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.
- Risk factors same as 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.
- Sexual minority women at higher rates of all substance abuse compared to heterosexual counterparts (3)
- Depression
- 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.
- >30% have biologic children.
- 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
- Elders aging “back into the closet”
- Sexual abuse
-- To view the remaining sections of this topic, please log in or purchase a subscription --
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.
- Risk factors same as 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.
- Sexual minority women at higher rates of all substance abuse compared to heterosexual counterparts (3)
- Depression
- 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.
- >30% have biologic children.
- 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
- Elders aging “back into the closet”
- Sexual abuse
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