Impact of social factors and sexual behaviors on the knowledge of sexually transmitted infections among women who have sex with women/women who have sex with women and men

Abstract

Although heterosexual individuals’ knowledge of sexually transmitted infections (STIs) has been examined, no studies have been conducted in Poland of the STI knowledge in women who have sex with women (WSW) and women who have sex with women and men (WSWM). We enrolled a group of 146 WSW and 113 WSWM and asked them to complete a study questionnaire that contained items about socioeconomic factors, sexual behaviors, and STI knowledge. The level of STI knowledge among the studied WSW was insufficient. The frequency of correct answers was higher in WSWM. A multivariate regression model revealed that only the higher importance of sex to the respondents (F(1) = 4.31, p = 0.04) and a higher number of same-sex sexual partners within the last 12 months (F(1) = 14.86, p = 0.0001) influenced the level of STI knowledge. The results of the study allowed us to conclude that WSW have insufficient STI knowledge, whereas WSWM have better knowledge, and this is influenced by awareness that STI risk is not associated with the partner’s gender, age, importance of sex, sexual behaviors, and openness to discussing STIs with a sexual partner.

Keywords

High-risk behavior homosexual prevention sexual behavior women

Introduction

The literature regarding the knowledge of sexually transmitted infections (STIs) among Polish women is scant.^1–3 A recent analysis revealed a growing awareness of STIs but the level of knowledge is still insufficient, especially in men (52% of men and 17.3% of women have a low level of knowledge in the study by Wdowiak et al.³). The same conclusions were stated in Puszkarz et al.’s⁴ study that was conducted among young people living in the southeastern region of Poland and in Tritt’s⁵ study of the general population of men and women.

The literature about STI knowledge in the lesbian, gay, bisexual, transgender, queer, and intersex (LGBTQI) population is also limited, especially among women who have sex with women (WSW) and women who have sex with women and men (WSWM). The latest study from Canada showed that 19.1% of LGBTQI people had a history of STIs, with a higher rate in bisexual participants (38%), followed by queer (21%), lesbian (10%), and gay (5%) participants. The authors revealed that some intrapersonal factors, such as the number of lifetime sexual partners and male partners, were associated with a history of STIs.⁶ A systematic review of low- and middle-income countries showed that WSW were engaging in risky sexual behaviors that may lead to STIs but that the STI knowledge was low.⁶ There are no data on prevalence of STIs in the Polish LGBTQI community.

Although there are some papers about STI knowledge among heterosexual respondents,^3–5 an analysis of this knowledge among WSW and WSWM has never been performed in Poland. For this reason, the authors believe that the present study might provide new insight into the sexual health of the WSW and WSWM community and thus contribute to creating more effective educational programs for all WSW and WSWM.

Methods

Three hundred and ninety-three WSW/WSWM were eligible for the questionnaire-based retrospective cross-sectional study conducted between May 2016 and May 2017. The inclusion criteria were being over 18 years old, having ever had sex with a woman, and agreeing to participate in the study. Both sexually active and inactive females were included. The study was approved by the local institutional review Board.

The invitation to participate in the study designed for WSW and WSWM and a link to the internet-based questionnaire were sent via e-mail to all individuals who subscribed to the Campaign Against Homophobia and Lambda Warsaw Association mailing lists. Three hundred and ninety-three women accessed the webpage containing the survey. The respondents were required to read an informed consent statement and to agree to participate by clicking ‘yes’ in the online questionnaire before being enrolled in the study. Out of the 393 eligible women who accessed the webpage with the questionnaire, 86 answered ‘no’ and terminated the survey. While 307 agreed to participate, 48 did not complete the questionnaire. Finally, 259 women completed the survey and they constituted the study group. The response rate was 65.9%.

