HIV seroprevalence and risk behaviors among lesbians and bisexual women in San Francisco and Berkeley, California

Scholarly literature in HIV-related lesbian, gay, bisexual, and transgender studies: A bibliometric analysis

Introduction

Lesbian, gay, bisexual, and transgendered (LGBT) people are marginalized and understudied. Analyzing research activity worldwide is vital to better understand their needs in confronting the HIV epidemic. This study aimed to evaluate the global literature to identify the research collaboration, content, and tendency in HIV-related issues among the LGBT populations.

Methods

Peer-reviewed original articles and reviews were achieved from the Web of Science Core Collection database. Country's collaborations and co-occurrence of most frequent terms were illustrated by VOSviewer software. The Latent Dirichlet Allocation (LDA) and the linear regression model were utilized to uncover the hidden topics and examine the research trend.

Results

From 1990 to 2019, a total of 13,096 publications were found. Stigma, sexual risk behaviors and HIV testing were the major topics in the LGBT research during the study period. Among 15 topics, topics about HIV/Sexually transmitted infections (STIs) prevalence, Outcomes of HIV/AIDS care and treatment, and Opportunistic infections in HIV-positive LGBT people showed decreasing attention over years, while other topics had a slight to moderate increase.

Discussion

Our study underlined the exponential growth of publications on the LGBT population in HIV research, and suggested the importance of performing regional collaborations in improving research capacity. Moreover, further research should focus on examining the manner to increase the coverage of HIV testing and treatment, as well as implement HIV-interventions with low cost and easy to scale-up.

Childhood Sexual Abuse and Adult Sexual Risk Behavior: A Review and Critique

Childhood sexual abuse (CSA) is a global problem with serious repercussions for survivors in various domains of adult interpersonal functioning, including sexual risk behavior. This review aimed to summarize findings from the recent literature on the connections between CSA and later adult sexual risk behaviors (e.g., unprotected intercourse, sexually transmitted infection [STSI] diagnosis). The sexual risk behaviors consistently associated with CSA were having sex under the influence of alcohol/substances and reports of concurrent sexual partners/infidelity. Notably, studies investigating the links between CSA and history of STI diagnosis and CSA and reports of unprotected sex (with the exception of samples comprised men who have sex with men) produced inconsistent findings. The methodological limitations of existing studies are considered and suggestions for future research are offered.

Characteristics of female sexually transmitted disease clinic clients who report same-sex behaviour

Female STD clinic clients were categorized by report of sex partners' gender in the preceding 2 months and characterized with respect to HIV risk and STD diagnosis. Among 18,585 visits, 290 women (1.5%) reported sex exclusively with women, and 841 (4.5%) reported sex with both men and women. Relative to women reporting sex only with men, those reporting sex with both men and women reported more recent partners, sex with partners at high risk for HIV, injection drug and crack cocaine use, and exchange of sex for drugs or money. Women reporting sex exclusively with women more frequently reported prior sex with a bisexual man or an HIV-infected partner. Female STD clinic clients who report sex with both men and women may be at increased HIV risk relative to women reporting sex exclusively with men, and women who report sex only with women may be more likely to have had sex with men at high risk for HIV infection.

Sensitivity and Specificity in Three Measures of Depression Among Mexican American Women

This paper examined the prevalence of depressive symptomotology among women of Mexican ancestry (N = 205), over the age of 18, of diverse incomes and nativity. We examined differences in rates of diagnosis by Spanish/English preference and the sensitivity and specificity of three common measures: the Patient Health Questionnaire (PHQ9), the Kessler Psychological Distress Scale (K-10), and depression questions from the Composite International Diagnostic Interview, Short Form (MDD CIDI-SF); PHQ9 was used as the "gold standard" measure. Results indicated 18-32 % of participants met criteria for depression with higher rates found among Spanish preference participants. The K-10 had significantly higher sensitivity (0.81) but lower specificity (0.79) than the MDD CIDI-SF items (0.57 and 0.89, respectively). This study suggests that the K-10 and MDD CIDI-SF measures are complementary to each other for screening of depressive symptomatology. Implications for cultural and linguistic assessment of depression are further discussed.

Understanding the effects of different HIV transmission models in individual-based microsimulation of HIV epidemic dynamics in people who inject drugs

We investigated how different models of HIV transmission, and assumptions regarding the distribution of unprotected sex and syringe-sharing events ('risk acts'), affect quantitative understanding of HIV transmission process in people who inject drugs (PWID). The individual-based model simulated HIV transmission in a dynamic sexual and injecting network representing New York City. We constructed four HIV transmission models: model 1, constant probabilities; model 2, random number of sexual and parenteral acts; model 3, viral load individual assigned; and model 4, two groups of partnerships (low and high risk). Overall, models with less heterogeneity were more sensitive to changes in numbers risk acts, producing HIV incidence up to four times higher than that empirically observed. Although all models overestimated HIV incidence, micro-simulations with greater heterogeneity in the HIV transmission modelling process produced more robust results and better reproduced empirical epidemic dynamics.

Misperceptions regarding protective barrier method use for safer sex among African-American women who have sex with women

BACKGROUND

Barrier methods for HIV and sexually transmissible infection (STI) prevention among women who have sex with women (WSW) are available, although their effectiveness has not been systematically investigated. These methods are infrequently used by WSW. As part of a larger study on STI risk perceptions and safer sex among African-American WSW, we discovered several misperceptions regarding barrier methods that may be associated with their limited use.

METHODS

Participants were recruited from the Jefferson County Health Department STI Clinic and through word of mouth in Birmingham, Alabama, for focus group discussions exploring perceptions of STI risk and safer sex.

RESULTS

Seven focus groups with 29 participants were conducted (age range: 19-43 years). Several misperceptions regarding barrier methods were identified, notably the conflation of dental dams and female condoms. Descriptions of the use of barrier methods were qualified with phrases suggesting their hypothetical, rather than actual, use. Additional evidence that barrier methods are not actually used came from beliefs that dental dams and female condoms are available in major grocery stores or department store chains.

CONCLUSIONS

Those providing sexual health services to WSW should be cautious in assuming that WSW have accurate information regarding barrier methods for safer sex. Sexual health services provided to WSW should include an accurate description of what barrier methods are, how to distinguish them from barrier methods more commonly used during heterosexual sex (female and male condoms), and how to use them correctly. Future studies are needed to address how effectively these measures reduce transmission of STIs among WSW.

