Risk Behavior Characteristics
Table 3 compares report of history of chlamydial infection, gonorrhea, trichomoniasis, syphilis, and HIV between exclusive AAWSW and AAWSWM. AAWSWM were significantly more likely to report a history of infection with C. trachomatis (35.0% vs. 13.5%, P < 0.001) and N. gonorrhoeae (28.75% vs. 2.7%, P < 0.001) than exclusive AAWSW. Although differences fell short of statistical significance, a higher proportion of AAWSWM reported prior infection with trichomoniasis (28.8%) than exclusive AAWSW (15.3%) (P = 0.05). There were no statistically significant differences between the 2 groups among the small proportion of women reporting prior infection with syphilis or HIV.
Table 4 compares select risk behaviors between the 2 groups of women. AAWSWM were significantly more likely than exclusive AAWSW to report a lifetime history of transactional sex (18.8% vs. 2.7%, P = 0.001). Although differences fell short of statistical significance, AAWSWM were more likely to report substance use (56.3% vs. 39.6%; P = 0.05) and alcohol use (71.3% vs. 56.8%; P = 0.06) within the past 30 days and less likely to report a history of consistent condom use on sex toys with female sexual partners (23.8% vs. 41.4%; P = 0.08) than exclusive AAWSW. There were no significant differences between the 2 groups regarding mean age at sexual debut with female or male partners, number of lifetime female sexual partners and number of female sexual partners within the past 12 months, tobacco use in the past 30 days, lifetime history of sex with an IV drug user, consistent barrier use at sexual exposure sites during the past 3 months (notably low at approximately 20% in both groups of women), or engaging in sexual activities with female partners during menstruation. Approximately 13.8% (11/80) of women in the AAWSWM group reported history of sex with a homosexual or bisexual man within the past 12 months (data not shown).
At the time of evaluation, trichomoniasis was the most frequently diagnosed STI with 18.3% (35/191) of all women infected, followed by C. trachomatis at 11.0% (21/191), M. genitalium at 7.6% (14/191), and N. gonorrhoeae at 3.7% (7/191) (Table 5). No cases of pelvic inflammatory disease, syphilis, or HIV were diagnosed during this study. AAWSWM were significantly more likely to be diagnosed with trichomoniasis (25.0% vs. 13.5%, P = 0.04), C. trachomatis (22.5% vs. 2.7%, P < 0.001), N. gonorrhoeae (7.5% vs. 0.9%, P = 0.01), or any STI infection (47.5% vs. 18.3%, P < 0.001) than exclusive AAWSW.
Significant findings from the multivariable analysis are shown in Table 6. We found that report of substance use within the past 30 days, history of gonorrhea infection, and new diagnosis of trichomoniasis and chlamydial infection were each independently associated with sex with a male partner(s) during the past 12 months.
To our knowledge, this is the first study of STI prevalence rates and associated risk behaviors in a sample of AAWSW in the southern United States. Lifetime history of sex with men was common, consistent with previous studies of WSW reporting lifetime history of sex with men in 80% to 93% of participants,4,6,16,18–20,31–34 whereas the percentage of AAWSWM who had a male sex partner(s) within the past 12 months (40.8%) was somewhat higher than that seen in previous studies (6.7%–29.6%).6,18–20,34 Consistent barrier use at sexual exposure sites during the past 3 months was relatively low in both groups of women. Trichomoniasis was the most frequently diagnosed STI, followed by C. trachomatis, M. genitalium, and N. gonorrhoeae. No new cases of HIV or syphilis were diagnosed. In this study, infection rates with trichomoniasis and C. trachomatis were significantly higher than those seen in previously published studies of WSW and WSWM, which have ranged between 0% and 5.2% for trichomoniasis,6,14,15,32,34,35 and between 0% and 7.1% for C. trachomatis.4,6,14–16,32,34–36 The increased rates of trichomoniasis and chlamydial infection seen in this study could be a reflection of more frequent heterosexual experiences with male sexual partners within the past 12 months, the higher prevalence of these infections in racial minority groups in the southern United States,28,37 or due to issues regarding lack of healthcare insurance (67.4% of women in the study reported not having healthcare insurance) with subsequent underutilization of healthcare services, including HIV/STD screening services. Additionally, the use of T. vaginalis InPouch culture may also have contributed to the higher rates of trichomoniasis seen in this study compared with prior studies of WSW and WSWM, several of which only used wet preparation for diagnosis.14,32,34 The sensitivity of wet prep (standard practice at the MSDH STD clinic and other public health clinics across Mississippi) for diagnosis of trichomoniasis in this study (using InPouch culture as the gold standard) was 65.7%.
Also of interest is the fact that there was a greater difference in rates of C. trachomatis and N. gonorrhoeae infection between exclusive AAWSW and AAWSWM compared with rates of trichomoniasis and M. genitalium infection. One potential explanation for this finding may be that differential participation in types of sexual activities within sexual risk groups (WSW vs. WSWM) may account for differences in rates of transmission of these organisms. For example, women engaging in penile-vaginal sex with men would be more likely to acquire a greater inoculum of C. trachomatis and/or N. gonorrhoeae transmitted through seminal fluid than women engaging in digital-vaginal penetration or penetration with sex toys with other women, sexual activities that have an unknown risk for transmission of these organisms. In contrast, transmission of trichomoniasis between women has been documented,8,38 although the frequency of this event is not well known. Alternatively, this observation could result in part from differences in the duration of untreated infection between the 4 organisms and rates of new sexual partner acquisition. Further study of this issue in WSW compared with WSWM will be of considerable interest.
