Prevalence of Unprotected Sex and HIV-Antibody Testing Among Gay, Lesbian, and Bisexual Youth.

Adolescents between the ages of 13 and 21 now account for 25% of newly reported HIV infections, and two adolescents under the age of 21 become infected with HIV every hour (Office of National AIDS Policy, 1996). While adolescents' infection rates are increasing as a whole, gay and bisexual male adolescents are particularly at risk. In New York City, 9% of gay or bisexual men between the ages of 18 and 24 are HIV infected (Dean & Meyer, 1995), and in San Francisco up to 17.9% of these young males are infected (Osmond et al., 1994). In a Houston study, although only 2% of adolescents reported male-to-male sexual contact, they accounted for 22% of all HIV-positive cases, with about 10% of males who have sex with males testing HIV-positive (Ilegbodu, Frank, Poindexter, & Johnson, 1994).

Lesbian and bisexual female adolescents may also be at risk, as studies have shown that some lesbians and bisexual women have unprotected vaginal intercourse with their gay and bisexual male friends (Cohen, Marmor, Wolfe, & Ribble, 1993; Rosario, Hunter, & Gwadz, 1994b). For example, Rosario et al. (1994b) found that 32% of lesbian youth reported having at least one gay or bisexual male sex partner. Furthermore, in one study 3 of 17 HIV-positive female adolescents identified as bisexual and had sex with other women (Futterman, Hein, Reuben, Dell, & Shaffer, 1993).

The current investigation presents information about the occurrence of sexually risky behavior and HIV-testing behavior among a group of gay, lesbian, and bisexual adolescents. Additionally, information about the youths' testing preferences and beliefs about HIV testing are assessed.

In terms of HIV risk, previous research has indicated that gay and lesbian adolescents engage in a variety of concerning behaviors. Specifically, Rosario, Hunter, and Gwadz (1994a, 1994b) found that gay, lesbian, and bisexual adolescents reported practicing inconsistent use of condoms or other barrier methods; having partners who are at risk for HIV; and exchanging sex for money, drugs, or a place to stay. In addition to examining the aforementioned risk factors, the present study considered previous history of sexually transmitted diseases (STDs), the use of alcohol and drugs prior to sex, the number of anonymous partners, and whether the individual communicates with his/her sex partners about HIV.

Although gay, lesbian, and bisexual adolescents engage in high risk behaviors, few are tested for HIV-antibodies, even when these services are readily available. In a sample that included gay and bisexual adolescents at a community-based organization where testing was accessible, less than 40% of the adolescents had been tested for HIV (Rotheram-Borus, Gillis, Reid, Fernandez, & Gwadz, 1997).

A consequence of low testing rates is that many youth who are HIV infected and could receive early medical intervention do not because they are unaware of their HIV status. For example, Lemp et al. (1994) found that in their sero-prevalence study, 70% of the gay and bisexual HIV-infected young men in their sample did not know that they were HIV-positive before participating in the study, and thus were not receiving treatment. Moreover, youth who are unaware of their HIV infection may not take steps to avoid further spread of HIV (Alvarez, 1996). The present study is one of the few to provide descriptive data regarding the rates of HIV testing in the context of specific risk behaviors among a sample of gay, lesbian, and bisexual youth.

In addition, we examined where gay, lesbian, and bisexual adolescents obtain HIV testing; where they prefer to be tested; and whether adolescents know where they can be tested: crucial questions if we are to make these services accessible to young people. Previous research with samples of adolescents where sexual orientation was not specified offers some information about patterns that might be found in the current sample. Specifically, according to Goodman and Berecochea (1994), adolescents who get tested for HIV are most often tested at free/community clinics (26%), county hospitals (17%), adolescent clinics (13%), youth service agencies (12%), and private doctor's offices (10%). Furthermore, Rawitscher, Saitz, and Friedman (1995) found that adolescents preferred to be tested at a place that does only HIV testing (25%), a regular doctor's office (22%), or a hospital (18%); the majority of adolescents preferred to be tested by someone who did not know them. Furthermore, 21% said they did not know where they preferred to be tested. Testing behavior among the current sample is important to document due to the risk behaviors prevalent in this population.

In addition to examining accessibility of and preferences for testing, it is important to consider whether gay and lesbian adolescents are receiving medical care that facilitates testing. More specifically, are these adolescents' risks being appropriately assessed, and are they being encouraged by their health care provider to obtain an HIV test if necessary? Gay and lesbian adolescents may be at a disadvantage because they may feel less comfortable discussing their sexual orientation with their physician or other health care worker, or they may avoid medical care for fear of being judged for their sexual orientation or behavior. Awareness of such barriers to health care is important, as studies have shown that physician recommendations are a primary reason for adolescent testing (Goodman, Tipton, Hecht, & Chesney, 1994).

