 The term “women who have sex with
women” describes sexual behaviour while lesbian is a term that describes
sexual identity. However, sexual identity does not necessarily predict
sexual behaviour—most lesbians have a history of sexual intercourse with
men.1 Women who have sex with women form a small but important group and
have specific health needs. A lack of awareness among healthcare professionals
about these needs may lead to ill informed advice and missed opportunities
for the prevention of illness.
An unfortunate perception exists among healthcare providers and women who have sex with women that they do not need regular cervical smears. High risk types of genital human papillomavirus are associated with developing high grade cervical intraepithelial neoplasia, and sexual intercourse with men is a powerful risk factor for cervical cancer. However, it is important to counter the erroneous assumption that women who have sex with women are not at risk of catching human papillomavirus. Around one in five women who have never had heterosexual intercourse have human papillomavirus.2 Cytological abnormality in women who have sex with women varies in prevalence between studies but ranges from inflammation to severe dyskaryosis.1 w1 w2 Specifically the development of high grade cervical intraepithelial neoplasia with human papillomavirus type 16 after exclusive lesbian behaviour has been described.w3 Therefore regular testing of cervical smears should be recommended to all women who have sex with women, regardless of their present or past sexual activities. Bacterial vaginosis is more common in women who have sex with women than heterosexual women—it is found in up to half of women who have sex with women.1 3 Debate exists about the sexual transmissibility of a causative organism within female partnerships due to the similarity of vaginal flora in women in monogamous relationships.4 5 Women who have sex with women are
traditionally viewed as being less likely to contract bacterial sexually
transmitted infections such as chlamydia and gonorrhoea. In studies from
the United Kingdom, the incidence and prevalence are lower in women who
have sex with women than heterosexual women, but they are still at risk.
Trichomoniasis has been transmitted sexually, supporting the hypothesis
that sexually transmitted infections can be transferred between
Human immunodeficiency virus has been isolated from vaginal secretions, cervical biopsies, and menstrual blood,7 and, although uncommon, female to female sexual transmission of HIV has been reported.w5-w7 Some women who have sex with women participate in high risk behaviours for the acquisition of HIV and hepatitis, such as intravenous drug use and unprotected intercourse with homosexual or bisexual men. These women may then act as a bridge, transferring risk to women who exclusively have sex with women.3 Unscreened semen from sources other than sperm banks may also facilitate HIV transmission.8 Mental health problems are persistently
cited by women who have sex with women as a notable health concern. Increased
risk of suicide, deliberate self harm, depression, and anxiety disorder
have been shown.9 10 However, causality is more difficult to establish.
Undoubtedly the medicalisation of the lesbian state compounds the stigma
of mental illness, and the experience of prejudice not only predisposes
to depression but can also discourage access and
Isolation and stigma put homosexual adolescents at risk of a range of psychological problems later in life and can also affect older women who have sex with women, particularly after the loss of a partner. The disparity in qualification for “nearest relative” status between heterosexual and same sex partners formalised in the Mental Health Act 1983 has recently been successfully challenged in the High Court.11 However, this type of statutory prejudice is widespread and needs to be addressed. To reduce perceived and actual prejudice in medical settings, healthcare providers should understand that lesbianism is within the normal range of sexual behaviour. They should also prefer gender neutral language and a non-judgmental approach, to make women who have sex with women more comfortable in disclosing sexual behaviour.7 The specific risk of cancers for women who have sex with women has not been formally studied. However, confluence of various risk factors and the absence of some protective factors put women who have sex with women as a group at greater risk of developing particular cancers than their heterosexual counterparts. The rates of smoking and consumption of alcohol among women who have sex with women are higher than in heterosexual women. They also tend to have a higher body mass index, lower parity, and poorer participation in health screening programmes. Fewer women who have sex with women have children than heterosexual women, and those who do tend to have them after the age of 30.7 Long exposure of breast tissue to oestrogens is known to make it prone to carcinogenic changes.w9 Use of the oral contraceptive pill, pregnancy, miscarriage, abortion, and having children protect against ovarian cancer,w10 but these protective factors may be commonly absent in women who have sex with women. Cumulatively these effects put women who have sex with women at an increased risk of breast, ovarian, endometrial, lung, and colon cancer.7 Lifestyle factors such as smoking, alcohol use, obesity, and low intake of fruit and vegetables also put women who have sex with women at a greater theoretical risk of cardiovascular disease than their heterosexual counterparts.12 Medical professionals need knowledge of these risk factors so that they can advise women who have sex with women on changes that may reduce their risk. They also need to be aware of the requirement for cervical screening and advisability of regular testing for sexually transmitted infections, and to be able to answer specific questions about other relevant health issues, including gynaecological cancers, risk factors for cardiovascular disease, and psychosocial problems. Clare
Hughes final year medical student
Amy
Evans specialist registrar, genitourinary medicine
Competing interests: None declared. << декларация специально для Антона 1 Fethers K, Marks C, Mindel A, Estcourt CS. Sexually transmitted infections and risk behaviours in women who have sex with women. Sex Transm Infect 2000;76:345-9. 2 Marazzo JM. Genital human papillomavirus infection in women who have sex with women: a concern for patients and providers. AIDS Patient Care STDs 2000;14:447-51. 3 Marazzo JM. Sexually transmitted infections in women who have sex with women: who cares? Sex Transm Infect 2000;76:330-2. 4 Berger BJ, Kolton S, Zenilman JM, Cummings M, Feldman J, McCormack WM. Bacterial vaginosis in lesbians: a sexually transmitted disease. Clin Infect Dis 1995;21:1402-5. 5 McCaffrey M, Varney P, Evans B, Taylor-Robinson D. Bacterial vaginosis in lesbians: evidence for lack of sexual transmission. Int J STD AIDS 1999;10:305-8. 6 Bauer GR, Welles SL. Beyond assumptions of negligible risk: sexually transmitted diseases and women who have sex with women. Am J Public Health 2001;91:1282-6. 7 Carroll NM. Optimal gynaecological and obstetric care for lesbians. Obstet Gynecol 1999;93:611-3. 8 Kennedy MB, Scarlett MI, Duerr AC, Chu SY. Assessing HIV risk among women who have sex with women: scientific and communication issues. J Am Med Women’s Assoc 1995;50:103-7. 9 Skegg K, Nada-Raja S, Dickson N, Paul C, Williams S. Sexual orientation and self-harm in men and women. Am J Psychiatry 2003;160:541-6. 10 Bailey JM. Homosexuality and mental illness. Arch Gen Psychiatry 1999;56:883-4. 11 Re: R. (on the application of SSG) v Liverpool City Council (1), Secretary of State for Health (2) and LS (Interested Party), October 22 2002. 12 Valanis BG, Bowen DJ, Bassford
T, Whitlock E, Charney P, Carter R. Sexual orientation and health – comparisons
in the Women’s Health Initiative sample. Arch Fam Med 2000;9:843-53.
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