Sexual orientation of women does not affect outcome of fertility treatment with donated sperm

STUDY QUESTION

Is there a difference in fertility between heterosexual women and lesbians undergoing sperm donation?

SUMMARY ANSWER

Women undergoing treatment with donated sperm are equally fertile regardless of sexual orientation.

WHAT IS KNOWN ALREADY

Lesbians have an increased prevalence of smoking, obesity, sexually transmitted diseases and, possibly, polycystic ovary syndrome, all factors known to affect fertility. Previous studies on sperm donation inseminations (D-IUI) show conflicting results regarding pregnancy outcome.

STUDY DESIGN, SIZE, DURATION

This is a national study of 171 lesbians and 124 heterosexual women undergoing sperm donation both as D-IUI (lesbian n = 438, heterosexual n = 298) and as embryo transfers (ET) after IVF with donated sperm (lesbians n = 225, heterosexuals n = 230) during 2005-2010.

PARTICIPANTS/MATERIALS, SETTING, METHODS

All clinics in Sweden offering sperm donation recruited patients. Differences in patients' medical history, treatment results and number of treatments to live birth were analyzed using independent samples t-test, Pearson's χ(2) test or Fisher's exact probability test.

MAIN RESULTS AND THE ROLE OF CHANCE

71.8% of heterosexuals and 69.0% of lesbians had a child after treatment. The mean number of treatments was 4.2 for heterosexual women and 3.9 for lesbians. The total live birth rate, regardless of treatment type, was 19.7% for heterosexuals and 19.5% for lesbians. For D-IUI, the live birth rate was 12.8% for heterosexuals and 16.0% for lesbians and the live birth rate for all IVF embryo transfers (fresh and thawed cycles) was 28.7% for heterosexuals and 26.2% for lesbians. There were no differences in live birth rate between the groups for each of the different types of insemination stimulations (natural cycle; clomiphene citrate; FSH; clomiphene citrate and FSH combined). Nor was there a difference in live birth rate between the groups for either fresh or thawed embryo transfer. There was no difference between the proportions of women in either group or the number of treatments needed to achieve a live birth. Heterosexuals had a higher prevalence of smokers (9.2%), uterine polyps (7.2%) or previous children (11.3%) than lesbians (smokers 2.8%, P = 0.03; polyps 1.8%, P = 0.03; child 2.5%, P = 0.003).

LIMITATIONS, REASONS FOR CAUTION

This study is limited to women living in stable relationships undergoing treatment with donated sperm in a clinical setting and may not apply to single women or those undergoing home inseminations.

WIDER IMPLICATIONS OF THE FINDINGS

These results may influence healthcare policy decisions as well as increase the quality of clinical care and medical knowledge of healthcare professionals. The data also have important implications for individuals regarding screening, infertility diagnostic procedures and treatment types offered to heterosexuals and lesbians seeking pregnancy through sperm donation.

STUDY FUNDING/COMPETING INTEREST(S)

Funding was granted by the Stiftelsen Familjeplaneringsfonden i Uppsala; the Swedish Research Council for Health, Working Life and Welfare; and the Marianne and Marcus Wallenberg Foundation. The authors report no conflicts of interest.

HIV/AIDS in older women: unique challenges, unmet needs

As persons living with HIV/AIDS live longer, both the prevalence and incidence of HIV infection in older women is expected to increase, and this review presents a model and review of the extant literature on older women with HIV/AIDS in the United States. Older women are rarely addressed in the discourse about HIV risk and prevention, and their concerns are often missed by risk-reduction programs that typically target men and younger adults. Societal biases around aging can compound factors such as stigma and disclosure for older women. Primary care providers are often not recommending routine HIV testing to older women, or addressing the impact of age-related physiological changes on risk and sexual health. Many older women may be starting new relationships, so it is important that providers understand the relational variables specific to this group of women. Empirical research focused on the needs of older women, and recognition of the diverse composition and needs of this group, are needed to inform prevention, intervention, and best practices with this population of women.

Sexual risk behaviors and psychosocial health concerns of female-to-male transgender men screening for STDs at an urban community health center

The sexual health of female-to-male (FTM) transgender men remains understudied. De-identified electronic medical records of 23 FTMs (mean age = 32, 48% racial/ethnic minority) who screened for sexually transmitted diseases (STDs) between July and December 2007 at a Boston, Massachusetts area health center were analyzed. Almost half (48%) were on testosterone and 39% had undergone chest surgery; none had undergone genital reconstruction. The majority (57%) were bisexual, and 30% reported sex with nontransgender males only in the prior three months. One individual was HIV-infected (4.3%) and two (8.7%) had a history of STDs (all laboratory-confirmed). Overall, 26% engaged in sexual risk behavior in the prior three months (i.e., unprotected sex with a nontransgender male, condom breakage, or anonymous sex). The majority (61%) had a DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition) diagnosis (52% depression, 52% anxiety, and 26% adjustment disorder), and regular alcohol use was common (65%). Alcohol use, psychosocial distress histories, and sex with males only (versus with males and females) were associated with sexual risk in the past three months. Transgender men have concomitant psychosocial health vulnerabilities which may contribute to sexual risk behaviors. Future research is needed to understand the myriad social, behavioral, and biological factors that contribute to HIV and STD vulnerability for FTMs.

A complex systems approach to evaluate HIV prevention in metropolitan areas: preliminary implications for combination intervention strategies

BACKGROUND

HIV transmission among injecting and non-injecting drug users (IDU, NIDU) is a significant public health problem. Continuing propagation in endemic settings and emerging regional outbreaks have indicated the need for comprehensive and coordinated HIV prevention. We describe the development of a conceptual framework and calibration of an agent-based model (ABM) to examine how combinations of interventions may reduce and potentially eliminate HIV transmission among drug-using populations.

