Sexual Risk-Taking Behaviour in Swedish Youth: Identifying and Targeting HighRisk Groups for Public Health Intervention

Masters Candidate: William Miller

Supervisors: Birger Forsberg / Kristina Ingemarsdotter Persson

Examiner: Associate Professor Anna Mia Ekstrm

14 / 5 / 2012

DECLARATION OF STUDENTS OWN WORK

The thesis Sexual Risk-Taking Behaviour in Swedish Youth: Identifying and Targeting High-Risk Groups for Public Health Intervention is my work.

Signature: William Miller

Total word count: 4979 Date: 14 / 5 / 2012

Abbreviations ECP emergency contraception pills HIV Human Immunodeficiency Virus MSM men who have sex with men OR odds ratio SRB sexual risk-taking behaviour STI sexually transmitted infection UngKAB09 Kunskap, Attityder, och Sexuella Handlingar Bland Unga

Abstract Aim Utilizing data from Kunskap, Attityder, och Sexuella Handlingar Bland Unga, this thesis aimed to identify associations between demographics and indicators of sexual risk-taking behaviour, and to illustrate the importance of routine surveys targeting at-risk Swedish youth.

Setting UngKAB09 survey participants consented to use of questionnaire data prior to answering the survey. The survey utilized a mixed mode design in which about 5600 people were recruited by mail as part of a representative sample and approximately 10000 responded in a self-selected sample conducted through the internet.

Method Variables were selected as background/demographics and others as indicators of sexual risk-taking behaviour. Chi-square tests and logistic regression were used to analyze the relationship between demographic variables and variables that indicate sexual risk-taking behaviour. Adjusted odds ratios were reported with 95% confidence intervals.

Results A large portion of respondents had experienced first-meeting sexual contact in the last 12 months and over half of participants were students. Greater odds ratios for sexual risktaking behaviour were seen in several demographic variables and groups. Participants who provided or received compensation for sexual activity had statistically significant greater odds ratios for many indicators of sexual risk-taking behaviour.

Conclusion Stockholm County residents, those buying/selling sex, and those using internet for finding partners had a notably greater odds ratio for sexual risk-taking behaviour. Although they may not be causal, these associations provide valuable information to Swedish health agencies to guide current and future interventions. In addition, the results necessitate routine monitoring of sexual attitudes and behaviour in Swedish youth.

Key words: sexual health, sexual risk, youth, Sweden, survey, UngKAB, routine 4

TABLE OF CONTENTS

INTRODUCTION.............................................................................................................6 AIM.....................................................................................................................................8 SETTING............................................................................................................................8 MATERIALS AND METHODS......................................................................................8 Data Handling and Processing.................................................................................8 Variable Selection....................................................................................................9 Analysis..................................................................................................................10 RESULTS.........................................................................................................................11 Descriptive Statistics..............................................................................................11 Chi-square p-values...............................................................................................12 Logistic Regression................................................................................................12 DISCUSSION...................................................................................................................18 Descriptive Statistics..............................................................................................18 Demographic and Sexual Risk-Taking Behaviour Relationships..........................20 Routine Monitoring and Study Issues....................................................................22 CONCLUSIONS AND RECOMMENDATIONS.........................................................24 ACKNOWLEDGEMENTS............................................................................................25 REFERENCES.................................................................................................................26 APPENDIX 1 Review of Relevant Literature............................................................29 APPENDIX 2 Chi-square p-values.............................................................................34

Introduction More than 9 million people populate Sweden and over 1 million of them are adolescents. With greater than 25% of the population having education past the high school level Sweden enjoys a high standard of intellectual prosperity and has historically held liberal views toward sexuality in the media, home, and within families [1, 2]. Swedens relatively young age of sexual consent at 15 years characterizes a culture open to sexuality. Since 1950, family and sexual education has been provided to children along with their regular schooling. In 1975, abortions became available at no direct cost to patients. Health clinics for Swedish youth are widely available and provide free counseling, oral contraception, and condoms. Childbearing frequently precedes marriage when couples living together decide to start a family. Since 1990, a growing fraction of the Swedish population, typically younger individuals, is beginning to view sexual intercourse outside a stable relationship as socially acceptable [3]. Even in the context of sexuality education, the general message has held a liberating tone geared toward empowerment and prevention instead of the often otherwise used oppressive scheme, creating good versus bad comparisons and judgments [4]. The Swedish National Agency for Education is currently reviewing sex education programs in Sweden, however, previous studies of sex education in Swedish schools have had mixed results. Some students appeared to be satisfied with the content, while others found that the quality and material covered in sex education was varied and inconsistent [5, 6]. During the 1990s Sweden began a period of slowed economic growth that resulted in decreased funding for sex education and increased segregation, truancy, drug use, and tobacco use [7, 8]. A report in 2001 examining teenage sexual and reproductive behaviour in Sweden made numerous observations reflecting the effects of economic stagnation [9]. Overall, birthrates declined, including a decrease in births from ages 15-19 and a relatively smaller decrease in the number of abortionsin fact, abortions outnumbered births in that age group and a 2002 study revealed no reduction in abortions despite easily available emergency contraception pills (ECP) [9, 10]. The age at first intercourse began to decrease slightly from 18.5 years to approximately 16.5 years, with boys first experience frequently at a younger age than girlssuggesting more liberal and potentially risky sexual lifestyles. An informative 2002 study examining Swedish boys 6

from 8-17 years of age found that sexual experience was related to high-perceived social age, early puberty, vocational study programme, tobacco use, and alcohol use [8, 11, 12]. In addition to increased SRB during the 1990s, Sweden has experienced increased chlamydial infections, from 14000 in 1994 to over 22000 in 2001, with adolescents and teens most significantly affected [13]. Chlamydia infection rates increased steadily since 1997 and appeared to peak in 2007. However, new detection methods confirmed a new strain of chlamydia was being transmitted [14]. As a result of increased detection and diagnosis, in 2007 the number of newly diagnosed infections spiked to over 35000. The rate soon plateaued and began to decline slowly, possibly due to public health efforts. Despite current efforts chlamydia remains the most prevalent STI in Sweden [3]. Accordingly, the prevalence and recent increases and fluctuations in incidence of chlamydia in Sweden support the notion that SRB is on the rise. The consequences of increased SRB are not isolated to chlamydia infection rates. From 1996 to 1997, Sweden began to see a reemergence of gonorrhea infections [15]. A study conducted from 2001 to 2008 showed that gonorrhea infection rates increased by over 30% [16]. The authors suggest this trend is likely due to increased SRB, with many heterosexual men acquiring infection in foreign countries while women and men who have sex with men acquire infection in Sweden. While these individual epidemiologic issues are relevant by themselves, they also demonstrate the overall importance of monitoring key data such as STI rates. Information regarding the epidemiology of STIs is essential to public health agencies and assists in accurate diagnosis and monitoring of disease occurrence. However, in the realm of global and public health it is crucial to focus on a goal of requiring only primary prevention and striving to avoid occurrence of disease altogether. Although achieving this goal is difficult, surveys that examine individuals perceived sexual risk-taking, overall attitudes toward sexuality, and cultural norms are instrumental in designing and targeting public health interventions. To date, several studies of sexual activity and attitudes have been conducted in Sweden [1-3, 6, 7, 11, 1721]. A survey that was carried out from 1989 through 2007 revealed that SRB increased significantly in adolescents and especially in young women [21]. Some notable findings from this study include: younger individuals were less likely to hold a restrained attitude to sexual intercourse outside of a stable relationship, the likelihood of having greater than two sexual partners increased, the likelihood of casual sexual intercourse without using a 7

condom increased, and in young women, the likelihood of casual sexual intercourse without a condom doubled.

