Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, SE-901 85 Umeå, Sweden
1 To whom correspondence should be addressed. E-mail: anneli.kero{at}obgyn.umu.se
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Abstract |
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Key words: ambivalence/contraception/legal abortion/partner relationship/sexuality
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Introduction |
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The total number of abortions in Sweden has varied from 30 000 to 37 000 annually since 1975 (1721 per 1000 women aged 1544; Official Statistics of Sweden, 2003). About 40% are repeat abortions, i.e. the woman has had at least one previous abortion. Scandinavian studies indicate that women applying for abortion not only support abortion as a principal female right but many also fully accept abortion as a realistic alternative, and a backup option, in the case of an unwanted pregnancy (Husfeldt et al., 1995
; Kero et al., 2001b
; Kero, 2002
). However, no studies indicate that abortion is regarded and used as a contraceptive method. The level of contraceptive use in Sweden is high, seen from an international perspective (Riphagen and Ketting, 1990
). Many pre-abortion studies also show that women have extensive experience of different contraceptive methods (Ingelhammar et al., 1994
; Savonius et al., 1995
; Barrett et al., 1998
; Kero et al., 2001a
) and that those with previous experience of abortion use contraceptives more than or as often as women facing their first abortion (Osler et al., 1992
; Holmgren, 1994
; Ingelhammar et al., 1994
; Savonius et al., 1995
; Kero et al., 2001a
).
A number of studies on emotional responses in women immediately after induced abortion have been conducted and most show that the predominant post-abortion feeling in women is relief and that severe difficulties are quite rare (Adler et al., 1990; Major et al., 2000
; Kero et al., 2004
). In previous studies we found that both women and men experienced abortion as a painful necessity, mostly undertaken to meet the needs of family planning (Kero et al., 1999
, 2001b
). Furthermore, ambivalent feelings in relation to abortion 1 year later revealed that, while women did not regret their decision, many expressed a wish that they had been spared the experience of having an abortion (Kero and Lalos, 2000
). However, there is a lack of prospective studies which investigate the impact of abortion not only on contraception practice but also on sexuality and partner relationships (e.g. as shown in a review by Bianchi-Demicheli et al., 2000
). Six months post-abortion, the majority of the women did not report any changes in their sexual satisfaction, and their use of contraceptives had increased (Bianchi-Demicheli et al., 2001
, 2003
). Furthermore, this study found no changes in the quality of the relationship among stable couples. Another prospective study 1 year post-abortion showed similar findings concerning sexual satisfaction but found that the partner relationship had become more difficult in the group who had undergone an abortion (Freudenberg and Barnett, 1988
). Arising from the lack of knowledge in this field, the aim of the present study was to examine prospectively the impact of abortion on contraceptive practice in women before and 12 months after legal abortion. In addition, the study aimed to elucidate the influence of abortion on partner relationship and sexual satisfaction.
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Subjects and methods |
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The questionnaire study contained questions about life conditions, sexuality, feelings in relation to the pregnancy and abortion, contraceptive use and attitudes and opinions about contraceptive methods. In order to get feedback and to validate the questionnaire, all the women who had also consented to participate in the longitudinal interview study were contacted by telephone within a few days for a follow-up interview. Several of the questionnaire items were repeated in order to check understanding and accuracy. It was found that the participants had reacted positively to the questionnaire, and had not had any problem understanding the questions. Furthermore, this contact showed that the answers given over the telephone agreed with the written answers. Apart from validating the questionnaire, a further aim in contacting these women was to establish a personal link prior to the follow-up interviews. Most questions from the questionnaire study before abortion were followed up in a semistructured interview 12 months later. The interviews were conducted over the phone by two experienced medical social workers of whom one is the first author (A.K.).
Both open and semistructured questions were used. The precise procedure when asking questions for which there were given response alternatives was for the interviewer to ask the question without mentioning the different response alternatives. Thus, the women were free to give any answer they wished, and subsequently the interviewer chose, with the women, the most suitable response alternative; for example, satisfied, rather satisfied or not satisfied as regards sexual satisfaction.