METHODOLOGY/PRINCIPAL FINDINGS

A multidisciplinary team of researchers from epidemiology, sociology, geography, and mathematics developed a conceptual framework based on prior ethnographic and epidemiologic research. An ABM was constructed and calibrated through an iterative design and verification process. In the model, "agents" represent IDU, NIDU, and non-drug users who interact with each other and within risk networks, engaging in sexual and, for IDUs, injection-related risk behavior over time. Agents also interact with simulated HIV prevention interventions (e.g., syringe exchange programs, substance abuse treatment, HIV testing) and initiate antiretroviral treatment (ART) in a stochastic manner. The model was constructed to represent the New York metropolitan statistical area (MSA) population, and calibrated by comparing output trajectories for various outcomes (e.g., IDU/NIDU prevalence, HIV prevalence and incidence) against previously validated MSA-level data. The model closely approximated HIV trajectories in IDU and NIDU observed in New York City between 1992 and 2002, including a linear decrease in HIV prevalence among IDUs. Exploratory results are consistent with empirical studies demonstrating that the effectiveness of a combination of interventions, including syringe exchange expansion and ART provision, dramatically reduced HIV prevalence among IDUs during this time period.

CONCLUSIONS/SIGNIFICANCE

Complex systems models of adaptive HIV transmission dynamics can be used to identify potential collective benefits of hypothetical combination prevention interventions. Future work will seek to inform novel strategies that may lead to more effective and equitable HIV prevention strategies for drug-using populations.

Risk behaviors for reproductive tract infection in women who have sex with women in Beijing, China

OBJECTIVES

To assess risk behaviors for reproductive tract infections (RTI) including sexually transmitted infections (STI) among women who have sex with women (WSW) in Beijing, China.

METHODS

A cross-sectional study of women recruited from venues and internet outreach analyzed using interviews.

RESULTS

We recruited 224 WSW, among whom were 37 couples. The average age of participants was 25.6 years. Sex with men in the past year was reported by 10.7% of participants. During the past year, 34.3% (77/224) had had >1 sexual partner and 72.4% (162/224) had ever had >1 sexual partner. Condom use in the last sex with a man was reported by 54.2% (13/24) of women; 12.5% (3/24) reported never having used a condom with a man in the past year. In the past year, 13.4% (30/224) reported using sex toys with their female partners; of these, 43.3% (13/30) reported consistent condom use with the sex toys and 36.7% (11/30) had shared sex toys. Among participants 65.2% (120/184) reported that their "G-spot" had been stimulated during sex, 49.2% (59/120) of whom reported bleeding during or after sex. Only 12.5% (8/64) of those never reporting "G spot" stimulation reported bleeding during or after sex (P<0.001).

CONCLUSIONS

WSW in Beijing engaged in high-risk sexual behaviors that may carry a substantial risk of being infected with STI/RTI. To implement STI/RTI prevention and intervention among women, women-women sexual behavior should be considered when doing research and intervention programs.

Social capital, acculturation, mental health, and perceived access to services among Mexican American women

OBJECTIVE

We examined whether individual-level social capital-the intangible resources in a community available through membership in social networks or other social structures and perceived trust in the community-was associated with acculturation, depression and anxiety symptoms, and perceived access to services among women of Mexican ancestry.

METHOD

Recruited through venue-based targeted sampling in King County, Washington, 205 women of Mexican descent ages 18 to 64 years who differed in socioeconomic status and nativity completed a cross-sectional survey. Half completed the survey in Spanish and half in English. Structural equation modeling was used for model testing.

RESULTS

Social capital increased with level of acculturation and was negatively related to depression and anxiety; it had no direct association with perceived access to services. Social capital mediated the relation between acculturation and both depression and anxiety symptoms. Acculturation had no direct association with psychological distress but was directly associated with perceived access to services. This community sample of women reported high levels of psychological distress, with 20% to 26% of women meeting diagnostic criteria for depression or anxiety.

CONCLUSIONS

Social capital can be assessed at the individual level, increases with acculturation, and may be a potential target for interventions to improve mental health among Mexican American women residing in the United States.

Sexually transmitted infections among women who have sex with women

Women who have sex with women (WSW) are a diverse group with variations in sexual identity, sexual behaviors, sexual practices, and risk behaviors. WSW are at risk of acquiring bacterial, viral, and protozoal sexually transmitted infections (STIs) from current and prior partners, both male and female. Bacterial vaginosis is common among women in general and even more so among women with female partners. WSW should not be presumed to be at low or no risk for STIs based on sexual orientation, and reporting of same-sex behavior by women should not deter providers from considering and performing screening for STIs, including chlamydia, in their clients according to current guidelines. Effective delivery of sexual health services to WSW requires a comprehensive and open discussion of sexual and behavioral risks, beyond sexual identity, between care providers and their female clients.

Emerging Sexual Health Issues Among Women Who Have Sex with Women

Women who have sex with women (WSW) comprise a diverse group of people who evidence a spectrum of sexual identity, sexual behaviors, sexual practices, and risk behaviors. WSW are at risk of acquiring a diversity of sexually transmitted infections (STIs) from current and prior partners, both male and female. Notably, human papillomavirus (HPV) is sexually transmitted between female partners, and Pap smear guidelines should be followed in this group. Bacterial vaginosis is common among WSW. WSW should not be presumed to be at low or no risk for STIs based on sexual orientation, and reporting of same sex behavior by women should not deter providers from considering and performing screening for STIs, including Chlamydia trachomatis, according to current guidelines. Effective delivery of sexual health services to WSW requires a comprehensive and open discussion of sexual and behavioral risks, beyond sexual identity, between care providers and their female clients.

Issues in gynecologic care for adolescent girls in the juvenile justice system

Incarcerated girls represent a captive audience, providing health care providers working in the juvenile justice system with a unique opportunity to intervene in this difficult to-reach population. Health care providers should promote and encourage healthy lifestyles with the aim of lowering their risk-taking behaviors, promote contraception and screen and treat sexually transmitted infections. For many delinquent girls this encounter represents their first contact with the medical care system as independent young women.It is important to encourage these girls to have a medical home and upon discharge from the facility, it is important to guarantee appropriate follow-up.

Chlamydia trachomatis infection among women reporting sexual activity with women screened in Family Planning Clinics in the Pacific Northwest, 1997 to 2005

OBJECTIVES

We sought to define Chlamydia trachomatis positivity among women who report sexual activity with women, a population for which sparse data on this infection are available and for whom health disparities including challenged access to comprehensive sexual and reproductive health services, have been reported.

