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Snow G, Roberts Joni, Sampath A. The sex lives of college students: pleasure, precaution and sexual health decisions. HPHR. 2024. 82. https://doi.org/10.54111/0001/DDDD4
University students engage in a variety of relationship dynamics that are accompanied by diverse sexual experiences; through these encounters, emerging adults may learn more about themselves and their peers. Despite the frequency with which participation in sexual activity occurs within this demographic, sexual health best practices, including consistent use of barrier methods, engagement in STI status conversations with partners, and STI testing per established guidelines, are lacking. The implications are observable, with over half of all new sexually transmitted infections in the U.S. occurring within the 15-24 age group. To explore these trends and deduce why students fail to prioritize their sexual health, this explanatory sequential mixed-methods study was conducted at a large public university in California; it involved a survey (n=540) and subsequent focus groups (n=16), followed by one-on-one interviews (n=35). Survey responses revealed that while students knew how to use and obtain barrier methods correctly, they struggled to do so, citing barriers such as “the heat of the moment,” physical discomfort associated with condom usage, and fear over disturbing partner dynamics. Focus group and interview respondents further divulged that conversations surrounding STI status vary in comfortability depending on the type of relationship, and condom use decisions stem from many interacting internal and external factors. To develop effective sexual health programming materials at the university level, understanding the complex relationships underlying condom-use decision-making is necessary and should be considered when formulating future interventions.
College students are an important and fascinating population to study based on the vast number of changes they undergo during emerging adulthood1. Individuals, upon entering college, may learn more about themselves and their peers through experimentation and other varied behaviors2. Indeed, college students as a cohort are highly sexually active, with around 86% reporting having ever engaged in sex in their lifetime3. Furthermore, hookups, defined as non-committed sexual encounters, are a common practice among college students, with over 60% of first-year undergraduate students reporting engagement in oral, anal, or vaginal sex by the end of their first year at college4.
Furthermore, in 2023, 29.1% of college students reported having engaged in oral intercourse within the last two weeks, while 30.4% and 2.3% reported having engaged in vaginal and anal intercourse within the same time frame, respectively5. The mean number of partners engaged with during the previous 12 months was 2.2, 1.8 and 2.3 for cisgender men, cisgender women, and transgender men, respectively5. Among students who had been sexually active within the last 12 months, 84.1% had used a form of contraception to prevent pregnancy the last time they engaged in sexual intercourse; among those students, most reported use of external condoms (51.8%) and/or oral contraceptive pills (51.8%)5.
Despite the frequency with which sexual activity takes place on university campuses, many students frequently engage in behaviors that do not align with sexual health best practices6. Sexual health best practices include consistent and correct use of barrier methods, testing for STIs at least once a year, after engaging in sexual activity with each new partner, and engaging in STI status conversations with partners. Furthermore, college students are at an elevated risk for sexually transmitted infections (STI), as nearly half of all new sexually transmitted infections in the U.S. occur within the 15-24 age group78.
The elevated rates of STI transmission within this population have raised questions as to which factors are most influential for students in promoting or deterring their adherence to sexual health best practices. Lack of exposure to key sexual health information during the course of youth and adolescence may play a role; indeed, only 25 states and D.C. currently mandate that curricula offer both sexual activity education and HIV education, while only 19 states require discussion of contraceptives and condoms. Still, another 19 require instruction on the importance of waiting to engage in sexual activity until marriage9.
In California, sexual health education (Sex Ed) is mandated for all students once in middle school and once in high school, at minimum.10 Sex Ed must be comprehensive, inclusive and accurate, and include education about HIV history, modes of transmission and prevention10. Yet, despite this comprehensive programming, rates of STI transmission among California university students remain high. Education is evidently not the only important variable to consider; interpersonal dynamics may exert considerable influence on college students’ willingness to use condoms11. These dynamics, which include intimate partner relationships and peer-to-peer relationships, may expose students to expectations that consequently influence sexual health decision-making behaviors12. Existing literature has examined the impact of pornography on sexual decision-making; among the college-age population, social expectations communicated through pornography may be harmful, given that 60% of college-age individuals report watching pornography weekly13. Indeed, exposure to pornography that depicts condomless sex has been associated with enhanced risk for individual engagement in sex without condoms14. Additional studies have demonstrated the apparent association between perceptions of peer condom-use behavior and individual decision-making of condoms, despite individual self-efficacy and knowledge surrounding HIV15.
Despite the disparate rates of STI infection in this population, as well as the tangible and observed consequences of uninformed sexual health decision-making, existing research fails to fully understand the social variables and complex inter-variable relationships that contribute to these alarming rates.
This study, therefore, explored the predominating knowledge, attitudes, and beliefs (KAB) surrounding condom usage among college students at a large California public University to better understand the most pertinent psychosocial factors underlying sexual health decision-making processes within this population. In other words, how successful is comprehensive Sex Ed for California’s young adults when they go away to college? Social variables, namely personal and public condom perceptions, as well as relationship status, were examined to determine the concurrent nature of these factors, in addition to KAB, and the extent of their association with student adherence to sexual health best practices.
