Sexual Behaviour and Fantasies in a Group of Young Italian Cohort

Over the years, sexual behaviour has changed due to the growing interest in everything related to the sexual sphere. The purpose of the study was to collect information on the sexual habits and behaviours of Italian people of all ages, sexes and sexual orientations and to describe the patterns of sexual behaviour, with the aim of gaining a representative picture of sexuality in Italy, before the COVID-19 pandemic. Participants completed a survey with 99 questions about their sexual habits. In our group first sexual experiences occurred on average around the age of 15, whilst the median age of the first sexual intercourse was 17. The fantasies that most stimulated and excited our group (Likert scale ≥ 3) was having sex in public (63.9%), having sex with more than one person at the same time (59.4%), blindfolded sex (64.9%), being tied up (56.3%) and observing a naked person (48.6%). As for pornography, we have shown that 80% of our group watched porn at home, alone or from their smartphones. Our results have several practical implications for the areas of sex education and sexual health. It is necessary to safeguard the health of young people and support them increasing their sexual well-being.


Introduction
Sexual behavior has consistently changed over the years. In fact, there is a growing interest in specific topics that have been considered a stimga in the past, and also physicians should constantly pay attention to patients' preferences [1,2].
Scientific evidences have underlined that the majority of information on sexuality collected through the internet by young people regard explicit messages including and facilitating sexual practices like autoerotism and masturbation [3].
Exploring patterns of current sexual behaviours is important for several reasons, but mainly because the description of behavioural trends can provide an important empirical context for examining the associations between patterns of emerging sexual behaviour and aspects of sexual health and well-being among young people [4]. A recent survey by Herbenick et al. (2020) observed that more frequent past-year pornography use and a greater lifetime range of pornography accesses were significantly associated with engaging in both dominant and target sexual behaviors among all participants [5]. Furthermore, sex aids are also considered tools to help individuals achieving sexual pleasure and can also be particularly helpful for sexual dysfunction [6]. Indeed, sexual fantasies play a major role in influencing later sexual behavior, in reflecting past experiences and these are a core variable in the systematic study of sexual identity and sexuality [7]. Italian society has generally less favourable attitudes towards unions that differ from the traditional wedding [8]. This could be due to the presence of the Catholic Church [9].
Furthermore, although teenagers have the tendency to have their first sexual relationship earlier than had been reported in the past, in Italy it has been observed a decrease of marriage and birthrate [10].
All these considerations may arise some questions about the social background of Italy and the influence on many aspects of sexuality, including internet pornography, sex toys and sexual orientation.
Interestingly, Ross et al. [11] showed that between participants who reported using the internet to retrieve information on sexuality, younger participants displayed higher use of the medium compared to older participants, as well as bisexual men compared to heterosexual men, and males compared to females, respectively, suggesting as internet may facilitate sexual fantasies. Moreover, Daneback and Löfberg [12] suggested that using internet facilitates the expression as well as the engagement of individuals in new experiences, to a degree that would normally be not tolerated.
Finally, The COVID-19-related lockdown has profoundly changed human behaviors and habits, impairing general and psychological well-being with psychosocial consequences on sexual behavior. Jannini et al. demonstrated that anxiety and depression scores were significantly lower in subjects sexually active during lockdown [13]. In particular, sexual activity, and living without partner during lockdown as significantly affecting anxiety and depression scores [13].
Based on all these premises, the scope of web survey was to collect information about sexual habits and behaviours of Italian people of all ages, genders and sexual orientations and to describe patterns of sexual behaviour.