Aim It is hypothesized that demographics such as gender, residence in Stockholm County, age, and purchasing or selling of sexual activity are associated with other variables from the UngKAB09 study that represent SRB. In addition, this thesis intends to show that routine collection of data from Swedish youth is useful in monitoring SRB and attitudes toward sexuality. Overall, the aim of this thesis is to identify associations between demographics and SRB and to illustrate the importance of routine surveys in monitoring Swedish youth SRB.

Setting Kunskap, Attityder, och Sexuella Handlingar Bland Unga (UngKAB09) utilized a digital questionnaire survey on sexuality [that] was conducted at the end of 2009 amongst youths and young adults. The survey focused on the knowledge, attitudes, and behaviour of sexuality of the respondents. The survey is scheduled to be repeated after four years and its results will be used as a basis for identifying and reinforcing healthpromotion work in matters of sexuality amongst youths and young adults. [19] Survey participants consented to use of survey data prior to answering the survey. Participants were given information about its content and assured about its anonymity. UngKAB09 utilised a mixed mode design in which about 5600 (of total 24000 contacted) were recruited by mail as part of a representative sample and approximately 10000 responded in a self-selected sample conducted through internet recruitment in online communities identified as relevant by a panel with an average age of 18 years.

Materials and Methods Data Handling and Processing Data was stored in an IBM SPSS file securely on a computer. Data was read, understood, and then particular variables were chosen to represent demographics while other variables were selected to represent indicators of SRB. The variables were dichotomized to facilitate statistical analysis using multivariate logistic regression. An example of this dichotomization is the variable for age. Initially, age was a range of values from 15 through 29. However, upon careful 8

consideration age was dichotomized by grouping subjects into two groups, 15 to 19, and 20 to 29. These ranges are used because the UngKAB09 study classifies youth and young adults in this manner. Additionally, they represent ages at which Swedes would either be studying in gymnasium versus studying at university, travelling, or working, respectively. A similar process was carried out for other variables. For example, the variable describing whether someone lives inside or outside Stockholm County was originally a variable with a list of major cities and areas in Sweden. The variable was recomputed so all responses except those living in Stockholm County were coded lives outside of Stockholm County. Multivariate regression typically requires dichotomization of only outcome variables. However, this thesis was conducted through dichotomizing all variables. Given the scope and length of this project, this allowed a larger and more diverse set of factors to be investigated in the analysis.

Variable Selection Note that some of the variables could be categorized either as demographics or as indicators of SRB. In particular, the variables pertaining to internet could be interchanged in this manner. However, the current categories are chosen such that variables listed as internet demographics are not directly or overtly risky behaviors, whereas the internet indicators of SRB are themselves, distinctly risky actions. Variables chosen as demographics include: Gender Whether one was born in Sweden Whether one currently lives inside or outside of Stockholm County Whether or not religion plays at least some role in ones life Whether you are between 15 and 19 or 20 and 29 years of age Whether one has ever provided compensation for sexual activity Whether one has ever received compensation for sexual activity Whether one is currently job-seeking Whether one is currently working Whether one is currently a student Whether one has looked on the internet for someone to flirt with during the last 12 months 9

Whether one has looked on the internet for a partner/sex partner during the last 12 months

Variables that were selected to represent or indicate SRB include: Whether one had sexual contact upon first-meeting someone in the previous 12 months Having ever had chlamydia Having ever had herpes Having ever had gonorrhea Having ever been diagnosed with HIV Whether one drank any alcohol the first time they had sex Whether one took any drugs the first time they had sex Whether one drank alcohol the last time they had sex Whether one took drugs the last time they had sex Whether one placed or answered sex adverts on the internet during the last 12 months Whether one put naked picture(s) of oneself on the internet during the last 12 months

Analysis Analysis began by computing basic descriptive statistics. Frequencies were calculated for each variable demonstrating the percentage of that variable represented by each possible value. Note that each variable has two frequencies to report due to the dichotomous nature of the recomputed data. Next, chi-square tests were used to analyze the independence between demographic variables and indicators of SRB. Chi-square and their respective p-values were calculated. Finally, adjusted odds ratios (OR) were calculated with multivariate logistic regression. Each indicator for SRB was treated as a separate dependent variable and underwent its own logistic regression with all twelve demographics, which were entered as covariates. Per guidance of statisticians with the Global Health Department at Karolinska Institutet, all regression analyses were performed adjusting for gender and age by including them in the model as covariates. Due to limitations in scope of this thesis, 10

ORs were adjusted only for gender and age. This produced adjusted ORs of the selected demographics for each of the chosen indicators of SRB. The IBM SPSS variable selection method of logistic regression selected was Enter, meaning that all covariates are entered into the regression simultaneously.

Results 15278 individuals between the ages of 15 and 29 participated in the UngKAB09 study.

Descriptive Statistics Percentages that resulted from dichotomization of the variables are shown in Figures 1 and 2. Percent values are superimposed upon their corresponding bars in Figures 1 and 2. There was a fairly equal distribution between genders and most respondents were born in Sweden and living outside of Stockholm County. Other demographics had less equal distributions. For example, few respondents had ever provided or received compensation for sexual activity. Also, frequency of alcohol use at first and last intercourse was greater than frequency of drug use at first and last intercourse. However, drug use was slightly higher at last intercourse than at first intercourse while alcohol use is slightly more frequent at first intercourse than at last intercourse.

Figure 1. Demographic Percentages. The order of the percentages is indicated by the labels in parentheses.

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Figure 2. Sexual Risk-taking Percentages. The order of the percentages is indicated by the labels in parentheses.

Chi-square p-values Considering that the ORs calculated through logistic regression are the most relevant measure of association for this thesis, specific chi-square values are listed in Appendix 2.