Table 1: Definitions of Key Terms
Term | Definition |
Sexual Health Best Practices | Sexual health best practices refer to the set of behaviors that confer the greatest degree of protection against unwanted health outcomes resulting from sexual activity, primarily referring to STI transmission and unwanted pregnancy. These practices include consistent and correct use of barrier methods (i.e., condoms, dental dams, latex gloves for penetrative sex, oral sex, and digital penetration, respectively) each time one has intercourse, testing for STIs after each new partner, and at least once a year if in a committed, monogamous relationship with the same person, and engaging in conversations about STI status and sexual health history with partner(s). |
Hookups | Hookups are defined as casual sexual encounters that may occur between friends or strangers and may be planned or spontaneous. These interactions are casual, with the absence of commitment. They generally occur one to a few times and are primarily centered around engagement in sexual activity, which may include penetrative sex, oral sex, or other sexual activity. |
Social Variables | In this context, social variables refer to the diverse set of external factors that influence condom use decision-making behaviors. These include trust, comfortability, and stigma. |
Table 1. Defining key terms that are employed consistently throughout the manuscript.
Figure 1: Mixed Methods Model
Figure 1. A visual representation of the three phases of the explanatory mixed-methods study, demonstrating data collection and analysis strategies.
The Purpose: This study was undertaken to gain a better understanding of predominating knowledge, attitudes, and beliefs surrounding condom usage among college students, as well as to understand better the most pertinent psychosocial factors underlying sexual health decision-making processes within this population.
The Design: The study employed an explanatory sequential mixed-methods design, in which quantitative data was collected initially, after which initial findings were more thoroughly investigated through qualitative approaches (focus group discussions and one-on-one interviews). See Table 1 for an overview of the methodology phases.
Institutional Context: At the time of the study, the study site was comprised of roughly 22,000 students, the majority were men (51.04%), undergraduates (95.78%) with an average age of 20.316. Students predominately came from six states: California (78.3%), Washington (31.1%), Colorado (15.3%), Oregon (9.5%), Texas (5.7%) and Illinois (3.2%)16. Enrolled students identified in the following ways white (53.2%), Hispanic/Latino (19.39%), Asian American (13.44%), African American (0.72%), Hawaiian/Pacific Islander (0.23%), and Native American (0.12%)16.
After Institutional Review Board approval, a survey was emailed to a convenient sample of 2,000 undergraduate students at a large California master’s level university in the Winter term of 2021. The study was promoted through physical and digital fliers and shared in classrooms by instructors. If students consented to participate, the anonymous Qualtrics survey took between 20 and 30 minutes to complete, and students were compensated with a sexual health goodie bag filled with condoms and lubricant upon completion of the survey. The dataset was cleaned and coded for accuracy and completeness, and appropriate variables were calculated.
A 54-question Qualtrics survey was developed and disseminated from January 2021 through March 2021. The survey instrument consisted of several scales and items asking about perceptions and attitudes about sexual health practices. Relevant demographics were also included (see Table 1 for a summary). Sexual health questions included knowledge of barrier method usage (correct way to use an external condom), engagement in sexual activity (sexual activity status, number of partners within last six months, number of hookups, sex while inebriated), barrier method utilization1 (usage of internal condoms, external condoms, and dental dams), and sexual health conversations with partners (discussion of STI status, barrier methods, sexual history, drug use). Eighteen Likert-style questions were included to gauge student perceptions surrounding condoms, while five questions analyzed respondent perceptions concerning sexual health conversations within sexual relationships.
Participants: 639 participants completed the survey, while 544 were included in the analysis; 91 were removed due to failure to satisfy the inclusion criteria of being 18 or older and a current student. (see Table 1 for demographics for all participants). Most participants included in the analysis were cisgender women (68.9%) and heterosexual (81.8%).
Analysis: After running descriptive analyses (SPSS Version 29.0.0.0) for the major variables and covariates, the primary knowledge, attitudes, and beliefs reported by students were further explored. Univariate frequency analyses were performed on the dataset to determine the demographic distribution of participants, baseline engagement in sexual activity, and barrier method utilization rates. Likert scales included three primary categories to the associated statements: agree, neutral, and disagree. Outcomes for these bivariate analyses include 95% confidence intervals and p-values to support the strength of the associations.
At the end of the quantitative survey, respondents were asked if they would like to be considered for the study’s focus group phase. Eighty-six students indicated interest, and 64 students agreed to participate in one of 16 groups. Those who completed a focus group received a $10 Starbucks Gift Card upon completion.
Focus Groups: Each group occurred over Zoom during February and March 2021. The discussions were split into three discrete sections: a) conversation surrounding condom usage and perceptions surrounding their use, b) discussion of partner dynamics and contraceptive responsibility, and c) dialogue about campus-specific sexual and reproductive health services. Data was recorded using the Zoom audio recording feature and was automatically uploaded to a secure cloud file.
