Preventive Health Care for Women Who Have Sex with Women

 

Despite recent shifts in societal attitudes toward same-sex relationships, women who have sex with women face a variety of barriers to optimal health, including a history of negatively perceived interactions in clinical settings that lead them to delay or avoid health care. Women who have sex with women may be at disproportionate risk of obesity, tobacco use, substance use, mental health issues, intimate partner violence, sexually transmitted infections, and some cancers. Disparities can exist throughout the lifetime. Lesbian and bisexual adolescents are vulnerable to bullying, family rejection, and risky sexual behavior that may lead to sexually transmitted infections or unintended pregnancy. Sexual minority stress, which is a response to stigmatization, prejudice, and internalized homophobia, contributes to many of these conditions. Family physicians should foster trust and communication to provide a nonjudgmental, welcoming environment supportive of culturally competent health care and optimal outcomes. When indicated, clinicians should refer women who have sex with women to culturally sensitive community resources and legal advisors for assistance with medical decision making, hospital visitation, conception, and legal recognition of nonbiologic parents.

Quantifying the number of lesbians and bisexual women in the United States is challenging, in part because self-reported sexual identity does not always correlate with sexual behavior.1  While the prevalence of lifetime same-sex behavior by women is estimated at 7.1% to 11.2%, the number of women self-identifying as a sexual minority (Table 126) tends to be lower. One study found that 1.3% to 1.9% of U.S. women identified as lesbians and 3.1% to 4.8% identified as bisexual.7

View/Print Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

WSW should be screened for obesity, type 2 diabetes mellitus, cancer, and cardiovascular disease.

C

2, 8, 17, 27, 36

Regular Papanicolaou testing should be performed in WSW, and these patients should be referred for mammography according to guidelines for all women.

C

10, 11, 36

WSW should be screened for depression, anxiety, and suicide risk.

B (depression)

2, 8, 9, 22, 23, 25, 26, 36, 37

C (anxiety, suicide)

WSW should be screened for substance use, including tobacco, alcohol, and illicit drugs.

A (tobacco)

2, 8, 16, 23, 32, 33, 36, 39

B (alcohol)

C (illicit drugs)

WSW should be screened for sexually transmitted infections following standard guidelines for all females, according to behaviors and risks.

C

1, 7, 8, 15, 21, 30

WSW should be screened for intimate partner violence.

B

12, 42


WSW = women who have sex with women.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

WSW should be screened for obesity, type 2 diabetes mellitus, cancer, and cardiovascular disease.

C

2, 8, 17, 27, 36

Regular Papanicolaou testing should be performed in WSW, and these patients should be referred for mammography according to guidelines for all women.

C

10, 11, 36

WSW should be screened for depression, anxiety, and suicide risk.

B (depression)

2, 8, 9, 22, 23, 25, 26, 36, 37

C (anxiety, suicide)

WSW should be screened for substance use, including tobacco, alcohol, and illicit drugs.

A (tobacco)

2, 8, 16, 23, 32, 33, 36, 39

B (alcohol)

C (illicit drugs)

WSW should be screened for sexually transmitted infections following standard guidelines for all females, according to behaviors and risks.

C

1, 7, 8, 15, 21, 30

WSW should be screened for intimate partner violence.

B

12, 42


WSW = women who have sex with women.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

View/Print Table

Table 1.

Definitions Related to the Care of WSW

TermDefinition

Bisexual (female)2

Women who are attracted to or engage in sexual behavior with both sexes

Dental dam3,4

A sheet of latex rubber used as a barrier between the mouth and vulva or the mouth and anus

Heterosexism5

Practices or beliefs based on the assumption that all persons are heterosexual; for example, patient intake forms that lack options for partners (as opposed to spouses) and assuming that all females have only male sex partners

Heterosexual5

A person who is sexually attracted to persons of the opposite sex; some WSW may self-identify as heterosexual

Internalized homophobia5

Negative feelings about homosexuality that are turned inward by persons with same-sex attraction

Lesbian2

Women with same-sex attraction or same-sex sexual behavior

LGB or LGBT

Lesbian,

The Authors

show all author info

DANIEL A. KNIGHT, MD, is an associate professor in the Department of Family and Preventive Medicine at the University of Arkansas for Medical Sciences, Little Rock....

DIANE JARRETT, EdD, is an assistant professor in the Department of Family and Preventive Medicine at the University of Arkansas for Medical Sciences.

Address correspondence to Daniel A. Knight, MD, University of Arkansas for Medical Sciences, 4301 W. Markham, Slot 530, Little Rock, AR 72205 (e-mail: knightdaniela@uams.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

REFERENCES

show all references

1. Everett BG. Sexual orientation disparities in sexually transmitted infections: examining the intersection between sexual identity and sexual behavior. Arch Sex Behav. 2013;42(2):225–236....