Logistic Regression Results of logistic regression calculations are in Tables 1 through 4. Overall, there were several significant associations in which particular demographics demonstrated increased ORs for associating with SRBs. Table 1 shows that females, Stockholm County residents, non-religious people, people ever paying/receiving payment for sexual activity, job-seekers, students, and those looking to flirt or search for a sex partner on the internet were more likely to have had first-meeting sexual contact in the last 12 months. The association with individuals who have looked on the internet for someone to flirt with or for a partner/sex partner in the previous 12 months was relatively greater when compared to other demographics used in the analysis.

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Table 1. Relationship between demographics and individuals having had 1st-meeting sexual contact in the last 12 months. ORs adjusted for age and gender. Note that the direction of the OR is indicated in parentheses next to the listed demographics. All listed p-values are statistically significant.

Adjusted OR
Gender (F/M) Live inside or outside of Stockholm? (inside/outside) What role does religion play in your life? (at least some/none)

1.099 1.214 0.897 1.287 1.223 1.327 1.398 2.767

Adjusted Lower 95% C.I. 1.012 1.101 0.82 1.19 1.148 1.09 1.183 2.482

Adjusted Higher 95% C.I. 1.193 1.339 0.981 1.391 1.303 1.616 1.651 3.084

p-value 0.025 0.000 0.017 0.000 0.000 0.005 0.000 0.000

Have Had 1stMeeting Sexual Contact in the Last 12 Months

Have ever provided compensation for sexual activity? (yes/no) Have ever received compensation for sexual activity? (yes/no) Currently Job-seeking (yes/no) Currently a Student (yes/no) Have you looked on the internet for someone to flirt with during the last 12 months? (yes/no) Have you looked on the internet for a partner/sex partner during the last 12 months? (yes/no)

1.966

1.771

2.183

0.000

Table 2 explores the associations between the demographics and having ever been diagnosed with a variety of STIs. One of the significant associations included residents of Stockholm County being more likely to have ever been diagnosed with chlamydia, gonorrhea, or HIV. In addition, people ever having provided or received compensation for sexual activity were more likely to have ever had chlamydia, gonorrhea, herpes, or HIV. With respect to age, older participants generally were more likely to have ever had a STI, with 20-29 year-olds having had a statistically significant higher OR with respect to nearly every STI analyzed.

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Table 2. Relationship between demographics and individuals having had chlamydia, herpes, or gonorrhea at least once, or having ever been diagnosed with HIV. ORs adjusted for age and gender. Note that the direction of the OR is indicated in parentheses next to the listed demographics. All listed p-values are statistically significant.

Adjusted OR
Gender (F/M) Live inside or outside of Stockholm? (inside/outside) What role does religion play in your life? (at least some/none)

1.925 1.164 0.786 3.684 1.281 1.332 0.612 1.511 1.925 1.164 0.786 3.684 1.281 1.332 0.612 1.511 2.399 1.443 2.051 2.399 1.443 2.051

Adjusted Lower 95% C.I. 1.716 1.024 0.695 3.107 1.175 1.242 0.504 1.301 1.716 1.024 0.695 3.107 1.175 1.242 0.504 1.301 1.396 1.128 1.668 1.396 1.128 1.668

Adjusted Higher 95% C.I. 2.16 1.323 0.888 4.367 1.396 1.429 0.744 1.756 2.16 1.323 0.888 4.367 1.396 1.429 0.744 1.756 4.121 1.844 2.522 4.121 1.844 2.522

p-value 0.000 0.021 0.000 0.000 0.000 0.000 0.000 0.000 0.000 0.021 0.000 0.000 0.000 0.000 0.000 0.000 0.002 0.003 0.000 0.002 0.003 0.000

Have Had Chlamydia at Least Once

15-19 years old/20-29 years old Have ever provided compensation for sexual activity? (yes/no) Have ever received compensation for sexual activity? (yes/no) Currently a Student (yes/no) Have you looked on the internet for someone to flirt with during the last 12 months? (yes/no) Gender (F/M) Live inside or outside of Stockholm? (inside/outside) What role does religion play in your life? (at least some/none)

Have Had Herpes at Least Once

15-19 years old/20-29 years old Have ever provided compensation for sexual activity? (yes/no) Have ever received compensation for sexual activity? (yes/no) Currently a Student (yes/no) Have you looked on the internet for someone to flirt with during the last 12 months? (yes/no)

Have Had Gonorrhea at Least Once

Live inside or outside of Stockholm? (inside/outside) Have ever provided compensation for sexual activity? (yes/no) Have ever received compensation for sexual activity? (yes/no) Live inside or outside of Stockholm? (inside/outside) Have ever provided compensation for sexual activity? (yes/no) Have ever received compensation for sexual activity? (yes/no)

Have Been Diagnosed with HIV

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Table 3 contains data describing associations between demographics and drug/alcohol use at first and last intercourse Some overall patterns found are that individuals who have ever provided or received compensation for sexual activity were more likely to have used alcohol or drugs at both the first and most recent intercourse. Individuals for whom religion played at least some role in their life were less likely to have used alcohol at first intercourse; however, there was no difference in likelihood for alcohol use at the most recent intercourse.

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Table 3. Relationship between demographics and individuals alcohol or drug use at first and last time having sex with someone. ORs adjusted for age and gender. Note that the direction of the OR is indicated in parentheses next to the listed demographics. All listed p-values are statistically significant.

Adjusted OR
Born in Sweden? (yes/no)

1.2 0.784 1.496 1.112 1.071 1.119 2.399 1.443 2.051 1.157 1.197 1.153 1.083 1.333 1.304 1.847 0.732 0.727 1.238 1.498 0.595 1.554

Adjusted Lower 95% C.I. 1.009 0.716 1.35 1.032 1.005 1.003 1.396 1.128 1.668 1.043 1.073 1.068 1.015 1.105 1.085 1.64 0.563 0.537 1.051 1.322 0.373 1.076

Adjusted Higher 95% C.I. 1.427 0.859 1.659 1.198 1.141 1.248 4.121 1.844 2.522 1.283 1.335 1.244 1.156 1.607 1.566 2.08 0.952 0.984 1.457 1.697 0.951 2.245

p-value 0.039 0.000 0.000 0.005 0.035 0.045 0.002 0.003 0.000 0.006 0.001 0.000 0.015 0.003 0.005 0.000 0.020 0.039 0.011 0.000 0.030 0.019

Drunk Alcohol the First Time Having Sex with Someone Took Drugs the First Time Having Sex with Someone

What role does religion play in your life? (at least some/none) 15-19 years old/20-29 years old Have ever provided compensation for sexual activity? (yes/no) Have ever received compensation for sexual activity? (yes/no) Have you looked on the internet for someone to flirt with during the last 12 months? (yes/no) Live inside or outside of Stockholm? (inside/outside) Have ever provided compensation for sexual activity? (yes/no) Have ever received compensation for sexual activity? (yes/no) Live inside or outside of Stockholm? (inside/outside)

