Lesbian Health

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Basics

Description

  • A lesbian is a woman who has her primary emotional and sexual relationships with women.
  • Sexual behaviors
    • May be celibate, sexually active only with women or with men, women and/or nonbinary partners
    • ~75% of self-reported lesbians have reported prior or ongoing sexual contact with men.
  • Sexual orientation and gender are complex concepts and defining them can be challenging.

Epidemiology

Prevalence

  • Estimated to be between 1% and 5%
  • Approximately 1.4 million women living in the United States identify as lesbians. Another 2.6 million women identify as bisexual. 2020 Gallup Poll results had 1.3% of women identifying as lesbian, 4.3% as bisexual, and 1.3% as something else.
  • 2016 American Community Survey from United States Census Bureau estimates 451,594 households are headed by female same-sex couples.

Risk Factors

Higher incidence for the following risk factors compared to heterosexual women:

  • Elevated BMI
    • Lesbian women have a higher prevalence of overweight/obesity than all other female sexual orientation groups.
    • Higher prevalence rates of obesity have been found among lesbians who are:
      • African American
      • Live in urban or rural areas
      • Have lower levels of education
      • Lower socioeconomic status
  • Alcohol use
    • More common use than reported in heterosexual women
    • Age 20 to 34 years is at highest risk for daily use and heavy use of alcohol. Those numbers decline in older age groups, but even 1 drink per day can increase risks for cancer, hepatic, and heart disease.
  • Tobacco use
    • 1.5 to 2 times more likely to smoke than heterosexual women
    • Aggressive marketing by tobacco industry to LGBT individuals
  • Sexual minority stress (1)
    • Increased risk for health issues secondary to greater exposure to social stresses related to prejudice and stigma
    • Many of the increased health risks in lesbians can be attributed to behaviors that are the result of dealing with the stress and stigma of homophobia and discrimination.
  • The above factors can increase risks for cardiovascular disease (CVD), type 2 diabetes, hepatic disease, cancers.

