Experience of sexual harassment and assault is common among women

The majority are satisfied with their sex life, but there are large differences between the genders

Women feel freer to take initiative and to say no to sex than men

Most people know how to communicate if and how they want to have sex

Seventy percent of men consume pornography, while 70 percent of women do not

Almost 10 percent of men have paid for sex

Reproductive health: results on contraceptives, pregnancy, abortion, miscarriage, children, and child delivery

SRHR2017 showed differences in sexual and reproductive health and rights between different groups in the population. The answers to almost all questions in the survey differed between women and men, and the greatest gender differences were seen for:

• sexual harassment and sexual violence
• experiences of payment in exchange for sex
• pornography use
• several different experiences in people’s sex lives

This reflects different gender conditions regarding sexual and reproductive health. Further, the results show greater vulnerability among women, younger people, non-heterosexuals, and trans people and to a certain degree among people with lower income and education.

A majority of the population have good sexual health, which of course is a positive result. At the same time, sexuality and people’s sex lives differ, sometimes a lot, between women and men. For example, women more often experience low sex drive because of fatigue and stress compared to men. Why men less often feel free to say no to sex needs to be studied further. There are strong norms in our society regarding sex and sexuality, and gender roles, norms regarding femininity and masculinity, and norms regarding heterosexuality affect to what extent people feel free to live their lives as they see best.

Sexual harassment, assault, and sexual violence and how these affect our health is an important public health issue. The prevalence and the consequences do not just affect the victimized individual; they are also a marker for how equal a society is.

Based on the results of SRHR2017, there appears to be a need for more discussions and analyses on sexuality regarding support, advice, and education. For young people we have youth clinics and maternity health care centers where issues related to sex also can be discussed – but that mainly target women – and there are few places where older people can turn to receive help regarding their sex life and sexuality. There is a need to systematically monitor and evaluate these preventive institutions, especially youth clinics, also because of the need of men for support, advice, and care related to their sexuality. We need to emphasize the reproductive rights and health of men and discuss men’s rights to reproductive health, the path to having children, their use of contraceptives, treatment for sexually transmitted diseases, and general sexual health.

In SRHR2017, we see that women and men of all ages use digital arenas for sexual purposes. Young people are more active online, and differences between the sexes are small among young people. UMO.se is an online youth clinic and a good example of how to handle sexuality issues in way that reaches many and with high quality.

Schools are important arenas for improving gender equality and equity regarding health, and the sex education in schools constitutes an important part of SRHR. Sex education in schools and school health care are to provide information to all students about structural perspectives, like legislation and norms, and individual perspectives, such as the physical body, sexual health, relationships, and sexuality. Studies show that students receive more information on sexual health, pregnancy, and contraceptive use than about gender equality, LGBT perspectives, and relationships even though sex education has been subjected to improvements such as integration into other subjects. The improvement work with sex education is supported by a quality assessment from the School Inspection, improvements from the School Authority, and international guidelines regarding sex education from UNESCO and WHO Europe.

SRHR in Sweden – how to proceed

The Public Health Agency of Sweden coordinates SRHR nationally, builds knowledge, and monitors SRHR in Sweden. The purpose with the government’s assignment for the agency to perform a population survey on SRHR was to increase knowledge and by doing so create better conditions for SRHR in Sweden.

Paradigm shift in sexuality issues

The link between sexuality and health has been investigated previously. Sweden performed the first population-based sexuality survey in the world in 1967. After ten years of preparation, the former Public Health Institute of Sweden undertook, on assignment from the government, the study “Sex in Sweden” in 1996. This study is often cited concerning sexuality and health issues, largely due to the lack of larges studies on the topic.

During the past 20 plus years since 1996, several important changes and reforms have been passed. In the time line below, we show a selection of these societal changes. Some of the greatest changes are the introduction of the Internet, improved rights for LGBT people, and Sweden’s membership in the EU, which together with increased globalization have increased the mobility of people and services.

Figure 1. Time line with some of the changes in the SRHR field since 1996.

