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Sexual behaviour of lesbians and bisexual women

Article  in  Sexually Transmitted Infections · May 2003

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ORIGINAL ARTICLE

Sexual behaviour of lesbians and bisexual women

Sex Transm Infect 2003;79:147–150

Objectives: To provide data about the sexual histories of a large sample of lesbians and bisexual
women, to inform those who provide health care or carry out research with women who may be sexu-
ally active with other women.
Design: Cross sectional survey.
Setting/subjects: 803 lesbians and bisexual women attending, as new patients, lesbian sexual health
clinics, and 415 lesbians and bisexual women from a community sample.
Main outcome measures: Self reported sexual history and sexual practice with both male and female
partners.
See end of article for Results: 98% of the whole sample gave a history of sexual activity with women, 83% within the past
authors’ affiliations year, with a median of one female partner in that year. 85% of the sample reported sexual activity with
.......................
men; for most (70%) this was 4 or more years ago. First sexual experience tended to be with a man
Correspondence to: (median 18 years old), with first sexual experience with a woman a few years later (median 21 years).
Julia Bailey, King’s College Oral sex, vaginal penetration with fingers, and mutual masturbation were the most commonly reported
London, Department of
General Practice and
sexual practices between women. Vaginal penetration with penis or fingers and mutual masturbation
Primary Care, 5 Lambeth were the most commonly reported sexual activities with men.
Walk, London SE11 6SP, Conclusions: These data from the largest UK survey of sexual behaviour between women to date dem-
UK; [email protected] onstrate that lesbians and bisexual women may have varied sexual histories with both male and female
Accepted for publication partners. A non-judgmental manner and careful sexual history taking without making assumptions
30 October 2002 should help clinicians to avoid misunderstandings, and to offer appropriate sexual health advice to les-
....................... bians and bisexual women.

I
t is estimated that at least 4.9% of women aged 16–44 years
Glossary
in Britain have had one or more female sexual partners at
some point in their lives, rising to 6.9% in Greater London.1
Bisexual: in this article used to represent women who identify
An equivalent estimate in the United States is 4.1% for women themselves as bisexual
aged 18–59, with 6.2% in the USA’s largest cities.2 Lesbians Dental dam: a square of latex which may be placed over the
and bisexual women may be invisible within health services if vulva as a safer sex barrier in oral-vaginal sex
health carers assume heterosexual sexual orientation3 4 and if Fisting: vaginal or anal penetration with the whole hand
mistrust or other factors lead lesbians and bisexual women to Khush: signifying Asian lesbians or homosexual men
avoid disclosing their sexual orientation.5 6 Studies from the Lesbian: in this article used to represent women who identify
United Kingdom,7 8 United States,9 and Canada10 describe themselves as lesbian, gay, dyke, khush, or zami
prejudiced attitudes of health carers and fear of this may lead Sado-masochism: a form of consenting sexual practice in
to delay in seeking medical care or to seeking health care from which participants eroticise power, control, and/or the endur-
alternative sources.11 Clinicians’ assumptions of heterosexual- ance of physical pain
ity or incomplete sexual histories from lesbians and bisexual Zami: a word used by lesbians of the African diaspora,
women may lead to inappropriate advice or treatment being meaning women who work together as friends and lovers
offered.4
London’s two lesbian sexual health clinics were established
by a doctor working in genitourinary services who had Bernhard or the Audre Lorde lesbian sexual health clinics in
observed that lesbians and bisexual women were not well London (clinic sample n=803). In addition to the clinic sam-
served by existing services. The first clinic, the Sandra ple, a community sample was purposively selected12 to include
Bernhard, was established in 1992 at Charing Cross Hospital those who were diverse in terms of geography, race, class, and
in west London.3 The demand for appointments at this clinic disability. Groups or organisations were identified through
led to the opening of a second in 1993, the Audre Lorde at the listings in the lesbian and gay press and respondents were
Royal London Hospital in east London. These clinics were set recruited from across England and Scotland by distributing a
in genitourinary departments with female staff, offering questionnaire after focus group sessions concerning general or
sexual health services to lesbians and bisexual women. sexual health and at conferences (n=415).3 A snowballing
We present survey data from these two clinics as well as method12 was used to disseminate further questionnaires to
from lesbian and bisexual women’s community groups and contacts of the focus group attenders.
snowball contacts across the United Kingdom. This detailed All female respondents who reported past or present sexual
information about the sexual histories and practices of well activity with women were included as well as women who
over 1000 lesbians and bisexual women is intended to inform gave no history of same sex sexual activity, but who defined
those who provide health care or carry out research with their sexual orientation as lesbian, bisexual, gay, dyke, khush,
women who may be sexually active with other women. or zami. Those who described themselves as heterosexual,
with no history of sexual activity with women, were excluded
METHOD from the study.
In the period 1992–5 a numbered questionnaire for self com- The questionnaire gathered demographic data, sexual
pletion was offered to all new patients attending either the history with both men and women, and sexual practice with