Commonly Associated Conditions

  • Cervical cancer
    • Lesbians are equally at risk for developing cervical cancer compared to heterosexual women.
    • HPV can be transmitted genitally skin to skin, oral to genitals, and digital to genitals.
    • Risk of cervical cancer is highest in lesbians:
      • With prior HPV infection/abnormal Pap smear
      • Who have had a history of heterosexual intercourse
    • Lesbian and bisexual women are 10 times less likely to have adequate cervical cancer screening compared to heterosexual women.
    • Tobacco use influences cervical cell atypia.
  • Breast cancer
    • Risk factors same as heterosexual women
      • Moderate or heavy alcohol consumption
      • Obesity
      • Nulliparity or first child born after age 30 years
    • Mammogram screening rates lower among lesbians
    • Data suggest lesbians have increased mortality rate compared to heterosexual women.
  • Ovarian cancer
    • Elevated BMI and tobacco use increases risks.
    • Lesbians less likely to have been on hormonal contraception for 5 years or longer
    • Lesbians less likely to have been pregnant or breastfed an infant before age 30 years
    • Lesbians at increased risk for ovarian cancer may want to explore potential benefits of long-term progestin-containing contraception to reduce risk.
  • Endometrial cancer
    • Elevated BMI and tobacco use increases risks.
    • Lesbians less likely to have been pregnant
    • Lesbians with polycystic ovarian syndrome should be asked about sustained amenorrhea and consider use of progestin-containing contraception or regular schedule of induced “withdrawal bleeds” to reduce risks.
  • CVD—lesbians have higher rates of obesity, alcohol use, smoking, and stress, which increase risks for CVD
  • Mental health diagnoses
    • 2 times more likely to see general physician for mental/emotional complaint compared to heterosexual women
    • More likely to seek care if physician is aware of their sexual orientation
      • Depression
        • Discrimination stress proposed factor
        • Double the rate compared to heterosexual women
      • Suicide
        • “Out” lesbian women 2 to 2.5 times more likely to have had suicidal ideation in last 12 months compared to heterosexual women
        • Lesbian women who were not “out” were more likely to have attempted suicide compared to heterosexual women.
      • Anxiety disorders
        • 3 times risk, multiple diagnoses
        • Higher rates of PTSD, panic, phobia, and 2- to 4-fold higher rate of generalized anxiety disorder
      • Alcohol abuse
        • Greatest in lesbians ages 20 to 34 years
        • Bar culture
        • May not feel comfortable in traditional Alcoholics Anonymous environment
        • Sexual minority females more likely than heterosexual counterparts to be current alcohol users, binge drinkers, and heavy drinkers (2)
      • Substance abuse
        • Sexual minority women at higher rates of all substance abuse compared to heterosexual counterparts (3)
          • Bisexual women have highest rates of substance abuse compared to lesbian and heterosexual women.
        • Higher levels of socioeconomic instability were associated with increased odds for substance abuse.
          • Household Pulse Survey from United States Census Bureau showed COVID-19 pandemic impacted LGBTQ population significantly greater than heterosexual counterparts.
  • Sexually transmitted infections (STI)
    • Many lesbians underestimate their STI risks.
    • Difficult to ascertain accurate statistics because of lack of research and the confounding factors of relying on identifiers of sexual orientation versus sexual behaviors
    • Increased risk during menstruation and activities causing friction
    • Lesbian sexual practices include the following:
      • High risk: oral–vaginal contact, genital–genital contact, oral–anal contact, digital stimulation/penetration, and sharing of sex toys
      • Lower risk: kissing, rubbing genitals against partner’s body/clothing
  • Bacterial vaginosis
    • Higher rate than heterosexual women; estimated 25–52% prevalence
    • Increased incidence with smoking, receptive oral sex, symptomatic partner, and new partner
    • Often found in monogamous lesbian couples suggesting it can be sexually transmitted. Consider treating asymptomatic partner especially in recurrent cases.
  • Chlamydia, gonorrhea, hepatitis B, syphilis, trichomonas, and herpes—can all be transmitted woman to woman (WTW)
  • HPV
    • Can be transmitted WTW
    • Up to 30% of women who have sex with women (WSW) have genital HPV.
    • 12% of WSW report genital warts.
    • 25% of WSW report cervical abnormalities.
    • WSW may not get HPV vaccine due to perceived decreased risk.
  • HIV—transmission between women rare but possible; WSW more likely to have sexual contact with men having sex with men (MSM) than heterosexual women
  • STI screening and prevention
    • Screen based on woman’s history.
    • Encourage safer sex practices:
      • Avoid menstrual blood/open sores.
      • Dental dams for oral sex, condoms on sex toys, and cleaning immediately after use
      • Vinyl/latex gloves for manual sex, limit friction with lubricants
  • Psychosocial considerations
    • Sexual abuse
      • 3 times more likely than heterosexual women to report having been sexually assaulted
      • 43% of lesbians reported at least one sexual assault in their lifetime.
      • History of childhood sexual abuse can be associated with more complicated and difficult “coming out.”
    • Intimate partner violence: 17–45% of lesbians report at least one act of physical violence at the hands of a lesbian partner.
    • Parenthood: A reported 41% of lesbians desire to have a child. Perinatal depression is common and may be more common than in heterosexual women.
      • >30% have biologic children.
        • Often from previous heterosexual relationship
        • Adoption
        • Assisted reproductive technology/donor insemination
        • Some will engage in high-risk sexual behaviors (MSM, “one-night stand”) in an attempt to get pregnant.
        • Providers should discuss parenting with their lesbian patients.
        • Encourage both partners or nonbiologic parent to adopt child to ensure permanent legal relationship to child.
        • Discuss durable power of attorney for health care and finances in the event of death or separation.
        • Adolescents who have been reared in lesbian mother families since birth demonstrate healthy psychological adjustment.
    • Adolescent lesbians
      • Increased risk for eating disorders
      • Higher rates of substance use particularly polysubstance abuse
      • If also having sexual contact with males, higher rates of pregnancy compared to heterosexual counterparts due to (4)
        • High rates of early sexual initiation
        • Greater number of partners
        • Less contraceptive use
      • Higher rates of physical and/or sexual abuse—childhood sexual abuse does not cause children to become LGBTQ
    • Aging lesbians
      • Elders aging “back into the closet”
        • Discrimination by religious and other groups that own nursing homes
        • Fear of discrimination by caregivers/health care workers
        • Few elder care programs specifically directed at LGBT persons

-- To view the remaining sections of this topic, please or --

Basics

Description

  • A lesbian is a woman who has her primary emotional and sexual relationships with women.
  • Sexual behaviors
    • May be celibate, sexually active only with women or with men, women and/or nonbinary partners
    • ~75% of self-reported lesbians have reported prior or ongoing sexual contact with men.
  • Sexual orientation and gender are complex concepts and defining them can be challenging.