When the Public Health Agency in 2017 conducted the survey described here, it was done in a new context for SRHR. This is most evident regarding gender equality and feminism, norm awareness, improved LGBT rights, and of course the Internet. In addition, the Guttmacher–Lancet commission for sexual and reproductive health and rights developed a thorough and evidence-based agenda with priorities for SRHR in 2018. Their definition of SRHR is:

Sexual and reproductive health is a state of physical, emotional, mental and social well-being in relation to all aspects of sexuality and reproduction, not merely the absence of disease, dysfunction or infirmity. Therefore, a positive approach to sexuality and reproduction should recognize the part played by pleasurable sexual relationships, trust and communication in promoting self-esteem and overall well-being. All individuals have a right to make decisions governing their bodies and to access services that support that right.

Achieving sexual and reproductive health relies on realizing sexual and reproductive rights, which are based on the human rights of all individuals to:

• have their bodily integrity, privacy, and personal autonomy respected
• freely define their own sexuality, including sexual orientation and gender identity and expression
• decide whether and when to be sexually active
• choose their sexual partners
• have safe and pleasurable sexual experiences
• decide whether, when, and whom to marry
• decide whether, when, and by what means to have a child or children and how many children to have
• have access over their lifetimes to the information, resources, services, and support necessary to achieve all of the above free from discrimination, coercion, exploitation, and violence

To monitor SRHR

Method

The results from this survey show that many forms of sexual harassment and sexual assault are widespread in the Swedish population, among both women and men. All forms of sexual harassment, assault and violence are however more common among women than among men, and lesbian, gay, bisexuals and transgender (LGBT) people are more often subjected to these types of assaults, compared to the general population.

The most commonly reported forms of assault were sexual harassment and so-called “other sexual offenses” (e.g. unwanted touching). Four in ten women and one in ten men reported having been subjected to sexual harassment or other sexual offenses. Among women 16-29 years of age, over half reported having been subjected to sexual harassment and a similar proportion reported having been subjected to “other sexual offenses”.

The largest proportion of those who had been subjected to sexual harassment was found among bisexual women, where three out of four reported having been sexually harassed. Gay men were also more often harassed than heterosexual men, with one in three gay men reported having been sexually harassed. The most violent forms of sexual assault, attempt at sexual intercourse through threats or violence and sexual intercourse through physical violence, were most common among lesbians. Gay men were subjected to these types of severe assaults to the same extent as heterosexual women.

The number of people reporting themselves victims of these crimes decreases with age among both sexes.

Results in short:

• Many forms of sexual harassment, sexual assault and sexual violence are common and significantly more common among women than among men.
• Four in ten women in Sweden had been subjected to sexual harassment such as unwanted texts, phone calls, sexual proposals or been subjected to exhibitionists (42 percent among women and 9 percent among men). Over half (57 percent) of women 16-29 years of age and half (48 percent) of women 30-44 years of age has experienced sexual harassment.
• Similarly, almost one in two women and almost one in ten men had experienced other sexual assault such as being forced to touch someone’s body in a sexual way against their will. Over half (55 percent) of women 16-29 years of age and almost half (47 percent) of women 30-44 years have experienced this.
• 11 percent of women and 1 percent of men had been subjected to attempted intercourse by physical violence or threat of physical violence. This also was more common among LGBT-people where 30 percent of lesbian women and 10 percent of gay men had been subjected to this form of assault.
• 7 percent of women and 1 percent of men had been subjected to forced intercourse by physical violence or threat of physical violence.
• 23 percent of women and 5 percent of men had been subjected to sexual assault by psychological pressure. This also was more common among lesbian, gay and bisexual people, 44 percent among bisexual women and 16 percent among gay men.
• 9 percent of women and 3 percent of men had been subjected to sexual humiliation such as for example that someone criticized your body, your sexual desire or capacity, or made you watch porn against your will.
• Homosexual-, bisexual- and transgender people are significantly more likely to report being subjected to sexual harassment, sexual assault and sexual violence than heterosexual and cis-people.

This study shows that many forms of sexual harassment and sexual offenses are prevalent in the Swedish population and mainly affects women but LGBT people are also a vulnerable group.

There is still a great need for preventive measures against sexual harassment and violence. These phenomena are both unacceptable and criminal and must stop. Schools play an important role. Issues such as norms, gender patterns, gender equality, sexuality and relationships need to be included at an early stage in the broad work with knowledge and fundamental values in general, and particularly in sexuality education.

