A comprehensive study has shed new light on sexual practices and sexual identity in Australia.
What are the patterns of sexual behaviour across different populations in Australia? Are same-sex sexual attraction and experience common? In what ways do they relate to sexual behaviours and health outcomes? Answers to such questions are important in determining the need, and type of interventions necessary, for the management of risky or harmful behaviours.
The Australian Study of Health and Relationships (ASHR) was the largest, most comprehensive population-based survey of sexuality ever undertaken in Australia. In 2001–02, telephone interviews were conducted with a randomly selected sample of 10,173 men and 9134 women aged 16–59 years from all states and territories of Australia.1 The sample was adjusted statistically to reflect the location, age and sex distribution of the 2001 census, and can therefore be regarded as being broadly representative of the Australian population. For the first time, it provided an in-depth, representative overview of the sexual practices and health of different populations across the nation.
Sexual relationships and experience
The onset of sexual activity was examined with respect to the decade in which people were born.2 Half the men born between 1941 and 1950 had had vaginal intercourse by age 18 and this median age of first vaginal intercourse declined to 16 for men born between 1981 and 1986. For women, the median age at first vaginal intercourse declined from 19 to 16.2 The median age of first homosexual experience was higher than the age of first heterosexual experience.
Heterosexual men reported more partners over their lifetime, and in the last five years and in the last year, than did heterosexual women.3 In all, 15.1 per cent of heterosexual men and 8.5 per cent of heterosexual women reported two or more sexual partners in the last year, although these partnerships were not necessarily concurrent. People who identified as homosexual or bisexual reported more partners than those who identified as heterosexual, and homosexual men and bisexual men and women had had more partners than had lesbians.4 For example, 38.2 per cent of homosexual and 9.6 per cent of bisexual men reported more than 50 same-sex partners in their lifetime, compared to 0.5 per cent of homosexual and 0.9 per cent of bisexual women.4 The percentage of heterosexually identified men and women reporting 50 or more opposite-sex partners was 6.6 per cent and 0.9 per cent, respectively.3
By far the majority of those who reported ever having been heterosexually active were currently in a regular heterosexual relationship (85.3 per cent of men and 89.5 per cent of women), equivalent to 73.5 per cent of all men in the survey and 77.0 per cent of all women. Only 4.9 per cent of men and 2.9 per cent of women in regular relationships had had concurrent sexual partners in the last 12 months.5 Among those who indicated they were homosexually active in the year prior to being interviewed (1.9 per cent of men and 1.5 per cent of women), 22.2 per cent of men and 46.9 per cent of women were in a regular homosexual relationship at the time of completing the survey, 7.0 per cent and 2.9 per cent of which reported two or more regular partners, respectively.5
Sexual identity, attraction and experience
Here, the terms ‘lesbian’, ‘gay’ and ‘bisexual’ are used to describe only those people who identify by these terms and not those who are attracted to others of the same sex or who have had same-sex sexual experience, but do not identify with these terms.6 Of those surveyed, 97.4 per cent of men identified as heterosexual, 1.6 per cent as gay and 0.9 per cent as bisexual.7 For women, 97.7 per cent identified as heterosexual, 0.8 per cent as lesbian and 1.4 per cent as bisexual.7 Nevertheless, 8.6 per cent of men and 15.1 per cent of women reported either feelings of attraction to persons of the same sex or some sexual experience with the same sex. Indeed, half the men and two-thirds of the women who had had same-sex sexual experience regarded themselves as heterosexual rather than homosexual or bisexual, suggesting that same-sex attraction and experience are far more common in Australia than is indicated by the relatively few people reporting a homosexual or bisexual identity.
