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82 - Sex, Gender & Cognitive Health

Confidence in Sexual Health Communication by Gender Identity and Sexual Orientation Among College Students

By Stacey B. Griner, PhD, MPH, CPH; Alexandra N. Farris, MPH, CPH; Kaeli C. Johnson, MS; Idara N. Akpan, MPH, CPH; Sarah Alkhatib, MPH; Ann T. Chirayil, MS; Holly N. Dewitt, JD, MS, MBA; and Malinee Neelamegam, PhD, MPH, CPH

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Citation

Griner S, Farris A, Johnsohn K, Akpan I, Alkhatib S, Chirayil A, Dewitt H, Neelamegam M. Confidence in sexual health communication by gender identity and sexual orientation among college students. HPHR. 2024;82. https://doi.org/10.54111/0001/DDDD7

Confidence in Sexual Health Communication by Gender Identity and Sexual Orientation Among College Students​

Abstract

Introduction

College-aged individuals are more likely to engage in behaviors associated with negative health outcomes, such as inconsistent condom use and having multiple concurrent sexual partners. Communication about sexual health topics with partners has been shown to predict safer sex practices in heterosexual students, yet few studies have examined sexual health communication skills by other demographic factors. This study examined differences in sexual health communication confidence among college students by gender identity and sexual orientation.

Methods

Data were collected via an online survey at a large southeastern university (n=812). Items assessing confidence in communicating with sexual partners regarding seven topics, including condom use, sexually transmitted infections (STIs), and unplanned pregnancies, were analyzed. Kruskal-Wallis tests and post-hoc Mann-Whitney tests with Bonferroni adjustment were conducted.

Results

Significant differences in confidence were found across gender identity and talking about what they want during sex (p=0.031) and STIs (p=0.007) and across sexual orientation and talking about sex with partners (p=0.002), saying no to sex (p=0.010), and talking about what they want during sex (p=0.031).

Discussion

Higher education institutions should emphasize communication skills when providing sexual health information and education to students, specifically regarding STI screening and prevention, consent communication, and discussions about sexual pleasure with partners. Furthermore, sexual health information should be tailored based on gender identity and sexual orientation to improve communication confidence between partners.

Conclusion

These results suggest that there are specific areas of communication to be addressed in sexual health programming on college campuses. Future studies should examine the qualitative differences in communication and the specific barriers and facilitators to each topic.

Introduction

Compared to other age groups across the life course, college-aged individuals (18-24) report high rates of sexual behaviors associated with negative health outcomes, such as inconsistent condom use and multiple sexual partners.1 Despite comprising only a quarter of the sexually active population, individuals aged 18 to 24 account for more than half of sexually transmitted infections (STIs) annually.2 Moreover, the 18 to 24-year-old age group reports high rates of unintended pregnancies, highlighting the critical need for prevention behaviors as a national public health concern.3

Communication between partners regarding sexual health topics, such as condom use, is one prevention method that has been shown to improve health behaviors, such as contraceptive and condom use, and improve the overall relationship and sexual satisfaction.4 While the role of between-partner communication in predicting safer sex behaviors among heterosexual students is widely acknowledged,5 few studies have explored individuals’ confidence in discussing specific sexual health topics and the potential influence of sociodemographic factors on sexual health communication.

Gender differences exist in communication roles regarding sexual activities, with men viewed as the ones who initiate sexual activity and women regarded as the ones responsible for responding to the initiation of sexual activity.6,7 However, when examining communication about other sexual health topics, studies have not shown a consistent trend in gender differences. While some studies have revealed similarities among men and women with regards to sexual communication8 and the perception of sexual health topics as difficult to discuss with partners,9 other studies have indicated that women are more likely to communicate sexual health topics with their partners than men,10,11 and still other studies have publicized that men are more confident and efficacious in their sexual health communication with partners,12 including communication about condom use and HIV prevention.11

Overall, the health communication literature typically defines gender identity as binary (men and women), excluding transgender and gender-diverse individuals. Although very little research has been conducted on sexual health communication practices among transgender college students,13 research of transgender adults has indicated the disclosure of transgender status is the primary reason communication about sexual health topics with partners is avoided.14,15 This suggests gender identity may play an important role in interpersonal communication about sexual health topics and warrants further exploration.

