Women who have sex with women (WSW) and women with multiple sexual partners are both unique subsets of women with presumed different levels of risk for sexually transmitted infections (STIs). Women who have sex with women, particularly those without a lifetime history of sex with men, are traditionally thought to be at low risk for STI acquisition.1,2 In contrast, some research has shown women who have sex with both women and men (WSWM) may have a higher risk of STI acquisition compared with other female sexual behavior groups including WSW and perhaps women who have sex with men (WSM).3–5 This increased STI risk among WSWM may be due to larger numbers of sexual partners and being more likely to engage in risky sexual behaviors (ie, anal sex).6 In contrast, multiple studies have demonstrated that women with greater numbers of sexual partners are at higher risk of STI acquisition because of increased sexual exposures.7–10 Most studies which have drawn these conclusions have primarily included either white WSW/WSWM/WSM or populations outside the United States.9–11 There are little data directly comparing African American (AA) WSW, WSWM, and WSM with differing numbers of sexual partners, particularly in the Southern United States, an area with high human immunodeficiency virus (HIV)/STI rates.12,13 We had a unique opportunity to look at both partner gender and partner number among AA women in this area.
The objective of this study was to compare sexual risk behaviors and STI prevalence among AA women presenting to a busy, urban sexually transmitted disease (STD) clinic. We focused on women within the following groups: WSW, WSM reporting a single male partner over the past year, WSM with 4 or more male partners, and WSWM. We hypothesized a continuum of STI risk, with WSW having the lowest risk, followed by WSM with a single male partner, WSM with 4 or more male partners, and WSWM having the highest risk.
We conducted a secondary analysis of data from two prospectively conducted studies that enrolled AA women presenting to the Jefferson County Health Department STD clinic in Birmingham, AL, for routine evaluation. The first was a study of women with single and multiple sexual partners that compared WSM reporting a single male partner (n = 106) to WSM reporting 4 or more male partners (n = 107) during the past year.14 Of these women, 91 who reported a single male partner and 78 who reported 4 or more male partners were of AA race and included in this secondary analysis. Women with 2 to 3 sexual partners during the past year were not included in the sexual partners study as we wanted to initially focus on the more extreme ends of the partner numbers spectrum. The second study, the Women’s Sexual Health Project, included AA WSW (n = 78) and WSWM (n = 85), categorized based on self-reported gender of sexual partners during the past year.15 The 2 studies were conducted concurrently enrolling between May 2011 and October 2013. The institutional review board at the University of Alabama at Birmingham and the Jefferson County Health Department approved both studies (protocols F110609002 and X110304008, respectively).
Participants in both studies completed similar interviewer-administered questionnaires that collected sociodemographic and sexual risk behavior information, substance use history, sexual assault and intimate partner violence (IPV) history,16,17 STI history, and whether they had ever been tested for HIV. All participants in both studies had pelvic examinations and were tested for bacterial vaginosis (BV) by Amsel criteria.18Trichomonas vaginalis was detected by wet mount and InPouch culture (BioMed Diagnostics, White City, OR). Cervical swabs were collected by a clinician for Chlamydia trachomatis and Neisseria gonorrhoeae nucleic acid amplification testing using the GenProbe Aptima Combo 2 assay (Gen Probe, Inc., San Diego, CA). Serum was collected for HIV (ICMA HIV ELISA; Siemens, Malvern, PA), syphilis (RPR), and herpes simplex virus (HSV) type 2 (HerpeSelect HSV-2 ELISA; Focus Diagnostics, Cypress, CA) serologic testing.
We conducted this secondary analysis on the combined datasets from both studies (overall, n = 332). We examined whether the distribution of any sociodemographic characteristics, sexual risk behaviors, or STI outcomes varied by group (ie, WSW, WSM with 1 partner, WSM with ≥4 partners, and WSWM) using χ2 tests of independence. P values less than 0.05 were considered statistically significant.
Table 1 shows sociodemographic characteristics and sexual risk behaviors of women in the groups in addition to BV and STI diagnoses at the time of study enrollment. Mean number of sexual partners during the past year was 2.39 (±3.46) for the WSW group and 6.29 (±7.02) for the WSWM group (data not shown). Age was significantly different between groups (P = 0.029) with the majority of women in the WSM with 4 or more male partners and WSW groups being 25 years or younger (62.8% and 56.4%, respectively). Women who have sex with men with a single male partner had a significantly lower prevalence of tobacco use in the past 30 days (36.3% vs 59.7–67.9% for the other groups, P = <0.001) although there was no significant difference in recent alcohol or illicit drug use. There was also no significant difference between groups in terms of educational attainment or current employment (results not shown).