The questionnaire contained items regarding socioeconomic factors (age, residency, education, and employment), sexual behaviors (age of sexual initiation, number of heterosexual partners and same-sex partners), the importance of sex to the individual, steady sexual partner, age of the partner, out-of-relationship encounters, the Heterosexual-Homosexual Rating Scale, psychosexual orientation, history of STIs defined as genital warts, HIV, gonorrhea, syphilis and trichomoniasis (all definitions were provided at the beginning of the study), and STI knowledge (how they rated their STI knowledge, the chance of acquiring an STI, the definition of an STI, the risk of having an STI based on the gender of the partner, the symptoms of STIs, the route of the transmission of STIs and entry into the body, and the association between sex toys and STIs). The questions on STI knowledge comprised signs, symptoms, and method of transmission for genital warts, HIV, bacterial vaginosis, gonorrhea, syphilis and trichomoniasis. The level of knowledge was calculated by summing the points for each correct answer (one point for the correct answer and zero points for the wrong answer or a lack of response). Questions 16–23 were used to assess the STI knowledge (question 16, 17, and 22 were scored maximum 1 point each; Q18, 19, and 23 – maximum 6 points each; Q20 and 21 – maximum 5 points each). The score ranged between 0 and 31 points (please see the questionnaire in the supplementary material for details). A field testing of the questionnaire on a group of ten WSM/WSWM was conducted to check for clarity and comprehension.

Psychosexual orientation was defined as sexual attraction, emotions, fantasies, behavior, self-labeling, or a combination of these. Women were classified as WSW if they had experienced or were currently experiencing sexual desire, intentions toward, or sexual behavior with other women and have never had sex with a man, whereas WSWM were classified as such if they had experienced or were currently experiencing sexual desire, intentions toward, or sexual behavior with both women and men.

The Kinsey scale was used to measure psychosexual response/reaction and sexual experiences. It measures the level of heterosexuality/homosexuality by using 7-point scale from 0 – exclusively heterosexual to 6 – exclusively homosexual.⁷ The scale was validated and previously used in the population of Polish women.⁸

The statistical analysis was performed using the Statistica 12.0 computer software (StatSoft, Krakow, Poland). All variables were checked for normality (Shapiro–Wilk’s test) and homogeneity of variances (Levene’s test). As none of the variables met the assumption of normality, nonparametric tests were used. To compare WSW and WSWM, the Chi square test or Fisher’s exact test in case of sample size <5 was used for the qualitative variables and the Mann–Whitney U test was used for the quantitative variables. Spearman’s rank correlation was used to calculate the intercorrelations between the selected variables and level of knowledge. To evaluate the impact of the different factors on STI knowledge, forward multiple and forward logistic regression analysis was used. In the first step all variables were included; in the second step only variables with p < 0.05 were included in the final forward analysis. A p-level less than 0.05 was considered statistically significant.

Results

The median age of the respondents was 30 ± 5.77 years. Of the respondents, 221 (85.3%) had received tertiary education, 31 (12.0%) had secondary education, and 7 (2.7%) had primary education. Around 50% of the women (n = 131) were working and less than 50% studying (n = 116), whereas 96.9% (n = 251) were living in a city. The respondents rated sex as very important (42.5%, n = 140) and extremely important (14.4, n = 40). The median number of points in the STI knowledge test was 14 (out of 31), and 66.5% (n = 165) of women described their knowledge of the STI transmission pathways as good or excellent (Table 1).

Table 1.

General characteristics of the studied population for the quantitative variables.

Variable	TotalN = 259	WSWN = 146	WSWMN = 113	p^a (WSW versus WSWM
Variable	Median (lower–upper quartile) QD	Median (lower–upper quartile) QD	Median (lower–upper quartile) QD	p^a (WSW versus WSWM
Age (years)	30 (28–34) 5.77	30 (28–34) 5.72	30 (27–34) 5.88	0.58
Age of the steady female partner (years)	30 (28–34) 5.28	30 (27–34) 5.21	30 (28–35) 5.45	0.11
Importance of sex to the respondents^b	2 (2–3) 0.83	2 (2–3) 0.83	2 (2–3) 0.85	0.35
No. of lifetime female sexual partners	3 (2–8) 3.91	5 (2–9) 3.94	3 (2–7) 3.87	0.84
No. of female sexual partners in the past 12 months	3 (3–4) 2.15	3 (3–4) 2.21	3 (2–4) 2.09	0.38
Declared knowledge on ways of STI prevention^b	2 (2–3) 0.88	2 (2–3) 0.92	2 (2–3) 0.83	0.71
Level of STI knowledge	14 (11–17) 3.73	14 (11–16) 3.83	14 (12–17) 3.62	0.22

QD: quartile deviation; STI: sexually transmitted infection; WSW: women who have sex with women; WSWM: women who have sex with women and men.

^aMann–Whitney U test.

^b5-point Likert scale.