While gender is an important factor to consider, studies also suggest an interaction between gender identity and the gender of partners, as communication often varies in relation to these two factors.16 This indicates that communication styles and confidence may be influenced by sexual orientation. For example, messages about sexual behaviors may differ based on the gender of the partner communicating and the gender of the partner receiving the information.17 More specifically, women in lesbian relationships often have strong communication skills and behaviors regarding their sex life compared to women in heterosexual relationships.16 Others have noted differences in how both male and female college students frame their communication about unwanted sex differently depending on their sexual orientation.18 Overall, similar to gender identity, previous studies do not describe a clear, consistent direction in sexual health communication confidence by sexual orientation, as these variables are often related to other factors such as relationship status and satisfaction.19 This inconsistency across research studies reveals the importance of further investigation regarding sexual orientation as a mediating factor in sexual health communication.

As described above, there is a dearth in the health communication literature on the perceived confidence in sexual health communication between partners. Confidence and self-efficacy are important considerations, as these factors can influence behaviors.20 In studies with college students, high self-efficacy in sexual consent communication was associated with higher odds of discussing other sexual health topics,11, but confidence in communication about other sexual health topics, such as sexual pleasure and desire, is understudied particularly among sexual minority individuals. To address this gap, the present study explored confidence in sexual health communication by gender identity and sexual orientation among college students.

Methods

To explore sexual health communication confidence among college students, data were collected via convenience sampling through the student organization portal of a large southeastern university. Inclusion criteria to participate in this study were: (1) current enrollment in the specified college and (2) over the age of 18 years old. The survey was distributed to a total of 803 student organizations via the portal. During administration, 1,212 students began the survey, and 1,195 students completed the survey. However, 80 observations were not included due to missing responses for gender identity, 21 observations were missing other demographic variables, and 282 missing communication confidence questions; thus, the final analytic sample size was 812 students.

Measures

Demographics measured included gender identity, sexual orientation, relationship status, sexual activity, age, race, ethnicity, and year in school. Gender identity was measured with an item asking, “How do you identify your gender?” Response options were man, woman, transgender (assigned male at birth), transgender (assigned female at birth), and another identity with a write-in option. However, due to a small number of students identifying as transgender, the last three categories were combined into a gender-diverse category. For the item measuring sexual orientation, participants were given response options of straight/heterosexual, gay, lesbian, bisexual, or another identity with a write-in option. Relationship status included response options of single, partnered but not living together, partnered and living together, married or civil union, and other. Sexual activity was measured by asking, “Who are you currently sexually active with? This means vaginal, anal, oral sex, or mutual masturbation. Check all that apply.” Response options included: Not sexually active, steady partner (monogamous relationship), steady partner (open relationship), more than one steady partner, only casual partners, only anonymous partners, and something else with a write-in option. Year in school ranged from freshman to graduate level. Race was measured by response options of Black, Asian or Pacific Islander, Native American, white, multiracial, or another identity; ethnicity included response options of Hispanic/Latino, not Hispanic/Latino, and other.

Items assessing communication confidence with sexual partners regarding seven topics were analyzed. Item stem was “How confident do you think college students feel about: Talking to their sexual partners about sex?; Saying no to sex with their partner?; Talking to their partners about what they want during sex?; Talking to their partners about what they don’t want during sex?; Talking to their partners about using condoms?; Talking to their partners about sexually transmitted infections?; Talking to their partners about unplanned pregnancy?” Response options for these items were measured using a five-point Likert scale, ranging from not at all confident to very confident.

Analysis

Frequencies were conducted for all demographic variables. Bivariate statistics were used to describe the association between communication confidence and gender identity, sexual orientation, and relationship status, respectively. Due to the small number of responses by some groups, Kruskal-Wallis tests were conducted to determine independence of demographics and communication confidence. Post-hoc Mann-Whitney tests were conducted to evaluate pairwise differences among the groups, controlling for Type I error across tests by using the Bonferroni approach. Adjusted p values for each analysis indicating significance are reported. All analyses were performed in SPSS.

Results

Overall, the majority of study participants (n=812) identified as women (72%), heterosexual (84%), partnered and not living together (36%), were in a monogamous relationship (65%), white (67%), and enrolled in a graduate program (30%). Over 28% of students were aged 25 or older.

