Archives of Sexual Behavior

, Volume 42, Issue 8, pp 1561–1572 | Cite as

Sexual Health Behaviors and Sexual Orientation in a U.S. National Sample of College Students

Original Paper

Abstract

Many studies have examined differences in sexual behavior based on sexual orientation with results often indicating that those with same-sex partners engage in higher risk sexual behavior than people with opposite sex partners. However, few of these studies were large, national sample studies that also include those identifying as unsure. To address that gap, this study examined the relationship of sexual orientation and sexual health outcomes in a national sample of U.S. college students. The Fall 2009 American College Health Association–National College Health Assessment was used to examine sexual health related responses from heterosexual, gay, lesbian, bisexual, and unsure students (N = 25,553). Responses related to sexual behavior, safer sex behaviors, prevention and screening behaviors, and diagnosis of sexual health related conditions were examined. The findings indicated that sexual orientation was significantly associated with engaging in sexual behavior in the last 30 days. Sexual orientation was also significantly associated with the number of sexual partners in the previous 12 months, with unsure men having significantly more partners than gay, bisexual and heterosexual men and heterosexual men having significantly less partners than gay, bisexual and unsure men. Bisexual women had significantly more partners than females reporting other sexual orientations. Results examining the associations between sexual orientation and safer sex, prevention behaviors, and screening behaviors were mixed. Implications for practice, including specific programmatic ideas, were discussed.

Keywords

Sexual orientation College students Sexual behavior Safer sex Prevention and screening 

Introduction

Late adolescence is a time of self-exploration and identity development (Erikson, 1968), which includes sexual identity formation (Eliason, 1995; Moore & Rosenthal, 1993; Tasker & McCann, 1999). Exploring one’s sexual identity is shown to have a positive association with sexual well-being (Muise, Preyde, Maitland, & Milhausen, 2010). College life provides a sense of independence and pressure for sexual experimentation (Ragon, Kittleson, & St. Pierre, 1995).

At the same time, multiple sexual partners and lack of condom use, often associated with hooking-up among heterosexuals (Fielder & Carey, 2010), may exacerbate potential negative physical health outcomes from sexual exploration. For example, youth of college age are at high risk for sexually transmitted infections. An estimated 19 million STIs occur annually with almost half occurring among 15–24 year olds (Centers for Disease Control and Prevention [CDC], 2011c). Young people aged 15–24 years also have four times the reported Chlamydia and gonorrhea rates of the total population aged 10–65+ years (CDC, 2011b). Moreover, adolescents and young adults aged 13–29 years accounted for 39 % of new human immunodeficiency virus (HIV) infections in 2009. Young gay and bisexual men (13–29 years of age) are at particular risk as they accounted for 27 % of all new HIV infections in 2009 and were the only group for whom new HIV infections increased between 2006 and 2009 (Prejean et al., 2011).

Some research indicates that individuals with same-sex partners may engage in higher risk sexual behavior (Bailey, Farquhar, Owen, & Mangtani, 2004; Bauer, Jairam, & Baidoobonso, 2010; Ciesielski, 2003; Fethers, Marks, Mindel, & Estcourt, 2000; Glick et al., 2012; Reisner et al., 2010; Scheer et al., 2002) than people with opposite sex partners. However, understanding the health needs of sexual minority individuals is challenging as limited large-scale and/or nationally representative data exist (Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities, 2011). Likewise, the intersection of minority sexual identity and emerging adult identity may increase the sexual risk taking behaviors of individuals. For many late adolescents in the United States, the experience of college represents a critical point in life where individuals shift from a role of dependence to one of independence. This transition requires the reframing and reshaping of many aspects of the individual, making it ideal and significant for shaping people’s behavior (Tinto, 1988). Understanding the sexual behaviors and related prevention strategies of all students in this life phase, regardless of sexual orientation, can aid in the development of appropriate programming.

Unfortunately, empirical data regarding differences in sexual behaviors and sexual health outcomes among gay, lesbian, bisexual, and heterosexual college students are scarce. A large-scale assessment of sexually active college females aged 18–24 years found that bisexuals were most likely to have had an STI during the past year (Lindley, Barnett, Brandt, Hardin, & Burcin, 2008). Similarly, females who had multiple partners of both sexes were more likely to have had an STI than females with male only partners or female only partners.

Additionally, the screening and prevention behaviors related to sexual health among sexual minorities are also not well examined, especially among gay males. Research on females demonstrates that women identifying as lesbian or bisexual were less likely to have received Pap screenings (Cochran et al., 2001; US Department of Health and Human Services, 2011). In one nationally representative study of females ages 17–25, those who identified as mostly heterosexual or bisexual were less likely to have had a Pap test within the last year and more likely to have been diagnosed with an STI when compared to those identifying as completely heterosexual. Females who identified as mostly or completely homosexual were less likely to have had a Pap test in their lifetime and a Pap test within the last year when compared with completely heterosexuals (Charlton et al., 2011).

