The Sexual Acceptability of Contraception: Reviewing the Literature and Building a New Concept.

In this part, we review the literature on individual contraceptive methods, drawing whenever possible from the model of sexual acceptability. We identified a total of 103 peer-reviewed journal articles that assessed sexual outcomes associated with contraceptive use. Table 1 summarizes the positive and negative sexual aspects of contraception that have been documented by peer-reviewed research in the past decade. For a more detailed table with studies’ sample characteristics, measures, methods, and relevant findings as they pertain to our model of sexual acceptability, readers may refer to the online appendix. Given both space restrictions and the review’s goals, we do not provide a methodological critique of each study. Instead, we draw on cumulative findings to inform our understanding of sexual acceptability and identify areas where more attention is needed to enhance this model. Here, we briefly present tallies from the articles contained in Table 1 . The 103 references included seven reviews, for a total denominator of 96 empirical studies. Of these latter 96 studies, 61% ( n  = 59) were cross-sectional, 29% (28) were prospective, 18% (17) were randomized controlled trials, 28% (27) were qualitative, and 44% (42) had sample sizes of more than 200 participants. The text that follows summarizes the main findings from the methods in Table 1 and suggests implications for the larger sexual acceptability of each method. As we note in our concluding section, the large majority of the studies reviewed in Part 2 focused primarily on sexual functioning and not on other aspects of the model. Very few approached sexual acceptability using the kind of broader ecological approach we proposed in Part 1. However, even in the absence of findings from the literature, we do comment on other aspects of the model that are likely to play a role with particular methods—for example, partner and couple dynamics, sexual aspects of side effects such as bleeding and cramping, and women’s perceptions. TABLE 1. SUMMARY OF STUDIES REVIEWED IN PART 2: Positive and negative sexual aspects of contraception documented by peer-reviewed research, 2005-2015 Methods Citations Select Positive Sexual Impacts Select Negative Sexual Impacts Comments and Commonalities Male Condom 1 (n=54 identified in the review) Reviewed here: Male condom research that addresses women’s experiences (n=21) (Bolton et al., 2010 ) (Braun, 2013 ) (Crosby et al., 2008 ) (Crosby et al., 2013 ) (Crosby et al., 2010 ) (Deardorff, Tschann, et al., 2013 ) (Fennell, 2014 ) (Free et al., 2007 ) (Garcia et al., 2006 ) (Gebhardt et al., 2006 ) (Higgins et al., 2009 ) (Higgins & Wang, 2015a ) (Kaneko, 2007 ) (Randolph et al., 2007 ) (Sanders et al., 2010 ) (Sunmola, 2005 ) (Træen & Gravningen, 2011 ) (Tung et al., 2012 ) (Versteeg & Murray, 2008 ) (Wang, 2013 ) (Widdice et al., 2006 ) Among women, condom use was positively associated with feeling comfortable communicating about sex and about sex in general. Young women expressing higher levels of sexual self-acceptance were less likely to report a dislike of condoms as a strategy to avoid using them (Deardorff, Tschann, et al., 2013 ). Female sex workers described skills in applying condoms in sexually arousing ways in order to increase client acceptance of condom use (Free et al., 2007 ). Men and women perceived condoms as hygienic and as providing sense of security and protection (Garcia et al., 2006 ). Among women who always used condoms, 28% agreed that condoms reduce sexual sensation; this figure was significantly larger (53%) among women who did not always use condoms (Kaneko, 2007 ). In a nationally representative survey of young adults in Norway, of the 20% who used a condom at most recent sex, 15% of men and 9% of women reported they did so to feel more clean; 18% of men and 23% of women reported a condom was used to avoid mess; 2% of both men and women stated they used a condom for fun; 9% of men and 7% of women used a condom to make sex last longer; and 2% of men and 7% of women reported using a condom to facilitate more penetration (Træen & Gravningen, 2011 ). Many participants in a qualitative study invoked a narrative of how “natural” or “proper” heterosex does not involve condoms and use of a common metaphor of “condom-as-killer” highlighted the tension between condoms and sexual pleasure (Braun, 2013 ). Identifying the most common condom “turn-offs”, Crosby et al. ( 2008 ) found: 75% of men and 40% of women reported that decreased sexual sensation was a major turn-off in using the male condom. The disruption of sex with putting on the condom was a turn-off listed by 43% of men and 30% of women. Approximately one-third of both men and women declared that the smell of condoms was a turn-off. More than half of women and over one-third of men reported that condoms decreased their partners’ sensations during sex. 20% (Crosby et al., 2008 ) to 34% (Higgins et al., 2009 ) of both men and women reported loss of arousal and orgasm difficulties with male condom use. Almost one-third of both women and men reported problems with condom “feel” during sex (Crosby et al., 2013 ). For both young women and men, pleasure-related attitudes were more strongly associated with lack of condom use at last PVI than all other socio-demographic or sexual history variables (Higgins & Wang, 2015a ). Research overwhelmingly associated condoms (versus other methods) with reduced physical pleasure (Fennell, 2014 ). Though popular discourses about “proper” sex may mean that many young adults find condoms sexually unacceptable, one author argued that common anti-condom sentiments are socially constructed and thus possible to change (Braun, 2013 ). Pleasure-related reasons and feelings of increased intimacy with skin-to-skin contact influence condom discontinuation and non-use among women (Bolton et al., 2010 ). Studies including both women and men suggest a number of commonalities by gender. For example, the most common turn-offs relate to loss of pleasure for both men and women (Crosby et al., 2008 ) . Both women and men report condoms can reduce sexual spontaneity. Associations between women’s and men’s pleasure attitudes and their use/non-use patterns are similar if not identical (Higgins & Wang, 2015a ). However, some findings illustrate gender-specific findings. Women were more likely than men to report that their partner experienced sexual discomfort with condom use. Many women also report an inability to negotiate condoms with partners due to reduced pleasure for their male partners, perceived and/or actualized side effects, and trust (Versteeg & Murray, 2008 ). Findings suggest that more emotional, affective motivations for sex can undermine condom use. More research is needed on how to normalize condom use within sexual contexts of expressing love and pleasing one’s partner (Gebhardt et al., 2006 ). Oral Contraception (n=24 here, n=38 in the table; please see “multiple methods” section below for more information) (Avellanet et al., 2009 ) (Battaglia et al., 2012 ) (Bishop et al., 2009 ) (Caruso et al., 2011 ) (Caruso et al., 2013 ) (Caruso et al., 2009 ) (Davis et al., 2013 ) (Di Carlo, Gargano, et al., 2014 ) (Gardella et al., 2011 ) (Goldstein et al., 2010 ) (Goretzlehner et al., 2011) (Guzick et al., 2011 ) (Kucuk et al., 2012) (Lee et al., 2011 ) (Machado et al., 2012 ) (Nappi et al., 2014 ) (Pastor et al., 2013 ) (Shahnazi et al., 2015 ) (Skrzypulec & Drosdzol, 2008b ) (Strufaldi et al., 2010 ) (Wallwiener, Wallwiener, Seeger, Muck, et al., 2010) (Warnock et al., 2006 ) (Wonglikhitpanya & Taneepanichskul, 2006 ) (Zimmerman et al., 2015 ) Pooled results from a systematic review show that 85% of women using combined OCs reported an increase or no change in libido (Pastor et al., 2013 ). In a study of women using Klaira®, a combined multiphasic (4 phases) combined OC pill containing estradiol valerate (E2V)/dienogest (DNG), found significant improvements in Quality of Life (QoL), sexual enjoyment, desire, and pain after 3 and 6 cycles of OC use while adhering to a reduced hormone-free interval (26/2 regimen). This regimen was also associated with improvements in QoL, sexual function, PMS symptoms, and reduced bleeding (Caruso et al., 2011 ). Another study of Klaira® showed that after 6 months of use, younger women reported significant improvements in sexual pain and older women reported significant improvement in desire and overall sexual function compared to their baseline measures (Di Carlo, Gargano, et al., 2014 ). A study on continuous cycling regimens (OCs unspecified) reported positive sexual function (mainly improvement in orgasm, satisfaction, and pain) and QoL outcomes related to body pain, general health, and social function after 5 months (2 cycles of 72/4 regimen). Reports of desire, arousal, and lubrication did not change (Caruso et al., 2013 ). In a study of women diagnosed with PCOS, after 6-9 cycles of Belara® (combined OC containing 30 ug EE/2 mg chlormadinone acetate (CMA) used for 9 cycles), 81% reported significant increases in frequency of partnered sex, orgasm during intercourse, and a significant decrease in masturbation frequency (Caruso et al., 2009 ). A separate study of Belara® using an extended cycle regimen showed the pill was associated with improvement in: skin problems, symptoms of dysmenorrhea, headache, breast tenderness, withdrawal bleeding, bleeding duration, and libido (Goretzlehner et al., 2011). Results from a randomized, prospective study of women using either a combined OC containing 30 mcg EE/150 mcg LNG or a combined OC containing 20 mcg EE/100 mcg LNG, found significant increases in sexual desire, but this increase was statistically significant only for women using EE20/LNG100 (compared to EE30/LNG150) (Strufaldi et al., 2010 ). Yasmin® use was related to increased pain during sex, decreased libido, issues with spontaneous arousal, and reductions in frequency of weekly sex and orgasm during sex. However, no women in this study met clinical criteria for sexual dysfunction (Battaglia et al., 2012 ). In a study assessing genetic biomarkers, women with the ll genotype were almost 8 times as likely to be classified as having sexual dysfunction if they used OC (OC type unspecified) (Bishop et al., 2009 ). Breast tenderness after 1 cycle of combined OC use ranged from 10% (Caruso et al., 2013 ) to 16% (Wonglikhitpanya & Taneepanichskul, 2006 ), with a majority reporting that the symptom had resolved by 6 months of use. One study of Italian women found that all 102 women reported a significant reduction in vaginal lubrication after 6 months of using Klaira® (Di Carlo, Gargano, et al., 2014 ). The use of combined OCs containing ethinylestradiol (EE) may have long-lasting effects on sex hormone binding globulin (SHBG) production even after method discontinuation. This may help explain why genital pain disorders do not always resolve with discontinued use of OCs (Goldstein et al., 2010 ). Pooled results from a systematic review show that 15% of women reported a decrease in sexual desire (libido) after OC use; decreased libido was significantly associated with using pills that containined 15ug ethinylestradiol (EE) (Pastor et al., 2013 ). Results from a large cross-sectional survey found no significant differences in sexual function based on women using combined OCs containing either androgenic or antiandrogenic progestins, or between different doses of EE. However, women