Chapter 5

Assessment of Sexual Behavior

Lori A.J. Scott-Sheldon, Seth C. Kalichman, and Michael P. Carey

1 Assessment of Sexual Behavior behavior, these markers are incomplete because

they convey little information about the fre-
quency, number of sexual partners, and the
Sexuality is essential to human life, experienced
co-occurrence of sexual behavior with other
through individual thoughts and desires, behav-
behaviors (e.g., alcohol or drug use). Because
iors, relationships, and cultures (Robinson et al,
no objective indicators are available and sexual
2002; WHO, 2006). A responsible, safe, and ful-
behavior cannot readily (or ethically) be mea-
filling sexual life experience requires a positive
sured through direct observation, researchers
approach to sexuality and an understanding of
often rely on self-reports of sexual behavior.
the social, economic, and political factors (e.g.,
Obtaining detailed and accurate self-reports of
gender inequality and poverty) that may lead
sexual behavior are necessary to fully evalu-
to sexual ill-health (WHO, 2006). Sexual well-
ate and further develop prevention programs,
being involves positive sexual expression, cou-
assess and treat sexual problems and trauma,
pled with the possibility of satisfying and safe
and inform public policy and health care (Bogart
sexual experiences. To promote sexual health,
et al, 2007; Catania et al, 1990; Cecil et al,
public policy experts, health educators, physi-
2005; Schroder et al, 2003b; Wincze and Carey,
cians, and clinicians, benefit from extensive
2001).
knowledge and understanding of sexual behavior
Measurement of sexual behavior poses
including sexual aspects of relationships (e.g.,
unique challenges to health researchers given
sexual arousal and functioning).
(a) concerns about privacy, cultural taboos, and
Since the 1980s, research in sexual health has
stigmatizing behaviors, (b) the nature of the
escalated due to the sexual revolution, advent
behavior (i.e., dyadic rather than individual),
of the HIV pandemic, and the pharmacologi-
and (c) motives for sexual behavior (Catania
cal treatment of sexual problems. Advances in
et al, 1990; Schroder et al, 2003a). Moreover,
data collection methods and the assessment of
assessment of complex sexual behavior likely
sexual behavior have furthered our understand-
necessitates multiple types of assessment mea-
ing of sexual behavior patterns and functioning.
sures and methodology. In this chapter we
Although biological markers (e.g., incidence of
address the importance of measuring sexual
sexually transmitted diseases or pregnancy) pro-
behaviors, measures and assessment methods,
vide useful information about an individual’s
and challenges to sexual behavior measure-
ment. We provide information about clinical
interviewing and written assessments. Although
L.A.J. Scott-Sheldon ()
Center for Health and Behavior, Syracuse University,
we focus primarily on retrospective methods
430 Huntington Hall, Syracuse, NY 13244-2340, USA (e.g., questionnaires), we also present con-
e-mail: lajss@syr.edu temporaneous assessment methods (e.g., daily

A. Steptoe (ed.), Handbook of Behavioral Medicine, DOI 10.1007/978-0-387-09488-5_5, 59

© Springer Science+Business Media, LLC 2010
60
diary). We conclude by offering suggestions for
improving sexual behavior assessments in future
research.
2 Reasons for Measuring Sexual
Behavior
Sexual expression is a fundamental aspect of
human relationships. While most research has
focused on the problems, risks, and dangers
of sex, there are a number of physiological
and psychological benefits of sexual expression
(Whipple, 2006). For example, frequent sexual
activity increases fertility (Cutler et al, 1985),
the probability of conception (Wilcox et al,
1995), and improves sexual functioning and sat-
isfaction (Laumann et al, 2006; Parish et al,
2007). Benefits aside, consequences related to
sexual activity (e.g., sexual coercion, HIV) may
threaten an individual’s ability to have satisfying
sexual experiences. Accurate, reliable, and valid
self-reports of sexual behavior provide essential
information to assist researchers and interven-
tionists in developing efficacious programs to
improve sexual health.
2.1 General Health Benefits
Studies examining the benefits of sexual activity
on physical health have suggested sexual activ-
ity improves physical and psychological health
in a number of domains. Sexual activity: (1)
Increases longevity: Men with increased orgas-
mic frequency (i.e., had sex at least two times
per week) had a 50% lower risk of mortality at
a 10-year follow-up (Davey Smith et al, 1997);
(2) Lowers the risk of chronic disease (e.g., heart
disease and cancer): Among men, frequency of
sex was associated with a lower risk of fatal
coronary heart disease (Ebrahim et al, 2002).
Furthermore, a national survey of US men found
high ejaculation frequency (i.e., ≥21 ejacula-
tions per month) was associated with decreased
risk of total prostate cancer (Leitzmann et al,
L.A.J. Scott-Sheldon et al.