2. ACOG Committee on Health Care for Underserved Women. ACOG Committee Opinion No. 525: Health care for lesbians and bisexual women. Obstet Gynecol. 2012;119(5):1077–1080.

3. Richters J, Prestage G, Schneider K, Clayton S. Do women use dental dams? Safer sex practices of lesbians and other women who have sex with women. Sex Health. 2010;7(2):165–169.

4. Centers for Disease Control and Prevention. National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention. Oral sex and HIV risk. http://www.cdc.gov/hiv/pdf/risk/cdc-hiv-oral-sex-fact-sheet.pdf. Accessed June 20, 2016.

5. Knight DA, Jarrett D. Preventive health care for men who have sex with men. Am Fam Physician. 2015;91(12):844–851.

6. Frost DM, Lehavot K, Meyer IH. Minority stress and physical health among sexual minority individuals. J Behav Med. 2015;38(1):1–8.

7. Marrazzo JM, Gorgos LM. Emerging sexual health issues among women who have sex with women. Curr Infect Dis Rep. 2012;14(2):204–211.

8. McNair RP, Hegarty K. Guidelines for the primary care of lesbian, gay, and bisexual people: a systematic review. Ann Fam Med. 2010;8(6):533–541.

9. U.S. Preventive Services Task Force. Final recommendation statement: depression in adults: screening. http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/depression-in-adults-screening1. Accessed June 20, 2016.

10. U.S. Preventive Services Task Force. Cervical cancer: screening. http://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/cervical-cancer-screening. Accessed December 7, 2015.

11. U.S. Preventive Services Task Force. Breast cancer: screening. https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/breast-cancer-screening1. Accessed November 7, 2016.

12. U.S. Preventive Services Task Force. Final recommendation statement: intimate partner violence and abuse of elderly and vulnerable adults: screening. http://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/intimate-partner-violence-and-abuse-of-elderly-and-vulnerable-adults-screening. Accessed June 20, 2016.

13. Smalley KB, Warren JC, Barefoot KN. Differences in health risk behaviors across understudied LGBT subgroups. Health Psychol. 2016;35(2):103–114.

14. Mravcak SA. Primary care for lesbians and bisexual women. Am Fam Physician. 2006;74(2):279–286.

15. Office of Disease Prevention and Health Promotion. Healthy People 2020: Lesbian, gay, bisexual, and transgender health. http://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay-bisexual-and-transgender-health. Accessed December 1, 2015.

16. Goldbach JT, Tanner-Smith EE, Bagwell M, Dunlap S. Minority stress and substance use in sexual minority adolescents: a meta-analysis. Prev Sci. 2014;15(3):350–363.

17. Massad LS, Xie X, Minkoff H, et al. Abnormal pap tests and human papillomavirus infections among HIV-infected and uninfected women who have sex with women. J Low Genit Tract Dis. 2014;18(1):50–56.

18. Sabin JA, Riskind RG, Nosek BA. Health care providers' implicit and explicit attitudes toward lesbian women and gay men. Am J Public Health. 2015;105(9):1831–1841.

19. Khalili J, Leung LB, Diamant AL. Finding the perfect doctor: identifying lesbian, gay, bisexual, and transgender-competent physicians. Am J Public Health. 2015;105(6):1114–1119.

20. Shakil A, Bardwell J, Sherin K, Sinacore JM, Zitter R, Kindratt TB. Development of verbal HITS for intimate partner violence screening in family medicine. Fam Med. 2014;46(3):180–185.

21. Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015 [published correction appears in MMWR Recomm Rep. 2015;64(33):924]. MMWR Recomm Rep. 2015;64(RR-03):1–137.

22. Adelson SL; American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). Practice parameter on gay, lesbian, or bisexual sexual orientation, gender nonconformity, and gender discordance in children and adolescents. J Am Acad Child Adolesc Psychiatry. 2012;51(9):957–974.

23. Committee On Adolescence. Office-based care for lesbian, gay, bisexual, transgender, and questioning youth. Pediatrics. 2013;132(1):198–203.

24. Pompili M, Lester D, Forte A, et al. Bisexuality and suicide: a systematic review of the current literature. J Sex Med. 2014;11(8):1903–1913.

25. LeFevre ML; U.S. Preventive Services Task Force. Screening for suicide risk in adolescents, adults, and older adults in primary care: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2014;160(10):719–726.

26. Cochran SD, Mays VM. Mortality risks among persons reporting same-sex sexual partners: evidence from the 2008 General Social Survey-National Death Index data set. Am J Public Health. 2015;105(2):358–364.