Finally, beliefs about HIV testing will be examined as a potential variable that distinguishes individuals who obtain HIV-antibody tests from those who do not. Kalichman, Somlai, Adair, and Weir (1996) examined beliefs about HIV-antibody testing among adults. Participants who were tested differed from those who were not because they believed that getting tested would help them feel better about their health. Relative to those not tested, individuals who were tested also believed that people should be tested to protect their sexual partners. Perceived benefits such as the ones above have not been examined in an adolescent population.

Other researchers have examined beliefs about HIV testing which may act as obstacles to testing, though none have focused on gay, lesbian, and bisexual adolescents. Rotheram-Borus et al. (1997) reported that the most common reasons that adolescents provide for not having been tested included fear of being under increased stress (47%), fear of becoming suicidal (21%), lack of importance of the test or of the result (14%), and fear of losing current housing (10%). The top two reasons were psychological in nature, which is similar to a study of adult gay and bisexual men where 48% reported that testing HIV-positive would be too worrisome, and 31% reported that they would be unable to cope with being HIV-positive (Lyter, Valdiserri, Kingsley, Amorosso, & Rinaldo, 1987). Similarly, in an STD clinic sample, fear was a significant factor for individuals who were not tested (Kalichman et al., 1996). Additionally, Myers, Orr, Locker, and Jackson (1993) found that in their sample of gay and bisexual men, 77% of the men did not want to be tested because of not wanting their name on a government list, and that self-perceived health, desire for anonymity, and no benefit and denial were the three most common reasons for not being tested.

There are several additional beliefs about HIV testing that may prevent young people from seeking testing, such as fear that others will find out the results of their test without their consent (Goldsmith, 1993). For gay, lesbian, and bisexual youth, concerns regarding exposure of their sexual orientation upon testing HIV-positive may also play an inhibitory role. Although it is possible to speculate which barriers are most relevant to adolescents, especially gay, lesbian, and bisexual adolescents, there has been little systematic research on why most of these adolescents do not seek HIV testing.

This study focused on the HIV testing behavior of gay, lesbian, and bisexual Southern youth. The purpose of this study was to (a) examine the extent to which Southern gay, lesbian, and bisexual youth are at risk for HIV infection and present information regarding the percentages of these youth who have been tested for HIV in the context of specific risk behaviors; and (b) explore the testing preferences and beliefs about testing of these youth.

Based on previous studies conducted with adolescents of unspecified sexual orientation, we hypothesized that about half of these youth have not been tested for HIV; that most youth prefer to be tested at a gay-sensitive site, such as at an AIDS service organization; that the majority of youth do not feel comfortable talking to a health care provider about their sexuality; and that the Beliefs About HIV Testing measure distinguishes those who have been tested from those who have not.

METHODS

Participants

Participants were 117 gay, lesbian, bisexual, and transgendered youth. Participants were recruited during a regional southern conference for gay, lesbian, bisexual, and transgendered youth held at a Southeastern university during the fall of 1997 (n = 103), and from a Southeastern gay and lesbian community services center (n = 14). Of the total sample, 52% were male, 44% were female, and 4% were transgendered. Forty-six percent identified as gay, 29% as lesbian, 22% as bisexual, and 3% wrote in queer as their identity. When participants were asked to what extent they were out (open about their sexual orientation), 69% were open about their sexual orientation almost all of the time, 29% were open some of the time, and 2% were not open about their sexual orientation. Participants were 75% White, 11% Black, 5% Latino, 4% Asian/Pacific Islander, 4% Biracial, and 1% Other. Mean age was 19.9 years old (range 14 to 27, SD = 2.78). Participants self-identified as working class (10%), middle class (57%), upper-middle class (29%), and upper class (4%).

Procedures

Potential participants were asked to complete a pencil and paper survey pertaining to issues concerning gay, lesbian, and bisexual adolescents that would take about 15 minutes. This questionnaire and the study procedures were approved by the authors' Institutional Review Board. All youth who were at either the leadership conference or the community service center were eligible to participate in the study. Based on their self-identification as a sexual minority, youth at these locations were approached and offered the opportunity to fill out the questionnaire. Ninety-eight percent of the adolescents approached agreed to participate, and participation was taken as implied consent. No data are available on the two adolescents who refused to participate. Adolescents were not asked to provide their name for consent in order to assure their anonymity. Similar to previous studies involving gay, lesbian, and bisexual adolescents, adults at the organization serving these youth were asked to act in loco parentis, or in place of the parents, in giving consent for adolescents under 18 to participate. Many of these adolescents had not disclosed their sexual identity to their parents, and obtaining this type of consent would not be in their best interest. Participants were assured of their confidentiality and were encouraged to ask questions. Adolescents were able to complete the surveys privately both at the conference and at the youth group. Participants recruited from the conference were provided with a $3 incentive for their participation. Adolescents recruited from the community center volunteered to participate without incentive payments.