While rates of prevention screening behaviors among men are less available, some research shows that sexual orientation is related. For example, gay and bisexual men were more interested in receiving the human papillomavirus (HPV) vaccine (Gilbert, Brewer, Reiter, Ng, & Smith, 2011) though no studies have examined actual rate differences based on sexual orientation. In fact, in our review of the literature, no other studies investigating sexual outcomes, screening or prevention behavior compared by sexual orientation among college students were found.

Given the lack of data regarding college students in these areas, this study’s purpose was to examine the relationship of sexual orientation with sexual health behaviors, related outcomes, screening practices, and other prevention behaviors using data from the Fall 2009 American College Health Association–National College Health Assessment (ACHA–NCHA) (American College Health Association [ACHA], 2010b).

Method

Participants

Institutional review board approval to analyze the most recently available data set from the ACHA–NCHA (ACHA, 2010b) was secured for this study. This data set contains information collected from 34,208 undergraduate and graduate students enrolled part time and full time at 57 two- and four-year universities (ACHA, 2010a). Individual universities conduct the process on their campuses in accordance with their institution’s policies. Data can be collected in person through classroom sampling or online. The ACHA–NCHA data set used in these analyses included only colleges and universities that randomly selected students or that surveyed students from randomly selected classrooms. Previous studies have demonstrated that the ACHA–NCHA provides similar results to nationally representative surveys (ACHA, 2004).

To garner a focused response to the research topic, inclusion/exclusion criteria were applied. Students who did not identify a sexual orientation (heterosexual, bisexual, gay/lesbian, or unsure) were not included in the analyses (n = 1,649). Participants reported a wide range of ages (18–97 years); however, only participants under 30 years of age were included in the analyses in order to generalize as best as possible to the “typical” demographic of university students. According to the National Center for Education Statistics (2010), three-fourths (75.8 %) of students enrolled in a university in the U.S. are under 30 years of age. In addition to those 30 years of age and older (n = 2,783), participants attending universities outside the U.S. were also excluded (n = 4,913), Transgender students were also not included for two reasons: the small number of participants (0.1 %, n = 42) and individuals who identify as transgender have different experiences on college campuses compared to non-transgender students who identify as gay, lesbian, or bisexual (Beemyn, 2005; Bilodeau, 2009). Some of those excluded fit into multiple exclusion categories.

After applying these inclusion/exclusion criteria, the total resulting sample was 25,553 students from 55 different universities and all regions of the U.S. Most student participants (94.7 %) were enrolled in a 4-year college or university. Nearly two-thirds (61.1 %) attended public institutions, with 12.4 % attending religiously affiliated institutions. The majority of participants identified as heterosexual (93.8 %, n = 23,971). Less than 7 % of the total sample identified as gay (1.1 %, n = 273), lesbian (0.7 %, n = 184), bisexual (2.9 %, n = 731), or unsure (1.5 %, n = 394). See Table 1 for other demographic data.
Table 1

Demographic characteristics

Characteristic

Participants (N = 25,553)

n

%

Age in years (M = 20.50, SD = 2.58)

 18–21

18,947

74.1

 22–25

4,971

19.5

 26–29

1,635

6.4

Gender

 Female

16,372

64.1

Sexual orientation

 Heterosexual

23,971

93.8

 Lesbian

184

0.7

 Gay male

273

1.1

 Bisexual

731

2.9

 Unsure

394

1.5

Full-time? (N = 25,339)

 Yes

24,233

95.6

Ethnicity

 White

18,361

71.9

 Black

2,210

8.6

 Hispanic

1,772

6.9

 Asian/Pacific Islander

2,775

10.9

 American Indian, Alaskan Native, Native Hawaiian

519

2.0

 Biracial, multiracial and other

1,442

5.6

International student? (N = 25,279)

 Yes

2,611

10.3

Relationship status

  

 Not in a relationship

12,976

51.1

 In relationship, not living together

9,270

36.5

 In relationship, living together

3,130

12.3

Current residence (N = 27,280)

 Campus residence hall

10,198

40.2

 Fraternity/sorority house

514

2.0

 Other campus housing

1,088

4.3

 Parent/guardian’s home

4,212

16.6

 Other off-campus housing

8,424

33.2

 Other

956

3.8

Classification (N = 25,271)

 1st year undergraduate

8,244

32.6

 2nd year undergraduate

4,744

18.8

 3rd year undergraduate

4,680

18.5

 4th year undergraduate

3,774

14.9

 5th year undergraduate

1,411

5.6

 Graduate/professional

2,276

9.0

 Other

142

0.6

Attends 2- or 4-year college?

 2-year college

507

2.0

 4-year college

24,207

94.7

 Other type of institution (e.g., professional or training school)

837

3.3

Measures

Sexual health issues were examined using items from three main categories: sexual behavior and safer sex behavior, prevention and screening behaviors, and sexual health diagnoses. Demographic items included age, gender, sexual orientation, year in school, relationship status, residence, and other student status (e.g., full- or part-time student, international).