2004); (3) Increases immunity: Increased levels
of immunoglobulin A, an essential antibody used
by the immune system to protect against viral
infections, were found in college students report-
ing having sex at least three times per week
(Charnetski and Brennan, 2004); (4) Associated
with reduced stress: Participants who had vagi-
nal sex in the last 2 weeks had lower blood
pressure and stress response to stress-inducing
tasks (Brody, 2006). Among medical residents,
stress negatively affected desire, sexual arousal ,
and sexual satisfaction (Sangi-Haghpeykar et al,
2009); and (5) Increases physical fitness: Sexual
intimacy was associated with physical fitness
level among Fifty Plus Fitness Association mem-
bers (Bortz and Wallace, 1999); frequency of
sexual activity was higher among men enrolled
in an intensive physical fitness program (White
et al, 1990).
2.2 Sexual Health Outcomes
Prior research suggests sexual health and well-
being are directly related to sexual behavior.
Sexual experiences (e.g., frequency of sex or
orgasm) have been associated with both positive
and negative aspects of sexual and reproductive
health.
2.2.1 Positive Sexual Health Outcomes
Among other benefits, fertility and conception
are two ways by which sexual activity may have
a positive effect on sexual health. Researchers
have shown frequent vaginal sex (i.e., at least
weekly) is associated with increased fertility
(Cutler et al, 1985); women who have sex daily
during their fertile period (i.e., five consecutive
days in a woman’s menstrual cycle culminat-
ing with a sixth day of ovulation) had a 37%
chance of conceiving compare to a 15% chance
among women having sex once during the same
period (Wilcox et al, 1995). Moreover, frequent
sexual activity, including sexual intercourse and
orgasm, are positively associated with sexual and
5 Assessment of Sexual Behavior
emotional satisfaction and relationship quality
among both men and women (Costa and Brody,
2007; Laumann et al, 2006).
2.2.2 Negative Sexual Health Outcomes
Despite the benefits, sexual health is under-
mined by intimate partner violence (e.g., sexual
coercion and rape) and by sexually transmitted
infections (STIs). Recent US estimates of sexual
coercion indicate that 1 in 59 adults have expe-
rienced unwanted sexual activity in the past year
with 1 in 15 adults forced to have sex at least
once in their lifetime (Basile et al, 2007). Among
a diverse sample of women (adolescents, patients
attending a STI clinic, homeless women, and
college students), sexual coercion was consis-
tently related to subsequent risky sexual behav-
ior (Biglan et al, 1995). Risky sexual behavior
(e.g., unprotected sex with infected partners)
threatens sexual health and puts people at risk
of contracting STIs. In the USA, an estimated
19 million new STIs are diagnosed each year,
including 56,000 new cases of HIV/AIDS, over
1 million cases of chlamydia, 355,991 cases of
gonorrhea, and 11,466 cases of syphilis (CDC,
2009; Hall et al, 2008).
3 Assessment of Sexual Behavior:
How to Gather the Data
Biological outcomes (e.g., STI or pregnancy)
can confirm sexual activity but provides limited
information regarding the prevalence, frequency,
or problems associated with sexual behavior.
Both positive and negative effects of sexual
expression vary depending on a number of
highly complex contextual factors. Information
regarding the prevalence of specific behaviors
is contingent upon accurate, reliable, and valid
self-reports of sexual behavior (Catania et al,
1990; Schroder et al, 2003b). Thus researchers
need to make two fundamental decisions when
they decide to assess sexual behavior: How to
gather the data? What data to collect?
61
3.1 Modes of Assessment
The first question a researcher needs to answer
involves the choice of data collection strategies
or modes of assessment. In most clinical settings,
it is customary to use a face-to-face interview,
whereas in most public health and community
settings, it is customary to use self-administered
methods.
3.1.1 Interviews
In clinical settings, interviews are often preferred
over self-administered assessments because
interviewees are seeking treatment, have imme-
diate questions and concerns that need to be
addressed, and expect, and are often eager, to
reveal sensitive information. In the clinical con-
text, interviews are conducted by professionals
(or trainees) who know how to establish rapport,
elicit information efficiently, establish a diagno-
sis, formulate etiologic hypotheses, and suggest
interventions. In the research context, by con-
trast, the goals of the interview are different but
interviewers also need to be empathic, highly
skilled, and efficient.
Several interviewer and process character-
istics tend to increase the quality of sexual
behavior data obtained. Assessment of behavior
should occur after a respondent and interviewer
have established rapport and the interviewer has
assured the respondent of confidentiality. Sexual
history interviews should always begin with
an appropriate introduction for the respondent.
During this time the reasons for asking ques-
tions about sexual and other socially sensitive
behaviors should be provided. For example, one
might explain the purpose of the research and
how it will benefit the interviewee or the larger
community. It can be helpful to contextualize
sexual behavior as an important health behavior,
just as one might discuss smoking, exercise, or
stress management strategies. If biological spec-
imens are to be collected, these can be likened
to taking blood pressure or collecting serum for
cholesterol levels (i.e., frame the assessment as
62
a health inquiry, not an exploration of morality).