Women with 4 or more male partners in the past year reported the highest proportions of C. trachomatis, N. gonorrhoeae, and T. vaginalis infections, whereas women with only female partners in the past year reported the lowest (P = < 0.001) (results not shown). Having ever been tested for HIV was high in all groups (>85%-95%), though WSW were significantly less likely to have been tested (P = 0.005). Women who have sex with women and WSWM were significantly more likely to report a history of sexual assault compared to WSM with either a single or with 4 or more male partners (P = <0.001). Women who have sex with women (47.4%), WSWM (43.5%), and WSM with 4 or more male partners (43.6%) were significantly more likely to report a history of IPV than WSM with a single male partner (26.4%) (P = 0.02). Transactional sex declined in stepwise fashion and was significantly more common among WSM with ≥4 male partners than WSWM, WSM with a single male partner, or WSW (23.1% vs 11.8%, 4.4%, and 6.4%, respectively, P = 0.001). Women who have sex with both women and men (57.6%) and WSM with 4 or more male partners (71.8%) were significantly more likely to report a new or casual partner during the past month than WSW (26.9%) or WSM with a single male partner (6.6%) (P = <0.001). Use of barrier protection (ie, condoms, dental dams) at last sexual encounter was low in all groups but lowest in WSW (14.1% compared to 23.1%-35.3% for other groups, P = 0.006).
BV prevalence did not differ significantly by group. In contrast, STI prevalence was significantly associated with group, though patterns varied by infection. Women who have sex with men with 4 or more male partners had a higher prevalence of C. trachomatis (15.6%, P = 0.016) and N. gonorrhoeae (9.1%, P = 0.029) than other groups. Although WSWM had the highest prevalence of T. vaginalis (23.5%), this was not significantly different from other groups. The majority of women had serologic evidence of HSV-2 (51.3–64.3%) except for WSW which had a significantly lower HSV-2 seroprevalence (25.6%, P = <0.001). There were no new syphilis or HIV diagnoses in the groups.
We hypothesized a continuum of STI risk among AA women at an urban STD clinic in the Southern United States based on literature review and our prior studies.1,2,6,9–11,14,15,19 We hypothesized that WSW would have the lowest risk, followed by WSM with a single male partner, WSM with 4 or more male partners, and WSWM at the highest risk. The results of this study partially support this hypothesis. Women who have sex with women and WSWM were more likely to report a history of sexual assault and, along with WSM with 4 or more male partners, IPV. In contrast, WSM with 4 or more male partners were more likely to report a history of transactional sex and, along with WSWM, a new or casual partner within the past month. Women who have sex with women were least likely to use barrier protection at last sexual encounter which may be reflective of inaccurate information about the need for and/or use of barrier methods among WSW.20 The majority of women in all groups had received HIV testing.
Women in all groups were diagnosed with BV and STIs at their study visit. Consistent with our hypothesis, WSW had the lowest prevalence of C. trachomatis, N. gonorrhoeae, and HSV-2. Women who have sex with both women and men had the highest prevalence of T. vaginalis and HSV-2 (though not statistically significant). In contrast to our hypothesis, WSM with 4 or more male partners in the past year were most likely to have C. trachomatis and N. gonorrhoeae. The data differentiating STI prevalence among WSM with a single male partner and WSM with 4 or more male partners were also less consistent with our hypothesis. Overall, these data suggest that there was not a clear continuum of STI risk among AA women in our study; all women were at risk.
This study was limited by the small sample of women. Study questionnaires for the parent studies were administered by research personnel and subject to social desirability bias. Unfortunately, lifetime and past year anal intercourse histories were not obtained in the sexual partners study and could not be compared between groups. In addition, because we did not know the exact number of sexual partners among women in the WSM with 4 or more male partners group, we could not directly compare numbers of partners between groups and their association with STI diagnoses. AA WSM with 2 to 3 male sexual partners during the past year were also not included in the sexual partners study; where they fall within the spectrum of STI risk is not known. Finally, these results may not be generalizable to all AA women. Future studies should include AA women from other locales in other regions of the U.S. in addition to AA WSM with 2 to 3 male sexual partners during the past year to provide a more complete picture of the spectrum of STI risk among AA women.
Despite these limitations, this study provides evidence of the need for targeted education and interventions (ie, routine STD screening,21 barrier methods education, and resources for sexual assault and domestic violence19) for all AA women regardless of the gender or number of their sexual partners. These efforts are needed to prevent STIs in AA women in the Southern United States, including those traditionally seen as at low risk (ie, women with only female sexual partners or WSM with only 1 male sexual partner).
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