Analysis of non-participants
As mentioned above, 33 women (34%) did not want to participate in the follow-up study. Statistical tests of comparison were carried out between those women who did (n = 58) and those who did not participate in the follow-up study (n = 33). As both groups had participated in the questionnaire study before abortion, they could be compared for a large number of variables, such as age, civil status, education, personal finances, children, partner relationship, sexual life, contraceptive use and social support. Furthermore, there were also data on attitudes and feelings in connection with the pregnancy and the abortion, the partners attitude to the abortion and experiences of previous abortion(s) in all women. The results from all these comparisons show that there were no significant differences between these two groups of women apart from a tendency to have a lower educational level among those who did not participate in the follow-up study (Fishers exact test, P < 0.03).
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Results |
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Contraceptive use
When asked whether the current pregnancy was planned, all replied in the negative except one, who stated that it was more or less planned. However, almost half the women (26/58) had not used any contraceptives at the time of conception and four did not know whether they had used one (Table II). It emerged that the most common reasons for not using a contraceptive were that the women thought it was a safe period (10/26), took a chance (9/26) and allowed sexual feelings to take over (7/26). Among those who had tried to prevent a pregnancy (28/58), most had used condoms, relied on coitus interruptus or on safe periods (Table II). In addition, nearly half the women (26/58) considered abortion a realistic alternative in the case of an unwanted pregnancy even before the current pregnancy.
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Most women had previous experiences of both coitus-independent methods, such as various contraceptives pills (48/58) and intrauterine devices (IUDs) (13/58), and coitus-dependent methods, such as the condom (46/58), coitus interruptus (30/58) and the rhythm method (14/58). When asked which contraceptive method they really preferred, most stated contraceptive pills (27/58) and/or IUDs (7/58), while the rest answered condom (16/58), rhythm periods (5/58) or coitus interruptus (5/58). Seven women reported either that there are no suitable contraceptive methods whatsoever or that they had no preference among the methods. Of all the women, more than half (31/58) expressed serious concerns about using IUDs and hormonal contraceptives.
One-year follow -up
Partner relationship and sexual satisfaction
At the 1-year follow-up, 40 women (40/58) still had a partner relationship with the man they had become pregnant with 1 year previously. The majority of these women (28/40) considered that they were satisfied with their partner relationship, nine were rather satisfied while three were dissatisfied. When comparing their opinion about the quality of their partner relationship before abortion, no great changes were found (26/40 were satisfied, 11/40 rather satisfied and 3/40 dissatisfied). In addition, almost half (18/40) said at the follow-up that the abortion process had deepened their relationship in a positive manner, 17 reported no influence on their relationship, while five described a negative influence. Eight women who had a stable partner relationship before abortion (8/48) had separated. In total, six women had a new partner (6/58) 1 year post-abortion and the number who were single had increased from 10 before abortion to 12. Four women had already become pregnant, two had given birth and one had had another induced abortion.
The majority of the women had resumed sexual relations within 1 or 2 months post-abortion (32/58 and 18/58, respectively). At the 12-month follow-up 15 women (15/58) stated that they were not sexually active; however, four of them did not lack a partner. Among those who had an ongoing sexual relationship, the majority reported that they were sexually satisfied (30/43), five were rather satisfied and eight were not satisfied. Of all women, most (45/58) stated that the abortion 1 year previously had not had any influence on their current sexual life. Three described a positive influence, while another three could not tell whether or not the abortion had had any influence. In addition, seven women reported a negative influence and referred to it as generally reducing their sexual desire, as they were afraid of becoming pregnant again. Furthermore, they had problems finding suitable contraceptives.
In answer to the question about whether the women planned to have children in the future, more than half (30/58) answered in the affirmative, 11 did not know and the rest (17/58) had no such plans. The women were also asked what their opinion would be regarding a new pregnancy in their current circumstances. Twenty-two (22/58) stated that they would then continue the pregnancy to full term. Sixteen would have an abortion again and the remaining 20 did not know what they would do.