Materials and Methods
A quantitative correlational research design was implemented for this study to evaluate the sexual habits in Italian participants in all gender and sexual interest. The study was conducted from 1 June 2019 to 31 December 2019.
Participants were selected through posts on social networks (Instagram and Facebook) and the survey was developed and administered online through Google Forms. Each participant gave the consent to complete the study.
Basic demographic information was collected: gender, age, height, weight, smoking habit, place of residence, sexual orientation, education level, religion and relationship status and duration.
After that, participants completed a survey with questions about their sexual habits. The questions evaluated a variety of aspects: frequency and pleasantness experienced when being involved in various sexual activities (self-stimulation, being masturbated by the partner, masturbate the partner, receiving and giving oral sex, vaginal penetration, receiving and giving anal penetration), sexual satisfaction, frequency of orgasm, stimuli used to get aroused during auto-eroticism, the use of sex toys, pleasantness of various sexual fantasies, pornography use, betrayal, traumatic sexual experiences, stress, contraception, protection against sexually transmitted infections, use of medications or drugs, use of dating apps or sites and sexting.
The survey was conducted in Italian according to the Checklist for Reporting Results of Internet E-Surveys [14].
All the study procedures were carried out in accordance with the Declaration of Helsinki (2013) of the World Medical Association. The survey was anonymous and participants provided their consent to participate.

Statistical Analysis
The qualitative data was tested using the chi-square test or Fisher's exact test, where appropriate, while the continuous variables, presented as median (interquartile range [IQR]), were tested using Mann-Whitney U-Test or Student t test according to their dis-tribution (according to the Kolmogorov-Smirnov test). For all statistical comparisons, significance was considered as p < 0.05.

Sexual Experience
We questioned responders about their sexual behaviors and we investigated the frequency of each experience by dividing them into "Never", "Few times a year", "About once a month", "About once a week", "Several times a month "," Several times a week "," Several times a day "and" Every day ". These results are shown in Table 2.

Sex Toys, Sexual Pleasure and Pornography
We asked which sex toys were used during autoeroticism. We investigated what brought pleasure and arousal. The answers were expressed according to the Likert scale, where 1 indicates "not pleasure", 2 indicates "a little pleasure", 3 indicates "enough pleasure", 4 indicates "very pleased" and 5 indicates "maximum pleasure". These results are shown in Supplementary Table S1. Table 3 shows results of sex toys usage, types and use frequency. With our survey, we investigated the use of pornography, by asking in which context, how often and which type of pornographic material they prefer to use (Table 4).   At the chi-square test we demonstrated that heterosexuals, homosexuals and bisexuals and were more likely to watch porn more than several times a week (40.9%, 56.4% and 47.4%) respect to Demi (24%), Queer (40.9%) or Pansexual (39.7%) (p < 0.01).
The rate of watching lesbian among male, female and other were 22.5%, 77.1% and 0.4% respectively, while for 18 years old/Teenagers/Young category they were 80.9%, 18.9% and 0.2% respectively.

Contraception and Frequency of Sexual Intercourse
We also investigated the use of contraception, the frequency of sexual intercourse and masturbation and the frequency of reaching orgasm (Supplementary Tables S2 and S3).

Use of Substances and Dating App
We investigated the possible use of exciting substances, drugs and substances that increase sexual potency (Table 5).    Male were more likely to use drugs always than other categories (90.9% vs. 1.1%; p < 0.01) and similar heterosexuals (81.8% vs. 9.2%; p < 0.01).
Finally, we investigated the use of social networks or dating sites to find partners with whom to have sex, and we asked what type of material was exchanged on these platforms. The results are indicated in Supplementary Table S4.

