Changes In Sexual Practices Research Articles

Erratum to: A Qualitative Investigation of the Impact of a Livelihood Intervention on Gendered Power and Sexual Risk Behaviors Among HIV-Positive Adults in Rural Kenya.

Despite the recognized links between food insecurity, poverty, and the risk of HIV/AIDS, few randomized trials have evaluated the impact of livelihood interventions on HIV risk behaviors. The current study draws upon data collected from a qualitative process evaluation that was embedded into a pilot randomized controlled trial that tested whether a multisectoral agricultural intervention (Shamba Maisha) affected the HIV-related health of HIV-positive adults in rural Kenya. In the current study, we drew upon longitudinal, in-depth interviews with 45 intervention participants and nine control participants (N = 54) in order to examine the impacts of the intervention on gendered power and sexual risk reduction among both women and men. Female and male participants in the intervention described positive changes in sexual practices and gendered power dynamics as a result of intervention participation. Changes included reduced sexual risk behaviors, improved gender-related power dynamics, and enhanced quality of intimate relationships. These findings illuminate how a multisectoral agricultural intervention may affect inequitable gender relations and secondary transmission risk. Further research is needed to explore how to best leverage agricultural interventions to address the important intersections between poverty and inequitable gender relations that shape HIV risks.

A Qualitative Investigation of the Impact of a Livelihood Intervention on Gendered Power and Sexual Risk Behaviors Among HIV-Positive Adults in Rural Kenya.

Despite the recognized links between food insecurity, poverty, and the risk of HIV/AIDS, few randomized trials have evaluated the impact of livelihood interventions on HIV risk behaviors. The current study draws upon data collected from a qualitative process evaluation that was embedded into a pilot randomized controlled trial that tested whether a multisectoral agricultural intervention (Shamba Maisha) affected the HIV-related health of HIV-positive adults in rural Kenya. In the current study, we drew upon longitudinal, in-depth interviews with 45 intervention participants and nine control participants (N=54) in order to examine the impacts of the intervention on gendered power and sexual risk reduction among both women and men. Female and male participants in the intervention described positive changes in sexual practices and gendered power dynamics as a result of intervention participation. Changes included reduced sexual risk behaviors, improved gender-related power dynamics, and enhanced quality of intimate relationships. These findings illuminate how a multisectoral agricultural intervention may affect inequitable gender relations and secondary transmission risk. Further research is needed to explore how to best leverage agricultural interventions to address the important intersections between poverty and inequitable gender relations that shape HIV risks.

P09.16 Isolation of neisseria meningitidis during a gonorrhoea treatment trial

Introduction Neisseria meningitidis (NM) urethritis presenting clinically as Neisseria gonorrhoeae (NG) urethritis and other NG urogenital infections have been described. NM was isolated from participants in a multi-site gonorrhoea treatment trial. Methods From February 2014 through November 2014, ninety-two men were enrolled at the LSU site in New Orleans, LA. Urethral and pharyngeal swabs for culture and GenProbe ® CT/GC were collected from all participants and rectal swabs if receptive anal intercourse was reported. There were 424 culture isolates from the trial, 107 of those from LSU. Preliminary isolate NG identification, confirmatory NG/NM identification and NM serotyping were performed at the LSU, UAB and LA OPH Laboratories, respectively. Urethral NG cultures collected in New Orleans from 2013 were reviewed. Results Eighty-seven (95%), 8 (9%) and 4 (4%) men at the LSU site had positive NG cultures at the urethra, pharynx and rectal sites, respectively. Eight (2%) isolates from the trial were NM and all were from LSU. Eight (8%) LSU isolates were NM from 5 (5%) men. Three (3%) isolates were urethral (Group C-2/Group B-1), 1 (1%) was rectal (Group B-1) and 4 (4%) were pharyngeal isolates (Group B-1/Non-typable-3). One heterosexual and two homosexual men with NM urethritis had purulent discharge and urethral smears identical to gonorrhoea. All Group B isolates were from a vaccinated college student. No NM isolates (0/192) were found in urethral cultures collected in New Orleans in 2013. Conclusion Reports of urogenital NM infections clinically indistinguishable from NG have increased with changes in sexual practices, particularly increase in oral sex. All men with NM urethritis in this report received oral sex. In most clinical settings NM infection will not be recognised because NAAT testing has replaced culture and Gram stains are seldom performed. In addition, sexually transmitted NM infections may also cluster geographically and in time periods. Disclosure of interest This study was funded by Melinta Therapeutics.