Survey Instrument

Demographics. Participants reported their gender, sexual identity, ethnicity, to what extent they were out, age, and socioeconomic status.

Sexual risk history. Participants were asked whether they had ever engaged in any unprotected and protected (with a condom or other barrier device) anal sex, vaginal sex, or oral sex. They were also asked a series of questions about their sexual history, such as whether they had been with a partner who engaged in IV drug behavior or with one known to be HIV-positive; whether they ever exchanged sex for money, drugs, or a place to stay; whether they ever had an STD; and how many times in the past year they had sex after drinking alcohol or after using drugs. Participants were asked to report their lifetime number of anonymous sex partners (defined as a partner you met that day). In addition, participants were asked with how many of their partners (over the course of their lifetime) they had specifically discussed HIV before having sex.

HIV testing experience. Participants were asked if they had ever received an HIV test. They were then asked to rate their experience as positive, negative, or neutral. In addition, participants were asked to report the number of times they had been tested for HIV in their lifetime and the age at which they were first tested. They were asked where they had gone most frequently to be tested, where they most preferred to be tested, and if they knew where to go locally to get an HIV test. Finally, participants were asked if they had a regular physician and, if so, whether they felt comfortable talking to this person about their sexuality.

Beliefs' About HIV Testing. This 11-item scale was derived from several different articles assessing individuals' beliefs about HIV testing (e.g., Kalichman et al., 1996). Items were counterbalanced to indicate both positive and negative beliefs on a four-point scale, from Not true for me (1) to Very true for me (4). This scale was subjected to exploratory factor analysis, and three factors emerged. Based on examination of items, these factors were labeled in the following way: (a) a psychological factor, including stigmatization and interpersonal relationships; (b) a physical health factor; and (c) a low priority factor. For items loading on each factor, see Table 1.

Table 1. Beliefs about HIV Testing: Factor Loadings

Factor                                      Loading

Factor 1: Psychological items

I am afraid how the test results would
affect my personal relationships.             .69

I am afraid that I might be discriminated
against if I found out I am HIV positive.     .66

I would become depressed if I were HIV+.      .64

People in my life would leave me if
I had the AIDS virus.                         .61

Finding out my HIV test results is or
would be stressful for me.                    .59

I am afraid others will find out
the results of my test.                       .59

I would rather not know if I have HIV.        .46

Factor 2: Physical health items

Getting tested for the AIDS virus would
help me feel better about my health.          .58

People should get tested for the AIDS
virus because the earlier
HIV is detected, the better your
chances of survival.                          .53

Factor 3: Low priority items

I am so sure I don't have the AIDS virus
that I don't have to be tested.               .70

I have more important things to worry
about than getting an HIV test.               .51

RESULTS

Risk Factors

In terms of the total sample, 36% of the adolescents reported ever having unprotected anal sex, 28% reported ever having unprotected vaginal sex, and 79% reported ever having unprotected oral sex. In addition, adolescents reported several other risk factors: 6% reported having a sexual partner who was an IV drug user; 7% reported having a sexual partner who was HIV-infected; 28% of the females reported having a male partner who was gay or bisexual; 7% of the adolescents reported trading sex for money, drugs, or a place to stay; 11% reported having an STD in their lifetime; 38% reported having sex after drinking alcohol in the last year; 19% reported having sex after using drugs in the last year; and 34% reported having at least one anonymous partner.

In terms of communicating with their sexual partners about HIV, male adolescents were least likely to talk to all of their male partners about HIV, with only 30% engaging in this behavior. In contrast, 63% reported talking to all of their female partners about HIV. In terms of females, 60% reported talking to all of their male partners about HIV, while 48% reported talking to all of their female partners about HIV.

