Healthcare workers need to be aware of the specific needs of women who have sex with women, argue Clare Hughes and Amy Evans

The term "women who have sex with women" describes sexual behaviour while lesbian is a term that describes sexual identity. However, sexual identity does not necessarily predict sexual behaviour-most lesbians have a history of sexual intercourse with men.1 Women who have sex with women form a small but important group and have specific health needs. A lack of awareness among healthcare professionals about these needs may lead to ill informed advice and missed opportunities for the prevention of illness.

An unfortunate perception exists among healthcare providers and women who have sex with women that they do not need regular cervical smears. High risk types of genital human papillomavirus are associated with developing high grade cervical intraepithelial neoplasia, and sexual intercourse with men is a powerful risk factor for cervical cancer. However, it is important to counter the erroneous assumption that women who have sex with women are not at risk of catching human papillomavirus. Around one in five women who have never had heterosexual intercourse have human papillomavirus.2

Cytological abnormality in women who have sex with women varies in prevalence between studies but ranges from inflammation to severe dyskaryosis.1 3 4 Specifically the development of high grade cervical intraepithelial neoplasia with human papillomavirus type 16 after exclusive lesbian behaviour has been described.5 Therefore regular testing of cervical smears should be recommended to all women who have sex with women, regardless of their present or past sexual activities.

Bacterial vaginosis is more common in women who have sex with women than in heterosexual women-it is found in up to half of women who have sex with women.1 6 Debate exists about the sexual transmissibility of a causative organism within female partnerships due to the similarity of vaginal flora in women in monogamous relationships.7 8

Women who have sex with women are traditionally viewed as being less likely to contract bacterial sexually transmitted infections such as chlamydia and gonorrhoea. In studies from the United Kingdom, the incidence and prevalence are lower in women who have sex with women than in heterosexual women, but they are still at risk. Trichomoniasis has been transmitted sexually, supporting the hypothesis that sexually transmitted infections can be transferred between women through vaginal secretions.5 Transmission of syphilis by orogenital sex between women has been described,9 and overall more than 10 of women with exclusively female partners have a history of sexually transmitted infections.10

DAVID PERRY/PHOTONICA

Lesbians have specific health needs

Human immunodeficiency virus has been isolated from vaginal secretions, cervical biopsies, and menstrual blood,11 and, although uncommon, female to female sexual transmission of HIV has been reported.12-14

Some women who have sex with women participate in high risk behaviours for the acquisition of HIV and hepatitis, such as intravenous drug use and unprotected intercourse with homosexual or bisexual men. These women may then act as a bridge, transferring risk to women who exclusively have sex with women.5 Unscreened semen from sources other than sperm banks may also facilitate HIV transmission.15

Mental health problems are persistently cited by women who have sex with women as a notable health concern. Increased risk of suicide, deliberate self harm, depression, and anxiety disorder has been shown.16 17 However, causality is more difficult to establish. Undoubtedly the medicalisation of the lesbian state compounds the stigma of mental illness, and the experience of prejudice not only predisposes to depression but can also discourage access and disclosure in the healthcare setting.

Isolation and stigma put homosexual adolescents at risk of a range of psychological problems later in life and can also affect older women who have sex with women, particularly after the loss of a partner. The disparity in qualification for "nearest relative" status between heterosexual and same sex partners formalised in the Mental Health Act 1983 has recently been successfully challenged in the High Court.18 However, this type of statutory prejudice is widespread and needs to be addressed.

To reduce perceived and actual prejudice in medical settings, healthcare providers should understand that lesbianism is within the normal range of sexual behaviour. They should also prefer gender neutral language and a non-judgmental approach, to make women who have sex with women more comfortable in disclosing sexual behaviour.11

The specific risk of cancers for women who have sex with women has not been formally studied. However, confluence of various risk factors and the absence of some protective factors put women who have sex with women as a group at greater risk of developing particular cancers than their heterosexual counterparts.

The rates of smoking and consumption of alcohol among women who have sex with women are higher than in heterosexual women. They also tend to have a higher body mass index, lower parity, and poorer participation in health screening programmes.

Fewer women who have sex with women have children than heterosexual women, and those who do tend to have them after the age of 30.11 Long exposure of breast tissue to oestrogens is known to make it prone to carcinogenic changes.19

Use of the oral contraceptive pill, pregnancy, miscarriage, abortion, and having children protect against ovarian cancer,20 but these protective factors may be commonly absent in women who have sex with women. Cumulatively these effects put women who have sex with women at an increased risk of breast, ovarian, endometrial, lung, and colon cancer.11

Lifestyle factors such as smoking, alcohol use, obesity, and low intake of fruit and vegetables also put women who have sex with women at a greater theoretical risk of cardiovascular disease than their heterosexual counterparts.21

Medical professionals need knowledge of these risk factors so that they can advise women who have sex with women on changes that may reduce their risk. They also need to be aware of the requirement for cervical screening and advisability of regular testing for sexually transmitted infections, and to be able to answer specific questions about other relevant health issues, including gynaecological cancers, risk factors for cardiovascular disease, and psychosocial problems.

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