Also of note, 3 cases of C. trachomatis, 1 case of N. gonorrhoeae, and 5 cases of M. genitalium were diagnosed among women reporting no history of sex with men in the past 12 months. Additionally, 1 woman in this group, infected with both C. trachomatis and M. genitalium, denied lifetime history of sex with a male partner. It could be hypothesized that this woman acquired these STIs from another female sexual partner although this cannot be proven as sexual partner(s) were not available for testing. Prior reports of transmission of C. trachomatis and N. gonorrhoeae between WSW have largely been anecdotal and unpublished.22 As mentioned previously, little is known about the efficiency of transmission of these STIs between women. Exchange of infected cervicovaginal secretions during receptive vaginal and anal sexual activity with fingers, hands, and sex toys is the most plausible mechanism, as supported by reports of infection with genital human papillomavirus,12,19,20 HIV,10,11 and trichomoniasis8,38 among women reporting sexual activity exclusively with women. Further study of sexual partnerships among women exclusively having sex with other women in whom both partners are infected with C. trachomatis or N. gonorrhoeae should be conducted to gain further insight on this issue. Additionally, prior data does not exist on the prevalence of M. genitalium among WSW, and it is unknown if this pathogen can be sexually transmitted between women.
Few studies have looked at subpopulations of sexual minority women to examine the frequency of risk-taking behaviors that could facilitate STI acquisition or transmission. Findings from our study demonstrate that AAWSWM who have had a male sex partner within the past 12 months were significantly more likely than exclusive AAWSW to report engaging in behaviors that are known risk factors for STI infection (such as reporting a history of transactional sex and having sex with a homosexual or bisexual man during the past 12 months). They were significantly more likely to report history of chlamydia and gonorrhea infection, and be diagnosed with trichomoniasis, C. trachomatis, N. gonorrhoeae, or any STI than exclusive AAWSW. These heightened sexual risk-taking behaviors among WSWM have also been noted in data from a large British probability survey conducted between 1999 and 2001.39 This survey found that WSWM over the past year were significantly more likely to report greater numbers of male partners, anal intercourse, failure to use barrier protection, and alcohol and drug abuse than women reporting sex exclusively with men (WSM). WSWM also had an increased likelihood of induced abortion and STI diagnosis (age-adjusted odds ratios = 3.07 and 4.41, respectively) than WSM. Another study of sexual risk factors among self-identified lesbian, bisexual, and heterosexual women accessing primary care settings found that bisexual women reported substance use with sex at a higher rate than lesbians or heterosexual women (P < 0.001).40 Bisexual women also had more homosexual male partners and a higher mean number of male sexual partners than heterosexual women (P < 0.001). In addition, self-identified bisexual women have also been found to experience a higher likelihood of frequent mental distress (P < 0.001) and poorer general health (P < 0.01) than women identifying as lesbian.41 Overall, this growing body of data is beginning to show that WSWM may be a unique at-risk group of women that merits tailored STI/HIV intervention efforts.
As mentioned previously, 67.4% of AAWSW in our study reported not having health insurance. This lack of insurance with subsequent underutilization of health care services may have contributed to the high rates of trichomoniasis and chlamydial infection noted. This percentage of uninsured women is significantly higher than that noted in a recent Kaiser Family Foundation report compiling population-based data on health insurance status of American women by state and by race/ethnicity.42 In this Kaiser report, approximately 27.0% of all AA women living in Mississippi did not have health insurance. Identifying reasons that would explain this discrepancy in health insurance rates between AAWSW and the general population of AA women in Mississippi was beyond the scope of the current study. In addition, how this finding impacts utilization of healthcare services by AAWSW is unknown but merits further study.
Our study has several limitations. First, data were collected from a small (n = 196) convenience sample of AAWSW presenting to a large urban STD clinic, limiting the generalizability of the results to other populations of AAWSW. This limitation is inherent to many prior studies of WSW as this group is frequently a hidden population and difficult to access. Second, the small sample size limited our ability to include variables found to be significant in univariate analysis (such as marital status) in the multivariable analysis to look for independent associations. Third, the majority of the data collected in this study was obtained by participant self-report and was inherently limited by recollection bias or social desirability bias by the respondents. Fourth, as this was a pilot study and did not include participant compensation, the numbers of questions asked in the written questionnaire were limited. Consequently, we were unable to explore detailed sexual practices (oral, vaginal, and/or anal) that participants may engage in with their female and male sexual partners and assess which practices were more likely to be associated with diagnosis of an STI. Future studies of AAWSW and AAWSWM should attempt to include this information. Finally, the cross-sectional design of this study limits our ability to determine STI incidence, rates of reinfection, and changes in partnership dynamics over time among this group of women and how this may affect their STI rates. A prospective analysis of AAWSW, evaluating their sexual risk behaviors, changes in partnership gender and number over time, and STI incidence is an important next step in this line of research.
In conclusion, we are only just beginning to understand the burden of disease due to HIV/STI among AAWSW living in the southern United States. This is the first study that specifically focuses on this aspect of sexual health among this group of racial- and sexual-minority women. Prevalence of trichomoniasis, C. trachomatis, N. gonorrhoeae, and M. genitalium was high, comparable with heterosexual women receiving STI services in our STD clinic (data not shown). Recent sex with men was common, and independently predicted report of substance use within the past 30 days, history of gonorrhea infection, and a new diagnosis of trichomoniasis and chlamydial infection. AAWSWM, as a subgroup, may demonstrate heightened sexual risk-taking behaviors and higher STI rates compared with exclusive AAWSW. Sexual health services provided to AAWSW should take into account partner gender heterogeneity and all aspects of sexual orientation when screening for STI and providing prevention counseling.
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