Introduction The Influence of Heteronormativity on Sexual Health Disparities

CHAPTER 1: INTRODUCTION

The World Health Organization (WHO; 2019) defines comprehensive sexual health as

well-being across physical, mental, and social domains. With that, comprehensive sexual health

“requires a positive and respectful approach to sexuality and sexual relationships, as well as the

possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination

and violence” (WHO, 2019, p.1). However, to date, much of the sexual health research has

focused narrowly on the absence of disease and unintended pregnancy (i.e., physical domains)

rather than all of the other comprehensive aspects described above (WHO, 2019; Zielinski,

2013). Accordingly, most of the sexual health information we know is about disease and

unintended pregnancy (Zielinski, 2013). For example, although global data is limited, when

compared to other industrialized countries (i.e., France, Germany, Netherlands) the United States

is one of the least sexually healthy (Advocates for Youth, n.d.). In 2009, the United States had

HIV/AIDS diagnoses that were six times higher than those in Germany, three times higher than

those in the Netherlands, and one and a half times higher than those in France (Advocates for

Youth, n.d.). Further, best estimates suggest that approximately 50% of all sexually active people

in the United States will acquire some type of sexually transmitted infection (STI) by the age of

25, which is significantly higher than other industrialized counties (ASHA, 2019). For example,

estimates suggest that in the United States there were more than 1.7 million Chlamydia

diagnoses in 2017 (CDC, 2018). This is approximately four times higher than the number of

Chlamydia diagnoses in the EU/EEA in 2016 (ECDC, 2016). Additionally, the United States has

more unintended pregnancies than any other industrialized country (Advocates for Youth, n.d.;

Guttmacher Institute, 2019). For example, in 2006 the US had more than four times the number

of teenage pregnancies than the Netherlands (Advocates for Youth, n.d.). Taken together, and

compared to other industrialized counties, the United States appears to host poorer levels of

physical sexual health, thereby, warranting further examination of this public health concern.

Importantly, not all individuals in the United States are at equal risk to experience

negative sexual health outcomes. Specifically, individuals who have at least one minority status

(e.g., women, racial or ethnic minorities, LGBTQ+, individuals with low SES) are more likely to

experience poorer sexual health outcomes when compared to the majority (CDC, 2017b;

ODPHP, 2019). These are known as sexual health disparities (CDC, 2017; ODPHP, 2019). Two

of the most vulnerable groups that experience sexual health disparities are queer individuals

(LGBTQ+; National LGBT Health Education Center, 2016) and women (CDC, 2011).

Additionally, queer women (also referred to as women who have sex with other women; WSW;

CDC, 2015) are significantly more likely to be diagnosed with Human Papilloma Virus (CDC,

2015) and Herpes Simplex Virus (HSV-2) when compared to women who engage in different

gender sexual relationships (CDC, 2015). Finally, approximately 1.1 million cases of chlamydia

were diagnosed in women (regardless of their sexual identity) in 2017 (CDC, 2018). Thus,

sexual health disparities among these groups are evident.

Because research has examined health disparities as the presence of disease diagnosis (as

listed above; Zielinski, 2013), the primary disparities we know about are the presence and

absence of disease. By minimizing sexual health to disease diagnoses, the field has overlooked

myriad ways that indicate someone’s sexual health, foregoing further insight into other potential

sexual health disparities (Zielinski, 2013). Although there is not much research on other

indicators of sexual health (e.g., sexual pleasure such as orgasm, sexual functioning, feelings of

safety, feelings of sexual anxiety or depression), research does broadly suggest that disparities

exist across these indicators. For example, there are significant gaps in rates of orgasm between

heterosexual men and women when engaging in penetrative sexual intercourse (Kinsey Institute,

2019). Additionally, heterosexual women are significantly more likely than heterosexual men to

experience shame, depression, and guilt about their sexuality after engaging in casual sexual

behavior with another person (Allyn, 2000; Garcia, Reiber, Massey, & Merriwether, 2012).

Queer women are more likely than their heterosexual counterparts to experience sexual assault,

rape, or violence (i.e., 61% of bisexual women, 44% of lesbian women compared to 35% of

heterosexual women; Human Rights Campaign, 2019) leading to lower perceptions of safety.

Therefore, by attending to these already conceptualized, yet understudied, comprehensive

domains of what sexual health is, we may be able to gain more insight into sexual health

disparities in vulnerable groups, such as queer individuals and women.

Determinants of Health and Sexual Health Disparities

Another important line of inquiry focuses on identifying the factors and processes

involved in the creation and persistence of sexual health disparities. The Determinants of Health

Framework (DoH), created by the World Health Organization, examines how policymaking,

social factors, health services, individual behaviors, and biology/genetic makeup lead to health

disparities (ODPHP, 2019). Importantly, these determinants examine more than just disease

because they examine how social factors can contribute to who is healthy and who is not. By

taking a DoH perspective toward sexual health (WHO, 2010b), we can examine sexual health

disparities beyond medical diagnoses of STIs and unintended pregnancies. For example, a queer

person may not have an STI (which traditionally would be perceived as sexually healthy), but

may experience cultural discrimination because of their sexual identity (Meyer, 2003). The

discrimination they experience may be internalized, leading to poor physical and mental health

outcomes (Meyer, 2003). Thus, even though the individual may be physically healthy (i.e. they

do not have any STIs), the experience of cultural discrimination still contributes to disparate

health outcomes (WHO, 2019). Accordingly, the DoH framework helps to broaden the analysis

of sexual health disparities and provides a deeper examination of the social factors that

contribute to these disparities.

A particularly understudied contributor to sexual health disparities is culture. Culture

includes the beliefs, values, systems, and practices in which someone develops, that are socially

constructed and enforced (Ratcliff, 2017). More specifically, scant research has examined the

impact of heteronormativity on comprehensive sexual health disparities. Heteronormativity is a

cultural norm which privileges individuals who are heterosexual, monogamous, and only have

sex inside the confines of marriage (van Eeden-Moorefield, 2018). This norm started from the

Puritan era push for sexual morality which sought to suppress sexual desire outside of marriage

and limited sexual interactions to those for the purposes of reproduction only (Easton & Hardy,

2009; D’Emilio & Freedman, 2012). Messages about sexuality included demonizing

masturbation, same-gender relationships, and shaming forms of contraception and birth control

(D’Emilio & Freedman, 2012).

Importantly, heteronormativity does not appear to have a direct effect on health

outcomes, but instead, it exudes an indirect effect on health through its influences on the

processes occurring between systems (e.g., practitioner presumptions of heterosexuality;

Utamsingh, Richman, Martin, Lattanner, & Chaikind, 2015), between people (e.g., engaging in

safe sex behaviors; Baptiste-Roberts, Oranuba, Werts, & Edwards, 2017) and/or internally (e.g.,

feelings of sexual communication self-efficacy; Meyer, 2003; Quinn-Nilas, et al., 2016). For

example, sexuality education often takes a heteronormative perspective and excludes important

and affirming information for queer individuals about sexual health, which leaves queer

individuals at higher risk for health disparities (Baptiste-Roberts, et al., 2017). Additionally,

cultural heteronormative scripts suggest that women should be sexually ambivalent whereas men

should be sexually aggressive, contributing to a gendered power dynamic where women’s needs

are second to men’s in heterosexual sexual encounters (Currier, 2013). Often, these

heteronormative structures and scripts create challenges for queer individuals and women to

advocate for their sexual health and limits their knowledge of how to engage in processes that

may benefit sexual health outcomes (such as using barrier methods in sexual intercourse;

Marazzo, Coffey, & Bingham, 2005; Lehmiller, VanderDrift, & Kelly, 2014; Quinn-Nilas et al.,

2016).

Statement of Purpose

The first aim of the program of research is to create a more comprehensive understanding

of sexual health disparities. Current research has taken a disease-centered approach to sexual

health, which only provides a restricted understanding of sexual health disparities (ODPHP,

2019; Zielinski, 2013). Importantly, there is evidence that sexual health disparities span more

than just the absence of disease and unintended pregnancy, but these indicators are understudied

(e.g., Allyn, 2000; Human Rights Campaign, 2019; Kinsey Institute, 2019; Zielinski, 2013). By

employing a comprehensive definition of sexual health and expanding sexual health

measurement to more than just disease and unintended pregnancy (i.e., sexual functioning,

sexual pleasure, safety, depression, anxiety, and perceptions of sexual health), we may gain more

comprehensive insight into health disparities.

The second aim of this program of research is to examine heteronormativity’s indirect

influence on systematic, interpersonal, and individual sexual health processes that may

contribute to disparities. Although some research has examined the role that cultural factors,

such as heteronormativity, have on health (e.g., Baptiste-Roberts, et al., 2017; Meyer, 2003), to

our knowledge, no research has examined how heteronormativity acts as a moderating influence

on sexual health disparities in vulnerable populations. Due to their particularly vulnerable

intersections, we focus specifically on queer women (in this program of research-- LGB+) and

heterosexual women. Understanding how culture indirectly influences sexual health disparities

through interpersonal processes may be a step toward creating more equitable sexual health

outcomes for queer and heterosexual women (ODPHP, 2019). Therefore, the purpose of this

program of research is to model how heteronormativity influences interpersonal and individual

processes which may contribute to sexual health disparities across women.

This program of research was split into three manuscripts. The first manuscript created

and validated a comprehensive measure of sexual health using a multi-group confirmatory factor

analysis (CFA). This latent measurement was then utilized in manuscript two and three. The

second manuscript examined how heteronormativity influenced sexual communication

selfefficacy and safe sex behaviors in queer women and how those contributed to comprehensive

sexual health outcomes. Similarly, the third manuscript examined sexual health communication

self-efficacy, safe sex behaviors, and comprehensive sexual health outcomes in heterosexual

women. Together, these manuscripts examined how individual, interpersonal, and cultural

processes interact and contribute to sexual health disparities. Of note, I used the term queer as an

umbrella term to refer to women who are attracted to other women regardless of their

selfidentified sexual orientation (e.g., bisexual, lesbian, pansexual). Because sexual orientation is

comprised of attraction, behavior, and identity, and these may not always align (Vrangalova &

Savin-Williams, 2012), the use of queer is a more inclusive approach to capturing a range of

queerness among women. Each manuscript is outlined below.

Manuscript 1: Creating a Comprehensive Measure of Sexual Health

As stated previously, to date, much of the sexual health research has focused narrowly on

the absence of disease and unintended pregnancy (i.e., physical domains of sexual health).

However, the World Health Organization (WHO; 2019) defines comprehensive sexual health as

well-being across physical, mental, and social domains. Few studies have attempted to create a

comprehensive measure of sexual health and incorporate it into their research. Therefore, most of

the sexual health information we know is about disease and unintended pregnancy (Zielinski,

2013). This perpetuates a narrow perspective of what it means to be sexually healthy, who is

sexually healthy, and processes that contribute to comprehensive sexual health.

When sexual health is reduced to the absence/presence of negative outcomes it reinforces

a stigmatizing and reductionist perspective of sexual health (WHO, 2010a). When positive and

comprehensive indicators of sexual health (such as categorizing orgasm as being sexually

healthy) are included, we promote positive rhetoric and this has potential to slowly change

stigmatizing cultural messages (Ott, Millstein, Ofner, & Halpern-Felsher, 2006). Further, by

expanding the conceptualization of sexual health, it creates the ability to ask new and innovative

questions that a reductionist conceptualization would overlook. These questions may be more

culturally relevant, inclusive, and comprehensive. For example, by including indicators of what

it means to be mentally sexually healthy (i.e., positive perceptions about one’s sexual identity,

low levels of sexual anxiety) we can ask questions about how cultural discrimination of some

groups, such as sexual minorities, may contribute to the sexual health disparities these groups

face (Hatzenbuehler, 2010).

Thus, the purpose of this study was to create and validate a comprehensive measure of

sexual health through a multi-group confirmatory factor analysis. As informed by the WHO’s

(2019) definition of sexual health, this measure included indicators of anxiety, depression,

perceived physical sexual health, safety, sexual functioning, sexual satisfaction and pleasure, and

STIs/HIV. Once validated, this measure was used in manuscripts two and three.

Manuscript 2: The Impact of Heteronormativity on Queer Women’s Communication

Processes and Comprehensive Sexual Health

For queer individuals, heteronormative sexual scripts are often negative (e.g.,

homophobic; Meyer, 2003) or simply lacking information important for these groups (i.e.

noninclusive sex education; Baptiste-Roberts, et al., 2017). For example, many queer individuals

report never having learned about sex outside of heterosexual relationships throughout their

sexuality education (Baptiste-Roberts et al., 2017). GLSEN (2015) states that omitting queer

sexual health information in sexuality education puts queer individuals at greater risk for

negative sexual health outcomes. Further, queer women are often perceived to be at less risk for

STIs and unintended pregnancy (Baptiste-Roberts, et al., 2017; Power, McNair & Carr, 2009),

and therefore, sexual heath programming frequently ignores them (Baptiste-Roberts, et al.,

2017). Thus, many queer women are unaware of their sexual risk, and report under-using safe

sex practices, such as barrier methods (Baptiste-Roberts, et al., 2017).

Thus, heteronormativity indirectly influences queer women’s engagement in safe sex

behaviors due to inaccurate risk perceptions. Importantly, sexual health communication has been

found to improve sexual health outcomes (Planned Parenthood, 2019; Quinn-Nilas et al., 2016),

and therefore, may be an individual mechanism through which queer women’s sexual health can

be improved. Taken together, the purpose of this study was to model how sexual health

communication self-efficacy can promote more safe-sex behaviors among queer women, and

ultimately lead to better comprehensive sexual health outcomes.

Manuscript 3: Heteronormativity, Sexual Health Communication, and Comprehensive

Sexual Health in Heterosexual Women

For heterosexual men and women, gender socialization often perpetuates power

dynamics (i.e., that men grow up to be strong and aggressive, and women grow up to be quiet

and submissive; Lefkowitz, Shearer, Gillen & Espinosa-Hernandez, 2014; Masters, Casey, Wells,

& Morrison, 2013). Specifically, heterosexual scripts promote hypermasculinity among men

(Ward, 2005) and femininity among women (D’Emilio & Freedman, 2012).