Drunk Alcohol the Last Time Having Sex with Someone

15-19 years old/20-29 years old Have ever provided compensation for sexual activity? (yes/no) Have ever received compensation for sexual activity? (yes/no) Currently Working (yes/no) Currently a Student (yes/no) Have you looked on the internet for someone to flirt with during the last 12 months? (yes/no) Gender (F/M) 15-19 years old/20-29 years old

Took Drugs the First Time Having Sex with Someone

Have ever provided compensation for sexual activity? (yes/no) Have ever received compensation for sexual activity? (yes/no) Currently Working (yes/no) Have you looked on the internet for someone to flirt with during the last 12 months? (yes/no)

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Table 4 contains results concerning SRBs involving the internet. Individuals who have provided or received compensation for sexual activity were more likely to have placed or answered sex adverts on the internet, and to have put naked pictures of themselves on the internet during the last 12 months. Males were more likely to have ever placed or answered sex adverts on the internet within the previous 12 months, while females were slightly more likely to have put naked pictures of themselves on the internet within the previous 12 months. Individuals who looked on the internet for someone to flirt with or for potential partners during the last 12 months were also more likely to have placed or answered sex adverts or to have posted naked pictures of themselves during the last 12 months.

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Table 4. Relationship between demographics and individuals participating in internetrelated SRB. ORs adjusted for age and gender. Note that the direction of the OR is indicated in parentheses next to the listed demographics. All listed p-values are statistically significant.

Adjusted OR
Gender (F/M) Have ever provided compensation for sexual activity? (yes/no)

1.173 1.266 1.552 0.669 0.596 3.378

Adjusted Lower 95% C.I. 1.012 1.149 1.442 0.512 0.46 2.522

Adjusted Higher 95% C.I. 1.36 1.395 1.67 0.874 0.771 4.524

p-value 0.034 0.000 0.000 0.003 0.000 0.000

Put Naked Pictures of Self on the Internet during Last 12 Months

Have ever received compensation for sexual activity? (yes/no) Currently Working (yes/no) Currently a Student (yes/no) Have you looked on the internet for someone to flirt with during the last 12 months? (yes/no) Have you looked on the internet for a partner/sex partner during the last 12 months? (yes/no) Gender (F/M) 15-19 years old/20-29 years old Have ever provided compensation for sexual activity? (yes/no) Have ever received compensation for sexual activity? (yes/no) Currently a Student (yes/no) Have you looked on the internet for someone to flirt with during the last 12 months? (yes/no) Have you looked on the internet for a partner/sex partner during the last 12 months? (yes/no)

4.117 0.502 1.396 1.397 1.388 0.625 1.979

3.305 0.435 1.174 1.28 1.286 0.481 1.384

5.129 0.579 1.661 1.524 1.5 0.812 2.829

0.000 0.000 0.000 0.000 0.000 0.000 0.000

Placed or Answered Sex Adverts on the Internet During Last 12 Months

23.345

16.681

32.672

0.000

Discussion This study sought to explore parts of UngKAB09 data that represent demographics and indicators of SRB. Upon highlighting some of the results it is now worthwhile to explore the significance of these results in the context of Swedish youth, society, and Swedish public health agencies. After thoroughly exploring the significance of the results, overall potential biases and problems with this study will be examined.

Descriptive Statistics Initially looking at the descriptive statistics in Figure 1, note there is a fairly equal distribution between male and female genders. Over 90% of respondents were born in 18

Sweden and we can thus posit that just a fraction of participants are immigrants. Given that only part of Swedens population lives in Stockholm County (about 2 million of Swedens total of 9.5 million people), it is sensible that approximately 20% of individuals indicated living in Stockholm County [22]. Over 60% of responses indicated being in the age group from 20-29 years old. There is half the number of 15-19 year-olds, which follows logically since this age group contains half the number of years. Note there are more participants admitting to receiving compensation for sexual activity than there are admitting providing compensation. This discrepancy could be due to a variety of causes. One possible explanation is that according to Swedish law it is illegal to purchase sexual activity but legal to sell it [23, 24]. Thus, respondents may have some fear of retribution despite the studys assurance of anonymity. Additionally, one study showed that many pay for sex while abroad, although it is unclear how this finding affects these results [23]. Next we consider the employment, job-seeking, and student statuses of respondents. Responses to these questions were not mutually exclusive, however, over half of subjects considered themselves students in some way, and over one-fourth of participants were currently working, with only 10% currently job-seeking. Given the young age of most respondents, this distribution is logical. The remaining demographics, involving use of the internet to flirt or find sexual partners are well-represented in the survey. The potential for bias here is clear since almost two-thirds of participants were recruited directly via the internet. Figure 2 includes a list of variables that are dichotomized and were determined indicators of SRB. First-meeting sexual contact is widely considered to be SRB in the literature [17]. As seen in the descriptive statistics, about one-third of individuals responding had first-meeting sexual contact in the previous 12 months. This is not surprising given that so many participants were recruited via internet and many have used the internet for flirting or searching for partners. Though it will be discussed later, note the UngKAB09 study admits potential self-selection bias and difficulty in generalising to Swedish youth. The frequency pattern concerning STIs is consistent with recent epidemiological data regarding STI prevalence in Sweden [13-16, 25]. Since numerous SRBs increase the chances of undesired pregnancy or contracting STIs, diagnostic histories of STIs are used here as a proxy to represent SRBs [3, 19-21, 26]. Frequency of alcohol and drug use was comparable between first and last intercourse, with minor differences. Alcohol and drug use are indicators of SRB due to their ability to impair judgment and reasoning ability, thus making undesired consequences of sexual contact 19

more likelyother studies have demonstrated similar associations [27-29]. Finally, placing nude pictures or sex adverts on the internet is risky behaviour due to potential societal consequences, privacy concerns, cyberbullying, sexual predation, and the effect any consequences might have on future prospects in work and relationships [30, 31].

Demographic and Sexual Risk-Taking Behaviour Relationships There are several statistically significant ORs present in the tables that link particular demographics to be more likely to undertake SRB. Although the ORs should be interpreted with caution, these statistically significant results lend support to the original hypothesis of this thesis. As seen in Table 1, participants who had first-meeting sexual contact within the last 12 months had interesting associations with some of the demographics. For example, living in Stockholm County, job-seeker status, and student status imparted ORs of 1.21 (CI 1.101-1.34), 1.33 (CI 1.09-1.62), and 1.40 (CI 1.18-1.65), respectively. It is possible that the increased likelihood for residents of Stockholm County is possibly due in part to the urban lifestyle, ease of transportation, and active nightlife in Stockholm County when compared to the rest of Sweden. Although this analysis was not pursued in further detail, such information could be useful in targeting populations at-risk for first-meeting sexual activity. Another interesting finding was that people looking on the internet for someone to flirt with and those looking for a partner/sex partner during the last 12 months had ORs of 2.77 (CI 2.48-3.08) and 1.97 (CI 1.77-2.18), respectively. Potentially these higher ORs might be partly explained by the very fact these individuals are looking for dating or sexual activity on the internet. The UngKAB09 survey explicitly states that sexual contact includes all forms of sexual contact. Despite this terminological clarification, there is still much room for interpretation by various participants. Thus there is potential for misclassification bias if subjects inadvertently provide inaccurate responses [32]. Tables 2 addresses chlamydia, herpes, gonorrhea, and HIV. It is worth noting that for nearly each STI, the 20-29 age group was significantly more likely to have been diagnosed. This adds validity to the measurement because we can intuitively expect that with an increase in age and thus, life experience, one would be more likely to have had an STI at some time. Respondents in Stockholm County are more likely to have had an STI during there life. It is feasible that in addition to the similar aforementioned reasons regarding first-meeting sexual contact, STIs may be endemic in Stockholm County and, except for chlamydia, they might be more sporadic in the countryside. 20

