STDs are a significant health issue for college students in the United States. Human papillomavirus [HPV], chlamydia and genital herpes are among the most commonly reported STDs in college students.1 Female college students are at higher risk of contracting STDs than are their same-age peers not attending college, because they tend to use alcohol more frequently and have a greater number of sex partners.2 Moreover, having an immature cervix makes young females particularly susceptible to infection with HPV or chlamydia.3,4 A segment of this population, lesbian and bisexual college women, may be at even greater risk for STDs than their heterosexual counterparts, as they are more likely to use drugs and alcohol and to engage in a variety of sexual behaviors without the use of condoms or other barriers.5–7 Yet, young lesbian and bisexual women have been largely ignored in both STD research and sexual health promotion programs.
A common misperception among health care providers, as well as among sexual minority [nonheterosexual] women themselves, is that lesbian and bisexual women are not at risk for STDs.8,9 However, research with older populations of lesbian and bisexual women suggests that this is grossly inaccurate: In various studies, 13–44% have reported having had an STD.10–12 In addition, when women, including asymptomatic women, have been tested for STDs, lesbian and bisexual women have had a higher prevalence of bacterial vaginosis, hepatitis B and C, gonorrhea, genital herpes and chlamydia than heterosexual women.12,13
Several risk factors have been positively associated with STDs among lesbian and bisexual women, including age, substance use, number of sex partners and engaging in vaginal intercourse with men.8,9,12,14 Furthermore, most sexual minority women in these studies, including 44–85% of lesbians, have reported participating in penile-vaginal intercourse during the past year, the majority of the time without using a condom or other barrier method.9,12 Additionally, lesbians are significantly more likely than their heterosexual counterparts to drink and smoke—behaviors that are related to increased levels of sexual risk-taking or sexual risk—and are less likely to obtain routine gynecologic examinations.9,11,12
Most sexual health research involving lesbian and bisexual women has been with adult populations in the United Kingdom or with U.S. women in lesbian bars, attending music festivals or at STD clinics.15–19 Very little research has explored STD risk among younger populations of lesbian and bisexual women or among lesbian and bisexual college women exclusively.8 Furthermore, the extent to which sexual orientation is associated with substance use, sexual risk behaviors and STDs has not been examined among this population.
This study examines STDs and risk factors among sexually active female college students of different sexual orientations who participated in the spring 2006 National College Health Assessment [NCHA].
METHODS
Survey and Sample
In spring 2006, a self-selected sample of 123 postsecondary institutions participated in the American College Health Association’s NCHA survey. Of these, 117 institutions utilized a random sampling technique, which yielded a final sample of 94,806 students, including 57,903 females. [The remaining six institutions did not use random sampling and were excluded.] Most participating institutions were four-year [97%], public [62%] colleges or universities located throughout the United States [22% in the Northeast, 25% in the Midwest, 22% in the South and 27% in the West]; 3% were located in Canada.1
Schools administered the survey either in class to a sample of classes that had been randomly selected at each course level or online to students who had been randomly selected and sent an e-mail invitation to participate. In total, 22 schools used the classroom survey, 92 used the Web-based survey and three used a combination of the two. The mean response rate was 85% for institutions using classroom surveys and 23% for those using Web-based surveys, producing an overall mean response of 35%. Students taking the Web survey were slightly younger than those taking the classroom survey; however, no other significant differences were found on the variables of interest, and data from the two surveys were combined. Additional details about the NCHA are available elsewhere.1
The survey examines a variety of behaviors and topics that affect the health and academic success of college students, including substance use, sexual behaviors, weight and nutrition, violence, and physical and mental health.1 In addition, it collects information regarding students’ age, sex, race and ethnicity, year in school, residence, relationship status and sexual orientation. This investigation is based on a subsample of 29,952 female students from the United States or Canada who were sexually active [i.e., had had one or more sex partners during the last school year] and of traditional college age [18–24].
Measures and Analyses
Sexual orientation was defined by students’ response to the question "Which of the following best describes you?" Possible responses were "heterosexual," "gay/lesbian," "bisexual," "transgendered" and "unsure." Students who identified themselves as transgendered were not included in these analyses, as gender identity [whether someone identifies as male or female] is a different construct from sexual orientation [the gender to which someone is sexually attracted]. Students were also asked whether their sex partners during the last school year were "male,""female,""both male and female" or "n/a." Students who responded "n/a" were excluded from the analyses.
Alcohol use was measured with the question "The last time you ‘partied’/socialized, how many alcoholic drinks did you have?" This item was dichotomized, and students reporting four or more drinks were considered to have participated in binge drinking. The survey also asked on how many days within the past 30 days students had used cigarettes, marijuana [pot, hash or hash oil], cocaine [crack, rock or freebase], amphetamines [diet pills, speed, meth or crank] and ecstasy. Responses were coded as zero or at least one.
Students were asked if they had ever engaged in oral, vaginal or anal intercourse; if they had used a condom the last time they had had oral, vaginal or anal intercourse; if they had had a routine gynecologic examination in the past year; if they had ever been tested for HIV; and whether they had had HPV, chlamydia, genital herpes, gonorrhea or HIV within the last school year. An item was created from responses regarding STDs, indicating whether they had had any of the above conditions in the past year. Students also were asked to report the number of partners, if any, with whom they had had oral, vaginal or anal sex within the past school year.
We conducted descriptive analyses, chi-square tests, t tests, analyses of variance and multiple comparisons using the Tukey post hoc multiple comparison procedure to identify characteristics that were associated with respondents’ sexual orientation. Adjusted odds ratios were calculated to assess associations between having had an STD and sexual orientation, and logistic regression analysis using the forward stepwise procedure was conducted to identify behaviors and characteristics associated with having had an STD during the past year. SPSS 15.0 was used for analyses, and all tests were considered significant at or below the .05 alpha level.
RESULTS
Respondent Characteristics
Most students in this sample were white [78%] and were undergraduates [93%]; 42% were single, and 54% were in a committed dating relationship or engaged to be married [Table 1, page 214]. Ninety-four percent identified themselves as heterosexual, 1% as lesbian and 3% as bisexual; 1% were unsure of their sexual orientation. Similarly, 96% reported that during the past school year, they had had sex only with males, 2% only with females and 2% with both males and females. Two-thirds had had only one partner during the past year.
The vast majority of heterosexual students [98%] and students who were unsure of their sexual orientation [81%] had had sex only with males during the past year [Table 2, page 214]; the majority of lesbians [85%] had had sex only with females. Among bisexual students, 56% had had sex only with males, and 10% had had sex only with females. Some 35% of bisexual students, 10% of lesbian students, 14% of students who were unsure of their sexual orientation and fewer than 1% of heterosexual students had had sex with both males and females during the past year.
Behavioral Risk Factors
Nearly all respondents had ever engaged in oral sex [94%] and vaginal intercourse [91%]. Close to one-quarter [23%] had ever engaged in anal intercourse. Lesbians were significantly less likely [p