METHODS

We analyzed data from 9358 family planning clinic visits with C trachomatis tests among women aged 15 to 24 years who reported sexual activity within the past year exclusively with women (WSW) or with men and women (WSMW), in the Region X Infertility Prevention Project. Characteristics were compared with women who reported sexual activity exclusively with men (WSM). Results. C trachomatis positivity among both WSW and WSMW was 7.1%, compared with 5.3% among WSM. Behavioral risks were more commonly reported by WSW and WSMW, compared with reports by WSM. Risks for C trachomatis positivity were comparable across groups and included younger age, non-White race, behavioral risks, and clinical signs.

CONCLUSIONS

Higher C trachomatis positivity among women reporting same-sex sexual behavior supports investigation into potential explanatory factors, including sexual behaviors, biological susceptibility, routine C trachomatis screening disparities, sexual identity disclosure, and sexual network assessment.

HIV risk behaviors among young drug using women who have sex with women (WSWs) in New York City

Previous research has suggested that multiple stressors may work in tandem to affect the health of women who have sex with women (WSWs). WSWs have been a part of the HIV epidemic in New York City since the beginning, making it an ideal setting to further explore these women's risk. Among a sample of 375 heroin, crack and/or cocaine using women recruited from economically disadvantaged communities in New York City, we examined HIV seroprevalence and risk behaviors among WSWs as compared to women who have sex with men only (WSMOs). We also explore differences between WSWs and WSMOs with respect to potential stressors (i.e., decreased access to resources and health care utilization and violence victimization) that might contribute overall HIV risk. The study's limitations are noted.

The risk less known: female-to-male transgender persons’ vulnerability to HIV infection

Studies have consistently found high levels of HIV infection among male-to-female (MTF) transgender people, particularly MTF sex workers. Due to lack of empirical data, HIV/AIDS risk among female-to-male (FTM) transgender people, however, is not well understood. This study analysed data from two needs assessment surveys to compare risk for HIV infection between 122 MTF and 62 FTM transgender people. Results show that there was a significant gender difference in HIV risk among the survey respondents. Compared to MTFs, FTMs were significantly less likely to have used protection the last time they had sex and significantly more likely to have engaged in recent high risk sexual activity. The gender difference existed even after controlling for demographic variables, AIDS knowledge, perceived AIDS knowledge, perceived effectiveness of condom usage, perceived susceptibility to AIDS and self-esteem. Findings from this study suggest that a thorough examination of HIV risk factors among FTMs is necessary.

Sexual behaviors and sexually transmitted infections among self-identified lesbian and bisexual college women

Sexually transmitted infections (STIs) are a significant health issue for lesbian and bisexual women. Older age and having a history of sexual intercourse with males are primary risk factors for STIs among this population. However, little research has been conducted to assess sexual risk among lesbian and bisexual college women exclusively. A cross-sectional Internet survey was conducted with 230 self-identified lesbian and bisexual female college students to examine their sexual risk and to determine with which, if any, STIs they had ever been diagnosed. Eight percent of lesbian and bisexual college women reported ever being diagnosed with an STI; the human papillomavirus, bacterial vaginosis, and genital herpes accounted for 84% of STI cases. Number of lifetime sex partners was significantly associated with an STI diagnosis among this population. Older age, engaging in penile-vaginal intercourse with a male (lifetime), and younger age at first same-sex experience were significantly associated with a greater number of lifetime sex partners. Results may be useful to sexual health programs targeting lesbian and bisexual college women and/or their providers.

Present but not accounted for: exploring the sexual risk practices and intervention needs of nonheterosexually identified women in a prevention program for women with HIV/AIDS

Nonheterosexually identified (NHI) women may be present, but not accounted for, in HIV and sexually transmitted infection (STI) prevention interventions. This study used quantitative and qualitative methods to examine the sexual risk behaviors and intervention needs of NHI women in Protect and Respect, a safer sex intervention for HIV-positive women. Study participants (n=32) were predominantly Black, low income, and between 28 and 51 years old. Although NHI participants were more likely than heterosexual participants (p < .05) to report obtaining their income from sex work, hustling, or selling drugs; and having a higher median number of male sex partners, qualitative analyses revealed that the intervention often neglected NHI women's experiences and unique safer sex needs. Heterosexist HIV and STI prevention programs may hinder NHI women's ability to protect themselves and their partners from reinfection and infection respectively. We discuss the implications of our research for future HIV/AIDS and STI research, services and interventions for NHI women.

Dimensions of sexual orientation and HIV-related risk among adolescent females: evidence from a statewide survey

OBJECTIVES

We examined the relationship of 2 dimensions of sexual orientation--sexual identity and sex of partners--with self-reported behaviors and experiences to identify factors that may place adolescent females at risk of HIV/AIDS.

METHODS

We gathered data on sexually experienced female high school students from 4 waves of a population-based survey. We used logistic regression analyses to investigate the association between their sexual identity (3666 heterosexual; 184 lesbian, gay, or bisexual; 113 not sure) and sex of partners (3714 male only, 79 female only, and 180 both males and females) with HIV-related risk behaviors.

RESULTS

Self-defined sexual identity was often inconsistent with sex of sexual partners. Sexual identities other than heterosexual and having same-sex partners (either exclusively or in addition to male partners) were associated with high rates of several HIV-related risk behaviors. Coerced sexual contact was significantly associated with every risk outcome. AIDS education in school predicted lower HIV risk on 4 of 6 indicators.

CONCLUSIONS

Programs to prevent HIV infection among adolescent females should take into account the complexity of sexual orientation and should address the needs and behaviors of sexual-minority youths.

Sexual orientation and sexual health care needs: a comparison of women beneficiaries in outpatient military health care settings

The objectives of this study are to compare the sexual concerns, interest and experiences in discussing these concerns with their doctor for women of "Only Men" and "Some to Only Women" sexual orientation. A survey was mailed to women patients from two military outpatient settings, with 1,196 women responding. Of eligible respondents (N = 1,170), 90% reported "Only Men" and 10% reported "Some to Only Women" sexual orientation. Sexual concerns varied by sexual orientation, while interest and experience in discussing sexual concerns and desire for physicians to initiate the topic differed minimally. Women with "Some to Only Women" sexual orientation have both similar and differing sexual concerns compared to "male-only" oriented women. Larger primary care patient-based studies of sexual health care needs of sexual minorities are needed.