Epidemiology

Prevalence

  • Estimated to be between 1% and 5%
  • Approximately 1.4 million women living in the United States identify as lesbians. Another 2.6 million women identify as bisexual. 2020 Gallup Poll results had 1.3% of women identifying as lesbian, 4.3% as bisexual, and 1.3% as something else.
  • 2016 American Community Survey from United States Census Bureau estimates 451,594 households are headed by female same-sex couples.

Risk Factors

Higher incidence for the following risk factors compared to heterosexual women:

  • Elevated BMI
    • Lesbian women have a higher prevalence of overweight/obesity than all other female sexual orientation groups.
    • Higher prevalence rates of obesity have been found among lesbians who are:
      • African American
      • Live in urban or rural areas
      • Have lower levels of education
      • Lower socioeconomic status
  • Alcohol use
    • More common use than reported in heterosexual women
    • Age 20 to 34 years is at highest risk for daily use and heavy use of alcohol. Those numbers decline in older age groups, but even 1 drink per day can increase risks for cancer, hepatic, and heart disease.
  • Tobacco use
    • 1.5 to 2 times more likely to smoke than heterosexual women
    • Aggressive marketing by tobacco industry to LGBT individuals
  • Sexual minority stress (1)
    • Increased risk for health issues secondary to greater exposure to social stresses related to prejudice and stigma
    • Many of the increased health risks in lesbians can be attributed to behaviors that are the result of dealing with the stress and stigma of homophobia and discrimination.
  • The above factors can increase risks for cardiovascular disease (CVD), type 2 diabetes, hepatic disease, cancers.

