This first study was performed among a representative sample of Jewish participants aged 18–44 in Israel and found that 10.2 % of males and 8.7 % of females had at least a single lifetime same-sex sexual encounter, while 4.5 and 3.7 % self-identified as gays or bisexual men, and lesbians or bisexual women, respectively. Gays and bisexual males, as well as discordant males and females heterosexuals who performed same-sex practice, were more likely to engage in risky sexual behavior than concordant heterosexuals or discordant heterosexuals who were attracted to some extent to the same sex.
The rates of lifetime same-sex practices among men in this study were higher than reported in the U.S. (Purcell et al., 2012; Ward et al., 2014), the United Kingdom (Hayes et al., 2012), and France (Lhomond et al., 2014) (6.9, 5.9, and 3.5 %, respectively). Rates of lifetime same-sex practices among women were lower than those reported from the U.S. (Nield et al., 2015) and United Kingdom (Hayes et al., 2012), yet higher than reported from France (Purcell et al., 2012) (11.2, 7.1, and 3.5 %, respectively). The heterogeneity in the results between the different studies might be associated with the distinguishable wording used in the relevant questions presented to the participants across the various studies, the different periods in which these studies were performed, and the different age groups which were captured in each of the publications. It might also be that the different timeframes pertaining to the questions regarding same-sex practices distorted the results, as participants were requested to respond to questions concerning same-sex practices over their lifetime, while same-sex attraction was referred to at the time they completed the questionnaires.
The differentiation between the three dimensions of sexual orientation (same-sex sexual attraction, sexual practices, and self-reported sexual definition) once again underlines the importance of using the precise study instruments in sex research in order to define populations at risk (Hayes et al., 2012). For example, asking research participants if they have ever had same-sex encounters in a sensitive and direct approach may encourage participants to respond more accurately regarding their sexual orientation than asking if they are gay or straight. This may also be applied to in clinical anamnesis in medical settings. Practitioners should have better understanding of the sexuality of their clients and be aware that self-reported sexual definition is not always concordant with sexual practices.
Our findings indicate that men and women who reported same-sex practices were generally engaged in riskier sexual behavior than those who only had opposite-sex encounters, which included a greater number of partners, earlier sexual debut, and more frequent substance use, as found in other studies (Hayes et al., 2012; Nield et al., 2015). Detailed medical anamnesis, which includes relevant questions about sexual behaviors and risks, allows providers to gain deeper insight into the health needs of their patients and tailor screening and prevention strategies. Prevention advice should also include additional lifestyle aspects, such as substance use and smoking.
Sexual risk among discordant heterosexuals were associated with same-sex practices, but not with same-sex attraction, in line with other studies (Nield et al., 2015). Discordant individuals, in a similar way to bisexuals, may be confronted with discomfort with their sexuality, fear of social isolation, expectations of rejection, express guilt or shame, concealment, and internalized homophobia (Mor et al., 2015; Rosario, Schrimshaw, & Hunter, 2006). It was also demonstrated that discordant heterosexuals have poorer social family support and limited social network (Corliss et al., 2009). They also experience a greater density of intrapersonal, interpersonal, and environmental difficulties that increase their risk behavior and vulnerability to HIV/STD. Finally, it was also speculated that discordant heterosexuals could have higher level of sex drive, while exploring their sexuality in a greater depth despite the stigma associated with same-sex practices, which increases their sexual repertoire and engagement in greater number of sexual partners and practices (Vrangalova & Savin-Williams, 2014). Discordant heterosexuals may therefore not only experience more stress and fewer coping resources than concordant heterosexuals (Ellen et al., 2015), but also less connected with the homosexual culture and circumvent venues that are perceived to be gay/lesbian, thereby avoiding the support that these establishments can provide (Reback & Larkins, 2010). In addition, discordant heterosexuals were found to perform higher risk practices, and may form a “bridge” population for HIV/STD to their steady partners and who are not members of a high-risk group.
Although males and females who only had opposite-sex partners were more likely to be in steady partnership than those who reported having same-sex encounters, almost 14 % of male and 10 % of females in steady relationships reported concomitant casual partners. In addition, nearly 20 % of the males had ever paid for sex. Individuals who had sexual encounters within an active (and probably riskier) sexual network such as CSW, are at a higher risk for HIV/STD acquisition and may also “bridge” the infections to their steady partners, with whom they probably do not use condoms regularly. Prevention efforts should incorporate education regarding safe-sex, while in steady relationships, establishing HIV/STD tests prior to engagement in unprotected sex with steady partners and suggest strategies to avoid “importing” HIV/STD into the dyadic relationships (Mor et al., 2011).
