Lesbian, Gay, Bisexual, and Transgender Women’s Health
Kirsten M. Smith
Olivia Bolles
Lesbian and bisexual women are part of our patient population. It is estimated that 1.4 to 5.0% of the female population in the United States have engaged in same-sex behavior with other women.1,2 In the year 2000 census in the United States, “same-sex” households were found in over 99% of counties, with the highest prevalence in urban areas, where they ranged from 5 to 7% of households.3 This translates to 1.9 to 6.8 million women when using U.S. Census Bureau estimates from July 2009 (age 10 years and older for a total of 135,070,678 females in the United States).4
How does one define “lesbian”? Human sexuality has three components: attraction, behavior, and identity. So this means a lesbian may be defined as a woman who is attracted to a woman, a woman who engages in sexual behavior with a woman, and/or a woman who self-identifies as lesbian. A bisexual woman may be a woman who has attraction for and/or engages in sexual behavior with both men and women. Surveys of self-identified lesbians show a wide range of sexual behaviors (e.g., celibacy, heterosexuality, bisexuality, homosexuality). Behavior is not always concordant with self-identification and may change, sometimes frequently, over time. For example, a self-identified lesbian may also be attracted to, and engage in, sex with transgender individuals. Because of this fluidity in sexual behavior, it is advisable to discuss sexual behavior history with every patient at each visit. These discussions may be easier if patients are told that questions relating to sexual identity and behavior are asked of everyone because these issues have direct, and indirect, relevance to health care and preventive medicine decisions.
As alluded to above, human sexual orientation exists as a continuum ranging from solely heterosexual to solely homosexual. Although the mechanisms for the development of a particular sexual orientation are unclear, current literature and most scholars in the field state that sexual orientation is not a choice. Sexual orientation is likely determined by a combination of genetic, hormonal, and environmental influences.5,6
Lesbian and bisexual women are at risk for the same kinds of health problems as other women; their sexual orientation alone does not put them at higher risk for any particular health issues per se. However, their health risks may be influenced in unique ways, that is, differential risks for disease may arise because of specific behaviors that may be more common in this population. According to large-scale national surveys, women who have sex with women are more likely to smoke and drink alcohol, have a high body mass index (BMI), be nulliparous or of low parity, and have fewer preventive health screenings than heterosexual women7,8; they are less likely to have used oral contraceptives or to have breastfed. These characteristics constitute high-risk factors predisposing to colon, lung, endometrial, ovarian, and breast cancer, as well as cardiovascular disease and diabetes.
There are also differences in the stresses to which they are exposed that have a psychosocial impact. Although homosexuality is a normal variation of human sexual and emotional expression, lesbian women frequently endure prejudice and discrimination in both their public and private lives across their lifespan.
Lesbian and bisexual women are confronted with many barriers to quality health care, including fears of disclosure and the subsequent homophobic and heterosexist attitudes among health care providers.9, 10, 11 Homophobia is defined as the irrational fear of and negative attitude toward homosexual people. In the United States, there are two particularly prominent influences that foster antihomosexual attitudes—religious fundamentalism and heterosexism. Heterosexism is the belief in the moral superiority of institutions and practices associated with heterosexuality.12,13 Heterosexism not only exerts external pressures from societal expectations, it also has internal influences. It may instill shame in lesbian, gay, and bisexual individuals, causing them to internalize the homophobia that is directed toward them by society.