Redefining Rape: Sexual Violence in the Era of Suffrage and Segregation, by Estelle B. Freedman

Redefining Rape: Sexual Violence in the Era of Suffrage and Segregation, by Estelle B. Freedman. Cambridge, Harvard University Press, 2013. 387 pp. $35 US (cloth). Estelle Freedman is arguably the most distinguished historian of US sexual history. Her 1988 Intimate Matters, co-written with John D'Emilio, provided a synthesis of historical change in sexual practices and meanings from the earliest days of the republic, so it is no surprise that her new survey, Redefining Rape, is similarly comprehensive. A study both synthetic and analytic, based on new research as well as mastery of the scholarship, it is quite possibly the most important of her works. This is not a book for specialists in gender or sexual politics: its material should be integrated centrally into American history textbooks and teaching--as well as used by historians as a guide to the questions and research we need about other regions. This is because, as Freedman so definitively shows, rape has been a fundamental shaper of citizenship. As today's feminists are reviving campaigns against sexual assault, not only in the US but around the world, this history becomes particularly vital because it illustrates what is at stake. The book's leading motif is the several-century-long struggle about the definition of rape. Raping women was long understood in law as an injury to the woman's father, husband, or other male guardian, a spoiling of her marriage-ability and/or her social worth. But that seemingly simple aspect of coverture was intersected since time immemorial by other social and economic structures. Armies promised sexual access to women as an entitlement, an entitlement still widespread today. Landlords, employers and slaveowners expected the same. Men of ruling races claimed access to women of subordinate races. In the US, where racialized conquest and slavery placed racial domination at the centre of its political and economic organization, rape functioned as far more than a satisfaction for individual assailants; rape established and confirmed structures of dominance. It could be said to be a form of terrorism, inasmuch as its message reached not only direct victims, but all women; and not only women, because it told subordinated men that they should not aspire to a masculinity that included marital fidelity or their own access to women of their group. Freedman's book is full of vivid cases of rapists' impunity, of course, but it is more importantly a history of campaigns against rape, fought on gendered, racial, and class bases as fundamental parts of the stmggle for freedom and social justice. Until the feminism of the 1960s and 1970s, there were no explicit, single-issue campaigns against rape, but there were many that eroded some of that impunity. Of particular importance is Freedman's fine discussion of nineteenth-century feminists' campaign to criminalize seduction. …

Human Papillomavirus Prevalence in Invasive Penile Cancer and Association with Clinical Outcome

The incidence of penile cancer is increasing, and is suggested to be explained by changes in sexual practice and increased exposure of men to sexually transmitted high risk human papillomavirus infection. In penile cancers from a Dutch population treated in 1963 to 2001 we found a high risk human papillomavirus prevalence of about 30%. In this study we assessed the prevalence of high risk human papillomavirus-DNA in a more recent, contemporary penile cancer cohort and its association with patient survival. High risk human papillomavirus-DNA presence was assessed by GP5+6+ polymerase chain reaction in 212 formalin fixed, paraffin embedded invasive penile tumor specimens of patients treated between 2001 and 2009. The 5-year disease specific survival was calculated using the Kaplan-Meier method with the log rank test and Cox regression. High risk human papillomavirus-DNA was detected in a subset of penile cancer cases (25%, 95% CI 19-31). HPV16 was the predominant type, representing 79% (42 of 53) of all high risk human papillomavirus infections. The 5-year disease specific survival in the high risk human papillomavirus negative group and the high risk human papillomavirus positive group was 82% and 96%, respectively (log rank test p=0.016). Adjusted for stage, grade, lymphovascular invasion and age, human papillomavirus status was still prognostic for disease specific survival (p=0.030) with a hazard ratio of 0.2 (95% CI 0.1-0.9). High risk human papillomavirus-DNA was observed in a quarter of penile cancer cases. No relevant increase in high risk human papillomavirus prevalence in recent decades was observed. The presence of high risk human papillomavirus-DNA in penile cancer confers a survival advantage.