using any type of combined OC reported significantly poorer sexual function scores compared to women not using combined OCs (Wallwiener, Wallwiener, Seeger, Muck, et al., 2010). One randomized, double-blind study provided good evidence that women who suffer from reduced desire and arousal attributed to their birth control pill may find significant improvement in sexual function if they switch to a different pill formulation, particularly those containing E2V/DNG or EE/levonorgestrel (LNG) (Davis et al., 2013 ). Though some women report positive or negative sexual impacts in relation to their use of combined OC, the large majority of women report no impact in sexual function or frequency of sex related to their OC use. Nonetheless, women who do report decreases in sexual function may wish to switch to another OC formulation. Differences in aspects of sexual function such as experiences with sexual pain and levels of sexual desire vary by age and should be contextualized and accounted for in contraceptive research and clinical care. In terms of OCs and sexual pain, combined OCs may be a beneficial treatment for endometriosis-related pelvic pain (Guzick et al., 2011 ). However, the effects of OCs on experiences with genital pain and interstitial cystitis (Gardella et al., 2011 ) are not well understood. More research is needed on potential long-term, long-lasting impacts of OC use on women’s sexual pain. The sexual repercussions of seemingly non-sexual side effects of OC use should also be considered; examples include body/facial hair growth changes, and breast tenderness. Aesthetic changes, for example, may be related to improving women’s sexual and social self-esteem as evidenced by increased frequency of partnered sex and reductions in masturbation (Caruso et al., 2009 ). Genetic differences may influence experiences of depression and sexual function in women taking both SSRIs and OCs. More research is needed to better understand how genetics may play a role in sexual function, particularly in the context of hormonal contraception use (Bishop et al., 2009 ). Though results remain inconclusive as to the effects of a combined OC pill containing DHEA, the potential for positive sexual function improvements in some women with androgen-sensitivity and/or oral contraceptive-associated sexual dysfunction show promise and requires further investigation (Zimmerman et al., 2015 ). Women using 3 rd generation combined OCs (containing 0.03 mg EE/0.15 mg desogestrel) reported significantly better improvements in sexual function compared to women using 2 nd generation combined OCs (low-dose estrogen pills containing 0.03 mg EE/0.15 mg LNG); even though both groups demonstrated higher sexual function after 4 months compared to baseline (Shahnazi et al., 2015 ). IUD/IUC/IUS (n=7 here, n=12 in the table; please see “multiple methods” section below for more information) (Bastianelli et al., 2011 ) (Enzlin et al., 2012 ) (Gomez & Clark, 2014 ) (Gorgen et al., 2009 ) (Higgins et al., 2015 ) (Panchalee et al., 2014 ) (Skrzypulec & Drosdzol, 2008a ) In one study of the levonorgestrel (LNG) IUS, women reported a significant decrease in sexual pain and a significant increase in sexual desire after one year of use (Bastianelli et al., 2011 ). A cross-sectional study comparing women who had used either the LNG IUS or copper IUD for at least 6 months found that most women using both IUDs reported changes in menstrual bleeding after IUC placement, though LNG-IUS users were significantly more likely to report shorter menses and less blood flow. Women using either LNG IUS or copper IUD reported similar rates of self-perceived sexual satisfaction (58-60%), sex more than twice per week (48-49%), desire for sex more than twice per week (50-53%), ease in reaching physical arousal (47-54%), and ease in achieving orgasm (76-78%) (Enzlin et al., 2012 ). A qualitative study described both IUD users’ and non-users’ perceptions of the sexual aspects of IUDs. Sexual benefits included security , or enhanced sexual disinhibition thanks to IUDs’ efficacy, spontaneity , or improved sexual flow, and scarcity of hormones , which meant no/low hormonal influences on libido (Higgins et al. 2015 ). Breast tenderness was reported by 35% of women using the LNG IUS, but resolved by 6 months of use (Bastianelli et al., 2011 ). Compared to women using copper IUDs, women using the LNG-IUS perceived their method to have a greater negative impact on aspects of their sex life (frequency of sex, arousal and desire); however, orgasm and overall satisfaction with sex did not change with LNG IUS use (Enzlin et al., 2012 ). One study reported that, after 6 months of use, 12% of women using the LNG IUS reported decreased libido and 35% reported no change in libido. 13% reported experiences with pelvic pain (Gorgen et al., 2009 ). A qualitative study described both IUD users’ and non-users’ perceptions of the sexual aspects of IUDs. Sexual detractions included string , or negative sexual effects on partner, and sexual aspects of bleeding and cramping , which could affect sexual experiences (Higgins et al., 2015 ). In general, women using copper IUDs reported neither positive nor negative changes in sexual function related to their method. Women who reported existing sexual distress while using either type of IUD were more likely to attribute negative sexual function changes to their IUD usage rather than to other factors in their lives (Enzlin et al., 2012 ). Most studies show sexual improvements and/or no sexual changes among women using IUC. Studies indicate potential improvements to women’s sexual well-being through IUD/IUS use. For example, decreases in bleeding associated with IUDs for many users are likely to increase sexual acceptability of these methods. Young women also report psycho-sexual benefits of the IUC’s efficacy and no/low hormones (Higgins et al., 2015 ). Prospective research is needed to better understand the extent to which positive sexual function outcomes in women using a hormonal IUS can be attributed to the method itself versus particular characteristics of the women who choose to use this method (Witting, Santtila, Jern, et al., 2008). Vaginal Ring (n=4 here n=12 in the table; please see “multiple methods” section below for more information) (Caruso et al., 2014 ) (Merkatz et al., 2014 ) (Roumen, 2008 ) (Terrell et al., 2011 ) One study found that women reported an increase in desire, arousal, lubrication, orgasm, satisfaction, and improvement in dyspareunia during 2 extended use cycles (approximately 4.5 months of use). No changes in sexual frequency were observed. FSFI scores increased and sexual distress (FSDS) scores decreased at both follow-up assessments (after 63 days and 126 days of use) (Caruso et al., 2014 ). In one study, male partners reported never feeling the ring during sex (72%), no change in sexual sensations (92%), and never feeling the ring move during coitus (87%). Though 16% of male partners experienced ring expulsion during sex, only 2 men found this experience disruptive. Most women and their partners found the ring to be highly sexually acceptable and women using the ring expressed fewer issues with vaginal dryness compared to combined OC users. (Roumen, 2008 ). Adolescent women most willing to try the ring reported more comfort with their genitals and greater knowledge of positive ring attributes (month-long protection, covert use) (Terrell et al., 2011 ). In one study, over 91% of women using the ring reported a steady increase or no change in sexual desire over 12 cycles (Sabatini & Cagiano, 2006 ) (see citation in “Multiple Methods” section). 2% of women using ring reported vaginal discomfort and 4% reported device-related events such as ring slipping out. The most common sexual “problems” with this method pertain to the mechanics of the ring during sexual activity and discomfort with touching their own genitals. Ring-related events (feeling the ring inside vagina, interference with sex, and expulsion) were associated with higher rates of discontinuation (Roumen, 2008 ). Women less willing to try the ring reported concerns of the ring getting lost inside or falling out of the vagina (Terrell et al., 2011 ). Mild adverse outcomes included bleeding, nausea, headache, and breast tenderness (Caruso et al., 2014 ; Roumen, 2008 ). Some women using the ring have reported improvements in sexual function and quality of life and decreases in sexual distress. A small minority of users have reported adverse sexual outcomes such as vaginal discomfort. Higher user satisfaction with the ring is related to ease of removal, not being able to feel the ring during normal use, and either no change or an increase in sexual pleasure and/or sexual frequency. Women who were more satisfied with the method (including positive sexual attributes of the method) were more likely to adhere to correct use and to continue use over time (Merkatz et al., 2014 ). Among women less comfortable touching own genitals, providing alternative strategies such as wearing gloves or using an applicator to insert/remove the ring may facilitate willingness to try the method (Terrell et al., 2011 ). The extent to which ring users enjoy and/or find bothersome vaginal wetness associated with use should be explored to better understand sexual acceptability (Battaglia et al., 2014 ) (see citation in “Multiple Methods” section). Implant (n=5 here n=7 in the table; please see “multiple methods” section below for more information) (Aisien & Enosolease, 2010 ) (Di Carlo, Sansone, et al., 2014 ) (Duvan et al., 2010 ) (Gezginc et al., 2007b) (Visconti et al., 2012 ) Participants in one study exhibited significantly increased FSFI scores at 3 months, showing improvement in domains measuring arousal, orgasm, satisfaction and pain; no changes were observed at 6 months compared to 3 months (Di Carlo, Sansone, et al., 2014 ). Visconti et al. ( 2012 ) found that by 3 months, women reported statistically significant improvements in frequency and intensity of orgasm, better sexual satisfaction, and less sexual anxiety. By 6 months, scores measuring sexual pleasure, personal initiative, orgasm frequency, sexual satisfaction, discomfort and anxiousness had all improved significantly from baseline. Weekly frequency of sex increased significantly by 6 months compared to baseline (Visconti et al., 2012 ). A small minority (2%-9%) of women using the implant reported reduced libido (Aisien & Enosolease, 2010 ) (Duvan et al., 2010 ) (Gezginc et al., 2007b). Bleeding profiles associated with implant use after one year of use were variable. The range from several studies is as follows: amenorrhea: 32% - 41% infrequent bleeding: 3% - 24% frequent bleeding: 7% - 18% prolonged bleeding: 10% - 21% Other reported side effects that may have sexual repercussions included the following: weight gain: 16% anxiety: 10% breast tenderness: 7% - 19% headaches: 4% - 13% depressed mood: 4% hirsutism: 3% acne: 2% - 10% pelvic pain: 3% (Aisien & Enosolease, 2010 ) (Duvan et al., 2010 ) (Gezginc et al., 2007b) (Visconti et al., 2012 ) Several studies indicate improvements in women’s sexual functioning and satisfaction with implant use. The authors of one study (Visconti et al., 2012 ) attributed an increased sense of security from pregnancy as leading factor in increased frequency of sex and improvements in sexual function associated with this method. A minority (<10%) of users report libido reductions. A minority of women also report a number of bleeding changes and/or side effects such as breast tenderness, weight gain, or headaches that could decrease women’s sexual well-being. 