Heather L. Armstrong

Women who have sex with women: a comprehensive review of the literature and conceptual model of sexual function

Women who have sex with women (WSW) have been underrepresented in studies on sexual function. Consequently, much of what is known of female sexual function may not be representative of, or generalizable to, the experiences of WSW. The purpose of this paper is to provide a comprehensive and critical review of the literature on the sexual function of WSW, followed by an integration of the literature in a conceptual model to guide and stimulate research. Twenty-six articles are reviewed and 15 factors are identified as contributing to sexual functioning in WSW and are subsequently included in the conceptual model. Of these, it is suggested that eight factors may contribute directly to sexual function. These include: age, income, religion, cultural recognition, relationship duration, sexual satisfaction, psychological well-being, and relationship satisfaction. The literature suggests the remaining seven factors may indirectly contribute to sexual function. These include: sexual frequency, desire discrepancy between partners, internalized homonegativity, power, social support, emotional intimacy, and a discrepancy between partners in level of being “out” as a lesbian or bisexual woman. Comparisons are made to the sexual function of women who have sex with men and the implications of having a model that recognizes similarities while also considering unique influences for WSW are discussed.

Women’s Motivations to Have Sex in Casual and Committed Relationships with Male and Female Partners

Women report a wide variety of reasons to have sex (e.g., Meston & Buss, 2010), and while it is reasonable to assume that those reasons may vary based on the context of the relationship, this assumption has not yet been tested. The purpose of this study was to explore how relationship type, sexual attraction, and the gender of one’s partner interact and affect the sexual motivations of women. A total of 510 women (361 who reported exclusively other-sex attraction and 149 who reported same-sex/bisexual attraction) completed the YSEX? questionnaire. Participants rated their sexual motivations for casual sex and sex in a committed relationship with male and/or female partners, depending on reported sexual attraction. Results showed that relationship type affected reported motivation for sex: physical motivations were more strongly endorsed for casual sex, whereas emotional motivations were more strongly endorsed for sex in committed relationships. No significant differences in motivation were reported between women who reported same-sex attraction and those who did not. Women who reported bisexual attraction and identified as being lesbian, bisexual, or another sexual minority reported no significant differences in motivation for sex with male or female partners. The results of this study highlight the importance of relationship context when discussing sexual motivation and suggest a high degree of similarity in motivation for women, regardless of sexual orientation or gender of partner.

Pelvic Floor Physical Therapy for Lifelong Vaginismus: A Retrospective Chart Review and Interview Study

Pelvic floor physical therapy is used in the treatment of sexual pain disorders; however, women with lifelong vaginismus have not yet been included in treatment studies or have not been differentiated from women with acquired vaginismus and/or dyspareunia. This retrospective chart review and interview study was intended to obtain initial information on physical therapy interventions, course, and outcome in women who have never been able to experience vaginal intercourse. The files of 53 women, consecutively treated at one physical therapy clinic, were included in the chart review; 13 of these women volunteered to be interviewed. The chart review revealed significant pelvic floor pathology and an average treatment course of 29 sessions. Internal manual techniques were found to be most effective, followed by patient education, dilatation exercises, and home exercises. Although participants were very satisfied with the physical therapy, some symptoms, such as pain, anxiety/fear, and pelvic floor tension remained and scores on the Female Sexual Distress Scale and Female Sexual Function Index indicated clinical levels of sexual distress and impaired sexual function after treatment. Although there appears to be no linear relation between symptom reduction and healthy sexual function, this initial information suggests that physical therapy may be a promising treatment option for some women with lifelong vaginismus and merits further evaluation.