Interestingly, people who stated that religion plays at least some role in their life were 0.79 (CI 0.70-0.89) times less likely to have ever had chlamydia. Considering chlamydia is the most common STI in Sweden, this information may be useful when planning future public health interventions such as Chlamydia Monday [3, 33, 34]. For example, health officials might direct more resources toward more secular communities. Participants who have ever provided or received compensation for sexual activity were more likely to have had one of the STIs. Although the exact setting for the buying and selling of sexual activity (on the street, in school, underground brothels, or via the internet) is not known, the very fact that individuals selling sex may have multiple partners places them and their customers at higher risk for contracting [35]. Note that females were 1.93 (CI 1.72-2.16) and 3.22 (CI 2.53-4.10) times more likely to have had chlamydia or herpes, respectively. Women and men can contract chlamydia and often the infection is asymptomatic [36, 37]. However, it is widely known that women more often are symptomatic and can develop disproportionately more sequelae from infection [38-40]. Thus, the increased diagnosis and ORs may be partly explained by a greater number of symptomatic infections and routine gynecologic care that bring females to a health care provider. Additionally, women may be more prone to seek examination after unplanned sexual activity since they are at risk of developing complications such as salpingitis and infertility [36, 37]. This and the recent increases in chlamydia incidence should prompt further, novel studies to prevent and treat chlamydia and other STIs [41]. The increased likelihood of women having had herpes is more difficult to explain; however, the same reasons discussed above for chlamydia might apply. In addition, a previous study also witnessed higher herpes prevalence among females [42]. Table 3 shows the relationship between the demographics and alcohol or drug use at first or last intercourse. Again, participants with a history of providing or receiving compensation for sexual activity were associated with risky behavior. Here, they were more likely to have used alcohol or drugs during intercourse. This result follows logically because buying and selling of sexual services is often associated with other forms of risktaking behaviour [43-45]. Another aspect that makes this behaviour combination particularly concerning is that injection-drug users might combine their risk of bloodborne transmission with sexual transmission, which is possible with HIV. Individuals who looked for someone to flirt with on the internet in the previous 12 months were 1.85 (CI 1.64-2.08) and 1.55 (CI 1.08-2.25) times more likely to have used alcohol or drugs 21

the last time they had sex. Information such as this can enable public health agencies in Sweden to better target effortsperhaps through campaigns for internet flirting communities such as dating websites, to raise awareness about the risks of combining sex with alcohol or drugs. Finally, note that students were 1.3 (CI 1.09-1.57) times more likely to have consumed alcohol the last time they had sex. This is a prevalent, impressionable, and well-defined population that is ripe for public health intervention. Table 4 addresses SRB involving the internet. Note the remarkably higher likelihood of placing or answering sex adverts or posting naked pictures of oneself for respondents who have looked on the internet for a partner/sex partner or someone to flirt with during the past 12 months. This is very likely due to the clear congruency between the demographic and related indicator of SRB. Again, individuals that have ever provided or received compensation for sexual activity were more likely to have engaged in risky behaviorhere, either of the internet-related SRBs. Another notable finding is that females had half the likelihood (OR 0.502, CI 0.435-0.579) of having placed or answered sex adverts on the internet in the last 12 months. At first glance this is peculiar; however, it is possible that this can be partly explained by the frequent use of the internet by men who have sex with men (MSM) to find potential partners [46, 47]. Interestingly, the risks of using the internet for this are not clear. One study concluded there was no association between partner-searching on the internet and contracting chlamydia or gonorrhea, but that the implications for other STIs including HIV are unclear [46]. A different study concluded that high-risk MSM use the internet as a tool for meeting partners and not that meeting partners online causes risky sex [47]. Older age (20-29 years) imparts 1.4 (CI 1.17-1.66) times greater likelihood of placing or answering sex adverts in the last 12 months. It is possible this could be because older individuals may be out of school or looking for work, thus lacking a structured environment of peers in which to meet potential partners. This reasoning is somewhat supported by the fact that students were less likely to engage in either of the internet-related SRBs.

Routine Monitoring and Study Issues This thesis suggests several possible associations between groups of respondents and indicators of SRBs. Although these relationships are basic, they provide a framework for routine monitoring and collection of sexual risk-taking data in Swedish youth. In addition, while there are several statistically significant associations, one should note that 22

statistically significant small associations may arise due to the large sample size and they may have little meaning in reality. However, the information these surveys produced could be used to guide public health programs to more effectively mobilize resources for at-risk groups. As mentioned earlier, some of the variables could be categorized either as demographics or as indicators of SRB. In particular, the variables pertaining to internet could be interchanged in this manner. The current categorization of these variables are chosen such that variables listed as demographics (looking on internet for flirtation or as a partner/sex partner) are not direct or overtly risky behavior, whereas the internet indicators of SRB (placing/answering sex adverts or placing naked pictures of oneself on the internet) are themselves, distinctly risky actions. The analysis used for this thesis considered only gender and age as potential confounding variables. However, other variables such as specific geographic location, ethnicity, educational level, vocational field, etc. may be confounding variables. Thus, the adjusted ORs should be interpreted cautiously. The UngKAB09 study declares some potential biases. People that respond to sexual surveys might have a strong sense of responsibility in life, in addition to their sexual behaviour [19]. In addition, people in chaotic or impoverished circumstances might be less likely to respond to a survey. Thus, subjects with potentially the most risky behaviour may be missing from the study, or alternatively, individuals with more interest in sex might respond more frequently [19]. Upon completion of the survey, subjects were offered a chance to enter to win electronic devices; specifically, mp3 players and computers. While such methods can improve recruitment and participation, they also introduce their own form of selection bias. For example, this bias might manifest in that the study might tend to attract only individuals who need or want an mp3 player or computerindividuals that may tend to come from a lower socioeconomic status and thus result in a misrepresentative sample. Misclassification bias was previously mentioned and should not be overlooked as an issue with this study [32, 48]. For example, how respondents interpret and define sexual activity can affect their responses. Selection bias is also a potential issue since studies of national sexuality surveys conducted through postal mail revealed that respondents often had higher socioeconomic status, higher levels of education, more sexual experience, and tended to hold more liberal views toward sexuality [49, 50]. Despite these potential selection biases, one study suggests their effect may be small and 23

the bias might not seriously affect estimation at the population level [50]. Participants knew they were being studied and thus there is potential for the Hawthorne effect to affect responses, though likely the effect is minimal given the anonymity of the survey. If subjects felt the need to provide socially desirable answers there may be measurement bias present. The fact that about two-thirds of participants were recruited online potentially introduces serious sampling bias. In total, only 24% of subjects solicited by postal mail actually participated in the study. Thus, sampling bias and low participation in the postal mail-recruited sample make generalisation of results to other 15-29 year-olds in Sweden difficult.