Contraceptive use
One woman (1/58) was pregnant at the time of the follow-up 1 year post-abortion and 10 (10/58) stated that they did not currently use any contraceptives, as they were not having sexual intercourse at the time of the follow-up. Among the others (47/58) most either used hormonal contraceptives [25/47 (various contraceptive pills, 22/47; injectables, 2/47; implants, 1/47)] or had an IUD (10/47) 1 year later (Table II). Condom use was the most common among the rest; however, some also relied on safe periods, coitus interruptus and a diaphragm. Thus, the number of women reporting the use of modern effective contraceptives had increased to 35 (35/47) compared with the time of conception before abortion, when only four women (4/58) reported doing so.
Furthermore, 42/47 women stated that they never had sexual intercourse without using some method of contraception and also 40 declared that they never relied on methods such as safe periods or coitus interruptus. On the other hand, six women did rely on safe periods and/or coitus interruptus (Table II). All six were satisfied with their sexual life and only one of them was dissatisfied with the contraception situation. Five of these said that they occasionally had sexual intercourse without using any contraceptives whatsoever. At the time of conception before abortion, four of these had not used any contraceptive method. Concerning the women who still had a partner relationship with the man they had become pregnant with 1 year previously (40/58), more than half (26/40) used either hormonal methods or had an IUD 1 year post-abortion. The corresponding number before abortion was three (3/40). Ten of these women (10/40) used barrier methods both before and 1 year post-abortion while the number of women who relied on the safe period and/or coitus interruptus had declined from 17 (17/40) to six (6/40). Five women who had a new partner (6/58) used hormonal methods or had an IUD at the 1-year follow-up. The corresponding number for those without a partner (10/58) was four.
All except one had been offered contraceptive counselling at the time of their abortion. Eight (8/57) had declined and ten (10/57) were not pleased with this counselling. A common comment was that their aversion to and worries about the pill and an IUD were not taken seriously. At the 1-year follow-up, most women (39/58) stated that they were satisfied with their contraceptives. However, eight were dissatisfied and eleven did not answer the question (seven of them had no current sexual partner relationship). Many stressed that one consequence of the abortion was that they had become more careful about contraceptives because they did not want to undergo another abortion. During the year following the abortion, most women (37/58) had tried at least one contraceptive method, 15 had practised two and an additional two had used three different methods. Fifteen women, for example, had tried hormonal contraceptives (14/15) or an IUD (1/15) during the year but had stopped using them mainly because of negative effects and worries about risks. Of these fifteen women, 11 had experienced previous abortion(s). Among women who had hesitated to use hormonal contraceptives and/or an IUD (31/58) before abortion, 17 had tried the pill post-abortion but only six still used it. Another six had tried an IUD and five still had it one year post-abortion.
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Discussion |
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The present study shows increased contraceptive use in women 1 year post-abortion compared with the time of conception before abortion. Most women tried to protect themselves from pregnancy and the majority (35/58) used modern effective contraceptives. Furthermore, most women who practised sex at the time of the follow-up (42/47) stated that they never had unprotected intercourse. This certainly contrasts with the time of conception before abortion, when most had had unprotected sex or trusted unreliable methods. These long-term findings are in agreement with another follow-up study which shows that after 6 months post-abortion the number of women who used some kind of contraception had increased from 69% before abortion to 83%, and that most had changed from unsafe to safer methods (Bianchi-Demicheli et al., 2001). Our findings are also in line with studies which have found that women with previous experiences of more than one abortion use contraceptives more often than women facing their first abortion (Osler et al., 1992
; Holmgren, 1994
; Ingelhammar et al., 1994
; Kero et al., 2001a
). As regards men, we have also found increased contraceptive use 1 year post-abortion (Kero and Lalos, 2004
).
Regarding opinion about partner relationships, most women who 1 year post-abortion had a partner relationship with the man they had become pregnant with were still satisfied. In addition, more than half stated that their relationship had even deepened as a consequence of coping jointly with the stressful situation caused by the unwanted pregnancy. This is in agreement with our previous findings showing that most women and men had no emotional distress post-abortion and generally experienced mental growth, in terms of e.g. maturity, as an effect of the abortion process (Kero et al., 2004; Kero and Lalos, 2004
). As concerns sexual life, it was found that most women had not experienced any negative change in sexual satisfaction as a consequence of the abortion. This is in agreement with two of the few follow-up studies on sexuality post-abortion, which show that satisfaction in sexual life generally does not change significantly after induced abortion (Freudenberg et al., 1988; Bianchi-Demicheli et al., 2001
). However, the present study shows that, among women who had a sexual partner relationship, approximately every sixth woman experienced a negative influence on sexual life due to the abortion. Many of them had great problems finding suitable contraceptives.