Experiences of Social Harm and Changes in Sexual Practices among Volunteers Who Had Completed a Phase I/II HIV Vaccine Trial Employing HIV-1 DNA Priming and HIV-1 MVA Boosting in Dar es Salaam, Tanzania

BackgroundVolunteers in phase I/II HIV vaccine trials are assumed to be at low risk of acquiring HIV infection and are expected to have normal lives in the community. However, during participation in the trials, volunteers may encounter social harm and changes in their sexual behaviours. The current study aimed to study persistence of social harm and changes in sexual practices over time among phase I/II HIV vaccine immunogenicity (HIVIS03) trial volunteers in Dar es Salaam, Tanzania.Methods and ResultsA descriptive prospective cohort study was conducted among 33 out of 60 volunteers of HIVIS03 trial in Dar es Salaam, Tanzania, who had received three HIV-1 DNA injections boosted with two HIV-1 MVA doses. A structured interview was administered to collect data. Analysis was carried out using SPSS and McNemars’ chi-square (χ2) was used to test the association within-subjects. Participants reported experiencing negative comments from their colleagues about the trial; but such comments were less severe during the second follow up visits (χ2 = 8.72; P<0.001). Most of the comments were associated with discrimination (χ2 = 26.72; P<0.001), stigma (χ2 = 6.06; P<0.05), and mistrust towards the HIV vaccine trial (χ2 = 4.9; P<0.05). Having a regular sexual partner other than spouse or cohabitant declined over the two follow-up periods (χ2 = 4.45; P<0.05).ConclusionParticipants in the phase I/II HIV vaccine trial were likely to face negative comments from relatives and colleagues after the end of the trial, but those comments decreased over time. In this study, the inherent sexual practice of having extra sexual partners other than spouse declined over time. Therefore, prolonged counselling and support appears important to minimize risky sexual behaviour among volunteers after participation in HIV Vaccine trials.

Oropharyngeal Carcinoma in Young Adults: An Alarming National Trend

To assess the incidence, treatment methods, and outcomes of oropharyngeal squamous cell carcinoma (OPSCC) in patients younger than 45 years. Retrospective population based. Surveillance Epidemiology End Results (SEER) 9 database. The SEER 9 database was queried from 1973 to 2009 for OPSCC patients <45 years of age. There were 1603 patients with OPSCC younger than 45 years. The incidence in patients between 36 and 44 years increased from 0.79 to 1.39 (per 100,000). In the same time period, there was an increase in the rate from 0.20 to 0.42 in whites and a decrease in the rate in African American (AA) patients from 0.67 to 0.32. The proportion of grade III/IV tumors also steadily increased from 28% in 1973 to 1979 to 43% in 2000 to 2009 (P < .0001). Surgery alone was performed in 220 patients (13.72%) and in combination with radiation therapy in 734 patients (45.79%). Five-year survival for the study cohort is 54%. Compared with white patients, AA patients had worse survival (P < .0001). Patients who had surgery, either alone (localized stage patients) or in combination with radiation, had the highest 5-year survival followed by those who had radiation. There was an increase in OPSCC in the study patients within the past 4 decades, particularly in those aged 36 to 44 years. Interestingly, the incidence in whites increased and in AA patients it decreased. It is important to note that most of these patients were treated with surgery, either alone or with radiation therapy. The rising incidence within recent decades is thought to be related to human papillomavirus transmission and changes in sexual practices.

New pornography and the modification of sexual relations among youth

The impact of internet-dis­tributed “new pornography” on sexual behavior and gender relations cannot be denied. To solve this problem, we have conducted a study based on a well-founded theoretical and empirical approach. The study was designed to obtain a sample of activities in the private sphere, in relation to the consumption of pornography on the internet, differentiat­ed by gender. Results and conclusions: 1) pornography on the internet can influ­ence sexual attitudes, moral values, and sexual activity of youth; 2) males are the greatest consumers of pornography on the internet and are the most likely to experience changes in sexual practices; and 3) easy access to pornography on the internet is part of a highly sexualized environment.

HIV Risk Perception, Sexual Behavior, and HIV Prevalence among Men-Who-Have-Sex-with-Men at a Community-Based Voluntary Counseling and Testing Center in Kuala Lumpur, Malaysia.

We describe the HIV risk perception, sexual behavior, and HIV prevalence among 423 men-who-have-sex-with-men (MSM) clients who received voluntary counseling and testing (VCT) services at a community-based center in Kuala Lumpur, Malaysia. The mean age was 29 years old. One hundred one (23.9%) clients rated themselves as low risk, 118 (27.9%) as medium risk, 36 (8.5%) as high risk, and 168 (39.7%) were unsure of their risk. Twenty-four (9.4%) clients tested HIV positive (4 (4%) low risk, 9 (7.6%) medium risk, 11 (30.6%) high risk, and 13 (7.7%) unsure risk). We found a positive correlation between risk perception and HIV infection in this study. Clients with high HIV risk perception have 17x the odds of testing HIV positive compared to low risk clients. High HIV risk perception was significantly associated with multiple sex partners, multiple types of sex partners, alcohol use before intercourse, unprotected sex beyond 6 months, and inconsistent condom use during anal sex compared to low risk clients. There were no statistically significant differences between medium risk and unsure risk clients compared to low risk clients. Strategies should be targeted towards change in sexual practices among those who are perceived to be at high risk.

