Recently, I was invited to give a talk about lesbians and sexually transmitted diseases (STDs) at a conference highlighting the disproportionate burden of infectious diseases borne by women worldwide. My presentation took place in a session devoted to a discussion of barriers to the prevention of infectious diseases. This seemed reasonable, because barriers to care—especially gynecologic care—do indeed exist for many women who identify as lesbians. When I arrived at the conference, I found that my two copresenters planned to discuss barriers to care in two other groups of women: those with physical disabilities, and those in prisons and jails. Perhaps you do not find this particularly disturbing. Barriers are barriers, after all, and those for disabled and incarcerated women are often formidable. Yet … I could not help but note that lesbians were categorized with two groups whose barriers to health care arose from unenviable circumstances.
As researchers and healthcare providers, we thrive on categorizing our subjects and our patients; definitions make our work accessible, understandable, and reproducible. Unfortunately, our penchant for categorization—the terms “low risk” versus “high risk”; “STD clinic patients” versus “HIV clinic patients”—sometimes blends into an addiction to labeling that continuously reinforces our internal assumptions about our subjects and patients. At best, this tendency is perilously imprecise; at worst, it obstructs our ability to obtain a clear and complete picture of what we are actually trying to study or cure. Ingrained assumptions about women who identify as lesbians are just one example. When it comes to lesbians, some are all too ready to invoke the concept of “sexual death”1: the period in one's life after which no meaningful contributions to the chain of STD transmission in the population are made. Some common beliefs about lesbians that underlie this reasoning are that lesbians: 1) never have sex with men, 2) are too “clean” to get an STD, and 3) do not really have sex anyway—so why bother studying STD in women who have sex with women? These are all beliefs that people—including researcher colleagues—have conveyed to me.
Solid data counter the first three assumptions; most (>80% in most studies) self-identified lesbians have had sex with men, and a substantial minority continues to have sex with men.2 With STD as a surrogate outcome, it would appear that lesbians—at least some of them—do have sex. Transmission of trichomoniasis,3 syphilis,4 and genotype-concordant HIV5 have been well-documented; genital types of human papillomavirus6,7 and genital herpes8 are prevalent in the absence of prior or current sex with men; and bacterial vaginosis may represent an STD in this group.9–11 Reports of sexual transmission of Chlamydia trachomatis and Neisseria gonorrhoeae between women are anecdotal, and prevalence is primarily reflective of prior or current sex with men12; however, in populations with generally low prevalence of these STDs, positivity in lesbians has not differed from those in heterosexual women.12,13 Although case reports and clinic-based prevalence are not necessarily generalizable, we do not yet have surveillance data to estimate STD prevalence in lesbians because risk classification schemes have either excluded same-gender sex among women or subsumed it under a hierarchy of other behaviors viewed as higher risk. The situation is further complicated by the question of whether most lesbians receive appropriate preventive health care14 and thus are even likely to access systems that might capture prevalent STD or related syndromes. Furthermore, research funding is primarily focused on disease and populations recognized as “high risk”; even when funds are available, it is challenging to recruit a reproducible study group while simultaneously acknowledging the inherent heterogeneity in any population defined by a specific sexual practice. While advising that everyone disrupt the calcified preconceptions they have about “low-risk” women, ingrained assumptions are supported by accepted risk stratifications and existing research infrastructures.
In this issue of Sexually Transmitted Diseases, Koh and colleagues make clear that there is more to the superficially tranquil world of lesbian sex, including the “low-risk” woman who has not been well-represented in the few studies that have assessed lesbians' sexual risk-taking.15 The authors describe a successful attempt to circumvent the methodological challenges inherent in studying a population that has been relatively invisible to the STD world focused on heterosexuals and men who have sex with men (MSM). The study is important because the 1,304 subjects were drawn from 33 outpatient primary care settings across the United States. To enrich the study population with lesbians, the investigators used a sampling scheme that took into consideration the proportion of lesbian patients (>30% as estimated by lead clinicians) served by contributing sites. They used an extensive questionnaire (98 items) with a good response rate (>50%). Respondents were mostly white, highly educated, and had relatively high income. Although most were in a stable relationship (71%), many (23%) reported substance use while having sex or sex with a gay or bisexual man (6%) in the past year. Among women who recently had sex with men (N = 600), 51% reported ever using condoms. Bisexual women reported substance use with sex at a higher rate than lesbians or heterosexual women, a finding that generally supports findings among STD clinic attendees, where women who report sex with both women and men are more likely to report HIV-related risk behaviors, including sex with MSM, use of injection drugs and crack cocaine, and exchange of sex for drugs or money compared with heterosexual women or those who have sex with women exclusively.16,17 In the Koh study, although lesbians more frequently reported sex with bisexual men and injection drug users, they also reported using condoms more frequently than did bisexual or heterosexual women. Notably, lesbians who participated believed that their risk for HIV infection was high, yet few reported ever having had tests for non-HIV STD, which are considerably more likely in this group. Why were lesbians using risk reduction measures? The authors propose that proximity to the issue of HIV/AIDS in the MSM community might inform this choice (although this might not be consistent with the inverse relationship between age and report of condom use in this subgroup); it could also relate to lesbians' choice of MSM as partners when they do choose to have sex with men. Of great interest is that among women who reported sex with men in the prior year, lesbians reported a higher number of male sex partners than either heterosexual or bisexual women. This finding was modified by age, with younger women tending to report this behavior more commonly. Finally, the authors' data on heterosexual women's condom use are valuable because of the paucity of data for women whom most primary care providers might categorize as “low risk”; variations in the frequency of condom use by income and age in this group deserve further scrutiny.