Conclusions and Recommendations This study cautiously demonstrates that various demographics and groups may be more likely to have engaged in certain SRBs. Although this information does not reveal causal relationships, it still provides valuable information regarding which demographics may be more likely to undertake SRB. Despite current difficulty in generalising results, I strongly recommend continued, routine use of surveys like UngKAB09 to monitor behaviour and attitudes. More research should be conducted to elucidate how we can obtain data via online sexual health surveys that is representative of and generalisable to Swedish youth. Regardless, even before obtaining gold-standard methods of monitoring, rudimentary associations from earlier studies should be heeded as precautionarythey should influence and provide at least some guidance in current and future public health interventions. As Sweden moves forward in the 21st century, its population may continue a trend toward more liberal sexual attitudes and behaviour. Without public health intervention, STI incidence and increases in SRB may follow suit. In order to ensure public health strategies remain contemporary and innovative, it is crucial to routinely monitor sexual risk-taking behaviour and attitudes among Swedish youth. The ability to track changes in reported behaviours and attitudes will empower Swedish public health agencies to not simply react to, but rather anticipate future sexual health concerns.

24

Acknowledgments I would like to thank Birger Forsberg at Karolinska Institutet and Kristina Ingemarsdotter Persson at Smittskyddsinstitutet for their kind guidance and willingness to let me collaborate with them. I also thank Smittskyddsinstitutet for making the dataset available for analysis. Finally, I give my gratitude to the statisticians at Karolinska Institutets Global Health Department for their guidance.

25

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Tyden, T., M. Palmqvist, and M. Larsson, A repeated survey of sexual behavior among female university students in Sweden. Acta Obstet Gynecol Scand, 2012. 91(2): p. 215-9. Herlitz, C.A. and M. Forsberg, Sexual behaviour and risk assessment in different age cohorts in the general population of Sweden (1989-2007). Scand J Public Health, 2010. 38(1): p. 32-9. Statistics Sweden. Population Statistics - Population in the countryside, counties and municipalities on 31/12/2011 and Population Change in 2011. Available from: http://www.scb.se. Danna, D., Client-Only Criminalization in the City of Stockholm: A Local Research on the Application of the Swedish Model of Prostitution Policy. Sexuality Research and Social Policy, 2012. 9(1): p. 80-93. Dolley, M., Sweden considers criminalising prostitution. BMJ, 1995. 310(6984): p. 892. Whitley, R.J. and J.W. Gnann, The incidence and severity of herpes simplex encephalitis in Sweden, 1990-2001. Clin Infect Dis, 2007. 45(7): p. 881-2. Tyden, T., M. Palmqvist, and M. Larsson, A repeated survey of sexual behavior among female university students in Sweden. Acta Obstet Gynecol Scand, 2011. Hingson, R.W., et al., Beliefs about AIDS, use of alcohol and drugs, and unprotected sex among Massachusetts adolescents. American Journal of Public Health, 1990. 80(3): p. 295-299. Strunin, L. and R. Hingson, Alcohol, Drugs, and Adolescent Sexual Behavior. Substance Use & Misuse, 1992. 27(2): p. 129-146. Jackson, C., H. Sweeting, and S. Haw, Clustering of substance use and sexual risk behaviour in adolescence: analysis of two cohort studies. BMJ Open, 2012. 2: p. e000661. Mitchell, K.J., et al., Prevalence and characteristics of youth sexting: a national study. Pediatrics, 2012. 129(1): p. 13-20. Dowdell, E.B., A.W. Burgess, and J.R. Flores, Original research: online social networking patterns among adolescents, young adults, and sexual offenders. Am J Nurs, 2011. 111(7): p. 28-36; quiz 37-8. Sanders, S.A., et al., Misclassification bias: diversity in conceptualisations about having 'had sex'. Sex Health, 2010. 7(1): p. 31-4. Deogan, C.L., et al., A cost-effectiveness analysis of the Chlamydia Monday--a community-based intervention to decrease the prevalence of chlamydia in Sweden. Scand J Public Health, 2010. 38(2): p. 141-50. Hansdotter, F. and A. Blaxhult, 'Chlamydia Monday' in Sweden. Euro Surveill, 2008. 13(38). Scott, M.E., et al., Risky adolescent sexual behaviors and reproductive health in young adulthood. Perspect Sex Reprod Health, 2011. 43(2): p. 110-8. Gradison, M., Pelvic inflammatory disease. Am Fam Physician, 2012. 85(8): p. 791-6. Crossman, S.H., The challenge of pelvic inflammatory disease. Am Fam Physician, 2006. 73(5): p. 859-64. Haggerty, C.L., et al., Risk of sequelae after Chlamydia trachomatis genital infection in women. J Infect Dis, 2010. 201 Suppl 2: p. S134-55. Hwang, L. and M.A. Shafer, Chlamydia trachomatis infection in adolescents. Adv Pediatr, 2004. 51: p. 379-407. 27

40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50.

Su, W.H., et al., Diagnosis of Chlamydia infection in women. Taiwan J Obstet Gynecol, 2011. 50(3): p. 261-7. Sylvan, S. and B. Christenson, Increase in Chlamydia trachomatis infection in Sweden: time for new strategies. Arch Sex Behav, 2008. 37(3): p. 362-4. Lowhagen, G.B., et al., Epidemiology of genital herpes infections in Sweden. Acta Derm Venereol, 1990. 70(4): p. 330-4. Gossop, M., et al., Female prostitutes in south London: use of heroin, cocaine and alcohol, and their relationship to health risk behaviours. AIDS Care, 1995. 7(3): p. 253-60. Plant, M.L., et al., The sex industry, alcohol and illicit drugs: implications for the spread of HIV infection. Br J Addict, 1989. 84(1): p. 53-9. Gossop, M., et al., Sexual behaviour and its relationship to drug-taking among prostitutes in south London. Addiction, 1994. 89(8): p. 961-70. Al-Tayyib, A.A., et al., Finding sex partners on the internet: what is the risk for sexually transmitted infections? Sex Transm Infect, 2009. 85(3): p. 216-20. Mustanski, B.S., Are sexual partners met online associated with HIV/STI risk behaviours? Retrospective and daily diary data in conflict. AIDS Care, 2007. 19(6): p. 822-7. Malacad, B.L. and G.C. Hess, Sexual behaviour research using the survey method: a critique of the literature over the last six years. Eur J Contracept Reprod Health Care, 2011. 16(5): p. 328-35. Bogaert, A.F., Volunteer bias in human sexuality research: evidence for both sexuality and personality differences in males. Arch Sex Behav, 1996. 25(2): p. 125-40. Dunne, M.P., et al., Participation bias in a sexuality survey: psychological and behavioural characteristics of responders and non-responders. Int J Epidemiol, 1997. 26(4): p. 844-54.