Comparison of HIV Risks among Gay, Lesbian, Bisexual and Heterosexual Homeless Youth

Youth who are homeless and gay, lesbian or bisexual (GLB) are one of the most disenfranchised and marginalized groups in our society. The purpose of this study is to examine and compare HIV in GLB homeless youth with their heterosexual counterparts. Participants for this study included 268 youth involved in treatment outcome studies with substance abusing homeless youth. Results suggest that GLB youth have greater HIV risks and that these risks are greater among bisexual females. In examining the predictors of sexual health risks, survival sex emerged as the most significant. Survival sex was high among females regardless of their sexual orientation and also among gay males. Implications of these findings suggest that a greater emphasis needs to be paid to preventive interventions among this population.

Sex in Australia: Injecting and sexual risk behaviour in a representative sample of adults

OBJECTIVE

Some blood-borne and sexually transmissible agents may be spread by using non-sterile injecting equipment and by unprotected sexual intercourse. The objective of this study was to describe the prevalence of these risk factors in the general population of Australia.

METHODS

Computer-assisted telephone interviews were completed by a representative sample of 10,173 men and 9,134 women aged 16-59 years. The overall response rate was 73.1% (69.4% men, 77.6% women).

RESULTS

3% of respondents had ever injected non-prescription drugs; men were more likely than women to have done so. Predictors of injecting in men and women included being aged 20-29, homosexual or bisexual identity, and lower levels of education and income. Injecting was not more common in cities than elsewhere. Among people who had injected in the past year, 12.4% had shared needles and 43.0% had shared other paraphernalia. Sharing was significantly related to lower income. Unprotected sex with casual partners was more common in heterosexual activity than in male homosexual activity. Among heterosexually active respondents, 3.3% reported unprotected vaginal sex with casual partners (59% of those with such partners) and among homosexually active males 2.1% reported unprotected anal sex with casual partners (12% of those with such partners). Predictors of unprotected sex included indices of lower socio-economic status.

CONCLUSION

Sexual and injecting risks are reported by substantial minorities of the Australian population and are associated with indices of lower socio-economic status and bisexual identity. Programs are needed to address vulnerabilities to these infections.

Women who report having sex with women: British national probability data on prevalence, sexual behaviors, and health outcomes

OBJECTIVES

We estimated the prevalence of same-sex experience among women and compared women reporting sex with women and men and women reporting sex exclusively with women with women reporting sex exclusively with men, in terms of sociodemographics and sexual, reproductive, and general health risk behaviors and outcomes.

METHODS

We used a British probability survey (n=6399 women, aged 16 to 44 years) conducted from 1999 to 2001 with face-to-face interviewing and computer-assisted self-interviewing.

RESULTS

We found that 4.9% of the women reported same-sex partner(s) ever; 2.8% reported sex with women in the past 5 years (n=178); 85.0% of these women also reported male partner(s) in this time. Compared with women who reported sex exclusively with men, women who reported sex with women and men reported significantly greater male partner numbers, unsafe sex, smoking, alcohol consumption, and intravenous drug use and had an increased likelihood of induced abortion and sexually transmitted infection diagnoses (age-adjusted odds ratios=3.07 and 4.41, respectively).

CONCLUSIONS

For women, a history of sex with women may be a marker for increased risk of adverse sexual, reproductive, and general health outcomes compared with women who reported sex exclusively with men. A nonjudgmental review of female patients' sexual history should help practitioners discuss risks that women may face.

Health Care Recommendations for Lesbian Women

OBJECTIVE

To review research literature to provide clinicians with data-based recommendations for care of lesbians.

DATA SOURCES

Medline searches and references from selected articles with the search term "lesbian health."

STUDY SELECTION

Literature was selected whether lesbian or women who have sex with women was utilized as a category in the study and results were available on this population.

DATA EXTRACTION

Data were organized according to specific health problems noted frequently in the research articles.

DATA SYNTHESIS

Lesbians have previously been invisible in health services and research, but in several areas, data now exists on which to base care.

CONCLUSIONS

Lesbians are now more comfortable "coming out" to providers but continue to have lower screening rates than other women. Risk is especially high in this population for cancer, heart disease, depression, and alcohol abuse. Adolescent lesbians are especially at risk for smoking and suicide/depression.

I don't know who I am: severely mental ill Latina WSW navigating differentness

We examine interviews from a qualitative study designed to examine HIV perceptions, risk, and risk management among Puerto Rican women who have sex with women (WSW) and who also have been diagnosed with major depression, bipolar disorder, or schizophrenia. These women's stories challenge both the lesbian and the Latino communities to reexamine how and why they claim individuals as their own and they similarly challenge professional communities, including HIV educators, health researchers, and medical care providers, to develop effective HIV prevention programs and counseling approaches that facilitate patient/client self-disclosure and consider cultural and contextual barriers to both self-disclosure and the provision of services.

Who is epidemiologically fathomable in the HIV/AIDS epidemic? Gender, sexuality, and intersectionality in public health

This paper examines the shifting nature of contemporary epidemiological classifications in the HIV/AIDS epidemic. It first looks at assumptions that guide a discourse of vulnerability and circulate around risk categories. It then examines the underlying emphasis in public health on the popular frame of "vulnerable women" who acquire HIV through heterosexual transmission. Drawing on work on gender, sexuality, and intersectionality, the paper asks why a discourse of vulnerability is infused into discussions of heterosexually-active women's HIV risks but not those pertaining to heterosexually-active men's. The paper then moves to current surveillance categories that are hierarchically and differentially applied to women's and men's risks in the HIV epidemic. Here, the focus is on the way in which contemporary classifications allow for the emergence of the vulnerable heterosexually-active woman while simultaneously constituting lack of fathomability concerning bisexual and lesbian transmission risk. Lastly, theories of intersectionality, are used to examine current research on woman-to-woman transmission, and to suggest future more productive options.

Sexual Risk Factors Among Self-Identified Lesbians, Bisexual Women, and Heterosexual Women Accessing Primary Care Settings

OBJECTIVES

There is scant data on the sexual behaviors of women of diverse sexual orientations in a low-risk population.

GOALS

The goals of this study were to sample women of all sexual orientations in primary care settings and to evaluate sexual behaviors and risk for HIV and other sexually transmitted diseases (STDs).

STUDY

A total of 1,304 women (self-identified as 49% heterosexual, 11% bisexual, and 40% lesbian) were surveyed by anonymous questionnaire at 33 healthcare sites.

