Recruitment Participants were recruited through several mechanisms: Interested participants called a telephone number associated with the study and were informed by J. We filled in the sampling frame's cells as recruitment progressed. All those screened for eligibility and selected for the final sample consented to participate, although 1 person failed to appear for her first interview and could not be reached to reschedule.
Another respondent with a similar demographic profile was quickly identified to replace this individual. Interview Protocol Respondents read and signed a consent form at the first meeting. The study protocol and interview instruments were reviewed and approved by the institutional review board at Emory University, our home institution at the time of data collection.
This allowed not only greater rapport but also observation in people's homes and neighborhoods, which provided contextual information on class differences in housing, neighborhoods, and community geographies. Each interview took approximately 3 hours to complete. A total of hours of interviews were digitally recorded and transcribed.
The semistructured interview guide contained sections on health care history, reproductive and contraceptive histories including likes and dislikes about various contraceptive methods and their effect on sexual functioning and pleasure , current and previous romantic and sexual relationships, sexuality education i.
The guide was designed so that topics moved from less to more sensitive as a way to enhance rapport and data validity. However, part of our research framework was not to impose models of disease versus pregnancy prevention onto participants. Instead, we wanted to elicit their contraceptive motivations in their own words and frameworks.
Finally, we also administered close-ended questionnaires to collect information on income level, public assistance, and highest level of education completed. In the use of a single coder, we diverged from public health researchers within a positivist tradition. Within a positivist framework, bias is addressed by using multiple coders, who presumably offer a check on the possible bias of any 1 coder. Interpretivist researchers instead achieve scientific rigor through attention to the issues of positionality and representation.
For example, we remained attuned to how J. We then came up with a list of codes based on the research questions of interest, the literature, and J. An ethnographic, grounded theory approach was used in analyzing the data.
The analysis was informed by both preexisting themes from the literature and the research questions and by themes that arose from the data. Coding types involved the collection of coded blocks of text and the creation of new thematic data files capturing various dimensions of the key themes, for example, frequency, duration, size, specific vocabulary, and differences in intensity and emphasis.
We describe the 5 prominent themes related to these attributes. Of course, these categories are not mutually exclusive. Nor do we wish to suggest that these 5 themes represent an exhaustive list of types of sexual activity people seek. Rather, they represent the topics that arose from our interviews that seemed the most salient in terms of contraceptive use.
Table 2 presents an overview of the results, including summaries of the most prominent sexual goals and how those goals shaped contraceptive practices. More women than men complained about the physical displeasures of male condoms. Women were also more likely to experience contraceptive side effects, because most methods are designed for women's bodies.
Less socially advantaged women were more likely to have experienced more-extensive side effects from longer-acting methods, which detracted from their sexual enjoyment and contributed to discontinuation.
He can come inside me, there's skin-on-skin contact…. The sex has never been this good. I am always linking the two in my mind. I used to worry about it so much that I had trouble enjoying sex. Contraception became a prerequisite to sexual enjoyment. I just freaked out. The socially advantaged were more likely to eroticize safety because of the perceived costs of unprotected sex.
Fear of unintended pregnancy, especially at sexual initiation, contributed to effective contraceptive use. Open in a separate window Physical pleasure and lack of discomfort. As expected, respondents sought sex that felt good in terms of sensation. At times for women and almost always for men, physical enjoyment entailed orgasm. More frequently for women, physical enjoyment involved sufficient arousal, the desired amount of lubrication, and in many cases, appealing smell, taste, and touch.
Maximizing sexual enjoyment and comfort also meant minimizing discomfort. Vaginal dryness or contraceptive side effects such as heavy bleeding or nausea can all quell sexual pleasure. Spontaneity and sexual flow. Respondents commonly highlighted how one of the pleasures of sex was its opportunity for spontaneity. They suggested that ideal sex should be a spontaneous and smooth flow of erotic events, uninterrupted by contraception.
Sex could represent a union of 2 bodies and sometimes 2 hearts. To facilitate the closeness of intercourse and the intensity of this union, many people preferred sex that involved skin-on-skin contact, including genital contact. Close sex was particularly important for those in long-term relationships. For many, part of the appeal of sex was to give pleasure to one's partner.
