Sexual Practices, Risk Perception and Knowledge Of Sexually Transmitted Disease Risk Among Lesbian and Bisexual Women

In the United States, where an estimated 2.3 million women describe themselves as lesbian,1 transmission of common sexually transmitted diseases (STDs)—including trichomoniasis, genital herpes, human papillomavirus and HIV—between female sex partners has been reported.2 In the few studies that have examined this topic, sexual practices involving digital-vaginal or digital-anal contact, particularly with shared penetrative sex toys, have been frequently reported among female sex partners; such practices present a plausible means for STD transmission, presumably by transfer of infected cervicovaginal secretions or by direct mucosal contact.3 Although messages pertaining to safer sex between women are available on the Internet and from some community organizations, none have been specifically tested for either acceptability, potential for adherence or efficacy in reducing STD transmission. Lesbians also have an unusually high prevalence of bacterial vaginosis, the most common cause of vaginal complaints among U.S. women of reproductive age.4 Bacterial vaginosis results from a shift in the vagina’s microbial ecosystem from predominance with human Lactobacillus species to overgrowth by bacteria that can cause numerous problems in the upper genital tract (including pelvic inflammatory disease and chorioamnionitis, an inflammation of the membranes surrounding the fetus), as well as increased risks of acquiring gonorrhea and HIV. The etiology of bacterial vaginosis is unknown, although some evidence suggests that having sex with a new male partner and not using condoms play a role;5 the condition occurs in 5–23% of U.S. women who are sexually active with men.6 Among 392 lesbian and bisexual women participating in an earlier community-based study in Seattle, we found that 27% had bacterial vaginosis, a prevalence considerably higher than the 23% found among age-matched heterosexual women seen at the local STD clinic during the same time.7 Women in that study commonly reported sexual practices that transmit vaginal secretions and are strongly associated with bacterial vaginosis, even after other risks are controlled for. Further, 81% of those with bacterial vaginosis, but only 4% of other women, had partners with bacterial vaginosis. These data support the hypothesis that lesbians have a higher bacterial vaginosis prevalence because sexual transfer of vaginal fluid effects transmission of an as-yet undefined causative factor.8 An intervention aimed at reducing the sexual transfer of vaginal fluid as a means of reducing the recurrence of bacterial vaginosis and STD transmission in general could emphasize one or more protective strategies, depending on what sexual practices participants engage in. For example, if participants report having digital-vaginal sex, the intervention might emphasize the use of disposable gloves or a topical antimicrobial solution or gel; for women who report using vaginally insertive sex toys, it might stress the importance of using male condoms. In this article, we describe the results of focus group discussions whose purpose was to inform the development of such an intervention. The objectives of the discussions were to identify specific sexual practices women engage in with other women, determine what protective behaviors these women would find most acceptable and be most likely to practice, and assess knowledge of bacterial vaginosis.