RESULTS

Among women who recently had sex with men (N = 600), 51% reported ever using condoms. Heterosexual women were at highest risk for acquiring HIV as a result of lack of condom use (P <0.001), particularly in higher-risk situations. Bisexual women reported substance use with sex at a higher rate than lesbians or heterosexual women (P <0.001). Lesbians had higher rates of sex with bisexual men (P <0.001) and injection drug users (P <0.02), but also a higher rate of condom use (P <0.001) compared with bisexual or heterosexual women.

CONCLUSION

Women of all sexual orientations, and particularly heterosexual women, engaged in behaviors that put them at risk for HIV and STD.

Australian lesbian and bisexual women's health and social experiences of living with hepatitis C

We recruited women in two Australian locations to complete a questionnaire on their health and social experiences of living with the hepatitis C virus (HCV). Among 462 respondents 9% identified themselves as lesbian and 14% as bisexual. Bisexuals were more disadvantaged than lesbians or heterosexuals on income, work status, home ownership, and level of education. Lesbians and bisexuals were less likely to be referred for HCV treatment and were more likely to report being treated negatively by any health professional. Lesbians and bisexuals experience HCV differently from one another and from heterosexuals. Their needs are not being met by women's health and HCV-specific services.

Changes in women's sexual risk behaviors after therapeutic community treatment

This study examines sexual risk behaviors among 197 women mandated to substance abuse treatment in therapeutic communities. The women's risk behaviors after treatment are compared with their behaviors prior to treatment, and risk behaviors among those who completed treatment are compared with those who did not. The women had a high prevalence of sexual risk behaviors (i.e., multiple partners, unprotected sex, sex trade, not asking partners to use condoms, sex with injection drug users [IDUs]) and relationship violence and conflict before treatment and a significant decrease in unprotected sex, sex trade, sex with multiple partners, and relationship violence or conflict after treatment. Those who completed treatment were significantly less likely to participate in sex trade or have sex with IDUs and were more likely to have a new sexual partner and only one sexual partner after treatment as compared with those who did not complete treatment. The present study shows that therapeutic community treatment is associated with the reduction of sexual risk behaviors among female substance abusers mandated to treatment.

Risks and prevention of sexually transmissible infections among women who have sex with women

Health care providers working with women who have sex with women (WSW) have been ill-informed about a range of sexual health issues for these women. Pertinent issues include sexual behaviours that carry risks of sexually transmissible infection (STI), prevention strategies for safer sex and understanding experiences of abuse. A relative silence continues in all of these areas within the mainstream medical literature, textbooks, research and policy documents, which perpetuates medical ignorance. There is evidence that the prevalence of STIs among WSW is at least as high as among heterosexual women, if not higher among some sub-groups. Risk factors include the sex and number of sexual partners, minimal use of protected sexual behaviours and low levels of knowledge of STI prevention among WSW. Importantly, marginalisation leading to poorer mental health and experiences of abuse can combine to influence risk taking including substance abuse and risky sexual behaviours. Safe-sex guidelines and the need to recognise the impact of sexual abuse are presented.

Sex in Australia: homosexual experience and recent homosexual encounters

OBJECTIVE

To describe the prevalence and features of homosexual experience and recent homosexual encounters among a representative sample of Australian adults.

METHODS

Computer-assisted telephone interviews were completed by a representative sample of 10,173 men and 9,134 women aged 16-59 years from all States and Territories. The overall response rate was 73.1% (69.4% among men and 77.6% among women).

RESULTS

Overall, 8.6% of women and 5.9% of men reported some homosexual sexual experience in their lives (p<0.001); these figures fell to 5.7% and 5.0% respectively (p=0.106) when non-genital sexual experience was excluded. 1.9% of men and 1.5% of women reported homosexual experience in the past year. Men who reported homosexual experience reported more same-sex partners than did women (means 31.6 and 3.2, p<0.001), and men and women who identified as homosexual or bisexual reported more sexual partners in total than those who identified as heterosexual. Respondents reporting homosexual experience were significantly more likely to be from an English-speaking background, have higher levels of education, live in a major city, and report a white-collar or managerial/professional occupation. Women who reported homosexual experience were less likely to have a middle or high income. In the most recent homosexual encounter, genital touching was the most commonly reported practice, and oral sex was reported much more frequently than in heterosexual encounters.

CONCLUSION

Homosexually and bisexually identified men and women had higher total numbers of partners than heterosexuals. Improved societal attitudes towards homosexuality are likely to lead to further increases in estimates of the prevalence of homosexual experience in the community.

HIV/STI associated risk behaviors among self-identified lesbian, gay, bisexual, and transgender college students in the United States

An Internet survey was conducted during the 2001-2002 academic year to examine the health risk behaviors, including HIV/STI associated behaviors, of self-identified lesbian, gay, bisexual, and transgender (LGBT) college students in the United States. A total of 450 LGBT college students completed the entire online survey. Most respondents attended a 4-year (96.9%), coeducational (98.6%), non-religiously affiliated (87.5%), public (68.6%) institution. Eighty-nine percent reported having sex with someone of the same sex and 45% had multiple (6 or more) sex partners during their lifetime. Most reported using a condom consistently during penile-vaginal (61%) and anal sex (63%). However, only 4% used a condom or other barrier consistently during oral sex and 28% used a condom or other barrier during their last sexual encounter. Injection drug use and needle-sharing behavior was low (2.1% and 1.1%, respectively). Comparisons with heterosexual college students' HIV/STI associated risk behaviors are included. Results may be useful for HIV/STI prevention programs targeting LGBT college students.

Nuances and shifts in lesbian women's constructions of STI and HIV vulnerability

This study examines the subjective side of vulnerability as a social construct rooted in interpersonal relationships and community membership. Analysis is based on a survey of an especially diverse sample of 162 lesbian women, 67 of whom also participated in depth interviews. Another 24 of the original sample also participated in transcribed focus groups. One third were African American, Latina, and Asian, and two thirds were white. This sample reported an overall infection rate of 23%. Three subjective stances, or risk frames, are identified: essentially invulnerable, socially inoculated, and fundamentally vulnerable. Some women describe shifts in their interpretations of their own vulnerability, moving from one stance to another in response to obtaining information, becoming infected, having friends or acquaintances who become infected, and becoming involved with new partners. It is suggested that these shifts comprise a subjective "vulnerability career". The significance of lesbian women's constructions of vulnerability is examined, and the implications of this study for a better understanding of their risk for STIs are discussed.

