respondents female vs. 39% male), while the university students invited were 57% female and 43% male. Most students lived in close proximity to other students with 71% living in a residential college or sharing a flat/house. Sixty-nine percent of both women and men reported having had sexual intercourse.

The characteristics of the study population are described in Table 1.

Table 1. Characteristics of the study population, weighted for sampling design
Variables
Total
(n=2922)
%
Men 
(n=1140)
%
Women 
(n=1782)
%
Age group
17–19 years
20–21 years
22–24 years
25–26 years

46
37
17
<1

46
35
19
<1

46
39
15
<1
Ethnicity 1
NZ European
NZ Māori
Chinese
Pacific Islands
Other

75
29
6
3
9

69
25
6
3
9

80
32
6
3
9
Residence type
Share a flat/house
Hall of Residence
Live with parent/guardian
Live in own home/renting
Board
Other

51
20
23
3
2
1

51
19
25
3
2
1

51
20
22
3
2
1
Ever had sex
Yes
No
Prefer not to answer

69
26
5

69
25
7

69
26
5
1Categories of ethnicity are not mutually exclusive

Sexual behaviours—Of students who reported having had sex, the median age at sexual debut was 17 overall (16 for women, 17 for men) and 21% of respondents reported that they had sex before they were 16 years old (24% of women, 16% of men). The distribution of lifetime number of sexual partners was right-skewed, and the median for both women and men was three partners. For the number of sexual partners in the last 12 months the median was just one partner although the distribution shows that about 25% of university students had three or more partners during this time.

The majority of students (66%) reported that the person they last had sex with was someone with whom they were in a “steady relationship” or were “living together, engaged, or married”. However, 3% of women and 11% of men reported that they had “just met” the person they last had sex with.

Only about half of the respondents (54%) reported using a condom the last time they had sex (men 58%, women 51%). There was a trend of decreasing condom use with increasing age (Chi-squared p<0.0001), and women were less likely to use condoms than men (Student’s t-test p<0.001). Overall, 32% of respondents reported that they had been drinking the last time they had sex (men 38%, women 29%).

Prevalence rates of reported sexual behaviour and risks are presented in Table 2.

Table 2. Prevalence of sexual behaviours in participants who had ever had sex, weighted for sampling design
Variables
Total
(n=2017)
%
Men (%)
(n=783)
%
Women
(n=1234)
%
Age at first sexual intercourse (years)
<14
14
15
16
17
18
≥19
Median

1
5
15
23
24
21
11
17 years

2
4
10
21
29
22
13
17 years

1
5
18
24
22
20
11
16 years
Number of sex partners ever
1
2
3
4
5
6–9
10–20
>20
Median

27
16
11
11
9
13
10
3
3

27
15
13
12
8
13
9
3
3

26
17
10
10
9
16
10
2
3
Number of sexual partners in last 12 months
0
1
2
3
4
5
6–9
10–20
>20
Median

5
57
18
8
5
3
1
3
0.3
1

7
54
20
8
6
3
2
0.4
0.4
1

4
59
17
8
5
4
3
1
0.1
1
Last sexual partner
Just met for the first time
Met recently
Known, no steady relationship
In a steady relationship
Living together/engaged/married

5
8
20
52
14

9
12
22
47
10

3
6
19
55
17
Condom use at last sex
Yes
No
Prefer not to answer

54
43
3

58
39
3

51
46
3
Drinking alcohol at last sex
Not at all
A little
Quite a lot

68
18
14

62
22
16

71
16
13

There was an association between use of a condom at last sex, and both partner choice and number of sexual partners, shown in Table 3. Use of a condom at last sex declined both as number of sexual partners increased (p=0.042) and as partner choice became more stable (p<0.0001).

Table 3. Reported condom use at last sex, by reported number of sexual partners in the last 12 months and by last sexual partner, weighted for sampling design
Variables
Condom used at last sex?
Yes (%)
No (%)
Number of sexual partners in last 12 months (n=1927)
1
2
3–5
6–8
≥9

52
61
50
48
42
p=0.0421
46
38
49
52
58
Describe last sexual partner (n=2068)
Just met for the first time
Had met recently
Known, no steady relationship
In a steady relationship
Living together, engaged, or married

74
68
64
51
40
p<0.00012
26
30
34
47
59
1Two-sided, unpaired Student’s t-test of the association between increasing number of sexual partners in last 12 months and decreasing use of a condom at last sex.
2Two-sided, unpaired Student’s t-test of the association increasing stability of relationship and decreasing reported condom use at last sex.

Unintended pregnancies—Of the women in the study, 112 (5.8% of those who had ever had sex) reported having had an unintentional pregnancy. Younger women reported lower rates of terminations: 3.3%, 4.4%, and 3.3% of 17, 18, and 19 year old women who had ever had sex, respectively. Additionally, 43 men (5.0% of the men who had ever had sex) reported having had sex that resulted in an unintentional pregnancy.