Out of the 259 women, 146 respondents (56.4%) declared that they had experienced or were currently experiencing sexual desire, intentions toward, or sexual behavior only with other women (WSW), whereas the remainder (n = 113, 43.6%) were experiencing at the time of the interview this with both men and women (WSWM). The comparison of the WSW and WSWM revealed statistically significant differences in psychosexual orientation, sexual experiences and psychosexual reaction/response as evaluated by the Kinsey Scale, number of lifetime male partners, having a steady sexual partner (higher rates in WSW), sex outside of the relationship (higher rates in WSWM), and perceived chance of having STIs (the WSWM rated the chance as ‘high’ more frequently than the WSWM) (Tables 1 and 2).

Table 2.

General characteristics of the studied population for the qualitative variables.

Variable	Total (n = 259)		WSW (n = 146)		WSWM (n = 113)		p^a
Variable	N	%	N	%	N	%	p^a
Age at first sex with women
Before 18 years old	116	44.9	68	46.6	48	42.5	0.51
Between 19 and 20 years old	42	16.1	26	17.8	16	14.1	0.42
Over 20 years old	84	32.4	48	32.9	36	31.7	0.86
No answer	17	6.6	4	2.7	13	11.1	0.01
Kinsey scale
Predominantly heterosexual, only incidentally homosexual	55	21.2	0	0.0	55	48.7	0.001
Predominantly heterosexual, but more than incidentally homosexual	14	5.4	0	0.0	14	12.4	0.001
Equally heterosexual and homosexual	38	14.7	26	17.8	12	10.6	0.1
Predominantly homosexual, but more than incidentally heterosexual	68	26.3	36	24.7	32	28.3	0.51
Predominantly homosexual, only incidentally heterosexual	84	32.4	19	13.1	0	0.0	0.001
Exclusively homosexual	65	25.1	65	44.5	0	0.0	0.001
Psychosexual orientation
Homosexual	143	55.2	122	83.6	21	14.7	0.001
Bisexual	84	32.4	13	8.9	71	62.8	0.001
Heterosexual	18	6.9	6	4.1	12	10.6	0.001
Questioning	14	5.4	5	4.4	9	7.9	0.001
No. of lifetime male partners
None	152	59.7	146	100.0	6	5.3	0.001
One	34	13.1	–	–	34	30.1	–
Two	24	9.3	–	–	24	21.2	–
Between three and five	31	11.9	–	–	31	27.4	–
Over five	18	6.9	–	–	18	15.9	–
Steady sexual partner	164	63.3	102	69.9	44	30.1	0.01
Out-of-relationship sex
No	129	69.7	92	80.7	37	51.1	0.001
Yes, polyamory	8	4.3	0	0.0	8	11.3	0.001
Yes, but only once with one partner	25	13.5	12	19.5	13	18.3	0.10
Yes, with 2–4 different partners	16	8.7	8	7.0	8	11.3	0.27
Yes, with 5–10 different partners	3	1.6	1	0.9	2	2.8	0.29
Yes, with more than 10 different partners	4	2.2	1	0.9	3	4.2	0.11
Have you ever talk about STIs with your partner
No	98	38.0	46	31.5	23	20.5	0.05
Yes, but only with some	91	35.3	50	34.2	41	36.6	0.69
Yes, with all partners	69	26.7	50	34.2	48	42.9	0.15
Have you ever been diagnosed with STI – YES	17	7.1	7	5.1	10	9.6	0.19
How do you rate your chance to have STI
It is impossible	36	13.9	24	16.5	12	10.6	0.20
Low	152	58.9	81	55.9	71	62.8	0.26
Medium	33	12.8	20	13.8	13	11.5	0.58
High	6	2.3	0	0.0	6	5.3	0.01
Difficult to say	31	12.1	20	13.8	11	9.7	0.31
Education
Primary	7	2.70	1	0.7	6	5.3	0.05
Secondary	31	11.97	18	12.3	13	11.5	0.82
Tertiary	221	85.33	127	87.0	94	83.2	0.32
Employment
Working	131	50.58	76	44.5	55	48.7	0.55
Student	116	44.76	65	44.5	51	45.1	0.96
Unemployed	12	4.63	5	3.4	7	2.7	0.23
Residency
City	251	96.91	143	97.9	108	95.6	0.31
Rural	8	3.09	3	2.1	5	4.4	0.31

STI: sexually transmitted infection; WSW: women who have sex with women; WSWM: women who have sex with women and men.