Although sensitivity is essential, it is important
to ask questions directly, without apology or hes-
itancy (Kinsey et al, 2003). If the interviewer
appears embarrassed or unsure of the appropri-
ateness of the questions, interviewees will detect
this and may provide incomplete, ambiguous, or
socially desirable responses.
After the introductory remarks, the respon-
dent should be invited to ask any questions they
might have. It is often important to “listen with
the third ear” (Reik, 1983), that is, to use skills
and intuition to sense what a respondent may be
intending and to guide the interview accordingly.
Careful listening serves as the cornerstone of the
interview process. Some interviewees may freely
offer information about their sexual behavior
in response to direct questions. However, many
interviewees will be embarrassed and perhaps
confused by the range of questions and require
patience and explanation. It is not uncommon
for interviewees to have had distressing experi-
ences in the past, for example, to report that they
had tried previously to discuss sexual behav-
ior with a health-care professional, but were
met with avoidance, embarrassment, or appar-
ent lack of interest; as a result, they did not
pursue their concerns. So, interviewers need to
be open to respondents’ disclosures regarding
sexual behavior and to be aware of subtle non-
verbal cues that may discourage the disclosure
of sensitive information.
When assessing sexual behavior, we have
found it helpful to adopt assumptions in order
to gather the most accurate information with-
out wasting time and effort (Wincze and Carey,
2001). These assumptions reflect the preferred
direction of error. Thus, for example, one might
assume a low level of understanding on the part
of the respondent so that language is directed to
the respondent in a clear and concrete manner.
Other useful assumptions include: respondents
will (a) be embarrassed about and have diffi-
culty discussing sexual matters; (b) not under-
stand medical terminology; and (c) be misin-
formed about STIs. As the interviewer learns
about the interviewees, these assumptions are
adjusted.
L.A.J. Scott-Sheldon et al.
Depending upon the interviewee and context,
it may be useful to sequence the inquiry from the
least to most threatening questions. Thus, ques-
tions about courtship, dating, or relationships
might precede questions regarding sexual behav-
ior, hookups, and casual sex. Experience in the
assessment of sexual behavior also suggests that
it can be helpful to place the “burden of denial”
on the respondent (Kinsey et al, 2003). That is,
rather than ask “if” a respondent has engaged in
a particular sexual activity, the interviewer might
ask “how many times have you ...” engaged in it.
Use of this strategy will depend upon the nature
of the relationship that has been established with
the respondent and needs to be done sensitively.
Finally, it can often be helpful to follow
a semi-structured format, so that information
is gathered systematically, and no important
areas are neglected. This, too, requires sensitivity
because it is important to attend to intervie-
wee responses and tailor the questions accord-
ingly. Attention to the interview structure at the
expense of the interpersonal dynamic can under-
mine rapport, which will jeopardize both the
relationship and the quality of the data.
3.1.2 Self-Administered Questionnaires
The self-administered questionnaire (SAQ), an
alternative approach to the in-person interview,
is the most commonly used method of assess-
ing self-report behavior. SAQs offer a number
of advantages over in-person interviews such
as providing a more private, less intrusive, and
less threatening means of reporting sensitive
behaviors, allowing participants to skip poten-
tially embarrassing questions and administration
to large numbers of people thus reducing costs
(Catania et al, 1990; Durant and Carey, 2000;
Schroder et al, 2003b). Despite these advantages,
there are several disadvantages of SAQs. Self-
administration precludes additional clarification
of unclear questions or contingent questioning,
increasing the chance for missing responses or
inconsistent data reporting.
Several formats have been used for SAQs:
paper-and-pencil, postal mail, electronic mail,
5 Assessment of Sexual Behavior
or computer delivered. Studies examining dif-
ferences between SAQ formats demonstrate that
computer-administered self-interviews (CASI)
may increase the reporting of sexual behav-
iors. Over a 3-month period, participants recalled
their sexual behavior (e.g., frequency of unpro-
tected sex) more accurately using the CASI com-
pared with other types of self-report assessments
(McAuliffe et al, 2007). College students com-
pleting CASI report more alcohol consumption
and riskier sexual behaviors than those com-
pleting paper-based SAQ (Booth-Kewley et al,
2007). Finally, an increase in gynecological
symptoms was reported among STI patients
completing a CASI compared with those using
a paper-based SAQ (Robinson and West, 1992).
Higher self-reports of sensitive behavior among
CASI users may be due to an increased a sense
of privacy and credibility not provided by paper-
and-pencil SAQs (Schroder et al, 2003b).
3.1.3 Internet Surveys
With the increasing popularity and availability
of the Internet, researchers have begun using the
Internet as a means to assess sexual behavior.