88% of women in one study reported no negative feelings about the method (Aisien & Enosolease, 2010 ), though 25% of women in another study discontinued Implanon® within the first year of use; 35% discontinued due to bleeding irregularities and 10% stopped due to interference with sexual function (Gezginc et al., 2007b). Tolerability of irregular bleeding patterns associated with the implant should be further explored in regards to sexual acceptability. Injectable (n=2 here, n=8 in the table; please see “multiple methods” section below for more information) (Gubrium, 2011 ) (Wanyonyi et al., 2011 ) After 6 months of Depo® use, women reported marginally significant improvements in physical health, which could have sexual repercussions. Women reported no significant changes in either mental health or sexual function after 6 months of use of injectable contraception (Wanyonyi et al., 2011 ). Results from a qualitative study illustrate decreased libido (sexual desire) as a key theme associated with Depo® use. Participants linked this libido decrease with emotional and body image changes (Gubrium, 2011 ). 33% of women reported menstrual irregularities. Main reasons for discontinuation in one study included: menstrual irregularity (27%); reduced libido (13%); and weight gain (20%) (Wanyonyi et al., 2011 ). Few studies report improvements to women’s sexual well-being with use of injectable contraception. Studies suggest that a minority of women experience libido reductions on this method, which may also be related to factors such as weight gain and changes in body image, unpredictable bleeding, and emotionality. Side effects associated with the shot are not experienced singly, but as a constellation of factors (examples: weight gain leads to changes that, taken together, contribute to the sex-acceptability of the method). Female Condom (n=7 here, n=8 in the table; please see “multiple methods” section below for more information) (Latka et al., 2008 ) (Mack et al., 2010 ) (Mathenjwa & Maharaj, 2012 ) (Okunlola et al., 2006 ) (Sobze Sanou et al., 2013 ) (Telles Dias et al., 2006 ) (van Dijk et al., 2013 ) Studies have documented a number of positive sexual aspects of the female condom, including the following: high level of sexual comfort due to sufficient lubricant and better lubrication compared to male condom; low risk of breakage, especially during rough sex; ability to accommodate all penis sizes; reduced interruption of sexual encounter due to ability to insert before intercourse; greater protection of the outer labia; preferred the smell to the male condom; lack of side effects; increased protection from pregnancy & STIs/HIV; female-controlled use; lower likelihood of allergic reaction compared to male condom; increased ability to relax and enjoy sex; increased sensation; clitoral stimulation through external ring; and massage of head of penis with internal ring (Latka et al., 2008 ) (Mack et al., 2010 ) (Mathenjwa & Maharaj, 2012 ) (Telles Dias et al., 2006 ) (van Dijk et al., 2013 ). Initially, women in one study reported that the method’s design, particularly the internal ring, made it difficult (and painful) to insert and remove. However, after several uses, more than half of participants preferred the female to the male condom (Mack et al., 2010 ). Among female condom users, the most common complaint (30%) was poor sexual satisfaction associated with use. 22% reported difficulties with insertion, and 5% experienced pain during intercourse when using the female condom (Okunlola et al., 2006 ). Common complaints included noise during intercourse, stiffness of internal ring, resistance of partners to use, and excessive lubrication (Telles Dias et al., 2006 ). The preconceived notion that female condoms decrease sexual pleasure can be a barrier to use among both men and women (Sobze Sanou et al., 2013 ). Women in a number of studies discussed difficulties with insertion and/or aesthetic detractions such as noise and stiffness of the internal ring. However, women in a variety of studies reported myriad sexual advantages to female condoms, especially compared to male condoms. Pleasure-related aspects experienced by both men and women increased acceptability and long-term use of this method. Though women’s first impressions of the female condom may be negative, particularly regarding insertion and large size, perceptions are likely to improve with time and practice. Women with greater personal autonomy were more likely to report sustained use (Telles Dias et al., 2006 ). Female Sterilization (n=3 here, n=7 in the table; please see “multiple methods” section below for more information) (Dias et al., 2014 ) (Schaffir, Fleming, et al., 2010 ) (Smith et al., 2010 ) 92% of women were satisfied with the procedure and would recommend it to friends (Dias et al., 2014 ). After controlling for age and other socio-demographic characteristics, women with a tubal ligation were significantly less likely than non-sterilized women to experience negative sexual outcomes such as a lack in sexual desire, issues with vaginal lubrication, or taking too long to orgasm. Sterilized women reported significantly higher levels of sexual and relationship satisfaction and sexual pleasure compared to non-sterilized women (Smith et al., 2010 ). After tubal ligation, women reported significantly more bleeding, premenstrual symptoms, dysmenorrhea, and noncyclic pelvic pain; they also reported significantly reduced libido and fewer sex acts per week (Dias et al., 2014 ). 37% of women undergoing sterilization agreed with a statement that they would have less sexual desire after procedure (Schaffir, Fleming, et al., 2010 ). Studies report both positive and negative impacts of sterilization on aspects of sexual function, yet women report overwhelmingly high rates of satisfaction with the method, highlighting the aspect of safety and freedom from pregnancy as important aspects of method acceptability. Many women report sexual concerns in anticipation of gynecological procedures. We recommend that physicians address sexual concerns with women in more detail before surgery and continue to address concerns as needed post-procedure. Vasectomy (n=3 here, n=5 in the table, please see “multiple methods” section below for more information) (Al-Ali et al., 2014 ) (Bunce et al., 2007 ) (Shih et al., 2013 ) Female partners in one study reported significantly more positive sexual function after vasectomy. No significant changes were reported in men’s sexual function (Al-Ali et al., 2014 ). Men often cited seeking vasectomy to allow their female partners to discontinue hormonal methods (Bunce et al., 2007 ). Loss of manhood and misconceptions around negative impacts on men’s sexual function, desire, and performance were cited by men and their partners as reasons for not selecting vasectomy. Both male and female participants cited potential for infidelity as both a positive and negative aspect of vasectomy (Shih et al., 2013 ). Partner influence, including partner’s approval, was an important factor in men seeking vasectomy (or not) (Bunce et al., 2007 ). Though vasectomies are performed on male bodies, women may experience positive sexual effects from this method, potentially related to security against unwanted pregnancy and/or no longer having to take contraceptive responsibility. Cultural constructions of gender relating to infidelity and manhood and sexuality may deter some men and their partners from vasectomy. Highlighting the rapid return to prior sexual function is an important component in vasectomy counseling and could increase knowledge and acceptability of the procedure (Shih et al., 2013 ). Withdrawal (n=4 here, n=5 in the table, please see “multiple methods” section below for more information) (Higgins & Wang, 2015b ) (Ortayli et al., 2005 ) (Rahnama et al., 2010 ) (Sirkeci & Cindoglu, 2012 ) For both women and men, those who felt condoms could diminish sexual pleasure were significantly more likely to have used any/only withdrawal at last sexual intercourse (Higgins & Wang, 2015b ). Iranian women who use withdrawal cited dissatisfaction with sexual sensation associated with condom use and partners’ unwillingness as reasons for not using modern (more highly effective) methods of contraception (Rahnama et al., 2010 ) Turkish men who did not use withdrawal reported anxiety, decreased sexual pleasure, and dislike of coital-dependent methods as reasons for non-use. Almost all current withdrawal users cited reductions in sexual pleasure with the method, but less so than with male condom use (Ortayli et al., 2005 ). 34% of women reported decreased sexual enjoyment when using withdrawal; 42% perceived their partner to experience decreased enjoyment as well (Rahnama et al., 2010 ). Participants acknowledged female sexual pleasure as a consideration for using withdrawal as well as difficulties with climax control for some men (Ortayli et al., 2005 ). Findings suggest that sexual acceptability issues may play a larger role in shaping withdrawal and other contraceptive practices than acknowledged by prior research. Withdrawal reduced both women’s and men’s sexual well-being in a number of studies; other studies suggested that couples were more likely to use withdrawal when they experienced pleasure-reductions with other methods (e.g., male condoms). Authors acknowledge the need for climax awareness and control for male partners in order for withdrawal to work successfully (Freundl et al., 2010 ). Diaphragm (n=2) (Sahin-Hodoglugil et al., 2011 ) (Thorburn et al., 2006 ) Current users described the diaphragm as valuable to women’s autonomy with a female-initiated method and the ability to use covertly. Women and men enjoyed the increased sexual pleasure when using the diaphragm with a gel (Sahin-Hodoglugil et al., 2011 ). 66% of women who had never used a diaphragm perceived that it “does not decrease sexual pleasure” (Thorburn et al., 2006 ). Less than 25% of women in one study felt confident in using the method correctly when sexually excited or in the heat of the moment. 