Hypermasculinity is defined as those masculine scripts that promote dominance, hypersexuality,

assume men always want to have sex, and that men are sexually skilled (Masters et al., 2013;

Ward, 2005). Femininity is characterized as not desiring sex, not knowing very much about sex,

and perpetuates higher cultural value of women who have less sexual experience (Masters et al.,

2013). These heterosexual scripts directly promote power imbalances when it comes to sex and

sexual decision making (Rinaldi-Miles, Quick, & LaVoie, 2014). With that, research suggests

that safe sex behaviors are often under-utilized in heterosexual sexual encounters because

women are more likely to follow male condom use preferences (i.e., men report often disliking

the use of condoms; Cook-Lindsay, 2013) and less likely to discuss their safe sex preferences

(Rinaldi-Miles, et al., 2014). Because feminine scripts suggest that women should not

understand their sexuality and should be sexually inexperienced, this promotes silence about

sexuality leading to less communication. Therefore, heteronormativity influences sexual

communication processes, thereby indirectly contributing to health disparities in heterosexual

women. Taken together, the purpose of this study was to examine how heteronormativity

influences sexual health communication, safe-sex behaviors, and comprehensive sexual health

outcomes in heterosexual women

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CHAPTER 2: CREATING A COMPREHENSIVE MEASURE OF SEXUAL HEALTH

Human sexuality is shaped and understood through a series of individual behaviors,

interpersonal exchanges, and social constructions-- biology, mental health, and social exchanges

all contribute to human sexuality and sexual experiences (WHO, 2010). In other words, human

sexuality is more than simply sexual behavior-- it encompasses an entire person interacting with

others in context. Therefore, it makes sense that in order to best understand sexual health we

must conceptualize (and measure) it comprehensively. The World Health Organization (WHO;

2019) defines comprehensive sexual health as the level of well-being across physical, mental,

and social domains. They suggest that comprehensive sexual health “requires a positive and

respectful approach to sexuality and sexual relationships, as well as the possibility of having

pleasurable and safe sexual experiences, free of coercion, discrimination, and violence” (WHO,

2019, p.1). Many of the leading national organizations consider this the standard when defining

sexual health (ASHA, 2020; CDC, 2020; WHO, 2019). However, to date, much of the extant

literature has focused primarily on only the physical domain, more generally, and on the

presence/absence of disease (e.g., Everett, 2013; Weitzman et al., 2019) and unintended

pregnancy (e.g., Finer & Zolna, 2011; Madden et al., 2019), more specifically.

From this limited view focused on physical sexual health, we know that significant health

disparities exist across various parts of the population and particularly among women. For

example, women are more likely than men to contract and experience complications from a

sexually transmitted infection (STI; CDC, 2019). Additionally, in 2011, there were 2.8 million

unintended pregnancies among women in the United States with significant variations among

women based on various intersectional social locations (Guttmacher Institute, 2019). Rates were

highest among low-income women, women between the ages of 18 and 24, women who

cohabited with a partner, and women of color, compared to those who had higher income, were

White, had graduated college, and were married respectively (Guttmacher, 2019). Across these

population based studies, it is clear that disparities exist across different groups of women.

Only recently have studies started to consider and examine the sexual health of queer

women (i.e., an umbrella term for lesbian, bisexual, pansexual, and women who have sex with

other women). This emergent research suggests that cisgender queer women are less likely to use

protective barriers when engaging in same-gender sexual behavior, putting them at greater risk

for STI transmission. For example, rates of Human Papilloma Virus (HPV) and Herpes Simplex

Virus 2 (HSV2) are particularly high in cisgender queer female populations (e.g., 36% of women

who reported a same gender partner in their lifetime have HSV 2; CDC, 2015). It is also

important to acknowledge that these disparities are even higher among trans* women, regardless

of their sexual orientation (CDC, 2019)

Thus, there appears to be a disconnect between leading definitions of sexual health and

the conceptualizations and measurement strategies of sexual health used in the extant literature.

Importantly, the definition of a construct informs the conceptualization of a construct, which then

informs the later measurement of that construct (Engel & Schutt, 2014). Additionally, when

constructing surveys, it is critical to consider best practices for survey length, time to

completion, and funding, to ensure adequate response rates (Urban & van Eeden-Moorefield,

2018), which may dissuade researchers from attempting to measure complex and comprehensive

constructs. Constructs, such as comprehensive sexual health, may be complex and therefore, it is

critical to include all of the dimensions within conceptualizations to ensure accurate yet,

parsimonious measurement (Engel & Schutt, 2014).

Therefore, the purpose of this study was to create and validate (e.g., construct validity;

Urban & van Eeden-Moorefield, 2018) a comprehensive measure of sexual health for women

that has the potential to add to surveys without overburdening participants by adding too much

length or time (See Figure 2.1). The model was grounded in WHO’s (2019) conceptual

framework of comprehensive sexual health, using a multi-group confirmatory factor analysis

(CFA). Informed by the extant literature, the indicator variables included to ensure the presence

of each of the three domains were: anxiety, depression, perceived sexual health, feelings of

safety, sexual functioning, sexual satisfaction/pleasure, and STIs/HIV. Given the between group

sexual health disparities present among queer and heterosexual women, a multi-group CFA was

conducted to ensure model fit for both groups.

Literature Review

Again, the WHO (2019) defines comprehensive sexual health as “requir[ing] a positive

and respectful approach to sexuality and sexual relationships, as well as the possibility of having

pleasurable and safe sexual experiences, free of coercion, discrimination, and violence” (p.1).

Using this definition and the extant literature, the author identified seven observed variables to

create a latent measure of comprehensive sexual health: anxiety, depression, perceived sexual

health, feelings of safety, sexual functioning, sexual satisfaction/pleasure, and STIs/HIV. All of

these indicators fall under one of the domains of sexual health (i.e., physical, mental, social).

These indicators have all been studied in the sexuality-related literature and therefore, should

work together to measure comprehensive sexual health. These are outlined below.

Physical Domain

Sexual Functioning. Sexual functioning has been widely examined across the extant

sexual health literature (e.g., Stefanou & McCabe, 2012) and has been used as a significant

indicator of sexual health (WHO, 2010). Sexual functioning (and/or sexual dysfunction) has

most often been studied in the context of aging (e.g., Clayton & Harsh, 2016), illness (e.g.,

Boquiren et al., 2016 ), and/or trauma (e.g., DiMauro, Renshaw, & Blais, 2018). For example,

Clayton and Harsh (2016) examined sexual functioning across aging. They stated that across the

life course, women experience multiple biological, mental, and social factors that may impact

their sexual functioning. Specifically, female bodies change due to hormone shifts, pregnancy

and childbirth, medical problems and medication, as well as mental health issues such as

depression. Similarly, WHO (2010), states that sexual functioning is strongly linked to

psychological and social processes that are beyond the scope of the person. Thus, sexual

functioning is a strong predictor of sexual health across diverse contexts and throughout a

woman’s life, suggesting that it would contribute to the measurement of comprehensive sexual

health.

STI/HIV. STI and HIV diagnoses are a traditional indicator of sexual health. In the extant

literature, the absence of disease is indicative of good sexual health, which has led to many

prevention initiatives across the globe (WHO, 2010). For example, the CDC conducts STI and

HIV population based surveillance studies to examine the prevalence and disparities across

diagnoses (e.g., CDC, 2018). Within the literature, STI and HIV diagnoses have most commonly,

been studied within male populations, and specifically in men who have sex with other men due

to high prevalence rates (Beyrer, et al., 2013). Additionally, much of the extant literature that has

examined women, STIs, and HIV examines experiences of women in other countries (e.g., Dude,

2011). Of those that examine HIV and STI rates of women in the United States, many focus on

minoritized populations. For example, Painter, Wingwood, DiClemente, DePadilla, & Simpson-

Robinson (2012) surveyed 848 African American college women about their educational

attainment and STI/HIV risk. Surveys asked about demographic, psychosocial, and behavioral

indicators and also cross-referenced biological vaginal swabs that tested for STIs. They found

that African American women who attended college were 73% less likely to have an STI or HIV

when compared to those who did not. Taken together, STIs and HIV have been vastly explored

across the literature with diverse populations, and should be a good indicator of sexual health.

Mental Domain

Anxiety. Sexual anxiety is defined as discomfort, worry, or anxiety about one’s self

and/or sexuality (Brassard, Dupuy, Bergeron, & Shaver, 2015). Much of the extant sexual health

research has examined the impact of anxiety on sexual functioning and sexual satisfaction (e.g.,

Brassard et al., 2015). For example, Brassard and colleagues (2015) conducted a mediation

analysis which examined the role that sexual anxiety had in women’s sexual functioning and

satisfaction. They surveyed 556 women who had anxious and avoidant attachment styles and

found that women with higher levels of sexual anxiety, and lower levels of sexual self-esteem,

had lower sexual functioning and lower sexual satisfaction. Research also suggests that anxiety

may contribute differently to sexual health outcomes for queer and heterosexual women. Beaber

and Werner (2009) examined the relationship between anxiety and sexual functioning in lesbian

and heterosexual women using online surveys which targeted women with anxiety. They found

that lesbian women reported more sexual satisfaction than heterosexual women (i.e., higher

levels of arousal and higher frequency of orgasms). Contrastingly, heterosexual women with

anxiety experienced lower levels of sexual functioning and sexual satisfaction. Studies such as

these suggest that sexual anxiety is an indicator of sexual health, which supports that it would be

a strong indicator of comprehensive sexual health.

Depression. Much of the extant literature has examined depression as a contributor to

sexual health outcomes. The research suggests that women are more likely than men to

experience depression, which in turn contributes to greater sexual dysfunction (i.e., lubrication,

desire, orgasm; Dobkin, Leiblum, Rosen, Menza & Marin, 2006). Additionally, many of the

medications used to treat depression reduce women’s sexual interest and sexual response

(Dobkin, 2006). Lykins, Janssen, and Graham (2006) examined how anxiety and depression

contributed to college aged women’s sexual excitation and inhibition. They found that most

women were not interested in engaging in sexual behavior when they were anxious or depressed.

In another study on college women with depression, Frolich and Meston (2002) found that

women who had depression were had lower sexual satisfaction, lower arousal, more inhibited

orgasms, and more sexual pain. Additionally, they found that women who were depressed were

more likely to engage in solo masturbation when compared to their non-depressed counterparts.

However, the use of depression as an indicator of sexual health has been underexplored.

For queer and heterosexual women, heteronormative cultural messages that silence and shame

women for their sexuality may contribute to negative mental health outcomes, such as depression

(Easton & Hardy, 2009). Additionally, for queer individuals, cultural discrimination and

homophobia may lead to depression (Meyer, 2003). Thus, depression may be an indicator of

sexual health and therefore, should be included in the comprehensive measurement of it.

Perceived Sexual Health. Perceived sexual health consists of one’s own perception of

how sexually health they are. In the sexual health research, this self-perception of sexual health

as an indicator of sexual health has been underexplored. Hebernick and colleagues (2010)

examined women’s sexual behaviors, relationships, and perceived health status using the

NSSHB national dataset. They found that women who perceived themselves to be more sexually

healthy were more interested in engaging in sex, may have more opportunities to engage in sex,

and may have an easier time engaging in sexual intercourse. Thus, perceptions may be influential

in a woman’s desire and overall, perception of her sexuality. Therefore, perceptions of sexual

health may be a strong indicator of sexual health.

Social Domain

Sexual Satisfaction. Sexual satisfaction has been largely examined in the previous

literature. Specifically, the extant literature has studied individual, interpersonal, and cultural

factors that contribute to sexual satisfaction (e.g., Biss & Horne, 2005) as well as other relational

processes that sexual satisfaction is related to (e.g., relationship satisfaction; Heiman et al.,

2011). Specifically, sexual satisfaction has been found to be a key contributor to overall

wellbeing across the lifespan for women (Woloski-Wruble, Oliel, Leefsma, & Hochner-

Celnikier, 2010). Holmberg, Blair, and Phillips (2010), modeled how sexual satisfaction related

to relationship well-being, mental health, and physical health for women in same-gender vs.

mixedgender relationships. They found that sexual satisfaction was a strong predictor of

relationship well-being and mental health regardless of relationship type. Additionally, sexual

satisfaction may be a sexual health outcome that is influenced by mental health and culture (Biss

& Horne, 2005). Biss and Horne (2005) surveyed 596 queer men and women to understand how

psychological well-being, in the context of a heteronormative culture, influenced sexual

satisfaction. They found that living with a partner, age, internalized homonegativity, and other

relational processes all contributed to sexual satisfaction. Therefore, sexual satisfaction may be

an indicator of comprehensive sexual health and therefore, was included in the model.

Safety. Outside of the sexual assault literature (e.g., Ahrens, Abeling, Ahmad, &

Hinman, 2010), scant sexual health research has examined the role that feeling safe in a sexual

encounter has on women’s sexual health outcomes. Additionally, most of the sexual health

research that examines safety in sexual encounters focuses on safe sex behaviors (e.g., McBride,

& Fortenberry, 2010), rather than feeling safe in the sexual encounters. In other words, this

indicator has been underexplored as an indicator of sexual health in the context of consensual

relationships. However according to the WHO (2019) definition of sexual health, feeling safe is

an important aspect. Thus, theoretically, feelings of safety during a sexual encounter should be a

strong indicator of sexual health, and therefore, it was added to the model.

Summary

In summary, these seven indicators have been used, to some extent, as indicators of

sexual health across the extant sexual health literature. However, no study has examined how

they function together to measure comprehensive sexual health. Importantly, these indicators are

grounded in the WHO (2019) conceptualization of comprehensive sexual health, suggesting

theoretical support. Specifically, they span all sexual health domains, as defined by WHO

(2019), and have all been used to measure sexual health to some extent. Therefore, it is predicted

that these indicators should accurately and comprehensively measure sexual health as a latent

variable.