Internet-based self-interviews (IBSI) share many
of the advantages provided by CASI methods
(e.g., increased sense of privacy, automated con-
tingent questioning, eliminates data entry errors)
but offer the potential to survey a wider range of
participants and difficult-to-reach populations,
allow completion at a time and place conve-
nient for the participant, and participants are less
vulnerable to coercion (Pequegnat et al, 2007;
Rhodes et al, 2003). Limitations of using an IBSI
include lack of Internet access among impover-
ished individuals (i.e., the digital divide), com-
puter literacy issues, and concerns about data
confidentiality or security (Baer et al, 2002;
Pequegnat et al, 2007). Few studies have exam-
ined IBSI compared with other forms of self-
assessments; to date, inconsistent results have
been found between web- versus paper-based
questionnaires (for a discussion, see Whittier
et al, 2005).
63
3.1.4 Self-Monitoring and Diary Methods
Diaries have become an increasingly popular
method of collecting health-related information
almost contemporaneously to the actual event,
thus avoiding recall bias and reducing mea-
surement error (Bolger et al, 2003; Graham
et al, 2005). Because diaries minimize memory
demands and promise more accurate results, they
are effective for eliciting highly detailed data on
sensitive sexual behaviors (Graham et al, 2005;
Schroder et al, 2003b). Compared with other
SAQ formats, diaries allow for the assessment
of events occurring in everyday situations as
well as the contexts in which those events occur,
assess behaviors closer in time to the actual
event, increase privacy, credibility, and confiden-
tiality, and require minimal reading and writing
skills (Bolger et al, 2003; Schroder et al, 2003b).
Moreover, diaries improve accuracy, have high
completion rates over time, and can easily be
used among participants with low literacy skills
(Bolger et al, 2003; Schroder et al, 2003b).
Although there are several advantages to
using daily diaries, researchers have begun to
question the extent to which participants fol-
low instructions regarding the date, time, and
place of the diary entries (Bolger et al, 2003;
Stone and Shiffman, 2002). The accuracy of
written diaries (e.g., booklets, packets of ques-
tionnaires, postcards) is uncertain due to the
lack of data monitoring (i.e., no time stamp),
possibility of backfilling, retrospection errors,
and incomplete data (Bolger et al, 2003; Green
et al, 2006). Recent technological advances have
enabled researchers to ascertain exactly when a
report is completed and/or to impose a restricted
time frame in which participants may complete
those reports. Computers and other electronic
devices (e.g., personal digital assistants, cell
phones) allow researchers to not only record the
date and time of each diary record but also pro-
vide the ability to signal participant responses at
fixed or random intervals and send participants
response reminders (Green et al, 2006). Similar
rates of compliance between paper-and-pencil
and electronic diaries have been found (Green
et al, 2006).
64
Limited research has compared the accuracy
of daily diaries with retrospective self-reports.
After completing a written daily diary of their
sexual activities, McAuliffe et al (2007) ran-
domly assigned participants to complete one
of the three types of retrospective measures
(audio-CASI, CASI, or paper-based SAQ); these
authors found substantially less sexual behavior
reported retrospectively compared to the daily
diaries. Although daily diaries yield more sexual
behavior – and purportedly more accurate behav-
iors – diaries may not be appropriate in all con-
texts (e.g., among homeless persons) (Patterson
and Strathdee, 2005). High demands on partici-
pants’ need for adherence, likelihood of dropout
rates, and increased likelihood of assessment
reactivity may prevent researchers from using
diaries in some public health contexts.
3.1.5 Virtual Reality
Virtual reality (VR), a computer-simulated envi-
ronment in which an individual has the ability
to control his/her actions, has recently been used
to measure sexual behavior. Since sexual behav-
ior cannot be readily or ethically measured via
direct observation, VR has the ability to greatly
enhance the ecological validity of sexual assess-
ment by assessing behavior in a context similar
to a real-life situation. Research examining the
use of VR to measure sexual behavior is lim-
ited but there is some evidence that past sexual
risk-taking behaviors predict VR risk taking and
VR risk taking predicts future risk behaviors 3
months later (Godoy, 2007). Other research has
shown VR to be an effective means of assessing
sexual preferences (Renaud et al, 2002).
4 Measures of Sexual Behavior:
What to Gather
Sexual behavior has been assessed using a wide
range of measures (Noar et al, 2006; Schroder
et al, 2003a; Sheeran and Abraham, 1994).
L.A.J. Scott-Sheldon et al.