In the present study more than a third of the women did not plan to have more children and almost half of them clearly stated that they would have an abortion again if they became pregnant. This is in line with the reasoning concerning the importance of the contraceptive methods fitting into the womens social and sexual lifestyle (Bajos et al., 2003). Possibly, sterilization would be an appropriate alternative for those who definitely do not want to have any (further) children. It is of interest to note that 21% of the abortions in Sweden involve women older than 35 years and 7% women older than 40 years (Official Statistics of Sweden, 2003
), Furthermore, it is well known that women over 35 years constitute a risk group regarding the use of unreliable contraceptive methods (Oddens et al., 1994; Oddens and Milsom, 1996
). In addition, it is known that women who continue to practise unprotected intercourse post-abortion are slightly older and often involved in a good, long-term relationship (Bianchi-Demicheli et al., 2003
). As regards sterilization, this is quite an unusual method in Sweden; a recent population-based survey has shown that 8% of women and 3% of men are sterilized (Lalos, 2000
). In contrast, the acceptance of sterilization in e.g. the Netherlands is widespread and that country also has one of the lowest abortion rates in Europe. Approximately every fifth woman and man aged 3049 years has been sterilized (Ketting and Visser, 1994
). Thus, more extensive use of sterilization among those who neither want to use highly effective contraceptives nor wish to have any (further) children might contribute to reducing worries about unwanted pregnancies as well as the actual number of abortions. However, there is a need for further investigation concerning both the long-term effects of sterilization and the attitudes of counsellors and gynaecologists towards giving information about sterilization.
Certainly, there are multifactorial explanations for why women who apply for abortion take risks regarding contraception. A recent Swedish study showed, for example, that one out of three women applying for abortion did not use contraceptives, as they believed they could not become pregnant (Larsson et al., 2002). Another study found that the main reason an unplanned pregnancy occurred was not a lack of knowledge, but rather a failure to integrate that knowledge with situational, intrapsychic and social factors (Törnbom and Möller, 1999
). An unconscious desire to become pregnant (Blumenfield, 1978
) or to strengthen the feminine identity (Pines, 1990
) are also suggested as motives behind contraceptive avoidance. Findings in the present study also draw attention to womens ambivalent attitudes to hormonal contraceptives and the IUD. Previously we have shown that more than half the women applying for abortion were hesitant about using an IUD and/or hormonal contraceptives (Kero et al., 2001a
). These women had usually tried many different contraceptive methods and were well informed about contraceptives. Their main arguments were that they disliked the fact that hormonal methods disturbed the natural biology of the body or that they did not want to have strange things in their body. This is in agreement with findings in another Swedish study, in which women were worried about the daily consumption of unknown compounds (Ingelhammar et al., 1994
). In the present study we found that before abortion more than half the women were hesitant about using modern effective contraceptives. However, 1 year post-abortion more than half of these women had tried the pill or an IUD but most had stopped using them. This is in accordance with studies showing that experiences of side-effects and fear of possible health risks are common reasons for not using modern highly effective methods, both in women in general as well as in women seeking an abortion (Milsom et al., 1991
; Ingelhammar et al., 1994
; Savonius et al., 1995
; Larsson et al., 1996
, 2002
). Apart from worries about health risks, gender differences appear in this issue. For example, one notable finding in our previous study was that the womens partners were in favour of hormone pills and IUDs to a greater extent than the women themselves. Thus, there may be conflicting views within the couple regarding prevention of pregnancy.