17% of women preferred methods that require no genital touching (Thorburn et al., 2006 ). Current diaphragm users reported the need for partner negotiation as an attribute that contributed to overall acceptability (Sahin-Hodoglugil et al., 2011 ). Few study participants reported negative sexual attributes of diaphragms, though (like condoms and other coitus-dependent methods) this method may hinder sexual flow and spontaneity. Women acknowledge the difficulty of stopping to insert one’s diaphragm in the heat of the sexual moment. The ability to insert the diaphragm before sexual activity increased its acceptability. Along these lines, comfort with genital touching will impact acceptability. Natural Family Planning (NFP) (n=1 here, n=3 in the table; please see “multiple methods” section below for more information) (Freundl et al., 2010 ) Results from a systematic literature review highlighted sexual self-control and increased body awareness as positive attributes of NFP reported by users (Freundl et al., 2010 ). Natural family planning methods may disallow spontaneity as most methods require abstaining from PVI during peak periods of fertility (Freundl et al., 2010 ). Couple-focused research may enlighten effective sexual communication strategies of couples who successfully use NFP or other methods negotiated by both partners. Highlighting and promoting strategies for intimacy and other sexual activities that don’t involve PVI may increase the sexual acceptability of NFP methods; more research is needed. EC Pills (n=1) (Escajadillo-Vargas et al., 2011 ) N/A Regression analyses from a nested case-control study indicate that women using oral EC in the past 3 months had significantly greater odds for increased risk of sexual dysfunction (Escajadillo-Vargas et al., 2011 ). More research is needed to better understand the characteristics of women who use EC and how oral EC use might be related to sexual function. Multiple Methods Measured in the Same Study (n=19) (Battaglia et al., 2014 ) (Davison et al., 2008 ) (Elaut et al., 2012 ) (Fataneh et al., 2013 ) (Gabalci & Terzioglu, 2010 ) (Guida et al., 2014 ) (Halmesmaki et al., 2007) (Higgins, Hoffman, et al., 2008 ) (Mohamed et al., 2011 ) (Nishtar et al., 2013 ) (Ott et al., 2008 ) (Roumen, 2007 ) (Sabatini & Cagiano, 2006 ) (Sanders, Smith, et al., 2014 ) (Schaffir, Isley, et al., 2010 ) (Smith et al., 2014 ) (Stewart et al., 2007 ) (Tabari et al., 2012 ) (Witting, Santtila, Jern, et al., 2008) In a genetic study using a within-subject, crossover study design with random-order use of 3 contraceptive methods (combined OCs, progestin-only pills, and the ring), both partners’ level of sexual desire was statistically significantly higher among women using the vaginal ring (Elaut et al., 2012 ). Compared to women using the ring, pill, or no method (control group), after 6 months, implant users reported the most significant improvements in sexual discomfort, anxiousness, personal initiative, and fantasy. All method users reported significantly more sexual pleasure, satisfaction and higher orgasm frequency at 6 months compared to controls (Guida et al., 2014 ) Women reported that the ring was more likely to interfere with sex compared to the pill and significantly more women reported that their sex partners preferred the pill (Stewart et al., 2007 ). A systematic review found either improvement or no change in sexual function and sexual experience in women using both implants and IUD/IUS (Sanders, Smith, et al., 2014 ). Results from a prospective study found that women using drospirenone-containing OC (Yasmin®) reported significant reductions in sexual frequency and orgasm during sex, and reported more pain during sex after 6 months of use compared to baseline measures. After 6 months of use, women using Yasmin® and vaginal ring demonstrated significant decreases in sexual function scores compared to baseline assessment (Battaglia et al., 2014 ). Results from a case-controlled study found that, compared to controls, women using any contraceptive method reported significantly poorer scores in the domains measuring desire, arousal, lubrication, orgasm, pain, and satisfaction (Fataneh et al., 2013 ). Controlling for a number of socio-demographic and relationship characteristics, results of one cross-sectional study demonstrated that male condoms, either used alone or in conjunction with hormonal methods (dual use), were most strongly associated with decreased sexual pleasure (Higgins, Hoffman, et al., 2008 ). In a randomized, prospective trial conducted from method initiation to 12 months or method discontinuation, findings show that, compared to pill users, ring users reported significantly more experiences with vaginitis, decreased libido, and ring-related problems. Conversely, compared to ring users, women using combined OCs reported significantly more experiences with increased weight, acne, and emotional lability (Mohamed et al., 2011 ). Results from a large cross-sectional study show that a regression controlling for a number of socio-demographic and relationship characteristics indicated that women using hormonal contraception experienced significantly less frequent sex, and significantly more problems with arousal, pleasure, orgasm, and vaginal lubrication compared to women using non-hormonal methods (Smith et al., 2014 ). Studies comparing sexual outcomes for multiple methods show mixed findings. However, studies of multiple methods do highlight that contraceptives can affect a wide range of sexual domains for women, from inference with sexual flow to partner preference to sexual functioning and pleasure to more general sexual satisfaction. Most studies of multiple methods compare and contrast various formulations of hormonal methods. Studies with sufficient sample sizes to compare a wider range of methods are warranted. Researchers have paid especially little attention to women’s sexual experiences with long-acting reversible contraception, or LARC (implants and IUDs) in the past 10 years. With the recent public health focus on LARC, more research is needed, especially in the US context (Sanders, Smith, et al., 2014 ). In one study, the authors note that dual users are likely “erotizing safety” associated with doubling up on pregnancy and STI prevention methods. (This group reported higher sexual satisfaction levels than pill-only or condom-only users (Higgins, Hoffman, et al, 2008 ).) Adolescents and young women often report frequent method switching, starting, and stopping, all of which reflect their dynamic lives and intimate experiences. More research is needed on how mood influences interest in sex and reasons for method switching or discontinuation among young women (Ott, Shew et al, 2008 ). 1 Methods are presented in descending order per number of citations, with those methods most commonly cited appearing first and articles assessing multiple methods (n=19) located at the end of the table. SUMMARY OF STUDIES REVIEWED IN PART 2: Positive and negative sexual aspects of contraception documented by peer-reviewed research, 2005-2015 75% of men and 40% of women reported that decreased sexual sensation was a major turn-off in using the male condom. The disruption of sex with putting on the condom was a turn-off listed by 43% of men and 30% of women. Approximately one-third of both men and women declared that the smell of condoms was a turn-off. More than half of women and over one-third of men reported that condoms decreased their partners’ sensations during sex. 20% (Crosby et al., 2008 ) to 34% (Higgins et al., 2009 ) of both men and women reported loss of arousal and orgasm difficulties with male condom use. amenorrhea: 32% - 41% infrequent bleeding: 3% - 24% frequent bleeding: 7% - 18% prolonged bleeding: 10% - 21% weight gain: 16% anxiety: 10% breast tenderness: 7% - 19% headaches: 4% - 13% depressed mood: 4% hirsutism: 3% acne: 2% - 10% pelvic pain: 3% Methods are presented in descending order per number of citations, with those methods most commonly cited appearing first and articles assessing multiple methods (n=19) located at the end of the table. Though male condoms help prevent STIs, they also play an enormous role in pregnancy prevention. Population-level research indicates that at least one in three sex acts among 15- to 44-year-old adults in the United States involves the use of male condoms (Higgins, Smith, et al., 2014 ). Prior studies have examined the sexual acceptability of male condoms for men, with findings that condoms can reduce men’s pleasure and sensation, and that men who report these condom-related sexual detractions are less likely to use them than men who do not report them as strongly (Crosby, Milhausen, Yarber, Sanders, & Graham, 2008 ; Hensel, Stupiansky, Herbenick, Dodge, & Reece, 2012 ). A novel vein of research has also documented men’s experiences of sexual condom-use problems, including condom-associated erection loss (Crosby, Sanders, Yarber, & Graham, 2003 ; Sanders, Hill, Crosby, & Janssen, 2014 ; Sanders et al., 2012 ). Research has been slower to document women’s sexual experiences with condoms (Higgins & Fennell, 2013 ). However, the winds may be shifting: Our review identified 21 articles from the past 10 years that deal in some way with women’s sexual experiences of condoms. Taken cumulatively, these studies confirm prior findings that some women perceive condoms as a barrier to intimacy and trust, which can lead to a waning of condom use as a relationship ensues (Bolton, McKay, & Schneider, 2010 ; Sanders et al., 2010 ; Versteeg & Murray, 2008 ; Wang, 2013 ), and that sexual motivations pertaining to love (versus, say, pleasure or fun) can undercut the likelihood of condom use (Gebhardt, Kuyper, & Dusseldorp, 2006 ). However, the reviewed studies also convincingly demonstrate that women, too, can experience reductions of both pleasure and sensation with condom use (Crosby et al., 2013 ; Crosby et al., 2008 ). For example, especially when used in the absence of exogenous lubricants, condoms may reduce vaginal lubrication, which can cause some women discomfort or pain (Fennell, 2014 ; Higgins & Hirsch, 2008 ). In fact, these studies exhibit far more gender similarities than differences, with reporting of condom “turn-offs” similar for women and men (Crosby et al., 2013 ; Crosby et al., 2008 ). (Exceptions from one study include the following: Men were more likely than women to report “fit and feel” issues with male condoms (Crosby et al., 2013 ); women were more likely than men to report that their partner experienced sexual discomfort due to condoms (Crosby et al., 2013 ); and women were more likely than men to report pain associated with condom use (Fennell, 2014 ).) Most notably, although men were proportionally more likely than women in these studies to say that condoms diminish their physical pleasure (Kaneko, 2007 ; Randolph et al., 2007 ; Træen & Gravningen, 2011 ; Widdice, Cornell, Liang, & Halpern-Felsher, 2006 ), at least three studies showed that the associations between such pleasure attitudes/reductions and actual condom practices may be just as strong, if not stronger, for women (Fennell, 2014 ; Higgins et al., 2009 ; Higgins & Wang, 2015a ). The 21 reviewed studies did not document solely negative aspects of male condoms’ (lack of) sexual acceptability. One nationally representative study from the United Sttes showed no associations between (reduced) sexual functioning and condom use at last penile–vaginal intercourse (Sanders et al., 2010 ). Young adults in one study associated condoms with a number of sexual benefits, such as reduced mess, longer-lasting sexual intercourse, and personal feelings of cleanliness and sexual hygiene (Træen & Gravningen, 2011 ). Sex workers in two studies reported that being able to apply condoms in an erotic, sexually pleasing way was particularly effective at enlisting male partners’ support for condom use (Free, Roberts, & McGuire, 2007 ; Garcia, Yam, & Firestone, 2006 ). And in one analysis of the “condom as killer” discourse among young adults, one researcher pointed out that anti-condom narratives are socially constructed, and thus can—and should—be shifted to narratives in which condoms can be better integrated into the sexual experience (Braun, 2013 ). Given that successful condom strategies have been associated with sexual communication skills and women’s sexual self-comfort (Deardorff, Tschann, et al., 2013 ), we should endeavor to increase these latter phenomena as well. Contraceptive researchers and practitioners should start with the assumption that many women, like many men, experience reductions in pleasure and sensation when using male condoms; moreover, women may uniquely experience condom-related pain and reductions in vaginal lubrication. Future research and interventions should assess contraceptive users’ beliefs about and experiences with