Analysis: Audio files were transcribed, first using Microsoft transcription software, followed by manual revision by members of the research team to ensure accurate recording of the data and its more nuanced components, such as laughter and nervousness. After transcription, data files were uploaded to NVIVO qualitative analysis software. Thematic analysis was employed to qualitatively analyze data by generating themes and codes, resulting in a finalized codebook. A grounded approach was used, which involved three rounds of coding where one research assistant conducted primary coding and two additional assistants conducted subsequent secondary and tertiary reviews to ensure inter-coder reliability.
At the end of the quantitative survey, respondents were asked if they would like to be considered for the study’s focus group phase. Eighty-six students indicated interest, and 64 students agreed to participate in one of 16 groups. Those who completed a focus group received a $10 Starbucks Gift Card upon completion.
Focus Groups: Each group occurred over Zoom during February and March 2021. The discussions were split into three discrete sections: a) conversation surrounding condom usage and perceptions surrounding their use, b) discussion of partner dynamics and contraceptive responsibility, and c) dialogue about campus-specific sexual and reproductive health services. Data was recorded using the Zoom audio recording feature and was automatically uploaded to a secure cloud file.
Analysis: Audio files were transcribed, first using Microsoft transcription software, followed by manual revision by members of the research team to ensure accurate recording of the data and its more nuanced components, such as laughter and nervousness. After transcription, data files were uploaded to NVIVO qualitative analysis software. Thematic analysis was employed to qualitatively analyze data by generating themes and codes, resulting in a finalized codebook. A grounded approach was used, which involved three rounds of coding where one research assistant conducted primary coding and two additional assistants conducted subsequent secondary and tertiary reviews to ensure inter-coder reliability.
Due to the homogeneity of the participant pool of phases 1 and 2, a third phase was instituted a year later using one-on-one interviews to a) build upon the results most reported in the focus groups and b) provide diverse responses from sexual minorities.
Recruitment took place from February 2022 until May 2023. Participants were recruited through convenience sampling, including digital flyers posted on social media and physical flyers posted around campus. Digital flyers were also emailed to professors, clubs, and teams on campus to encourage participation. Thirty-five students agreed to participate and were compensated with a goodie bag, which contained condoms, lube, and informational cards on STIs and condom usage.
Interviews: Thirty-five individuals completed a one-on-one interview in person or over Zoom. The interviewer asked questions in a pre-determined order; interviews were split into two sections: a) discussion surrounding personal sexual history and b) dialogue of engagement in STI status conversations and personal perceptions surrounding STI status stigma on campus. All interviews were audio recorded and uploaded to a secure database.
Analysis: Data analysis was identical to phase two, using a grounded approach and three levels of coding. Due to the homogeneity of the participant pool of phases 1 and 2, a third phase was instituted a year later using one-on-one interviews to a) build upon the results most reported in the focus groups and b) provide diverse responses from sexual minorities. Recruitment took place from February 2022 until May 2023. Participants were recruited through convenience sampling, including digital flyers posted on social media and physical flyers posted around campus. Digital flyers were also emailed to professors, clubs, and teams on campus to encourage participation. Thirty-five students agreed to participate and were compensated with a goodie bag, which contained condoms, lube, and informational cards on STIs and condom usage.
Interviews: Thirty-five individuals completed a one-on-one interview in person or over Zoom. The interviewer asked questions in a pre-determined order; interviews were split into two sections: a) discussion surrounding personal sexual history and b) dialogue of engagement in STI status conversations and personal perceptions surrounding STI status stigma on campus. All interviews were audio recorded and uploaded to a secure database.
Analysis: Data analysis was identical to phase two, using a grounded approach and three levels of coding.
Table 2: Demographic Distribution of Survey Respondents
Gender n (%) |
|
Female Male Non-Binary Other | 375 (68.9%) 161 (29.6%) 6 (1.1%) 2 (0.4%) |
Age n (%) | |
18 19 20 21 22+ | 113 (20.7%) 112 (20.6%) 137 (25.2%) 126 (23.2%) 56 (10.3%) |
Year at University n (%) |
|
1 2 3 4 5+ | 144 (26.5%) 129 (23.7%) 134 (24.6%) 120 (22.1%) 17 (3.1%) |
Sexual orientation n (%) |
|
Heterosexual Homosexual Bisexual Questioning Asexual Pansexual | 441 (81.8%) 18 (3.3%) 49 (9.0%) 18 (3.3%) 5 (0.9%) 9 (1.7%) |
Sexual Activity Status* n (%) |
|
Sexually Active Not Sexually Active | 401 (73.7%) 143 (26.3%) |
# of Partners Within Last 6-12 Months | |
None 1-5 6-10 11-15 16-20 21+ | 122 (21%) 382 (65.7%) 27 (4.6%) 4 (0.7%) 5 (0.9%) 3 (0.5%) |
Know Correct Way to Use a Condom: |
|
Yes No | 472 (86.8%) 72 (13.2%) |
Table 2. Demographic variable distributions (gender identity, age, sexual orientation, sexual activity status, # of recent partners, knowledge of the correct way to use condoms).