Discussion
Our survey has investigated contemporary sexual behaviour in Italy before COVID-19 pandemic in most of its forms, taking into consideration any gender and sexual orientations. When it comes to sex, there is always plenty of curiosity, but, at the same time, often reticence and embarrassment.
Very often, the interest in the sexual habits of the healthy general population is not properly studied. Most of the studies in the literature, in fact, focus on various pathologies of interest and on specific clinical outcomes. However, it is also important to have information on the sexual habits of the healthy general population in order to be able to establish future educational measures but also to provide data on the potential economic impact of the world regarding "sex". Furthermore, considerable interest in the psychological aspects of sexual dysfunctions is also emerging from some international guidelines [15].
Given that the pleasure that sexual pleasure is a fundamental component of sexual health, devices designed to enhance and diversify sexual pleasure could be particularly useful in clinical practice. Despite their growing popularity and widespread use in various biopsychosocial circumstances, many taboos still seem to exist, as indicated by the paucity of scientific literature on the prevalence, application and effectiveness of sexual devices for therapeutic use [16].
Interestingly, compared to our European fellows, the use of sex toys in Italy is not widespread. In fact, a study of Döring et al. (2019) showed that in Germany about 50% of the respondents reported using sex toys both when masturbating and in presence of a partner [1]. Instead, our survey showed that only between 20 and 30% of the participants use sex toys and the preferred ones seem to be plugs. The fantasies that most stimulate and excite our participants are having sex in public, having sex with more than one person at the same time, blindfolded sex, being tied up and observing a naked person.
As concerning anal sex, about 80-90% of the respondents answered that they did not practice it. A study by Habel et al., conducted in the general population of the United States between 2011-2015, reported that the prevalence of anal sex among heterosexual people is between 33-38%, which is slightly higher, compared to previous years [17]. It is possible that, in Italy, sexual freedom and the desire to experiment with new sexual practices might be overshadowed by a common feeling of shame. However, we have to consider the high rate of heterosexual respondents in our study.
As for pornography, our results are in line with the study of Herbenick et al. [5], with 80% of our participants watching porn at home, alone or from their smartphones.
Previously, we have demonstrated a positive association between porn addiction and erectile function, suggesting that a normal balancing between sexual activity, masturbation and pornography [18].
Furthermore, the impact of pornography on sexual behaviour is extremely important, expecially during previous COVID-19 pandemic.
In fact, different studies demonstrated an increased interest in pornography and coronavirus-themed pornography after the outbreak of COVID-19 in both eastern and western countries [19,20].
All these data reflect the development of faster internet connections and the pervasive distribution of smartphones, that have somehow partially replaced the use of larger computers and devices, making pornography even more easily and discreetly accessible from everywhere, at any time, and its importance in the context of sexual behaviour.
The most worrying data that arises from our survey is that only 66% of the respondents use condoms and only 37% use them regularly, when in a stable relationship. Since in our cohort the rate of occasional partners (10.5%) and polyamorous relationship (1.2%) were low, we believe is fundamental that new and more incisive awareness campaigns should be carried out, in order to avoid the spread of sexually transmitted diseases.
Strenght of the current study are represented by the inclusion of a large number of participants and to have investigated different aspect of sexuality and sexual behaviour. Our results could be useful for further researches in the field and to have a photography of sexual behaviuour of a young Italian population Limitations of our study include the lack of investigation of older people, due to the use of Internet as source of enrolment, and the use of not standarized questionnaires. Futhermore, sexual habits and behaviours of may be different after COVID-19 pandemic and they should be taken into account by future researches. Finally, our cohort was young and it may be not representative of the general population.

Conclusions
Our survey was born with the aim of gaining a representative picture of sexuality in Italy before COVID-19 pandemic. There is still much to be done in order to increase people's awareness of sexual pleasure and get to the point of feeling free to express sexual desires to a partner, without fearing to be judged. But even more important, it is necessary to increase awareness campaigns for the prevention of sexually transmitted diseases, especially among young people, who are more at risk, since they have fewer stable relationships and therefore often relate with different sexual partners. Moreover, our results can have several practical implications for the areas of sex education, sexual health and to counteract sexual dysfunction during COVID-19 pandemic. Given the current trends of sexual habits, it is necessary to safeguard the health of young people and support them by increasing their sexual well-being.
Supplementary Materials: The following are available online at https://www.mdpi.com/article/10 .3390/jcm10194327/s1, Table S1. Sexual pleasure patterns in the all population, Table S2: Contraception use in the all cohort, Table S3: Sexual intercourse patterns, Table S4: Dating app use in the all cohort.