Commonly Associated Conditions

  • Cervical cancer
    • Lesbians are equally at risk for developing cervical cancer compared to heterosexual women.
    • HPV can be transmitted genitally skin to skin, oral to genitals, and digital to genitals.
    • Risk of cervical cancer is highest in lesbians:
      • With prior HPV infection/abnormal Pap smear
      • Who have had a history of heterosexual intercourse
    • Lesbian and bisexual women are 10 times less likely to have adequate cervical cancer screening compared to heterosexual women.
    • Tobacco use influences cervical cell atypia.
  • Breast cancer
    • Risk factors same as heterosexual women
      • Moderate or heavy alcohol consumption
      • Obesity
      • Nulliparity or first child born after age 30 years
    • Mammogram screening rates lower among lesbians
    • Data suggest lesbians have increased mortality rate compared to heterosexual women.
  • Ovarian cancer
    • Elevated BMI and tobacco use increases risks.
    • Lesbians less likely to have been on hormonal contraception for 5 years or longer
    • Lesbians less likely to have been pregnant or breastfed an infant before age 30 years
    • Lesbians at increased risk for ovarian cancer may want to explore potential benefits of long-term progestin-containing contraception to reduce risk.
  • Endometrial cancer
    • Elevated BMI and tobacco use increases risks.
    • Lesbians less likely to have been pregnant
    • Lesbians with polycystic ovarian syndrome should be asked about sustained amenorrhea and consider use of progestin-containing contraception or regular schedule of induced “withdrawal bleeds” to reduce risks.
  • CVD—lesbians have higher rates of obesity, alcohol use, smoking, and stress, which increase risks for CVD
  • Mental health diagnoses
    • 2 times more likely to see general physician for mental/emotional complaint compared to heterosexual women
    • More likely to seek care if physician is aware of their sexual orientation
      • Depression
        • Discrimination stress proposed factor
        • Double the rate compared to heterosexual women
      • Suicide
        • “Out” lesbian women 2 to 2.5 times more likely to have had suicidal ideation in last 12 months compared to heterosexual women
        • Lesbian women who were not “out” were more likely to have attempted suicide compared to heterosexual women.
      • Anxiety disorders
        • 3 times risk, multiple diagnoses
        • Higher rates of PTSD, panic, phobia, and 2- to 4-fold higher rate of generalized anxiety disorder
      • Alcohol abuse
        • Greatest in lesbians ages 20 to 34 years
        • Bar culture
        • May not feel comfortable in traditional Alcoholics Anonymous environment
        • Sexual minority females more likely than heterosexual counterparts to be current alcohol users, binge drinkers, and heavy drinkers (2)
      • Substance abuse
        • Sexual minority women at higher rates of all substance abuse compared to heterosexual counterparts (3)
          • Bisexual women have highest rates of substance abuse compared to lesbian and heterosexual women.
        • Higher levels of socioeconomic instability were associated with increased odds for substance abuse.
          • Household Pulse Survey from United States Census Bureau showed COVID-19 pandemic impacted LGBTQ population significantly greater than heterosexual counterparts.
  • Sexually transmitted infections (STI)
    • Many lesbians underestimate their STI risks.
    • Difficult to ascertain accurate statistics because of lack of research and the confounding factors of relying on identifiers of sexual orientation versus sexual behaviors
    • Increased risk during menstruation and activities causing friction
    • Lesbian sexual practices include the following:
      • High risk: oral–vaginal contact, genital–genital contact, oral–anal contact, digital stimulation/penetration, and sharing of sex toys
      • Lower risk: kissing, rubbing genitals against partner’s body/clothing
  • Bacterial vaginosis
    • Higher rate than heterosexual women; estimated 25–52% prevalence
    • Increased incidence with smoking, receptive oral sex, symptomatic partner, and new partner
    • Often found in monogamous lesbian couples suggesting it can be sexually transmitted. Consider treating asymptomatic partner especially in recurrent cases.
  • Chlamydia, gonorrhea, hepatitis B, syphilis, trichomonas, and herpes—can all be transmitted woman to woman (WTW)
  • HPV
    • Can be transmitted WTW
    • Up to 30% of women who have sex with women (WSW) have genital HPV.
    • 12% of WSW report genital warts.
    • 25% of WSW report cervical abnormalities.
    • WSW may not get HPV vaccine due to perceived decreased risk.
  • HIV—transmission between women rare but possible; WSW more likely to have sexual contact with men having sex with men (MSM) than heterosexual women
  • STI screening and prevention
    • Screen based on woman’s history.
    • Encourage safer sex practices:
      • Avoid menstrual blood/open sores.
      • Dental dams for oral sex, condoms on sex toys, and cleaning immediately after use
      • Vinyl/latex gloves for manual sex, limit friction with lubricants
  • Psychosocial considerations
    • Sexual abuse
      • 3 times more likely than heterosexual women to report having been sexually assaulted
      • 43% of lesbians reported at least one sexual assault in their lifetime.
      • History of childhood sexual abuse can be associated with more complicated and difficult “coming out.”
    • Intimate partner violence: 17–45% of lesbians report at least one act of physical violence at the hands of a lesbian partner.
    • Parenthood: A reported 41% of lesbians desire to have a child. Perinatal depression is common and may be more common than in heterosexual women.
      • >30% have biologic children.
        • Often from previous heterosexual relationship
        • Adoption
        • Assisted reproductive technology/donor insemination
        • Some will engage in high-risk sexual behaviors (MSM, “one-night stand”) in an attempt to get pregnant.
        • Providers should discuss parenting with their lesbian patients.
        • Encourage both partners or nonbiologic parent to adopt child to ensure permanent legal relationship to child.
        • Discuss durable power of attorney for health care and finances in the event of death or separation.
        • Adolescents who have been reared in lesbian mother families since birth demonstrate healthy psychological adjustment.
    • Adolescent lesbians
      • Increased risk for eating disorders
      • Higher rates of substance use particularly polysubstance abuse
      • If also having sexual contact with males, higher rates of pregnancy compared to heterosexual counterparts due to (4)
        • High rates of early sexual initiation
        • Greater number of partners
        • Less contraceptive use
      • Higher rates of physical and/or sexual abuse—childhood sexual abuse does not cause children to become LGBTQ
    • Aging lesbians
      • Elders aging “back into the closet”
        • Discrimination by religious and other groups that own nursing homes
        • Fear of discrimination by caregivers/health care workers
        • Few elder care programs specifically directed at LGBT persons

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