Sexual and Safer Sex Behavior

The participants were asked about their sexual behavior and safer sex behavior through seven different items. One item asked the participants to identify the number of sexual partners they had oral, vaginal or anal sex with in the last 12 months; individuals could respond 0–99. Three items asked if individuals had engaged in oral, vaginal and anal sex in the last 30 days. Possible responses were “no, have never done this sexual activity”; “no, have done this activity in the past but not in the last 30 days”; and “yes.” Three additional items asked about safer sex behaviors: “Within the last 30 days, how often did you or your partner(s) use a condom or protective barrier (e.g. male condom, female condom, dam, glove) during oral, vaginal and anal sex?” Possible responses included “not applicable, never did this sexual activity”; “have not done this sexual activity during the last 30 days”; “never”; “rarely”; “sometime”; “most of the time”; or “always.” For the three items related to safer sex, only those individuals who had engaged in that activity in the last 30 days were included in the analyses.

Prevention and Screening Behaviors

Six items asked about prevention and screening behaviors. Individuals were asked if they had ever been tested for HIV, had received a HPV (cervical cancer) vaccine, and had received a Hepatitis B vaccine. Possible responses for these three questions were yes, no, and don’t know. There were also three sex-specific items that related to screening. Females were asked if they had performed a breast self-exam in the last 30 days and if they had a routine gynecological exam in the last 12 months. Males were asked if they performed a testicular self-exam in the last 30 days. Possible responses were yes, no, and don’t know.

Diagnoses or Treatment Related to Sexual Health

Eight items addressed diagnoses and treatment for sexual health conditions. Specifically the items asked “Within the last 12 months, have you been diagnosed or treated by a professional for….” with the following conditions included: Chlamydia, endometriosis, genital herpes, genital warts/HPV, gonorrhea, Hepatitis B or C, HIV, or pelvic inflammatory disease (PID). Individuals could respond yes or no.

Statistical Analysis

Basic descriptive analyses were calculated using SPSS Statistics 19.0 for Windows (http://www.spss.com). To examine the research questions, both non-parametric and parametric analyses were used in separate analyses for males and females. For most questions (34 of 36), separate cross-tabulations were conducted with chi square reported for significance and Cramer’s V reported as a measure of association. Cramer’s V is robust regardless of table size and can be used with non-dichotomous data. Association levels were reported as low or weak for values 0-.1, moderate for values between .11 and .30, and strong if they were greater than .30 (Healy, 2011). Some cells have less than the expected count of 5. McDonald (2009) recommended using the chi square test without the Williams’ correction for total samples over 1,000 and we have followed that recommendation. For the item regarding the number of sexual partners in the last 12 months, Levene’s test for homogeneity of variances was significant for both males and females, so the Brown–Forsyth statistic is reported and Tukey HSD was used for the post hoc analyses. In order to control for Type I error, the Bonferroni adjustment was performed (.05/36). This set the statistical significance level at p = .001.

Results

Sexual and Safer Sex Behaviors

Participants were asked to report number of sexual partners in the past 12 months. The overall mean was 1.36, with a median of 1.00 (SD = 2.85), and the range was 0–99. Over one-third of participants (34.5 %, n = 8,735) indicated no sexual partners in the last 12 months. Individuals who did not report any sexual partners in the last 12 months were eliminated from the analyses regarding sexual behaviors. Of those who indicated having a partner in the last 12 months, men identifying as unsure reported the highest mean (M = 7.56, SD = 15.08), followed by gay men (M = 4.91, SD = 8.40), bisexual men (M = 3.99, SD = 5.61), and bisexual women (M = 2.54, SD = 2.77). Among women, bisexual women reported the highest number of partners.

For females, the Brown–Forsyth test indicated significant differences between participants’ self-identified sexual orientation, F(3, 676.10) = 21.21, p < .001. Post-hoc analyses showed significant differences between bisexual women and lesbians and heterosexual women. For males, the Brown–Forsyth test was also significant, F(3, 113.13) = 10.14, p < .001. Heterosexual men significantly differed in responses when compared to all other groups and men identifying as unsure significantly differed in responses when compared to all other groups. Means and SDs for groups are shown in Table 2.
Table 2

Mean number of sexual partners in previous 12 months

 

M

SD

Females (N = 10,840)

 Lesbian

1.75

1.38

 Bisexual femalesa

2.54

2.77

 Unsure females

2.27

2.01

 Heterosexual females

1.77

2.17

Males (N = 6,267)b

 Gay males

4.91

8.40

 Bisexual males

3.99

5.61

 Unsure males

7.56

15.08

 Heterosexual males

2.32

4.00

Individuals with 0 sex partners in last 12 months were excluded from analyses

aPost-hoc analysis showed female bisexual participants reported significantly more partners than lesbian, unsure, and heterosexual females (ps < .001)

bPost-hoc analysis showed unsure male participants reported significantly more partners than gay men, bisexual males, and heterosexual males (ps < .001); gay men and bisexual men had significantly more partners than heterosexual men (ps < .001)

Students were also asked if they had engaged in three sexual activities (oral, vaginal or anal sex) in the previous 30 days. The responses were analyzed separately by sex. A significant association between sexual behavior and sexual orientation was found for vaginal sex and anal sex among females and for all three sexual behaviors for males. Percentages, chi square values, and Cramer’s V values are shown in Tables 3 and 4.
Table 3