Tel Aviv, being the biggest metropolitan center in Israel, showed the highest rate of participants who reported same-sex practices, as also found in other studies exploring same-sex behavior in major cities (Brown, 2012). Big cities are usually characterized with a greater social liberalism and greater degree of independence and freedom from social pressure and family supervision (Michaels & Lhomond, 2006) and therefore it is recommended that safe-sex interventions are portrayed in big metropolitan areas.
As expected, gays and bisexual men reported the riskiest sexual risk behaviors among all study participants. In addition, their substance use rates were higher than those who only had encounters with the opposite sex, as found in other publications (Lhomond et al., 2014; Mravcak, 2006). Substance use may be a response to lower perceived or actual well-being or minority stress (Wong, Kipke, Weiss, & McDavitt, 2010). Additionally, gays and lesbians may also have been exposed to drugs and smoking in the gay/lesbian community and are probably under higher social pressure to use drugs or smoke.
This is the first study performed in Israel to describe sexual behavior on a national scale in a representative sample, yet it is subject to several limitations. First, we did not have enough statistical power to differentiate bisexual men and women from gays and lesbians, and therefore we collapsed the two sexual dimensions into one non-heterosexual group. Previous studies have outlined the physical, mental, and sexual differences between bisexual men and women with those of gays and lesbians. Bisexuals tend to display more psychological distress and report riskier sexual behavior than exclusively heterosexuals or homosexuals (Friedman et al., 2014). Additionally, bisexuals’ community support is limited and their social resilience may be inadequate. Moreover, their unique health needs are often not appropriately responded to the health system, as bisexuals express discomfort in disclosing their sexual identity in the health settings (Dodge et al., 2012). Similar findings were also reported among Israeli bisexual women (Mor et al., 2015). They were scored lower on socioeconomic status, engaged in higher risk behaviors, and had inferior health-related outcomes in comparison to lesbians. Accordingly, bisexual women reported more frequent visits to the emergency rooms, were less likely to visit their primary care clinicians, and reported poorer subjective health status. They also were less comfortable sharing their sexual orientation with the healthcare provider. As a result of the limited number of bisexuals in our study (especially females), we were unable to replicate previous findings and examine the possible differences health outcomes among bisexual men and women. Second, the cross-sectional nature of this study limits our ability to define causality. Third, although explicitly defined in the questionnaire, participants may have erroneously classified only penile-vaginal/anal penetration as the difference between being heterosexual versus gay/lesbian, rather than, for example, oral sex, resulting in a possible reporting bias and underestimation of same-sex behaviors. Fourth, participants were offered the opportunity to respond only to 3 options of sexual identities (i.e., heterosexual, gay/lesbian, and bisexual), limiting the heterogeneity of additional alternatives. Fifth, sexual contact included penetration practices only, while other practices, such as body contact/kissing or digital sex were excluded. Yet, this limitation is conservative, as we used only those practices which may expose the participants to HIV/STD. Sixth, this study is subject to recall bias regarding same-sex practices. However, we believe that even incidental same-sex practices, especially encounters which involved penetrative practices are unforgettable experiences throughout life. This may be even more noticeable among discordant heterosexuals. Additionally, in order to increase the reliability of self-reported sexual behavior, the question regarding condom use was limited to the last sexual encounter (Richter et al., 2014). Last, the age group of 18–44 was chosen to reflect the Statistical Abstract’s publications, while excluding members from other age groups and religions.
In summary, this first representative study demonstrated that 9.5 % of participants have ever had same-sex practices, while 6.5 % identified themselves as gay/lesbian or bisexual. Those who had same-sex practices reported greater risk for acquiring HIV/STD than those who only had opposite-sex partners. Risky sexual behavior among discordant heterosexual was associated with same-sex practices rather than same-sex attraction. Discordant heterosexual and gays or bisexual males should be aware of a potential for increasing the risk of acquiring or transmitting HIV/STD. It is also recommended that medical practitioners and health educators should not necessarily assume a low-risk profile for those who self-identify as heterosexuals. Practitioners should be able to provide appropriate prevention strategies and recommend screening tests to the populations they care for, such as frequent HIV/STD tests and psychological support if needed. Sexual health professionals should improve their communication skills with heterosexual clients to identify discordant heterosexuals. Furthermore, effective sex education should illuminate the syndemic effects of drugs/alcohol, stigma against minorities, and social norms have on sexual health risks.