Table 1: Sample Demographics for the Total Sample of College Students (n=812)
Table 1
*Eight participants missing response for age

The majority of students in this sample reported feeling Not Very Confident, Neutral, or Confident about sexual health communication with their partner. Most students felt Confident in taking to their partners about sex (43%) and about condom use (43%). Students felt Not Very Confident in talking to their partners about saying no to sex (36%), what they want during sex (36%), what they do not want during sex (34%), STIs (35%), and unintended pregnancies (34%).

Table 2: Communication Confidence by Topic among the Sample of College Students (n=812)
Table 2: Communication Confidence by Topic among the Sample of College Students (n=812)

Gender Identity

Kruskal Wallis tests showed differences in communication confidence by gender identity with talking to partners about what they want during sex (Kruskal Wallis [KW], X2 = 6.94, df = 2, p = 0.031) and talking to partners about STIs (KW, X2 = 9.93, df = 2, p = 0.007). The results of the post-hoc Mann-Whitney tests with Bonferroni Adjustment (adjusted p value <0.017) found that men (p = 0.004) reported significantly higher confidence in talking to partners about STIs than women. However, no significant differences were found in communication confidence between men and gender diverse people (p = 0.041) or women and gender diverse people (p = 0.497). The five remaining topics of communication were not significantly different by gender identity.

Table 3: Communication Confidence by Gender Identity for a Sample of College Students, N (%)
Table 3: Communication
* Kruskal-Wallis Test significant at <0.05; + Significant pairwise difference (Mann-Whitney Test) at p<0.017

Sexual Orientation

Significant differences in confidence were found in the topics of talking about sex with partners (KW, X2 = 17.56, df = 4, p = 0.002), saying no to sex with partners (KW, X2 = 13.17, df = 4, p = 0.010), and telling partners what they want during sex (KW, X2 = 10.64, df = 4, p = 0.031). Ten post-hoc Mann-Whitney tests with Bonferroni Adjustment (adjusted p value <0.005) were conducted and found that students who identified as straight/heterosexual were more confident in talking to partners about sex (p < 0.000) and saying no to sex with partners (p = 0.001) than those in the “another identity” sexual orientation group. Additionally, the students who identified as gay (p = 0.003) were more confident in saying no to sex with partners than students in the “another identity” category. However, telling partners what they want during sex was not significantly different between groups, and no other significant pairwise comparisons were found among sexual orientation.

Table 4: Communication Confidence by Sexual Orientation Among a Sample of College Students, N (%)
Table 4: Communication Confidence by Sexual Orientation among a Sample of College Students, N (%)
* Kruskal-Wallis Test significant at <0.05; + Significant pairwise difference (Mann-Whitney Test) at p<0.017

Discussion

This study presented an analysis of sexual health communication confidence in college students and explored confidence levels by gender identity and sexual orientation. The findings contribute to health communication literature by reporting the differences in communication confidence across two sociodemographic factors that have been historically understudied. Confidence levels discussing sexual pleasure/desires (what they want during sex) and STIs significantly differed by gender identity, indicating communication patterns may have an impact on STI prevention specifically among those identifying outside of the gender binary. Across sexual orientation, confidence levels differed in talking about sex with partners, saying no to sex, and talking about sexual pleasure/desires. Those identifying their sexual orientation as “another identity” were less confident in saying no to sex than those who were heterosexual or gay, indicating an area for further exploration. This research highlights specific subgroups within the college population that could benefit from sexual health communication interventions.

Gender identity was associated with differences in talking to partners about what they want during sex and talking to partners about STIs. However, no significant pairwise comparisons were found for talking to partners about what they want during sex. In this sample, college men were more confident than women in talking to partners about STIs. This aligns with previous research indicating that college women were less likely to discuss condom use and HIV risk reduction compared to men.5 However, findings from this study contrast with previous research showing similarities between men and women in communication with sexual partners and topics that are perceived to be too taboo to discuss with partners.21 Among transgender individuals, sexual health communication is perceived as complicated due to the need to be “outed” by a discussion of their transgender status when communicating about sexual behaviors.14

Our results suggest a need to better understand the gendered nature of sexual health communication patterns and behaviors across the spectrum of gender identities among college students. Due to the social construction of gender, future analyses may benefit from exploring complex interactions of the interpersonal, relational, community, and social level factors influencing an individual’s communication behavior.