Methods

Data Collection

Using social media to recruit participants for research has become popular, due to its

ability to reach widespread diverse networks and its ease of online survey dissemination (Urban

& van Eeden-Moorefield, 2018; Gelinas et al., 2017). Also, online surveys have been found to be

a useful methodology when discussing sensitive information, such as questions about sex and

health, because of their enhanced anonymity (i.e., the researcher may never know the identity of

the participant; Lefever, Dal, & Matthaisdottir, 2007). Accordingly, data were collected using a

30-minute online cross-sectional survey created in Qualtrics. The recruitment announcement

(Appendix A) and survey link were posted on the research team members’ personal Facebook

profiles, which asked friends to participate in a survey about sexual health. The announcement

also asked Facebook friends to please share the recruitment announcement on their own

Facebook pages (i.e., convenience/snowball sampling). Facebook has become a popular forum

for survey recruitment because of its widespread use and ability to reach diverse populations

(Pederson & Kurz, 2016). Additionally, studies focused on health have had particular success

recruiting participants through Facebook because of its low cost and ability to reach participants

for follow up questions if necessary (Pederson & Kurz, 2016). Participants who decided to

participate in the survey, clicked the survey link and were redirected to the Qualtrics survey

(Qualtrics, 2020). At the beginning of the survey, participants were required to provide informed

consent (Appendix B) and could only participate if they were 18 years or older. From there, they

were redirected to the survey questions (Appendix C). At the end of the survey, in the Thank

You message (Appendix D), participants were provided the option to enter a raffle to win one of

40 $25 Amazon gift cards. If participants decided that they wanted to participate, they clicked a

link which redirected them to a separate unlinked survey (Appendix E), which asked for their

email address. All identifying information was kept separate from survey responses to ensure

anonymity of survey responses. Participants were only allowed to participate in the survey one

time to ensure data independence. In other words, the survey could not be completed multiple

times from the same IP address (Birnbaum, 2004).

Participants

The sample consisted of a convenience sample of 247 cisgender heterosexual and queer

women. This met power needs for the analysis (.90; G*Power). Participants’ ages ranged from

19 to 82 years old (M = 33.26, SD = 10.27). The majority of the sample self-identified as

heterosexual (76.10%) followed by women who identified as bisexual (9.70%), lesbian (5.70%),

pansexual (4.0%), queer (2.40%), and asexual (2.0%). The majority of the sample was

NonHispanic White (89.10%) followed by Latina or Hispanic (7.30%), East Asian/Asian

American

(2.0%), Native America/Alaska Native (1.20%), South Asian/Indian American (1.20%), Middle

Eastern/Arab American (1.20%), Black or African American (<1.00%), and Hawaiian or Pacific

Islander (<1.00%). The sample was highly educated: 78.90% of participants reported earning a

Bachelor’s degree or an advanced degree (e.g., Master’s, PhD). Five percent of the sample

earned a high school degree, 9.70% took some college courses, 4.50% earned an Associate’s

degree, and 1.60% of participants reported technical school education. Additionally, more than

half of our participants reported a yearly household income of more than $75,000.

Measures

The survey asked participants general demographic information (e.g., age, sexual

identity, race/ethnicity). Additionally, participants were asked to reflect on their sexual

experiences within the last 12 months when answering all questions. With regard to STI/HIV

diagnoses, the CDC (2015) suggests that individuals get tested every 12 months and therefore,

some sexual health outcomes may not become known until 12 months later. All measurement

scores were coded and summed so that higher scores indicated better comprehensive sexual

health (e.g., lower depression scores indicated better sexual health so they were reversed coded;

See Table 2.1).

Anxiety. A three-item author created scale measured sexual anxiety. A sample question

was “I generally feel anxious about masturbation” (1= Not true of me at all, 7= Very true of me).

This scale was reversed scored so that higher scores indicated lower sexual anxiety.

Depression. A modified 10-item version of Radloff (1977) CESD-R was used to measure

depressive symptoms. Questions asked participants to indicate the number of times they felt or

behaved in a certain way in the last week (1= Rarely or none of the time; less than 1 day, 4=

Most or all of the time; 5-7 days). A sample question included: “I had trouble keeping my mind

on what I was doing.” This scale was reversed scored so that higher scores indicated lower levels

of depression (i.e., more sexual health).

Perceived sexual health. A global perceived sexual health measure was created by the

author(s). The question asked, “To what extent do you feel you are physically healthy enough to

have sex?”(1= Not at all healthy, 4=Very healthy). Most participants believed that they were

physically healthy enough to have sex.

Safety. An author created global measure of perceived safety in sexual encounters was

used. The question asked “Think about the last time you engaged in sex with a partner. How safe

did you feel?” (1= Not safe at all, 5=Very safe). Most participants reported feeling very safe in

their sexual encounters.

Sexual functioning. A modified 5-item version of Rosen’s (2000) Female Sexual

Function Index was used to assess female sexual functioning (e.g., lubrication). A sample

question was “How often did you find it difficult to have an orgasm when you wanted to?” (1=

Never, 7= Always). Scores were reversed coded so that higher scores reflected higher sexual

functioning (in contrast to higher sexual dysfunction).

Sexual Satisfaction. The author modified a version of the Male Sexual Health

Questionnaire (Rosen et al., 2004) to use with women to measure sexual satisfaction.

Specifically, gendered language was removed so that questions were inclusive of women. A

sample question included “How satisfied are you with the quality of the sex life you have?” (1=

Not at all satisfied, 5= Very satisfied).

STIs/HIV. Author created questions were used to assess participant STI and HIV

diagnoses and experiences. Questions asked the number of times participants had been

diagnosed with Chlamydia, Gonorrhea, and/or Syphilis over the last year. Questions also asked if

participants had herpes and/or HIV because they are treatable chronic conditions (i.e., you can

only get them once); two single-item measures were used to identify if participants had herpes or

HIV. The questions asked, “Do you have herpes?” and “Do you have HIV?” Answers included

“yes, no, not sure, prefer not to answer.” In this sample, no women responded that they were

HIV positive and therefore, HIV was excluded from scale combination. Because herpes is a

chronic condition, it can only be contracted once and therefore herpes was recoded so that yes =

1 and no = 0. Then all STI scores were combined. Higher scores indicted fewer STIs and

therefore, better sexual health. Most participants had never been diagnoses with an STI.

Data Analysis Plan

Through substantial research and conceptual grounding in the WHO’s (2019) definition

of sexual health, criteria for model specification were met prior to data analysis. Specifically,

seven factors were identified as important concepts of sexual health and used as indicators to be

loaded onto one latent variable of comprehensive sexual health. No factors or measurement

errors were hypothesized to be correlated to one another initially, but some research indicates

that some correlations might be plausible. This was considered during analysis. Next, model

identification was assessed. This model was over-identified (df=14) and therefore, parameter

estimation occurred.

Data were imported into SPSS for cleaning, assessment of normality, and assessment of

missingness. Responses were missing at random (i.e., no more than 20% missing per variable;

Schumacker & Lomax, 2010). Data were then imported into Mplus 8.0 and missing data were

computed using Full Information Maximum Likelihood (FIML; Muthen & Muthen, 2017)

because of its reliability to produce accurate, unbiased, and robust estimates when compared to

other missing data strategies (e.g., similar response pattern imputation; Enders & Bandalos,

2001). Additionally, FIML is less likely to have convergence failures when running SEM (Enders

& Bandalos, 2001). One heterosexual woman was excluded because data was missing on all

variables making the final sample size 246.

Using Maximum Likelihood Estimation with standardized output, we conducted a

multigroup confirmatory factor analysis (CFA) to assess model fit. Chi Square (χ2) test, Root

Mean

Square Error Approximation (RMSEA), and Critical Fit Index (CFI; Schumacker & Lomax,

2010) were used as model fit indicators. Mplus automatically sets one factor loading to 1.

Additionally, standardized estimates and standard errors were recorded for each observed factor,

which showed the factors that were significant contributors to the latent variable and accounted

for more of the variance across the latent measure. Additionally, MODINDICIES were used to

identify any theoretically sound modifications that could be added to enhance model fit (Muthen

& Muthen, 2017; Schumacker & Lomax, 2010).

Results

A multi-group confirmatory factor analysis (CFA) was conducted using maximum

likelihood estimation (Schumacker & Lomax, 2010) to ensure fit of the measurement model for

both queer and heterosexual women. Originally, model fit was not strong (e.g., RMSEA > .07).

However, modification indices suggested that sexual functioning and safety be correlated and

sexual satisfaction and safety be correlated, for better model fit. These correlations were added to

the model, because theoretically they made sense although there is limited empirical evidence

that has examined these relationships: if a woman feels safe she may experience better sexual

functioning and more sexual satisfaction (Jozkowski & Wiersma- Mosley, 2015). Once these

modifications were added, model fit indices denoted strong fit (RMSEA = 0.06, CFI = 0.93, TLI

= 0.92). However, the chi-square test suggested slight differences in the queer and heterosexual

latent measurement models, particularly regarding strength of factor loadings χ2 (36, N = 246) =

52.89, p < .05. Importantly, all significance of factor loadings remained the same across both

models.

All factor loadings for both models were statistically significant except for STI diagnoses

(see Table 2.2, Figure 2.2, and Figure 2.3). Theoretically, STI diagnoses should be a strong

indicator of sexual health. Therefore, this path was not trimmed from the model. Additionally,

84.60% of participants reported that they had never been diagnosed with an STI, so there was

limited variation across STI diagnoses scores. Sexual satisfaction, anxiety, and sexual

functioning had the strongest factor loadings for both queer and heterosexual women, however

the strength of the factor loadings differed. Specifically, sexual satisfaction, anxiety, and sexual

functioning had a moderate to large effect on queer women’s comprehensive sexual health. In

contrast, these indicators had small to moderate effect on heterosexual women’s comprehensive

sexual health.

Discussion

A multigroup CFA was used to validate the latent measure of comprehensive sexual

health, grounded in the WHO’s (2019) definition of sexual health, for queer and heterosexual

women. Data from 246 women, from an online survey, collected through social media were used

to validate this measure. The sample was mostly White, highly educated, and made over $75,000

annually, and therefore, relatively homogenous and lacking variation.

Results suggested strong model fit for both queer and heterosexual women, proposing

that this latent measure is a good predictor of comprehensive sexual health for women.

Importantly, this measure is one of the first parsimonious measurements of comprehensive

sexual health and should be used in future research. By using this measurement, scholars may be

able to ask research questions that seek to understand comprehensive sexual health rather than

single biological indicators (e.g., STIs). Additionally, future research can ask questions about

individual, interpersonal, and social influences on comprehensive sexual health, which considers

sexuality as more than biology. For example, new sexual health disparities, specific to women,

can be explored such as orgasm gaps (e.g., Frederick, John, Garcia, & Lloyd, 2017) feelings of

safety in consensual sexual encounters (Jozkowski & Wiersma, 2015), and sexuality specific

anxiety and depression (Kalmbach, Kingsberg, & Cielsa, 2014).

Importantly, sexual satisfaction, anxiety, and sexual functioning strongly loaded onto

comprehensive sexual health, and accounted for a significant amount of variance across the

measurement for both queer and heterosexual women. This is an important finding, because

although the significant chi square statistic suggested that sexual orientation may moderate the

strength of indicator relationship (i.e., queer women and heterosexual women have slightly

different models of sexual health), these three indicators were the strongest factor loadings on

comprehensive sexual health for both models. Queer women’s factor loadings were stronger than

heterosexual women’s suggesting a stronger relationship between those three indicators for queer

women. This is in line with previous literature (e.g., Garcia, Llyod, Wallen, & Risher, 2014;

Frederick, John, Garcia, and Lloyd, 2018).

First, research suggests that queer women experience more sexual satisfaction in their

sexual encounters when compared to heterosexual women (Garcia et al., 2014). Using an online

survey, Garcia and colleagues examined orgasm occurrence across sexual orientation and gender.

They found the mean occurrence of orgasm for lesbian women was 74.70% compared to 61.60%

for heterosexual women. However, interestingly in their study they found that the mean orgasm

rates for bisexual women was less than both lesbian and heterosexual women.

Contrastingly, Frederick and colleagues (2018) used a national sample and found that lesbian and

bisexual women were more likely than heterosexual women to report orgasming while engaging

in sexual intercourse. This study posited that perhaps queer women experienced more orgasms

because women in same-gender sexual encounters are more aware of behaviors that would lead

to sexual satisfaction in their partners when compared to different-gender sexual encounters.

Queer women may experience more sexual satisfaction in their relationships, which may

influence how much it impacts their sexual health. That being said, sexual satisfaction was the

most influential indicator of comprehensive sexual health for both queer and heterosexual

women.

Anxiety was another strong predictor of comprehensive sexual health for queer and

heterosexual women. For women specifically, experiences of anxiety may ebb and flow across

the lifespan, due to life stressors, hormonal fluctuations (Hantsoo & Epperson, 2017) and

cultural values and norms (Hofmann & Hinton, 2014). It is important to note that generally,

women are often shamed for their sexuality, regardless of their sexual orientation (Easton &

Hardy, 2009) and internalizing these beliefs may lead to negative physical and mental health

outcomes (Easton & Hardy, 2009). According to sexual scripting theory (Wiederman, 2005),

culture creates gendered and rigid scripts regarding sexuality and sexual processes. These create

guidelines for sexual behaviors that are often internalized. For women, these scripts teach

women that they should not be sexual or discuss sexuality. Therefore, when women are asked

about their sexuality or their sexual behaviors it is possible that provokes feelings of anxiety

(Wiederman, 2005). However, for queer women, within group cultural scripts promote sexual

pleasure and normalize engaging in sexual behavior (e.g., masturbation; Meiller & Hargons,

2019). Thus, heterosexual women may identify more strongly with larger cultural scripts that

stigmatize female sexuality and thus, it may not be as strong of an indicator of comprehensive

sexual health.

Research suggests that sexual functioning, and particularly sexual dysfunction, is a

common concern for women (Faubion & Rullo, 2015). When a woman experiences sexual

dysfunction, she may lose sexual interest, may find it challenging to become aroused, may not be

able to reach orgasm, and may experience pain during sexual intercourse (Faubion & Rullo,

2015). Sexual functioning may also be contingent upon mental and physical health (Nobre &

Pinto-Gouveia, 2006). For example, Nobre & Pinto-Gouveia (2006) examined emotional

responses to regular thoughts that often occur during sexual activity. They found that both men

and women who had less sexual functioning may experience more thoughts of sadness,

disillusion, and fear (i.e., negative thoughts). Flynn, Lin, and Weinfurt (2017) conducted a

crosssectional online survey to examine sexual function and satisfaction across gender and

sexual orientation. They found that lesbian women may experience less vaginal discomfort,

higher lubrication, and easier orgasms when compared to heterosexual women. However,

bisexual women had more vulvar and labial discomfort, and higher anal discomfort when

compared to heterosexual women. There were no differences among women in clitoral

discomfort, or pleasure from orgasms and sexual satisfaction. Thus, sexual functioning is an

important factor in women’s sexual health and may be varied based on numerous factors.