Females’ sexual behavior in the previous 30 days

 

Heterosexual

Lesbian

Bisexual

Unsure

χ2

Cramer’s V

Oral sex (N = 10,782)

 No, never done

8.3 % (831)

7.7 % (11)

4.9 % (22)

9.4 % (12)

16.11

.027

 No, not in the last 30 days

32.0 % (3,224)

3.1 % (44)

28.7 % (129)

40.6 % (52)

 Yes

59.7 % (6,008)

61.3 % (87)

66.4 % (298)

50.0 % (64)

Vaginal sex (N = 10,759)

 No, never done

6.8 % (687)

16.5 % (23)

4.9 % (22)

14.1 % (18)

75.58

.058*

 No, not in the last 30 days

20.9 % (2,096)

37.4 % (52)

25.4 % (114)

28.9 % (37)

 Yes

72.3 % (7,260)

46.0 % (64)

69.7 % (313)

57.0 % (73)

Anal sex (N = 10,707)

 No, never done

74.3 % (7,428)

78.3 % (108)

52.6 % (234)

63.0 % (80)

141.97

.081*

 No, not in the last 30 days

21.3 % (2,130)

19.6 % (27)

33.9 % (151)

29.9 % (38)

 Yes

4.4 % (439)

2.2 % (3)

13.5 % (60)

7.1 % (9)

Individuals with 0 sex partners in last 12 months were excluded from analyses

p < .001

Table 4

Males’ sexual behavior in the previous 30 days

 

Heterosexual

Gay

Bisexual

Unsure

χ2

Cramer’s V

Oral sex (N = 6,217)

 No, never done

5.8 % (336)

0.4 % (1)

2.3 % (3)

8.8 % (5)

34.49

.053*

 No, not in the last 30 days

34.9 % (2,024)

25.1 % (58)

30.8 % (41)

43.9 % (25)

 Yes

59.3 % (3,436)

74.5 % (172)

66.9 % (89)

42.4 % (27)

Vaginal sex (N = 6,209)

 No, never done

6.9 % (397)

75.8 % (172)

26.3 % (35)

18.2 % (10)

1,262.24

.319*

 No, not in the last 30 days

26.2 % (1,519)

22.0 % (50)

34.6 % (46)

41.8 % (23)

 Yes

66.9 % (3,878)

2.2 % (5)

39.1 % (52)

40.0 % (22)

Anal sex (N = 6,133)

 No, never done

69.5 % (3,970)

10.8 % (25)

32.1 % (42)

41.4 % (23)

848.33

.263*

 No, not in the last 30 days

24.4 % (1,394)

35.3 % (82)

36.6 % (48)

41.4 % (23)

 Yes

6.1 % (350)

53.9 % (125)

31.3 % (41)

17.9 % (10)

Individuals with 0 sex partners in last 12 months were excluded from analyses

p < .001

Regarding safer sex behaviors, only responses from those individuals who indicated one or more sexual partners in the last 12 months and that they had engaged in that particular behavior in the previous 30 days were included in the analyses. For females, sexual orientation was significant for condom use during vaginal sex, χ2(12) = 124.94, Cramer’s V = .075, p < .001. For males, only condom/barrier use during oral sex had a significant association with sexual orientation χ2(12) = 32.72, Cramer’s V = .055, p < .001. Tables 5 and 6 show percentages for all responses.
Table 5

Females’ safer sex behavior of those sexually active in previous 30 days

 

Heterosexual

Lesbian

Bisexual

Unsure

χ2

Cramer’s V

Oral sex (N = 6,269)

 Always

3.8 % (223)

1.2 % (1)

2.4 % (7)

1.7 % (1)

6.40

.018

 Most always

1.2 % (69)

1.2 % (1)

1.0 % (3)

0 % (0)

 Sometimes

2.2 % (128)

1.2 % (1)

2.1 % (6)

3.4 % (2)

 Rarely

4.3 % (252)

3.6 % (3)

4.5 % (13)

1.7 % (1)

 Never

88.5 % (5,169)

92.8 % (77)

89.9 % (257)

93.2 % (55)

Vaginal sex (N = 7,465)

 Always

35.7 % (2,513)

10.0 % (6)

24.8 % (76)

30.4 % (21)

124.94

.075*

 Most always

16.8 % (1,183)

3.3 % (2)

15.0 % (46)

13.0 % (9)

 Sometimes

10.9 % (764)

1.7 % (1)

13.1 % (40)

17.4 % (12)

 Rarely

10.6 % (743)

3.3 % (2)

9.2 % (28)

14.5 % (10)

 Never

26.0 % (1,827)

81.7 % (49)

37.9 % (116)

24.6 % (17)

Anal sex (N = 484)

 Always

20.4 % (85)

0 % (0)

21.1 % (12)

12.5 % (1)

9.30

.080

 Most always

7.5 % (31)

0 % (0)

15.8 % (9)

0 % (0)

 Sometimes

6.7 % (28)

0 % (0)

5.3 % (3)

12.5 % (1)

 Rarely

6.5 % (27)

0 % (0)

3.5 % (2)

12.5 % (1)