Identifying as homosexual or bisexual was associated with higher levels of education, higher status occupations and living in major cities7, and homosexual experience was associated with having an English-speaking background, homosexual or bisexual sexual identity, higher levels of education and living in a major city.4 Men who reported same-sex attraction, regardless of whether they had had same-sex experience, tended to report higher levels of psychosocial distress, as did women reporting any same-sex attraction or experience.7
Safer sex, condom use and STIs
Among those reporting casual partners, unprotected sex was more common in heterosexual activity than in homosexual activity among men. Of heterosexually active people, 3.3 per cent reported unprotected sex with casual partners in the last six months, representing 58.5 per cent of heterosexuals who had had casual partners.8 Among homosexually active males, 2.1 per cent reported unprotected anal sex with casual partners in the last six months (12 per cent of those with such partners). Condoms were used in 21.2 per cent of the most recent episodes of vaginal intercourse.9 In the previous six months, few people (7.1 per cent) had always used condoms with a regular live-in partner, more (22.5 per cent) had always used condoms with a regular partner who did not live with them, and more again (41.4 per cent) had always used condoms with casual partners.9 Among men who had used condoms in the 12 months prior to the survey, condom breakage was experienced by 23.8 per cent and condom slippage by 18.1 per cent.10
Results suggested that Australians generally have poor knowledge about the transmission and health consequences of STIs.11 Although the majority of respondents knew that cold sores and genital herpes were caused by the same virus (64.5 per cent of men and 71.4 per cent of women) and that once infected with herpes a person would always have the virus (60.7 per cent and 74.8 per cent), somewhat lower proportions knew that hepatitis B could be transmitted sexually (58.6 per cent and 60.3 per cent) or that gonorrhoea could be transmitted through oral sex (54.4 per cent and 54.2 per cent). Further, relatively few knew that chlamydia could lead to infertility in women (34.4 per cent of men and 57.3 per cent of women) or that it affected both women and men (29.6 per cent and 32.3 per cent).11 Overall, women were more knowledgeable about STIs than men, as were those who identified as homosexual or bisexual, aged 20–24 years, spoke English at home, had higher levels of education or higher status occupations and had previously been diagnosed with an STI.11
In terms of STI incidences, 20.2 per cent of men and 16.9 per cent of women had ever been diagnosed with an STI or blood-borne virus, and 2.0 per cent and 2.2 per cent, respectively, had been diagnosed in the last year.12 The most commonly diagnosed STI among women was candidiasis or thrush (31.9 per cent of respondents), although it is recognised that symptomatic thrush is frequently not sexually transmitted. The next most common STIs among men and women were pubic lice or crabs (7.1 per cent), genital warts (4.2 per cent), chlamydia (2.4 per cent), herpes (2.3 per cent) and gonorrhoea (1.4 per cent). Overall, 1.8 per cent of respondents had been diagnosed with hepatitis A and 0.7 per cent with hepatitis B. The respondent’s usual general practitioner was the most common location of treatment.12 Correlates of having been diagnosed with an STI in the 12 months prior to interview included identifying as homosexual or bisexual, having had more than one sexual partner in the previous year, ever having worked as a sex worker, ever having been to a sex worker and ever having injected drugs.12
Patterning of sexual practices and sexual identity
There are a number of ways in which ASHR sheds light on relationships between sexual practices, identity and health in Australia. While the majority of respondents were in current relationships, a substantial proportion reported multiple partners in the previous year. This suggests that there is a large segment of the Australian population engaging in either concurrent relationships or serial monogamy. Having multiple partners and not always using condoms are a partial explanation for why STIs and blood-borne viruses appear to be somewhat common in the population. Unfortunately, knowledge of the transmission routes and health consequences of the most common STIs seems quite poor. Most people with STIs present to their general practitioner. This underlines the importance of ensuring that GPs are appropriately trained and resourced to effectively diagnose and treat STIs. It also means that instead of being exclusively directed at young people, education about safe sex should also address the needs of people throughout their lives.
Importantly, although the proportion of people who identified as gay, lesbian or bisexual was small, the proportion reporting some homosexual experience was considerably greater. Since the overwhelming majority of health education and promotion is focused on heterosexuals, the appropriate representation of lesbian, gay and bisexual people in these activities is long overdue. The additional complexities presented by those who have same-sex attraction or experience, but identify as heterosexual should also be addressed where appropriate. Indeed, the results reviewed here clearly emphasise the need for health professionals to be sensitive to the complex interrelationship between an individual’s sexual identity and his or her sexual practices and consequent health outcomes.
This work was supported by the National Health and Medical Research Council Project grant 1002174.