Particularly for women, sexual enjoyment encompassed her partner's fulfillment at least as much as her own. They also desired mutual sexual attraction and enjoyed sharing physical pleasure as well as emotional intensity.
For example, many women said their preferred sexual activity was vaginal intercourse even though their partners were much more likely than they were to reach orgasm through this activity. Eroticization of safety and responsibility. These respondents experienced a certain type of pleasure in taking responsibility or, alternately phrased, a displeasure in not being protected.
For risk-averse respondents for whom avoiding pregnancy or disease was imperative, effective prophylaxis was a precondition for enjoying sex to its fullest.
This eroticization of safety was not a factor in why, but rather how, people had sex. It also provides an example of how social inequality intersects with sexual and contraceptive practices. Relationships Between Sexual Goals and Prevention Practices Now we explore how each of the 5 elements we described shaped contraceptive preferences and practices.
We should note that our findings do not regularly distinguish between pregnancy prevention and disease prevention; for the purposes of this exploratory study, we were more interested in how contraceptive methods of all types shape the sexual experience and vice versa. Contraceptive effects on women's sensation and well-being. Respondents preferred contraceptive methods that allowed for as much physical pleasure as possible and that did not cause discomfort.
Most notably, when women rejected male condoms it was to feel more sexual sensation or to be more physically comfortable. This differs from avoiding condoms out of a desire for closer, skin-on-skin sex. Indeed, the majority of women respondents said they disliked the physicality of condoms. They criticized the way condoms felt in terms of sensation and not just what they signified in terms of trust, intimacy, and love.
In the words of 3 women: At least some women rejected the way condoms felt because they exacerbated vaginal dryness. Maya aged 23 years, less socially advantaged indicated that condoms aggravated her vaginal dryness and that, as a result, she was much more likely to resist condom use than her male partners were. Two women also reported that oral contraceptives decreased their ability to become as lubricated as desired during sex.
Among those women who regularly experienced insufficient lubrication, minimizing discomfort could be a more conspicuous goal than maximizing pleasure or than protection against pregnancy or HIV and STIs. We should note that although the majority of women complained of being insufficiently lubricated during sex, at least 2 women disliked excess wetness caused by some methods.
For a number of women, contraceptive practices were shaped by the side effects of hormonal methods that can alter the physical experience of sex.
Side effects such as breast tenderness or nausea diminished both women's physical relationship with their bodies and their interest in sexual activity. So did hormone-associated weight gain, which both women and men reported could interfere with women's ability to fully enjoy sex. Contraceptive effects on sexual spontaneity and flow.
Barrier methods in particular threatened the sexual flow. These attributes did not always prevent people from using these methods, but they led to negative associations and, in some cases, intermittent or improper use. Other researchers have written about the desire for sexual spontaneity.
In fact, this has always been acknowledged as part of the enormous appeal of hormonal methods. Here, however, we place spontaneity within a broader model of pleasure—that is, pleasure as more than just a physical sensation. Charlotte aged 31 years, socially advantaged said she and her sexual partners would often initiate intercourse without a condom and only apply one after several minutes, if at all.
Although relatively protected from pregnancy, she remained at risk for HIV and STIs, particularly given her current number of lovers and relatively long list of lifetime sexual partners. Eventually, she experienced an unintended pregnancy. After seeking an abortion, she started taking oral contraceptives. Even though she reported that the pill reduced her libido, she valued the spontaneity it facilitated.
Alex, Charlotte, and other respondents preferred methods that allowed for maximum flow and minimal disruption. How the desire for closeness and intensity shaped contraceptive use. Many participants sought methods that enhanced both the physical and emotional pleasures of closer, skin-on-skin sex. Why didn't I hear more about it before? Why don't they encourage more women to get these things?
The sex is fantastic. There's skin on skin contact, [my husband] can come inside me, and I'm not worried about it…. The sex has never been this good! The closeness and connection facilitated by the IUD sealed her acceptance of the method. The contraceptive practices of Susan aged 49 years, less socially advantaged similarly reflect a search for closeness with her long-term partner. She estimated they used condoms during approximately half their episodes of sexual intercourse.