Statistically important variables are bolded.

^aWSW versus WSWM – Chi square test or Fisher’s exact test.

The analysis of sexuality and sexual behaviors revealed that the majority of the investigated population first had sexual intercourse with a woman before 18 years of age (44.9%, n = 116), were mostly homosexual, mostly described their sexual experiences and psychosexual reactions as exclusively homosexual according to the Kinsey Scale (44.5% of the WSW group) or as predominantly heterosexual, were only incidentally homosexual (48.7% of the WSWM group), had a steady sexual partner, had one lifetime sexual partner, had never had out-of-relationship encounters, had never been diagnosed with an STI, had never talked about STIs with a sexual partner, and rated the risk of having an STI as low (Table 2).

The level of knowledge of STIs among the studied women was rather insufficient; there were no differences in the STI test scores between the WSW and WSWM groups (Table 1). Most of the respondents did not properly recognize the chain of transmission of STIs or sources of infection. However, the know-ledge of the place where the microorganisms enter the body was sufficient. Only 50% of respondents correctly answered that STIs are possible both when there is and when there is not a condom on the vibrator when it is used by both partners at the same time. Furthermore, 44% correctly stated that the chance of STIs in homosexual women is the same as in heterosexual women, whereas 38% said that it is lower, 2.7% said that it is higher, and 14.1% stated that the risks cannot be compared. Interestingly, the frequency of the correct answer was lower in the WSW group than in the WSWM group (33.1% versus 55.8%, respectively, p = 0.01), and 48.6% of WSW compared to 25.3% of WSWM believed that the risk is lower in homosexual women (p = 0.001). Further analysis revealed that there was a positive correlation between choosing the correct answer for that question and psychosexual orientation (r = 0.13; heterosexual women were more likely to answer correctly), type of sexual behavior (r = 0.19; WSWM were more likely to score correctly compared to WSW), STI knowledge (r = 0.31), and No. of lifetime male partners (r = 0.21; the higher the number, the higher prevalence of a correct answer), while there was a negative correlation with the number of female partners (r = −0.12; the higher lower, the higher tendency to score correctly). Finally, the logistic regression model revealed that only the type of sexual behaviors (WSW versus WSWM) had a statistically important impact on the chance of a correct answer; WSWM were 2.2 times more likely to answer correctly (95% confidence interval: 1.33–3.63; p = 0.002).

The analysis of the correlations between the level of STI knowledge and the different socioeconomic and sexual behavior variables revealed a weak negative correlation with having out-of-relationship encounters (r = −0.18), that is women with more sexual partners had a lower STI knowledge. Furthermore, the declared knowledge of methods for preventing STIs was correlated with the importance of sex (r = 0.19; declared knowledge was higher when sex was considered more important), age (r = −0.13; greater declared knowledge was associated with older age), age of first sex with a female partner (r = 0.14; declared knowledge was higher in individuals who initiated sex at an earlier age), Kinsey scale (r = 0.13; higher declared knowledge in women describing their sexual experiences and psychosexual reactions as exclusively homosexual), and talking about STIs with a partner (r = 0.21; declared knowledge was higher in individuals who had discussed STIs with partners) (Table 3).

Table 3.

Spearman rank correlation between studied variables.