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Appendix 1 Review of Relevant Literature Sexuality in Sweden has been extensively studied. Significant studies that were available internationally with English versions became prominent starting in the 1990s. In 1991 a study surveyed about 3500 adolescents in three communities with a middle class background [8]. Although the survey did not examine sexuality in adolescents, it did reveal significant differences between reported illnesses by the adolescents and actual epidemiological data at the time. In 1995 a study was published that examined developmental behaviour in the context of sexuality and growth [12] that revealed there was minimal experimentation with respect to health habits that children learned early on. In 1990 a national survey study was done to evaluate sexual behaviour in 17 yearold females born in 1973 [17]. The data surveyed children that were in school and children that were not. The study had a higher percentage of school-attenders participating than non-attenders (92% versus 44%). This study revealed that over 60% of students had already had first intercourse and over 15% were described by the authors as early starters undergoing coitarche before reaching 15 years of age. Of the early starters, STIs and pregnancy had been experienced by approximately 15%. Not surprisingly, higher rates of SRB, such as increased number of partners, first-meeting intercourse, anal sex, and oral sex were seen in girls with earlier coitarche. Interestingly, early starters were 2 times more likely to have menarche at 11 years of age than non-early starters. A seriously concerning statistic is that 11 and 20 percent of later starters and early starters, respectively, reported sexual abuse at some point in their life. When considering girls not in school, over 80% of girls had already experienced intercourse and almost half of them were early starters with over a quarter of the girls alleging sexual abuse. A similar study was also conducted with 17 year-old boys in Sweden [11]. The response rate profile was similar to the study discussed above. Over half of students had experienced intercourse and over 15% were early starters. Factors that were associated with early coitarche included being a vocational study programme, alcohol use, tobacco use, and early puberty. Astonishingly, 15% of the early starters indicated they had at least 10 sexual partners. Not surprisingly, this was associated with higher risk of STIs. Also, having first-meeting intercourse resulted in being 14 times more likely to having ever impregnated a girl. About one-third of boys that do not attend school were early starters 29

and over one-tenth had made a girl become pregnant at some point. As one might expect, the authors identified school non-attenders as a group at risk. In 1992 a study described what is now termed the Knowledge/Attitude versus Behavioural gap [18]. Youth clinics throughout Sweden surveyed patients with questions about sexuality. Their knowledge of STI and STI protection was considered good, with recognition by most that HIV and chlamydia are potential risks. In addition, knowledge about contraception methods was high. The average participant was about 17.5 years old and the mean number of sexual partners was over 3, with over 90% having undergone coitarche and almost 10% having experienced a pregnancy. The authors concluded that despite adequate knowledge and attitudes toward sexuality, sexual risk-taking still permeates Swedish youth. A report from the Alan Guttmacher Institute in 2001 took a close look at teenage sexual and reproductive behaviour in Sweden [9]. The report found similar trends as previous research, conveying Swedish youth having liberal and open views toward sexuality. The report ascribes some of this as due to the historically open attitude toward premarital sexual relationships. The study discussed how STIs were a particularly serious issue in the 1970s, but since the onset of social programs and improved public health, STIs such as gonorrhea have declined compared to those times. Notably, the report points out groups that have been identified as disadvantaged such as some young mothers, second generation immigrants, schoolgirls being targeted for sexual harassment, and young homosexuals and lesbians. The report also reveals that in 1999, the Swedish National Agency for Education conducted a study that found not all pupils have access to the same standard of education. As Sweden entered the 21st century an increasing number of studies examining the sexual attitudes and behaviours of Swedish youth began to surface. In 2002, an informative review of adolescent sexuality in Sweden was published [7]. This study, like many others, reaffirmed the liberal attitude Swedes hold toward sexuality. It reported general information on the availability of sexual education, contraceptives, and abortions. The author points out that teenage abortion rates have increased from 17 per thousand in 1995 to over 22 per thousand in 2001. A reemergence of chlamydia was also occurring at the time and this called for renewed efforts by Swedish public health agencies. Notably, over half of chlamydial infections were occurring in young people with the greatest increases in the teen group. 30

As the previous study highlights key problems such as the increasing number of abortions in Sweden, another study took a closer look at why there was an increasing number abortions despite easy access to ECPs in the country [10]. The study found that most women are aware of the option to use ECPs, but many lack the knowledge or guidelines surrounding their use. The study posits that this lack of knowledge may be partly responsible for their low use in Sweden. The study even suggests perhaps that women keep ECPs at home so that they may be used within the correct time period after intercourse. Additionally, the study emphasized that the medication should remain available without a prescription. In 2005, Margareta Forsberg published a comprehensive review of the research in adolescent sexuality [2]. The study published updated findings in addition to comparing them to results seen in an earlier study she published in 2000 [1]. Here she combined quantitative and qualitative approaches. In addition to reviewing past research, she also conducted group interviews. The study reveals a weakening of the romantic love complex where boys have less restricted attitudes about love and sexuality than do girls. In particular, immigrants tended to have a more restrictive position. Females are expected to act respectably and are held more responsible for their own sexuality when compared to boys. The weakening of the romantic love complex is suggested to be linked to the notion that sexual relationships do not necessarily have to be combined with love. Forsberg points out an increase in fuck buddy relationships, casual sex, and willingness to try group sex are all indicative of this trend. She states such attitudes and behaviours are facilitated by globalisation, migration, exposure to diverse sets of attitudes and norms, and increased communication through means such as the internet. Many studies exploring SRB in Sweden have been published in the 21st century. A 2009 study sought to describe SRB in the Sweden from 1989 through 2007 with particular focus on HIV and other STIs [3]. Again, the review found a decline in restrictive views toward sexual activity, in particular regarding thoughts on sexual intercourse outside of a stable relationship. Accordingly, the average number of sexual partners increased throughout the study, as did casual intercourse without a condom through 2003. However, condom-less casual intercourse declined slightly after 2003. Not surprisingly, younger individuals demonstrated greater amounts of SRB than older individuals. Given the patterns of SRB identified, the study concluded that campaigns with STI education are needed for the whole of Sweden and, especially for younger Swedes. 31