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148 Bailey, Farquhar, Owen, et al

Table 1 Description of the sample Table 2 Lifetime sexual partnerships with women and
men
Community
Clinic sample sample
(n=803) (n=415) Female partners Male partners
Number of sexual
Age: partners ever No (%) No (%)
Mean (SD) 31.2 (6.4) 34.4 (9.8) None 24 (2) 183 (15)
Residence: One 134 (11) 155 (13)
London 91% 32% 2–5 438 (36) 414 (34)
Other England and Scotland 9% 68% 6–10 341 (28) 238 (20)
Sexual identity: >10 280 (23) 228 (19)
Lesbian 92% 86%
Bisexual 7% 11%
Other 1% 2%
Employment:
Employed 65% 64%
Unemployed 21% 15%
Student 10% 16%
Male sexual partners
Other 4% 5% Eighty five per cent of the whole sample reported past or
present sexual activity with men. Of these, 12% had been
sexually active with men within the past year, 18% 1–3 years
ago, 42% 4–10 years ago, and 28% more than 10 years ago.
Younger women were more likely to report sex with men
female partners. In addition, most of the community sample within the past year (23% of those under 25 compared with
were asked questions about sexual practice with men and 7% of those 36 or over, p<0.0001). The median number of
safer sex (n=328). male partners in the past year was one (interquartile range
Data were entered into a statistical analysis package (SPSS 1–2), and median age of first sexual experience with men was
Version 10) and analysed using simple proportions, correlation 18 years (interquartile range 16–21).
coefficients, and χ2 tests of significance. Table 2 shows the distribution of lifetime sexual partner-
ships with women and men.
RESULTS The number of female sexual partners does not correlate
Response rates with number of male sexual partners (correlation coefficient
Exact response rates are not known; questionnaires were 0.094); for example, women with a history of larger numbers
offered to approximately 1000 new attenders to the two Lon- of male partners do not also have a history of larger numbers
don sexual health clinics; 803 clinic responses were received of female partners, and vice versa.
and analysed. In all, 1136 questionnaires were given to Table 3 shows the frequency of different sexual practices
community groups (some of which may not have been with women and men.
distributed); 415 of these were received and analysed.
Response rates to individual questions varied; there was a Pregnancy history
good response to demographic questions (96.2–99.8%), with a Twenty six per cent reported a history of pregnancy; 13.5%
poorer response to questions addressing anal sex (77.2– reported one or more live births, 0.3% reported stillbirths,
79.7%). Where questions were asked only of the community 5.8% had miscarried, and 13.5% had undergone termination
subgroup, this is indicated in the results. of pregnancy. There was no difference in pregnancy rates by