Cost-effectiveness of cervical cancer screening methods in low- and middle-income countries: A systematic review

The incidence of cervical cancer in low‐ and middle‐income countries (LMICs) is five times higher than that observed in high‐income countries (HICs). This discrepancy is largely attributed to the implementation of cytology‐based screening programmes in HICs. However, due to reduced health system infrastructure requirements, HPV testing (self‐ and provider‐collected) and visual inspection with acetic acid (VIA) have been proposed as alternatives that may be better suited to LMICs. Knowing the relative value of different screening options can inform policy and the development of sustainable prevention programs. We searched MEDLINE and EMBASE for English language publications detailing model‐based cost‐effectiveness analyses of cervical cancer screening methods in LMICs from 2000 to 2016. The main outcome of interest was the incremental cost‐effectiveness ratio (ICER). Quantitative data were extracted to compare commonly evaluated screening methods and a descriptive review was conducted for each included study. Of the initial 152 articles reviewed, 19 met inclusion criteria. Generally, cytology‐based screening was shown to be the least effective and most costly screening method. Whether provider‐collected HPV testing or VIA was the more efficient alternative depended on the cost of the HPV test, loss to follow‐up and VIA test performance. Self‐collected HPV testing was cost‐effective when it yielded population coverage gains over other screening methods. We conclude that HPV testing and VIA are more cost‐effective screening methods than cytology in LMICs. Policy makers should consider HPV testing with self‐collection of samples if it yields gains in population coverage.

An Event-Level Analysis of the Interpersonal Factors Associated With Condomless Anal Sex Among Gay, Bisexual, and Other Men Who Have Sex With Men (MSM) With Online-Met Partners

The interpersonal determinants of condomless anal sex (CAS) within online-initiated sexual relationships remain poorly understood. Therefore, respondent-driven sampling was used to recruit a prospective cohort of sexually active gay, bisexual, and other men who have sex with men (MSM), aged ≥ 16 years in Vancouver, Canada. Follow-up occurred every 6 months, up to seven visits; at each visit participants reported their last sexual encounter with their five most recent partners. Stratified by self-reported HIV status, individual-level, interpersonal, and situational covariates of event-level CAS with partners met online were modeled using generalized estimating equations (GEE). CAS was reported during 32.4% (n = 1,015/3,133) of HIV-negative/unknown mens events, and 62.1% (n = 576/928) of HIV-positive mens events. Social (i.e., collective identity, altruism, network size social embeddedness) and situational (i.e., number of encounters, location, comparative age, seroconcordance, substance use) factors were identified as important correlates of CAS. Implications include the need for HIV prevention addressing social contexts associated with CAS.

Factor reliability analyses of the YSEX? in a sample of women with same-sex attraction

The “Why Have Sex?” questionnaire (YSEX?) is a comprehensive research tool developed to provide an organized taxonomy of reasons for engaging in sex for men and women. The measure has been empirically validated and has shown high internal reliability in general samples. The current study evaluated the psychometric properties of the YSEX? in a sample of 146 women with same-sex attraction. The questionnaire was completed by women considering motivations for casual sex and sex in a committed relationship with a female partner. Cronbachs alphas were calculated for each of the factors and subfactors of the YSEX? and overall reliability was excellent. Additionally, principal component analyses were conducted to determine if the previously established four-factor structure of the YSEX? could be replicated in this sample. While the four-facture structure accounted for much of the observed variance (79.0% for motivations for casual sex; 71.2% for motivations for sex in a committed relationship), results suggest that a three-factor structure may be more representative of the data, likely due to characteristics of the current sample. Based on the results of the analyses conducted, the YSEX? measure is reliable for women with same-sex attraction considering casual sex and sex in a committed relationship with a female partner.

Seroadaptive Strategies of Vancouver Gay and Bisexual Men in a Treatment as Prevention Environment

ABSTRACT British Columbia’s treatment as prevention policy has provided free access to highly active antiretroviral therapy (HAART) to all HIV-positive provincial residents since 1996. One outcome is an increase in HIV-positive gay and bisexual men (GBM) with suppressed viral loads. Previous cross-sectional analyses indicated that some Vancouver GBM now recognize condomless anal sex with men on HAART who report a suppressed viral load as a seroadaptive strategy. To test the hypothesis that this new strategy, termed viral load sorting (VLS), is recognized and used among by GBM in the Momentum Health Study, we analyzed longitudinal data for HIV-negative/unknown (n = 556) and HIV-positive (n = 218) serostatus participants. Analyses indicated that both groups reported VLS, and that serostatus and Treatment Optimism Scale scores were significant determinants in frequency and use. Results exemplify the medicalization of sex and Rogers’ Diffusion Of Preventative Innovations Model, and they have important implications for HIV research and GBM sexual decision-making.

