Muzny, Christina A. MD*; Harbison, Hanne S. MHS, MSN, CRNP*; Pembleton, Elizabeth S. MPH†; Austin, Erika L. PhD*
Women who have sex with women (WSW) and women who have sex with women and men (WSWM) are distinct subpopulations of women with unique sexual health concerns.1 They are often not identified as such by health care providers because of lack of sexual behavior disclosure and providers’ assumptions of heterosexuality when taking sexual histories.2 Owing, in part, to this invisibility, there continues to be confusion and incorrect assumptions regarding sexually transmitted infection (STI) risk among this group of women. Although commonly believed to be at low risk for STIs, a number of studies have demonstrated that rates of STIs among WSW/WSWM are similar to rates among heterosexual women,3,4 with some subgroups of women (i.e., WSWM) having even higher STI rates than their heterosexual counterparts.5 The risk of STI transmission between women is dependent on the STI in question and the specific sexual practices in which women engage.6,7 There is considerable evidence that WSW/WSWM frequently engage in sexual behaviors that put them at risk for STI acquisition.6,8–12 Most notably, most WSW/WSWM report past or concurrent sexual relationships with men,4,7,10,12 and some studies suggest that WSW/WSWM are more likely than heterosexual women to engage in high-risk sexual behaviors including larger numbers of male sexual partners,5,13 anal intercourse with men,5 and failure to use barrier methods for protection.4,5,10 Nevertheless, WSW/WSWM are often perceived by both health care providers14–17 and WSW/WSWM themselves to be at extremely low or no risk for STI transmission18–20 and therefore not in need of STI screening or risk reduction counseling.
Data on the sexual health of African American WSW/WSWM are more limited than the data for WSW/WSWM as a whole because most existing studies on WSW/WSWM have drawn predominately on samples of white women living in the Northeastern and Northwestern United States.6,9,10,12,21,22 Rates of HIV and other STIs are known to be disproportionately high among African Americans, especially among those living in the Southern United States23; it is therefore likely that African American WSW/WSWM are at an even higher risk for STIs and other negative sexual health outcomes than their white counterparts. A study by Muzny et al.24 of 196 African American WSW/WSWM in Jackson, Mississippi, found significantly higher rates of 2 common STIs (Trichomonas vaginalis and Chlamydia trachomatis) than in previously published studies of WSW/WSWM. African American women in this study who reported sex with both women and men were more likely to engage in high-risk sexual behaviors and have higher rates of STIs compared with women who reported sex exclusively with women.
Greater insight into the perceptions and experiences of African American WSW/WSWM are necessary to better understand the context surrounding their increased risk for STIs and to inform development of appropriate sexual health services tailored to this population. The objective of this study was to explore sexual behaviors, perceptions of STI risk, and practice of safe sex among African American WSW/WSWM living in the Southern United States, a region of the country where disclosure of nonheterosexual sexual behavior to health care providers and open discussion of same-sex behavior may be less common because of conservative social norms.25
MATERIALS AND METHODS
Participants were recruited from the Jefferson County Health Department (JCDH) Sexually Transmitted Disease (STD) Clinic and through word of mouth in Birmingham, Alabama, to participate in focus group discussions exploring African American WSW/WSWM’s sexual behaviors with women, perceptions of STI risk from female (and male) sexual partners, and practice of safe sex (i.e., condom use on sex toys and on male sexual partners, use of latex gloves for digital penetration, use of dental dams to cover the genital area during oral sex, etc.). Eligibility criteria included African American race, age 16 years or older, self-report of sexual activity (oral, vaginal, and/or anal) with a female partner during the past 12 months, and self-report of sexual activity (oral, vaginal, and/or anal) with a male partner during the past 12 months (WSWM only). Focus groups were initially stratified by both age (16–24 years vs. ≥25 years) and reported history of sex with men during the past 12 months (WSW vs. WSWM) because we hypothesized that exposure to different sexual practices, perceptions of STI risk, and practice of safe sex might differ between age and sexual behavior groups. However, owing to difficulty recruiting sufficient numbers of WSW and WSWM aged 16 to 24 years to participate in their representative focus groups, focus groups were subsequently stratified by age only to allow younger women to continue to participate in the study.
The University of Alabama at Birmingham Institutional Review Board approved this study. Oral informed consent was obtained from all participants. Participants received a cash incentive for their participation in the focus group discussions.
The participants completed a brief anonymous survey at the beginning of each focus group to provide a general demographic and behavioral context for the results. The moderators (authors C.M. and E.A.) posed 4 open-ended questions to guide each focus group discussion (Table 1). These questions evolved as the study progressed, as findings from previous focus groups were incorporated into subsequent focus groups. Women were encouraged to speak from the perspective of women in their community, both to illustrate community norms and understandings and to limit the amount of personal information shared. Focus groups lasted 1 to 2 hours each and were audio-recorded.