 Never

58.9 % (245)

1.1 % (3)

54.4 % (31)

62.5 % (5)

Individuals with 0 sex partners in last 12 months were excluded from analyses; only individuals who reported engaging in the specific behavior in the previous 30 days were included

Safer sex behavior was defined as “use a condom or other protective barrier (e.g., male condom, female condom, dam, glove)”

p < .001

Table 6

Males’ safer sex behavior of those sexually active in previous 30 days

 

Heterosexual

Gay

Bisexual

Unsure

χ2

Cramer’s V

Oral sex (N = 3,550)

 Always

4.1 % (134)

4.9 % (8)

8.0 % (7)

14.8 % (4)

32.72

.055*

 Most always

1.4 % (45)

4.3 % (7)

2.3 % (2)

3.7 % (1)

 Sometimes

2.6 % (85)

1.8 % (3)

5.7 % (5)

0 % (0)

 Rarely

3.7 % (120)

6.1 % (10)

8.0 % (7)

3.7 % (1)

 Never

88.3 % (2,888)

82.9 % (136)

75.9 % (66)

77.8 % (21)

Vaginal sex (N = 3,803)

 Always

36.6 % (1,363)

75.0 % (3)

46.9 % (23)

31.8 % (7)

10.76

.031

 Most always

18.8 % (702)

0 % (0)

12.2 % (6)

18.2 % (4)

 Sometimes

11.3 % (423)

2.5 % (1)

10.2 % (5)

4.5 % (1)

 Rarely

8.6 % (319)

0 % (0)

12.2 % (6)

9.1 % (2)

 Never

24.7 % (921)

0 % (0)

18.4 % (9)

36.4 % (8)

Anal sex (N = 498)

 Always

25.2 % (83)

37.0 % (44)

32.5 % (13)

44.4 % (4)

30.71

.143

 Most always

10.6 % (35)

12.6 % (15)

12.5 % (5)

0 % (0)

 Sometimes

8.2 % (27)

11.8 % (14)

22.5 % (9)

11.1 % (1)

 Rarely

6.1 % (20)

10.1 % (12)

10.0 % (4)

0 % (0)

 Never

50.0 % (165)

28.6 % (34)

22.5 % (9)

44.4 % (4)

Individuals with 0 sex partners in last 12 months were excluded from analyses; only individuals who reported engaging in the specific behavior in the previous 30 days were included

Safer sex behavior was defined as “use a condom or other protective barrier (e.g., male condom, female condom, dam, glove)”

p = .001

Because safer sex behaviors may differ based on relationship status, analyses were also conducted to determine if there were differences based on sexual orientation within three distinct relationship categories: individuals not in a relationship, in a relationship but not living together, and those in a relationship and living together. Sexual orientation was not significantly related to safer sex practices of males when grouped by relationship status. For females, sexual orientation was significantly and moderately associated with condom use during vaginal sex in single women only χ2(12) = 44.82, Cramer’s V = .101, p < .001. Sexual orientation was not significant for all other sexual behaviors and relationships categories related to condom or other barrier use.

Prevention and Screening Behaviors

Six items asked about prevention and screening behaviors. Because the FDA did not approve the HPV vaccine for males until October 2009, only responses from females were considered for that question. All responses were included in these analyses (regardless of sexual experience) and again they were analyzed separately by sex. For women, three items had chi square values indicating a significant association: if the participants had ever been tested for HIV, if they had received the HPV vaccine, and if they had a routine gynecological exam in the previous 12 months. Bisexual women reported higher rates of all three compared to other female participants. For males, only being tested for HIV was significantly and moderately associated with sexual orientation. For this item, gay and bisexual men had the highest rate of testing at 48.7 % and 34.8 %, respectively. Tables 7 and 8 contain all percentages and related values.
Table 7

Screening and preventative sexual health behaviors of females

 

Heterosexual

Lesbian

Bisexual

Unsure

χ2

Cramer’s V

Ever tested for HIV (N = 16,275)

 Yes

24.6 % (3,760)

28.5 % (51)

39.3 % (218)

21.0 % (54)

78.06

.049*

 No

71.7 % (10,953)

71.5 % (128)

57.7 % (320)

72.0 % (185)

 Don’t know

3.7 % (571)

0 % (0)

3.1 % (17)

7.0 % (18)

Had HPV vaccine (N = 16,243)

 Yes

44.8 % (6,841)

41.2 % (73)

45.4 % (251)

42.8 % (110)

35.81

.033*

 No

49.2 % (7,503)

52.0 % (92)

46.7 % (258)

42.8 % (110)

 Don’t know

6.0 % (912)

6.8 % (12)

8.0 % (44)

14.4 % (37)

Had Hepatitis B vaccine (N = 16,268)

 Yes

77.7 % (11,871)

77.2 % (139)

76.0 % (421)

68.5 % (176)

19.53

.024

 No

8.9 % (1,361)

12.8 % (23)

8.8 % (49)

10.9 % (28)

 Don’t know

13.4 % (2,045)

10.0 % (18)

15.2 % (84)

20.6 % (53)

Performed breast self-exam (N = 16,277)

