Lesbians, bisexual women need to have screenings

If your practice includes care of lesbian and bisexual women, and most practices do, don’t dismiss taking their reproductive histories. New research indicates that previous pregnancy, induced abortion, and hormonal contraceptive use are common among women who report sex with women, regardless of whether they identify themselves as lesbian.1

Why is it so important for clinicians to perform Pap smears and sexually transmitted disease (STD) screens for lesbian and bisexual women? According to the researchers involved with the new study, parity and hormonal contraceptives modify the risk of reproductive cancers and cardiovascular disease; however, clinicians may not obtain reproductive histories from patients who self-identify as lesbian.1

"Pap smears are important because our work, and case studies from some other authors,2 have shown that oncogenic strains of human papillomavirus [HPV] occur at the cervix in many lesbians, including those who report no prior sex with men," states Jeanne Marrazzo, MD, MPH, assistant professor of medicine at the University of Washington in Seattle.

The Seattle scientists have detected not only oncogenic HPV types at cervix, vagina, and vulva sites in this group, but also demonstrated a high prevalence of serum antibody to HPV-16 and HPV-6 in earlier research,3 she notes.

According to Marrazzo, most women who self-identify as lesbians have had sex with men, which places them at some risk for chronic viral STD infection such as HPV and herpes. Nonetheless, research indicates that lesbians may not seek Pap smears because they don’t believe they are at risk for cervical cancer, and providers may mistakenly tell them they are not needed, she explains.

Women who have sex with women are at the same risk for STDs as heterosexual women; findings from a 2000 study indicate that women who had sex with women had a higher prevalence of bacterial vaginosis (BV), hepatitis C, and HIV risk behaviors than heterosexual women.4

While the reasons are unclear, lesbians have a higher prevalence of bacterial vaginosis,5 says Marrazzo. Since BV has been strongly associated with adverse outcomes of pregnancy, lesbians planning pregnancy may consider being screened for this condition, she notes.

Providers need to realize that many lesbians carry a rich concentration of risk factors for breast, uterine, and ovarian cancer,6 and they should counsel women on these items, says Kate O’Hanlan, MD, a Portola Valley, CA-based gynecologic oncologist and past president of the Gay and Lesbian Medical Association in San Francisco, a health advocacy group for lesbian, gay, bisexual, and transgender patients.

A 2001 cross-sectional community-based survey indicates that lesbians may be more likely to report cigarette and alcohol use and may have higher body mass than heterosexual women.7 Respectfully counsel women to lower their body mass index if the reading is higher than 25, and discuss the importance of regular cholesterol, blood pressure, and blood sugar checks, advises O’Hanlan. Also, stress the importance of lifestyle issues such as exercise and healthy eating, she notes.

Health care providers are "woefully uneducated" about many aspects of lesbian sexual health, from sexual behaviors and associated risks, to types of protective measures women might take against STD/HIV, says Marrazzo. She and her associates maintain a web site, www.lesbianstd.com, to get the word out to patients and providers about lesbian sexual health issues.

"We get a large number of questions e-mailed to us at this site, and we have archived quite a few answers," says Marrazzo. "There is no other site that I am aware of that provides this level of detail for lesbians who have questions about their STD risk as related to sex with other women."

Make women welcome 

Research indicates that lesbian and bisexual women are more likely than heterosexual women to smoke cigarettes and use alcohol, and they have worse access to health care.8 Making these women feel comfortable when they walk into your practice is paramount in providing good care, says O’Hanlan.

Posting a nondiscrimination statement on the waiting room wall that reads, "This office proudly celebrates the diversity of our patient population and does not discriminate by age, national origin, religion, ethnicity, ability, sexual orientation, or gender identity," she suggests. Such a statement immediately lets women know that the facility and its staff will provide care in a nonjudgmental manner, she says. See that your intake forms reflect the same level of sensitivity; make sure that "domestic partner" is listed along with the check boxes for married, divorced, separated, and widowed, O’Hanlan points out.

Use cultural sensitivity in discussing reproductive health manners, she suggests. Ask women questions such as, "Do you need any contraception?" instead of "What kind of birth control pill are you using?" and ask "Do you have a spouse or partner?" rather than "What does your husband do?" she offers.

"The lesbian patient likely has a family," says O’Hanlan. "And the clinician should ask about her life in the context of her family."

References 

1. Marrazzo JM, Stine K. Reproductive health history of lesbians: Implications for care. Am J Obstet Gynecol 2004; 190:1,298-1,304.

2. O’Hanlan KA, Crum CP. Human papillomavirus-associated cervical intraepithelial neoplasia following lesbian sex. Obstet Gynecol 1996;88(4 Pt 2):702-703.

3. Marrazzo JM, Koutsky LA, Stine KL. Genital human papillomavirus infection in women who have sex with women. J Infect Dis 1998; 178:1,604-1,609.

4. Fethers K, Marks C, Mindel A, et al. Sexually transmitted infections and risk behaviours in women who have sex with women. Sex Transm Inf 2000; 76:345-349.

5. Marrazzo JM, Koutsky LA, Eschenbach DA, et al. Characterization of vaginal flora and bacterial vaginosis in women who have sex with women. J Infect Dis 2002; 185:1,307-1,313.

6. O’Hanlan KA. Do we really mean preventive medicine for all? Am J Prev Med 1996;12:411-414.

7. Aaron DJ, Markovic N, Danielson ME, et al. Behavioral risk factors for disease and preventive health practices among lesbians. Am J Public Health 2001; 91:972-975.

8. Diamant AL, Wold C, Spritzer K, et al. Health behaviors, health status, and access to and use of health care: A population-based study of lesbian, bisexual, and heterosexual women. Arch Fam Med 2000; 9:1,043-1,051.