BARRIERS TO CARE
Interaction with the health care system may be inherently different for lesbian women. The Institute of Medicine (IOM) defines three primary types of barriers when considering access to health care. These are (a) structural, (b) financial, and (c) personal and cultural barriers. Potential structural barriers include difficulty in accessing needed services, difficulty in finding and choosing a lesbian-friendly health care provider, lack
of health insurance coverage for members of lesbian households, and the lack of legal recognition of partners. Financial barriers exist for lesbian and bisexual women just as they do for heterosexual women—many women do not receive health care simply because it is unaffordable. They may lack health care insurance coverage and may have lower overall incomes.14 Personal and cultural barriers that affect access to health care include the lack of cultural competency among health care providers, the fear of disclosure to providers, and the lack of lesbian focus in preventive and other health care. Many health care providers and many lesbians have misconceptions. For example, there are health care providers and lesbian women who believe lesbians do not need regular Pap tests or routine gynecologic care and that lesbian women are not at risk for sexually transmitted infections, including HIV.15
of health insurance coverage for members of lesbian households, and the lack of legal recognition of partners. Financial barriers exist for lesbian and bisexual women just as they do for heterosexual women—many women do not receive health care simply because it is unaffordable. They may lack health care insurance coverage and may have lower overall incomes.14 Personal and cultural barriers that affect access to health care include the lack of cultural competency among health care providers, the fear of disclosure to providers, and the lack of lesbian focus in preventive and other health care. Many health care providers and many lesbians have misconceptions. For example, there are health care providers and lesbian women who believe lesbians do not need regular Pap tests or routine gynecologic care and that lesbian women are not at risk for sexually transmitted infections, including HIV.15
Cultural competency can be defined as a set of congruent behaviors, attitudes, and policies that enable a system or group to work effectively in cross-cultural situations. In health care settings, it is a comprehensive system of clinical practices, standards of care, management policies, and institutional philosophy that provides and optimizes health care by integrating and being responsive to the cultural factors that influence the attitudes and behaviors of every patient.16,17 Cultural competency generally refers to the provision of services to differing ethnic or racial groups; however, it effectively encompasses the skills that are required to provide comprehensive care to lesbian and bisexual patients.15
Many lesbian and bisexual patients do not reveal their sexual orientation to health care providers. It has been reported that 53 to 72% of lesbians do not disclose their sexual orientation to physicians at the time they seek medical care.18,19 Lesbian and bisexual women report and fear negative experiences with health care providers, including a reluctance/refusal to treat, negative comments during the patient-provider encounter, and rough handling during examination.19,20
In order to help establish a good patient-provider relationship, the office setting should be perceived as welcoming and nonjudgmental. The administrative and clinical office staff should be culturally competent. There should be clear and understood expectations for respecting patient confidentiality. Registration forms and questionnaires should use inclusive language. They should include terms that recognize the patient’s significant relationships. For example, instead of simply asking if the patient is single, married, separated, widowed or divorced, include options such as “have a significant other” or “live with a domestic partner.” A nondiscrimination policy can be displayed in the waiting area that includes sexual orientation and gender identity. It is also helpful to have reading materials available and posters/pictures that are inclusive of lesbians; these can be placed in the waiting areas, bathrooms, and/or exam rooms (Fig. 25.1).21
 FIGURE 25.1 Nondiscrimination policy. (From O’Hanlan K. Health policy considerations for our sexual minority patients. Obstet Gynecol. 2006; 107:709-714.) |
SEXUALLY TRANSMITTED INFECTIONS
It is important to consider screening lesbian and bisexual women for sexually transmitted infections (STIs) if their sexual behavior places them at risk. Most lesbians have been sexually active with men at some point in their lives. Approximately 80% of lesbians report having had sex with men in their lifetime and 21 to 30% report having sex with men in the past 1 to 5 years.14 Although the overall incidence of vaginitis and STIs appears to be quite low in the lesbian population, all types of infections have been reported in lesbian and bisexual women and should be part of the differential diagnosis for vaginal discharge and pelvic pain.22,23 STIs can be transmitted by exclusive lesbian sexual activity, although exclusive lesbian sexual activity is associated with the lowest rates of infection. Bisexual women are more likely to contract an STI than women with exclusive sexual activity with other women.24,25
Infectious agents can be transmitted between women through sexual behaviors resulting in the exchange of vaginal secretions on hands or objects, for example, finger-to-vagina contact, genital-to-genital contact, or sharing objects (sex toys) without condom use or cleaning between partners. Sex toys and fingers can also transmit bacteria from the anal region to the vagina.
Bacterial Vaginosis
Bacterial vaginosis (BV) is a condition characterized by overgrowth of anaerobic flora relative to the normal protective lactobacilli in the vagina. It may produce a vaginal discharge that may or may not have a fishy odor and it may cause vaginal and vulvar irritation. BV is commonly found among women who have sex with women and frequently occurs in both members of monogamous lesbian couples.26 It has been identified in 25 to 52% of women who have sex with women.26, 27, 28 One study found the prevalence of BV among lesbians to be 28.7%, and 72.7% of the patients’ monogamous partners were concordant for BV. BV has been associated with receptive vaginal sex (penetration with fingers, a penis, or sex toy), receptive oral sex, a higher lifetime number of female sex partners, failure to always clean an insertive sex toy before use, and oral-anal sex with female partners.26, 27, 28, 29, 30
Herpes Simplex Virus
Transmission of herpes simplex virus (HSV) types 1 and 2 occurs with direct skin and mucous membrane contact. HSV transmission has been reported in women who have sex with women.31 One study reported HSV among 7.4% of screened lesbians.32 Marrazzo31 examined the prevalence of HSV infection in 392 women who reported having sex with a woman in the preceding year, and HSV-1 and HSV-2 antibodies were measured by Western blot. HSV-1 antibodies were detected in 46% and HSV-2 antibodies were detected in 8% of study participants.31 Transmission of herpes between women, from the mouth to the genital area, has been documented.33 Because the virus can be transmitted even when no lesions are present, genital-genital, oral-genital, and digital-genital contact should involve latex barriers and couples should abstain from sex during HSV outbreaks. This is one of the most difficult areas to address when speaking to a lesbian individual/couple. If there are frequent oral and/or genital outbreaks, antiviral suppressive therapy should be discussed. Measures to prevent oral-genital transmission should be reviewed. Latex barriers can include condoms that have been cut open lengthwise, gloves that have been cut open, and dental dams. Plastic wrap may be used, although there is no data to support its effectiveness.