Survey respondents were primarily female (n=375; 68.9%) and heterosexual (n=441; 81.8%). Most students were sexually active, with 73.7% (n=401) reporting engagement in oral, anal, vaginal, or other sexual contact with a partner. Within the last 6-12 months, 65.7% (n=382) of respondents reported having between one and five sexual partners, while only 6.7% (n=39) reported engaging with more than five, and 21% (n=122) reported having engaged with zero partners. See Table 2 for a detailed description of the demographic variables.
Respondents reported varied engagement in behaviors aligned with sexual health best practices. While 37.7% of survey respondents reported having discussed disease status before engaging in sexual activity with a new partner within the past 6-12 months, 37.8% reported ever having discussed other sexual partners with a new partner during this same period. In addition, 32.5% reported having discussed how to prevent STIs with a partner at least once within the past 6-12 months, and 44.3% indicated that they had discussed sexual history with a new partner within this time frame. However, in this same period, 65.8% of participants reported that they had insisted on using a condom during sexual intercourse, either sometimes (38.5%) or often/a lot (27.3%). Furthermore, condom usage during oral sex was reportedly very low (33%), while dental dam usage was virtually non-existent, with only four (0.0074%) survey respondents indicating they had ever used one.
Condom perceptions and use patterns were more thoroughly explored in subsequent interviews and focus group discussions. Both men and women revealed that they perceived condoms to impart positive benefits related to STI and pregnancy prevention. Yet, they had a negative influence on specific facets of the sexual experience, including spontaneity, intimacy, and sensation.
Approximately 71% of students agreed that condoms were a reliable method of preventing pregnancy, while 85% believed that condoms were an excellent way to prevent STIs. In focus groups, STI prevention and pregnancy prevention were commonly cited as benefits of using condoms during sexual intercourse. The psychological benefit imparted by using condoms to prevent STI transmission and unintended pregnancy was discussed, with one woman having reported the following: “I think peace of mind is a huge advantage, knowing that if he finishes, he’s not going to finish inside of you. That you’re being protected from STDs.” In interviews, STI and pregnancy prevention were similarly consistently cited as benefits afforded by consistent condom usage, with one woman revealing: “I just felt a lot more secure and safer, and obviously, I was a lot less worried about pregnancy.”
Some survey respondents indicated that the use of condoms made intercourse seem less spontaneous; 8.2% of respondents agreed that condoms made intercourse seem too planned, while 14.2% agreed that condoms were an interruption of foreplay. Disruption of the passionate moment was discussed in some focus groups as a deterrent for condom use; one woman revealed: “It’s annoying to like, you know, stop in your foreplay [to] have to go grab a condom and put it on and then like try to get back into it, that is always annoying for me.” In addition to disrupting foreplay, some students reported that condoms negatively impacted the degree of intimacy within sexual relationships. For 10.4% of respondents, condoms made sex seem less romantic. Participants elaborated upon this notion in focus group discussions, with one woman saying, “I think there is like a certain emotional connection that comes along with not wearing one.” In one-on-one interviews, this sentiment was similarly shared.
Many students expressed that one of their primary reasons for electing to engage in condomless sex was that condoms negatively affect physical sensation during intercourse. While 34.4% reported that condoms were comfortable once on or in, 21% of students disagreed. In addition, 12.8% of respondents indicated that condoms were uncomfortable for both parties. Perceived impediments on physical sensation during sex were commonly cited as a primary reason to forego using a condom during penetrative sexual intercourse in focus group discussions. Both men and women reported experiencing diminished pleasure and sensation when using condoms. One woman stated that “one of the disadvantages is it personally doesn’t feel as good when the guy is wearing the condom,” with another woman indicating that “sometimes with a condom it’s like harder to stay wet.”
Regarding the idea that condoms diminish the degree of sensation for both men and women, one woman explained the following: “[it’s] not as pleasurable for me, as well as for them, like, I think it goes both ways in my experience.” One man reported that condoms diminished sensation because they “bunch and like [do] not feel as good.” Furthermore, in the context of oral sex, condoms were implicated in reducing the amount of time spent engaging in the act itself. One woman reported that, when performing oral sex on a male partner, she would “go up to like probably three times longer without a condom.”
Mirroring the remarkably low rate of utilization among survey respondents, focus group and interview participants also largely failed to address dental dam usage during their conversations about barrier methods. In only one focus group discussion were dental dams discussed, during which the participant made clear her qualms about their practicality:
I know with girls like I’ve tried dental ones with like a long-term partner just kind of for fun to like see if actually worked [and] it was like such a mess…
Elaborating, she then stated that dental dams were “not really functional [and] there’s not really a functional way to [use them].” In addition, the participant indicated that the education she received surrounding dental dams was considerably lacking, revealing the following:
No one ever like mentioned [using them] is tricky and it’s not like something you learned in Sex ED or like reinforced at all. So, like you like don’t even know where you get dental dams and stuff.