Self-reported sexual identity, sexual behaviors and health risks

SUMMARY Data from a population-based survey of low-income young women (n = 2,438) was used to examine substance use patterns and exposure to coerced sexual activity among women who self-identify as lesbian (n = 34) or bisexual (n = 91), or who report sexual behavior exclusively with other women (n = 17) or with both women and men (n = 189). Findings for women classified by self-identity and by sexual behavior are compared. Women who identified as bisexual or lesbian reported higher rates of lifetime and recent substance use and were more likely to report experiences of coerced sex than women who identified as heterosexual. Women with both male and female sex partners reported higher rates of substance use and coerced sexual experiences than did women with male partners only. Heterosexual women with both male and female partners were more similar to self-identified bisexuals, compared to heterosexual women with male partners only. The implications of assessing multiple dimensions of sexual orientation in research focusing on lesbians' mental health are discussed.

Abuse, Social Support, and Depression Among HIV-Positive Heterosexual, Bisexual, and Lesbian Women

SUMMARY A nonprobability sample of HIV-positive mostly African American and Puerto Rican women in New York City were surveyed regarding abusive experiences, social support, and depressive symptoms. Seventy-five percent reported experiencing physical or sexual abuse at some point in their lives. Multiple regression analyses controlling for relevant sociodemographic variables indicated that child physical and sexual abuse and adult sexual abuse were significantly associated with depressive symptomatology (i.e., CES-D scores). HIV-related social support had a significant negative correlation with CES-D scores but did not have a moderating impact on the effects of physical or sexual abuse. Lesbian/bisexual women reported higher rates of lifetime sexual and physical abuse than heterosexual women. However, there were no differences between the groups in total CES-D scores. Lesbian/bisexual women had significantly greater support from friends and groups/organizations than the heterosexual women. The implications of the findings for future research and the provision of services for HIV-positive women are considered.

Lesbian health research: a review and recommendations for future research

Prior to 1990 lesbians were "invisible" in health care research. Researchers who asked questions specifically about lesbian health concerns were rare, and the burgeoning research on women's health seldom included variables that measured sexual orientation or behavior. In the last decade, however, lesbian health has emerged as a major area of study. A 1999 Institute of Medicine (IOM) report on Lesbian Health has outlined the challenges and gaps in this area of research and has called for focus and funding on specific areas of need. In this article I review research on lesbian health, discuss methodological issues specific to this area of research, and summarize the recommendations of the IOM report.

Beyond assumptions of negligible risk: sexually transmitted diseases and women who have sex with women

OBJECTIVES

This study evaluated the association of female-female sexual behavior with sexually transmitted diseases (STDs).

METHODS

Female participants (n = 286) were recruited from the Twin Cities Gay/Lesbian/Bisexual/Transgender Pride Festival. Logistic regression was used to examine the association between female-female sexual behavior and STDs.

RESULTS

Women in all partner history groups, including 13% of women with only female partners, reported a history of STD. Increased sexual exposures with women predicted an increase in the likelihood of STDs after known risk factors had been controlled. Neither number of female partners nor number of exposures was associated with obtaining regular STD testing.

CONCLUSIONS

The risk of STDs through female-female sexual exposure is not negligible. Nevertheless, patterns of STD testing do not reflect this risk.

Sexual orientation and HIV infection prevalence among young Latino injection drug users in Harlem

Among injection drug users (IDUs), those at highest risk for HIV infection include Latinos, young women, and young men who have sex with men (homosexual men). We examined how HIV infection prevalence is affected by gender and sexual orientation among young Latino IDUs in New York City. We used baseline data from a cohort study of young (18-30 years) IDUs in Harlem, New York City, conducted from 1997 through 1999. Participants were asked about drug use and sexual behaviors, and blood was taken for HIV, hepatitis B, and hepatitis C viral antibody testing. Of 156 participants who self-identified as Latino, 145 (94%) were Puerto Rican. Overall, 101 (65%) were heterosexual men, 11 (7%) were men who have sex with men (MSM), 32 (20%) were heterosexual women, and 12 (8%) were women who have sex with women (WSW). Of the whole cohort, 17 (11%) were HIV positive. HIV infection rates were higher among WSW (42%, p < 0.05), heterosexual women (16%, p < 0.05), and homosexual men (18%, p = 0.09) than heterosexual men (5%). Compared with heterosexual men, homosexual men were significantly (p < 0.05) more likely to have received money or drugs for sex (64% versus 33%), and WSW were significantly more likely to have had unprotected sex with an IDU 5 years or more older (50% versus 16%). Multivariate analysis showed being a WSW (adjusted odds ratio [AOR] = 8.68, 95% confidence interval [CI] 1.78-42.26) and having unprotected sex with an older IDU (AOR = 7.01, 95% CI 2.23-21.96) to be associated with HIV infection. Sexual transmission may account for many HIV infections among young Latino IDUs. The high prevalence of HIV infection among WSW may, in part, be due to their having unprotected sex with older men, but studies with larger sample sizes are needed to confirm this.

The coming-out process and its adaptational and health-related associations among gay, lesbian, and bisexual youths: stipulation and exploration of a model

A model is proposed and explored that links the coming-out process to the psychological functioning (i.e., self-esteem and distress) and sexual behaviors of gay, lesbian, and bisexual youths recruited from gay-focused community-based and college organizations in New York City. The coming-out process is multidimensional, consisting, as defined here, of involvement in gay/lesbian activities, attitudes toward homosexuality, comfort with homosexuality, self-disclosure of sexual identity to others, and sexual identity. The coming-out dimensions were related to self-esteem, distress, and unprotected sexual behaviors. In addition, the relations between the coming-out dimensions and unprotected sexual behaviors were explained by psychological functioning. In particular, limited involvement in gay/lesbian activities was associated with more unprotected sex. Negative attitudes toward homosexuality were related directly to more unprotected sex, and they were related indirectly to more unprotected sex by means of increasing emotional distress. These and other findings have implications for designing preventive interventions to increase the youths' psychological functioning and reduce their unprotected sexual behaviors.