Future Research and Limitations

Taken together, although models were slightly different, model fit for the latent measure

of comprehensive sexual health for both queer and heterosexual women was strong. It is

important to recognize that sexual satisfaction, anxiety, and sexual functioning were three of the

strongest indicators of comprehensive sexual health across women regardless of their sexual

orientation. Additionally, all indicators except for STI diagnoses were significant measures of

comprehensive sexual health. Future models should examine how STIs play a role in

comprehensive sexual health, since the lack of significance in this model was likely due to error

and homogeneous samples. One such way to gain access to participants with diverse STI

diagnoses would be to recruit through STI clinics that serve at risk populations (Carey, Vanable,

Coury-Doniger, & Urban, 2005). Additionally, populations based studies could employ this

measure of comprehensive sexual health, which would greatly contribute to the literature and

also access diverse populations. Further, while this measure is parsimonious, it may be important

for surveys to be shorter, to ensure that participants complete the survey (Urban & van

EedenMoorefield, 2018). Perhaps creating some single item measurements that encompass each

domain of sexual health (i.e., how physically healthy do you feel, how mentally healthy do you

feel, how socially healthy do you feel), would provide a comprehensive approach to measuring

sexual health.

Moreover, this study did not ask about experiences with unintended pregnancy, which is

a traditional indicator of sexual health. The study chose not to include this indicator within the

comprehensive measurement of sexual health because unintended pregnancy is not mentioned

within the WHO (2019) conceptualization. Future research could include unintended pregnancy

as an indicator of comprehensive measurement of sexual health to understand how that may

change the measurement. Finally, future research should use this model in more diverse

populations to understand comprehensive sexual health across diverse intersections. The sample

used in this study was very homogenous (White) and privileged. The extant literature suggests

that women of color, who are less educated, and low income are disproportionately impacted by

sexual health disparities (CDC, 2020, Guttmacher, 2019). To survey more diverse populations

through social media, future research should use targeted advertisements to encourage diverse

groups of women to participate (NIH, 2020). Therefore, applying this measurement to a sample

that resembles those characteristics more closely may exhibit different results. Taken together,

this study is a first step toward finding a comprehensive measurement of sexual health that

reflects the comprehensive definitions commonly used in health organizations.

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Table 2.1

Measurement Descriptive Information

Measure

Min

Max

M (SD)

Anx*

17.49 (4.15)

.70

Dep*

30.97 (6.35)

.88

PSH

3.68 (.60)

---

Safe

4.83 (.53)

---

SFW*

24.03 (5.73)

.82

SexSat

21.10 (6.90)

.94

STI*

5.79 (.80)

.76

Note. *Scales were recoded so that higher scores indicate better sexual health.

Anx= Anxiety, Dep= Depression, PSH= perceived physical sexual health, safe= safety, SFW=

sexual functioning, SexSat= sexual satisfaction, STI= Sexually transmitted infections

Table 2.2

Comprehensive Sexual Health Observed Variable Factor Loadings

Queer Women

Heterosexual Women

Observed Variable

Estimate

S.E.

Observed Variable

Estimate

S.E.

Sexual Satisfaction

0.74*

0.06

Sexual Satisfaction

0.57*

0.06

Anxiety

0.71*

0.07

Anxiety

0.49*

0.06

Sexual Functioning

0.64*

0.07

Sexual Functioning

0.53*

0.07

Depression

0.56*

0.07

Depression

0.50*

0.07

Perceived Sexual

Health

0.51*

0.07

Perceived Sexual

Health

0.41*

0.07

Safety

0.51*

0.07

Safety

0.32*

0.08

STI

0.03

0.08

STI

0.04

0.08

Note. * indicates p<.05

STI/HIV

Anxiety

Figure 2.1. Hypothesized model.

Comprehensive

Sexual Health

Sexual Functioning

Sexual

Satisfaction/

Pleasure

Safety

Depression

Perceived sexual

health

.08

Anxiety

Figure 2.2. Confirmatory factor analysis: seven-factor model of Comprehensive Sexual Health

for queer women with factor loadings and standard error.

Note: * p < .05

.07

Comprehensive

Sexual Health

STI/ HIV

Sexual Functioning

Sexual

Satisfaction

Safety

Depression

Perceived sexual

health

.07

.06

.09

.07

.03

.64*

.74*

.40*

.56*

.51*

.07

.71*

.08

Anxiety

Figure 2.3. Confirmatory factor analysis: seven-factor model of Comprehensive Sexual Health

for Heterosexual Women with factor loadings and standard error.

Note. * p < .05

CHAPTER 3: THE IMPACT OF HETERONORMATIVITY ON QUEER WOMEN’S

COMMUNICATION PROCESSES AND COMPREHENSIVE SEXUAL HEALTH

Health disparities are present when members of a particular minoritized group (e.g.,

LGBQ women) have greater risk for, or actually experience, poorer health compared to those in

a majority group (Russell, Coleman, & Ganong, 2018). Decades of documentation suggest such

disparities are pervasive in the United States (Weinstein, Geller, Negussie, & Baciu, 2017), and

the types of health outcomes tracked range from mental health and substance abuse to sexual

.06

Comprehensive

Sexual Health

STI/ HIV

Sexual Functioning

Sexual

Satisfaction

Safety

Depression

Perceived Sexual

Health

.04

.53*

.07

.57*

.32*

.08

.06

.50*

.07

.41*

.07

.49*

health and general physical health (CDC, 2017; Weinstein et al., 2017). Unfortunately, statistics

on queer women’s (e.g., bisexual, lesbian, pansexual), sexual health are limited but do suggest

the presence of some significant sexual health disparities (Baptiste- Roberts, Oranuba, Werts, &

Edwards, 2017). Of note, we use the term queer as an umbrella term to refer to women who are

attracted to other women regardless of their self-identified sexual orientation. Because sexual

orientation is comprised of attraction, behavior, and identity, and these may not always align

(Vrangalova & Savin-Williams, 2012), the use of queer is a more inclusive approach to

capturing a range of queerness among women. Most queer sexual health programming and

research has focused exclusively on queer, cisgender men, likely due to a long-standing focus on

the HIV/AIDS crisis and their perceived risk of disease acquisition (Power, McNair & Carr,

2009). Further, most female sexual health research and programming has focused on cisgender,

heterosexual women (Baptiste-Roberts, et al., 2017), suggesting that queer women are

underexamined and underserved.

As stated, research, albeit limited, suggests queer women may be at risk for sexual health

disparities. For example, reports suggest that Human Papilloma Virus (HPV) is a common

sexually transmitted infection (STI) diagnosed in women who have sex with other women

(WSW; i.e., an umbrella term that includes queer women; CDC, 2015a). The CDC (2015a)

reports that 13%-30% of WSW have some strain of HPV. Additionally, best estimates suggest

that 36% of women who reported having a same-gender partner in their lifetime had HSV-2

antibodies (i.e., the herpes virus), which is higher than women who reported never engaging in

same-gender behavior (24%). Transmission of the herpes simplex virus (HSV-1 & HSV-2) may

be higher in same-gender sexual encounters due to the prevalence of oral sex in these sexual

relationships when compared to different-gender sexual encounters (CDC, 2015a). Although

there are few statistics on bacterial infections, queer women are still at high risk for chlamydia,

gonorrhea, syphilis, and hepatitis A, B, and C due to limited use of barrier methods in sexual

encounters (Mount Sinai Adolescent Health Center, 2017; Power et al., 2009; Knight & Jarrett,

2017).

Importantly, health is not solely determined by the absence of disease, but instead, is a

product of the larger social, structural, and political context in which some lives are more valued

than others (Ratcliff, 2017). Accordingly, health disparities often emerge. The Determinants of

Health (DoH) framework created by the World Health Organization explains how social

contextual factors, such as cultural inequities, contribute to differential health outcomes (Office

of Disease Prevention; ODPHP, 2019; WHO, 2019). It asserts that there are five DoH (i.e.,

policymaking, social factors, health services, individual behavior, and biology and genetics) that

influence the presence of health disparities. This study focuses on the influence of social factors

on individual and interpersonal sexual health processes (ODPHP, 2019).

Social factors are defined as those macro level phenomenon that may influence health,

and contribute to health disparities (ODPHP, 2019). These include, but are not limited to, social

norms and attitudes (including discrimination), availability of resources, social support, mass

media, and socioeconomic factors (ODPHP, 2019). Such influences often, but not always, are

indirect and stem from issues of cultural exclusion and inclusion. This may contribute to queer

health disparities, and more specifically sexual health disparities. For example,

heteronormativity is a social factor that privileges sexual partnering between two married,

cisgender, and heterosexually-identified individuals (van Eeden-Moorefield, 2018) and has

shaped the foundation of many of our social structures (Herek, 2004). Most sexuality education

curriculum (e.g., exclusion of queer sexual health and identities; Guttmacher Institute, 2019),

policies (e.g., adoption policies and child custody policies for queer families; van Eeden-

Moorefield, 2018), and the healthcare system (e.g., patient is often assumed to be heterosexual

unless otherwise stated; Sekoni, Gale, Manga-Atangana, Bhaduri, & Jolly, 2017; van Eeden-

Moorefield, 2018) are heteronormative. In turn, queer women are often underserved because

they fall outside of the heterosexual norm. Accordingly, queer women may find themselves with

little information about maintaining their sexual health and how to discuss it with others

(Marazzo, Coffey, and

Bingham, 2005)

Further, heteronormativity may influence individual behaviors (e.g., communication),

another DoH (ODPHP, 2019). For example, most learn that penile penetrative sexual behavior is

one of the only ways to have sexual intercourse in heterosexual relationships and carries high

sexual risk (McNeill, 2013). WSW do not typically engage in penile penetration, and therefore,

may assume that they are at lower sexual risk (Baptiste- Roberts, et al., 2017). Therefore, this

heteronormative perspective of sexual behavior and sexual risk would lead to the assumption

(both culturally and medically) that in order to have sexual risk, penile penetration is necessary.

Because of this presumption queer women may perceive they are not at risk for HIV, STIs or

unintended pregnancy and, accordingly, have reported underusing barrier methods

(BaptisteRoberts et al., 2017). Such an example demonstrates how heteronormativity can

influence individual behaviors in a way that accounts for the presence of a health disparity

among queer women. Taken together, individual behaviors can act as a mechanism through

which cultural factors influence health, and this may be a particularly salient pathway among

queer women.

To be more inclusive of queer women’s experiences, sexual health research must examine

how both individual, interpersonal, and social processes operate in determining sexual health

outcomes, especially those that represent disparities (Baptiste-Roberts et al., 2017; Weinstein et

al., 2017; ODPHP, 2019). Earlier, we describe how the cultural factor of heteronormativity might

be linked to health (Meyer, 2003). We suggested that its link is through individual behaviors.

Prior research suggests the role of sexual health communication (which may include, but is not

limited to, the discussion of one’s sexuality with another person, sexual history, concerns,

consent, and desires; Horan, 2016; Lehmiller, VanderDrift, & Kelly, 2014), may be a process

through which heteronormativity is perpetuated. For example, we know that women who

communicate about their sexual health with a potential partner are likely to engage in more safe-

sex practices, which, in turn, predicts improved sexual health outcomes (Lehmiller, et al., 2014).

This is likely due to increased discussion between partners about their sexual health histories and

discussion of safe sex preferences (Lehmiller, et al., 2014; Quinn-Nilas et al., 2016). Yet,

heteronormative messages about sexual health may indirectly lead to inaccurate health risk

perceptions in queer women (i.e., that they are not at risk for STIs) and therefore, they may not

feel the need to discuss their sexual health or engage in safe sex practices. Using focus groups,

Marazzo and colleagues (2005) examined queer women’s sexual practices and understanding of

sexual health. They found that many queer women were not well versed in preventative sexual

health measures (e.g., washing sex toys between partner usage). Those that used barrier methods

reported doing so if someone reported having an STI. Therefore, they were used, but relatively

infrequently. By improving sexual communication self-efficacy (i.e., an individual’s perception

of how well they communicate about their sexuality with a partner; Quinn-Nilas, et al. 2016)

among queer women, perhaps safe sex behaviors will improve, and queer women will have

better comprehensive sexual health outcomes. Therefore, the purpose of this study was to test a

model examining how heteronormativity influences sexual health communication self-efficacy in

queer female populations, and how that influences comprehensive sexual health outcomes. The

hypothesized model was outlined below.

Model Hypothesis

We know that there is a relationship between sexual health communication, safe sex

behaviors, and comprehensive sexual health outcomes (e.g., Quinn-Nilas et al., 2016). However,

cultural heteronormativity may alter this relationship, because queer women are left with

inaccurate information about their sexual risk (Baptiste-Roberts et al., 2017), and also there is

stigma surrounding women discussing their sexuality (Easton & Hardy, 2009). Therefore, we

hypothesized that there would be a direct relationship between sexual communication

selfefficacy and comprehensive sexual health. This relationship would be partially mediated by

safe sex behaviors since this is a mechanism to improve sexual health outcomes (CDC, 2020).

Further, heteronormativity experienced by queer women would moderate the relationship

between sexual communication self-efficacy and safe sex behaviors because queer women may

not understand the importance of discussing sexual health due to misinformation about their

sexual risk (Baptiste-Roberts et al., 2017). Heteronormativity would also moderate the

relationship between safe sex behaviors and sexual health outcomes because queer women may

choose to forgo engaging in safe sex practices due to misperceptions of risk (Marazzo et al.,

2005).

Methods

Design

This study used a 30-minute cross-sectional Internet survey design. Online surveys are

cost effective and time efficient (Urban & van Eeden-Moorefield, 2018). Online methodologies

enable more diversity by casting a wide recruitment net (van Eeden-Moorefield, Proulx, &

Pasley, 2008) and permit anonymity and/or high confidentiality of respondent identities. This is

critical when surveying about sensitive topics such as sexual health, and there may be lower

response bias (Ayling & Mewse, 2009; Urban & van Eeden-Moorefield, 2017).

Sample and Procedures

This study used a convenience sample consisting of 110 cisgender queer women between

the ages of 19 and 60 from across the United States (see Table 3.1). This meets power needs

(.90) for the analyses (G*Power). All participants reported queer attraction, ranging from only

attracted to women, to having some attraction to women but with higher attraction toward men.