 Yes

39.1 % (5,974)

40.3 % (73)

43.7 % (241)

3.5 % (81)

15.69

.023

 No

60.1 % (9,194)

58.6 % (106)

55.0 % (303)

66.5 % (171)

 Don’t know

0.8 % (120)

1.1 % (2)

1.3 % (7)

1.9 % (5)

Had gynecological exam (N = 16,252)

 Yes

51.0 % (7,784)

35.9 % (65)

56.5 % (312)

34.2 % (88)

64.34

.044*

 No

48.1 % (7,343)

62.4 % (113)

42.2 % (233)

62.6 % (161)

 Don’t know

0.9 % (130)

1.7 % (3)

1.3 % (7)

3.1 % (8)

p < .001

Table 8

Screening and preventative sexual health behaviors of males

 

Heterosexual

Gay

Bisexual

Unsure

χ2

Cramer’s V

Ever tested for HIV (N = 9,754)

 Yes

17.8 % (1,628)

48.7 % (145)

34.8 % (64)

16.9 % (24)

208.97

.103*

 No

78.9 % (2,205)

49.7 % (148)

63.6 % (117)

78.9 % (112)

 Don’t know

3.3 % (297)

1.7 % (5)

1.6 % (3)

4.2 % (6)

Had Hepatitis B vaccine (N = 9,759)

 Yes

69.2 % (6,327)

75.1 % (223)

76.9 % (140)

68.5 % (98)

19.68

.032

 No

13.8 % (1,258)

12.8 % (38)

16.5 % (30)

15.4 % (22)

 Don’t know

17.0 % (1,552)

12.1 % (36)

6.6 % (12)

16.1 % (23)

Performed testicular self-exam (N = 9,762)

 Yes

34.8 % (3,182)

43.0 % (128)

42.6 % (78)

34.3 % (49)

13.59

.026

 No

62.1 % (5,679)

53.7 % (160)

55.2 % (101)

62.9 % (90)

 Don’t know

3.0 % (277)

3.4 % (10)

2.2 % (4)

2.8 % (4)

p < .001

Diagnoses or Treatment Related to Sexual Health

Eight items asked about diagnosis or treatment of a sexual health issue by a professional within the last 12 months. For women, of these eight conditions, only genital herpes had a significant chi square value. Two percent of female bisexual participants reported having genital herpes whereas less than 1 % from each of the other groups reported the condition. For males, three conditions (genital warts/HPV, gonorrhea and HIV) all had a significant association with sexual orientation. A higher percentage of gay male students reported a positive diagnosis for genital warts and HIV whereas a higher percentage of unsure male students reported a positive diagnosis for gonorrhea. See Tables 9 and 10 for reported rates for each condition.
Table 9

Diagnosis or treatment of sexual health condition in previous 12 months for females

 

Heterosexual

Lesbian

Bisexual

Unsure

χ2

Cramer’s V

Chlamydia (N = 16,263)

1.1 % (175)

1.6 % (3)

2.7 % (15)

1.2 % (3)

11.36

.026

Endometriosis (N = 16,249)

1.0 % (147)

0.5 % (1)

2.0 % (11)

0.8 % (2)

6.27

.020

Genital herpes (N = 16,250)

0.6 % (91)

0 % (0)

2.0 % (11)

0.4 % (1)

17.98

.033*

Genital warts/HPV (N = 16,251)

2.2 % (332)

0.6 % (1)

4.2 % (23)

2.0 % (5)

12.26

.027

Gonorrhea (N = 16,258)

0.2 % (31)

0 % (0)

0.9 % (5)

0 % (0)

12.90

.028

Hepatitis B or C (N = 16,213)

0.3 % (41)

0.6 % (0)

1.1 % (6)

0 % (0)

13.33

.029

HIV (N = 16,229)

0.2 % (34)

0 % (0)

0.5 % (3)

0.4 % (1)

3.07

.014

PID (N = 16,230)

0.3 % (41)

0.6 % (1)

0 % (0)

0 % (0)

2.75

.013

p < .001

Table 10

Diagnosis or treatment of sexual health condition in previous 12 months for males

 

Heterosexual

Gay

Bisexual

Unsure

χ2

Cramer’s V

Chlamydia (N = 9,743)

0.9 % (78)

1.0 % (3)

0.6 % (1)

2.8 % (4)

6.35

.026

Genital herpes (N = 9,719)

0.5 % (43)

1.0 % (3)

0.6 % (1)

2.1 % (3)

8.69

.030

Genital warts/HPV (N = 9,731)

0.8 % (69)

2.7 % (8)

1.1 % (2)

2.1 % (3)

15.40

.040**

Gonorrhea (N = 9,727)

0.4 % (33)

1.7 % (5)

0.6 % (1)

2.1 % (3)

21.17

.047*

Hepatitis B or C (N = 9,696)

0.6 % (57)

1.4 % (4)

1.1 % (2)

2.1 % (3)

7.13

.068

HIV (N = 9,704)

0.3 % (26)

2.0 % (6)

1.1 % (2)

0 % (0)

28.36

.054*

p < .001, ** p = .001

Discussion

While connections between sexual behavior and sexual orientation have been explored previously, this study was the first examination of the relationship between sexual orientation and sexual health behaviors among a national sample of male and female U.S. college students. Because college is a transitional time when many students begin to examine their own health behaviors and possibly develop life-long health habits, this is a critical time to reinforce low risk sexual behaviors and prevention practices. Our results begin to fill a void in the literature and provide direction for effective campus-based sexual health programming inclusive of sexual minority students.

