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