Genital human papillomavirus infection in women who have sex with women: a review

Sexual transmission of human papillomavirus between women has been postulated on the basis of reports of abnormal Papanicolaou smears in women who reported no prior sex with men and by studies using amplified deoxyribonucleic acid technology for human papillomavirus detection. To review the current knowledge of the epidemiology of human papillomavirus and the Papanicolaou smear screening practices among women who have sex with women, studies were identified from a search of the MEDLINE database from January 1980-June 1999. Several factors, including prior or concurrent sex with men and sexual behaviors between women, validate the possibility of human papillomavirus infection among women who have sex with women, and data support that human papillomavirus transmission also occurs. Limited data indicate that the frequency of routine Papanicolaou smear screening among women who have sex with women may be suboptimal relative to heterosexual women. Education of women who have sex with women and the providers of their health care should counter any assumptions that sex between women confers no risk of human papillomavirus transmission. Women who have sex with women should receive Papanicolaou smear screening in accord with current guidelines.

Genital human papillomavirus infection in women who have sex with women: a concern for patients and providers

Certain types of the human papillomavirus (HPV) are sexually transmitted and cause genital warts and cervical neoplasia. Little is known about the epidemiology of HPV among women who have sex with women (WSW), but recent research using amplified techniques for HPV DNA strongly suggests that HPV is sexually transmitted between female sex partners. In a pilot study of 149 WSW in Seattle, Washington, prevalence of HPV as detected by DNA amplification assay was 30%, and was 19% among women reporting no prior sex with men. Although most cervical cancer can be prevented with Pap smear screening by detection of squamous epithelial lesions (SIL), some data suggest that the frequency of Pap smear screening is suboptimal in WSW. Reasons for this are unclear, but may include perceptions by patients and providers that WSW are not at risk for many STD and, by extension, cervical cancer. In our study, WSW who reported no prior sex with men had routine Pap smear screening less frequently than the comparative group, and had a prevalence of SIL of 14%. Combined with the work of other investigators, these data strongly suggest that current recommendations for Pap smear screening among WSW should not differ from those for heterosexual women. WSW and their providers should understand that sex between women may confer a risk of HPV transmission; risk of transmission of other STD, including HIV, deserves further study.

Women Injection Drug Users Who Have Sex with Women Exhibit Increased HIV Infection and Risk Behaviors

This article is a comprehensive review of published research on HIV seroprevalence and HIV-related risk behaviors among women injection drug users (IDUs) who have sex with women (WSW). At least 14 studies since the late 1980s converge into a consistent pattern: compared to other IDUs, WSW IDUs report higher levels of HIV-related risk behaviors and in many cases exhibit higher rates of HIV seroconversion or seroprevalence. Data from these and additional studies also indicate that large numbers of women IDUs are WSWs. Since information regarding WSW IDUs are widely collected but infrequently analyzed and reported, we suggest promising research and analysis strategies for exploring the meaning behind this pattern of increased vulnerability to HIV. Finally, we assert that enough is currently known to warrant significant investment in targeted prevention and intervention programs to address the critical HIV-related needs of lesbian, bisexual, and other WSW IDUs.

HIV risk behavior among bisexual and heterosexual drug users

This study examined the sexual and drug use behaviors for bisexual and heterosexual drug users (n=11,435 males and n=5,636 females) who participated in the NIDA AIDS Cooperative Agreement study. Results of the study suggest that, for males, bisexuality was highly associated with being homeless, having ever been paid for sex, having five or more sex partners in the month preceding the interview, having an IV drug-using sexual partner in the month preceding the interview, using crack, and sharing injection equipment in the month preceding the interview. For females, bisexuality was associated with ever having been arrested, past substance abuse treatment, ever having been paid for sex, ever having paid for sex, having five or more sexual partners in the month preceding the interview, ever using cocaine, and sharing injection equipment in the month preceding the interview. Overall, results from this study indicate that both male and female bisexuals, when compared to heterosexuals, were at higher risk for HIV and were more likely to be HIV positive. One implication of these results is that a universal prevention message may not be as effective as targeting prevention messages specifically for bisexual males and females.

Use of preventive health behaviors by lesbian, bisexual, and heterosexual women: questionnaire survey

OBJECTIVES

To determine whether lesbians and bisexual women are less likely than heterosexual women to use preventive health measures.

DESIGN

Written, anonymous, self-administered questionnaire.

SETTING

33 physicians' offices and community clinics mainly in urban areas of 13 states.

PARTICIPANTS

524 lesbians, 143 bisexual women, and 637 heterosexual women.

RESULTS

Bisexual women were less likely than heterosexual women to have had appropriate cholesterol screening (odds ratio 0.29, 95% confidence interval 0.11 to 0.73) or appropriate mammography (0.33, 0.13 to 0.84). Human immunodeficiency virus testing was more common in lesbians (2.38, 1. 51 to 3.74) and bisexual women (1.99, 1.17 to 3.38) than in heterosexual women. Illicit drug use was higher in lesbians (2.04, 1. 14 to 3.70) and bisexual women (1.96, 1.07 to 3.57) than in heterosexual women. Lesbians were more likely than heterosexual women to practice safer sex (2.60, 1.23 to 5.49) and less likely to have ever been infected with human papillomavirus (0.48, 0.25 to 0. 89).

CONCLUSION

There were important differences in the preventive health measures taken by lesbians and bisexual women and those taken by heterosexual women. All patients should receive standard health tests, such as cholesterol screening and mammography, regardless of their sexual orientation. Lesbians and bisexual women who report illicit drug use should receive counseling, as appropriate.

Perceptions of health care professionals and patients about the risk of HIV transmission through oral sex: a qualitative study

We explored health care professionals' beliefs and methods for counseling patients about risks for transmitting human immunodeficiency virus (HIV) through oral sex and HIV-seropositive patients' beliefs and practices regarding oral sex behavior. Health care professionals used divergent counseling strategies, avoided specific recommendations, and expressed ambivalence about recommending barrier protection for oral sex. Patients expressed differing beliefs about oral sex risk; the majority have engaged in unprotected oral sex since diagnosis. Few professionals or patients mentioned oral sex risk for other sexually transmitted diseases (STDs), which can be cofactors for HIV. Although scientific evidence indicates a potential risk for transmitting HIV via oral sex, and patients in our sample want more information about this risk, the health care professionals we interviewed have adopted a largely noncommittal approach to communicating potential risk to patients. Health care professionals should consider discussing more specifically with patients the oral sex risk for transmission of HIV and other sexually transmitted diseases.