Many people who have sex with both men and women perceive themselves as heterosexual
This has consequences for their sexual health. We should help people find their right sexual identity so that they can align their self-reported sexual orientation with their sexual behaviour, writes Bente Træen.
Women and men who have sex partners with both sexes are more exposed to sexually transmitted infections than groups with a different sexual behaviour.
Nevertheless, bisexuals should not be the target group for the prevention of sexually transmitted infections. Why not?
The first thing we need to ask ourselves is how people’s experience of their sexual identity corresponds with the partners they actually have sex with.
In the University of Oslo’s 2020 Sexual Behaviour Survey – a study that includes 4160 Norwegians – we examined differences and similarities between several different groups according to whom they have sex with:
- Women who only have sex with men
- Women who only have sex with women
- Women who have sex with both women and men
And correspondingly for men:
- Men who only have sex with women
- Men who only have sex with men
- Men who have sex with both men and women
Mismatch between identity and behaviour
It is easy to believe that a person's sexual behaviour – that is, the partners they have sex with – is consistent with the person's own experience of their sexual identity. But it’s not that simple. On the contrary, our study shows that the respective groups do not necessarily identify as heterosexual, homosexual or lesbian, or bisexual.
When a person grows up in an environment that does not accept homosexuality, they will often use these negative attitudes to understand themselves and their own sexual preferences.
Women who have sex with both women and men, for example, very often identify as heterosexual (76 per cent). Fewer women in this group report being bisexual (24 per cent). Correspondingly for men who have sex with both men and women, 76 per cent stated their identity as heterosexual and 22 per cent as bisexual.
The six groups mentioned above have sexual behaviour that entails different levels of risk for sexually transmitted infections. Two groups stand out: women who have sex with both women and men, and men who have sex with both women and men. These two groups are particularly vulnerable.
This has some consequences for their sexual health.
Big differences in sexual risk behaviour
Sexual risk behaviour involves choices and actions a person takes that increase the chance of contracting sexually transmitted infections, including having sex with multiple partners and unprotected sex.
Among women who have sex with both women and men, only three in ten used a condom the last time they had sex with a new partner. This group also reported the highest number of sexual partners in the past year (62.4 partners on average).
Men who have sex with both women and men were the least frequent condom users, while having the second highest number of sex partners. These men averaged 36.5 partners in the past year.
Men who only have sex with men were the group that most frequently used condoms.
By comparison, women who only have sex with men had 1.4 partners, and women who only have sex with women had 4.8 partners in the past year.
Men who only have sex with women reported 1.8 partners in the past year compared to 11.3 sex partners among men who only have sex with men.
The conclusion is that women who have sex with both men and women, and men who have sex with both men and women, are clear target groups for preventive work against sexually transmitted infections.
However, since most individuals in these groups do not identify as bisexual, bisexuals should not be the target group for preventive work against sexually transmitted infections.
In other words: For anyone who does preventive work, this means that messages about sexually transmitted infections should not primarily be aimed at people who identify as gay/lesbian or bisexual. Rather, they need to be aimed at men and women who have sex partners with both sexes.
Concordance between sexual identity and practice is important
Women and men who only have sex partners of the same sex, and women and men who have sex with partners of the same and different sex, are both minority groups that are exposed to minority stress.
Minority stress describes the additional stress you might experience because you belong to a stigmatized minority in the population.
Furthermore, minority stress is linked to poor mental health and can arise as a result of social stigmatisation, discrimination and prejudice.
Of particular importance for mental illness – and for risky sexual behaviour – is the extent to which a person has shaped their understanding of themselves based on negative societal attitudes towards homosexuality. When a person grows up in an environment that does not accept homosexuality, they will often use these negative attitudes to understand themselves and their own sexual preferences.
The result is that gay and lesbian individuals may grow to dislike themselves and consequently experience a reduced quality of life, psychological challenges linked to substance abuse, depression or suicide, in addition to risky sexual behaviour like unprotected sex.
We should therefore help people find their right sexual identity so that their sexual behaviour and sexual identity are in alignment.
Measures for identity and sexual health
In order to improve mental and sexual health in sexual minority groups, we should actively work as a society to reduce negative attitudes towards homosexuality and the need to hide one's sexual identity. This would help many women and men with sex partners of the same sex who are struggling.
Many women and men who have sex with partners of both the same and different sex do not consider themselves as belonging to a minority group. It is thus important for health personnel to routinely ask patients’ about their sexual behaviour, the gender of their sex partners and also to assess whether the person may be affected by minority stress.
In addition, it is important to provide anonymous low-threshold services to these groups, both to support their mental health and to prevent the spread of sexually transmitted infections.
For example, the Norwegian foundation Helseutvalget is a low-threshold service where people can walk in to test themselves anonymously for HIV and other sexually transmitted infections, as well as talk to staff with expertise in psychology.
Such low-threshold options are important for people who identify as heterosexual, but who have sex both with people of the same and different sex than themselves.