Sexual Activity during Pregnancy in Taiwan: A Qualitative Study.

BackgroundPregnancy is a special period in a woman's life that involves physical and mental changes. These changes are influenced by cultural, social, religious, and emotional factors among others.AimThe aims of this article were to gather information, to describe the changes and behavior of sexual experiences in pregnancy, and to identify the reasons why pregnant women from central Taiwan decrease coital frequency during pregnancy.MethodsThis phenomenological qualitative research was intended to respond to open-ended questions that allowed the respondents to elaborate on the individuals' experiences. We collected data from in-depth, tape-recorded, and semi-structured interviews conducted in a cross-sectional study of 62 healthy pregnant women. The investigation ended when three consecutive interviewed subjects could not offer any new activities, which indicated that the study had reached its saturation point.Main Outcome MeasuresWe performed data collection and content analysis to ensure standards of rigor and reliability. Credibility was enhanced by prolonged engagement, triangulation, referential adequacy, member checking, and expert review; we categorized meaningful unit-codes in a mutually exclusive and exhaustive manner into perceptions, experiences, and practices such that common themes were grouped into categories.ResultsThree themes emerged: negative aspects of sexual experiences; stress and emotional responses; and changes in sexual practices. The majority of the women stopped engaging in coital activities during pregnancy. We determined that in most cases, the 62 participants obtained information regarding sexual activity during pregnancy from postpartum women and the Internet.ConclusionsThe current evidence-based findings encourage the provision of sexuality education to newlyweds and the discussion of sex-related issues during pregnancy. We propose developing strategies for increasing sexual knowledge and focusing on emotional support to decrease pregnant women's anxiety regarding sexuality in Taiwan. Liu HL, Hsu P, and Chen KH. Sexual activity during pregnancy in Taiwan: A qualitative study. Sex Med 2013;1:54–61.

Long-term trends in incidence, survival and mortality of primary penile cancer in England

Few population-based studies exist of long-term trends in penile cancer. We report incidence and mortality trends in England over the 31 years 1979-2009 and survival trends over the 40 years 1971-2010. We calculated annual incidence and mortality rates per 100,000 by age and calendar period. We estimated incidence and mortality rate ratios for cohorts born since 1890, and one- and five-year relative survival (%) by age and deprivation category. A total of 9,690 men were diagnosed with penile cancer during 1979-2009. Age-standardized incidence rates increased by 21 %, from 1.10 to 1.33 per 100,000. Mortality rates fell by 20 % after 1994, from 0.39 to 0.31 per 100,000. Survival analyses included 11,478 men diagnosed during 1971-2010. Five-year relative survival increased from 61.4 to 70.2 %. Five-year survival for men diagnosed 2006-2010 was 77 % for men aged under 60 years and 53 % for men aged 80-99 years. The 8 % difference in five-year survival (66-74 %) between men in the most affluent and most deprived groups was not statistically significant. The 21 % increase in penile cancer incidence in England since the 1970s may be explained by changes in sexual practice, greater exposure to sexually transmitted oncogenic human papilloma viruses, and decreasing rates of childhood circumcision. Improvement in survival is likely due to advances in diagnostic, staging and surgical techniques. There is a need for public health education and potential preventative strategies to address the increasing incidence.

Incidence and Treatment Trends in Young Patients with Oropharyngeal Cancer: The SEER Analysis

Objectives: 1) Assess the incidence of oropharyngeal squamous cell carcinoma (OPCa) in patients &lt;45 years. 2) Assess treatments and outcomes. Methods: The SEER 9 database was queried (1973-2009) for OPCa patients &lt;45 years of age. Results: There were 1603 patients who met the study criteria. The incidence in patients between 36-45 years increased from 0.79 to 1.39 (per 100,000). In the same time period, there was an increase in rate from 0.20 to 0.42 in whites and a decrease in rate in black patients from 0.67 to 0.32. Surgery was performed alone in 220 (13.72%) and in combination with radiation therapy in 734 (45.79%). Five-year survival for the study cohort is 54%. Compared to white patients, black patients had worse survival ( P &lt; 0.0001). Patients who had surgery as part of their treatment, either alone (localized stage patients) or in combination with radiation had the highest 5-year survival, followed by radiation. Conclusions: There was an increase in OPCa in patients within the last 4 decades, particularly in the 36-44 age range. Interestingly, the incidence increased in whites and decreased in blacks. It is important to note that the majority of these patients were treated with surgery, either alone or with radiotherapy. The rising incidence within recent decades is thought to be related to HPV transmission and changes in sexual practices.