Variable	Age (years)	Age of sexualinitiation} \cr \rotate{(years)	Steady relationship (Yes/No)	Age of the female partner } \cr \rotate{(years)	No. of lifetime heterosexual } \cr \vskip5pt \hskip3pt\rotate{ partners	No. of lifetime homosexual } \cr \vskip0pt \hskip3pt\rotate{partners	No. of female partners } \cr \rotate{in the last 12 months	Importance of sex\vskip -2pt{a}	Declared level of STI } \cr \hskip3pt\rotate{knowledge	STI knowledge (points)	Kinsey scale	Psychosexual orientation	Sexual behaviors } \cr \hskip3pt\rotate{(WSM/WSWM)	Out-of-relationship sex\vskip -2pt{b}	Have you ever been } \cr \rotate{diagnosed with STI } \cr \rotate{(Yes/No)	Have you ever talk } \cr \rotate{about STIs? (Yes/No)	Education	Employment	Residency	What is your risk } \cr \rotate{of acquiring STI?}
Age (years)	1.00	0.38	−0.10	0.52	0.08	0.32	0.02	−0.05	−0.13	0.04	−0.07	−0.11	−0.02	0.17	−0.08	0.00	0.32	−0.54	0.01	1.00
Age of sexual initiation (years)	0.38	1.00	−0.13	0.23	−0.08	−0.02	0.17	−0.06	0.14	0.06	0.03	−0.14	−0.09	−0.06	−0.11	−0.01	0.16	−0.21	0.05	−0.07
Steady relationship (Yes/No)	−0.10	−0.13	1.00	−0.06	0.15	−0.11	−0.19	−0.01	0.03	−0.01	−0.11	0.13	0.15	0.16	0.03	0.25	−0.01	0.08	0.10	0.02
Age of the female partner (years)	0.52	0.23	−0.06	1.00	0.08	0.22	0.00	−0.01	−0.02	0.06	−0.07	−0.13	0.01	0.10	−0.01	0.01	0.35	−0.26	−0.10	0.02
No. of lifetime heterosexual partners	0.08	−0.08	0.15	0.08	1.00	−0.03	−0.03	−0.08	−0.04	0.05	−0.67	0.52	0.91	0.33	−0.11	0.11	−0.01	0.03	0.09	−0.10
No. of lifetime homosexual partners	0.32	−0.02	−0.11	0.22	−0.03	1.00	0.33	−0.08	−0.05	0.01	0.03	−0.34	−0.11	0.25	−0.06	−0.10	0.07	−0.23	−0.15	0.20
No. of female partners in the last 12 months	0.02	0.17	−0.19	0.00	−0.03	0.33	1.00	−0.01	0.03	−0.08	0.02	−0.23	−0.06	−0.04	−0.10	−0.15	−0.05	−0.13	−0.09	−0.13
Importance of sex^a	−0.05	−0.06	−0.01	−0.01	−0.08	−0.08	−0.01	1.00	0.19	−0.10	0.11	−0.07	−0.03	−0.11	0.11	0.04	−0.12	0.00	0.06	−0.08
Declared level of STI knowledge^a	−0.13	0.14	0.03	−0.02	−0.04	−0.05	0.03	0.19	1.00	−0.12	0.13	−0.08	−0.06	0.01	−0.03	0.21	0.04	0.08	0.01	−0.06
STI knowledge (points)	0.04	0.06	−0.01	0.06	0.05	0.01	−0.08	−0.10	−0.12	1.00	−0.05	−0.03	0.08	−0.18	−0.03	−0.11	0.06	0.03	−0.05	−0.06
Kinsey scale	−0.07	0.03	−0.11	−0.07	−0.67	0.03	0.02	0.11	0.13	−0.05	1.00	−0.56	−0.71	−0.24	0.13	−0.10	0.04	0.02	−0.07	0.32
Psychosexual orientation	−0.11	−0.14	0.13	−0.13	0.52	−0.34	−0.23	−0.07	−0.08	−0.03	−0.56	1.00	0.60	0.25	−0.05	0.12	−0.10	0.10	0.04	−0.12
Sexual behaviors (WSM/WSWM)	−0.02	−0.09	0.15	0.01	0.91	−0.11	−0.06	−0.03	−0.06	0.08	−0.71	0.60	1.00	0.28	−0.09	0.12	−0.06	0.04	0.07	0.14
Out-of-relationship sex^b	0.17	−0.06	0.16	0.10	0.33	0.25	−0.04	−0.11	0.01	−0.18	−0.24	0.25	0.28	1.00	−0.22	0.17	0.02	−0.08	0.05	0.19
Have you ever been diagnosed with STI (Yes/No)	−0.08	−0.11	0.03	−0.01	−0.11	−0.06	−0.10	0.11	−0.03	−0.03	0.13	−0.05	−0.09	−0.22	1.00	0.06	0.03	−0.01	0.05	0.06
Have you ever talked about STIs? (Yes/No)	0.00	−0.01	0.25	0.01	0.11	−0.10	−0.15	0.04	0.21	−0.11	−0.10	0.12	0.12	0.17	0.06	1.00	−0.05	0.03	0.15	−0.09
Education	0.32	0.16	−0.01	0.35	−0.01	0.07	−0.05	−0.12	0.04	0.06	0.04	−0.10	−0.06	0.02	0.03	−0.05	1.00	−0.12	−0.11	0.00
Employment	−0.54	−0.21	0.08	−0.26	0.03	−0.23	−0.13	0.00	0.08	0.03	0.02	0.10	0.04	−0.08	−0.01	0.03	−0.12	1.00	0.08	−0.03
Residency	0.01	0.05	0.10	−0.10	0.09	−0.15	−0.09	0.06	0.01	−0.05	−0.07	0.04	0.07	0.05	0.05	0.15	−0.11	0.08	1.00	0.07
What is your risk of acquiring STI?	−0.07	0.02	0.02	−0.10	0.20	−0.13	−0.08	−0.06	−0.06	0.32	−0.12	0.14	0.19	0.06	−0.09	0.00	−0.03	0.07	0.11	0.11