Modern contraceptive methods are generally regarded as safe and the most important goal in counselling is often to motivate women to use them in order to avoid unwanted pregnancies and reduce the number of abortions (Osler et al., 1992; Ingelhammar et al., 1994
; Oddens and Milsom 1996
). For example, discourse about sexual politics in Sweden from 1970 indicated clearly that contraception was the responsibility of the women and that contraceptives such as the pill and the IUD were to be preferred to the diaphragm and the condom (Sandström, 2001
). Furthermore, these modern contraceptive methods are predominantly associated with release and liberation, while the oppositebeing obliged to continuously use contraceptivesis seldom given any attention. This clash of interests has barely been problematized; instead, womens resistance to using these methods has been identified as the problem. It is important to consider that underlying approaches and expectations from both society and male partners might result in such female resistance not being considered valid within the context. In the present study, for example, a common negative comment about the counselling received before the abortion was that the women felt the staff did not take their worries seriously, or negative experiences with pills and IUD. However, womens resistance to using contraception on a continuous basis and/or their negative experiences must be listened to, and doing so would certainly add depth to the discussion about contraceptives in general and sexual conditions for women in particular. One challenge in the effort to reduce unwanted pregnancies and abortion, apart from information about contraceptives, is to establish an open dialogue between the gynaecologist/counsellor and the woman/the man/the couple. This dialogue should comprise not only the pros and cons of coitus-dependent and coitus-independent methods but also gender differences in sexual behaviour, as well as attitudes towards unwanted pregnancy and abortion. In this context it is of the utmost importance to include and focus on the male and his role and responsibility in finding a contraceptive method, suited to both the woman and the man.
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Acknowledgements |
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References |
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Bajos N, Leridon H, Goulard H, Oustry P, Job-Spira N and The COCON Group (2003) Contraception: from accessibility to efficiency. Hum Reprod 5,994999.[CrossRef]
Barrett G, Peacock J and Victor CR (1998) Are women who have abortions different from those who do not? A secondary analysis of the 1990 national survey of sexual attitudes and lifestyles. Public Health 112,157163.[CrossRef][ISI][Medline]
Bianchi-Demicheli F, Kulier E, Perrin E and Campana A (2000) Induced abortion and psychosexuality. J Psychosom Obstet Gynecol 21,213217.[ISI][Medline]
Bianchi-Demicheli F, Perrin E, Lüdicke F, Bianchi PG, Fert, D, Bonvallat, F, Chatton D and Campana, A (2001) Sexuality, partner relations and contraceptive practice after termination of pregnancy. J Psychosom Obstet Gynecol 22,8390.[ISI][Medline]
Bianchi-Demicheli F, Perrin E, Bianchi PG, Dumont P, Lüdicke F, Campana A (2003) Contraceptive practice before and after termination of pregnancy: a prospective study. Contraception 67,107113.[CrossRef][ISI][Medline]
Blumenfield M (1978) Psychological factors involved in request for elective abortion. J Clin Psychiatry 39,1725.[ISI][Medline]
Freudenberg N and Barnett W (1988) Relationship with a partner following legal abortiona longitudinal comparative study. Fortschr Neurol Psychiatr 56,300308.[Medline]
Holmgren K (1994) Repeat abortion and contraceptive use. Report from an interview study in Stockholm. Gynecol Obstet Invest 37,254259.[CrossRef][ISI][Medline]
Husfeldt C, Hansen SK, Lyngberg A, Noddebo M and Petersson B (1995) Ambivalence among women applying for abortion. Acta Obstet Gynecol Scand 74,813817.[ISI][Medline]
Ingelhammar I, Möller A, Svanberg B, Törnbom M, Lilja H and Hamberger L (1994) The use of contraceptive methods among women seeking a legal abortion. Contraception 50,143152.[CrossRef][ISI][Medline]
Kero A, Lalos A, Högberg U and Jacobsson L (1999) The male partner involved in legal abortion. Hum Reprod 14,26692675.