Reported changes in sexual behaviour and human papillomavirus knowledge in Peruvian female sex workers following participation in a human papillomavirus vaccine trial

Limited data exist on the effect of clinical trial participation on sexual behavioural change. Two hundred female sex workers working in Lima, Peru received human papillomavirus (HPV) vaccine in either the standard (0, 2, 6 months) or modified (0, 3, 6 months) schedule. Participants received comprehensive screening and treatment for sexually transmitted infections (STIs), counselling on safe sex practices, education about HPV and the HPV vaccine, contraceptives (oral and condoms) and family planning at each visit. We assessed vaccine completion rates, change in sexual practices, and changes in HPV knowledge before and after participation in the vaccine trial. There were high rates of vaccine completion, 91% overall. The estimated number of reported new and total clients over a 30-day period decreased significantly (P < 0.001). Knowledge about HPV and HPV-related disease increased among all participants. In addition, all participants listed at least one preventive strategy during the month 7 follow-up survey.

Oropharyngeal cancer incidence trends: diminishing racial disparities

The aim of this article is to evaluate oral cavity/pharyngeal cancer (OCPC) trends that may reflect changes in cigarette smoking, alcohol consumption, and human papillomavirus (HPV) infection. We used Surveillance, Epidemiology, and End Results program data for 58,204 cases diagnosed during 1977-2007 to classify if squamous cell carcinomas of the OCP by anatomic site are potentially HPV-related. OCPC rates among men peaked during 1982-1986 before declining, most rapidly (46%) among blacks. Rates decreased least rapidly among white males while declining at intermediate paces among other ethnic groups (Asian/Pacific Islanders and Hispanics) and females. Among the men during the recent 16-year time period, the annual percent change for HPV-unrelated sites was much steeper [-6.0% (95% CI = -7.2 to -4.9)] among blacks than whites [-2.5% (95% CI = -2.9 to -2.1)]; for HPV-related sites, it was -1.7% (95% CI = -2.6 to -0.7) among blacks, in striking contrast to +3.3% (95% CI = 2.5-4.0) among whites. HPV-related rates rose rapidly among the white men born since the mid-1940s, tripling among those aged 25-44 and recently surpassing the black male rate. Relative survival rates rose over the study period due to improvements among HPV-related cases. The OCPC decreases found among all the race/sex groups reflect reductions in smoking prevalence and alcohol consumption. Rising HPV-related cancers among white men may reflect changes in sexual practices since the mid-1960s.

An analysis of temporal and generational trends in the incidence of anal and other HPV-related cancers in Southeast England

Patients diagnosed in 1960–2004 with cancer of the cervix, anus, vulva, vagina or penis were identified from the Thames Cancer Registry database, and age-standardised period (temporal) incidence rates calculated by direct standardisation. Age-cohort modelling techniques were used to estimate age-specific incidence rates in the earlier and later cohorts, enabling the calculation of age-standardised cohort (generational) rates. Incidence of anal cancer increased for both men and women over the period studied, mainly in those born from 1940 onwards. Similar generational patterns were seen for cancers of the vulva and vagina, but those for penile cancer were different. For cervix cancer, the steep downward trend in cohort rates due to screening levelled off in women born from 1940 onwards. Our findings are compatible with the hypothesis that changes in sexual practices were a major contributor to the increases of these cancers. Programmes of vaccination against HPV, aimed at reducing the burden of cervical cancer, may also help to reduce the incidence of cancer at other anogenital sites.