Description of sample
Table 1 shows demographic features of the sample.
Table 3 Sexual practice with male and female
Ethnicity partners
Eighty eight per cent of respondents categorised themselves as Occasionally Often
white (white British, Irish, European, white other), 4% black (%) (%)
(black Caribbean, black African, black British, black other), 2% Sexual practice with women ever (n=1218)
Asian (Indian, Pakistani, Chinese, Asian British), and 5% Oral sex (mouth-vagina) 25 72
“other.” Vaginal penetration with fingers 13 84
Mutual masturbation 24 71
Sexual identity Genital-genital contact 42 50
Anal penetration with fingers 42 13
Ninety per cent of the whole sample described themselves in
Vaginal penetration with sex toy 37 16
the following terms: lesbian, gay, dyke, khush, or zami. Eight Fisting (hand-vagina) (n=415) 17 16
per cent identified themselves as bisexual and 2% “other” Rimming (mouth-anus) 29 10
sexual orientation. Sado-masochistic activity 19 5
Eighty two per cent (887/1085) of lesbians had a history of Anal penetration with sex toy 12 4
Fisting (hand-anus) (n=415) 3 2
sex with men, 5% within the past year. Virtually all (98/101,
Sexual practice with men in past 10 years (n=328)
97%) bisexual women had a history of sex with men, 50% Vaginal penetration with penis 32 53
within the past year. Women aged 30 and under were more Mutual masturbation 38 40
likely to describe themselves as bisexual (63/567, 11%) than Vaginal penetration with fingers 39 39
those over 30 years old (39/625, 6%) (p<0.01). Receiving oral sex (mouth-vagina) 46 31
Giving oral sex (mouth-penis) 48 25
Anal penetration with penis 24 4
Sexual history Anal penetration with fingers 14 5
Female sexual partners Vaginal penetration with sex toy 16 4
Virtually all (98%) of the whole sample reported past or Sado-masochistic activity 6 2
present sexual activity with women, 83% within the last year. Fisting (hand-vagina) 2 1
The median number of female partners in the past year was Fisting (hand-anus) 1 0
one (interquartile range 1–2), and median age of first sexual
experience with a woman was 21 (interquartile range 18–25).

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Sexual behaviour of lesbians and bisexual women 149