The same 2009 study mentioned above was the subject of another publication that aimed to explore in more detail the SRB of Swedish adolescents and young adults [21]. Some notable findings are similar to those published previously, but worth mentioning. The OR for casual sex without a condom and for having greater than two partners increased significantly. Females between the ages of 16 and 24 saw a doubling of these aforementioned ORs during the study period. This specific publication emphasized the crucial importance of educating younger Swedes about condom use in casual sexual encounters. Utilising repeated cross-sectional surveys, a study published in 2012 examined contraceptive use and SRB in females studying at university in 2009 to compare with results from 1999 and 2004 [20]. The average respondent was 23.5 years of age and over half were in a stable relationship. Nearly every participant had experienced coitarche and over 90% had given or received oral sex. Notably, the average number of sexual partners increased from 5.4 in 1999, to 7.4 in 2004, to 11.0 in 2009. Over half of respondents had experienced first-meeting intercourse without a condom and over a third had experienced anal intercourse. Condoms were used three-fourths of the time at first intercourse and contraceptive pills were used in over half of most recent intercourse encounters. The use of emergency contraception increased from 22% in 1999 to 52% in 2004. Additionally, experience of STIs steadily increased from 14% in the first survey in 1999 to 29% in 2009. Given the importance that sexuality surveys have in terms of monitoring the health of adolescents in a population, investigation of possible bias is worthy of investigation. This is particularly difficult because of the difficulty in acquiring information about people who choose not to participate in a study. A study conducted in 1997 by postal mail to Australian twins in a long-term national research database revealed that individuals who consented and participated in the survey were more likely to have a higher education, more likely to smoke tobacco or drink alcohol, went to church less frequently, had more liberal voting preferences and sexual attitudes [50]. In addition, people who answered the survey were more outgoing, less risk-averse, and more noveltyseeking. Interestingly, responders were more likely to have had depression, alcohol abuse problems, earlier first intercourse, and suffered sexual abuse. Individuals who consented but then dropped from the study more resembled consenters than those who never consented in the first place. The authors of the study concluded that despite these 32

differences, the biases discovered should not affect population estimates based on the data. Another potential source for error in sexuality studies surrounds the problem with consistent definitions of terminology used in studies. One study conducted in the United States explored in detail how different people define the word sex and how people interpret it [32]. This fascinating study used random-digit-dialing to conduct telephone surveys of people aged 18 to over 90 years of age. Participants were asked about whether the following behaviours constituted having had sex: manual-genital stimulation, oralgenital stimulation, penile-vaginal intercourse, and penile-anal intercourse. The authors concluded that there is no consensus as to which behaviours represent having had sex. They suggest that researchers and studies use behaviour-specific terminology, being careful not to assume definitions are unanimous across study participants and investigators. A 2011 study reviewed over 60 articles to discover typical methodological problems with sexuality research conducted through surveys. The study found that almost half of studies neglected to query about sexual orientation and sexual behaviour terminology was clearly defined in only one-third of studies. Less than 5% of the reviewed studies asked about whether sexual encounters were consensual and almost one-fifth of the articles did not address confidentiality or anonymity.

33

Appendix 2 Chi-square p-values

Table 5. Chi-square p-values for demographics and four of the indicators of SRB. Statistically significant p-values are less than 0.05.

Chi-square p-values
Gender Born in Sweden? Live inside or outside of Stockholm County? What role does religion play in your life? 20-29 years old/15-19 years old Have ever provided compensation for sexual activity? Have ever received compensation for sexual activity? Currently Job-seeking Currently Working Currently a Student Have you looked on the internet for someone to flirt with during the last 12 months? Have you looked on the internet for a partner/sex partner during the last 12 months?

Had sexual contact the first time you met someone in the previous 12 months? 0.001* 0.430 0.000* 0.003* 0.000* 0.000* 0.000* 0.001* 0.000* 0.004* 0.000* 0.000*

Chlamydia history 0.000* 0.831 0.005* 0.000* 0.000* 0.000* 0.000* 0.001* 0.000* 0.000* 0.000* 0.000*

Herpes history 0.000* 0.163 0.061 0.517 0.000* 0.007* 0.000* 0.995 0.000* 0.000* 0.001* 0.000*

Gonorrhea history 0.007* 0.960 0.000* 0.943 0.004* 0.000* 0.000* 0.404 0.001* 0.004* 0.017* 0.000*

HIV history 0.595 0.020* 0.555 0.909 0.447 0.000* 0.000* 0.141 0.246 0.485 0.989 0.201

34

Table 6. Chi-square p-values for demographics and three of the indicators of SRB. Statistically significant p-values are less than 0.05.
Had you drunk alcohol the first time you had sex with someone? 0.021* 0.024* 0.118 0.000* 0.000* 0.000* 0.012* 0.881 0.000* 0.000* 0.045* 0.055 Had you taken any drugs the first time you had sex with someone? 0.656 0.166 0.207 0.464 0.001* 0.017* 0.000* 0.296 0.072 0.273 0.006* 0.001* Had you drunk alcohol the last time you had sex with someone? 0.029* 0.863 0.000* 0.035* 0.025* 0.000* 0.000* 0.434 0.017* 0.156 0.000* 0.000*

Chi-square p-values
Gender Born in Sweden? Live inside or outside of Stockholm County? What role does religion play in your life? 20-29 years old/15-19 years old Have ever provided compensation for sexual activity? Have ever received compensation for sexual activity? Currently Job-seeking Currently Working Currently a Student Have you looked on the internet for someone to flirt with during the last 12 months? Have you looked on the internet for a partner/sex partner during the last 12 months?

Table 7. Chi-square p-values for demographics and three of the indicators of SRB. Statistically significant p-values are less than 0.05.
Had you taken any drugs the last time you had sex with someone? 0.004* 0.146 0.902 0.150 0.009* 0.000* 0.000* 0.200 0.027* 0.891 0.000* 0.000* Have you placed or answered sex adverts on the internet during the last 12 months? 0.000* 0.132 0.167 0.210 0.000* 0.000* 0.000* 0.000* 0.000* 0.000* 0.000* 0.000* Have you put naked picture(s) of yourself on the internet during the last 12 months? 0.045* 0.928 0.587 0.030* 0.012* 0.000* 0.000* 0.000* 0.493 0.000* 0.000* 0.000*

Chi-square p-values
Gender Born in Sweden? Live inside or outside of Stockholm County? What role does religion play in your life? 20-29 years old/15-19 years old Have ever provided compensation for sexual activity? Have ever received compensation for sexual activity? Currently Job-seeking Currently Working Currently a Student Have you looked on the internet for someone to flirt with during the last 12 months? Have you looked on the internet for a partner/sex partner during the last 12 months?

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