condom-related pleasure reduction, as failure to do so could mean overlooking one of the largest predictors of condom use/nonuse. Sexual health professionals might also wish to share ideas on how to better integrate condoms into the sexual experience with both male and female clients. Young men might struggle with condoms’ fit and feel, whereas young women might dislike texture or lubrication attributes; such clients should be encouraged to try a variety of condom types, sizes, and lubricants. Oral contraception has recently surpassed female sterilization as the most commonly used method among women in the United States (Daniels et al., 2014 ). OCs are often the first hormonal method used by young women for the treatment and regulation of painful periods and as they become sexually active; many women remain satisfied OC users for decades. The birth control pill recently celebrated its 50th birthday. Thanks to technological and medical innovation, the pills of today are much different from those used by its earliest adapters. Though the link between OC use and diminished libido is well documented, little clinical guidance exists to help women or their providers identify which pills may be better suited for those dealing with adverse sexual side effects. Encouragingly, preliminary findings suggest that women experiencing issues with desire or arousal may find relief when switching to a different hormonal formulation (Bednarczyk, Davis, Ault, Orenstein, & Omer, 2012 ; Shahnazi et al., 2015 ; Strufaldi et al., 2010 ). Specific recommendations for clinicians are needed to ensure optimal patient-centered care for women who wish to use the pill. In the past 10 years, several specific branded pills and hormonal combinations have received attention in the literature due to their potential impact on women’s sexual experiences. Studies of Yasmin ® (Battaglia et al., 2012 ; Battaglia et al., 2014 ; Drosdzol & Skrzypulec, 2008 ; Goldstein, Burrows, & Goldstein, 2010 ; Mabrouk et al., 2012 ), Q(K)laira ® (Caruso et al., 2011 ; Di Carlo, Gargano, et al., 2014 ), and Belara ® (Caruso, Rugolo, Agnello, Romano, & Cianci, 2009 ; Göretzlehner, Waldmann-Rex, & Schramm, 2011 ) make up almost one-third ( n  = 10) of all combined OC articles identified in the review. Yasmin, containing 30 μg ethinylestradiol (EE) and 3 mg drospirenone (DRSP), has received a particularly high level of attention ( n  = 5). Research consistently finds Yasmin related to increased pain during sex, decreased libido, issues with spontaneous arousal and orgasm during sex, and reduced frequency of sex (Battaglia et al., 2012 ; Battaglia et al., 2014 ; Drosdzol & Skrzypulec, 2008 ). However, the extent of these symptoms does not meet the level for clinical sexual dysfunction in most women (Battaglia et al., 2012 ). As the fine-tuning of hormonal components continues to evolve, we see improvements in many symptoms alongside the unfortunate emergence of new issues (e.g., dyspareunia) related to OC use, particularly with low-dose combined OCs. Studies are beginning to investigate how OC induces changes in labial thickness and pulsatility index of arteries located in the clitoris and labia minora (Battaglia et al., 2012 ). One study found that, compared to baseline measurements, after three months of Yasmin use labia minora thickness and the vaginal introitus (canal) area had decreased significantly. The pulsatility index of the dorsal clitoral artery and the posterior labial artery significantly increased after three months of use. These biomarkers show physical and physiological changes in women’s genitals with Yasmin use that may be related to sexual function (Battaglia et al., 2012 ). Our understanding of the long-term impacts related to genital pain and dyspareunia is conflicting, with some studies showing resolution of symptoms after discontinuing OC use (Avellanet, Patricia-Ortiz, Pando, & Romaguera, 2009 ), though others reveal long-lasting effects (Gardella et al., 2011 ; Goldstein et al., 2010 ). Goldstein et al. ( 2010 ) hypothesized that newer, low-dose combined OCs chosen for their anti-androgenic characteristics, in addition to the use of decreased hormone-free intervals, may be associated with an increased risk for experiencing vestibulodynia. Combined OCs containing estrogen may have long-lasting impacts on SHBG production even after pill discontinuation, which may help explain why genital pain disorders do not always resolve with discontinued use (Goldstein et al., 2010 ). Though levels of free testosterone are likely to be reduced in women using combined OCs (Bancroft & Graham, 2011 ), this reduction does not appear to be associated with changes in clitoral sensations as measured by heat, cold, and vibrations or with pain thresholds in the vulvar vestibule (Baeten et al., 2012 ). Zimmerman et al. ( 2015 ) have experimented with adding dehydroepiandrosterone (DHEA) to DRSP-containing pills in an attempt to counteract the possibility for sexual impairment that can result from reduced free and total testosterone. Though results of “androgen-restored contraception” remain inconclusive with regard to the effects of a combined OC pill containing DHEA, the potential for positive sexual function improvements in some women with androgen sensitivity and/or OC-associated sexual dysfunction shows promise and requires further investigation. More research is needed to understand if and how low androgen levels and/or individual sensitivity to androgens are related to genital sensations and sexual desire in women using hormonal contraception, particularly combined OCs (Warnock et al., 2006 ). Obviously not all women using OCs experience negative sexual function outcomes (Hoga, Rodolpho, Penteado, Borges, & Alvarez, 2013 ; Machado, De Melo, Prota, Lopes, & Megale, 2012 ; Witting, Santtila, Jern, et al., 2008 ; Wonglikhitpanya & Taneepanichskul, 2006 ). A randomized study showed positive improvement in sexual pleasure, orgasm frequency, and orgasm intensity compared to no-method controls (Farrell et al., 2014 ). Birth control pills also relieve dysmenorrhea and lighten menstrual bleeding (Di Carlo, Gargano, et al., 2014 ; Wonglikhitpanya & Taneepanichskul, 2006 ), two potential sexual benefits for many women and couples. OCs can mitigate potentially sexual, negative aspects of health conditions such as endometriosis and polycystic ovarian syndrome (PCOS). For example, OCs have been associated with reductions in endometriosis-related pelvic pain (Guzick, Huang, Broadman, Nealon, & Hornstein, 2011 ) and unwanted aesthetic aspects of PCOS such as hirsutism (excessive facial and body hair) (Caruso et al., 2009 ) and acne (Caruso et al., 2009 ; Wonglikhitpanya & Taneepanichskul, 2006 ). Extended cycle regimens, or continuous pill use without a hormone-free week for several cycles, have also been associated with positive changes across a variety of sexual acceptability factors, from sexual functioning to aesthetics. These include improvements in sexual function and libido, reductions in dysmenorrhea, duration and volume of withdrawal bleeds, and breast tenderness, and improvements in skin problems (Caruso et al., 2011 ; Caruso et al., 2013 ; Göretzlehner et al., 2011 ). However, other aspects of combined OC use, such as breakthrough bleeding, breast tenderness (Mabrouk et al., 2012 ; Roumen, 2007 ), and vaginal dryness (Sabatini & Cagiano, 2006 ), are likely to detract from sexual acceptability and should be further explored. IUDs have made a major resurgence in the family planning field in recent years, especially under the banner of long-acting, reversible contraception (LARC). LARC traditionally includes both intrauterine contraception (typically abbreviated IUC, as well as IUD or IUS, for intrauterine system) and subdermal contraceptive implants. LARC’s popularity has increased in the past decade, and public health practitioners are keen to increase LARC use among young, nulliparous women in particular. Though significant research explores provider- and financial-level barriers to IUDs, fewer studies employ a patient-centered approach among potential users themselves, especially in terms of how sexuality may shape client satisfaction with their method. These studies are particularly lacking in the United States, despite the current intensity of IUD promotion efforts there. However, we hypothesize that strong overall user satisfaction with IUDs may be influenced at least in part by their facilitation of enjoyable, spontaneous sex. A recent systematic review of women’s sexual experiences using an IUD/IUS located only 10 studies published in the past 30 years, with all research occurring outside of the United States (Sanders, Smith, & Higgins, 2014 ). The few studies that do exist consistently find that both hormonal and nonhormonal IUDs are associated with either no change or improvement in sexual function (Gorgen et al., 2009 ). After approximately six months of use, women report reductions in sexual and pelvic pain (Bastianelli et al., 2011 ; Gorgen et al., 2009 ; Witting, Santtila, Jern, et al., 2008 ), improvement in sexual desire (Bastianelli et al., 2011 ; Drosdzol & Skrzypulec, 2008 ; Gorgen et al., 2009 ; Witting, Santtila, Jern, et al., 2008 ), and arousal, specifically in women using the levonorgestrel (LNG) IUD (Drosdzol & Skrzypulec, 2008 ). Both copper and “hormonal” LNG IUDs work by creating an environment in the uterus that is hostile to sperm and impairs implantation; LNG IUDs also contain progestin to help thicken cervical fluid and suppress the endometrium, thereby reducing blood loss (Hatcher, 2011 ). Although LNG IUDs release only a small amount of localized hormones and contain no estrogens, hormonal-related side effects are not unheard of with this method: in one study, 35% of women using LNG IUDs reported breast tenderness, though this effect resolved within six months (Bastianelli et al., 2011 ). A study comparing sexual function and satisfaction among women using either the hormonal or nonhormonal IUDs found few differences between the groups (Enzlin et al., 2012 ). However, LNG IUD users were significantly more likely to report being “very satisfied” with their method compared to copper IUD users, perhaps due in part to reductions in menstrual bleeding. Of note, women in both IUD groups reported similar rates of self-perceived sexual satisfaction (58% to 60%), sexual activity more than twice per week (48% to 49%), desired sex more than twice per week (50% to 53%), ease in reaching physical arousal (47% to 54%), and ease in achieving orgasm (76% to 78%) (Enzlin et al., 2012 ). While these studies document more objective sexual outcomes in relationship to IUD use, other studies have assessed less sexually direct and/or more sexually subjective aspects of this method. A recent qualitative study in the United States of IUDs’ sexual aspects revealed mostly positive themes, such as increased sexual disinhibition due to strong efficacy, greater allowance for sexual spontaneity compared to condoms, and psychosexual benefits of no or fewer synthetic hormones compared to other hormonal methods (Higgins et al., 2015 ). These sexual themes connected to users’ method satisfaction and nonusers’ openness to the method. Another study documented that the women least interested in using an IUD wanted a method that they could see, highlighting the complexity of the relationship between contraceptive features and psychosexual well-being (Gomez & Clark, 2014 ). Illustrative of this point, Bastianelli et al. ( 2011 ) noted that recruitment of Italian women into their study took much longer than anticipated, as very few (9% of women seeking contraception in their clinic) were willing to try the IUD. In the U.S. qualitative study mentioned earlier, nonusers’ most frequently cited sexual concern about IUDs was the potential for their partner to feel or be “poked” by the string (Higgins et al., 2015 )—even though little evidence from clinical literature upholds this phenomenon. Nonetheless, counseling for sexual concerns could increase women’s willingness to try IUDs. Bleeding is another aspect that shapes IUDs’ sexual acceptability. For women preferring little to no menstrual bleeding, an IUD may be particularly enticing, as blood flow decreases significantly in many users. However, bleeding profiles differ by IUD type. Though both hormonal and nonhormonal IUDs are associated with lighter bleeding, LNG IUD users were significantly more likely than women using a nonhormonal IUD to report shorter menses and less blood flow (Enzlin et al., 2012 ), and approximately one-third of hormonal IUD users experienced amenorrhea within first six months of use (Bastianelli et al., 2011 ). The bleeding profile associated with IUD use is likely to increase sexual acceptability of this method, though it is important to note that preferences for monthly withdrawal bleeds may influence discontinuation for some women (Bastianelli et al., 2011 ). On the other hand, the sexual acceptability of IUDs may be thwarted for women who experience increases in amount of blood, unscheduled bleeding, and/or cramping with the device. Though the studies reviewed here demonstrate mostly positive effects of IUDs on women’s sexuality, this method’s sexual acceptability will vary according to individual user characteristics, including bleeding preferences, comfort with an object inside the body, and tolerance for hormonal-related side effects for women using hormone-containing devices. Women desiring “green” methods, free from hormones, may find the copper IUD particularly appealing, especially if amenorrhea is not a priority. IUDs may also be extremely desirable methods for women who have trouble “letting go” in sex unless securely protected against pregnancy. On the other hand, they may be less appealing to women who want more hands-on, day-to-day control over their contraception. The vaginal ring provides a powerful and unique glimpse into the sexual acceptability of contraception. Routine use calls for inserting the pliable ring into the vagina for three to four weeks and then removing for a ring-free interval every month (women can also continuous cycle with the ring). The largest studies of this method strongly suggested that women who associated the method with positive sexual attributes were more likely to continue using it over time (Merkatz et al., 2014 ). More specifically, studies document several pathways through which the ring may affect sexual functioning. At the basic level of sexual self-comfort, the ring requires touching one’s genitals. In one U.S. study of adolescent women, those participants most willing to try the ring expressed more comfort with their genitals (Terrell, Tanner, Hensel, Blythe, & Fortenberry, 2011 ). Women less apt to try the method were concerned that the ring could get lost inside or easily fall out of the vagina. Providing women with alternative strategies, such as wearing gloves, using an applicator (Terrell et al., 2011 ), or enlisting a partner’s assistance to insert and remove the ring, may facilitate willingness to initiate the method among those women who are less comfortable touching their own genitals. The mechanics of the ring also affect its sexual acceptability, for both women and their partners. In one review comparing the ring to combined OCs, women reported that the ring was more likely to interfere with sex, and a significantly larger proportion of women reported that their sex partners preferred the pill (Roumen, 2008 ). Ring-related events, such as feeling the ring inside the vagina, interference with sex, and expulsion, were associated with higher rates of discontinuation (Roumen, 2008 ). Conversely, the overwhelming majority of male partners reported that they never felt the ring during sex, expressed no change in sexual sensations, and did not report that the ring disrupted sex. Satisfied ring users in one U.S. study reported no or rare detection of the ring during normal use (Huang et al., 2014 ). As with any hormonal method, hormonal influences affect the ring’s sexual acceptability in both negative (mostly) and positive ways. Mild, adverse, hormone-related outcomes include bleeding, nausea, headache, breast tenderness, and vaginal discomfort (Caruso et al., 2014 ; Roumen, 2008 ). However, compared to combined OC users, ring users experienced comparatively fewer issues with vaginal dryness in one study (Roumen, 2008 ). Extended cycle use (63 days followed by hormone-free interval) has been associated with improvements in Italian women’s dyspareunia, sexual function, sexual distress, and quality of life (Caruso et al., 2014 ). Highly satisfied ring users in one U.S. study reported fewer side effects than with pills, no detection of the ring during normal use, and either no change or an increase in sexual pleasure and/or sexual frequency; these satisfied women were more likely to continue ring use (Huang et al., 2014 ). One study involved 130 sexually active U.S. women (ages 15 to 21) who were randomly assigned to the ring or pill for three cycles and then switched to the other method for an additional three cycles; women reported significantly higher rates of liking the ring, greater ease of use, and more inclination to recommend it to friends (Balkus et al., 2007 ). As with the IUD, the transdermal implant is receiving increased attention within the family planning community as a highly effective, reversible method that is acceptable to women of all ages and parity levels. In 2014, the American Academy of Pediatrics (AAP) recommended that implants and IUDs be promoted as “first line” methods of contraception for adolescents. Sometimes called “get it and forget it” contraception, the implant requires no attention for up to three years. Although its extremely strong efficacy is likely to enhance sexual disinhibition in many users, the implant may also decrease sexual acceptability through its associated unpredictable and highly irregular bleeding profile (Aisien & Enosolease, 2010 ; Duvan, Gozdemir, Kaygusuz, Kamalak, & Turhan, 2010 ; Gezginc, Balci, Karatayli, & Colakoglu, 2007; Visconti et al., 2012 ). Studies suggest that 21% to 50% of implant users report heavier or prolonged bleeding within the first year of use (Duvan et al., 2010 ; Visconti et al., 2012 ). However, at least one-third (32% to 42%) of users experience amenorrhea (Duvan et al., 2010 ; Gezginc et al., 2007)—which may be welcome to some women but concerning and undesirable to others (Gezginc et al., 2007). A variety of other common implant side effects may also indirectly decrease sexual acceptability, including breast tenderness, headaches, acne (Duvan et al., 2010 ; Gezginc et al., 2007), weight gain, and hirsutism (Duvan et al., 2010 ). Worth celebrating, however, are the positive sexual health outcomes documented with implant use. Compared to ring and pill users, as well as a no-method control group, Nexplanon ® users in one study reported the most significant improvements in sexual discomfort, anxiousness, personal initiative, and sexual fantasy over a six-month period (Farrell et al., 2014 ). Another study reported significantly higher FSFI scores measuring arousal, orgasm, satisfaction, and pain after three months of Nexplanon ® use compared to baseline assessments, and these higher scores persisted at six months (Di Carlo, Sansone, et al., 2014 ). Though 2% to 9% of new implant users across several studies reported libido loss (Aisien & Enosolease, 2010 ; Duvan et al., 2010 ; Gezginc et al., 2007), these figures are smaller than those seen in studies of OC and other hormonal methods. Tolerability of irregular bleeding patterns and other side effects should be further explored in regard to the sexual acceptability of the contraceptive implant. Particularly among adolescent women, whose menstrual cycles are likely not yet regular, the unpredictable bleeding profile could play a small role in sexual acceptability and may be far outweighed by sexual satisfaction, safety, and user-independent properties associated with the method. Sexual acceptability of the injectable contraceptive Depo-Provera (DMPA) will likely vary by a woman’s experiences with and tolerance for irregular bleeding, the most commonly cited reason for discontinuation (Wanyonyi et al., 2011 ). However, one study found that, compared to pill users, women using the shot for a minimum of six months reported fewer days of bleeding per month, and the investigators observed no differences in sexual function or relationship satisfaction between the two groups (Schaffir, Fleming, & Waddell, 2010 ). Several studies have documented a decrease in libido with DMPA use (Gubrium, 2011 ; Sedigheh, Maryam, Ali, & Mehdi, 2012 ; Wanyonyi et al., 2011 ), with one study reporting that up to 21% of women reported reductions in sexual desire (compared to only 8% reporting increases) (Tabari, Moslemi, Esmaelzadeh, & Bijani, 2012 ). The latter study also found that 20% of women using DMPA reported breast tenderness and 9% experienced sexual pain (Sedigheh et al., 2012 ). DMPA has also been associated with negative changes in mood (Abbott & Dalla, 2008 ) and weight gain (Gubrium, 2011 ; Wanyonyi et al., 2011 ), both of which could shape women’s sexual well-being. In an attempt to better understand the “lived experiences” of Depo-Provera use, Gubrium’s ( 2011 ) qualitative interview findings from 34 U.S. women highlighted that side effects are not experienced in isolation but rather as a constellation of factors including weight gain, changes in body image, unpredictable bleeding, and emotionality. Taken together, these factors can enact changes in sexual desire or libido, thus contributing in important and understudied ways to the sexual acceptability of this contraceptive method. Outside of male condoms, female condoms are the only currently available contraceptive method that helps prevent both pregnancy and STIs, including HIV. Though used less commonly than male condoms, they provide vital woman-controlled prophylaxis (Mathenjwa & Maharaj, 2012 ; Naidu, 2013 )—especially for female sex workers, among whom their use has been the most promoted by public health officials and policymakers (Peters et al., 2013 ). 