Health issues of WSW
Sexual identity is not necessarily in concordance with sexual behaviors and the sex of sexual partners. Some women who have sex with women consider themselves heterosexual despite having sex with women. Many do not claim bisexuality in research studies or surveys.10,64 It cannot be presumed that women who self-identify as lesbian do not have or have not had male partners. The majority of women (up to 87%) who report same-sex behavior have had male partners in the past and may continue to do so (6% to 23%).65,66
Women are frequently not asked about the sex of their sexual partners by primary care clinicians.63 Clinicians often presume heterosexuality when taking a sexual history of a woman. Also, many WSW report they feel uncomfortable reporting lesbian behavior.66-68 Consequently, many WSW are not screened for the specific health problems that are known to affect lesbians (Table 4).69 Women are also infrequently advised about how to engage in safe sexual activity with other women.70
STDs. There is an unfounded belief that WSW have a lesser chance of acquiring STDs.70-72 WSW are at risk of acquiring STDs from current and prior partners, both men and women (Table 5). According to Mravcak and associates,67 it is important to dispel the commonly held belief that the transmission of STDs between women is negligible. Notably, HPV, an STD that can cause cervical cancer, is sexually transmitted between female partners. HPV-associated squamous intraepithelial lesions have occurred in lesbians who have never had sex with men. Marrazzo and associates71 note that 13% to 30% of women who report having sex with women test positive for HPV infection. Many WSW, particularly those with a history of having only female partners, believe they have less need for Pap smear and cervical cancer screening. The majority of surveys report that only 44% to 56% of lesbians have regular Pap smears.73-76
Recommendations for cervical cancer and HPV screening in lesbians and bisexual women, regardless of their sexual history with men, should not differ from screening recommendations for women in general. According to Massad and colleagues,77 risks for abnormal Pap test results and HPV infection are modestly lower in WSW than in women who have sex with men (WSM), but both are common in HIV-seropositive women regardless of sexual preference. Both WSW and WSM should be screened similarly.
Genital herpes caused by herpes simplex virus type 1 (HSV-1) or type 2 (HSV-2) is common in WSW and bisexual women.78 It is important to educate women that HSV can be transmitted by skin-to-skin and mouth-to-genital contact. HSV infection is often asymptomatic and subclinical infection is highly contagious. Shedding of the virus among those who are asymptomatic is exceedingly common, accounting for the majority of transmission events.
In a study by Xu and colleagues,78 among women who ever had sex with women, the prevalence of HSV-2 was 45.6% in women who deemed themselves heterosexuals, 35.9% in bisexuals, and 8.2% in lesbians. In comparison, in women who reported no same-sex partners, the prevalence of HSV-2 was 23.8%.
Bacterial vaginosis (BV) is particularly prevalent in WSW, with an estimated prevalence of 25% to 52%.79-81 Having a history of female sex partners confers a twofold increased risk of BV.82 Exchange of vaginal fluid among female partners contributes to the initiation of BV. Susceptibility to BV increases with high lifetime number of female sexual partners, a history of receptive oral-anal sex, and not always cleaning an insertive sex toy between uses.79,80