Use of sexual enrichment aids (ie, sex toys) has become increasingly prevalent.1,2 Nearly 80% of surveyed sexually active women aged 18–35 years reported previous use.3 Sexual enrichment aid use is more prevalent among women who have sex with women and women who have sex with women and men, compared with women who have sex with men.3 Because of this, it is important to understand how sexual enrichment aids are used, particularly as related to women's health. Some women engage in behaviors such as sharing sexual enrichment aids with partners, lack of barrier protection, and irregular cleaning of sexual enrichment aids that could increase risk of sexually transmitted infection (STI) or other gynecologic infections.1–6 Sexual enrichment aid use may be associated with negative health outcomes, including diagnoses of bacterial vaginosis, candida vaginitis, or vulvovaginitis.2,5 Additionally, sexual enrichment aids may harbor pathogens such as human papillomavirus, even after cleaning.7
Because a subset of women engage in potentially risky behaviors when using sexual enrichment aids and there are few evidence-based resources that patients can easily access, women need better access to evidence-based information on safe sexual enrichment aid use, health-related risks associated with use, and proper hygiene. Health counseling is one way to meet this need. However, there are few professional guidelines or recommendations available to guide these conversations.8–14 Further, the available recommendations are often vague, noninclusive, and lack reference to primary literature, leaving the recommendations inadequate for use.
Using mixed methodology, we aimed to understand the experiences and preferences of women regarding STI screening and sexual enrichment aid use and hygiene counseling and related counseling practices of medical practitioners.
The data presented were collected under the University of New Mexico Health Sciences Center Institutional Review Board–approved SEARCH (Sexual Enrichment Aids: Research for Chlamydia and Hygiene) protocol. All participants provided informed consent, could withdraw from the study, and were informed of the time requirement, data storage and security plan, name of the investigator, and purpose of the study. To investigate women's experiences, the inclusion criterion was self-identifying as a sexually active woman aged 18–35 years, because these women are most at risk for STIs. We recruited participants using social media posts (Twitter, Facebook, Instagram) and institutional email listservs aimed at increasing sexual practice group and racial diversity of the participants. Any participants who visited the survey site were invited to participate. Recruitment methods make it impossible to calculate the number of women who saw the recruitment material; therefore, a survey response rate could not be calculated. Women who completed the survey were invited to participate in a semi-structured interview (convenience sample). The survey and interview were conducted in English and not limited by geographic location.
In April 2020, participants (n=800, eight excluded for not meeting criteria) completed a confidential online survey that gathered information about their demographics, STI testing experience, sexual behaviors, and sexual enrichment aid use and hygiene. Certain survey questions used branching logic, in that participants were prompted to answer questions only if indicated by their previous answers, accounting for the varying numbers of responses among questions. The survey was administered by REDCap.15 Demographic data were previously published3 (abbreviated in Table 1). Participation incentive was a $10 Amazon merchandise card.
Women interested in participating in the semi-structured interview were stratified based on sexual practice groups (response to “Who do you have sex with?”) and randomized for participation. Women were also recruited by social media postings in partnership with local sexual health resource centers, sex shops, and social media interest groups. All women confirmed use of a sexual enrichment aid before interview participation. Interviews were conducted from June 2020 through February 2021 using audio-only Zoom. Interviews were 30–60 minutes and guided by a semi-structured interview guide, focusing on questions about STI screening and preferences regarding health counseling on safe sexual enrichment aid use and hygiene. The guide was iterative and was reevaluated after the first and fifth interview based on responses and goals of the study.
Transcriptions of audio files were used for analysis, using an inductive content analysis approach that was team-based, iterative, and descriptive, using NVivo software (https://www.qsrinternational.com/nvivo-qualitative-data-analysis-software/home). The primary analyst created a preliminary coding structure, which was discussed among the team. Two analysts independently coded three additional transcripts and met until they reached at least 80% agreement. The primary analyst coded the remaining transcripts. All team members reviewed coding, and summaries of relevant themes were created by two team members and overseen by the senior analyst. Identification of the most used words describing the qualities of the practitioner (Fig. 1) was completed by isolating each characteristic mentioned by each participant within the qualities code. Negative characteristics were given appropriate antonyms, as agreed on with team members.
After 14 interviews, we paused to complete preliminary coding and assess data saturation, defined as the amount of data needed until no new information is gained and informational redundancy is met.16 Additional interviews were necessary. At 24 participants, we no longer created new codes and saw a similar distribution across groups of women and codes, reaching data saturation.16 All interview participants received a $20 Amazon merchandise card.