sexual identity; 26% (274/1069) of lesbians had been pregnant sexual orientation, formulation of questions, or descriptive
compared with 29% (29/99) of bisexual women (p=0.27). statistics. Comparisons can be made with six surveys of sexual
behaviour which were carried out during the 1990s. Two are
Use of barriers in sex (safer sex) British: (a) the Pride Survey,17 a convenience sample of 278
Three hundred and twenty eight women were asked questions lesbians at London’s annual Pride festival, and (b) the
about safer sex with women and men in the past 10 years. National Survey of Sexual Attitudes and Lifestyles 1990–1
(NATSAL),18 a probability sample of 18 876 of which 178
With women women reported same sex genital contact. Three surveys are
Eighty six per cent of those who reported oral sex with women American: (c) a national postal survey included in the maga-
(n=296) had never used dental dams; 13% used them zine The Advocate, which recruited 6935 lesbians,19 (d) the Bos-
occasionally or often and 1% always used them. Of those who ton Lesbian Health Project, a national survey of 1633 lesbians
reported sharing sex toys with women (n=127), 22% never recruited by snowballed sampling,20 and (e) the National
washed them before sharing, 31% washed them occasionally Health and Social Life Survey (NHSLS),2 a probability sample
or often, with 47% always washing them. In addition, 22% of of 3432, of which 140 women reported same sex partners. The
those sharing sex toys used condoms occasionally or often last is Australian: (f) a survey of 1408 women who have sex
when sharing, and 26% always did. with women attending a genitourinary clinic in Sydney.21
The comparisons outlined below indicate a relatively high
With men
level of consistency between survey results.
Of those who reported penetrative sex with men (penis-
In our survey, vaginal stimulation through oral sex or pen-
vagina) (n=170), 32% had never used condoms or femidoms,
etration with fingers was almost universally reported in sex
45% used them occasionally or often, and 23% always did. Of
between women. The use of sex toys and anal stimulation
those who reported anal penetration with a penis (n=35),
were less commonly reported. Similar preferences were
42% had never used a condom or femidom, 29% used them
recorded in the Pride Survey and the Boston Lesbian Health
occasionally or often, and 29% always did. Of the 128 women Project. The two national probability surveys (NATSAL in the
who reported oral sex with men, 80% never used condoms, United Kingdom, NHSLS in the United States) give details
16% occasionally or often, and 4% always used them. only about passive or active oral sex between women.
Differences in sampling methods are likely to account for
DISCUSSION differing proportions of subjects reporting sexual activity with
Critique of methodology men. Subjects in The Advocate, Boston Lesbian Health, and
Sample selection and response rates Pride surveys were defined by lesbian or bisexual identities;
Sexual orientation can be defined by sexual identity, sexual 77%, 77%, and 87% of respondents reported sexual activity
attraction, or sexual behaviour.13 These definitions are not with men. NATSAL and NHSLS were random population
necessarily congruent, and are likely to differ in degree and samples and the Sydney STI survey was a clinic population
over time. We selected subjects on the basis of both sexual which included 22% who were sex workers; 96%, 98.8%, and
identity and sexual behaviour. We used convenience sampling 93% of these respondents reported sexual activity with men.
(selected by virtue of attendance at lesbian clinics or through Data in other surveys are consistent with our finding that les-
lesbian and bisexual women’s community groups) since bian and bisexual women’s first sexual experience tends to be
lesbian and bisexual sexual orientation is stigmatised and heterosexual, followed a few years later by first same sex
subjects hard to reach for research.14 The clinics were sexual experience.
advertised as lesbian sexual health clinics, and the survey Lesbians and bisexual women may have reproductive
described as a survey of lesbian sexual health, so bisexual health needs22; in our survey 13.8% had given birth and 5.8%
women are likely to be under-represented. While the commu- reported miscarriage. An appreciable proportion had under-
nity sample was purposively selected to reflect demographic gone termination (13.5%); this is similar to the reported rate
diversity, the results presented may not be directly generalis- in NATSAL of 15.1% for all women aged 25–44. Lesbians and
able to lesbians and bisexual women in other settings. These bisexual women may seek advice about conception by donor
data are not intended to represent all lesbians and bisexual insemination.23 It is not known what proportion of our sample
women, but instead to describe diversity of sexual history and are non-biological parents.
practice in a large sample of women who have sex with Case studies and clinic based surveys indicate that woman
women. to woman transmission of infection is possible for
trichomoniasis,24 genital herpes,25 vulval and cervical human
Survey methods papillomavirus,26 hepatitis A,27 syphilis,28 and HIV,29 as well as
Surveys of sexual health are inevitably vulnerable to inaccura- bacterial vaginosis.30 Woman to woman transmission of
cies such as recall bias and social desirability bias.15 16 In addi- chlamydia or gonorrhoea has not been documented. The rela-
tion, questions about sexual behaviour are liable to be tive rarity of most of these STI diagnoses in lesbians or
interpreted in subtly different ways by respondents depending bisexual clinic attenders means that analysis of risks of
upon what is considered “sex” or a “partner” by respondents. particular sexual practices is difficult. Our data demonstrate a
For example, while 85% reported past sex with men, 82% range of sexual practice in sex between women, and counter
reported having had one or more male sexual partner. assumptions that a lesbian sexual orientation precludes
The survey used a structure with mainly closed questions sexual activity with men; this information is intended to guide
and predetermined response categories. The true diversity of appropriate screening, diagnosis, treatment, and prevention
sexual history and practice is therefore likely to be under- advice for STIs in lesbians and bisexual women.
represented by these results. We have noted differing response A sizeable proportion of lesbians and bisexual women in our
rates to different individual questions; the poorest response survey with a history of sexual activity with men had never
rates were for questions about anal sex and this may introduce used condoms for vaginal or anal penetrative sex (although
response bias. the numbers in this subgroup were small). A large proportion
of those who shared sex toys did not wash them or use
Discussion of results condoms on toys before use on another woman. Dental dams
This survey constitutes the largest data set of lesbian and were rarely used in sex between women. These data on use of
bisexual women’s sexual behaviour in the United Kingdom. barriers in sexual activity seem to imply that lesbians are at
Direct comparisons of our results with other surveys are diffi- risk of STI transmission from men or women, although safer
cult because of differences in sampling methods, definitions of sex may be negotiated in ways other than through the use of

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 150 Bailey, Farquhar, Owen, et al

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