The majority of the sample were White, followed by Hispanic/Latina, and Asian American

individuals. Additionally, the sample was highly educated: over a third of participants earned a

Master’s or Doctoral degree (e.g., PhD, MD) and almost half of participants reported making

over $75,000 a year.

Participants were recruited using Facebook posts on the research teams’ personal

accounts (Appendix A; Gelinas et al., 2017). Using social media to recruit participants has

become a widely used recruitment strategy due to researchers’ ability to access difficult to recruit

populations (e.g., sexual minorities; Urban & van Eeden-Moorefield, 2017). The post invited

people to participate in the study, provided a link to the informed consent (Appendix B) and

survey (Appendix C), and also asked viewers to share the post to their own pages (i.e., snowball

sampling). Those interested, clicked the link listed on the recruitment announcement and were

directed to the informed consent and beginning of the survey. Participants took the survey and in

the thank you letter (Appendix D) were notified that they had the opportunity to be entered into a

lottery, to receive a $25 gift card for their participation by providing their email on an unlinked

separate page (Appendix E). Only one survey per IP address was allowed to ensure

independence of responses (Birnbaum, 2004).

Measures

The survey asked participants about their feelings of sexual health communication

selfefficacy, safe sex behaviors they have engaged in within the past 12 months, experiences of

heteronormativity, and experiences of comprehensive sexual health over the last 12 months.

Often times, sexual health outcomes may not appear for an extended period of time (e.g. most

STIs and HIV are initially symptomless, but it is suggested that people get tested every 12

months; CDC, 2015b), and therefore, examining behaviors over a 12-month span accounts for

that. Participants were asked to report their demographic information. Sample questions included

participant age, race, ethnicity, and number of sexual partners in the last 12 months. Importantly,

scores were coded such that higher scores indicated more positive/healthier comprehensive

sexual health outcomes. This was to ensure consistency across the latent measure and also

highlights positive indicators of sexuality as opposed to negative. Therefore, heteronormativity,

anxiety, depression, sexual functioning (due to originally being a dysfunction scale) and STI

diagnoses were scored so that higher scores meant better sexual health (or lower levels of these

items). For example, anxiety was reverse scores so that higher scores indicated lower levels of

anxiety, which is indicative of better comprehensive sexual health (See Table 3.2).

Sexual communication self-efficacy. Sexual communication self-efficacy was measured

using a revised version of the Quinn-Nilas and colleagues (2016) sexual communication

selfefficacy scale. This scale measures self-efficacy of sexual communication. It was originally

intended to measure sexual communication self-efficacy in adolescents, but was adapted for use

with adult queer women. This revised 15-item scale asked participants to rate their confidence in

their ability to engage in 15 conversations with a sexual partner and was measured on a 4-point

Likert scale ranging from 1= very difficult to 4= very easy. Conversation topics (i.e., questions)

include: “Ask how many partners they have had?” and “Suggest a new sexual activity (e.g. a

new sexual position).” Scores were summed and higher scores indicated higher sexual

communication self-efficacy.

Safe sex behavior. Safe sex behavior was measured using a modified version of the Safe

Sex Behavior Questionnaire (DiIorio, 2009) which measured participant use of safe sex

behaviors. This 8-item scale was revised to only questions that were specific to sexual behaviors

and omitted questions related to substance abuse and sexual orientation. It was measured on a

4point Likert scale ranging from 1=never to 4= always. Sample questions included “I insist on

condom use when I have sexual intercourse,” and “I ask my potential sexual partners about their

sexual history.” Scores were summed and higher scores indicated more safe sex behavior.

Heteronormativity. Heteronormativity was measured using Habarth’s (2014)

Heteronormative Attitudes and Beliefs scale. This measure consisted of the Essential Sex and

Gender Subscale and the Normative Behavior Subscale within the larger scale. This 16-item

scale measuresd heteronormative attitudes and beliefs that individuals possess using a 7-point

Likert Scale (1= Strongly Disagree, 7= Strongly Agree). Sample questions include: “There are

only two sexes: male and female.” Scores were summed and higher scores indicated lower

heteronormative attitudes and beliefs.

Comprehensive sexual health. Comprehensive sexual health was a latent construct that

was measured using seven observed variables: anxiety, depression, perceived physical sexual

health, safety, sexual functioning, sexual satisfaction/pleasure, and STIs/HIV. Measures for this

construct were based off of the WHO’s (2019) definition of sexual health.

Anxiety. Anxiety was measured using a 3-item author created scale (modeled after Janda

& O’Grady’s, 1980, Sex Anxiety Inventory). This measured anxiety about sexuality and sexual

experiences. Questions were measured on a 7-point Likert scale (1= Untrue of me, 7= Very true

of me). Sample questions included “I generally felt anxious about sex with other people.” Scores

are summed and higher scores indicated less sex related anxiety.

Depression. Depression was measured using a modified version of Radloff’s (1977)

12item CESD-R scale, which measured depressive symptoms in the general population. This

10item scale was measured using a 4-point Likert Scale (1= rarely or none of the time; less than

1 day, 4= most or all of the time; 5-7 days). Participants were asked to select the number of

times they felt or behaved in the last week and sample questions included “I was bothered by

things that usually do not bother me.” Scores were summed and higher scores indicated lower

levels of depression.

Perceived physical sexual health. Perceived physical sexual health was measured using

an author created global measure which asked, “To what extent do you feel you are physically

healthy enough to have sex?” This question was measured on a 4-point Likert Scale (1= Not at

all healthy, 4=Very healthy).

Safety. Safety was measured using an author created global measure which asked

participants to “Think about the last time you engaged in sex with a partner. How safe did you

feel?” The item was scored using a 5-point Likert Scale (1= Not safe at all, 5=Very safe).

Sexual functioning. Sexual functioning was measured using a modified version (5-item

scale) of the Female Sexual Function Index (Rosen, 2000), which assesses common domains of

female sexual functioning. Desire, arousal, lubrication, orgasm, and pain are the domains of

sexual functioning that were measured. Sample questions include “How often did you find it

difficult to be aroused” (1= never, 7= always). Responses were measured on a 7-point Likert

scale; scores were summed and higher scores indicated better sexual functioning.

Sexual satisfaction/pleasure. Sexual satisfaction/pleasure was measured using the 6-item

modified version of Rosen et al., (2004) Male Sexual Health Questionnaire. This scale was

modified so that it was applicable to women. This scale assessed sexual satisfaction. Sample

questions were “How satisfied are you with the overall sexual relationships you have?”

Responses were measured on a 5-point Likert scale (1= Not at all satisfied, 5= Very satisfied).

Scores were summed and higher scores indicated higher sexual satisfaction.

STI/HIV. STI/HIV was measured using an author created questionnaire which asked

about respondent’s experiences with STI diagnoses. Respondents were asked to fill in how many

times they had been tested for STIs and HIV in the last year. They were also asked to fill in the

number of times they had Chlamydia, Gonorrhea, and/or Syphilis in the last 12 months. A

singleitem measure was used to ask if participants had herpes (because it is a treatable STI and

therefore, cannot be acquired multiple times). The question asked: Do you have herpes? Answers

included “yes, no, not sure, prefer not to answer”. A single-item measure was used to ask if they

had HIV (because this is a treatable STI and therefore, cannot be acquired multiple times). The

question asked: Do you have HIV? Answers included “yes, no, not sure, prefer not to answer.”

No women in this sample had HIV diagnoses and therefore, questions about HIV were excluded

from analysis. Since herpes can only be acquired once, scores were recoded so that “yes” = 1 and

no = 0. Number of STI diagnoses were summed and reverse scored so that higher scores

indicated better sexual health (i.e., lower STI diagnoses).

Data Analysis Plan

Data were imported into SPSS where cleaning and preliminary analyses (e.g., assessment

of normality, reliability, and missingness) occurred. Data were missing completely at random

(i.e., less than 20% of data per variable; Dong & Peng, 2013; Schumacker & Lomax, 2010).

Missing data was replaced using multiple imputation (MI) with five estimation rounds conducted

to ensure reliable estimates. MI is commonly used to account for missing data because it is able

to reliably estimate larger percentages of missing data with precise and efficient estimates

(Madley-Dowd, Hughes, Tilling, & Heron, 2019). Correlations were conducted to examine

variable relationships (See Table 3.3), which largely were as expected.

Next, a confirmatory factor analysis (CFA) of the latent construct (comprehensive sexual

health) was run to assess that the observed measures accurately measured the latent construct

(Schumacker & Lomax, 2010). Model fit was assessed here and across all other models using

several indices: Chi Square (χ2) test, Comparative Fit Index (CFI), Goodness of Fit Indices

(GFI), and Root Mean Square Error of Approximation (RMSEA; Schumacker & Lomax, 2010).

The full moderated-mediating model was tested in AMOS (Arbuckle, 2013) using ML

estimation with a mixture of observed and latent variables (Schumacker & Lomax, 2010). ML

estimation provides unbiased and strong parameter estimates (Lei & Wu, 2012). First, one

thousand bootstraps were used to test the base mediation model (Cheong & MacKinnon, 2012),

which means that random subsamples of safe sex behaviors were estimated 1,000 times to ensure

that mediation is present (Cheong & MacKinnon, 2012). Bootstrapping has been used more than

other types of resampling methods and produces strong confidence intervals.

A median split was used to determine groups that had high levels of internalized

heteronormativity vs. low levels of internalized heteronormativity. Moderation of the mediation

model was tested using multi-group analysis in AMOS (Arbuckle, 2013), comparing constrained

(i.e., theoretically based models) and unconstrained models (i.e., exploratory models; Byrne,

2010; Qureshi & Compeau, 2009; Savalei & Kolenikov, 2008).

Results

Preliminary Results

Correlations between demographic variables (e.g., age, income) and endogenous

variables were used to identify potential controls for use in the model. Participant age was

significantly correlated with feelings of safety (r(108) = .20, p < .05). Participant income was

significantly related to depression (r(108) = .32, p < .05). Finally, having insurance was

significantly related to perceived sexual health (r(108) = -.25, p < .05), depression (r(108) = .36,

p < .05), and sexual satisfaction (r(108) = .33, p < .05). When controls were added to the model,

age (p = .94) and income (p = .75) were not significantly related to comprehensive sexual health

outcomes. However, insurance was significantly related to comprehensive sexual health

outcomes and therefore, was kept in the final model as a control (p < .05). Results from the CFA

suggested strong model fit for the latent variable (See Chapter 2).

Hypothesized Model Testing

The base model was a mediation model that assessed the direct relationship between

communication self-efficacy and comprehensive sexual health and the indirect one on

comprehensive sexual health through safe sex behaviors. Model fit was strong, χ2 (31, N = 110)

= 36.03, p = .25, CFI = 0.97, GFI = .94, RMSEA = .04, and accounted for 44% of the variance in

comprehensive sexual health (see Table 3.4; Figure 3.1). Results show a strong positive

relationship between communication self-efficacy and comprehensive sexual health; when

sexual communication self-efficacy increases, comprehensive sexual health also increases.

However, indirect effects were not significant in spite of the strong model fit. This was expected

though given the model was hypothesized to be moderated.

Next, moderation of the model (i.e., high vs. low internalized heteronormativity) was

tested and results suggested moderation was present at the model level. Importantly, the model

for queer women with low internalized heteronormativity accounted for 67% of the variance in

comprehensive sexual health (R2=.67; Figure 3.2). In the model for queer women with high

internalized heteronormativity, sexual communication self-efficacy only accounted for 43% of

the variance in comprehensive sexual health outcomes (R2=.43), which is less than the base

mediation model (Figure 3.3).

First, we tested the direct link between sexual communication self-efficacy and

comprehensive sexual health for moderation using The Stats Tool Package excel file (Gaskin,

2012). This link was significantly different between those with high and low heteronormativity

(i.e., χ2 (63, N = 110) = 98.45> 96.35 which was the 95% CI threshold). Specifically, the link

between sexual communication self-efficacy and comprehensive sexual health outcomes was

significantly stronger for queer women who had low levels of internalized heteronormativity

compared to queer women with high levels of internalized heteronormativity (see Figure 3.2).

Upon further examination, we noticed the links between sexual communication self-efficacy and

safe sex behaviors was not significant for either group; thus, indirect effects remained

insignificant regardless of the level of heteronormativity and this runs counter to our

hypothesized model (i.e., χ2 (63, N = 110) = 93.04 < 95.22 which is the 90% CI threshold). A

difference in parameter estimates for the link between safe sex behavior and comprehensive

sexual health outcomes also was present, so we tested for moderation of this link. Results from

this confirmed this link also was not moderated (i.e., χ2 (63, N = 110) = 92.73 < 95.22 which is

the 90% CI threshold). It appears the magnitude of difference between groups for the direct

relationship was so strong that it made the results for model level moderation appear significant

when only one link was moderated. Stated differently, although model level moderation was

statistically present, it appears that it may not be meaningfully present. Nonetheless, this is an

important finding that is discussed below.

Discussion

This study, grounded in the DoH framework, sought to understand how heteronormativity

influences the direct and indirect links between sexual communication selfefficacy, safe sex

behaviors, and comprehensive sexual health outcomes. Notably, this study was one of the first to

use a comprehensive measurement of sexual health as opposed to studies (e.g., Painter et al.,

2012) that rely on single indicators of any of the three individual domains of sexual health (i.e.,

physical, mental, social; WHO, 2019). Secondly, it did so with a focus on queer women, a group

whose sexual health is not well understood in spite of being a group at particular risk to

experience health disparities (Marazzo et al., 2005). Results partially supported our hypothesized

moderated mediation model, although not entirely as expected. Specifically, the results of this

study suggested communication self-efficacy played more of a direct role in explaining variation

in comprehensive sexual health rather than an indirect role through engagement in safe sex

behaviors. Additionally, the link between sexual communication selfefficacy and comprehensive

sexual health, although significant for both groups, was significantly stronger for queer women

with low internalized heteronormativity than for those who had high internalized

heteronormativity. In other words, queer women who had low internalized heteronormativity and

high sexual communication self-efficacy were more likely to have higher comprehensive sexual

health. For queer women, with high internalized heteronormativity, the positive relationship

between sexual communication self-efficacy and comprehensive sexual health outcomes was not

as strong.

