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

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, who live in urban or rural areas, who have lower levels of education, or who have 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 one 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, and cancers.

GENERAL PREVENTION

Health Access and Outcomes

• Between 2013 and 2018, heterosexual women had significant reductions in delayed/absent medical care due to costs that was not seen in their lesbian peers.
• During 2016 and 2018, lesbian and bisexual women had significantly higher odds of undesirable health outcomes and access to health care compared to their heterosexual peers.

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.
  • The 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 increase risks.
  • Lesbians less likely to have been on hormonal contraception for ≥5 years
  • 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.
  • A study of French population published in the May 17, 2023 Journal of The American Heart Association identified lesbian and bisexual women as having lower cardiovascular health scores compared to their heterosexual peers
• 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 are 2 to 2.5 times more likely to have had suicidal ideation in the 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 are more likely than heterosexual counterparts to be current alcohol users, binge drinkers, and heavy drinkers.
    • Substance abuse
      • Sexual minority women are at higher rates of all substance abuse compared to heterosexual counterparts.
        • 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 how COVID-19 pandemic impacted the LGBTQ population significantly greater than heterosexual counterparts.
• Sexually transmitted infections (STIs)
  • 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.
  • Vaccine rates in WSW have improved significantly but still well below the 80% goal of Healthy People 2020 target. WSW may not get vaccine due to perceived decreased risks.
• HIV—transmission between women is rare but possible. WSW are 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: National Coalition Against Domestic Violence reports 43.8% of lesbians have experienced rape, physical violence, and/or stalking by an intimate 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.
      • Children raised by same-sex parents have similar academic performance levels as their peers raised by different-sex parents.
  • 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 (2)
      • 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

GENERAL MEASURES

• Create a safe practice environment for lesbian patients.
  • Have nondiscrimination policy posted where it is visible to patients.
  • Educate staff to be comfortable dealing with the needs of lesbian patients and their families.
  • Brochures/photos should feature both same-sex and heterosexual couples.
  • Intake forms should include options for patient to indicate sexual preference and include options for partnered status.
  • Use “gender-neutral” language. For example, “Do you have a significant other?”
  • Avoid heterosexist assumptions (“What do you use for birth control?” asking instead “Do you plan to become pregnant or have a child? Do you need birth control?”).
• Ask about sexual orientation.
  • Many physicians do not ask.
  • Intake/annual physical forms should include questions about orientation/activity.
  • Twice as likely to identify as a sexual minority if questions asked in an indirect way
• Take a detailed sexual history.
  • Sexual identity and sexual behaviors are not always strongly correlated.
  • Ask about behaviors (“Do you have sex with women, men, or both?”); do not just assume current/past sexual activity with women.
  • STI screening based on reported history/activity
  • Address contraception when appropriate.
  • Some physicians may create barriers by believing a patient’s sexual self-identity and behaviors are not pertinent to competent care (3).
• Respect the partners.
  • Treat them as you would to any other spouse/partner.
  • Assure access if partner is hospitalized.
  • Recommend durable power of attorney if couple is not legally married.
• Follow same preventive screening guidelines and lifestyle recommendations as for heterosexual women (Pap smear, mammography, colonoscopy screening, safer sex, exercise, diet, alcohol moderation, and tobacco avoidance).
• Legal/U.S. government
  • Healthy People 2010 identified lesbian/gay Americans as 1 of 6 population groups affected by health care disparities.
  • Healthy People 2020 goals are to increase routine data collection efforts on LGBT populations via health care surveys
    • Questions about sexual orientation and gender identity were added to many population surveys.
  • Healthy People 2030 focus is on collecting data on specific health needs of LGBT population and improving health in LGBT adolescents.
    • The goal is to add questions about gender and sexual identity on more state and national surveys.
• Access to health insurance was increased with supreme court decisions on United States v. Windsor in 2013 and Obergefell v. Hodges in 2015. Some states still recognize same-sex civil union, but access to health insurance varies by state.
• Affordable Care Act (ACA): prohibits discrimination based on sexual orientation in any program receiving federal funds (Medicare/Medicaid); increased emphasis on research and data collections in LGBT population; National Health Interview Survey (NHIS); In 2013, the survey added a question about sexual orientation.

ICD10

• E66.3 Overweight
• Z72.0 Tobacco use
• F10.10 Alcohol abuse, uncomplicated
• Z72.52 High risk homosexual behavior
• A64 Unspecified sexually transmitted disease
• Z72.53 High risk bisexual behavior

SNOMED

• 48499001 Increased body mass index (finding)
• 110483000 tobacco user (finding)
• 15167005 Alcohol abuse (disorder)
• 288311000119103 High risk homosexual behavior (finding)
• 288291000119102 High risk bisexual behavior (finding)