Human Papillomavirus
Seventy-five percent of sexually active adults in the United States demonstrate clinical or serologic evidence of genital human papillomavirus (HPV) infection.34 The prevalence of HPV, including high oncogenic risk HPV, in women who have sex with women has been reported to be 13 to 30%, and the prevalence of HPV in women who have only had sex with women has been reported to be 6 to 19%.35,36 HPV can be transmitted from woman to woman by skin-to-skin or skin-to-mucosa contact. The prevalence of HPV DNA by polymerase chain reaction (PCR) was strongly associated with more recent sex with men, higher lifetime number of male partners, and current cigarette smoking.35,36 Marrazzo31 also reports that the women who had never had sex with men were less likely to have ever received a pelvic examination, received their first Pap test at a later age, and had less frequent Pap tests than women who also reported a history of sex with men.35
Transmission of HPV may occur through direct genital-genital contact, digital-vaginal contact, and digitalanal contact. Genital HPV types have been identified on human fingers.37 HPV may also be transmitted through the use of shared sex toys.36
Cervical dysplasia occurs in less than 3% of lesbians.32 Although the risk for cervical dysplasia is increased with a history of previous heterosexual activity, high-grade squamous intraepithelial lesions have been identified in lesbian women who have no history of having sex with men.38,39 Routine Pap testing for lesbians and bisexual women is recommended regardless of current type of sexual activity.39,40 According to the current American College of Obstetricians and Gynecologists (ACOG) guidelines, cervical cancer screening should begin at age 21 years, regardless of timing of first sexual intercourse. Screening is recommended every 2 years for women between the ages of 21 and 29 years and can be performed with either conventional or liquid-based cytology. Women who are age 30 years and older, who have had three consecutive cervical cytology test results that are negative, should be screened once every 3 years. Women with certain risk factors may require more frequent screening, including those who have HIV, are immunosuppressed, have been exposed to diethylstilbestrol (DES) in utero, and have been treated for cervical intraepithelial neoplasia (CIN) 2, CIN 3, or cervical cancer.41
ACOG also recommends HPV vaccination, with the initial vaccination target being females between the ages of 11 and 12 years. Although obstetrician-gynecologists are not likely to care for many girls in this initial vaccination target group, they are critical to the widespread use of the vaccine for females aged 13 to 26 years. During a health care visit with a girl or woman in the age range for vaccination, an assessment of the patient’s HPV vaccine status should be conducted and documented in the patient record.42
Chlamydia and Gonorrhea
Chlamydia and gonorrhea are transmitted to the vagina or rectum by contact with infected genital fluids. A survey of 2345 women (1921 lesbians and 424 bisexual women) revealed that bisexual women were more likely to report a gonorrhea infection, 7.8% versus 3.0% of the lesbian women.43 Another survey, including 6935 lesbian women from across the United States, revealed that 17.2% had a lifetime history of sexually transmitted infection (STI). In this study, a lifetime history of chlamydia was reported in 4.6% of lesbians.44 Bailey45 reports a low prevalence of chlamydia (0.6%), pelvic inflammatory disease (0.3%), and gonorrhea (0.3%) among 708 lesbian and bisexual women attending a sexual health clinic in London—these infections were diagnosed only in women who had histories of having sex with men.
Syphilis
Hepatitis A, B, and C
Acute viral hepatitis is characterized clinically by symptoms of malaise, nausea, poor appetite, vague abdominal pain, and jaundice. Hepatitis A is spread largely by the
fecal-oral route either in contaminated food or by oral-anal contact. Acute hepatitis A is invariably a self-limited infection; the virus can persist for months, but it does not lead to a chronic infection, chronic hepatitis, or cirrhosis.47 Woman-to-woman transmission of hepatitis A has been reported.48 Patients should avoid receptive oral-genital or oral-anal sex while infected.
fecal-oral route either in contaminated food or by oral-anal contact. Acute hepatitis A is invariably a self-limited infection; the virus can persist for months, but it does not lead to a chronic infection, chronic hepatitis, or cirrhosis.47 Woman-to-woman transmission of hepatitis A has been reported.48 Patients should avoid receptive oral-genital or oral-anal sex while infected.
