Lesbians are members of all ethnic, age and socioeconomic groups. These women report a wide range of sexual identities (celibate, bisexual, homosexual), and up to 80 percent have a history of heterosexual activity. In general, lesbians are often of lower socioeconomic status than homosexual men, may have restricted family benefits such as health insurance and use health care services relatively infrequently. Carroll addresses the issues of health care for these women.
The disclosure of sexual identity can be very difficult, especially for adolescents. Medical histories should be based on gender-neutral statements and nonjudgmental attitudes to encourage patients to discuss sexual orientation, history and concerns.
The risk of sexually transmitted disease in lesbian patients depends on sexual practices, number of partners and use of prophylaxis. Vaginal insertion of fingers or objects can transmit pathogens, particularly if anal penetration is also practiced. Little is known about transmission of human immunodeficiency virus (HIV) infection during lesbian sexual activity, but woman-to-woman transmission has been documented, and the virus has been isolated from menstrual fluid, cervical biopsies and vaginal secretions. Women who use insemination to attempt pregnancy should be cautioned about the possibility of acquiring sexually transmitted diseases from donated body fluids. Studies have not shown any differences in sexual or gender identity, personality traits or intelligence in children raised by lesbians compared with children of heterosexual parents.
Lesbian patients may have an increased risk for certain cancers. Vulnerability to ovarian cancer may be increased because of low pregnancy rates and reduced exposure to oral contraceptive agents. Low fertility combined with an increased prevalence of smoking and alcohol use, and a decreased use of preventive health services contributes to an increased risk for cancers of the lung, breast and uterus. These factors also predispose lesbians to cardiovascular disease and diabetes.
Although it is generally believed that Papanicolaou screening is not indicated in lesbian patients, data from clinics serving lesbian populations indicate that significant pathology is frequently detected, particularly in patients with a history of first coitus at an early age, incest or sexual abuse, or other risk factors. Annual Pap screening should be considered for all women.