Sexual behavior and gender differences among adolescents consulting at a university public health system

The predetermined gender roles and the emphasis on reproductive responsibility on women, excluding men, have negative consequences on their sexual reproductive health and satisfactory sexual practices. To describe and analyze changes in sexual practices and gender differences in adolescents of the lower-middle socioeconomic level, users of public health system who started their sexual activity. We studied 4,971 adolescents of both sexes aged between 12 and 19 years, who consulted in a clinic for adolescents between the years 1990 and 2005. Several variables related to adolescent sexuality were considered. Uni and bivariate analysis were carried out and a model of stratified lineal regression per sex was fixed to explain the following variables: age at which sexual activity is initiated, number of sexual partners, time period between start of dating and the start of sexual activity along time. The average age when men and women start their sexual activity was 15.7 and 15.5 years, respectively. Along years and among women but not men, there was a reduction in the age of start of sexual activity and an increase in the number of sexual partners. The mean lapse between start of dating and the start of sexual activity in men and women was 6.2 and 7.5 months, respectively. This figure had an 11.696 and 13.9% reduction per year of study in females and males, respectively. There is an increasing expansion of sexual roles in adolescents, but certain patterns of contradictory conservative reasoning are maintained.

Assessment of HIV/AIDS awareness and changes in sexual practices among secondary school students in Nsukka environment

This study is aimed at assessing the awareness of HIV/AIDS and changes in sexual behaviour among the Nigerian teens. Two hundred and fifty secondary school students were interviewed. Only 5% of the respondents were able to state the full meaning of HIV or AIDS. A minority (28%) believed that HIV was real while the majority (72%) believed that HIV infects whites only. Forty-eight percent of them have changed their sexual practices owing to the AIDS menace. A small percentage, 12%, believed that HIV/AIDS could kill. The study revealed low awareness of HIV/AIDS as well as misconception about the infection, especially in non-urbanized cities of Nigeria.

Comportamientos sexuales y diferencias de género en adolescentes usuarios de un sistema público de salud universitario

The predetermined gender roles and the emphasis on reproductive responsibility on women, excluding men, have negative consequences on their sexual reproductive health and satisfactory sexual practices.To describe and analyze changes in sexual practices and gender differences in adolescents of the lower-middle socioeconomic level, users of public health system who started their sexual activity.We studied 4,971 adolescents of both sexes aged between 12 and 19 years, who consulted in a clinic for adolescents between the years 1990 and 2005. Several variables related to adolescent sexuality were considered. Uni and bivariate analysis were carried out and a model of stratified lineal regression per sex was fixed to explain the following variables: age at which sexual activity is initiated, number of sexual partners, time period between start of dating and the start of sexual activity along time.The average age when men and women start their sexual activity was 15.7 and 15.5 years, respectively. Along years and among women but not men, there was a reduction in the age of start of sexual activity and an increase in the number of sexual partners. The mean lapse between start of dating and the start of sexual activity in men and women was 6.2 and 7.5 months, respectively. This figure had an 11.696 and 13.9% reduction per year of study in females and males, respectively.There is an increasing expansion of sexual roles in adolescents, but certain patterns of contradictory conservative reasoning are maintained.

Pain Impacts Sexual Functioning among Interstitial Cystitis Patients

Ethnographic methods were used to gather illness narratives on 11 men and 38 women diagnosed with interstitial cystitis (IC). Content analysis using the Spradley ethnographic method reveals that patients directly link IC pain to diminished sexual functioning. We conclude: (1) Patients with IC are deeply concerned about diminished sexual function. Physicians and rehabilitation specialists should actively investigate and treat this problem. (2) Management of IC pain is inadequate and leads to disability and changes in sexual practices. (3) Linking treatments for sexual dysfunction with appropriate pain management strategies could substantially improve the quality of life for patients with IC. Structural factors in medical delivery along with health insurance policies reduce patient access to a comprehensive and interdisciplinary set of needed health interventions that could make a difference in the treatment of persistent pelvic pain and sexual dysfunction. Recognition of these structural issues is the key to improved health service delivery.

Meaningful evaluation of sex and relationship education

Effective sex and relationship education promotes agency and targets sexual practice as it is socially produced. The aim of evaluation therefore is to contribute to good sexual health through identifying when and how education is promoting agency and changes in sexual practice. Good evaluation takes account of the complexities of the specific object being addressed—sexual practice—which is fluid and essentially social. Innovative study design and the use of rigorous and transparent methods enable evaluators to track and understand the slow, unsteady and sometimes unpredictable mechanisms of change. The data gathered (both quantitative and qualitative) require interpretation, and interpretations inform the development of sex and relationship education programmes. Randomised controlled trials do not meet these criteria of meaningful evaluation, nor do evaluations of one‐off interventions. This paper considers the role of cross‐sectional and longitudinal surveys, in‐depth qualitative studies, and reviews in evaluating whether education works, how it works, how its messages are being actively taken up and transformed by the target population, and in informing the development of future education.