27. Eliason MJ, Ingraham N, Fogel SC, et al. A systematic review of the literature on weight in sexual minority women. Womens Health Issues. 2015;25(2):162–175.

28. Walters ML, Chen J, Breiding MJ. The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 findings on victimization by sexual orientation. Atlanta, Ga.: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention; 2013.

29. McCauley HL, Dick RN, Tancredi DJ, et al. Differences by sexual minority status in relationship abuse and sexual and reproductive health among adolescent females. J Adolesc Health. 2014;55(5):652–658.

30. Vodstrcil LA, Walker SM, Hocking JS, et al. Incident bacterial vaginosis (BV) in women who have sex with women is associated with behaviors that suggest sexual transmission of BV. Clin Infect Dis. 2015;60(7):1042–1053.

31. McRee AL, Katz ML, Paskett ED, Reiter PL. HPV vaccination among lesbian and bisexual women: findings from a national survey of young adults. Vaccine. 2014;32(37):4736–4742.

32. Johnson SE, Holder-Hayes E, Tessman GK, King BA, Alexander T, Zhao X. Tobacco product use among sexual minority adults: findings from the 2012–2013 National Adult Tobacco Survey. Am J Prev Med. 2016;50(4):e91–e100.

33. Fallin A, Goodin A, Lee YO, Bennett K. Smoking characteristics among lesbian, gay, and bisexual adults. Prev Med. 2015;74:123–130.

34. American Academy of Family Physicians. Adolescent health care, sexuality and contraception. http://www.aafp.org/about/policies/all/adolescent-sexuality.html. Accessed June 20, 2016.

35. Tracy JK, Lydecker AD, Ireland L. Barriers to cervical cancer screening among lesbians. J Womens Health (Larchmt). 2010;19(2):229–237.

36. Daniel H, Butkus R; Health and Public Policy Committee of American College of Physicians. Lesbian, gay, bisexual, and transgender health disparities: executive summary of a policy position paper from the American College of Physicians. Ann Intern Med. 2015;163(2):135–137.

37. Agency for Healthcare Research and Quality. Disparities within serious mental illness. https://effectivehealthcare.ahrq.gov/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=2236. Accessed November 7, 2016.

38. Friedman MR, Dodge B, Schick V, et al. From bias to bisexual health disparities: attitudes toward bisexual men and women in the United States. LGBT Health. 2014;1(4):309–318.

39. Lee JG, Matthews AK, McCullen CA, Melvin CL. Promotion of tobacco use cessation for lesbian, gay, bisexual, and transgender people: a systematic review. Am J Prev Med. 2014;47(6):823–831.

40. American Academy of Family Physicians. Tobacco: preventing and treating nicotine dependence and tobacco use (position paper). http://www.aafp.org/about/policies/all/nicotine-tobacco-prevention.html. Accessed June 20, 2016.

41. Allen JL, Mowbray O. Sexual orientation, treatment utilization, and barriers for alcohol related problems: findings from a nationally representative sample. Drug Alcohol Depend. 2016;161:323–330.

42. Badenes-Ribera L, Bonilla-Campos A, Frias-Navarro D, Pons-Salvador G, Monterde-I-Bort H. Intimate partner violence in self-identified lesbians: a systematic review of its prevalence and correlates. Trauma Violence Abuse. 2016;17(3):284–297.

43. American Academy of Family Physicians. Intimate partner violence. http://www.aafp.org/about/policies/all/intimatepartner-violence.html. Accessed June 20, 2016.

44. U.S. Department of Health and Human Services, LGBT Issues Coordinating Committee. Advancing LGBT health and well-being 2014 report. http://www.hhs.gov/sites/default/files/dhhs-lgbt2014annualreport.pdf. Accessed December 1, 2015.

45. Human Rights Campaign. Hospital visitation guide for LGBTQ families. http://www.hrc.org/resources/hospital-visitation-guide-for-lgbt-families. Accessed December 1, 2015.

46. Human Rights Campaign. Protecting your visitation and decision-making rights. http://www.hrc.org/resources/protecting-your-visitation-decision-making-rights. Accessed December 1, 2015.

47. U.S. Census Bureau. Household characteristics of opposite-sex and same-sex couple households: ACS 2014. http://www.census.gov/hhes/samesex/. Accessed November 30, 2015.

48. Human Rights Campaign. Donor insemination: the basics. http://www.hrc.org/resources/donor-insemination-the-basics. Accessed June 20, 2016.

49. American Civil Liberties Union. Marriage equality FAQ: parent-child relationships. http://marriageequalityfacts.org/topic/parentage/. Accessed December 1, 2015.

 

 

Copyright © 2017 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP

More in Pubmed

MOST RECENT ISSUE


May 15, 2017

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article