Although there has been a lack of consensus
regarding the best method of assessing self-
reports of sexual behaviors, some researchers
have suggested focusing on using measures that
are most appropriate for the specific context or
goal of the research (e.g., risk screening, risk
assessment, and risk event) (Noar et al, 2006;
Patterson and Strathdee, 2005; Weinhardt et al,
1998b). For instance, if the goal is to assess
the overall frequency of condom use among
members of a specific community (e.g., among
homeless adolescents), the researcher might ask
global questions regarding the number of times
a participant had sex and their overall frequency
of condom use during a specific reporting period
(e.g., past 3 months). Alternatively, if the goal
is to assess the risk of HIV within the same
community, a researcher might ask participants
specific questions regarding the co-occurrence of
sexual risk behavior (e.g., sex without a condom,
alcohol and/or drug use prior to sex). Accurate
measurement of sexual risk behavior is impor-
tant not only in assessing the effectiveness of
prevention programs, but also for ascertaining
the prevalence of disease within a community,
as well as informing policy decisions about how
best to prevent STIs.
4.1 Question Types
4.1.1 Frequency of Sexual Behavior
Sexual behavior is most commonly assessed
using frequencies. Reviews of the sexual behav-
ior risk-reduction literature find 36–64% of stud-
ies measure the frequency of condom use (Noar
et al, 2006; Schroder et al, 2003a; Sheeran and
Abraham, 1994). Relative frequency measures of
sexual behavior are often assessed using a sin-
gle item such as “how often did you have sex
in the past x months?” with a range of response
options. Participants rate their frequency of sex
using a Likert-type response with endpoints
ranging from never to always; intermediate-scale
points (e.g., rarely, sometimes, almost always)
are inconsistently used.
5 Assessment of Sexual Behavior
Despite the popularity of relative frequency
measures, research has shown the ability to accu-
rately measure sexual behavior decreases as the
frequency of the targeted behavior increases
(Durant and Carey, 2000; Jaccard et al, 2002).
Moreover, the accuracy of these ordinal mea-
sures of sexual behavior (specifically condom
use) depends on shared definitions of labels both
among participants and between the participants
and researcher (Cecil et al, 2005). Research has
shown category labels to be subject to individ-
ual interpretation. For example, nearly one-third
of college students rate using condoms once or
twice out of 20 events as “never” using con-
doms (Cecil and Zimet, 1998). Although most
researchers would refer to “always using con-
doms” as 100% use, more than one-third of
college students labeled using condoms 18 or
19 times out of 20 events as “always” using a
condom. Cecil et al (2005) found similar results
showing that “never” using condoms does not
mean 0% of condom use, but could mean infre-
quent condom use (e.g., 1 time out of 20), and
“always” using condoms does not mean 100%
condom use (i.e., 70% indicated always using
condoms when condoms were used 19 out of
20 times).
4.1.2 Consistency of Sexual Behavior
Another question type focuses on the consis-
tency of sexual behavior. Consistency of sexual
behavior may be obtained directly or indirectly.
For example, a direct measure of condom use
would ask participants to respond to the ques-
tion “over the past (time period), what propor-
tion of the time did you use condoms when
you had sex?” using an 11-point scale ranging
from 0 to 100%. An indirect measure of consis-
tent sexual behavior is calculated based on two
separate questions representing the total num-
ber of sexual events in a specific time period
and the total number of events in which, for
example, a condom was used in that same time
period; the proportion of time a participant used
a condom is obtained by dividing the number of
condom-protected events by the total number of
65
sexual events. Percentage ratings or proportions
are problematic as both fail to capture variance
in abstinence and/or reduced frequency rates.
For instance, a value of zero using the indirect
method may indicate a person abstained from
sex or always used a condom for numerous sex-
ual events, thus underestimating the risk of STI
transmission among those with high frequencies
of sexual events (Graham et al, 2005).
4.1.3 Dichotomies
Similar to ordinal measures of sexual behav-
ior, dichotomies categorize individuals as low
or high on a specified outcome measure.
Participants are typically asked to respond yes or
no regarding a particular sexual event (e.g., “Did
you use a condom the last time you had sex?”)
but may also be asked about more general occur-
rences (e.g., “Have you ever used a condom?”).
Dichotomies are useful when researchers are
interested in examining differences between two
groups (e.g., participants who have and have
not had sex), but the use of dichotomies may
be problematic because responses do not con-
vey typical sexual activity patterns (i.e., may
be restricted to a particular event). Dichotomies
are descriptive and therefore reduce information
available for analysis and interpretation (Graham
et al, 2005).
4.1.4 Count Measures of Sexual Behavior
Instead of using relative measures (e.g., fre-
quency of sex using assigned labels, percentage
ratings, dichotomies), Schroder et al (2003a)
suggest using absolute measures (i.e., count
data) to assess sexual behavior because counts
provide more specific data about a person’s risk
level. Count measures ask participants to provide
the exact number of times they engaged in sex-
ual behavior during a specific time period. For
example, unprotected sex is assessed by asking
participants the number of times they had vagi-
nal sex in a specified period and the number of
times they used a condom. An absolute measure
66
of the number of unprotected sex events would
be computed by subtracting the number of pro-
tected sex events from the number of times the
participant had sex (not a ratio of unprotected
sexual behavior). Absolute measures of sexual
behavior can also be obtained using event-level
data (e.g., daily diaries, timeline follow-back).