Despite the various factors deterring students from using condoms, focus group participants did indicate that concerns about decreased pleasure and sensation were at times outweighed by the protection afforded by using condoms. One woman said, “If anything, it[‘s] like. I feel better almost using it because it’s an added layer of comfort knowing, okay, here’s another concrete step I’m taking to protect myself.” In interviews, this was addressed further. One man explicitly discussed the bargaining process that occurred when he decided whether to use protection:
I’m perfectly happy still using condoms. It’s fine. I have had sex without a condom, and I mean, it’s not like the benefits of using one outweigh like any like benefits of not using one, I guess.
When considering the conflict presented between many students’ desires for pleasure and concerns for preventing STIs and unintended pregnancy, relationship status was reported to play an important mediating role in this bargaining process. In one-night stands, casual relationships, and committed relationships, condom use decision-making processes reportedly differed.
Many focus groups and interview participants explained that sexual history and STI status conversations occurred infrequently between new partners within casual sexual encounters. The awkward nature of these discussions was frequently cited as the primary deterrent for engagement in casual sexual encounters. In her focus group discussion, one woman revealed that to her,
Hookups tend to be one-night stands, and so…if you’re in the heat of the moment, you don’t want to like interrogate somebody about like their…history and stuff like that, so you’re more likely to use condoms.
In interviews, similar beliefs were commonly stated; one woman reported that “it’s harder to talk to short-term partners about using condoms, rather than long-term partners,” continuing to explain that she “found [herself] in that situation feeling really awkward.”
While STI status and sexual history conversations were seen as awkward and difficult to initiate, students commonly reported viewing condom usage as important and, in many instances, expected within hookups. Indeed, 84.3% of survey respondents agreed that partners should talk about condoms before having intercourse. In focus groups, several respondents expanded upon this thinking. One woman explained that this was because in-depth conversations about sexual history were an uncomfortable proposition in these casual encounters, stating, “In casual relationships… it’s less of like a discussion and more of just an expectation, um, given the nature of the relationship.” One-on-one interview respondents further shared their perspectives on this issue. Condom usage was reported as non-negotiable in hookups, revealed by one interviewee’s statement:
It’s a non-negotiable, none whatever for me, I think, for hookups. Just because it’s like I don’t know you very well, like, you’re telling me that you don’t have an STD, but how am I supposed to like… I’m like, I don’t know.
Rather than engaging in dialogue about STI status, sexual history, and other sexual partners during casual sexual encounters, condoms were seen as a more simplistic option for one woman, who reported the following: “I feel like in hookups, I would be more likely to just make sure we were using protection, and like I was protecting myself.”
Contrarily, many participants communicated that as their relationships progress and become increasingly committed, condom use becomes less frequent or, at times, ceases altogether. In these instances, however, conversations surrounding STI status and sexual history were more likely. For many participants, this enhanced comfortability when discussing STIs and sexual history with committed partners stemmed from a greater degree of trust present in those relationships as compared to hookups.
In focus group discussions, one woman said: “I think it’s easier for me to, like, talk with my partner about having sex when we are in a committed relationship for a longer period of time.”
For many participants, once conversations were held about sexual history and STI status, condom usage declined, often without confirmation of STI status through testing or the exchange of previous test results. One respondent indicated that after engaging in these conversations, “there was the mutual trust that like [they] were both being honest about [their] past history” and, therefore, a decreased likelihood they would use condoms. In feeling secure within a partnered dynamic and trustful of a partner’s statements, STI status may not be verified before ceasing use of condoms. In an interview, one woman explained that sex is not always contingent on condom use in committed relationships, whereas it certainly is in hookup scenarios. She stated:
Yeah, I would not have sex with someone else that I didn’t really know unless I had a condom, whereas if I was in a relationship with someone and didn’t have a condom, I could be convinced to have sex.
Figure 2: Students decision model regarding condom use
Each of the three phases within this study reveals the complex and interrelated variables associated with condom usage among university students. It appears that Sex Ed increased students KAB but wasn’t the only factor especially when discussing their attitudes and beliefs about condoms in practice (See Figure 2). These findings are corroborated by the American College Health Association’s National College Health Assessment III of Fall 2021, which revealed that only 5.1% reported using barrier methods while engaging in oral sex despite knowledge 5. Thus, chasms are evident between what the state teaches, what is retained by students, and what they successfully apply in practice. Although both middle and high school students receive mandated sexual health education in California. There is no mandate for Sex Ed at the collegiate level, thus, creating a situation in which many years may lapse between when students receive education and when they begin engaging in sexual activity.
Failure to use barrier methods may therefore stem not only from personal qualms about usage and issues related to accessibility, but also misconceptions that sexual activity sans penetration presents no risk for STI transmission. It is also plausible that many students are denied access to all-encompassing LGBTQ+ sexual and reproductive health education, which would address specific and unique issues experienced by individuals within the LGBTQ+ community. Although California mandates LGBTQ+ inclusive sex education, the degree of implementation and its implications have not yet been sufficiently researched. Regardless, the interest among students is present: surveys disseminated on the university campus revealed many students’ desires for enhanced education about queer sex and increased usage of inclusive language in the domain of sexual and reproductive health education.17In any case, the diverse set of factors that contribute to sexual health decision making among LGBTQ+ folks will not come to light if they are not adequately explored in the research process and highlighted within the literature.