Hepatitis B is spread predominantly by the parenteral route or by sexual contact. Chronic hepatitis B develops in 2 to 7% of adults infected with HBV. Chronic hepatitis B is a common cause of cirrhosis and an important cause of liver cancer.47 Woman-to-woman transmission of hepatitis B has been reported.40 Exchange of blood or body fluids, even by sharing a razor or toothbrush, may permit transmission. In addition to education and appropriate counseling, health care providers can offer vaccines for hepatitis A and hepatitis B.
Hepatitis C is primarily transmitted parenterally, although sexual and perinatal transmission does appear to occur. Injection drug users are at highest risk, accounting for more than 60% of cases. Prospective follow-up of spouses and sexual partners of patients with chronic hepatitis C shows the risk of sexual transmission to be low (less than 1% per year of exposure). Maternal-infant spread occurs in approximately 5% of cases.47 Woman-to-woman transmission has not been studied.
Human Immunodeficiency Virus
HIV has been identified in menstrual blood, the white blood cells of vaginal secretions, and in saliva. HIV is transmissible during lesbian sexual activity—possibly more so during menses, episodes of vaginitis, or after traumatic sexual behavior.14 In the February 2003 issue of Clinical Infectious Diseases, a likely case of HIV transmission between female partners was reported. An HIV-positive bisexual woman likely infected her lesbian partner by using sex toys so vigorously that her partner bled during intercourse. Genetic testing of the viral strains in the two women supported the suspicion that the bisexual woman had infected her partner. The bisexual woman was unaware that barrier protection was necessary when engaging in sexual activity with a woman partner.49 There are other cases of suspected woman-to-woman sexual transmission of HIV.50, 51, 52 There are also several studies that suggest considerable HIV risk behavior among some lesbian and bisexual women.53, 54, 55, 56 In a study of female STI clinic patients, Marrazzo31 reports that when compared to women who report sex only with men, women reporting sex with both men and women had more recent partners, sex with partners at high risk for HIV, injection drug and crack cocaine use, and exchange of sex for drugs or money. In addition, women reporting sex exclusively with women more frequently reported prior sex with a bisexual man or an HIV-infected partner.55,56
HIV-related research on women who have sex with women has been scarce yet notable for its unexpected findings: (a) higher HIV seroprevalence rates among women who have sex with both women and men compared to their exclusively homosexual or heterosexual counterparts, (b) high levels of risk for HIV infection through unprotected sex with men and through injection drug use, and (c) risk for HIV infection of unknown magnitude owing to unprotected sex with women and artificial insemination with unscreened semen.15
Trichomoniasis
Trichomoniasis is a single-celled protozoan parasite. It can be identified in vaginal fluid and the vulvar glands. Several surveys report a prevalence of approximately 6% among women who have sex with women.43,44,57 Woman-to-woman transmission has been clearly documented and is thought to occur by digital-genital contact and transfer of vaginal fluids.58,59 If trichomoniasis is identified in a patient, her sexual partner(s) should be treated as well.60
SAFER SEX MEASURES
Safer sex measures should be discussed with lesbian and bisexual patients. Safer sex measures for women who exclusively have sex with women include barrier protection such as covering, with a new condom for each person, any sex toy that penetrates more than one person’s vagina or anus; using a dental dam or latex barrier for oral-vaginal and oral-anal contact; and using latex or vinyl gloves and lubricant for any vaginal or anal penetration that may cause bleeding.22,23 Proper cleansing of sex toys, such as dildos and vibrators, should take place not only before and after personal use but also before switching toys between partners when the same sex toy is shared. Dildos and vibrators can be cleaned with warm water and soap. Silicone can be cleaned by boiling for 2 to 3 minutes or in the dishwasher. If there are any visible genital lesions, physical contact should be avoided.33 Additional safer sex measures for women who also have sex with men include always using a condom during vaginal or anal sex and always using a condom during fellatio (oral-penile contact).