This study shows that the majority of the Swedish population 16-84 years of age, were satisfied with their sex life, believed that sex is important and have had sex in the past year. The largest proportion of those who were satisfied with their sex life were women aged 30–44 and 45–64 (63 percent) and men aged 30–44 (67 percent). The youngest group among men (16–29 years of age) and the oldest group among women and men (65–84 years of age) were least satisfied with their sex life.

Gender was shown to be of significance for experiences and problems in relation to sex life. For example, it was more common among women than men to have lacked interest in having sex, lacked desire, pleasure and excitement during sex, experienced physical pain as a result of sex and had difficulty in reaching climax. Additionally, more than every tenth woman (13 percent) have had issues with vaginal dryness.

It was more common among men than women not to have had a sex partner, to have reached climax more quickly than they would have liked, not had sex in the way they wanted and to have wanted to have more sex partners. Seventeen percent of men reported that they had trouble getting or keeping an erection.

More women than men experienced that they were too tired or stressed to have sex in the last twelve months. In the age group 30–44, 37 percent of women and 17 percent of men stated that they were too tired or stressed to have sex. Eight percent of the population reported having had health issues or physical problems that had affected their sex life. 13 percent had sought advice or help from the health care system for problems in relation to their sex life, while the majority (82 percent) stated that they did not seek help and did not think they were in need of it.

Results in short:

• 58 percent of the Swedish population aged 16–84 were satisfied with their sex life over the past year and the majority thought that sex is important.
• Four out of five Swedes aged 16-84 (80 percent) had sex in the last twelve months. About every third man or fourth (28 percent) and every fifth woman (18 percent) reported that they had not had sex frequently enough.
• One fifth of women (21 percent) and just under one tenth of men (8 percent) had lacked sexual desire.
• Twice as many women (33 percent) as men (15 percent) had lacked interest in sex.
• One tenth of women (9 percent) and four percent of men had lacked sexual excitement.
• 13 percent of women had issues with vaginal dryness.
• It was more common among women (16 percent) than men (7 percent) to not have reached climax, while more men (18 percent) than women (2 percent) had reached climax more quickly than they wanted to.
• 17 percent of men had trouble getting or keeping an erection. This problem was more common in older men.
• 11 percent of women and 2 percent of men had experienced pain as a result of sex.
• Twice as many women (20 percent) as men (10 percent) had been too tired or stressed to have sex.
• 8 percent have had health issues or physical problems that have affected their sex life.
• 13 percent have sought help for problems in relation to their sex life.

This study shows that the majority of the Swedish population aged 16 – 84 were satisfied with their sex life during the last twelve months, have had sex in the past year and think that sex is important. The results further show that sex and age affect experiences and problems in relation to sex life. Information, counselling and care related to sexuality should be needs-oriented and should meet the requirements from a public health perspective through: availability, accessibility, acceptability and quality.

The majority of heterosexual, gay/lesbian women and men and bisexual women stated that they were satisfied with their sex life. A lower percentage of transgender people said they were satisfied, however, those aged 45 – 64 tended to be more satisfied than other age groups. Bisexual women and men were more often dissatisfied with their sex life than other groups. The results also showed that most LGBT people, as heterosexuals, have had sex in the last year, but that every fourth transgender person and every fifth bisexual man had not had sex.

Sexual identity and sex is of importance for experiences and problems in relation to sex life. Every fifth woman, regardless of sexual identity, had lacked sexual desire and every third woman had lacked interest in having sex. Bisexual women tended to have more difficulty reaching orgasm, wanted more sex partners and more often experienced worry or physical pain as a result of sex than heterosexual women. A larger proportion of lesbian women reported that they were satisfied with their sex life, more often had sex, and had an easier time reaching climax compared to heterosexual women.

Lack of sexual desire was more common among gay and bisexual men (16 percent and 14 percent respectively) compared to heterosexual men (8 percent). In addition, more gay and bisexual men had lacked interest in having sex, had more difficulty reaching orgasm, experienced more worry, and lacked enjoyment and excitement during sex in comparison to heterosexual men. It was more common among gay men (10 percent) than heterosexual men (2 percent) to have felt pain as a result of sex. More than every fifth of transgender person had lacked sexual desire (22 percent), been too tired or stressed to have sex (23 percent) and lacked a sex partner (24 percent). Forty-two percent of transgender people had lacked interest in sex, 26 percent had not had sex in the way they had wanted and 18 percent had health problems or physical problems that affected sex life. In all groups, approximately 15 percent had sought advice or help from the health care system for problems in relation to sex life, while the majority had not sought help and felt that they were not in need of it.