While condom use as taught in Sex Ed was seen as effective for preventing STIs and pregnancy and is most often recognized as best practice, many students prefered not to use condoms in practice due to concerns about intimacy, spontaneity, and sensation. These are topics often excluded from Sex Ed programs as these programs focus primarily on protecting youth from contracting illness not fostering pleasurable experiences.18,19 Similarly, STI status and sexual history conversations are perceived as necessary, yet students report that they occur relatively infrequently due to fears of discomfort. A bargaining process, therefore, emerges in which students actively weigh the perceived benefits and disadvantages of condom usage and engagement in STI status conversations. While the benefits are primarily physical, the disadvantages pertain most often to the emotional and mental experience of sexual activity. The mental calculation weighing perceived benefits and disadvantages does not exist within a vacuum, however, and the nature of sexual relationships themselves appears to influence which approach is taken to protect sexual health if one is taken at all.
Individuals, namely women, revealed that condom usage within hookups was also more likely due to the lack of trust generally present within these dynamics, as well as less overt concern for physical sensation and partner preferences. While individuals in committed relationships reported a deep understanding of their partner, their partner’s history, and their partner’s preferences, casual sexual experiences were rarely characterized by preoccupation with appeasing a partner and instead by heightened concern for personal safety. When trust and intimacy had yet to be developed in sexual dynamics, individual interests in health were more likely to exert influence over decision-making. When paired with concerns that STI status/sexual history conversations would be responded to poorly or turn an exciting encounter awkward, condoms were relied on as a practical, easy, and less disruptive strategy, but only in cases of casual, short-term relationships.
Contrarily, students described long-term relationships as characterized by more trust and a vested interest in the outcomes for both oneself and one’s partner. In these instances, STI status and sexual history were more likely to be discussed during an in-depth conversation or set of conversations. Respondents said this was because of an enhanced degree of comfort within these dynamics and less fear of making a situation awkward by addressing those topics. In addition, however, deference to partner preferences also played an important role in the decision to refrain from using condoms. When participants felt a greater sense of commitment to their partner and believed that their partners did not enjoy sex as much when condoms were used, they may be more likely to proceed in sexual activity without them, even if STI status had not yet been confirmed and they preferred using condoms. This presents an interesting and dynamic relationship between relationship status and condom usage. While hookups may present an inherent risk for STI transmission if the status is never discussed before engaging in sexual activity, committed relationships may be associated with their unique risks associated with over-reliance on trust as a mechanism for protecting oneself from STI transmission and unintended pregnancy.
Due to the homogeneity of the study sample, insight into diverse experiences and perspectives, particularly pertaining to barrier method utilization, is lacking. Without this understanding, it is difficult to identify barriers to adoption of sexual health best practices among members of marginalized sexual groups. University culture may restrict sexually diverse students from feeling confident in sharing their sexual experiences and may consequently also lead them to avoid using campus health services over fears of judgment. In focus group discussions involving 64 people, only one individual reported experience with a dental dam. Whether this was because she truly was the only person in the sample to utilize this method, or the only one comfortable enough to share her experience, this suggests that campus culture may not adequately promote and/or support its students in adhering to sexual health best practices that are non-heteronormative.
Further, despite our efforts, the lived experiences of BIPOC on campus were largely unaddressed by this study. Similar to individuals within the LGBTQ+ community, broader campus culture may contribute to an environment where individuals with marginalized identities feel uncomfortable engaging in dialogue about sensitive topics, such as sexuality and sexual health, if they do not feel supported by the institution. Similar observations have been noted on the study site’s campus regarding experiences of LGBTQ+ folks and sexual assault (Hackman etal). Hackman, noted that LGBTQ+ folks experienced greater barriers to disclosure and were less likely to report instances of assault to the university.20 Furthermore, individuals reported fear of outing one’s identity as a factor which complicated disclosure efforts, paired with concerns about receiving negative reactions from the university campus community more generally.20 ‘Institutional betrayal’, referring to concerns about the university’s capacity to appropriately respond to reports issued specifically by LGBTQ+ individuals, was similarly revealed on campus; students reported that they believed the campus health center was ill-equipped to address issues specific to queer students, leading to the resultant underutilization of services by many of these individuals.20 In other words, the university has a history of advocating heteronormative practices and ignoring all others, this history and culture may have contributed to the lack of data collected in our study.
Yet, campus culture is not solely responsible, there is likely a combination of systemic shortcomings with the provision of equitable, comprehensive sex education. Although California boasts some of the most comprehensive sex education programming in the nation, and roughly 78% of enrolled students are from California, gaps in sexual health knowledge were evident. For students who did not attend high school in California, they all moved from states that stress an abstinence-based approach to sexual health education further complicating the matter 9,16
The study design is also associated with a unique set of inherent strengths. Understanding is more complete given the use of a mixed-methods framework, specifically the explanatory model. Survey data yields statistical output that is beneficial for both conceptualization and the establishment of a more concrete understanding of what college students perceive regarding condoms and STIs; qualitative data provides the context necessary to determine further why and how these perceptions are formulated, as well as how they interact with variables beyond the scope of the survey to influence behaviors. Survey questions were extracted and modified from existing, validated survey instruments; pre-determined measures of reliability and validity afford confidence in the survey’s capacity to measure student perceptions of established constructs correctly. A semi-structured interview yielded responses aligned with the pre-established purpose yet provided the flexibility to probe beyond the listed questions.
