C trachomatis and N gonorrhoeae are the 2 most common bacterial STDs in the general population.83 Both of these STDs are reported to be less common in women who have sex exclusively with women. However, it is important to note that these STDs are higher in prevalence among bisexual women than the general population.84,85 Tao86 found similar higher prevalence results for viral STDs among bisexual women aged 15 to 44 years. Therefore, it is prudent to screen for C trachomatis and N gonorrhoeae in WSW. According to Mravcak,67 trichomoniasis is also common among WSW. When screening a woman for chlamydia or gonorrhea, the same sample can be used to test for trichomoniasis with the same laboratory-based techniques.87
Untreated chlamydia and gonorrhea can lead to pelvic inflammatory disease, tubal infertility, and chronic pelvic pain. Gonorrhea usually presents with vaginal discharge; however, chlamydia infections are commonly asymptomatic and do not usually cause visible signs of cervicitis. The CDC and the US Preventive Services Task Force recommend screening for C trachomatis at least annually for all women aged 24 years and younger.88
Syphilis, hepatitis A, hepatitis B, and HIV are uncommon STDs in WSW.67,89-91 In a study by Fishman and Andersen,72 53% of WSW reported that they were at low risk for HIV because of their knowledge of barrier methods and abstinence from sexual activity during menstruation.
However, in a study by Koh and colleagues,92 WSW who engage in high-risk behaviors are susceptible to HIV. These behaviors include unprotected sex with men, unprotected sharing of sex toys with women, and injection drug use. WSW are also uniquely at risk for HIV through the use of unscreened semen donation from sources other than a sperm bank.
Violence. Lesbians and bisexual women are commonly victims of prejudice and hate crimes, and often fear for their safety. Also, intimate partner violence may occur between women in same-sex relationships; however, these incidents are poorly reported.93
The National Violence Against Women survey of 8000 American women found that 35% of women who live with women had experienced physical abuse in their lifetimes.94 This is in contrast to a 20% rate of domestic violence for women with a history of only opposite-sex cohabitation. In the same survey, more than 11% of women in same-sex relationships reported having been raped, physically assaulted, or stalked by a female partner.94 According to Lhomond and Saurel-Cubiziolles,95 WSW report more physical violence than WSM.
Most aspects of domestic violence in the LGBT community mirror those of the heterosexual population. The power dynamics, the cyclical nature of abuse, and the increase of abuse over time are similar between LGBT and heterosexual relationships.96 However, there are some aspects of domestic violence that are unique to the LGBT experience. According to Kulkin and colleagues,96 “outing” acts as both a tool of abuse and a barrier to seeking help. LGBT individuals often hide outward expressions of their sexual orientation or gender identity for fear of stigma and discrimination; abusive partners may exploit this fear through the threat of forced outing. Even if batterers do not use outing as an abuse tactic, victims are often reluctant to out themselves to obtain help. Outing and associated negative feelings can inhibit them from turning to family, friends, or the police for support, further isolating them in abusive relationships.
Mental health. In a study by Reisner and colleagues,97 WSW were more than three times as likely to have a clinical mental health diagnosis relative to the WSM. Many research studies report WSW are disproportionately affected by depression and anxiety.22,98-102
According to Cochran and Mays,103 WSW are at greater risk for suicide than heterosexual women. WSW are also more likely to have a history of past suicide attempts22,104 and increased utilization of mental health services (eg, inpatient psychiatric/mental health treatment).102,105
Prior research suggests that stressors associated with being a WSW, such as leading a marginalized life, hiding one’s sexuality, facing verbal, emotional, or physical abuse, or stigma, may contribute to increased rates of mental health diagnoses among this population.68,106,107
In comparison with heterosexual adolescents, LGBT adolescents have higher rates of depression and suicidal ideation, higher rates of substance abuse, and more risky sexual behaviors.108 In interviews of men and women aged 26 years, women who have had same-sex attraction were significantly more likely to have engaged in deliberate self-harm or to have had suicidal ideation, compared with women who have not had same-sex attraction.109,110 Rates of depression in lesbians were found to be lower among women with social support, those involved in a satisfying relationship, and those more open about their sexual orientation.98,111 Primary care clinicians should identify life stressors and screen lesbians and bisexual women for depression and suicidal ideation. Referral to mental health professionals who have experience with LGBT patients is important.