Lesbian Health

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Basics

Description

  • A lesbian is a woman who has her primary emotional and sexual relationships with women.
  • Other sexual minorities include bisexual, transgender, and transsexual women.
  • Sexual behaviors
    • May be celibate, sexually active only with women or with both men and women
    • ~75% of self-reported lesbians have reported prior or ongoing sexual contact with men.
  • Sexual orientation and gender nonconformity 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.
  • 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.
  • 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.
  • Tobacco use
    • 2 times more likely to smoke than heterosexual women
  • Sexual minority stress (1)
    • Increased risk for health issues secondary to greater exposure to social stresses related to prejudice and stigma
  • 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 (2).
  • 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.
  • CVD
    • Lesbians have higher rates of obesity, smoking, and stress, which increase risks for CVD.
  • Mental health diagnoses
    • 2 times more likely to see general physician for mental/emotional complaint
      • Depression
        • Double the rate compared to heterosexual women
        • Discrimination stress proposed factor
      • Anxiety disorders
        • 2- to 4-fold higher rate of generalized anxiety disorder
        • Higher rates of PTSD, panic, phobia
        • Multiple diagnoses
        • 3 times risk
      • 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 (3)
  • 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
    • 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
  • 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
  • Chlamydia
    • Can be transmitted woman to woman (WTW)
  • Gonorrhea
    • Can be transmitted WTW
  • Hepatitis B
    • Can be transmitted WTW
  • Herpes
    • Can be transmitted WTW
  • HPV
    • Can be transmitted WTW
    • Up to 30% of women who have sex with women (WSW) have genital HPV (4).
    • 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
  • Syphilis
    • Can be transmitted WTW
  • Trichomonas
    • Can be transmitted WTW
  • 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
  • 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 (5)
        • 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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