STI: sexually transmitted infection.

^a5-point Likert scale.

^b6-point Likert scale.

Finally, the multivariate regression model revealed that only the importance of sex to the respondents (F(1) = 4.31, p = 0.04) and number of same-sex sexual partners within the last 12 months (F(1) = 14.86, p = 0.0001) influenced the level of STI knowledge; women for whom sex was more important and who had more same-sex sexual partners in the last 12 months had a higher STI knowledge. However, the model was weak (corrected R² = 0.11, p = 0.0001). Similarly, the age of the respondents (F(1) = 5.86, p = 0.01) and talking about STIs with sexual partners (F(2) = 8.65, p = 0.0001) contributed strongly to the level of declared STI knowledge; older WSW/WSWM and those who talked about STIs with all sexual partners declared to be more conscious about STIs (corrected R² = 0.15, p = 0.00001).

Discussion

Analysis of population-based and clinical samples of WSW has shown that the risk of STIs in this population is equal to that of other women.⁹ In case of WSWM the higher prevalence of STIs was found compared to heterosexual women.^10–15 A large study from Norway of 103,564 women revealed that WSW were at lower risk for acquiring STIs than WSWM, and that older age and a higher level of education decreased that risk, whereas smoking and having more than one sexual partner in the last six months increased the risk of STIs in WSW.¹⁶ Furthermore, sex with a man, lifetime number of male sexual partners, and a higher number of sexual partners were found to be associated with the risk factors of STIs, whereas being lesbian, have never been married, and having a woman as a first sexual partner decreased that risk.^15,17

The number of STI cases in lesbian individuals might be underestimated as a result of the low rate of using the healthcare system by this group of WSW/WSWM.¹⁸ It is also important to emphasize that all WSW/WSWM might have different needs, risks, and protective behaviors based on self-identified sexual orientation or self-described gender expression. For example, bisexual women are more likely to be tested for STIs compared to heterosexual women and are more likely to be diagnosed with STIs compared to lesbian women, while heterosexual women are more likely to have a Pap smear compared to exclusively homosexual WSW.^9,19 This has been recognized by the American College of Obstetricians and Gynecologists¹⁹ and more recently by the Polish Society for Sexual Medicine.²⁰

The results of our study show that the STI knowledge in WSW and WSWM is insufficient, which is in line with the results of studies of heterosexual samples of women^{3–5,10,11,21–26} and one study of WSW/WSWM.^11,12,27,28 Furthermore, both WSW and WSWM rated the likelihood of having an STI as low. Similarly, in a study of 78 predominately white, well-educated, lesbian-identifying women, Fishman and Anderson²⁸ found that more than half (53%) of the women perceived their risk of acquiring HIV to be low. In a survey of 10,986 young adults who had an STI, Kaestle and Waller²⁹ found that women who reported only same-sex sexual relationships were more likely to believe that they were at lower risk for STIs than women reporting only opposite-sex sexual relationships. Additionally, Muzny et al.’s³⁰ study, which involved a focus group of 29 African-American WSW and WSWM, demonstrated that they perceived that there is a lower risk of STI acquisition from female sexual partners than from male partners. Finally, in a study of 23 primarily white lesbian and bisexual women, participants reported feeling that they were more likely to be infected with an STI by a man than by a woman.³¹ We noticed a similar tendency, with WSW being more likely to perceive sexual activity with a female partner as not being associated with any risk of STIs.