Results in short:

• It was more common among cis people (57 %) than transgender people (34 %) to be satisfied with their sex life.
• 28 percent of bisexual men, 19 percent of gay men and 24 percent of transgender people had not had a sex partner.
• More than every fifth woman, irrespective of sexual identity, had lack of sexual desire.
• 39 percent of lesbian and bisexual women and 32 percent of heterosexual women had lacked interest in sex.
• It was more common that gay and bisexual men had lacked interest in sex (25 percent and 22 percent respectively) as compared to heterosexual men (15 percent).
• 42 percent of transgendered people had lacked interest in sex as compared to 24 percent of cis people.
• More bisexual women (27 percent) had not reached or had difficulty reaching climax compared to heterosexual and lesbian women (15 percent and 14 percent respectively).
• Every fifth gay man (19 percent) had not reached or had taken a long time to reach orgasm, compared to heterosexual and bisexual men (7 percent and 9 percent respectively).
• Every eighth gay man and lesbian woman (10 percent and 12 percent respectively) and every fifth bisexual woman (19 percent) had experienced pain as a result of sex.
• Vaginal dryness tended to be less common among lesbian women (5 percent) as compared to both heterosexual and bisexual women (14 percent).
• Every fifth bisexual man and transgender person (21 percent and 19 percent respectively) had difficulty getting or maintaining an erection.
• More than one in ten lesbian women and gay men (13 percent) and almost every fifth transgender person have had health problems or physical problems that had affected their sex life.
• About 15 percent sought advice or help for problems in relation to their sex life, while the majority had not sought help and considered that they were not in need of it either.

This study shows that the majority of the Swedish population, regardless of sexual identity, are satisfied with their sex life. A majority have had sex in the past year and thinks that sex is important. The results further show that sex, age and sexual identity affect experiences and problems in relation to sex life and that there are differences within and among different groups. It is important to look at sexual health from a holistic perspective, which includes understanding of the synergies between sexual, physical and mental health. Problems associated with sex life exist among all groups, but some problems might be more common in some groups. Information, counselling and care related to sexuality should be needs-oriented and should meet the requirements from a public health perspective through access, accessibility, acceptability and quality.

This is the first time the Swedish Public Health Agency has focused on pornography use and health. The results show that pornography use is a common phenomenon, especially among young men in Sweden. Previous studies have shown pornography use can potentially have a harmful impact on young people’s sex life and the personal sexual script. Women are also negatively affected by men’s pornography use when the pornography is based on an imbalance in power where women always are subordinate which is displayed by violence against women in pornography. En viktig del i det förebyggande arbetet är att diskutera pornografins negativa konsekvenser med pojkar och män, och skolan är en viktig arena för detta. Undervisning om jämställdhet, sexualitet, kön och relationer är också obligatorisk i svensk skola. Det är viktigt att vuxna är öppna för samtal om pornografi, men även för diskussioner kring vikten av respektfulla och ömsesidiga relationer. An important part of the preventive work is to discuss the negative consequences of pornography with boys and men in schools. Gender equality, sexuality, sex, and relationships are compulsory in Swedish schools. It is important that adults have an open mind regarding conversations about pornography, but also for discussions on how to form sound sexuality and the importance of respectful and mutual relationships.

The group people with experience of receiving payment or compensation for sex is an important target group in the work of the Public Health Agency for sexual and reproductive health and rights, against HIV/STI and for equal rights and opportunities regardless of sexual orientation, gender identity or gender expression.

Since the reasons for having transactional sex and the experiences of the phenomenon transactional sex are very different, the preventive work need to include many different preventive measures from for example public authorities, schools and health care services. The results also shows that experiences of transactional sex are more common among LGBQ-people. People with experience of transactional sex should be offered social support and interventions to improve sexual, physical and mental health, regardless of sex or sexual orientation.

• Hormonal contraceptive use is largely due to age, whether one has an on-going relationship, is sexually active, or if one wants to become pregnant.
• Income and educational level, but not cost, affects hormonal contraceptive use among women aged 16–29 . The proportion of women aged 16–29 years using the pill is lower among women with high income as compared to low-income and lower among women with high education as compared to women with low. Other factors that may influence the differences in use include worries about hormones and their side effects but more analysis is needed.
• The withdrawal method (pulling out) and safe periods are used by almost one fifth of women and men aged 16 to 44.