A latent class analysis of substance use and culture among gay, bisexual and other men who have sex with men

Abstract Assessments of gay and bisexual men’s substance use often obscures salient sociocultural and identity-related experiences related to how they use drugs. Latent class analysis was used to examine how patterns of substance use represent the social, economic and identity-related experiences of this population. Participants were sexually active gay and bisexual men (including other men who have sex with men), aged ≥ 16 years, living in Metro Vancouver (n = 774). LCA indicators included all substances used in the past six months self-reported by more than 30 men. Model selection was made with consideration to model parsimony, interpretability and optimisation of statistical criteria. Multinomial regression identified factors associated with class membership. A six-class solution was identified representing: ‘assorted drug use’ (4.5%); ‘club drug use’ (9.5%); ‘street drug use’ (12.1%); ‘sex drug use’ (11.4%); ‘conventional drug use’ (i.e. tobacco, alcohol, marijuana; 25.9%); and ‘limited drug use’ (36.7%). Factors associated with class membership included age, sexual orientation, annual income, occupation, income from drug sales, housing stability, group sex event participation, gay bars/clubs attendance, sensation seeking and escape motivation. These results highlight the need for programmes and policies that seek to lessen social disparities and account for social distinctions among this population.

Associations between sexual partner number and HIV risk behaviors: implications for HIV prevention efforts in a Treatment as Prevention (TasP) environment

ABSTRACT Previous research indicates that gay and bisexual men (GBM) have significantly more sexual partners than same-aged heterosexual men and women. As a result, some HIV intervention programs have focused on partner reduction. However, new research findings question the relevance of sexual partner number as a sexual risk measure for GBM given Treatment as Prevention (TasP) programs and new seroadaptive strategies which have led to lower GBM community viral load and new HIV prevention behaviors. To assess if sexual partner number continues to remain an important measure of sexual risk for GBM living in a city that actively promotes TasP as provincial policy, we analysed cross-sectional data from 719 GBM recruited through respondent-driven sampling in Vancouver, Canada. Multivariable negative binomial regression analysis showed that partner number was significantly associated with previously identified HIV risk factors including condomless anal intercourse with serodiscordant and/or unknown serostatus partners, using sex toys, attending group sex events, receiving money for sex, and sex drug use. These results indicate that sexual partner number remains an important proximate HIV risk measure. However, more nuanced measures of HIV treatment status and greater understanding of the possible causes of increased partner number among GBM are needed.

HIV treatment optimism and crystal methamphetamine use and initiation among HIV-negative men who have sex with men in Vancouver, Canada: A longitudinal analysis

BACKGROUND Treatment as Prevention (TasP) leading to increased HIV treatment optimism among men who have sex with men (MSM) has been previously associated with behavioural risk compensation, though not yet via crystal methamphetamine (CM) use. Among HIV-negative MSM in a TasP environment, this study aimed to investigate the prevalence of recent CM use over time, examine the association between HIV treatment optimism and CM use and initiation, and identify correlates of recent CM use and predictors of CM initiation. METHODS Using data from a prospective behavioural cohort study of sexually active MSM in the Vancouver area, we used multi-level generalized mixed effect models to evaluate temporal trends in CM use, univariable and multivariable logistic regression to identify covariates of recent CM use, and univariable and multivariable survival analysis to identify predictors of CM initiation. RESULTS Of 497 HIV-negative cohort participants, 10.3% reported any recent CM use at enrollment. From 2012-2016, there were no statistically significant temporal trends in overall CM use or with routes of administration. In multivariable logistic regression analyses, HIV treatment optimism was not associated with recent CM use (not retained in final model) or CM initiation (aHR = 1.06, 95% CI:0.98-1.15). Significant correlates of CM use include recent gamma-hydroxybutyrate (GHB) and ecstasy use, and having received/given drugs for sex. CONCLUSIONS Among HIV-negative MSM in Vancouver, HIV treatment optimism does not appear to be independently associated with CM use or initiation of use, though use of CM was both prevalent and stable over time.