Women reported that 74% of unintentional pregnancies resulted in a termination. Men reported that 72% of unintentional pregnancies resulted in a termination and an additional 19% of men did not know the outcome. Table 4 summarises the unintentional pregnancy data and Figure 1 demonstrates the distribution of outcomes by age and gender of respondent.

Table 4. Prevalence of unintended pregnancies and terminations of pregnancy (TOP) in those who have ever had sex
Variables
Women (n=1356)
Men (n=737)
%1
n
%1
n
Ever had sex that resulted in an unintentional pregnancy
Never
Once
Twice
>Twice

94
5
1
0.02

1245
95
16
1

95
5
0.2
0.03

694
39
3
1
Did this result in a TOP? 
Never
Once
Twice
Don’t know
Prefer not to answer
(n=112)
26
67
7

3

28
73
8

3
(n=43)
9
68
5
19
1

8
25
4
3
3
1Percentages weighted for sampling design.
Figure 1. Frequencies of outcomes of unintended pregnancies reported by female and male study participants by age at survey

content01.jpg

Sexual attraction—About 95% of both men and women reported sexual attraction to the opposite sex only or mainly, with men being more likely to report exclusively opposite sex attraction (90.8% vs 83.2%), shown in Table 5. About 2% of both the men and women reported attraction to both sexes equally and about 1% of women and 3% of men reported same sex attraction only or mainly.

Table 5. Self-reported current sexual attraction of NZ university students, weighted for sampling design
Best description of sexual attraction1
Total
(n=2872)
%
Men
(n=1045)
%
Women
(n=1827)
%
Opposite sex only
Opposite sex mainly
Both sexes equally
Same sex mainly
Same sex only
No attraction
87
10
2
1
1
1
91
4
2
1
2
1
83
13
2
1
0.1
1
1Numbers in columns may not add to 100% because of rounding.

Students who reported being attracted to both sexes equally were significantly more likely to report first sex before 16, and those reporting being attracted to the same sex only or mainly were significantly less likely to report first sex before 16 (Chi-squared p<0.001) (Table 6).

Table 6. Age of first sex, by self-reported current sexual attraction of NZ university students (n=2049), weighted for sampling design.
Age at first sex
Opposite sex only
%
Opposite sex mainly
%
Both sexes equally
%
Same sex mainly
%
Same sex only
%
No attraction
%
<14
14
15
16
17
18
≥19
1
5
14
23
25
21
12
3
7
17
21
22
18
12
3
2
24
22
20
23
6
10
2

27
16
43
2

1
22
44
20
5
8



90

10
Chi-squared p<0.001 that there are associations between current sexual attraction and age at first sex.
1Numbers in columns may not add to 100% because of rounding

Discussion

This paper describes indicators of sexual health in a representative sample of university students, a large subset of the 17–24 year old NZ population. The results highlight issues that may be of public health concern amenable to prevention, such as unintentional pregnancies and STIs.

Although most respondents report having two or fewer sexual partners in the last year, those with higher numbers of sexual partners reported less condom use. Importantly, 26% of the population that reported that they had met their last sex partner for the first time said that no condom was used, indicating there is a significant proportion of the population at substantially increased risk of adverse sexual health outcomes.

A strength of this study was the use of an Internet-based format that can obtain better quality data and higher response rates at a lower cost than traditional methods.13 This may be especially important to ensure validity of responses for sensitive topics such as sexual health and experience.14

An increasing proportion of young people are attending university in NZ,15,16 but this study is not generalisable to the total population of 17–24 year olds as there may be important differences in behaviour. For example, there is evidence from previous NZ university research that students drink more heavily than their non-student peers.17

The modest response rate is a limitation of the study and we can expect some effect of self-selection on the results. As women were more likely to complete the survey than men, any selection bias is likely to be less for women. Previous research comparing the characteristics of those who do and do not respond in the Tertiary Student Health Surveys demonstrates that those who do not respond are more likely to be hazardous drinkers18 and have a higher prevalence of other health risk behaviours.19 The extent of underestimation of hazardous drinking prevalence was estimated to be small (<1%) when the response rate is over 66% and progressively larger as the response rate falls.18 As we have an overall response rate of 51% in this study it is likely that to an extent we have underestimated hazardous drinking and other risk behaviours.

This study did not gather information on alternative choices in contraception, such as oral contraceptive pill uptake and use, limiting interpretation of condom use data, at least for pregnancies and terminations.

Frequency of sexually transmitted infections (STIs) was not included due to the unreliability of self-reported data.20,21 In any case, STI diagnosis may reflect healthcare seeking behaviour as well as disease prevalence, given the high asymptomatic rates of STIs like Chlamydia.22 However, the prevalence of STIs in this university student population could be substantial given the majority of students (69%) have had sex, at least 20% of those have had three or more sexual partners in the last year, and only 54% used a condom the last time they had sex.