Using multiple coders for the qualitative analysis enabled more objective result extraction than would have been possible with a singular coder. In addition, the large survey sample size enhanced the power of the various analyses run on the dataset. The focus group participant sample size (n=68) and interview participant sample size (n=35) were solid; varied perspectives were included, and individuals represented multiple ages, years in school, majors, and degrees of sexual experience.
Decisions about condom use and engagement in STI status/sexual health conversations are the product of many interacting factors, including personal attitudes, relationship status, trust, and perceived social norms. Given this subject’s nuanced nature, it is difficult to identify solutions that address all these factors and how they are interrelated. Furthermore, university students occupy a unique space regarding their age, expectations, and experiences and may benefit from alternative approaches from those employed in younger or older populations. Because college is often an exploratory phase of young adults’ lives, defined by newfound freedom and the capacity to identify individual likes and dislikes, their sexual perceptions and behaviors are subject to change, sometimes dramatically. Paired with inadequate education that fails to discuss the risks associated with reckless sexual behavior (namely STI transmission), students may become involved in sexual encounters that yield unexpected consequences. These consequences, for example, untreated STIs, may result in physical harm; they may also result in emotional harm inflicted by social stigma or an impaired degree of trust within romantic relationships. Preventing STI transmission should, therefore, be considered a concern in university health promotion efforts. In achieving this goal, condom-enhanced adherence to sexual health best practices should be a priority. This will require a multi-pronged approach. Rather than relying solely on individual-level interventions, interpersonal and societal domains should be addressed, given the considerable role these dynamics play in framing condom usage and STI status more generally.
While much work has been done to understand and improve adherence to sexual health best practices among youth and emerging adults, additional work has yet to be done; it is the collective responsibility of public health workers, researchers, and students alike to proceed with this work, empower campus communities, and promote wellbeing in all facets, including and in particular, the realm of sexual and reproductive health.
The study design is also associated with a unique set of inherent strengths. Understanding is more complete given the use of a mixed-methods framework, specifically the explanatory model. Survey data yields statistical output that is beneficial for both conceptualization and the establishment of a more concrete understanding of what college students perceive regarding condoms and STIs; qualitative data provides the context necessary to determine further why and how these perceptions are formulated, as well as how they interact with variables beyond the scope of the survey to influence behaviors. Survey questions were extracted and modified from existing, validated survey instruments; pre-determined measures of reliability and validity afford confidence in the survey’s capacity to measure student perceptions of established constructs correctly. A semi-structured interview yielded responses aligned with the pre-established purpose yet provided the flexibility to probe beyond the listed questions.
Using multiple coders for the qualitative analysis enabled more objective result extraction than would have been possible with a singular coder. In addition, the large survey sample size enhanced the power of the various analyses run on the dataset. The focus group participant sample size (n=68) and interview participant sample size (n=35) were solid; varied perspectives were included, and individuals represented multiple ages, years in school, majors, and degrees of sexual experience.
Decisions about condom use and engagement in STI status/sexual health conversations are the product of many interacting factors, including personal attitudes, relationship status, trust, and perceived social norms. Given this subject’s nuanced nature, it is difficult to identify solutions that address all these factors and how they are interrelated. Furthermore, university students occupy a unique space regarding their age, expectations, and experiences and may benefit from alternative approaches from those employed in younger or older populations. Because college is often an exploratory phase of young adults’ lives, defined by newfound freedom and the capacity to identify individual likes and dislikes, their sexual perceptions and behaviors are subject to change, sometimes dramatically. Paired with inadequate education that fails to discuss the risks associated with reckless sexual behavior (namely STI transmission), students may become involved in sexual encounters that yield unexpected consequences. These consequences, for example, untreated STIs, may result in physical harm; they may also result in emotional harm inflicted by social stigma or an impaired degree of trust within romantic relationships. Preventing STI transmission should, therefore, be considered a concern in university health promotion efforts. In achieving this goal, condom-enhanced adherence to sexual health best practices should be a priority. This will require a multi-pronged approach. Rather than relying solely on individual-level interventions, interpersonal and societal domains should be addressed, given the considerable role these dynamics play in framing condom usage and STI status more generally.
While much work has been done to understand and improve adherence to sexual health best practices among youth and emerging adults, additional work has yet to be done; it is the collective responsibility of public health workers, researchers, and students alike to proceed with this work, empower campus communities, and promote wellbeing in all facets, including and in particular, the realm of sexual and reproductive health.
The study design presents inherent limitations. First, using a cross-sectional survey instrument limits the ability to identify behaviors, knowledge, attitudes, and beliefs beyond the singular time the survey was administered; consequently, cause-and-effect conclusions and temporal associations cannot be determined.
