Optimizing Reproductive Health Care of Women Who Have Sex with Women
(Updated August 2008)
Chances are, if you treat women in your clinical practice, you will treat a woman who has sex with women (WSW). The proportion of the female population thought to identify as lesbian has been estimated to range from as low as 1.3% to as high as 8.6% of the US population.1 But not all WSW identify as lesbian. Views about sexual identity and sexual behavior can vary widely across cultures and racial and ethnic groups.2
WSW are known to access the health care system less frequently than heterosexual women and are less likely to receive routine gynecological services, including Pap tests.2 WSW are also less likely to have health insurance and to undergo cancer screenings.2
The health care received by WSW may be further compromised by overt discrimination or homophobia and incorrect assumptions made by health care providers while taking a sexual or social history. Many providers have not had the training necessary to understand the special reproductive health concerns of WSW.
Sexually Transmitted Infections
WSW are at a similar risk for sexually transmitted infections (STIs) as heterosexual women.3 Bacterial vaginosis, associated with pelvic inflammatory disease, is significantly more prevalent among WSW.4 Transmission of common viral STIs, especially human papillomavirus, herpes simplex virus infections, and Treponema palladium, which causes syphilis, requires only skin-to-skin or mucosa contact. Female-to-female transmission of HIV has also been reported.5
A complete and accurate sexual history is necessary to determine STI risk for WSW patients, regardless of age or the genders of sexual partners. Providers need to be sure they are fully asking about sexual history, even among their self-identified lesbian patients, because statistics show that many of these women have had sex with men in the past or currently also have sex with men (and are still at risk for STIs and pregnancy).6 In a sensitive manner, all WSW should receive accurate information about STIs, contraception (including emergency contraception), and safer sex practices that can be used to minimize transmission of STIs and the risk for unintended pregnancy. Some lesbian patients may feel it heterosexist for their provider to discuss contraception, but this can be done in a respectful and non-judgmental manner.
WSW have above-average prevalence rates of several risk factors for breast and gynecological cancers.7 They are significantly more likely to be obese, smoke, and abuse alcohol (known cancer risk factors)7,8 and less likely to have ever used oral contraceptives, been pregnant, or given birth (shown to protect against ovarian and endometrial cancers).9,10,11,12
The American Cancer Society recommends that all women should begin having regular Pap tests within three years of becoming sexually active or by age 21.13 Because WSW do not usually need contraceptives, they tend to wait longer between Pap tests and general gynecological exams, missing the opportunity to receive other preventive care. Like heterosexual women, WSW should follow guidelines for cancer screening including monthly breast self-exam, regular clinical breast exams, and age-appropriate mammography screening.
A Checklist for Optimal Reproductive Health Care of Women Who Have Sex with Women (WSW)
Rapport and Approach to Patients
- Use inclusive language on admissions and information forms and sexual and social history forms.
- If the patient wishes, include her significant other(s) or family of choice in health care discussions.
- Use open-ended questions about health behaviors and health care needs.
- Make no assumptions about the patient’s behavior or health needs. Ask the patient what language to use to describe her relationships, sexual behaviors, and health concerns. Use that language. If the patient is legally married, do not assume heterosexuality or monogamy.
- Discuss confidentiality, including documentation and access to records.
- Respect the patient’s wishes or needs to disclose (or not disclose) her sexual orientation.
- Provide access and referrals to print resources and area services for WSW.
- Advertise and “come out” in the community as WSW affirming.
- Be aware of your own biases, values, and limits of knowledge.
- Remember your commitment to ensuring high-quality care for all.
Organizational Policies and Practices
- Train and routinely update health care providers and clinical and administrative staff about WSW issues.
- Prominently post a non-discrimination policy for employees and patients that includes sexual orientation and gender identity.
- In waiting rooms and offices, place magazines, newspapers, posters, and brochures that are inclusive of and specific to WSW.
- Provide educational and screening services that are specifically geared toward WSW.
- Advocate for all patients to enact durable powers of attorney for health care and respect those choices when they are implemented.
