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Am J Public Health. 2002 July; 92(7): 1110–1112.
PMCID: PMC1447198

Sexual and Drug Use Behavior Among Women Who Have Sex With Both Women and Men: Results of a Population-Based Survey

Susan Scheer, PhD, MPH, Ingrid Peterson, MPH, Kimberly Page-Shafer, PhD, MPH, Viva Delgado, MPH, Alice Gleghorn, PhD, Juan Ruiz, MD, DrPH, Fred Molitor, PhD, William McFarland, MD, PhD, Jeffrey Klausner, MD, MPH, and the Young Women's Survey Team

Recent HIV/AIDS trends in the United States suggest a relative increase in HIV infections among women attributed to injection drug use or heterosexual contact.1 Although the biological risk of female-to-female sexually transmitted HIV is unknown, it is thought to be much lower than the risk of transmission between men and women, including instances in which a condom is used.2 However, studies focusing on women who have sex with women (WSW) have shown that some subgroups of WSW exhibit high levels of sexual risk behaviors with men as well as unsafe injection drug use.3,4 Thus, if risk assumptions are based on self-reported or presumed sexual identity, possible risks for HIV infection may be underestimated in some subgroups of WSW.

Few studies have estimated the proportion of WSW or characterized their behavior in samples representative of the population as a whole. Here we describe sexual and drug use behaviors associated with HIV and other sexually transmitted diseases (STDs) among WSW who took part in a door-to-door, population-based survey of women aged 18 to 29 years. The survey was conducted between April 1996 and January 1998 among residents of low-income neighborhoods in Northern California. Study methods have been described in detail in a previous article.5

Of 2547 women who completed the study, 2229 (88%) reported sex exclusively with men, 189 (7%) reported sex with both men and women, and 16 (1%) reported sex exclusively with women. Of the 7 HIV-positive women, 4 reported only male partners, 2 reported both male and female partners, and 1 reported only female partners. None of the 16 WSW who reported sex exclusively with women reported any injection drug use. Therefore, analyses of risk were limited to those who reported sex with both men and women and those who reported sex exclusively with men (Table 1 [triangle]).

—Prevalence of Sexual Behaviors, Injection Drug Use, and STD/HIV Infections: Population-Based Survey, Northern California

Compared with women who had sex exclusively with men, women who had sex with both men and women were significantly more likely to report past and recent high-risk sexual behavior, including sex with an HIV-positive man, multiple male sexual partners, sex with a man who has sex with men, sex with an injection drug user, trading of sex for drugs or money, and anal sex. They were also more likely to report past and recent injection drug use, including use of heroin, cocaine, and speed. Finally, they were more likely to have serological markers for both hepatitis B virus (anti-HBc, HbsAG, or both) and hepatitis C virus (anti-HCV). Rates of HIV and other STDs did not significantly differ owing to the small numbers of these infections.

The rates of sexual and injection drug risk activities exhibited by women in this population-based survey who reported sex with both men and women place this group at potentially higher risk of HIV and other STDs than women who were exclusively sexual with either men or women. Prevention efforts should avoid assumptions based on reported sexual identity and should acknowledge that women who report sex with both women and men may be at increased risk for HIV and other STDs.


The Young Women's Survey Team includes Geneva Bell-Sanford, San Joaquin County, California, Department of Public Health; Gail Bolan, San Francisco Department of Public Health; Cynthia Cossin, Viral and Rickettsial Disease Laboratory, Berkeley, California; Carla Dillard Smith, California Prevention Education Program, Oakland; Maria Hernandez, San Francisco Department of Public Health; Tanya Holmes, Alameda County, California, Department of Public Health; Martin Lynch and Juan Reardon, Contra Costa County, California, Department of Public Health; Charlotte Smith, San Mateo County, California, Department of Public Health; Hypolitta Villa, San Joaquin County, California, Department of Public Health; and Francis Wiser, San Mateo County, California, Department of Public Health.

This work was supported in part by cooperative agreements U62/CCU0200, U62/CCU906250-06, U62/CU902019-12, and U61/CCU902019-13 from the Centers for Disease Control and Prevention. Additional funding was provided by the San Francisco AIDS Office and STD Prevention and Control Section.

We thank the public health laboratory directors in the counties of Alameda, Contra Costa, San Francisco, San Mateo, and San Joaquin and the staff from the Viral and Rickettsial Disease Laboratory who tested specimens. Also, we thank Dr Gail Bolan and Harold Rasmussen for their support.


S. Scheer contributed to the conception, design, analysis, and writing of the brief. I. Peterson and K. Page-Shafer assisted with management and analysis of the data. V. Delgado, J. Ruiz, F. Molitor, W. McFarland, and J. Klausner contributed to coordination of and data collection for the study; they also contributed to the interpretation of the data. A. Gleghorn contributed to the conception and design of the study. All of the authors reviewed and edited the brief.

Peer Reviewed


1. HIV/AIDS Surveillance Report. Atlanta, Ga: Centers for Disease Control and Prevention; 1999;11(2).
2. Vernazza PL, Eron JJ, Fiscus SA, Cohen MS. Sexual transmission of HIV: infectiousness and prevention. AIDS. 1999;13:155–166. [PubMed]
3. Gonzales V, Washienko KM, Krone MR, et al. Sexual and drug-use risk factors for HIV and STDs: a comparison of women with and without bisexual experiences. Am J Public Health. 1999;89:1841–1846. [PMC free article] [PubMed]
4. Bevier PJ, Chiasson MA, Heffernan RT, Castro KG. Women at a sexually transmitted disease clinic who reported same-sex contact: their HIV seroprevalence and risk behaviors. Am J Public Health. 1995;85:1366–1371. [PMC free article] [PubMed]
5. Ruiz JD, Molitor F, McFarland W, et al. Prevalence of HIV infection, sexually transmitted diseases, and hepatitis and related risk behavior in young women living in low-income neighborhoods of northern California. West J Med. 2000;172:368–373. [PMC free article] [PubMed]

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