Digital audio-recordings were professionally transcribed and analyzed using HyperRESEARCH qualitative software.26 A list of codes was collectively developed by the research team based on recollection of important themes that emerged during the focus group discussions, multiple readings of the transcripts, and review of debriefing memos written by team members after each focus group session. Transcripts were then coded to illustrate the relative frequency of each code and to identify representative quotes. Whether emerging themes varied systematically by age (16–24 years vs. ≥25 years), the factor by which all focus groups were stratified, was also explored.
Between August 2011 and March 2012, a total of 79 eligible women (n = 36 for women aged 16–24 years and n = 43 for women aged ≥25 years) were invited to participate in this study, 73 of whom were recruited from the JCDH STD clinic and 6 of whom were recruited through word of mouth in the community. Among these 79 women, 25 (34.2%) of 73 recruited at the JCDH STD clinic and 4 (66.7%) of 6 recruited through word of mouth subsequently participated in focus group discussions. Seven focus groups with 29 total participants (n = 12 for women aged 16–24 years, 3 of whom were recruited through word of mouth, and n = 17 for women aged ≥25 years, 1 of whom was recruited through word of mouth) were conducted (Table 2). Characteristics of the focus group participants are shown in Table 3.
After initial qualitative data analysis, contrary to our expectations, no clear thematic differences between participant responses during the focus group sessions were noted based on age. Thus, the results of the study are presented for the focus group participants as a whole.
Focus group participants reported a range of sexual behaviors with their female partners, comparable with those reported in other studies.11,19,24,27,28 Oral sex, digital penetration (“fingering”), and vaginal grinding or bumping were mentioned frequently, although participants varied greatly in their preferences for these behaviors. Several women reported not engaging in oral sex with their female partners, and some expressed concern that health care providers often mistakenly believe that oral sex is universally practiced by WSW. One participant noted, “People, scientists, whoever, think that the only thing that women do with each other is oral sex… They don’t think that we’re going to be bumping vaginas or using toys… The only thing that they think about with lesbians is oral sex, you know?” Still, many women reported a strong preference for oral sex, often noting that their enjoyment of sex with female partners derives, in part, from the belief that women are more skilled at performing oral sex than men.
Moderator: Well, so why do you all choose to have sex with a woman versus a man? What do you get out of it?
Participant: I like it, because I like the oral sex.
Moderator: From which one?
Participant: From the woman. I think a woman can give better oral sex than a man can.
The use of sex toys was also common in this community. Participants shared a common language around the use of “the strap,” referring to the harness that is used to strap a dildo to a woman’s body to enable her to penetrate her partner. Women were divided in their preferences regarding the use of the strap and indicated that its use was strongly informed by the “stud” (dominant partner)/”femme” (less dominant partner) norms prevalent in this community (i.e., studs are more likely to wear the strap than femmes).
Perception of STI Risk
Broadly speaking, women in this study possessed a solid understanding of the behavioral principles associated with STI transmission in sexual partnerships with men, including unprotected sex or sex with multiple or concurrent partners. This knowledge seemed to derive from women’s recollections of school-based sex education or information provided by health care providers, both of which focused primarily on heterosexual sex. As a result, women perceived the risk of STI transmission between women to be low or nonexistent, especially relative to the risks associated with heterosexual sex. Said one participant, “…it’s a popular belief if you are a lesbian, you probably won’t catch anything, just for the simple fact that some lesbians do but most don’t. But if you’re with a male, you’re more likely to catch something.” Women frequently bemoaned the lack of reliable information available regarding the risk of sex between women, often asking the moderators to provide them with “correct” information at the conclusion of the focus group.
A careful examination of perceptions regarding STI transmission risk between women revealed that women’s efforts to apply their available knowledge of heterosexual sex to their experiences with women resulted in a number of inaccurate conclusions regarding the sources of STIs and how they are transmitted between sexual partners (Table 4). For example, a central theme in the focus groups was that men are the source of STIs. Some women based this on personal experiences: “Being with a female and a male, [with] a male I got an STD. I’ve been with the same girl for five years and I never had an STD.” This perception seemed to be based on informal calculations of risk, such that men transmit STIs more effectively than do women (“Just sleeping around, whether you’re sleeping with a hundred women or you’re sleeping with two men…it increases the risk of STD.”) and more quickly than women (“I just feel like you can catch something quicker from a male than you can a female.”) The participants noted that when women do become infected with STIs, it is caused by men and the women who have sex with men. As one woman said, “I think that if girls have STD’s, it’s from females going and having sex with males. I’m not saying you always get it from males, but I think it’s more females are having sex with males, then coming back and having sex with a female.”