This study found that sexual orientation was related to the number of sexual partners in the previous 12 months, the likelihood of engaging in specific sexual behaviors, and rates of prevention and screening behaviors related to sexual health. One of the strongest significant findings was the result that unsure males reported the highest number of sexual partners among men. Because many studies do not include individuals identifying as unsure (or conduct analyses identifying the group separately), this finding is critical. The results from this study are limited and more research to better understand those identifying as unsure and their sexual behaviors is warranted. Several other associations in the study were significant; however, Cramer’s V showed weak associations for most analyses with a few exceptions indicating moderate associations (males engaging in anal sex, males practicing safer sex during anal sex, and HIV testing for males) or strong associations (males engaging in vaginal sex).

Safer sex practices were not significantly different for most behaviors, the exception being oral sex for males and vaginal sex for females. While education about vaginal sex related prevention strategies is common, that oral sex safer sex practices was associated with sexual orientation is noteworthy. Given the connection of HPV to some oral and throat cancers (CDC, 2012b), protection during oral sex and educational efforts around oral sex risk are becoming increasingly important (Stocka, Petersona, Houlihanb, & Walsha, 2012). College students often perceive oral sex as less intimate than intercourse (Chambers, 2007). Additionally, college students are more knowledgeable of the STI risks of oral sex than ways to protect themselves during the act; male students reported greater knowledge of risks and barrier methods than females (Chambers, 2007). Thus, interventions that target barrier methods during oral sexual encounters (such as male condoms and dental dams) are critical for all college students regardless of sexual orientation. Interventions to increase barrier use during oral sex have been successful with sex workers (e.g., Wong, Chan, & Koh, 2002) but programs are needed to address the general population concerns such as reduced pleasure, lack of motivation, and lack of forethought (Stone, Hatherall, Ingham, & McEachran, 2006). Emphasizing perceived benefits of condom use during fellatio—like hygiene, elimination of the swallow or spit decision, and taste (Stone et al., 2006)—is one strategy. Programs designed to motivate college students to use dental dams could follow a similar pattern.

Bontempi, Mugno, Bulmer, Danvers, and Vancour (2009) found that college students’ rates of sexual behavior were high while condom use was low, particularly for females. Male college students reported significantly higher rates of condom use than female students. The current study found significant differences in safer sex practices across sexual orientation for vaginal sex for females. In opposite sex relationships, college students may perceive other forms of contraception as adequate if students are in monogamous relationships; however, in this study, the heterosexual females reported a higher percentage of always practicing safer sex than other sexual orientations. This higher response could be indicative of the promotion related to condom use during vaginal sex that often occurs on college campuses. For women who have sex with women, education about safer sex practices during vaginal penetration (e.g. condoms on sex toys, gloves for hands) may not be as prevalent.

While HIV testing was associated with sexual orientation, less than half of all groups reported being tested for HIV. Bontempi et al. (2009) found college students who had been tested for HIV or an STI were significantly less likely to report ever using condoms or frequent condom use. In this study, the frequency of condom use among the males and its relationship with HIV testing was unclear. The rate of HIV testing was the highest among gay males and the frequency of “always” using condoms during vaginal and anal sex was also highest among gay men. However, the rate of “always” using condoms or a barrier during oral sex was highest among unsure men. Higher rates of safer sex practices and testing among gay males may be due to awareness of high HIV rates among young gay men and consistent HIV messaging and prevention efforts targeting this cohort. Regardless, the rates for gay men were still low (37.0 % always use condom during anal sex and 48.7 % have been tested for HIV).

Additionally, information and social marketing campaigns regarding the HPV vaccine should be disseminated on college campuses. While sexual orientation was associated with the HPV vaccine, individuals regardless of sexual orientation are at risk for HPV. HPV is extremely common; approximately 50 % of sexuality active people will contract it during their lifetime (CDC, 2012a). Uptake of the HPV vaccine can reduce this prevalence. Many lesbians have had male sexual partners as their first sexual encounter is often with a male (Bailey, Farquhar, Owen, & Whittaker, 2003). Previous research (Diamant, Wold, Spritzer, & Gelberg, 2000; Lindley et al., 2008) has found that lesbians were less likely to have had a gynecological exam, and in this study lesbians had a lower rate than bisexual and heterosexual women, but a slightly higher rate than those identifying as unsure. Because of this lack of testing, many women may have health issues of which they are unaware.

While gay and bisexual men are considered at elevated risk for Hepatitis B (CDC, 2012c), sexual orientation was not associated with vaccination rates most likely because of the age of the participants. Most states have mandated Hepatitis B vaccination for school age children (Immunization Action Coalition, 2011) which nullifies any personal responsibility related to this behavior.