As hypothesized, sexual communication self-efficacy significantly predicted

comprehensive sexual health outcomes. This makes sense because it is well established within

the literature that communication between partners has been found to foster closeness and

emotional intimacy within romantic relationships, ultimately enhancing relationship satisfaction

(Yoo, Bartle-Haring, Day, and Gangamma, 2013). Additionally, sexual communication when

compared to general communication, has been found to predict sexual satisfaction, which is an

important indicator of comprehensive sexual health (Montesi, Fauber, Gordon, and Heimberg,

2010). Using surveys, Montesi and colleagues (2010) examined how general communication and

sexual communication contributed to sexual and relationship satisfaction. They found that sexual

communication was very important for sexual satisfaction, and that general communication only

impacted general relationship satisfaction. Thus, supporting the strong predictive relationship of

sexual communication self-efficacy and comprehensive sexual health outcomes.

However, results did not support the hypothesized indirect relationship of sexual communication

self-efficacy and comprehensive sexual health outcomes through safe sex behaviors. First, the

previous research that suggested safe sex behaviors mediate the relationship between sexual

communication self-efficacy and sexual health outcomes has largely focused on heterosexual

samples (e.g., Holland & French, 2012) or men who have sex with other men (MSM; Lapinski,

Braz, and Maloney, 2010) overlooking queer women’s unique sexual health experiences within

the context of heteronormativity. When we consider queer women, research suggests an

interaction between heteronormativity and safe sex behaviors (e.g., women with high levels of

internalized heteronormativity may not use safe sex behaviors due to misinformation about

sexual risk; Marazzo et al., 2005), thus, leading us to hypothesize a moderated mediation model.

Therefore, it is not surprising that mediation of the base model was not significant for this

specific group. As researchers, it is important to understand how these sexual health processes

occur within the larger heteronormative context for different intersections to truly begin to

understand nuances of comprehensive sexual health outcomes across diverse populations

(Santos, Williams, Rodriguez, and Ornelas, 2017).

That being said, results partially supported our hypothesis that heteronormativity would

completely moderate the mediation model. The direct relationship between sexual

communication self-efficacy and comprehensive sexual health outcomes was significantly

stronger for queer women with low internalized heteronormativity when compared to queer

women with high internalized heteronormativity. This is in line with previous research that

suggests queer women who have low internalized heteronormativity would ascribe less to the

stigma perpetuated by heteronormative culture (i.e., that women should not be sexual and

homophobia). For example, perhaps queer women with high internalized heteronormativity have

adopted intrusive thoughts that hinder their ability to communicate with a partner (Lewis,

Derlega, Clarke, & Kuang, 2006). Lewis and colleagues (2006) examined how lesbian women

who had high stigma consciousness and social constraints (which heteronormativity

perpetuates), had intrusive thoughts, internalized homophobia, and actual physical symptoms

related to awareness of heteronormative based discrimination. Therefore, perhaps for women

with high internalized heteronormativity, adding an indicator to this model that asked women

about their awareness of cultural stigma would present a clearer picture of the relationship

between communication self-efficacy and comprehensive sexual health.

Yet, even though the link between sexual communication self-efficacy and

comprehensive sexual health was significantly stronger for women with low internalized

heteronormativity, the link still remained significant across both groups. Previous research

suggests that queer women have strong sexual communication leading to better sexual health

outcomes (Frederick, John, Garcia, & Lloyd, 2018). Frederick and colleagues (2017) examined

orgasm frequency among gay, lesbian, bisexual and heterosexual men and women. They found

that queer women had more orgasms than heterosexual women. Importantly, they found that

women who had more orgasms were more likely to communicate about their sexual preferences

and praise their partner for sexual actus. Therefore, perhaps sexual communication is a strength

of queer women. Since there are two women involved, the gendered communication that would

be present in a different gender sexual encounter is not present (D’Emilio & Freedman, 2012)

potentially promoting more open communication. It is important to note that this information is

specific to women who have sex with women, and in this study we examined women who are

attracted to other women. Thus, this may not fully explain what is occurring in our sample, but is

a theory that would be applicable. Therefore, even though heteronormativity may reduce the

strength of the link between sexual communication self-efficacy and comprehensive sexual

health outcomes, it is still somewhat strong and significant for queer women across both models.

Finally, regardless of level of internalized heteronormativity, the indirect relationship

between sexual communication self-efficacy, safe sex behaviors, and comprehensive sexual

health outcomes was not significant. In line with previous research, perhaps heteronormative

scripts suggesting that queer women are not at risk for negative sexual health outcomes (i.e.,

STIs, unintended pregnancy; Marazzo et al., 2005) was so strong that even women who had high

sexual communication self-efficacy did not discuss or engage in safe sex behaviors. Using

qualitative interviews, Santos and colleagues (2017) examined young Latina queer women’s

sexual health. They found that women perceived their sexual health was largely shaped by

cultural context (e.g., a multiple minority status based on sexual identity, ethnicity, and gender).

Within this context, they reported that their sex education was largely heteronormative (i.e.,

discussed sex in the context of two heterosexual people in love), and these women often found

themselves without information on risk and protection for queer women. Additionally, women

reported perceptions of less risk when engaging in sexual behavior with a cisgender female

partner when compared to cisgender male partner. Therefore, this lack of risk perception may

completely mitigate queer women’s use of safe sex behaviors, suggesting no indirect effect.

Taken together, sexual health processes must be examined with cultural context in mind.

The indirect effect of sexual communication self-efficacy, safe sex behaviors, and

comprehensive sexual health outcomes are well supported in the literature (e.g., Donne, Hoeks,

& Jansen, 2017). Although this relationship may exist for some populations, it does not exist for

all. Specifically, for queer women, sexual communication self-efficacy may be more important

for comprehensive sexual health outcomes, because there are such large misconceptions about

queer women and sexual risk (Baptiste-Roberts, et al., 2017). Additionally, the strength of the

predictive relationship of sexual communication self-efficacy and safe sex behaviors varies

based on women’s internalization of heteronormativity. Therefore, as we begin to parse what

factors contribute to comprehensive sexual health outcomes for diverse groups of people, we

must also take into consideration cultural context and its influence on individual and

interpersonal processes.

Limitations

This study but be considered within the bounds of its limitations. The first major

limitation of this study is that the sample lacked diversity. Specifically, the sample was largely

White, highly educated, and made over $75,000. Therefore, these results cannot be generalized

to more diverse populations. This is a shortcoming of sampling through social media friend

networks, because most people are likely to be friends with individuals who are similar to them

(Naruchitparames, Gunes, & Louis, 2011). To recruit more diverse samples for health research,

the NIH (2020) suggests targeting survey recruitment to specific populations on Facebook. Thus,

future research should consider ways to ensure diversity across their samples. By employing this

model with more diverse populations, we can understand how these sexual health processes

function across divers intersections. Additionally, this study utilized queer attraction rather than

queer identity or behavior (Vrangalova & Savin-Williams, 2012). This was to be inclusive of the

broad definition of queer. However, same gender attraction does not necessarily mean that

someone will engage in sexual behavior with someone of the same gender, and therefore, it

poses challenges to measuring physical health outcomes. Therefore, it would be beneficial to use

this model with women who identify as queer as well as women who have sex with other

women, regardless of their identities.

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Table 3.1

Participant Demographic Characteristics

Variable

Percent

Race

White

90.90%

Hispanic/Latina

6.40%

East Asian/ Asian American

2.70%

Black/ African American

1.80%

South Asian/ Indian American

1.80%

Hawaiian/ Pacific Islander

<1.00%

Middle Eastern/ Arab American

<1.00%

Native American/ Alaska Native

<1.00%

Education

High School

5.50%

Some College

16.40%

Associate’s Degree

6.40%

Bachelor’s Degree

31.80%

Master’s Degree

25.50%

PhD, MD, DO, or advanced graduate work

13.60%

Other

<1.00%

Income

< $25,000

10.90%

$25,000-$49,999

20.00%

$50,000-$74,999

20.90%

$75,000-$99,999

16.40%

$100,000-124,999

14.50%

> $125,000

17.30%

Attraction

Mostly Males

64.5%

Equal Females & Males

13.60%

Mostly Females

10.90%

Only Females

8.20%

Not sure

2.70%

Health Insurance

Yes

94.50%

5.50%

Table 3.2

Measurement Descriptive Statistics

Measure

Minimum

Maximum

M(SD)

SCSE

46.77(9.31)

.92

SSB

18.14(4.66)

.64

Het*

112

93.60(15.75)

.91

Anx*

17.46(4.11)

.73

Dep*

29.36(6.76)

.89

PSH

3.65(.62)

---

Safe

4.80 (.51)

---

SFW*

23.35(6.05)

.83

SexSat

19.75(7.04)

.94

STI*

5.71(.89)

.81

Note. *Scales were recoded so that higher scores indicate better sexual health.

SCSE= sexual communication self-efficacy, SSB= safe sex behaviors, Het=

heteronormativity, Anx= Anxiety, Dep= Depression, PSH= perceived physical sexual health,

safe= safety, SFW= sexual functioning, SexSat= sexual satisfaction, STI= Sexually transmitted

infections

Table 3.3

Correlation of Variables

Measure

SCSE

SSB

Het

Anx

Dep

PSH

Safe

SFW

SexSat

STI

SCSE

SSB

-.01

Het^

.03

-.02

Anx^

.38**

-.19

.65

Dep^

.13

-.03

-.08

.42**

PSH

.10

-.06

.09

.40**

.04

Safe

.43**

-.08

-.07

.27**

.17

.27**

SFW^

.32**

-.13

.14

.46**

.21*

.31**

-.05

SexSat

.49**

-.14

.21

.53**

.38

.33**

.35**

.53**

STI^

-.01

.11

-.05

-.03

.10

-.01

.02

-.08

.01

Note. * p<.05, **p<.001

^ Scales were recoded so that higher scores indicate better sexual health.

SCSE= sexual communication self-efficacy, SSB= safe sex behaviors, Het=

heteronormativity, Anx= Anxiety, Dep= Depression, PSH= perceived physical sexual health,

safe= safety, SFW= sexual functioning, SexSat= sexual satisfaction, STI= Sexually transmitted

infections

HETERONORMATIVITY AND SEXUAL HEALTH 66

Table 3.4.

Unstandardized estimates, standardized estimates, and standard errors of the based mediation model, low heteronormativity model,

and high heteronormativity model.

Paths

Un.

Base Model

Stand.

S.E.

Low Heteronormativity High Heteronormativity

Un. Stand. S.E. Un. Stand. S.E.

SSB  CSE

-.00

.05

.04

.07

-.04

-.07

.06

Compsex  SSB

-.20

-.16

.10

-.23

-.186

.12

-.33*

-.28*

.03

Compsex CSE

.37*

.60*

.06

.52*

.81*

.06

.25*

.44*

.08

Insur  CSE

-5.7*

-.23*

2.13

-.62

-.02

2.55

-8.67*

-.381*

2.96

Note. * indicates p<.05

Un. = Unstandardized, Stand. = Standardized

HETERONORMATIVITY AND SEXUAL HEALTH 67

Note. * indicates significant path, p < .05

Anxiety

Sexual

Communication

Self-Efficacy

Safe Sex Behaviors

Comprehensive

Sexual Health

STI/ HIV

Sexual Functioning

Sexual

Satisfaction/

Pleasure

Safety

Depression

Perceived physical

sexual health

.60*

.00

.16

Figure

3.1

. Base mediation model with standardized estimates.

HETERONORMATIVITY AND SEXUAL HEALTH 68

Sexual

Communication

Self-Efficacy

Safe Sex Behaviors

Comprehensive

Sexual Health

STI/ HIV

Sexual Functioning

Sexual

Satisfaction/

Pleasure

Safety

Depression

Perceived physical

sexual health

Anxiety

Figure

. Model with standardized estimates for queer women

with low heteronormativity.

Note.

indicates significant path, p < .05

.81*

.07

.19

HETERONORMATIVITY AND SEXUAL HEALTH 69

Figure 3.3. Model with standardized estimates for queer women with high

heteronormativity.

Note. * indicates significant path, p < .05

Anxiety

Sexual

Communication

Self-Efficacy

Safe Sex Behaviors

Comprehensive

Sexual Health

STI/ HIV

Sexual Functioning

Sexual

Satisfaction/

Pleasure

Safety

Depression

Perceived physical

sexual health

.44

.07

.28

HETERONORMATIVITY AND SEXUAL HEALTH 70

CHAPTER 4: HETERONORMATIVITY, SEXUAL HEALTH COMMUNICATION,

AND COMPREHENSIVE SEXUAL HEALTH IN HETEROSEXUAL WOMEN

Sexual health has been a public health concern in recent decades (ODPHP, 2019a). The

World Health Organization (WHO; 2019) defines sexual health as “a state of physical, mental,

and social well-being in relation to sexuality” (ASHA, 2019, p.1). Unfortunately, disparities

often exist across a range of health outcomes, including those specific to sexual health.

Historically, research has frequently examined sexual health as the absence of disease (Zielinski,

2013), leading to narrow conceptualizations of sexual health and disparities (i.e., inequitable

chances of being sexually healthy based on a minority identity possessed; CDC, 2017a).

However, based on the WHO’s (2019) definition, sexual health spans more than disease and

should be examined in a more comprehensive way (Zielinski, 2013). One such group that

experiences disparities are heterosexual women. As outlined below, there appear to be sexual

health disparities present for this group across the domains described by the WHO (2019)

definition.

Heterosexual women, when compared to heterosexual men, often have poorer sexual

health outcomes (such as higher incidence of sexually transmitted infections with more severe

long-term health consequences; STIs; ODPHP, 2019a). The CDC (2019a) reported that

heterosexual women accounted for 19% of new HIV diagnoses in 2017. Of those diagnoses,

approximately 86% occurred from heterosexual contact. Conversely, best estimates suggest that

only 19% of heterosexual male HIV diagnoses occurred through heterosexual contact (CDC,

2017). The CDC (2017) also reported 1,127,651 chlamydia diagnoses in women and 577,644

chlamydia diagnoses in men. With regard to mental health, heterosexual women are more likely

HETERONORMATIVITY AND SEXUAL HEALTH 71

than heterosexual men to experience negative mental health consequences including feelings of

depression, shame, and guilt about their sexuality after engaging in sexual behavior (Allyn,

2000). Further, heterosexual women are less likely to orgasm than heterosexual men during

different-gender sexual interactions (Kinsey Institute, 2019), which has been identified as an

indicator of sexual health (WHO, 2019). Research also suggests that heterosexual women report

less autonomy in sexual decision making, such as condom use. Lower autonomy can make a

woman feel that she is not able to express her wants in the sexual encounter (Cook-Lindsay,

2013). Thus, there is substantial risk that undermine heterosexual women’s sexual health,

imploring research to examine these more closely.

