Despite contraception’s health and social benefits, many women1 report nonuse and discontinuation due to method dissatisfaction. Burgeoning research suggests that sexual acceptability influences contraceptive practices.1 In a large cohort of new-start contraceptive users, we examined the association of sexual function, satisfaction, and self-reported sexual acceptability with continued contraceptive use over time.
Data were obtained from the HER Salt Lake Contraceptive Initiative, a cohort study (Contraceptive Trial Registration Number NCT02734199) approved by the University of Utah institutional review board.2 All interested participants completed the informed consent process and the baseline survey in a private room. From March 2016 to March 2017, family planning clients received their desired contraceptive method at no cost and could switch or discontinue at any time. At baseline, 1, 3, and 6 months, participants completed sexual acceptability measures including the Female Sexual Function Index (FSFI-6)3 and the 20-item New Sexual Satisfaction Scale (NSSS).4 In follow-up surveys, they reported whether, and how, their contraceptive method had affected their sex life in the past month (from “a lot worse” to “a lot better”).5
Investigators used multivariable logistic regression models to assess patterns of noncontinuation (switching or discontinuation) of enrollment method by 6 months. Independent variables were perceived sexual effect of method and changes in FSFI-6 and NSSS scores. Covariates included bleeding changes and frequency of adverse effects captured by the Menstrual Symptom Questionnaire, divided into physical (eg, breast tenderness) and mood-related (eg, depression) changes.6 Controls included enrollment method and sociodemographic factors related to contraceptive practices (eg, age, relationship status, and education). Participants selected their race(s) and ethnicity from 7 listed categories, including a write-in option.
Among 2027 eligible participants included in the analyses, 610 (30.1%) selected the levonorgestrel, 52 mg, intrauterine device (IUD), 454 (22.4%) the etonogestrel contraceptive implant, 367 (18.1%) oral contraceptive pills, 303 (15.0%) copper T380A IUD, 190 (9.4%) depo medroxyprogesterone acetate injection, and 103 (5.1%) vaginal ring. Less than 1% selected all other methods.
Participants reported no significant changes in FSFI-6 and NSSS scores (Table 1). However, at 1 month, 107 participants (52.8%) in total said their new method improved their sex life (529 [26.1%] “improved a lot”; 542 [26.7%] “improved a little”); 340 (16.8%) in total said it made their sex life worse (291 [14.4%] “a little worse”; 49 [2.4%] “a lot worse”); and 616 (30.4%) reported no sexual effect. Respondents whose method made their sex life “a lot worse” had 3.3 increased odds of noncontinuation by 6 months relative to those whose method improved their sex life “a lot” (95% CI, 1.5-7.1; P = .002; those reporting “a little worse” had 2.0 increased odds (95% CI, 1.3-3.0, P = .002. Although bleeding changes were also significantly associated with noncontinuation, changes in FSFI-6 scores, NSSS scores, and adverse effects were not (Table 2).
Contraceptive users’ perceptions that their method negatively affected their sex life were strongly associated with noncontinuation by 6 months—more robustly than other adverse effects. Qualitative research on contraceptive sexual acceptability documents multiple domains that may help explain this effect, including sexual spontaneity, psychological disinhibition, and partner connection when feeling well protected against unwanted pregnancy.1
Study strengths include its large sample size, prospective design, and use of multiple measures to assess sexual experiences. Limitations of this study include that the outcome measure was affected by the large proportion of participants who initiated IUDs or implants—methods that require more effort to discontinue than pills, rings, and injections. Though we included only participants with complete variables, sensitivity analyses indicated that results held when we included all participants.
These findings suggest that the sexual acceptability of a contraceptive method may have an important role in whether a patient continues to use it. Finding methods that favorably align with users’ sexual experiences may reduce noncontinuation and improve patients’ sexual lives and well-being.
Accepted for Publication: March 6, 2021.
Published Online: April 26, 2021. doi:10.1001/jamainternmed.2021.1439
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Higgins JA et al. JAMA Internal Medicine.
Corresponding Author: Jenny A. Higgins, PhD, MPH, Department of Obstetrics and Gynecology, University of Wisconsin-Madison, 1010 Mound St, Madison, WI 53715 (jenny.a.higgins@wisc.edu).
Author Contributions: All authors had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Higgins, Turok, Sanders.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Higgins, Wright.
Critical revision of the manuscript for important intellectual content: Higgins, Kramer, Everett, Turok, Sanders.
Statistical analysis: Higgins, Kramer, Wright, Everett.
Obtained funding: Higgins, Turok, Sanders.
Administrative, technical, or material support: Higgins, Turok, Sanders.
Supervision: Higgins, Turok, Sanders.
Conflict of Interest Disclosures: Dr Higgins reported grants from Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) (R01 HD095661) and grants from Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) (Population Research Infrastructure Grant (P2C HD047873) during the conduct of the study. Dr Kramer and Ms Wright also receive support from, NICHD grant (P2C HD047873. Dr Turok reported grants from Eunice Kennedy Shriver National Institute of Child Health & Human Development Award number K24HD087436, nonfinancial support from Bayer pharmaceuticals They provided contraceptive devices for the study, nonfinancial support from Merck (they provided contraceptive devices for the study); nonfinancial support from Teva Pharmaceuticals (now Copper Surgical, they provided contraceptive devices for the study); grants from Anonymous Foundation, and grants from William and Flora Hewlett Foundation during the conduct of the study; fees from Sebela Pharmaceuticals The University of Utah Department of Obstetrics & Gynecology as a scientific advisor, fees from Medicines360. The University of Utah Department of Obstetrics & Gynecology has a contract to serve as a clinical research site used in this study. He also reports fees from Merck for the University of Utah Department of Obstetrics & Gynecology to conduct investigator-initiated research of the etonogestrel contraceptive implant outside the submitted work. Dr Sanders reported grants from NICHD R01 HD095661 and grants from NICHD K12 HD085852 during the conduct of the study. No other disclosures were reported.
Funding/Support: This analysis was funded by an award (R01 HD095661) from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD). Support for the HER Salt Lake Contraceptive Initiative comes from The Society of Family Planning Research Fund, the William and Flora Hewlett Foundation, and a large, anonymous family foundation. The following companies contributed contraceptive products: Bayer Women’s Healthcare, Merck & Co Inc, and Teva Pharmaceuticals. The authors also acknowledge support from two NICHD infrastructure grants (P2C HD047873 for the University of Wisconsin; the Building Interdisciplinary Researchers in Women’s Health K12 HD085852 for the University of Utah). Study data were collected and managed using REDCap (Research Electronic Data Capture) hosted at the University of Utah; this service is supported by Center for Clinical and Translational Sciences grant 8UL1TR000105. Dr Turok is funded by an NICHD Midcareer Investigator Award (K24 HD087436).
Role of the Funder/Sponsor: The Eunice Kennedy Shriver National Institute of Child Health and Human Development had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: This content is solely the responsibility of the authors and does not necessarily represent the official view of any of the funding agencies or participating institutions, including the NIH, the University of Wisconsin-Madison, the University of Utah, and the Planned Parenthood Federation of America, Inc.
Additional Contributions: The authors thank clinic staff at the 4 recruiting family planning clinics for their critical work in making the study a success.