For event-level data, researchers solicit informa-
tion regarding condom use or other behaviors
(e.g., drug and/or alcohol use) concurrent with
a single or multiple sexual event(s); the number
of sexual events are then summed.
Choice of sexual behavior measure depends
upon the nature of the research question;
however, count measures offer advantages not
afforded by frequency or consistency data.
Absolute measures of sexual behavior (1) reflect
only the number of risk occurrences thus provid-
ing precise information regarding sexual behav-
iors and (2) are more versatile (i.e., can be
converted to proportions) (Graham et al, 2005;
Schroder et al, 2003a). Although count data yield
both absolute and relative information useful
in quantifying sexual behavior, count data have
two primary disadvantages: (1) data collection is
more time consuming and expensive especially
if collecting event-level data (e.g., daily diaries)
and (2) data analysis is more difficult because the
data often deviate from the normal distribution
(Schroder et al, 2003a).
4.1.5 Composite Measures of Sexual
Behavior
Some researchers have suggested using com-
posite measures (e.g., frequency and proportion
items), safer sex algorithms, and risk indices to
assess sexual behavior (Burkholder and Harlow,
1996; Miner et al, 2002a; Sheeran and Abraham,
1994). Sheeran and Abraham (Abraham and
Sheeran, 1994; Sheeran and Abraham, 1994)
measured condom use using a composite of fre-
quency (never to always), temporal frequency
(never in the last year to most weeks in the last
year), and proportion of condom use (number
of times participants used a condom divided by
the total number of sex events). Miner et al
L.A.J. Scott-Sheldon et al.
(2002b) developed a Safer Sex Algorithm con-
sisting of decision rules for defining safe and
unsafe sex as well as relationship variables and
partner characteristics (i.e., length of relation-
ship, partner type, HIV status, alcohol or drug
use, and monogamy of individual and partner).
Moderate correlations were found between mea-
sures taken 3 months apart (r = 0.55 for the
number of unsafe sexual events and r = 0.52 for
the number of unprotected anal and/or vaginal
sex events).
4.2 Standardized (Published)
Measures
Questionnaires used to assess sexual behavior
and functioning can be accessed through profes-
sional journals or books devoted to self-report
questionnaires. Although there are a limited
number of reliable and valid scales of gen-
eral sexual behavior, scales targeting specific
populations are available. These scales include
the Coping and Change Sexual Behavior and
Behavior Change Questionnaire (Ostrow et al,
1995) for gay and bisexual men, the HIV Risk-
Taking Behavior Scale (Darke et al, 1991) or
the Risk Behavior Assessment (Needle et al,
1995) for drug users, and the Adolescent Clinical
Sexual Behavior Inventory (Friedrich et al, 2004)
targeting adolescents. An excellent resource con-
taining measures of sexuality as well as the
psychometric properties of each measure is the
Handbook of Sexuality-Related Measures (Davis
et al, 1998). As with any research, scales should
be selected based on the psychometric properties
(i.e., reliability and validity), research relevance
(i.e., measure fits the intended purpose), and
practicality (e.g., length of the questionnaire,
culturally appropriate) (Weinhardt et al, 1998b).
5 Challenges to Sexual Assessment
Numerous factors can influence the accuracy
of self-reports of sexual behavior. Cognitive,
5 Assessment of Sexual Behavior
memory, and literacy challenges, social desir-
ability, substance use, and level of assessment
have all been associated with reporting bias
(Catania et al, 1990; Graham et al, 2005;
Schroder et al, 2003b; Weinhardt et al, 1998b).
Recommendations for improving the assess-
ment of sexual behavior include use terms that
are clear and familiar to participants, pilot test
with the target sample to facilitate measurement
development, assess literacy skills, and evalu-
ate whether an audio-administered version of the
assessment is required (Weinhardt et al, 1998b).
Understanding known problems associated with
measuring sexual behavior will help increase the
reliability and validity of self-reports.
5.1 Cognition and Memory
Challenges
5.1.1 Length of Recall Period
Participants are typically asked questions about
their behavior over a specific time period.
To increase the accuracy of retrospective self-
reports, researchers have recommended recall
periods of 3 months or less. Research has shown
sexual behaviors can be reliably assessed by
self-report measures for intervals as long as 3
months but reliability decreases at longer inter-
vals (Kauth et al, 1991). In a study comparing
daily diaries to a SAQ 1, 2, and 3 months after
diary completion, Graham et al (2003) found
recall of condom use was stable across the 3-
month period but participants reporting more
frequent condom use had more errors. Jaccard
et al (2002) compared weekly mailed self-
report questionnaires with retrospective reports
at 1, 3, 6, and 12 months finding no differ-
ence between type of method at the 3- and 12-
month assessments, but not at the 1- or 6-month
assessments. They concluded that retrospective
SAQs accurately represent behavior for at least
3 months. Little evidence suggests that recall
periods longer than 3 months provide accurate
information (Schroder et al, 2003a; Sheeran and
Abraham, 1994).