HIV Testing Behaviors

Of the total sample, 47% had ever been tested for HIV. Adolescents who were tested reported doing so at an average age of 18.42 (SD = 2.05). Of adolescents tested, 51% reported that they had a positive experience, 41% reported that they had a neutral experience, and 8% reported that they had a negative experience. Adolescents who were tested reported being tested an average of 2.87 (SD = 2.33) times. Thirty-four percent reported being tested once, 26% reported being tested twice, and 40% reported being tested three or more times. Regarding the link between specific risk behaviors and testing, of those adolescents who reported anal sex and/or vaginal sex without a condom, 33% had not been tested. Of those adolescents who reported one or more of the following--having a partner who was an IV drug user, having an STD in their lifetime, trading sex, and/or having a partner who was HIV-positive--32% had not been tested. Of the females who reported having gay or bisexual male partners, 50% had not been tested. Of those who reported having sex after drinking in the last year, 39% had not been tested. Of those who reported having sex after using drugs, 46% had not been tested. Of those who reported having an anonymous partner, 41% had not been tested.

HIV Testing Preferences and Facilitators.

When asked where they were last tested, 45% reported testing at a public clinic, 29% reported testing at an AIDS service organization, 14% reported testing at a private doctor, 6% reported testing at a hospital, 4% reported testing at school, and 2% reported testing with a home test kit.

When asked where they preferred to be tested, 52% reported preferring testing at an AIDS service organization, 19% reported preferring a public clinic, 17% preferred a private doctor, 6% preferred a home test, 5% preferred a hospital, and 1% preferred school. Eighty-four percent knew where to obtain an HIV test locally.

In terms of facilitators, only 64% of the adolescents reported having a regular physician. Of those who had a regular physician, 42% reported that they did not feel comfortable talking to their physician about their sexuality.

Beliefs About HIV Testing

T-tests were computed for three factors, comparing those who had been tested for HIV to those who had not according to the Beliefs About HIV Testing measure. All three factors--psychological reasons (t = -2.25, p [is less than] .05), physical health (t = 2.13, p [is less than] .05), and low priority (t = -5.16, p [is less than] .01)--were significantly different among these two groups.

DISCUSSION

Results indicated that as hypothesized, the youth in the present investigation are engaging in behaviors that place them at risk for HIV infection. While over one third of the gay, lesbian, bisexual, and transgendered adolescents sampled reported unprotected anal sex, and almost a third reported unprotected vaginal sex, more than half of the sample had never been tested for HIV. In addition to unprotected sex, these adolescents reported a number of other risk factors, including engaging in sex after alcohol and drug consumption and having anonymous and risky partners. Given these data, it is important for professionals who work with these youth to be aware of the wide range of risk factors that gay, lesbian, bisexual, and transgendered youth exhibit, and to be willing to assess these factors when conducting risk assessments.

The present investigation also points to the importance of encouraging youth to communicate with their sexual partners. This is especially true for males, who reported the lowest rates of communication about HIV with their male partners.

Many of the adolescents who engaged in risky behaviors were not tested for HIV, indicating the need for more information regarding the benefits of testing and of early detection. Education should be provided in terms of testing procedures and locations for free and anonymous HIV testing, ideally staffed by HIV counselors who are sensitized to the needs of both adolescents and gay, lesbian, bisexual, and transgendered individuals. Providing youth with a choice of HIV testing providers that will be sensitive to their sexual and gender identities may minimize the negative experiences reported by these youth concerning HIV testing. In addition, because over half of the adolescents report that they prefer to be tested at an AIDS service organization, asking adolescents where they prefer to be tested may ensure that this type of information is provided when a location is recommended.

It is crucial for service providers to discuss the type of medical care that these youth are receiving, as previous studies have shown that adolescents who have a regular physician are the most likely to be tested. In this study, over one third of the adolescents reported not having a regular physician. Of those who had a regular physician, 42% reported that they did not feel comfortable talking to their physician about sexuality. Ensuring that youth are receiving appropriate medical care, where they feel comfortable talking with health professionals about their sexuality, is important. HIV testing is part of a larger picture of adequate health care for these youth. If this care is not being provided at the larger level, steps should be taken to ensure that this problem is ameliorated.

Findings of this study indicate that beliefs about HIV testing distinguish those adolescents who have been tested from those who have not been tested. Discussing psychosocial issues may be useful in helping these youth sort out dilemmas that they face regarding HIV testing. For example, one belief is that others will leave the adolescent if he or she is HIV-positive. Potential HIV results may be discussed in terms of support and interpersonal relationships. Clarification can be provided about mandatory reporting and the law in the state where the youth is being tested, since this varies between states.