ODPHP (2019) suggests that health disparities, including sexual health disparities, are an

outcome of larger social inequities. The Determinants of Health (DoH) framework, created by

the World Health Organization, proposes that health outcomes occur from a combination of

personal, social economic, and environmental factors (ODPHP, 2019). The five facets of DoH

are policymaking, social factors, health services, individual behaviors, and biology and genetics.

The role that social factors have on individual sexual health behavioral processes were examined

in this study (ODPHP, 2019).

Social factors, or social determinants of health, are the larger cultural context in which

someone exists, learns, and interacts with others (ODPHP, 2019). Social factors include cultural

norms, attitudes, social support, and social interactions. One prominent social norm in the United

States is heteronormativity (van Eeden-Moorefield, 2018). Heteronormativity is a socially

constructed, often internalized, and perpetuated belief that privileges individuals who are

heterosexual and engage in monogamous sex only in the context of legal marriage (D’Emilio &

HETERONORMATIVITY AND SEXUAL HEALTH 72

Freedman, 2012; van Eeden-Moorefield, 2018). With regard to heterosexual sexual behavior,

heteronormative scripts encourage men to be sexual aggressors and sexual decision makers,

whereas, they encourage women to be sexually chaste and ambivalent (D’Emilio & Freedman,

2012). When it comes to sexual behavior, these messages often lead to gendered power

imbalances, where women are thought to be subordinate to men (Hlavka, 2014). These

imbalances may minimize a woman’s perception of her ability to discuss her sexuality with male

partners (which is an example of an individual behavioral determinant of health, ODPHP, 2019).

This could potentially be due to fear of losing a potential sexual partner (Rinaldi-Miles, Quick,

and LaVoie, 2014) or fear of being deemed “slutty” (i.e., a woman who is presumed to be

sexually promiscuous; Armstrong, Hamilton, Armstrong & Seeley, 2014, p.104).

Importantly, the avoidance of sexual health communication has been linked to engaging

in fewer safe sex behaviors during sexual intercourse (FoSE, 2012; Widman, Noar,

ChoukasBradley, & Francis, 2014), which could result in negative sexual health outcomes.

Recent estimates suggest that only 56% of heterosexual women reported using a condom the

first time they had sex (Kinsey Institute, 2018). Additionally, in a 4 week study conducted by the

CDC (2019b), 75% of unmarried women reported never using a condom during sexual

intercourse over that span of time. This could be due, in part, to heteronormative messages

perpetuating gendered power imbalances (Rinaldi-Miles, Quick, & LaVoie, 2014). Using focus

groups, Rinaldi-Miles and colleagues (2014) found that women were likely to follow men’s

requests to not use condoms due to fear of losing a potential sexual partner. Heteronormative

scripts are patriarchal and often put men largely in charge of the sexual relationship (Lovejoy,

2015). Additionally, Rinaldi-Miles and colleagues (2014) found that men and women may share

HETERONORMATIVITY AND SEXUAL HEALTH 73

inaccurate sexual histories such that they align more closely with social norms (e.g., number of

sexual partners), which may have sexual health consequences (e.g., women saying they have

fewer sexual partners than they actually do and men saying they have more sexual partners than

they actually do to fit heteronormative scripts). Therefore, heteronormative messages may

contribute to women’s avoidance of sexual health communication and safe sex behaviors, which

may contribute to negative sexual health outcomes.

Research suggests that one way to combat these sexual health disparities is through

improving sexual health communication self-efficacy (Quinn-Nilas et al., 2016). Having high

levels of sexual communication self-efficacy (i.e., believing that you are able to discuss your

sexuality, Quinn-Nilas et al., 2016) has been linked to increased safe sex behaviors such as

improved condom use behavior (FoSE, 2012; Widman et al., 2014) as well as better overall

sexual experiences (e.g., pleasure; Jones, Robinson & Seedall, 2018). Li and Samp (2019)

examined how power was related to gender, sexual communication, and condom use in

heterosexual couples. Using an online survey, they found that women who had more power in

their relationships were more likely to use condoms and this relationship was mediated by sexual

communication. This suggests that when women felt they were able to communicate about their

sexuality, more safe sex behaviors occurred. Additionally, using dyadic path analyses of survey

data, Jones and colleagues (2018) found that sexual communication lead to higher orgasm

frequency in women and overall higher relationship satisfaction among both genders. This

further emphasizes the importance of sexual communication self-efficacy as a process to better

understand comprehensive sexual health outcomes.

HETERONORMATIVITY AND SEXUAL HEALTH 74

The Current Study

Taken together, women’s internalization of heteronormative attitudes may influence their

ability to discuss their sexuality with potential partners (Li & Samp, 2019; Rinaldi-Miles, et al.,

2014), lowering their use of safe sex behaviors (Li & Samp, 2019; Quinn-Nilas, et al., 2016),

and ultimately leading to negative comprehensive sexual health outcomes (WHO, 2019). Little

research has focused on the impact that heteronormativity has on heterosexual women’s sexual

communication self-efficacy and in turn their comprehensive sexual health outcomes. Therefore,

the purpose of this study was to examine the links between these three factors. Specifically, the

hypothesized model (see Figure 4.1) suggested a direct relationship between sexual

communication self-efficacy and comprehensive sexual health outcomes (Quinn-Nilas et al.,

2016; Widman, Choukas-Bradley, Helms, Golin & Prinstein, 2014). Because sexual

communication is often about safe sex behaviors (Widman et al., 2014), and safe sex behaviors

improve sexual health outcomes (Planned Parenthood, 2019), it was predicted that safe sex

behaviors would partially mediate this relationship. Additionally, it was predicted that

heteronormativity would moderate the entire model (see Figure 4.2). Women may avoid

discussing their sexuality with a potential partner because heteronormativity encourages women

to stay silent about their sexuality (D’Emilio & Freedman, 2012). Further, heterosexual women

may accept male condom use preferences (because of heteronormative scripts), and therefore,

engage in fewer safe sex behaviors leading to negative sexual health outcomes (Rinaldi-Miles et

al., 2014). Finally, it was predicted that heteronormativity would moderate the direct relationship

between sexual communication self-efficacy and comprehensive sexual health outcomes.

Women may feel that discussing their sexuality will lead to social and relationship repercussions

HETERONORMATIVITY AND SEXUAL HEALTH 75

and therefore, may choose not to discuss her sexual health. This in turn, would lead to more

negative sexual health outcomes (Cunningham, Tschann, Gurvey, Fortenberry & Ellen, 2002;

D’Emilio & Freedman, 2012).

Methods

Sample

Data were collected from a convenience sample of 188 cisgender heterosexual women

from across the United States who were surveyed online through Facebook (which meets power

needs for the analysis, .90; G*Power). Participant ages ranged from 19 to 82 (M = 34, SD =

11.14). The overwhelming majority of the sample was Non-Hispanic White women (88.80%).

Additionally, the sample was highly educated: 41.50% reported earning a bachelor’s degree,

followed by 28.70% reported earning a master’s degree, and 12.80% reported earning an

advanced graduate degree (e.g., PhD, MD, DO). Additionally, almost all participants (97.90%)

reported having health insurance at the time they participated in the survey. More than half (i.e.,

61.00%) of the participants made over $75,000 a year (Table 4.1).

Procedure

The research team posted a recruitment announcement (Appendix A) to their personal

Facebook pages that informed people about the online 30-minute study about sexual health. The

announcement included a link to the informed consent (Appendix B) and survey (Appendix C).

The announcement also asked followers to share information about the study on their own pages

(i.e., snowball sampling; Gelinas et al., 2017). Recruitment through social media has become a

popular strategy to identify participants because of its widespread use, ease of dissemination,

and ability to reach diverse and hard to reach populations (Urban & van Eeden-Moorefield,

2018; Gelinas et al., 2017). At the end of the survey participants were given the option to

HETERONORMATIVITY AND SEXUAL HEALTH 76

participate in a raffle to receive one of 40 $25 Amazon gift cards (Appendix D). Information for

the raffle was input into an unlinked page so that participant responses remained anonymous

(Appendix E).

The survey was set so that it could only be taken one time per each IP address to safeguard data

independence (Birnbaum, 2004).

Measures

The survey consisted of demographic questions (e.g., age, race, ethnicity, SES) as well as

those that asked participants about their sexual health communication self-efficacy, safe sex

behaviors, internalized heteronormativity, and comprehensive sexual health over the last 12

months. The CDC (2017a, 2017b, 2017c) recommends that individuals get tested for STIs and

HIV once every 12 months to assess their sexual health. Therefore, participants were asked to

reflect on their experiences over that time span. Some scales (i.e., Heteronormativity, Anxiety,

Depression, Sexual Functioning; originally a dysfunction scale, and STIs) were reverse scored so

that higher scores indicated better sexual health. For example, in the heteronormativity measure,

high scores indicated lower heteronormative attitudes and lower scores indicated higher

heteronormative attitudes. Although this might seem counterintuitive, we wanted all higher

scores to reflect a more positive dimension of the variables measured (e.g., a lower

heteronormative attitude is good and related to more positive outcomes; Habarth, Holmes,

Sandoval, & Balsam, 2019). Table 4.2 presents scale descriptive statistics (i.e., minimum,

maximum, mean, standard deviation, and reliability).

Sexual communication self-efficacy. A revised 15-item version of the Quinn-Nilas and

colleagues (2016) sexual communication self-efficacy scale was used to measure participants’

HETERONORMATIVITY AND SEXUAL HEALTH 77

perceptions of their ability to discuss their sexuality with a partner. Participants rated their

perceived ability to engage in 15 conversations with a sexual partner using a 4-point Likert scale

(1= very difficult to 4= very easy). Sample items included: “Tell them you would like to have

sex more often?” and “Tell them a sexual activity feels good.” Scores were summed and higher

scores indicated higher sexual communication self-efficacy.

Safe sex behaviors. Due to length, DiIorio’s (2009) Safe Sex Behavior Questionnaire

was modified to 8 questions and used to measure safe sex behavior. Questions that were specific

to the sexual health indicators used in this study were included. Sample questions include “I

stop foreplay long enough to put on a condom (or for my partner to put on a condom)” and “I

ask potential partners about their sexual histories” (1=never to 4= always). Two questions were

reverse scored. Scores were summed and higher scores indicated more safe sex behaviors.

Heteronormativity. Habarth’s (2014) Heteronormative Attitudes and Beliefs scale was

used to measure heteronormativity. This scale consisted of two subscales: Essential Sex and

Gender Subscale and the Normative Behavior Subscale. Together, this scale consisted of 16

items measured on a likert scale (1= strongly disagree, 7= strongly agree). Sample questions

included: “People who say that there are only two legitimate genders are mistaken”. Eight

questions were reverse scored. Items were summed.

Comprehensive sexual health. Comprehensive sexual health was measured as a latent

variable using the WHO (2019) comprehensive definition of sexual health. The observed

variables were anxiety, depression, perceived physical sexual health, safety, sexual functioning,

sexual satisfaction/pleasure, and STIs/HIV.

HETERONORMATIVITY AND SEXUAL HEALTH 78

Anxiety. With reference to Janda & O’Grady’s (1980) Sex Anxiety Inventory, an author

created 3-item scale was used to measure sexual anxiety. “I generally feel anxious about

masturbation” was a sample question and was measured using a 7-point Likert scale (1= Not

true of me at all, 7= Very true of me). Scores were then summed. The scale was reverse coded so

that higher scores indicated lower sexual anxiety.

Depression. A modified version of Radloff’s (1977) 12-item CESD-R was used to

measure depressive symptoms. This 10-item summed scale asked participants to indicate the

number of times they felt or behaved in a certain way in the last week. Responses were measured

on a 4-point Likert Scale (1= rarely or none of the time; less than 1 day, 4= most or all of the

time; 5-7 days). An example question was: “I had trouble keeping my mind on what I was

doing.”

Perceived physical sexual health. Author(s) created an item to measure global perceived

physical sexual health. The question asked, “To what extent do you feel you are physically

healthy enough to have sex?” and used a likert scale (1= Not at all healthy, 4=Very healthy).

Safety. Author(s) created an item to measure global perceived safety in sexual

encounters. The question asked “Think about the last time you engaged in sex with a partner.

How safe did you feel?” (1= Not safe at all, 5=Very safe).

Sexual functioning. A 5-item modified version of Rosen’s (2000) Female Sexual

Function Index was used to asses female sexual functioning (i.e., desire, arousal, lubrication,

orgasm, and pain). A sample question was “How often did you find it difficult to have an orgasm

when you wanted to?” (1= never, 7= always).

HETERONORMATIVITY AND SEXUAL HEALTH 79

Sexual Satisfaction/Pleasure. A version of the summed Male Sexual Health

Questionnaire (Rosen et al., 2004) was modified to apply to women and was used to measure

experiences of sexual satisfaction and pleasure. Questions were asked without assuming the

gender of the participant. “How satisfied are you with the quality of the sex life you have?” was

an example question and was measured on a 5-point Likert scale (1= Not at all satisfied, 5=

Very satisfied). Higher scores indicated more sexual satisfaction and pleasure.

STIs/HIV. Author created questions were used to assess participant experiences with

STIs and HIV. Questions assessed frequency of STI and HIV testing and number of Chlamydia,

Gonorrhea, and/or Syphilis diagnoses over the last year. Because herpes and HIV are treatable

chronic conditions, two single-item measures were used to identify if participants had herpes or

HIV. The questions asked, “Do you have herpes?” and “Do you have HIV?” Answers included

“yes, no, not sure, prefer not to answer.” In this sample, no women responded that they were

HIV positive and therefore, HIV was excluded from scale combination. For score combination,

herpes was recoded so that so that yes=1 and no =0. Then all STI scores were combined and

scores ranged from three to six.