Furthermore, using convenience sampling from a singular university jeopardizes the generalizability of these findings to the broader population. In addition, most respondents were white, female, cisgender, and heterosexual, demonstrating limitations in terms of generalizing conclusions to individuals who do not fall within the scope of some or all these very narrow characteristics.
During the data collection portion of the interviews, five individuals were trained to conduct interviews with participants; although instructed to administer the same questions in the same order, unique interview styles and interactions may have contributed to discrepancies in participant responses to questions. Additionally, one-on-one face-to-face interviews that involve sensitive discussions around sex may result in the threat of social desirability bias, in which interviewees attempt to respond in ways that align with what they perceive to be what the interviewer finds appropriate or acceptable.
A major limitation was the relatively homogenous nature of the study sample, the researchers attempted to recruit members of the LGBTQ+ community, in addition to those who identified as men. Doing so would have garnered insight into more diverse perspectives than are currently represented in the existing literature. The difficulty associated with recruiting members of these populations may be associated with aspects of campus culture that not only make discussion of sexual activity difficult, but also repress individual expression of marginalized sexual and/or gender identities. Even though LGBTQ+ folks certainly attend the university, the lack of concerted institutional effort to support these populations may make it difficult for individuals to express these identities openly, therefore deterring them from participating in research that explores sensitive aspects of identity, such as sexual history.
The study design presents inherent limitations. First, using a cross-sectional survey instrument limits the ability to identify behaviors, knowledge, attitudes, and beliefs beyond the singular time the survey was administered; consequently, cause-and-effect conclusions and temporal associations cannot be determined.
Furthermore, using convenience sampling from a singular university jeopardizes the generalizability of these findings to the broader population. In addition, most respondents were white, female, cisgender, and heterosexual, demonstrating limitations in terms of generalizing conclusions to individuals who do not fall within the scope of some or all these very narrow characteristics.
During the data collection portion of the interviews, five individuals were trained to conduct interviews with participants; although instructed to administer the same questions in the same order, unique interview styles and interactions may have contributed to discrepancies in participant responses to questions. Additionally, one-on-one face-to-face interviews that involve sensitive discussions around sex may result in the threat of social desirability bias, in which interviewees attempt to respond in ways that align with what they perceive to be what the interviewer finds appropriate or acceptable.
A major limitation was the relatively homogenous nature of the study sample, the researchers attempted to recruit members of the LGBTQ+ community, in addition to those who identified as men. Doing so would have garnered insight into more diverse perspectives than are currently represented in the existing literature. The difficulty associated with recruiting members of these populations may be associated with aspects of campus culture that not only make discussion of sexual activity difficult, but also repress individual expression of marginalized sexual and/or gender identities. Even though LGBTQ+ folks certainly attend the university, the lack of concerted institutional effort to support these populations may make it difficult for individuals to express these identities openly, therefore deterring them from participating in research that explores sensitive aspects of identity, such as sexual history.
While Sex Ed has made significant strides over the years, our study has found that education isn’t enough to have an impact on sexual practices among young adults. Researchers18 have long argued that Sex Ed curricula should focus more on desire and not just prevention, yet we have not seen those changes. 19 Further, a lack of discussion of sexual practices among non-heteronormative relationships is still missing. This blatant disregard for improvement is significantly impacting students’ understanding, interpretation, and engagement in sexual encounters as noted in our study. Therefore, it is imperative that schools significantly impact students on the actual needs of their constituents and not what we believe students should know. Failure to do so continues to place the future generation at risk.
While Sex Ed has made significant strides over the years, our study has found that education isn’t enough to have an impact on sexual practices among young adults. Researchers18 have long argued that Sex Ed curricula should focus more on desire and not just prevention, yet we have not seen those changes. 19 Further, a lack of discussion of sexual practices among non-heteronormative relationships is still missing. This blatant disregard for improvement is significantly impacting students’ understanding, interpretation, and engagement in sexual encounters as noted in our study. Therefore, it is imperative that schools significantly impact students on the actual needs of their constituents and not what we believe students should know. Failure to do so continues to place the future generation at risk.
Gabriella K. Snow is a graduating senior at California Polytechnic State University in Public Health. Her research focuses on the sexual health practices of undergraduate college students.
Joni K. Roberts, DrPH CHES® is an early-stage investigator who sits at the intersection of being Black, an immigrant, and a Caribbean woman. The experiences of her intersectionality propelled her to gain training as a health educator to address the health inequities of marginalized communities by leveraging both research and practice to bring about change. Her research involves projects that examine how various social determinants affect health and identify structural solutions to address health inequities.
Her research on health disparities and women’s health lends itself to understanding the interplay between sexual health, sex as exercise, and obesity intervention goals and sets the path to transformational practices in weight management care on behavior and its impact on obesity outcomes. This is ultimately useful for addressing obesity inequities, particularly among minoritized women and marginalized populations, focusing on Black and Hispanic populations.
Anusha B. Sampath is a rising senior at California Polytechnic State University in Public Health. Her research focuses on the sexual health practices of undergraduate college students.
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