There are important limitations in generalizing the findings from this study. However, the subjects are likely to resemble those seen in primary care practices everyday. They had access to and sought primary care and thus represent a group that is likely to seek interaction with healthcare providers, who should understand the implications of the study's findings. Apart from knowledge, however, providers and researchers also need to discard assumptions that are made everyday about lesbians. Assumptions do not inform a high level of readiness, which in turn informs one's ability to detect the unexpected. Recent increases in STD among MSM who do not identify as gay emphasize that simply categorizing patients by their self-defined sexual identity is not adequate. Assessment of specific sexual risk behaviors, and of previous sexual history, provides a more complete tool for assessment and counseling of patients' sexual health status, thus enabling delivery of client-centered counseling and for subjects' categorization in research studies. As Koh and colleagues indicate, this has especially important implications for counseling and evaluation of female adolescents; in one study of 392 women who reported sex with another woman in the past year, the most common pregnancy outcome for the 25% of those who reported prior pregnancy at age less than 25 years was induced abortion, which occurred in 59%.18 Describing the sexual networks in which lesbians participate—particularly as they involve men at potentially high risk for STD, notably HIV—should provide much-needed insight into the sexual and social dynamics of a highly diverse population. This information should not only contribute to advances in understanding the microbiology and sociology of STD in general, but more immediately, would inform a cogent approach to counseling lesbians and other “low-risk” women, and educating healthcare providers about STD-related risk and prevention.
1. Blower SM, Boe C. Sex acts, sex partners, and sex budgets: Implications for risk factor analysis and estimation of HIV transmission probabilities. J Acquir Immun Defic Syndr 1993; 6:1347–1352.
2. Diamant AL, Schuster MA, McGuigan K, Lever J. Lesbians' sexual history with men: Implications for taking a sexual history. Arch Intern Med 1999; 159:2730–2736.
3. Kellock D, O'Mahony CP. Sexually acquired metronidazole-resistant trichomoniasis in a lesbian couple. Genitourin Med 1996; 72:60–61.
4. Campos-Outcalt D, Hurwitz S. Female-to-female transmission of syphilis: A case report. Sex Transm Dis 2002; 29:119–120.
5. Kwakwa HA, Ghobrial MW. Female-to-female transmission of human immunodeficiency virus. Clin Infect Dis 2003; 36:e40–41.
6. Marrazzo JM, Koutsky LA, Kiviat NB, Kuypers JM, Stine K. Papanicolaou test screening and prevalence of genital human papillomavirus among women who have sex with women. Am J Public Health 2001; 91:947–952.
7. Marrazzo JM, Koutsky LA, Stine KL, et al. Genital human papillomavirus infection in women who have sex with women. J Infect Dis 1998; 178:1604–1609.
8. Marrazzo JM, Stine K, Wald A. Prevalence and risk factors for infection with herpes simplex virus type-1 and -2 among lesbians. Sex Transm Dis 2003; 30:890–895.
9. Berger BJ, Kolton S, Zenilman JM, Cummings MC, Feldman J, McCormack WM. Bacterial vaginosis in lesbians: a sexually transmitted disease. Clin Infect Dis 1995; 21:1402–1405.
10. Marrazzo J, Koutsky LA, Eschenbach DA, Agnew K, Stine K, Hillier SL. Characterization of vaginal flora and bacterial vaginosis in women who have sex with women. J Infect Dis 2001.
11. Smart S, Singal A, Mindel A. Social and sexual risk factors for bacterial vaginosis. Sex Transm Infect 2004; 80:58–62.
12. Bailey JV, Farquhar C, Owen C, Mangtani P. Sexually transmitted infections in women who have sex with women. Sex Transm Infect 2004; 80:244–246.
13. Fethers K, Marks C, Mindel A, Estcourt CS. Sexually transmitted infections and risk behaviours in women who have sex with women. Sex Transm Infect 2000; 76:345–349.
14. Cochran SD, Mays VM, Bowen D, et al. Cancer-related risk indicators and preventive screening behaviors among lesbians and bisexual women. Am J Public Health 2001; 91:591–597.
15. Koh AS, Gomez CA, Shade S, Rowley E. Sexual risk factors among self-identified lesbians, bisexual women and heterosexual women accessing primary care settings. Sex Transm Dis 2005 (in press).
16. Bevier PJ, Chiasson MA, Heffernan RT, Castro KG. Women at a sexually transmitted disease clinic who reported same-sex contact: Their HIV seroprevalence and risk behaviors. Am J Public Health 1995; 85:1366–1371.
17. Marrazzo JM, Handsfield HH. Characteristics of female sexually transmitted disease clinic clients reporting same-sex behavior, 1993–1997. Intl J STD AIDS 2001; 12:41–46.
18. Marrazzo JM, Stine K. Reproductive health history of lesbians: Implications for primary care. Am J Obstet Gynecol 2004; 190:1298–1304.