67
Reviews of the sexual risk behavior literature
show that 28–49% of studies ask participants
to recall condom use over a 3–6-month time
frame whereas 15–18% provide no specific time
frame (Noar et al, 2006; Sheeran and Abraham,
1994). Noar et al (2006) suggest that specific
and brief recall periods should yield optimal
responses but additional research is necessary
to evaluate the reliability of various recall peri-
ods. Moreover, research shows high-frequency
behaviors may be more difficult to recall over
longer periods of time, whereas rarer behaviors
may not occur over short recall periods. Since
low-frequency behaviors are more salient, par-
ticipants may be inclined to believe an event
occurred more recently (i.e., telescoping) poten-
tially leading participants to exaggerate sexual
behaviors. Patterson and Strathdee (2005) rec-
ommended using absolute frequency counts for
rare behaviors and relative frequency measures
(e.g., proportion of time condom was used) for
more frequent behaviors.
To enhance recall of retrospective self-
reports, Weinhardt et al (1998) suggest using
three strategies: (1) Provide anchor dates for
recall periods, (2) Encourage participant to use
calendars to aid the recall of memorable events,
and (3) Prompt participant recall of extensive
periods of sexual behavior (e.g., abstinence, con-
sistent sexual activities). All three of the sug-
gested strategies may be accomplished using
the timeline follow-back (TFLB; Sobell and
Sobell, 1996) procedure. The TLFB uses calen-
dars marked with landmark events, personally
meaningful dates, and other memory aides to
facilitate accurate recall. Because of the inter-
active format used for the TLFB, memory is
aided by the recalling of one event in reference to
another event. Using the TLFB, behavioral pat-
terns are recorded in greater detail and over mul-
tiple time points. Sexual risk information yielded
by the TLFB include number of sexual partners,
frequency of sexual events (vaginal, anal, oral),
frequency of unprotected sexual events (vagi-
nal, anal, oral), alcohol and/or drug use prior
to sex, number of occasions and quantity of
alcohol and/or drug use prior to sex, and STI
history. Research has confirmed the stability of
the 3-month retrospective self-reports using the
68
TLFB procedure (Carey et al, 2001; Weinhardt
et al, 1998a).
5.1.2 Partner and Sexual Act Specificity
Failure to specify and/or define type of partner or
sexual act may result in inaccurate self-reports of
sexual behavior. Researchers recommend using
measures that are specific to sexual partners and
specific to sexual acts, rather than general mea-
sures (Fishbein and Pequegnat, 2000; Schroder
et al, 2003b; Sheeran and Abraham, 1994). In
Sheeran and Abraham’s (1994) review of con-
dom use measures, they found 79% of the mea-
sures did not specify type of partner and most
(65%) did not specify the type of sexual act
being assessed (i.e., vaginal, anal, or oral sex).
An updated review of the literature examining
56 studies found 57% of measures did not spec-
ify partner type, 16% specified primary versus
non-primary partners, and 16% were tailored
to partner type (Noar et al, 2006); most stud-
ies reported the type of sexual activity (67%).
Because different levels of risk are associated
with various sexual practices, it is important
for researchers to specify both sexual partner
and sexual act to increase the accuracy of the
data.
Research examining aggregate (i.e., summed
across all sexual partners) versus partner-
specific (i.e., questions specific for each sexual
partner) formats has found partner-specific
SAQs produce more accurate self-reports
of sexual behavior than do aggregate ques-
tion formats (McAuliffe et al, 2007). Thus,
partner specificity (i.e., name of actual partner
rather than primary versus non-primary labels)
“may help cue the recall of sexual activities
by providing both a context and a focus for
past experiences and events” and improve
the accuracy of self-reported sexual behavior
(McAuliffe et al, 2007). Moreover, the use
of multiple terms, without clear definitions,
for partners (primary, steady, exclusive,
regular versus secondary, casual, nonexclu-
sive) makes comparisons between studies
challenging.
L.A.J. Scott-Sheldon et al.
5.2 Literacy Skills
Accuracy of self-reports hinges on the ability
of people to read and comprehend questions.
According to the 2003 National Assessment of
Adult Literacy (Kutner et al, 2006, 2007), more
than 30 million American adults had reading
skills below basic level and 14% had below basic
levels of health literacy (i.e., ability to read and
understand health information). Moreover, illit-
eracy is more likely to occur in high-risk popula-
tions. Among adults living with HIV, Kalichman
et al (2000) found 18% of participants had below
basic levels of health literacy. Among people at
risk for STIs, Al-Tayyib et al (2002) found a sub-
stantial proportion of adults scored at or below
an eighth grade level (28%) including 12% scor-
ing lower than a sixth grade level. Participants
with lower literacy scores provided more logi-
cally inconsistent answers and had higher skip
pattern errors when answering questions from
a SAQ.