• There is a relationship among both women and men aged 30 and older between socioeconomic position and wanting children as well as with the number of children you want. Men with low education and low income to a lesser extent have the number of children they want.
• Three per cent of women and men aged 30 and above report being involuntarily childless, whereas 5%, in all ages, do not want children.
• Approximately 7% of both women and men aged 30 to 84 have become parents without wanting to.

• Approximately one third of Swedish women have had one or more abortions.
• One third have experienced a miscarriage.

• Women aged 30–44 years were 28 years old on average at their first child delivery, whereas women aged 45–64 were 26 years old on average. The longer the education, the older the women were at their first child delivery.
• Twenty-six per cent of women aged 16–84 reported physical difficulties after at least one of their deliveries, 17% reported psychological difficulties, and 14% reported sexual difficulties. Experiences of the consequences of child delivery vary with age and educational level. Men also reported psychological and sexual difficulties after attending child delivery.
• Depending on age, 81–92% of women who had delivered a child had a vaginal delivery. It was more common among younger than older women to have had a caesarian section. The type of delivery did not vary by income or education.
• Vacuum-assisted, and rarely forceps, delivery was most common among women aged 30–44 (12%) years.
• Women having had an episiotomy were most often older than 45 years, while women younger than 45 years had most often had spontaneous laceration that, as the episiotomy had been sutured.
• The majority of women with experience of child delivery had had an episiotomy or a spontaneous laceration, and 8% had a rupture without sutures and 4% had a rupture involving the anal sphincter (grade 3 or 4).
• Approximately 12% had sought care for problems related to episiotomy or spontaneous lacerations in relation to delivery, 7% answered that they had received treatment that had helped, 3% said that they had not received treatment, and nearly 2% said that they had treatment that did not help.
• Age, education level, or income did not affect the seeking or receiving of care or problems related to child delivery.

Hormonal contraceptive use among women in Sweden vary based on age and need but also based on income and education. Thoughts regarding children vary by age and sex but also based on income and educational level. Reproductive experiences such as pregnancy, abortion, miscarriage and child delivery also vary according to a range of factors including age, income, educational level, sexual identity and sometimes geographical region.

All students in the Swedish school system are entitled to evidence based, recurring, relevant and knowledge building sexuality education that forms an important part of the foundation of sexual and reproductive health and rights (SRHR). School is a central health promoting arena and the right to information and knowledge are important parts of the SRHR work in general.

Several national and international guidelines and reports indicate that an evidence based sexuality education creates the foundation for the students to develop their reflective, critical and communicative ability and strengthen the students' opportunities to make informed and responsible decisions in the area of sexuality and relationships.

• 19 percent stated that they thought the school's sexuality education had given them the knowledge they needed. More men (22 percent) compared to women (16 percent) stated that the teaching provided them with the knowledge they needed. Almost a third (29 percent) stated that the sexuality education did not give them the knowledge they needed and every fourth respondent (26 percent) acquired the knowledge they needed from a different source.
• 8 percent stated that they never received any sexuality education.
• No significant differences between women and men with different educational attainment were found regarding if one had gotten the sexuality education needed.
• Men are more often satisfied with the sexuality education given, as compared to women and regardless of sexual identity.
• Lesbian/gay (39 percent) and bisexuals (36 percent) more often reported that their sexuality education had been inadequate, as compared to heterosexuals (28 percent).
• In comparison with UngKAB15, there is somewhat fewer in SRHR2017 that thinks that sexuality education has given them sufficient knowledge. In UngKAB15, 58 percent of the boys and 41 percent of the girls, aged 16-29, stated that they received sufficient knowledge through sexuality education. The corresponding figures in SRHR2017 are 37 percent for boys and 26 percent for girls.

The prerequisites for a work of high quality are found in the Swedish curricula. Even so, sexuality education in Sweden has problems regarding equality and quality according to quality reviews carried out.

In order to achieve equality and high quality, teachers' skills and confidence to handle these issues need to increase. Teacher education must address these issues and equip teachers for the work, and for the teachers in service there should be opportunities for competence development.

A prerequisite for this work is the governance from the headmaster or other school leaders and these perspectives must be integrated in the systematic quality work and be planned, monitored and evaluated regularly.