Out of the 259 WSW and WSWM, only 7.1% had ever been diagnosed with an STI (5.15% of WSW and 9.62% of WSWM). The frequency of reported STIs among heterosexual and homosexual women varies across different studies, from 16.9% in exclusively heterosexual women in an Australian sample¹⁰ to 58% of WSWM in a Norwegian population.¹¹ No data on the prevalence of STIs among WSW and WSWM in Poland have been published. We presume that the differences in the prevalence might be caused by including candidiasis and bacterial vaginosis as STIs in many studies; we did not recognize these as STIs in the current study.

In Logie et al.’s multivariate logistic regression analysis that controlled for sociodemographic variables, STI history was associated with intrapersonal factors, including higher HIV risk perception (R = 2.18), STI risk perception (R = 1.88), and STI knowledge scores (R = 1.08). Interpersonal factors associated with an STI history included the lifetime number of sexual partners (odds ratio = 1.03). Participants who reported having male sexual partners in the past three months were 3.5 times more likely to report an STI history than those with no recent male sexual partners.²⁷ Several structural variables associated with an STI history were also noted: participants who experienced actual sexual stigma were 6.5 times more likely to report an STI history and those who experienced perceived sexual stigma were twice as likely to report an STI history, whereas those with a history of forced sex were over twice as likely to have had an STI. Finally, participants who reported being gender nonconforming were almost half as likely to report an STI history.²⁷ We did not check the sample for such correlations.

Studies of the factors that affect the STI knowledge among WSW and WSWM are lacking. The results of only a few studies involving a heterosexual sample of women have been located. In the Australian study, factors affecting the STI knowledge of heterosexual women were ‘other’ sources of knowledge (F(6) = 4.77) and ever having had an STI test (F(2) = 5.75).³² In the Wdowiak et al.’s³ study, there was a positive association between the age of the respondent and level of STI knowledge, with older students (between 24 and 26 years of age) scoring higher in the STI test compared to their younger counterparts (high knowledge in 52.8% versus 27.3%, respectively). Similar results were shown by Puszkarz et al.,⁴ older subjects had a greater level of STI knowledge compared to younger ones (rs = 0.30; p < 0.01). We found that WSW and WSWM for whom sex was more important and who had more same-sex sexual partners in the last 12 months had a higher STI knowledge. However, the age was correlated with declared STI knowledge – similarly to cited studies older WSW/WSWM declared to be more conscious about the prevention of STIs (corrected R² = 0.15, p = 0.00001).

Limitations of the study

Our study has some limitations. First, the study sample was highly homogenous as almost all individuals had higher education and all were recruited via the LGBTQI community web mailing list; they were not randomly selected from the general population. Second, we did not use a standardized questionnaire to measure STI knowledge, such as The Sexually Transmitted Disease Knowledge Questionnaire.³³ However, that questionnaire was used only in one study on WSW/WSWM,²⁷ whereas in other studies self-prepared nonvalidated questionnaires were used. Third, we did not collect information regarding the type of STI that the participant declared having had in the past. However, it seems than none of these limitations affect the importance or the quality of the study. We also believe that, as the risk factors for STIs include the sex and number of sexual partners, minimal use of protective sexual behaviors, and low levels of STI knowledge,³⁴ increasing knowledge about these factors could decrease the probability of the transmission of STIs. This should be a goal for medical practitioners irrespective of their country of origin. Furthermore, as most LGBTQI individuals might conceal their same-sex history from physicians, higher STI knowledge might be essential for a proper and reasonably fast diagnosis and efficient treatment.

Conclusions

The WSW in this study had insufficient STI knowledge. However, that knowledge was higher in the WSWM group. Among the WSW, in contrast to the WSWM, it was observed that there was no awareness that the STI risk is not associated with the partner’s gender. Age, the importance of sex, sexual behaviors, and openness to discussing STIs with sexual partners are factors that influence actual and perceived STI knowledge in WSW and WSWM.

Supplemental Material

Supplemental material for Impact of social factors and sexual behaviors on the knowledge of sexually transmitted infections among women who have sex with women/women who have sex with women and men

Supplemental material for Impact of social factors and sexual behaviors on the knowledge of sexually transmitted infections among women who have sex with women/women who have sex with women and men by Robert Kowalczyk and Krzysztof Nowosielski in International Journal of STD & AIDS

Footnotes

Authors’ contribution

Category 1

Conception and Design – RK, KN

Acquisition of data – RK, KN

Analysis and interpretation of data – RK, KN

Category 2

Drafting the article – RK, KN

Revising it for intellectual content – RK, KN

Category 3

Final approval of the completed article – RK, KN

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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