6 6 Peters et al. ( 2013 ) reviewed 16 policy papers on female condoms. None of them advocated making female condoms available for all women; most focused on their importance to female sex workers in particular. The authors contrasted this focus with male circumcision, which public health officials promptly wanted to roll out to all men in Sub-Saharan Africa. The authors argued that “[n]ormalizing female condom use for commercial sex workers rather than for other categories of women who are sexually active, implicitly links HIV to sexually immoral behaviour, thus stigmatizing HIV-positive women in their local communities” (Peters et al., 2013 , p. 10). Most of the eight studies reviewed took place in developing countries and/or higher HIV-prevalence settings. Findings suggest that female condoms can be sexually acceptable to many women (especially sex workers) by way of enhanced level of lubrication (Mack, Grey, Amsterdam, Williamson, & Matta, 2010 ; Mathenjwa & Maharaj, 2012 ), greater pleasure and sensation than the male condom (Mathenjwa & Maharaj, 2012 ), clitoral stimulation through the outer ring (Mathenjwa & Maharaj, 2012 ), capacity to comfortably accommodate all penis sizes (Mack et al., 2010 ), ability to insert prior to sexual activity (Mathenjwa & Maharaj, 2012 ), and better smell than male condoms (Mack et al., 2010 ). Indeed, women’s experiences of greater pleasure and sexual sensations helped predict long-term use of female condoms among 255 women in Brazil (Telles Dias, Souto, & Page-Shafer, 2006 ). Peters et al. ( 2013 ) reviewed 16 policy papers on female condoms. None of them advocated making female condoms available for all women; most focused on their importance to female sex workers in particular. The authors contrasted this focus with male circumcision, which public health officials promptly wanted to roll out to all men in Sub-Saharan Africa. The authors argued that “[n]ormalizing female condom use for commercial sex workers rather than for other categories of women who are sexually active, implicitly links HIV to sexually immoral behaviour, thus stigmatizing HIV-positive women in their local communities” (Peters et al., 2013 , p. 10). However, not all women’s sexual experiences with this device are positive, and—just as with male condoms—a barrier to more widespread female condom use are women’s perceptions that it interferes with sexual satisfaction and pleasure (Okunlola, Morhason-Bello, Owonikoko, & Adekunle, 2006 ; Sobze Sanou et al., 2013 ). In a study of 850 Nigerian undergraduate students who had any history of female condom use, 30% reported reduced sexual satisfaction with this method (Okunlola et al., 2006 ). Women in smaller studies reported pain during intercourse (Okunlola et al., 2006 ), and a number of women who had not used it were concerned about insertion—both in terms of difficulty (Latka et al., 2008 ; Okunlola et al., 2006 ) and in touching one’s genitals (Latka et al., 2008 ). However, women can grow more comfortable with insertion through practice, and several studies show that the more women use female condoms, the more they like them and/or prefer them to male condoms (Mack et al., 2010 ; Telles Dias et al., 2006 ; Van Dijk, Pineda, Grossman, Sorhaindo, & García, 2013 ). In sum, female condoms can be a sexually acceptable option to many women and a unique woman-controlled dual-prevention technology. Women who struggle with sexual aspects of male condoms should be encouraged to try female condoms—and urged to try them several times before making up their mind about the method. Female sterilization is one of the most widely used contraceptive methods in the world, with more than 180 million women across the globe using this highly effective procedure—most of whom live in China and India (EngenderHealth, 2002 ). Female sterilization was also the most commonly used contraceptive method in the United States for decades, only recently surpassed in popularity by OCs (in 2014, 15.5% versus 16.0%, respectively) (Daniels et al., 2014 ). Despite the widespread prevalence of this method, few recent studies assessed its sexual acceptability. However, the research reviewed here suggests that, for most women, there is no negative impact (Fakoya et al., 2008 ; Schaffir, Fleming, & Waddell, 2010 ), and there is potential for a positive impact (American College of Obstetricians and Gynecologists [ACOG], 2008 ) on women’s sexual function after the procedure. One study conducted after sterilization found that the irregular bleeding, dysmenorrhea, and pelvic pain experienced by some women resulted in less frequent sexual activity and/or reduced libido, even among younger women; yet despite these changes 92% of study participants reported satisfaction with the sterilization process and would recommend it to a friend (Dias et al., 2014 ). Before undergoing sterilization, some women report concerns about losing their femininity and/or their desire for or ability to enjoy sex, though few women actually experience these outcomes after the procedure (Schaffir, Fleming, & Waddell, 2010 ). Though not documented by the studies reviewed here, subsequent sexual disinhibition due to strong contraceptive efficacy may counteract negative sexual changes. Especially after a reproductive lifetime of trying to prevent unintended pregnancy, many women may enjoy the psychological and sexual freedoms of no longer having to actively “practice” contraception. Celebrating the high sexual acceptability of female sterilization, particularly if done in tandem with in-depth counseling for sexual concerns, may prove beneficial for women seeking permanent contraception. Besides the male condom, vasectomy is the only contraceptive option currently available for men in the United States. (Though some other reversible and permanent methods are available to men in other countries, none of those methods arose in our review.) Compared to tubal ligations, vasectomies are cheaper, more cost-effective, and associated with fewer postoperative complications; however, the ratio of male to female sterilizations in the United States is 1:3 (Daniels et al., 2014 ). In a large number of countries, from Bangladesh to Morocco to Zimbabwe, vasectomy is rarely if ever carried out (EngenderHealth, 2002 ). This underutilization of vasectomy pertains at least in part to widespread concerns, documented in the United States and abroad, related to “loss of manhood” and potential interference with erection and ejaculation (Bunce et al., 2007 ; Shih, Dube, Sheinbein, Borrero, & Dehlendorf, 2013 ). Dispelling these misconceptions and highlighting the rapid return to sexual function after the procedure may result in increased use among men and couples seeking permanent contraception. Moreover, vasectomy is associated with few sexual side effects and may even promote better couple-level sexuality. In a study of Austrian couples, while men reported no changes in sexual function after six month, their female partners reported improved sexual functioning (Al-Ali et al., 2014 ). Findings from this study underscore the psychosexual benefits that many women feel when protected against pregnancy. The family planning community often dismisses withdrawal as a method of contraception. For example, the U.S. Centers for Disease Control and Prevention ( 2015 ) excludes coitus interruptus from its list of contraceptive methods. However, withdrawal is commonly practiced the world over, both as a sole or extra method. In a study of 4,634 adult women in the United States, Jones et al. (2014) found that 33% reported any use of withdrawal in the past 30 days, and 13% reported withdrawal exclusively. For a variety of cultural reasons, certain countries, such as Turkey, have particularly large rates of withdrawal use, with estimates of one-quarter to one-third of all Turkish couples reporting some recent use of withdrawal, with rates holding steady since the 1990s (Çiftçioğlu & Erci, 2009 ; Cindoglu et al., 2008 ). The few studies located for this review suggest several sexual implications of the method—primarily that although withdrawal interrupts the moment, requires climax awareness and control for effective use (Freundl, Sivin, & Batár, 2010 ), and can interfere with pleasure for both partners, it may still be sexually preferable to male condoms (Higgins & Wang, 2015a ; Ortayli, Bulut, Ozugurlu, & Çokar, 2005 ; Rahnama et al., 2010 ; Whittaker, Merkh, Henry-Moss, & Hock-Long, 2010 ). In one nationally representative study of U.S. young adults, both women and men who reported that condoms can reduce their pleasure had significantly greater odds of having used withdrawal at their last penile–vaginal episode (Higgins & Wang, 2015b ). A similar finding emerged from studies of withdrawal in both Turkey (Ortayli et al., 2005 ) and Uganda (Higgins, Gregor, et al., 2014 ): Withdrawal use was associated with perceptions that condoms can reduce pleasure in both these settings. Particularly if couples want to engage in additional pregnancy prevention (that is, dual- or even triple-method use), withdrawal may provide a more sexually acceptable “double-up option” than condoms if STI risk is not present. Our review resulted in two articles that assessed the sexual acceptability of the diaphragm—a method that has received increased research attention in recent years as a potential dual-prevention method for both pregnancy and STIs/HIV. Using a diaphragm may promote sexual autonomy for women, as it can be used covertly when inserted before sex (Sahin-Hodoglugil et al., 2011 ). Even women who do not want or need covert use report liking the notion that the diaphragm can be inserted before sexual activity, thereby being less sexually disruptive (Sahin-Hodoglugil et al., 2011 ). Other women feel confident they could use a diaphragm while sexually excited without breaking the mood (Kraft et al., 2007 ). Women in one study described the importance of having partner support when using the diaphragm, which some obtained by erotizing safety and highlighting the pleasurable, lubricating aspects associated with using microbicidal/spermicidal gel along with the diaphragm (Sahin-Hodoglugil et al., 2011 ). Barrier methods such as the diaphragm, sponge, and cervical cap require comfort with inserting the object inside the vagina; Thorburn, Harvey, and Tipton ( 2006 ) found that almost 20% of U.S. college-based women preferred a method that does not require genital touching, so these methods may not be well suited for everyone (Kraft et al., 2007 ; Thorburn et al., 2006 ). Enlisting a partner’s help with insertion of barrier methods could increase intimacy when used during foreplay and encourages both partners’ active engagement in family planning. More research is needed on how couples erotically incorporate barrier methods, including technologies such as dental dams, microbicides, and spermicides, into their sexual routine. Recent research has paid scant attention to natural family planning methods in the contraceptive literature, despite the United Nations’ estimate that 41 million couples worldwide used some form of natural family planning (Freundl et al., 2010 ). We located only three articles that referenced sexual outcomes associated with natural family planning (Badcock et al., 2014 ; Fataneh et al., 2013 ), one of which was a systematic review of fertility awareness–based methods (Freundl et al., 2010 ). The review highlighted increased bodily awareness and self-control as common positive experiences among natural family planning users (Freundl et al., 2010 ). Particularly given the necessity of couple participation with these methods, couple factors are likely to influence uptake and sexual acceptability. Many couples may choose natural family planning methods due to their “naturalness,” facilitation of skin-to-skin contact, and/or lack of hormonal influences. However, these methods do not allow for spontaneous sexual activity during periods of peak fertility—a phenomenon that could serve as a sexual turn-off for many potential users. Another turn-off could be these methods’ relatively high typical-use failure rates, which could stymie sexual disinhibition. On the other hand, couples who feel ambivalent about pregnancy intentions and/or who want a pregnancy to “just happen” could deliberately select natural family planning methods for the positive attributes listed.