Although the participants associated STIs with men, blame and negativity were particularly directed toward women who had sex with men and brought STIs back to their female partners. This hostility was surprising given that half of the focus group participants reported sex with both women and men in the past 12 months. These discussions represented one of the few instances in which women spoke in terms of the “lesbian community” and how the “germs that cause STIs” could infiltrate it. This concern about contagion related to a second major theme in women’s perceptions of STIs, namely, that STIs result from exposure to different bacteria than those normally contained within one’s body. From this perspective, STIs result from sexual contact with men specifically because they carry different bacteria than women: “I just think it’s the exchange of the different bacteria in semen and all of that stuff. That’s where I think the STD comes in.” Although never explicitly stated, the participants seemed to believe that women’s and men’s bodies contain different bacteria, and it is the mixing of the 2 that causes STIs.
Given prevailing beliefs regarding “different” bacteria as the source of STIs, many of the participants expressed concerns regarding sexual penetration. Again emphasizing the perception that STIs are the result of heterosexual contact, one woman stated, “…a lot of people have grown to think that by definition sex is man/woman penetration, so STDs would be considered man/woman penetration, you know? There has to be an exchange…from a man.” Another woman said, “Like even if you’re getting penetrated by a woman, you’re either getting like fingered or you’re getting strapped on…nothing’s being released in you.” Although penetration raised concerns for many women because of the exposure to semen (and thus men’s different germs), some women extended this avoidance of penetration to their female partners, as well: “I don’t do penetration, I don’t do the toys, or straps, or anything like that. I don’t like their fingers inside me, ’cause I think of staph and all of the germs that’s on hands.” In addition to forbidding penetration to prevent the introduction of germs from a partner’s body, women spoke of avoiding penetrating partners, again because of the perception that germs are on the “inside.”
Participant: But then you would be like penetrating her with your tongue. The clit is on top, so if you’re just licking her clit you still ain’t getting all of them germs…
Moderator: You think the germs are on the inside?
Participant: Yes. [Laughing]
Practice of Safe Sex
In each focus group, we asked how women could protect themselves against STIs in their relationships with women. Many listed practices that would be advised in all sexual relationships, including an emphasis on hygiene (washing before and after sex, sanitizing sex toys, avoiding oral sex during menstruation) and establishing trust between sexual partners. As one woman responded, “Just trying to keep the same partner, trying to know who you’re dealing with, and getting your checkups when you’re supposed to, and just keep up with yourself. Really, that’s all you can do.” As the end of this quote demonstrates, however, many women felt a sense of helplessness with regard to the practice of “safer sex” in their relationships with women, namely, because they perceive that few options for safer sex between women exist and are unsure how to obtain and/or use the options that do exist. As we have previously reported,29 this was particularly true with regard to protective barrier methods for preventing STIs (i.e., condoms on sex toys, use of latex gloves for digital penetration, and use of dental dams), which women regarded as potentially useful but unlikely to be used.
Given the misperceptions surrounding barriers methods and women’s self-reported reluctance to use them, many participants spoke instead of requiring proof of negative results from recent STI testing before beginning a new sexual relationship; as one woman said, “When I meet a female, I let them know, since we can’t use protection, you have to get tested.” Many women reported asking to see official test results from the local Health Department, noting that they often carry their own results with them for this purpose. Some had gone with potential partners to hear their results or listened in on a 3-way telephone call with the Health Department. Some women even offered to pay the Health Department fee for testing (usually $5) for their new partners. As noted by one participant, requiring results often resulted in delayed initiation of new sexual relationships: “We never got to the sexual part ‘til after we went to the clinic and after the results came back.” Many women expressed a desire to be tested for “everything” and were concerned that providers may not test them as comprehensively as they do heterosexuals; one participant stated, “Yeah, everything, every STD that there is, test me for them just like you would test me and a man.”
This study is unique in that it explores sexual behaviors, perceptions of STI risk, and practice of safe sex in African American WSW/WSWM living in the Southern United States, a population that is understudied in terms of sexual health. Women in this study were more aware of their risk for STI acquisition from male sexual partners than from female sexual partners. This idea seemed to be extrapolated from women’s knowledge of STI risk during heterosexual sex because many had not received detailed information regarding STI risk during female homosexual sex. This finding is corroborated by prior studies of WSW/WSWM, emphasizing the need for health care providers to have an adequate fund of knowledge to counsel these patients appropriately with regards to their sexual health. Marrazzo et al.19 found that knowledge of the potential for STI transmission between WSW/WSWM was limited. In a study of 23 primarily white lesbian and bisexual women, participants reported feeling more likely to be infected with an STI from a man than a from woman; as one woman stated: “…because we are girls and the only thing we need to worry about is pregnancy…we know that STDs can only be transferred to men and women…that’s what we are told, that two women are safe.” Similarly, in a study of 78 predominately white, well-educated, lesbian-identifying women, more than half (53%) of the women perceived that their risk for acquiring HIV was low.18 In addition, Kaestle and Waller20 found that among respondents of a survey of 10,986 young adults who had an STI, women who reported only same-sex sexual relationships were more likely to believe that they were at very low risk for STIs than were women reporting only opposite-sex sexual relationships. Despite the perception of lower risk for STI acquisition from female sexual partners than male sexual partners, participants in our study seemed to have pieced together a fairly accurate lay understanding of how STIs are transmitted (i.e., primarily through exposure to other people’s “germs”). Good hygiene and requiring proof of negative STI test results were ways in which women believed they could engage in safer sex with other women. They also specifically asked for accurate sexual health information tailored to the needs of WSW/WSWM.