DEMOGRAPHICS
Surveys of lesbian and bisexual women are generally based on convenience samples and nonprobability samples of women at lesbian social venues and organizations, counseling centers, and health clinics. These surveys report health behaviors such as tobacco, alcohol and drug use, obesity, and access to medical care. Survey data have suggested higher rates of nulliparity, higher BMI, less use of oral contraceptives, and higher rates of depression. In 1999, the IOM15 published a report on
lesbian health—Lesbian Health: Current Assessment and Directions for the Future. The IOM15 report made several recommendations for improving the knowledge base on lesbian health, each related to the need to fund and conduct research and disseminate information. Since the IOM report, several large population-based studies have been published. One of these studies was a subsample from the Women’s Health Initiative (WHI).
lesbian health—Lesbian Health: Current Assessment and Directions for the Future. The IOM15 report made several recommendations for improving the knowledge base on lesbian health, each related to the need to fund and conduct research and disseminate information. Since the IOM report, several large population-based studies have been published. One of these studies was a subsample from the Women’s Health Initiative (WHI).
The WHI was designed to investigate disease outcomes in older women; it was composed of three randomized clinical trials and a longitudinal observational study. Sexual orientation questions were embedded as one of many questions; response categories included “have never had sex,” “sex with a woman or with women,” “sex with a man or with men,” “sex with both men and women,” and “prefer not to answer.” Valanis et al.61 compared heterosexual and nonheterosexual women ages 50 to 79 years for specific demographic characteristics, psychosocial risk factors, screening practices, and other health-related behaviors. They found many of the same health behaviors—demographic and psychosocial risk factors—reported in the literature for their younger counterparts, despite higher socioeconomic status and access to health care.61 This WHI subsample had 96,007 participants; this accounts for 59.3% of the final WHI sample. Of the 96,007, 2696 preferred not to answer, leaving the sample size for this study at 93,311. Breaking this down by sexual orientation, there were 90,578 heterosexual women, 740 bisexual women, 264 lifetime lesbian women (defined as sex only with women ever), and 309 adult lesbian women (defined as sex only with women after the age of 45 years). According to data collected from this WHI subsample, lesbian and bisexual women are more likely to have a higher BMI and be obese, use alcohol, and use tobacco (past and present). Lesbian and bisexual women are also less likely to have used oral contraceptives or have ever been pregnant.61,62
POTENTIAL IMPLICATIONS FOR LESBIAN/BISEXUAL HEALTH
Coronary Artery and Cerebrovascular Disease
Risk factors for coronary artery and cerebrovascular disease include smoking, obesity/excessive weight, high blood pressure, high cholesterol, physical inactivity, stress, and diabetes. Of these, smoking, obesity, and stress are potential demographic risk factors for lesbian or bisexual patients. In light of the increased likelihood for these risk factors, it is particularly important during routine office visits to include counseling for weight control, the importance of regular exercise, and smoking cessation as appropriate.22 The WHI subsample data showed a slightly lower prevalence of stroke and hypertension in lesbian and bisexual women but the highest rates of myocardial infarction. Specifically, among the WHI population, 4.3% of adult lesbian women (defined as women who had sex only with women after age 45 years) and 3.1% of lifetime lesbian women (sex with only women during their lives) experienced myocardial infarctions compared with only 2.0% of heterosexual women and 1.2% of bisexual women.61 Other studies with large samples of women have found increased cardiovascular risk and heart disease among lesbian women as well.7,63 Risk factors included higher rates of obesity, smoking, and alcohol use as well as less intake of fruits and vegetables.
Cancer
There are risk factors that place women at greater risk for certain cancers (Table 25.1). For most cancers, risk increases with age or because there is a family history of that particular cancer. There are behavioral factors that can increase the risk of cancer as well. Because lesbians tend to have higher rates of smoking, alcohol use, poor diet, greater BMI, less use of oral contraceptives, and lower likelihood of bearing children, it has been suggested that lesbians are at higher risk for breast cancer.15 Cochran et al.62 examined behavioral risk factors, cancer screening behaviors, and self-reported breast cancer histories from seven independently conducted surveys of 11,876 lesbian and bisexual women. There was no statistically significant difference in self-reported prevalence of breast cancer between the lesbian sample and U.S. estimates for women.62 The WHI subsample revealed the age-standardized prevalence of breast cancer to be 4.9% of heterosexual women, 8.4% of bisexual women, 5.8% of lifetime lesbians (sex only with women ever), and 7.0% of adult lesbians (sex only with women after age 45 years).61
Less information is available for the prevalence of other cancers among lesbian women. With higher rates of smoking, there is increased risk of lung cancer. With a higher BMI and a high-fat diet, there is greater risk for colorectal, ovarian, and endometrial cancers. Because lesbians are less likely to have given birth and less likely to have used oral contraceptives, they may have greater risk for endometrial or ovarian cancer.15
TABLE 25.1 Cancer Risk Factors | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