SAQs are particularly vulnerable to inaccu-
rate estimates of sexual behavior caused by an
inability to fully understand and comprehend
the questions asked, failure to respond, and
difficulty following complex question patterns.
Both interviewer and audio-assisted methods
(e.g., audio-CASI) allow individuals with low
literacy to provide more meaningful responses.
Interviewer-assisted questionnaires provide par-
ticipants with additional instruction regarding
unclear terms or skip patterns but reduce pri-
vacy and anonymity. Audio-CASI provides par-
ticipants with an increased sense of anonymity
whereby the participant listens to questions
through headphones while keying in answers
on a computer unassisted. Moreover, audio-
CASI reduces cognitive demands and improves
comprehension (Schroder et al, 2003b). Studies
examining the effects of audio-CASI find fewer
missing responses and “don’t know” answers
compared with participants assigned to com-
plete written SAQs (Boekeloo et al, 1994;
Turner et al, 1998). Thus, the various modes of
assessment have different advantages and dis-
advantages, so selection of an optimal method
5 Assessment of Sexual Behavior
depends upon the research question, sample, and
context.
5.3 Social Desirability and
Presentation Concerns
Because sexual behavior is typically a pri-
vate activity, people may respond to sexual-
related questions in ways designed to avoid
embarrassment, reduce threat, or conform to
social norms. Social desirability and impres-
sion management biases have been associated
with refusal or failure to disclose sexual infor-
mation and inaccurate reporting (Catania et al,
1990; Gibson et al, 1999; Schroder et al, 2003b).
Whereas socially desirable behaviors tend to
be over-reported, socially undesirable behaviors
are more likely to be under-reported, because
of this tendency, assessment strategies yield-
ing higher self-reports of sexual risk behav-
iors are often assumed to be more accurate
(Lau et al, 2000; Tourangeau and Smith, 1996).
Accuracy is dependent upon participants’ per-
ceptions of anonymity, privacy, and credibil-
ity. The extent to which self-reports are biased
by self-presentation concerns may impact our
knowledge of the prevalence of sexual risk
behavior and undermine efforts to measure the
effects of prevention programs.
5.4 Cultural, Developmental, Sexual
Orientation and Gender
Matching
Assessments of sexual behavior should be appro-
priately matched to participants’ culture, devel-
opmental status, and gender. Focus groups and
pilot testing are needed to assist with the devel-
opment and refinement of appropriate measures
(Weinhardt et al, 1998b). Particular attention
to language, specifically meanings and contexts
of words, is critical in assessing sexual behav-
ior among different ethnic groups. Conducting
69
separate focus groups with men and women
may reveal cultural and contextual issues rele-
vant for sexual behavior assessment (Carey et al,
1997). For example, the expression of machismo
among Hispanic men is extremely important not
only from a social standpoint but also for an
individual’s self-esteem; measures that fail to
recognize cultural differences among Hispanic
men and women may elicit inaccurate self-
reports. Furthermore, emphasizing the personal
and community benefits of the research is likely
to increase participation and elicit more accurate
reporting.
5.5 Individual Versus Dyadic
Assessments
Even though sexual behavior occurs between
people, it is typically measured at the individual
rather than dyadic level. Since sexual behav-
ior is intrinsically linked with other people, the
strength of these linkages may be one of the most
important research questions yet to be examined.
Assessment of dyadic behaviors requires more
resources and coordinated efforts to retain both
partners. Because standard statistical methods
assume independence, more complicated data
analysis addressing the non-independence data
issue is needed. Kenny et al (2006) provide
an excellent resource on a variety of research
designs to analyze dyadic data (e.g., structural
equation modeling, longitudinal analyses).
6 Conclusions
Modalities and content of sexual behavior
assessment best suited for a specific study will
vary along several dimensions. The relative
advantages of various methods require a care-
ful weighing of administration approach (i.e.,
interviewer-, self-, or computer administered) as
well as assessment targets (i.e., what behaviors
to assess over what time frames using which
70
response formats). Assessment decisions are
decided optimally in the context of study popu-
lations and data collection context. The sensitive
and private nature of sexual behavior places
unique constraints on such assessments, includ-
ing the absence of objective verifiable measures.
New and improving technologies are increas-
ing the assessment alternatives, suggesting that,
in the future, our choices will be enhanced. It
is likely that the expanded armamentarium of
options will allow investigators to tailor their
choices to the situation, resulting in improved
reliability and validity of the data collected, and
improved understanding of sexual behavior and
its antecedents and consequences.
Acknowledgments Funding: The preparation of this
chapter was supported by National Institute of Mental
Health grants to Seth C. Kalichman (R01-MH71164) and
Michael P. Carey (R01-MH068171).
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