Although our study included roughly equal numbers of WSW and WSWM, participants spoke critically of WSWM who may transmit STIs acquired from men to their subsequent female sexual partners. The role of “behaviorally bisexual” individuals has been explored with regard to men who have sex with men and women serving as a “bridge” for HIV transmission between high-risk populations (i.e., men who have sex with men) and heterosexual women.30,31 However, the role of WSWM in this setting remains largely unexplored, perhaps owing to persistent perceptions of low STI risk among women reporting sex with women. Additional research is required to understand both the behavioral and the biological dynamics of sexual bridging between WSW and WSWM populations. Another key unanswered question is the extent to which WSW/WSWM, particularly African American WSW/WSWM, intentionally choose sexual relationships with female partners to avoid the risk of STIs that they associate with men. Additional research (in the form of one-on-one interviews to protect participant confidentiality) is needed to more fully understand the role of sexual partnerships among this group of women.
This study has several limitations. First, the results are limited by the small sample size of African American WSW/WSWM and the geographic location and may not be generalizable to all WSW/WSWM. Second, owing to difficulty recruiting younger women 16 to 24 years (only 12/36 [33%] of younger women recruited for this study actually participated), we were unable to stratify our sample by both age (16–24 years vs. ≥25 years) and sexual behavior group (WSW vs. WSWM), stratifying only by age in the final analysis. Thus, we were unable to determine if there were thematic differences among WSW/WSWM groups with regard to sexual behaviors, perceptions of STI risk, and practice of safe sex. Reasons that a large percentage of younger women declined to participate in this study included not being interested when being called about focus group dates (n = 2), cell phone was disconnected or did not have voicemail capabilities (n = 11), participant was on active military duty and deployed at the time she was called to schedule a focus group session (n = 3), participant was unable to attend because of other time commitments (n = 3), and/or unknown reasons (n = 5). Future studies of young WSW/WSWM should take these difficulties into consideration when trying to recruit participants. In addition, because most participants were recruited from an STD clinic setting, this may have biased participants’ responses regarding the use of STD testing as a prevention measure. These women may have more access to, or perceived access to, STD testing services than the general population of WSW/WSWM.
Lastly, the use of focus groups may have also influenced the results of this study in several key ways. Participants whose opinions differed from the majority may have been unwilling to speak because of social norms. In addition, the expectation generated by agreeing to participate in a group discussion of perceptions of STI risk from female (and male) sexual partners may have led women to overstate their perceived STI risk, although it should be noted that women repeatedly mentioned their lack of knowledge and desire for additional information, particularly as it pertained to their risk from female sexual partners. Women who did not perceive themselves to be at risk for STIs might have been uncomfortable stating this view, possibly fearing that they would be seen as uninformed by the other participants and the moderators. Finally, the inclusion of both WSW and WSWM in the same focus groups may have also silenced the unique perspective of WSWM, given that many of the groups spoke negatively of the role of WSWM in transmitting STIs. Future research in this area should use one-on-one interviews to reduce the stigma that WSWM may have faced when discussing their sexual behavior.
Despite these limitations, the results of this study have several important public health implications. First and foremost, health care providers should take comprehensive sexual histories on all patients, asking questions not only about sexual identity but also about specific sexual behaviors that women engage in with their female (and male) sexual partners. Health care providers should recognize that WSW/WSWM engage in a variety of sexual behaviors with their female partners (not just oral sex), and many also have sex with men, putting them at risk for STI transmission through heterosexual sex. Likewise, health care providers should assist WSW/WSWM in extrapolating what is known about heterosexual STI transmission to their female sexual partnerships when providing STI education and prevention counseling services. Comprehensive education on potential routes of STI transmission in WSW/WSWM is necessary (i.e., oral and genital skin-to-skin contact; exchange of infected cervicovaginal secretions during receptive vaginal and anal sexual activity with fingers, hands, and sex toys; sex during menses, etc.), as is the recommendation to use condoms consistently with male sexual partners and on sex toys. Finally, health care providers should affirm and encourage WSW/WSWM to continue safe sex behaviors that they do engage in, especially their use of STI testing as a protective practice.
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