- Review and revise all policies, forms, and patient literature to eliminate heterosexual bias and heterosexism.
- Revisit implementation and efficacy of confidentiality policies and procedures.
- Review policies on confidentiality with all patients and staff, including administrative staff.
- Form an advisory committee made up of staff and patients to address WSW health issues.
- Be an ally. Confront heterosexism and oppression of WSW wherever you see it.
Disease Screening and Treatment
- Begin with the patient—not from your assumptions about gender identity, sexual orientation, identity presentation, or sexual health and behaviors. Let the patient tell you who she is.
- Take a thorough sexual behavior survey. Order diagnostic tests and treatments accordingly.
- Be non-judgmental in response to information or answers the patient gives you.
- Ensure appropriate use of pre- and post-test guidelines for patient consent, counseling, confidentiality, and follow-up care when screening for HIV/STIs, substance abuse, and mental health.
- Instruct the patient on appropriate harm reduction guidelines for HIV/STIs based on sexual behavior, not on sexual identity or sexual orientation.
- Screen sexual partner(s) for STIs as appropriate.
- Ask open-ended questions to solicit information about psychosocial supports and stressors.
- Screen for, address, and treat patient concerns linked to mental health and substance abuse.
- Screen for, address, and treat patient concerns related to abuse and violence, whether domestic, sexual, or bias related.
- Acknowledge your limits: you may not know the screening or treatment answer, but you can work with your patient to ensure that she is referred to helpful resources.
- Aaron DJ, Chang YF, Markovic N, LaPorte RE. Estimating the lesbian population: a capture-recapture approach. J Epidemiol Commun Health. 2003;57(3):207-9.
- Office on Women’s Health, US Department of Health and Human Services. Lesbian Health Fact Sheet. The Institute of Medicine Report.
- Fethers K, Marks C, Mindel A Sexually transmitted infections and risk behaviours in women who have sex with women. Sex Transm Infect. 2000;76(5):345-9.
- Bailey JV, Farquhar C, Owen C. Bacterial vaginosis in lesbians and bisexual women. Sex Transm Dis. 2004;31(11):691-4.
- Kwakwa HA, Ghobrial MW. Female-to-female transmission of human immunodeficiency virus. Clin Infect Dis. 2003;36(3):e40-1.
- Diamant AL, Shuster MA, McGuigan K, Lever J. Lesbians’ sexual history with men: implications for taking a sexual history. Arch Intern Med 1999;159:2730-6.
- Cochran SD, Mays VM, Bowen D, Gage S, Bybee D, Roberts SJ, et al. Cancer-related risk indicators and preventive screening behaviors among lesbians and bisexual women. Am J Public Health 2001;91(4):591-7.
- American Cancer Society. Cancer Facts for Lesbians and Bisexual Women. Accessed on July 17, 2008.
- Emons G, Fleckenstein G, Hinney B, Huschmand A, Heyl W. Hormonal interactions in endometrial cancer. Endocrine-Related Cancer 2000;7(4):227-42.
- Centers for Disease Control and Prevention and the National Institute of Child Health and Human Development. The reduction in risk of ovarian cancer associated with oral-contraceptive use. The Cancer and Steroid Hormone Study of the Centers for Disease Control and the National Institute of Child Health and Human Development. New Engl J Med. 1987;316(11):650–5.
- Wu WH, Xiang YB, Ruan ZX, W Zheng, JR Cheng, Q Dai, et al. Menstrual and reproductive factors and endometrial cancer risk: Results from a population-based case-control study in urban Shanghai. Int J Cancer. 2004;108(4):613-9.
- Rieck G, Fiander A. The effect of lifestyle factors on gynaecological cancer [review]. Best Pract Res Clin Obstet Gynaecol. 2006;20(2):227-51.
- Smith RA, Cokkinides V, Eyre HJ. American Cancer Society guidelines for the early detection of cancer, 2006. CA Cancer J Clin. 2006;56:11-25.