Data Analysis Plan

Data were imported into SPSS for cleaning and assessment of normality, reliability, and

missingness. Scores were summed and preliminary relationships between variables were

analyzed and were as expected (see Table 4.3). Once cleaned, data were imported into AMOS for

analysis and model testing was conducted sequentially. First, to ensure fit of the measurement

model (i.e., the observed variables used to measure the latent construct of comprehensive sexual

health outcomes), a confirmatory factor analysis (CFA) was conducted using maximum

HETERONORMATIVITY AND SEXUAL HEALTH 80

likelihood estimation (Schumacker & Lomax, 2010). Model fit was assessed using Chi Square

(χ2) test, RMSEA, CFI, and SRMR (Schumacker & Lomax, 2010).

AMOS was used to test the hypothesized moderated-mediation model (Arbuckle, 2013)

using ML estimation because of its ability to predict robust parameters for a mix of observed and

latent variables (Schumacker & Lomax, 2010). To test for mediation, 1,000 bootstraps were run.

Bootstrapping takes random subsamples and estimates them to see if they are likely present in

the model (Cheong & MacKinnon, 2012). To test for moderation of the model, first a median

split was used to identify groups that had high internalized heteronormativity and low

internalized heteronormativity. Then a multi-group analysis was run in AMOS (Arbuckle, 2013)

which compared both the constrained (or theoretically predicted) and unconstrained (estimated

models).

Results

Preliminary Results

Correlations were used to assess the need to include controls in the model. A number of

demographic variables were correlated with at least one observed endogenous variable.

Specifically, education was correlated with sexual functioning (r(186) = -.18, p < .05), income

was significantly correlated with STIs (r(186) = .18, p< .05), depression (r(186) = .16, p < .05),

anxiety (r(186) = .24, p < .05), and feelings of safety (r(186) = .18, p < .05). Finally, health

insurance was related to sexual functioning (r(186) = .18, p < .05). However, when added to the

model, no controls were significant. Therefore, they were all dropped from the model.

Missing data analysis was conducted using SPSS’s Missing Value analysis. No variable

had more than 20% missing responses, suggesting responses were missing completely at random

HETERONORMATIVITY AND SEXUAL HEALTH 81

(Dong & Peng, 2013). Missing data were replaced using five estimation rounds of multiple

imputation (MI) in SPSS. MI is reliable with replacing missing data of varying sizes and is very

efficient (Madley-Dowd, Hughes, Tilling, & Heron, 2019). A CFA was conducted to validate

measurement of the latent construct of sexual health. Model fit was strong and all parameter

estimates were significant except STI diagnoses (See Chapter 2). As stated in the measurement

section, scores were coded so that higher scores indicated higher sexual health. This was to

ensure consistency within the latent measurement.

Hypothesized Model Testing

First, the base mediation model was tested. This model tested the direct relationship

between sexual communication self-efficacy and comprehensive sexual health outcomes as well

as the indirect relationship through safe sex behaviors. Results suggested the model had good fit,

χ2(21, N=188)=27.39, p = .16, CFI = 0.98, GFI = .97, RMSEA = .04, and accounted for 65% of

the variation in comprehensive sexual health. All parameter estimates were significant except the

link between sexual communication self-efficacy and safe sex behaviors (p = .06, See Table 4.4,

Figure 4.1). Therefore, the indirect effect was not significant for the full model. However, there

was a moderately strong negative relationship between safe sex behaviors and comprehensive

sexual health outcomes in this model. In other words, as safe sex behaviors increased,

comprehensive sexual health outcomes decreased. That is, as women used more safe sex

behaviors they experienced decreases in their comprehensive sexual health. Notably, results

suggest a strong direct positive relationship between sexual communication self-efficacy and

comprehensive sexual health outcomes. Thus, the base mediation model fit the data which

HETERONORMATIVITY AND SEXUAL HEALTH 82

suggested the presence of at least partial mediation might be found in the full moderated

mediation model.

Therefore, using multi-group analysis, moderation of the mediation model was tested.

Groups were heterosexual women with high internalized heteronormativity and heterosexual

women with low internalized heteronormativity. Results suggested that moderation was present

at the model level. Of additional interest, the model for women with high internalized

heteronormativity only accounted for 57% of the variation in comprehensive sexual health

outcomes (R2=.57), which is less than the variance explained by the base mediation model.

Contrastingly, the model for women with low internalized heteronormativity accounted for 73%

of the variance in comprehensive sexual health (R2=.73).

Further probing of model links was conducted using The Stats Tool Package excel file

(Gaskin, 2012) to identify which links demonstrated moderation. First, the direct link between

sexual communication self-efficacy and comprehensive sexual health was tested, and there was

not significant moderation (i.e., χ2(43, N =188) = 47.66 < 48.44 which was the 90% CI

threshold). Note, both groups demonstrated strong direct links though. Next, the link between

sexual communication self-efficacy and safe sex behaviors was tested for moderation.

Moderation was present with the link being significant (p < .05) for women who had high

internalized heteronormativity (see Figure 4.2), but insignificant for women who had low

internalized heteronormativity (see Figure 4.3; χ2(43, N = 188) = 48.55 > 48.44 which was the

90% CI threshold). We then tested the second part of the indirect effect pathway: the link

between safe sex behaviors and comprehensive sexual health outcomes. This link was not

significantly moderated, but remained significant for both groups (χ2(43, N = 188) = 46.70 <

HETERONORMATIVITY AND SEXUAL HEALTH 83

48.44 which was the 90% CI threshold). Taken together, partial moderation of the mediation

model was only present for women with high internalized heteronormativity.

Discussion

Grounded in a DoH framework, this study examined the links between sexual

communication self-efficacy, safe sex behaviors, and comprehensive sexual health outcomes,

within the context of heteronormativity among cisgender heterosexual women. The hypothesized

model predicted that sexual communication self-efficacy would predict comprehensive sexual

health, and that this link would be partially mediated by safe sex behaviors and moderated by

heteronormativity. Data partially support our moderated mediation hypothesis: Partial mediation

was only present for heterosexual women with high internalized heteronormativity. In other

words, the link between communication self-efficacy and comprehensive sexual health outcomes

acted differently for women with high internalized heteronormativity and women with low

internalized heteronormativity. However, the link between safe sex behaviors and comprehensive

sexual health outcomes and the direct relationship between sexual communication self-efficacy

and comprehensive sexual health outcomes did not significantly change. Therefore, although

data did not completely support the hypothesized model, these findings make significant

contributions to the literature. These are discussed below.

First, the direct relationship between sexual communication self-efficacy and

comprehensive sexual health outcomes stayed strong, positive, and significant for heterosexual

women regardless of their level of internalized heteronormativity. This is consistent with the

previous research that sexual communication self-efficacy contributes to better sexual health

outcomes (e.g., Widman et al., 2014). For example, Landor and Winter (2019) wanted to

HETERONORMATIVITY AND SEXUAL HEALTH 84

understand how relationship quality, comfort with sexual communication, and safe sex outcomes

are related for young women in monogamous relationships. They found that relationship quality

and being comfortable communicating about sex was associated to pregnancy prevention (i.e.,

through condom use and contraceptive use) and substance use during sexual encounters. Those

who were comfortable communicating about sex with a partner took more precautions during

sexual intercourse. Thus, supporting that women with high sexual communication self-efficacy

have better comprehensive sexual health.

Moderation of the indirect effect partially supported our hypothesized model.

Specifically, the indirect effect was only significant for heterosexual women with high

internalized heteronormativity. For women with low internalized heteronormativity, this path

remained insignificant with a low parameter estimate, suggesting that this relationship did not

exist for this group. Culturally, women are taught that they should not speak about sex or be

sexually knowledgeable about their bodies (D’Emilio & Freedman, 2012). For example, women

understanding what behaviors may lead to sexual pleasure and orgasm (e.g., through solo

masturbation) may result in women being slut shamed (D’Emilio & Freedman, 2012; Haus &

Thompson, 2019), perpetuating the sexual double standard that men should be sexual but women

should not (Haus & Thompson, 2019). Using grounded theory methodology, Kaestle and Allen

(2011) examined college student perceptions of masturbation. They asked questions about how

they learned about masturbation, how they internalized social stigma and taboos related to

masturbation, and how they navigated the relationship between stigma and pleasure. They found

that most students believed that masturbation was more acceptable for men than women, and

they were apprehensive to even discuss masturbation. Men discussed masturbation as a positive

HETERONORMATIVITY AND SEXUAL HEALTH 85

and healthy behavior, whereas women were less descriptive and positive about their experiences.

This demonstrated the pervasiveness of culturally stigmatizing scripts for women and their

sexuality. Thus, women with high internalized heteronormativity may not believe that they

should talk about the numerous facets of sexual health (e.g., sexual pleasure, sexual history,

sexual concerns; Horan, 2016; Lehmiller, et al., 2014) out of fear they may be viewed as a slut or

be shamed by a partner (e.g., sexual double standard; Greene, & Faulkner 2005).

However, for heterosexual women with high internalized heteronormativity, discussing

safe sex behaviors may be less threatening, and therefore, their sexual communication focuses on

those. The discussion of safe sex behaviors, within heterosexual relationships, is commonly

discussed in school sexuality education (Baptiste-Roberts, 2017), the media (Martino, Collins,

Kanouse, Elliot, & Berry, 2005), and by parents (Widman, Choukas-Bradley, Noar, & Garrett,

2016). Therefore, heterosexual women who have high heteronormativity may still feel

comfortable discussing safe sex behaviors with a partner, since that is somewhat normalized in

society. For women who have low internalized heteronormativity, perhaps they do not prescribe

to the cultural norms that have perpetuated shame and silence around women communicating

about their sexuality. This group of women may have more self-efficacy in discussing other

facets of sexual health with a partner, and therefore, indirect discussions of sexuality through

safe sex behaviors does not exist.

Finally, for both models, the relationship between safe sex behaviors and comprehensive

sexual health outcomes was negative and significant (i.e., safe sex behaviors decreased,

comprehensive sexual health outcomes increased). These findings were not consistent with our

hypothesis; however, they suggest that engaging in safe sex behaviors for heterosexual women

HETERONORMATIVITY AND SEXUAL HEALTH 86

may not lead to better comprehensive sexual health. First this could be due to error in

measurement of STIs, which would be the most directly affected indicator of engaging in safe

sex behaviors (e.g., CDC, 2013). If STIs were measured differently leading to a significant factor

loading on comprehensive sexual health, it is possible that this relationship would change to

positive. However, it is possible that these findings are a function of gendered power

differentials that often occur in heterosexual sexual intercourse (Hlavka, 2014). For example,

condom use negotiation can be a gendered and power-based. Men may prefer to have

unprotected intercourse due to decreased sensation when using a condom (Grady, et al., 1993).

So, when a woman suggests her preference to use condoms during sex her partner may

encourage her not to in order to improve his sexual experience (Conley & Collins, 2006; Grady,

Klepinger, Billy, & Tanfer, 1993). Women may agree to this, out of fear of losing the romantic

partner in the long run

(Rinaldi-Miles et al., 2014). Therefore, even though women feel that they are able to talk about

safe sex behaviors, male dominated sexual scripts override that self-efficacy. Additionally,

women may now have higher feelings of anxiety, depression, and lower feelings of safety, since

their preferences were ignored, resulting in lower comprehensive sexual health outcomes.

Additionally, this model explained less of the variance across comprehensive sexual health than

the base mediation model. This suggests that there may be other variables that influence

comprehensive sexual health outcomes that were not presented in the original model for this

group. Based on the previous explanation, perhaps more variance would be explained for women

with high heteronormativity, if the model included partner communication and partner safe sex

behavior preferences. The decision to engage in safe sex behaviors is more of a dyadic

HETERONORMATIVITY AND SEXUAL HEALTH 87

interpersonal process, and therefore, understanding both partners preferences may enhance the

model.

Conclusion

Notably, the extant literature has focused almost exclusively on behavioral and individual

indicators of sexual health (i.e., safe sex behaviors prevent STIs), which has overlooked how

individual and cultural processes interact, which can directly predict comprehensive sexual

health outcomes (Schalet, 2011). Results from the current study suggested that communication

self-efficacy is the strongest predictor of comprehensive sexual health for heterosexual women

and that the indirect relationship of sexual communication self-efficacy, safe sex behaviors, and

comprehensive sexual health outcomes is only present in women with high internalized

heteronormativity. Thus, when studying heterosexual women’s comprehensive sexual health,

research must consider cultural context and the impact of heteronormative gendered power

differentials and shaming women’s sexuality.

Limitations

Our results must be considered within the limitations of our study. First, research

suggests that when discussing sex, sexual behaviors, and sexual health, participants may respond

in socially desirable ways or untruthful ways to avoid disclosing potentially stigmatizing

information (Schroder, Carey & Vanable, 2003). Therefore, it is important to consider the

accuracy of the self-reports (Schroder et al., 2003). Using online surveys has been found to

alleviate some of the limitations that are present when surveying about sexuality, because of

enhanced anonymity (Schroder et al., 2003). Therefore, online survey methodology was selected

for this reason. However, online surveys comes with shortcomings of their own (Lefever, Dal, &

HETERONORMATIVITY AND SEXUAL HEALTH 88

Matthaisdottir, 2007). For example, the researcher cannot confirm that participants fit the

inclusion criteria to participate in the study (Lefver et al., 2007). To combat this, recruiting

through social media networks (such as Facebook) can provide more assurance that participants

fit search criteria. Additionally, this provides easy access to a population from which to collect

data (King, O’Rourke, & DeLongis, 2014). One limitation of recruiting through social media,

that was evident in this study, is the collection of homogenous samples (King et al., 2014). In

theory, people from diverse backgrounds are on social media and therefore, it is a tool to access

diverse samples (King et al., 2014). However, when recruiting through personal friend networks,

it is likely that samples will be somewhat homogenous given people tend to be friends with

people that are similar to them (Naruchitparames, Gunes, & Louis, 2011). Accordingly, it makes

sense that our sample was homogenous and socially privileged (e.g., mostly White, middleclass).

Additionally, our study was cross-sectional. Both of these factors combined suggest that our

results must be considered within the confines of our study. However, as outlined in the

discussion, enough research exists that supports our findings, which would suggest that similar

results may be seen across more diverse populations. That being said, future research should use

these models with more diverse populations, to understand how sexual communication

selfefficacy, safe sex behaviors, and comprehensive sexual health outcomes interact across

diverse groups.

HETERONORMATIVITY AND SEXUAL HEALTH 89

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