Original Article: Preventive Health Care for Women Who Have Sex with Women

Issue Date: March 1, 2017

Available online at: https://www.aafp.org/afp/2017/0301/p314.html

To the Editor: I appreciated this timely article, but the authors neglect to mention a crucial element of prevention in women who have sex with women (WSW): contraception.

Unintended pregnancy is a very real problem among WSW. As a family physician providing full-scope family planning services for women, I often hear from patients who identify as lesbian or bisexual (often seeking therapeutic abortion after consensual sex or rape) that their previous physicians neglected to offer contraception because “they thought I didn't need it.”

The authors point out that “a self-identity of being lesbian does not automatically exclude male sex partners,” and that “97% of women who report same-sex sexual behavior have had or still have male sex partners.” We can imagine that WSW may be likely to prefer certain contraceptive methods; be less likely to be offered certain methods (e.g., tubal ligation) because of different patterns of interaction with the health care system; and have different concerns about and barriers to accessing emergency contraception or therapeutic abortions.

At the very least, the SORT: Key Recommendations for Practice table should have included an item about offering contraceptive counseling. All family physicians should be attentive to this oft-neglected area of prevention in the WSW population.

In Reply: A discussion of contraception is important for every woman of childbearing age. As we discussed in our article:

• A self-identity of being lesbian or WSW does not automatically exclude male sex partners.

• About 50% to 97% of women who report same-sex sexual behavior have had or still have male sex partners.

• Among the 7% of women who reported a same-sex sexual relationship, 50% self-identified as heterosexual.

We also emphasized that the physician must ask WSW frank questions about sexual activities. In Table 4, we listed these questions to use as part of a culturally competent history:

• Are you having or have you ever had sex with women, men, or both?

• Have you ever been pregnant?

• Do you have oral sex? Vaginal sex? Anal sex? Other types of sex?

• Do you use barrier protection such as condoms?

• Are there times you do not use barrier protection?

• Do you use another method of birth control? (if sexually active with men)

• Do you (or does your partner) have any plans to conceive in the next 12 months?

These questions should lead the physician to have a pertinent discussion about the need for contraception for WSW.

The SORT table focused on health issues that are disproportionately represented in WSW. Although we certainly agree that WSW should be asked about contraception, we believe that we addressed this issue throughout the article.