Regarding STI diagnosis, only three items had a significant association with sexual orientation: HIV, gonorrhea, and genital herpes; however, these associations were weak. Higher rates of HIV among gay males is consistent with the literature showing that men who have sex with men are the group most affected by HIV infection (CDC, 2011a). Others (Kaestle & Waller, 2011; Lindley et al., 2008) have found that bisexual women were more likely to report an STI and be at risk for an STI; however, the current study’s results indicate genital herpes as a weak significant association with sexual orientation. While partial chi squares were not conducted, the number of bisexual women reporting genital herpes infection was the highest of all groups (2 %).

Limitations

With the ACHA–NCHA, there are concerns about the response rates and generalizability of data. The mean response proportion for this data set was 36 % and the median response proportion was 23 %, with much higher rates for paper administration (mean response proportion 90 %) versus web survey administration (mean response rate 21 %). The use of multiple data collection methods is a limitation. Paper administration captures only the experiences of students present the day the survey was administered. With web-based survey administration, participants may be able to complete the survey on more than one occasion and students other than those randomly selected to participate can actually complete the survey; however, these limitations exist for most studies using the web as a means of data collection (Mustanski, 2001). The low response rate and not being a true random sample of U.S. college students does affect generalizability. Moreover, ACHA–NCHA’s use of student survey data may result in self-report bias. At the same time, previous studies have demonstrated that the ACHA–NCHA does provide similar results to nationally representative surveys (ACHA, 2004).

Additionally, the sample size of gay male, lesbian, bisexual, and unsure students was small, with only 1.1 %, 0.8 %, 2.9 %, and 1.5 % of the sample, respectively, reporting each orientation. However, this was consistent with Ellis, Robb, and Burke’s (2005) work that found 97 % of college students labeled themselves as heterosexual and 3 % of males and 2 % of females labeled themselves as a gay, lesbian or bisexual. This study also used self-identified sexual orientation instead of examining the sex of the participants’ sexual partners (e.g., men who have sex with men, women who have sex with women, and men who have sex with men and women) (Bauer & Jairam, 2008). Everett (2012) suggested that STI research should examine self-identified sexual orientation and sexual behavior together in order to best understand risk factors.

The ACHA–NCHA data does not clearly define sexual behaviors and thus their meaning is open to interpretation. Vaginal sex could include vaginal-penile sex or vaginal penetration with fingers or a sex toy, which is common among lesbian and bisexual women (Bailey et al., 2003). The same may be true for anal sex as three lesbians indicated engaging in anal sex in the last 30 days. There was also no question to address if these behaviors were consensual, so a sexual assault survivor may report a behavior as well. As a result, the extent to which vaginal or anal intercourse was a risk factor for STI transmission cannot be completely determined from this study’s results. Additionally, the ACHA–NCHA survey does not allow for participants to list more than 99 sexual partners. Participants with more than 99 sexual partners may have greater health risks and more negative health outcomes. This study was unable to determine if such an association exists.

Conclusions

Despite the aforementioned limitations, this study had several noteworthy strengths. This study was the first to examine sexual health behaviors and outcomes based upon sexual orientation of a national sample of college students. This data set contained a large, national sample of college students enrolled in 2- and 4-year colleges in every region of the United States. Examining such data sets based upon sexual orientation is critical to understanding the needs of sexual minority individuals (Committee on LGBT Health, 2011). In addition the study included individuals identifying as unsure. This population is often overlooked or grouped together with gay, lesbian, and bisexual individuals; however, as demonstrated by our study’s results, their needs may be unique. Awareness of the sexual behavior of unsure individuals can remind educators of how education and programmatic efforts need to be inclusive of all individuals.

The findings from this study have important implications for college sexual health programming. Based upon this study’s results, differences in sexual health behaviors, prevention practices and outcomes exist among gay, lesbian, bisexual, heterosexual, and unsure college students. Thus sexual health programming on college campuses must focus on sexual behaviors yet be inclusive of the needs of all students, including sexual minority students. While we know that universal sexuality education would benefit all individuals, it is not realistic with limited resources. Within the college population, practitioners need to understand the risk for each subgroup in order to provide more targeted messages. Results from this study indicate that focused interventions could be directed toward unsure men and risks related to a high number of sexual partners and risk of gonorrhea; gay men and risk related to HPV/genital warts and HIV; lesbians and safer sex behaviors during oral and vaginal sex, gynecological exams and HPV vaccine; and unsure women and gynecological exams. At the same time some services, such as low-cost or free STI and HIV testing, reduced cost gynecological exams and HPV vaccines, could benefit all students.

Health risk behaviors do not occur in a vacuum; in fact, they are often covariates. Therefore, any sexual health programs must also address health risk behaviors associated with STIs such as alcohol and drug use, hooking-up or casual sex relationships, etc. regardless of sexual orientation. By understanding and responding to the specific risks of these groups, colleges and universities can better address the sexual health needs of their students, including those identifying as gay, lesbian, bisexual, and unsure.

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Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  1. 1.Department of Health and KinesiologyUniversity of Texas at San AntonioSan AntonioUSA

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