Sexual orientation was associated with differences in confidence levels in talking about sex with partners, saying no to sex, and talking about what they want during sex. Confidence in talking about sex with partners was significantly higher among heterosexual students when compared to the “other” sexual orientation category. Additionally, confidence in saying no to sex was higher among both heterosexual students and gay students when compared to the “other” category. A majority of those in the “other” category identify as pansexual or queer, and limited research exists regarding sexual communication methods among this population. Interestingly, both heterosexual couples and gay men facilitate sexual conversations by using humor, which may be a factor to consider when discussing sexual communications with students in the “another identity” category.

Future research should consider the heteronormative and gendered conceptualization of sexual health communication among college students and strive to re-conceptualize this definition with students who identify as pansexual, queer, and questioning.

This study contributes an interesting public health perspective towards existing communication literature by focusing on the impact of demographic characteristics on sexual health communication confidence. Future sexual health communication research should consider campus-based student health clinics and other key health agents for health promotion on college campuses, including wellness centers, resident assistants, and peer health educators – as resources that could provide information and skill-building regarding the importance of sexual health communication to students. With the knowledge of specific at-risk subgroups, health promotion professionals and college health providers are uniquely positioned to provide education to college-aged individuals on the importance of adequate sexual health communication skills as a method of prevention for adverse sexual and reproductive health outcomes.24

In addition to campus-based resources, future research should frame sexual health communication with partners as an individual behavior that is greatly influenced by dyadic relationships, other interpersonal factors, and macro-level factors (e.g., stigma in communities). This dynamic interplay counteracts the way in which communication is typically viewed: as an individual behavior. However, results from this study indicate that it is important to consider interpersonal relationships and the influence that gender identity and sexual orientation may have on communication behavior.

Findings should be considered in the context of the study’s limitations. Data used in this analysis were cross-sectional, and therefore represent one point in time and cannot identify causality. Additionally, these data were self-reported, which is subject to social desirability bias. Although participants were tasked with reporting their confidence in communication, this measurement was not objectively measured for accuracy. The high number of graduate students who responded may have also influenced this study, as they are not representative of the traditional college-age population. The authors understand that gender identity and sexual orientation exist on a spectrum rather than being described by specific categories. For the quantitative analyses in this paper, categories were used; future studies should consider more flexible methods to describe these constructs.

Conclusion

In summary, this study found that gender identity and sexual orientation impact sexual health communication confidence among college students. Higher education institutions are prime targets for intervention and are essential in providing resources related to sexual health communication to improve sexual health equity among this population. When providing sexual health information and education to students, colleges should emphasize communication information and skills, specifically regarding sex and condom negotiation, STI screening and prevention, and sexual desires. Moreover, to improve health communication, sexual health information should be tailored based on gender identity and sexual orientation to improve communication confidence and skills among all college students, including those who do not identify within a binary gender category.

Disclosure Statement

The authors have no relevant financial disclosures or conflicts of interest

References

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About the Author

Stacey B. Griner, PhD, MPH, CPH

Dr. Stacey Griner is an Assistant Professor in the School of Public Health at the University of North Texas Health Science Center.

Alexandra N. Farris, MPH, CPH

Alexandra Farris is a Project Coordinator in the School of Public Health at the University of North Texas Health Science Center.

Kaeli C. Johnson, MS

Kaeli Johnson is a PhD student and graduate research assistant in the School of Public Health at the University of North Texas Health Science Center.

Idara N. Akpan, MPH, CPH

Idara Akpan is a PhD candidate and graduate research assistant in the School of Public Health at the University of North Texas Health Science Center.

Sarah Alkhatib, MPH

Sarah Alkhatib is a PhD student and graduate research assistant in the School of Public Health at the University of North Texas Health Science Center.

Ann T. Chirayil, MS

Ann Chirayil is an OMS-II student in the Texas College of Osteopathic Medicine at the University of North Texas Health Science Center.

Holly N. Dewitt, JD, MS, MBA

Holly Dewitt is an OMS-II student in the Texas College of Osteopathic Medicine at the University of North Texas Health Science Center.

Malinee Neelamegam, PhD, MPH, CPH

Dr. Malinee Neelamegam is an Assistant Professor in the School of Public Health at the University of North Texas Health Science Center.

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