This review has documented an almost dizzying array of ways that contraceptives affect women’s sexual well-being in both positive and negative ways, from direct hormonal or even genetic impacts on sexual functioning and indirect psychosexual impacts of efficacy or side effects, to more subjective assessments of contraceptive-related pleasure and satisfaction for/among both women and their partners. The model proposed in Part 1 groups these factors into several socioecological layers: gender, cultural and structural factors, relationship factors, and individual factors. Though a few findings are unidirectional across studies (e.g., no women reported that condoms enhance sensation or that breast tenderness improves one’s sex life), many other themes show strong variability—with the very contraceptive feature sexually desired by one woman disdained by another (e.g., timing/method of application, effect on menstrual bleeding). However, several trends, take-home messages, and recommendations for future research stand out. Here, we review four. First, the array of studies documented here provides clear evidence that the way contraceptive methods affect women’s well-being matters to their overall happiness with their methods, which in turn influences continuation and, over time, exposure to unintended pregnancy. Moreover, these effects matter regardless of whether methods are “truly” or solely responsible for any sexual changes; even if stress, fatigue, and/or relationship factors are more likely the causes of sexual detractions, women’s perceptions of what caused these changes will ultimately shape contraceptive acceptability and behavior (Enzlin et al., 2012 ). Along the same lines, women’s concerns about contraceptive side effects can be more influential than actual side effects in shaping women’s willingness to try to continue using certain contraceptive methods (Frost, Lindberg, & Finer, 2012 ; Gilliam, Warden, Goldstein, & Tapia, 2004 ; Westhoff et al., 2007 ). Similarly, women’s perceptions of how contraceptives might affect their—or their partners’—sexual well-being will influence their contraceptive decisions (Higgins et al., 2015 ). Furthermore, though contraceptive efficacy is important to women, “not interfering with sexual pleasure” may be an equally if not more important contraceptive criterion (Gomez & Clark, 2014 ). After all, women do not engage in sexual activity to use contraception; they do so for a host of other sexual, psychological, and relational reasons, and it makes sense that they want their contraceptives to align with these reasons and goals. However, a second trend that emerges is that the overwhelming majority of the literature we reviewed for Part 2 in particular—that is, analyses that included sexual outcomes in relationship to contraceptive use—focused overwhelmingly on sexual functioning and not other aspects of the model, including women’s sexual perceptions or preferences. A focus on sexual functioning was especially common with methods involving hormonal configurations, particularly OCs—the most commonly used contraceptives in the United States (Daniels et al., 2014 ). The majority of these studies on hormonal methods employed more classic measures of sexual functioning (such as the FSFI) and/or biomarkers such as serum hormone levels, blood flow, or physical changes to women’s genitalia. 7 7 Even in studies that do measure functioning, more research is needed to determine whether standard cutoff points for determining “sexual dysfunction” are accurately identifying women who are distressed with their sexual life or sexual function (e.g., see Gabalci & Terzioglu, 2010 ). Such research is undoubtedly important, especially given the minority of women who do experience negative effects on sexual functioning, particularly libido (Bancroft et al., 2006 ), and who discontinue as a result (Sanders et al., 2001 ). On the other hand, while the concept of women’s physiologic sexual functioning should be vital to all contraceptive research, a narrow concentration on this one outcome fails to capture the other psychological, relational, or cultural factors that matter to actual contraceptive users and/or that influence contraceptive preferences and sexual practices. Extremely few studies in this review approached sexual acceptability using the kind of broader ecological approach we proposed in Part 1. Even if studies are not able to collect data on all levels of the model, researchers could at least comment in their discussion sections about how findings must be considered within the context of the couple, cultural constructions of sexuality, and/or social location, all of which may moderate results. Even at the individual level, we recommend the development and use of a more multifaceted measure of sexual acceptability that collects information on more than physiologic sexual functioning—work that we are engaging in ourselves and encourage others to do as well. We also argue that more research is needed on the interplay between solo and dyadic aspects of sexuality among couples using contraception (Elaut et al., 2012 ). Even in studies that do measure functioning, more research is needed to determine whether standard cutoff points for determining “sexual dysfunction” are accurately identifying women who are distressed with their sexual life or sexual function (e.g., see Gabalci & Terzioglu, 2010 ). Third, our review uncovered a number of limitations in study design. 8 8 Although it is a limitation directly related to study design, readers of this literature should also be mindful of studies that are sponsored by pharmaceutical companies versus nonsponsor funders. Pharmaceutical-sponsored research may be less likely to report contraceptive methods’ negative outcomes (Kemmeren, Algra, & Grobbee, 2001 ; Lexchin, Bero, Djulbegovic, & Clark, 2003 ), including those related to sexuality. (Many of these limitations have been discussed in a variety of places in the literature; for a small sampling, see (Bancroft & Graham, 2011 ; Bastianelli et al., 2011 ; Davis & Castano, 2004 ; Graham et al., 2007 ).) For example, many of the studies reviewed in Part 2 were cross-sectional. Cross-sectional study designs are unable to document sexual changes over time with continued contraceptive use; neither do they allow researchers to control for baseline characteristics that might influence both contraceptive choices and sexual outcomes. Furthermore, reports of negative sexual outcomes may be underestimated given that many of those women whose sexuality was negatively affected by a particular method will have already discontinued using it. Another limitation of some studies is insufficient sample size to compare methods and/or offer an appropriate comparison or “control” group. We acknowledge that no ideal, noninterventional control group exists for this type of research: women using no method, sterilized women, and/or women using natural family planning methods are likely to differ meaningfully from women using (other) reversible methods and thus are not a useful comparator (Higgins & Davis, 2014 ). On the other hand, researchers should at least consider recruiting new-start contraceptive users and collecting baseline data on factors such as functional health, relationship length and satisfaction, and other factors that could affect both contraceptive choice and sexual outcomes. On a related note, only a few studies in this review (e.g., Sanders et al., 2001 ) have been able to follow women for several months, a year, or longer periods of time to assess whether sexual outcomes at one time point can help predict method satisfaction and continuation at another time point. If the ultimate goal is to help direct women to methods they will like and use over time, thereby realizing the full benefits of contraception, we also need to document the degree to which sexual acceptability affects overall continuation and satisfaction compared to factors such as efficacy, access and cost, (nonsexual) side effects, method of administration, and other contraceptive features (Gomez & Clark, 2014 ). Although it is a limitation directly related to study design, readers of this literature should also be mindful of studies that are sponsored by pharmaceutical companies versus nonsponsor funders. Pharmaceutical-sponsored research may be less likely to report contraceptive methods’ negative outcomes (Kemmeren, Algra, & Grobbee, 2001 ; Lexchin, Bero, Djulbegovic, & Clark, 2003 ), including those related to sexuality. A fourth and final observation worth noting from our review is the absence of research on how to integrate sexual acceptability into educational, medical, or other program settings. Although we surely need more clinical studies that document methods’ sexual acceptability for women and their partners, we also need much more research on how to practically apply the outcomes of sexual acceptability studies to serve actual contraceptive clients. Due to the wide array of what women find sexually acceptable about contraception, the field (and women!) would be well served by investing research efforts in devising broader, more individualized measures of contraceptive sexual acceptability, with the ultimate goal of creating an algorithm that better links individual women with methods that align with their individual sexual preferences, lives, and relationships. This new scale or index of sexual acceptability could be useful in web-based tools and educational, clinical, and promotional programs. We also urge reproductive health researchers to devise and evaluate tools to help clinicians, educators, counselors, and other practitioners avail themselves of the larger sexual acceptability literature and amend their contraceptive counseling practices as a result. We conclude by advocating for a sex-positive approach in both research and programs and policies relating to contraception. Although we argue that sexual acceptability measures should be a standard part of contraceptive research and development, as well as all contraceptive acceptability studies, we also encourage incorporating and valuing women’s sexual pleasure, satisfaction, and well-being in public health discourse or even commercial efforts that promote contraceptive methods. Some researchers and practitioners have similarly advocated for the benefits of using pleasure-philic, sex-positive messages to promote condoms and other contraceptives (Philpott, Knerr, & Maher, 2006 ). Along similar lines, sex workers have described how they can increase successful use of both male and female condoms by emphasizing their pleasure for both partners, or by applying condoms in sexually appealing ways (Free et al., 2007 ). Positive sexual aspects of methods could greatly strengthen our counseling, marketing, and educational efforts. For example, by highlighting the sexual disinhibition benefits associated with very effective methods, counselors could help encourage use of IUDs and implants. Acknowledging that contraceptive users want methods that enhance their sexual well-being (or at least do not undermine it), we are more likely to take a patient-centered approach in our research and programs and, more specifically, our efforts to promote contraception and women’s well-being.

We employed a narrative review approach, which provides a broad overview of the topic area (Bettany-Saltikov, 2010a , 2010b ). This approach is apt for our goal of defining and then applying a novel concept versus methodically investigating a narrow, clearly defined question (per systematic reviews). The narrative approach is particularly well suited for topics in which vast evidence is lacking, as investigators can make recommendations or conjectures based on their work with the broader literature. Though explicit search protocols are more common in traditional systematic reviews than narrative reviews, we nonetheless used specific search criteria and terms to create boundaries for our endeavor. Our search terms in PubMed, Web of Science, CINAHL, and PsycINFO were as follows: (contraception OR contraceptive OR contraceptive device OR contraceptive devices) AND (pleasure OR libido OR “sexual function” OR “sexual functioning” OR sexuality NOT [“sexual behavior” OR “sexual health”]). Since we wanted to conduct a review of all contraceptive methods that have been approved by the Food and Drug Administration (FDA), not merely one type of method (as is more common), we elected to limit our search to a particular time frame. We focused on the past decade (2005–2015) given both the relatively rapid pace at which contraceptive technology evolves and the fact that second-generation IUDs and implants have only made a resurgence in the last five to 10 years. We thus limited the search to English language articles published in the past 10 years (2005–2015). We identified several other sources from earlier years given their particular relevance to the topic. After removal of duplications, the original search located 3,001 references (1,819 in PubMed, 438 in Web of Science, 661 in CINAHL, and 418 in PsycINFO). We enlisted a third, doctoral-level colleague with expertise in this area to help with the first review of these 3,001 references. Two people initially reviewed each title and abstract (sometimes the entire piece as well) to identify articles, chapters, commentaries, and other works that spoke to or informed some knowledge of the relationship between sexual experience and contraception use. Based on these assessments, each piece was placed into a yes, maybe , or no file. The first author then reviewed all those labeled as maybe ; she placed nine of these additional references in the yes category, for a total of N  = 485 citations identified for review in the next stage. The second author then categorized each citation based on the contraceptive method(s) covered and/or the section(s) of the review for which it was relevant. During the final review stage, we read each article to identify which best informed our understanding and conceptualization of sexual acceptability. For Part 1, we worked more closely with a subset of 264 citations, including articles, commentaries, book chapters, and dissertations; for Part 2, we identified 226 sources that referenced sexuality in relation to contraception use. Of those, 103 peer-reviewed articles explicitly measured sexual outcomes. We summarize these 103 studies in Table 1 . (For a more detailed outline of each of these 103 articles, please see our Supplemental Table online.) For the purpose of this review, our focus pertains to currently available contraceptive methods that people use primarily for pregnancy prevention. We acknowledge that many women use hormonal methods in particular for a variety of noncontraceptive benefits, from relieving severe menstrual pain to reducing acne or excess hair growth. One nationally representative survey found that upward of 14% of oral contraceptive users in the United States reported using the pill for noncontraceptive purposes only (Jones, 2011 ). However, given that the overwhelming majority of contraceptive methods are used at least in part to prevent pregnancy, we have focused our attention here on healthy populations of reproductive age and—to the best of our knowledge, based on the source—of reproductive capacity. Examples of articles we thus reviewed but ultimately excluded comprised studies of oral contraceptive use among postmenopausal women, acceptability of rectal microbicides among gay men, and contraceptive practices among women with special health issues (e.g., epilepsy, cancer, or endometriosis), though certainly these populations require tailored, patient-centered contraceptive care. However, we acknowledge that relatively healthy, reproductive-age people often use contraception for a wide variety of purposes, not only to prevent pregnancy, and that these purposes may well affect sexual acceptability. Although we highlight men’s roles when appropriate, we focus primarily on women’s sexual experiences of contraceptive methods given the dearth of women’s perspectives in the existing literature. Moreover, though condoms (and some of the other multipurpose technologies) can prevent transmittal of human immunodeficiency virus (HIV) and STIs for a variety of sexual acts, and can affect both partners involved, we focus here on penile–vaginal intercourse—and primarily on women’s experiences. That said, we make no assumptions about the sexual identities of women who have penile-vaginal intercourse and/or who use contraception. A growing body of research suggests that a large proportion of unintended pregnancies occur among sexual minority women (Charlton et al., 2013 ; Rosario et al., 2014 ), and many sexual minority women thus face situations in which they wish to prevent pregnancy in a sexually acceptable way. Finally, this review does not rigorously evaluate the methodological quality of all available studies; interested readers should refer to such critiques elsewhere (Bancroft, Hammond, & Graham, 2006 ; Graham & Bancroft, 2013a , 2013b ; Hong, Wu, & Fan, 2008 ). Rather, our purposes here are, first, to enlighten and broaden the concept of how contraceptives can influence sexuality and, second, to use the wider literature to overview method-by-method sexual acceptability when considered in a context more comprehensive than sexual physiology alone.

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