Kero A and Lalos A (2000) Ambivalencea logical response to legal abortion: a prospective study among women and men. J Psychosom Obstet Gynecol 21,8191.[ISI][Medline]
Kero A, Högberg U and Lalos A (2001a) Contraceptive risk-taking in women and men facing legal abortion. Eur J Contracept Reprod Health Care 6,205218.[ISI][Medline]
Kero A, Högberg U, Jacobsson, L and Lalos A (2001b) Legal abortion: a painful necessity. Soc Sci Med 53,14811490.[CrossRef][ISI][Medline]
Kero A (2002) Paradoxes in legal abortion. A longitudinal study of motives, attitudes and experiences in women and men. Thesis. Umeå University, Umeå, Sweden.
Kero A, Högberg U and Lalos A (2004) Wellbeing and mental growthlong-term effects of legal abortion. Soc Sci Med 58,25592569.[CrossRef][ISI][Medline]
Kero A and Lalos A (2004) Reactions and reflections in men, 4 and 12 months post-abortion. J Psychosom Obstet Gynecol 25:135143.[CrossRef][ISI][Medline]
Ketting E and Visser AP (1994) Contraception in the Netherlands: the low abortion rate explained. Patient Educ Couns 23,161171.[CrossRef][ISI][Medline]
Lalos A (2000) Reproduction, contraception and sexuality. In: Lewin B, Fugl-Meyer K, Helmius G, Lalos A and Månsson SA (eds) Sex in Sweden. On the Swedish Sexual Life. Stockholm, Sweden: National Institute of Public Health, pp. 189194.
Larsson G, Milsom I, Andersch B and Blohm F (1996) A comparison of contraceptive habits and pregnancy outcome at 19 years of age in two cohorts of Swedish women born 1962 and 1972. Contraception 53,259265.[CrossRef][ISI][Medline]
Larsson M, Aneblom G, Odlind V and Tydén T (2002) Reasons for pregnancy termination, contraceptive habits and contraceptive failure among Swedish women requesting an early pregnancy termination. Acta Obstet Gynecol Scand 81,6471.[CrossRef][ISI][Medline]
Major B, Cozzarelli C, Lunne Cooper M, Zubek J, Richards C, Wilhite M and Gramzow RH (2000) Psychological responses of women after first-trimester abortion. Arch Gen Psychiatry 57,777784.
Milsom I, Sundell G and Andersch B (1991) A longitudinal study of contraception and pregnancy outcome in a representative sample of young Swedish women. Contraception 43,111119.[CrossRef][ISI][Medline]
Oddens B and Milsom I (1996) Contraceptive practice and attitudes in Sweden 1994. Acta Obstet Gynecol Scand 75,932940.[ISI][Medline]
Official Statistics of Sweden (2003) StatisticsHealth and Diseases 2003:9. Abortions 2002. National Board of Health and Welfare, Centre of Epidemiology.
Osler M, Morgall JM, Jensen B and Osler M (1992) Repeat abortion in Denmark. Dan Med Bull 39,8991.[ISI][Medline]
Pines D (1990) Pregnancy miscarriage and abortion: a psychoanalytic perspective. Int J Psychoanal 71,301307.[Medline]
Riphagen FE and Ketting E (1990) Comparative overview of results from eight surveys on contraceptive behaviour. In: Ketting E (ed.) Contraception in Western Europe: A Current Appraisal. Carnforth, UK: Parthenon Publishing Group, pp. 77110.
Sandström B (2001) Den välplanerade sexualiteten. Frihet och kontroll i 1970-talets svenska sexualpolitik (The wellplanned sexuality. Freedom and control in the Swedish sexual politics of the 1970s). Studies in Educational Sciences 37, HSL Förlag, Stockholm.
Savonius H, Pakarinen P, Sjöberg L, Kajanoja P (1995) Reasons for pregnancy termination: Negligence or failure of contraception? Acta Obstet Gynecol Scand 74,818821.[ISI][Medline]
Törnbom M and Möller A (1999) Repeat abortion: a qualitative study. J Psychosom Obstet Gynecol 20,2130.[ISI][Medline]
Wellings K, Field J, Johnson A and Wadsworth J. (1994) Sexual behaviour in Britain. The national survey of sexual attitudes and lifestyles. London: Penguin Books, p. 316.
Submitted on November 25, 2004; resubmitted on May 3, 2005; resubmitted on June 3, 2005; accepted on June 10, 2005.
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