Women of all sexual orientations engage in sexual behaviors that put them at risk for acquiring HIV and other STDs, and should therefore receive counseling on prevention, although patterns of behavior differ by orientation.1 In a cross-sectional survey among women in primary care settings, the reported prevalence of lack of condom use with a male partner was highest among heterosexual women (54%), the prevalence of regular substance use during sex was highest among bisexual women (36%), and the prevalence of sex with bisexual men was highest among lesbian women (36%).
Investigators administered anonymous surveys to women visiting 33 primary care medical facilities in 11 states and the District of Columbia during 1996–1997. Sampling was designed to achieve roughly equal numbers of heterosexual respondents and of bisexual or lesbian respondents. The surveys asked about access to health care, use of screening tests, general health, substance use and demographic information. In addition, women were asked to indicate their sexual orientation, to provide information on sexual behaviors and on testing for HIV and other STDs, and to rate their perceived susceptibility to HIV infection.
The 1,304 women studied were, on average, 40 years of age. Most were white (83%) and had had at least some college education (92%). The majority (61%) had an annual household income of $40,000 or more. Some 49% of women reported that they were heterosexual, 40% that they were lesbian and 11% that they were bisexual.
Overall, 71% of women were married or in committed relationships. In the past year, 49% had had sex with men and 43% had had sex with women; on average, they had had 1.4 male and 1.5 female partners during this time. Among women who had had sex with men in the past year, 49% had never used condoms; 6% had had intercourse with bisexual men, and 2% with men who were injection-drug users. In addition, 23% of all women who had been sexually active in the past year said that they were always drunk or high on drugs during sex. Only 1% of women had had sex in exchange for money, drugs or shelter in the year before the survey. Some 59% of all women perceived their chance of HIV infection to be high, while 36% perceived that they had no chance of infection; 62% had ever been tested for the virus. In addition, 78% of women had ever been tested for another STD.
The prevalence of most of the sexual behaviors studied differed significantly by sexual orientation. The proportion of women who were married or in a committed relationship was highest among lesbians (78%), intermediate among heterosexuals (69%) and lowest among bisexuals (60%). Relative to other women, bisexual women had had more male sexual partners, and lesbians had had more female partners, in the past year. The proportion ever having used condoms with male partners in the past year was 94% among lesbian women, 75% among bisexual women and 46% among heterosexual women. Intercourse with bisexual men in the past year was markedly more prevalent among lesbians and bisexuals (36% and 22%) than among their heterosexual counterparts (3%). Some 6% of lesbian women had had sex with male injection-drug users in the year before the survey, while 4% of bisexual women and 2% of heterosexual women had done so. A greater proportion of bisexuals than of heterosexual and lesbian women reported always having been drunk or high during sex in the past year (36% vs. 24% and 19%).
Perceived susceptibility to HIV infection and testing patterns also differed significantly by sexual orientation. Thirty-nine percent of heterosexuals, 36% of lesbians and 23% of bisexuals perceived that they had no risk of HIV infection. The prevalence of HIV testing was 77% among bisexuals, 68% among lesbians and 54% among heterosexuals. Bisexual women also had the highest prevalence of STD testing (91%), followed by heterosexuals (79%) and then lesbians (73%).
Subsequent analyses focused on women who had had sex with men in the past year. Compared with their bisexual and heterosexual counterparts in this subgroup, lesbians averaged more male sexual partners during the year (2.4 vs. 2.2 and 1.4) and reported the highest prevalence of intercourse with bisexual men (36% vs. 22% and 4%). Some 38% of bisexual women were always drunk or high during sex, compared with 24% of heterosexuals and 12% of lesbians.
According to the analysts, the study’s findings highlight the need for HIV and STD prevention programs for all women, regardless of their sexual orientation. They recommend a combination of nonjudgmental history-taking and counseling tailored to a woman’s risky behaviors. “Universal principles of sexual risk reduction (applying to sexual partners of either gender) should also be discussed, particularly for younger patients or patients whose sexual identity is in flux,” they assert.
The author of an accompanying editorial recommends that health care providers and researchers discard assumptions about lesbians, which contribute to the perception that this group is at low risk for STD transmission.2 Such assumptions, she contends, stand in the way of effective prevention efforts and research. Greater insight into lesbians’ social and sexual dynamics not only would help advance understanding of STD transmission in general, “but more immediately, would inform a cogent approach to counseling lesbians and other ’low-risk’ women, and educating healthcare pro-viders about STD-related risk and prevention,” the editorialist concludes.
1. Koh AS et al., Sexual risk factors among self-identified lesbians, bisexual women, and heterosexual women accessing primary care settings, SexuallyTransmitted Diseases, 2005, 32(9):563–569.
2. Marrazzo JM, Dangerous assumptions: lesbians and sexual death, editorial, Sexually Transmitted Diseases, 2005, 32(9):570–571.