The median age of first sex found in the present survey of students (16 for women; 17 for men) is similar to that found in the Dunedin general population cohort in the late 1980s (17 for women; 16 for men), and the overall median age of 17, for both women and men in the Youth 2000 survey of high school students. This was also consistent with data from Australia in 200223 and the UK in 2001.24 The Australian Study on Health and Relationships (ASHR) found that people who self-identified as bisexual were significantly more likely to report first intercourse before 16 years of age, also consistent with our findings.23

Overall in our study 58% men and 51% of women (54% overall) used a condom at last sex but this varied by age and gender, with a trend of decreasing condom use with increasing age. In comparison, the Youth 2000 findings of 63% condom use at last sex are considerably higher in this younger age group.

In this contemporary university population there were high termination rates. About 3–4% of 17–19 year old women and 6% of women overall had ever had an unintentional pregnancy with about 74% of the pregnancies resulting in terminations. Comparatively, ASHR found 1.7% of women aged 16–19 had ever been pregnant, and 18.9% of these pregnancies resulted in a termination.25

Implications

We are interested in sexual experiences and behaviours in this population group because of the associated risks with negative health outcomes including sexually transmitted infections and unintended pregnancies and terminations.

NZ has a high prevalence of Chlamydia,1,26 and so failure to use condoms in NZ could be associated with a higher STI risk than in other countries. Teenage pregnancy rates are also high compared with other OECD countries,2 indicating suboptimal use of effective contraception in NZ.

There are few barriers to students accessing condoms or other contraceptives in NZ, as many are highly subsidised and available from a wide variety of sources.27 This study suggests that ease of access is not sufficient to ensure appropriate use. Efforts clearly need to continue in promotion of condom use amongst young people in NZ and further exploration of the reasons for not using condoms could help inform new approaches.

There is some previous research on the role of heavy drinking in sexual behaviour amongst university students10,28 and recently amongst genitourinary medicine clinic attendees in the UK31 that suggests that alcohol is frequently involved when young people make risky sexual choices.

Conclusion

The prevalence of risky sexual behaviours in this population raises concern about the number of students at risk of sexually transmitted infections and unintended pregnancies. We found that one in five students had three or more sexual partners in the last year. Given the relatively chaotic atmosphere of early university experience and the addition of frequent heavy drinking to the mix, a better understanding of how drinking behaviour affects sexual behaviour and barriers to using condoms would inform public health intervention strategies.

Summary

In a 2009 study of university students across New Zealand, we found frequent risky sexual behaviour, with 20% university students reporting 3 or more partners over the last 12 months, just over half reported using a condom last time they had sex, and about one-third had been drinking alcohol at last sex. Approximately 5% of students reported an unintentional pregnancy at some time in their life. Of particular concern was our finding that those with more sexual partners in the last 12 months were less likely to report using a condom at last sex. The prevalence of multiple partnerships in combination with low condom use puts students at risk of sexually transmitted infections and unintentional pregnancies.

Abstract

Aim

To describe the sexual health and behaviour of university students as a sentinel population of young New Zealanders.

Method

A random sample of 5770 students aged 17–24 from universities across New Zealand were invited to participate in an online survey in 2009. Questions on current sexual behaviours, lifetime unintended pregnancies and terminations, and sexual orientation were included.

Results

2922 students responded (51% of the sample), including 1857 women (61% of respondents), reflecting the high proportion of women in the university population (57%) and higher response from women. Sixty-nine percent of both men and women had ever had sex. Of these, 47% reported ≥3 partners ever, and 20% had ≥3 partners in the last 12 months, with no significant gender differences. Describing the last time they had sex, 58% of men and 51% of women reported using a condom and 38% of men and 29% of women had consumed alcohol. Approximately 6% of women and 5% of men reported ever having sex that resulted in an unintentional pregnancy. Of these pregnancies, 74% of women and 72% of men reported a termination while another 19% of men did not know the outcome.

Conclusion

Multiple sexual partnerships were common. Condom use was uncommon and inversely associated with number of recent sexual partners. One in 20 students had or contributed to at least one unintentional pregnancy. The prevalence of risky sexual behaviours in this population raises concern about the number of students at risk of sexually transmitted infections and unintentional pregnancies.

Author Information

Steven Lillis, Examinations Director; Malcolm Stuart, Assistant Examinations Director; Sidonie, Senior Professional Standards Coordinator (performance and examinations); Nikita Takai, Professional Standards Coordinator (performance and examinations), Medical Council of New Zealand, Wellington

Correspondence

Dr Steven Lillis, Medical Council of New Zealand, PO Box 11649, Wellington 6142, New Zealand.

Correspondence Email

lilliss@waikatodhb.govt.nz

Competing Interests

None known.

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