Physical health items also distinguish those who were tested from those who were not. Specifically, those who were tested differed from those who were not in terms of reporting that being tested helps them feel better about their health, and reporting a belief that the earlier HIV is detected, the better an individual's chances for survival. Adolescents who are at risk but have not been tested can be informed about the benefits of early detection and health monitoring in order to assist them in making their decision about HIV testing.

The third factor contains items which highlight the low priority of HIV testing in the given adolescent's life. These items include statements pertaining to the fact that the adolescent had more important things to worry about, and that the adolescent was so sure about his or her serostatus that HIV testing was not necessary. Concerning this low priority item, it is important to note that some youth may be in unstable situations where day-to-day survival is their first priority. Clearly, a youth who is in a compromised situation may not be ready to obtain HIV testing. For these youth, HIV testing is clearly a low priority. Consequently, it is important to be sensitive to the psychological state of a youth before recommending HIV testing. Furthermore, regarding the belief that HIV testing is not necessary, while many youth might not need to get tested because they are not at risk for HIV, many other youth may not have adequate information about HIV and may believe that they are not at risk, when this is not the case.

When interpreting the results of this study, it is important to realize several limitations. First, the majority of the sample was obtained at a conference for gay, lesbian, bisexual and transgendered youth. Youth attending this conference are clearly a biased sample, both because they are more likely to be out and because they are more likely to be in leadership roles. Therefore, there is a possibility that these adolescents' reports underestimate frequencies of unprotected sex and overestimate rates of HIV testing in gay, lesbian, and bisexual adolescents. Previous studies done with this population in other regions of the country have clearly found higher rates of unprotected sex and other risk acts. Because this is the first known study done in the South, it is unclear whether lower rates of these risk behaviors are the result of the region in which this study was conducted, the fact that some of these youth were from rural as opposed to metropolitan areas, or the fact that the majority of these youth were recruited at a leadership conference attended in part by peer educators with a higher degree of involvement in the gay, lesbian, bisexual, and transgendered community. On the other hand, despite the fact that some of these adolescents are leaders in their community and that adolescents in other regions of the country report more risk behaviors, rates of unprotected sex and other risk behaviors are high and rates of testing are relatively low. If these adolescents are leaders in their community, what do their counterparts who are not leaders look like? Second, and related to this point, it is important to realize that this sample was collected from two different sources, a leadership conference and a local community center. While ideally individuals from these two recruitment sites could be compared, this was not possible due to the small number of youth recruited from the community center (n = 14). Although direct comparison was not possible, we ran many of the key analyses without these fourteen individuals and found that results were very similar.

Third, it is important to note the diversity of the sample. While we feel that it is important to include diverse individuals in this sample in order to represent the many faces of gay, lesbian, bisexual, and transgendered youth, it is important to note that some of these groups could not be adequately compared due to small sample sizes. For example, when asked to choose between gay, lesbian, and bisexual, a few youth wrote in queer as their sexual identity. Although these individuals could have been grouped into existing categories on the basis of their sexual behavior, we felt that it was important to preserve this queer identity as reported by the youth. Queer is an important emergent identity that has been rarely scientifically examined in the context of youth. Future studies should include this as a category of sexual identity since some youth clearly prefer to be identified in this more inclusive category of sexual identity. In addition, we chose to keep individuals who identified as transgendered in the analyses, although this subsample was also small and could not be looked at separately. We chose to include these youth both because they are a part of the gay, lesbian, bisexual, and transgendered community, and because these youth are at risk for HIV just like their gay, lesbian, and bisexual counterparts. Further research needs to look at a larger sample of transgenedered youth, who have been marginalized and excluded from past research. Overall, the diversity of sexual identity continues to be a complicated issue. Future research should address differences between individuals who identify as gay, lesbian, bisexual, transgendered, and queer, including larger samples of each. Finally, when interpreting these results, one should also realize that this sample was collected in the South and since previous literature has shown regional differences on some of the variables measured, these findings should be generalized with caution.

In conclusion, this exploratory analysis highlights the importance of promoting HIV testing among gay, lesbian, and bisexual adolescents. Additionally, differences between adolescents who obtain an HIV test and those who do not are illuminated. Further research should continue to explore these issues so as to arrive at a more comprehensive understanding of how best to facilitate these adolescents in obtaining HIV testing and ensure that they are educated and comfortable when doing so.

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Manuscript accepted January 26, 2000

Shira Maguen and Lisa Armistead Georgia State University

The authors wish to acknowledge the contributions of Seth Kalichman, Ph.D., whose assistance was important to the collection of these data.

Address correspondence to Shira Maguen, Dept. of Psychology, Georgia State University, Urban Life Building, Atlanta, GA 30303: e-mail: [e-mail].