To investigate medical practitioner counseling behaviors, we recruited participants at local conferences and through email listservs to particular groups of practitioners. Recruitment efforts targeted primary care specialties such as internal and family medicine, obstetrics and gynecology, and midwifery. We asked participants to complete paper or online surveys through REDCap. Due to the methods of survey distribution used, the survey response rate cannot be calculated. Recruitment occurred between November 2019 and November 2020. Medical practitioner demographics are reported in Table 2. Full surveys and semi-structured interview guides are available from the authors on request.
For cross-sectional data sets, we used descriptive statistics to characterize all participants. Prevalence relative risks (RRs) with 95% CIs were estimated. All statistical analyses used two-sided alpha=0.05 and were conducted using SAS 9.4. Advertisements for the study are included as Appendices 1 and 2, available online at https://links.lww.com/AOG/C811.
People who self-identified as women aged 18–35 years met inclusion criteria and were subsequently stratified by sexual practice group: women who have sex with men, women who have sex with women, or women who have sex with women and men. Participants who identified as women who have sex with women were evenly distributed among age groups, whereas participants who identified as women who have sex with women and men skewed younger (P=.0009) and participants who identified as women who have sex with men skewed older (P<.0001) (Table 1). More than half of participants who identified as women who have sex with men described their relationship status as married or in a domestic partnership, whereas one third of participants who identified as women who have sex with women and participants who identified as women who have sex with women and men described themselves the same way. Among all groups, the majority of our surveyed participants had at least some college education (Table 1).
Participants expressed varying experiences obtaining STI testing and assessing risk for STIs. Because sexual enrichment aids may harbor pathogens,7 we first investigated the STI screening experiences of women. The majority (83.1%, 657/791) of women had received lifetime STI testing, and the RR of ever being tested was not significantly different among sexual practice groups (women who have sex with women vs women who have sex with men: 0.83 RR, 95% CI 0.53–1.30; women who have sex with women and men vs women who have sex with men: 1.03 RR, 95% CI 0.86–1.24).
Multiple women who have sex with women discussed feeling dismissed by their practitioners. One participant described trying to obtain STI screening at a university student health center and being told that she did not need one after she said she had sex with, “people that have vaginas typically.” Another woman who has sex with women described being told by a practitioner, “…if you only have sex with women, then you don't have to worry about a lot of things.’” Because of these lived experiences, one woman who has sex with women shared, “I think that opens up to a lot of risk behavior…the fact that you only have sex with women doesn't make you safer to not take care of yourself in a way that you should if you're having sex with men.” Half of women who have sex with women specifically stated that they had never received any STI testing because they never experienced any symptoms and, despite being sexually active, were not prompted by a practitioner to receive STI screening.
The overwhelming majority of all women (96.2%, 607/631) had never been counseled by a practitioner on safe sexual enrichment aid use and hygiene. The RR of being counseled on safe sexual enrichment aid use and hygiene was 2.76 times greater for women who have sex with women and men than for women who have sex with men (95% CI 1.19–6.36). An RR could not be calculated for women who have sex with women due to a low survey participation among that group.
The majority of women who have sex with men who received counseling stated that they had been counseled on a variety of topics, including usage, cleaning, sharing, and risks. Women who have sex with women and women who have sex with women and men indicated these same topics to a lesser extent, with no women who have sex with women stating that they had been counseled on sharing or risk. Few interviewed women said that they had received counseling on sexual enrichment aid use. Two women who had been counseled were told about the importance of cleaning sexual enrichment aids. One woman who has sex with men was told to, “Make sure that you never stick anything in your vagina that is dirty…[and] make sure you're not introducing any outside germs.” A woman who has sex with women and men had been counseled to, “…Make sure you wipe them down with an alcohol prep pad after you're finished…[and] keep them clean if I'm going to keep them because you can get infections from a dirty toy if it's just a continued build up.”
Although most women had not been counseled on safe sexual enrichment aid use and hygiene, all women stated that they would feel comfortable speaking to a medical professional about this topic, as long as the criteria they describe were met. However, many expressed surprise at the suggestion of having practitioners broach this topic. One stated, “I feel like that would be a really great addition to the conversation about sexual activity and safety practices. I feel like this is definitely missing…It really would have been nice if it was just part of the conversation with whoever is talking to me about birth control and condoms.” Another pointed out that, “…from a medical standpoint, if I'm using something wrong, or if the way I'm using my sex toys is causing problems, I won't be able to tell that on my own…” Together, this demonstrates that participants had a clear need and desire to be counseled on this topic.
When women described the characteristics they would prefer in a sexual enrichment aid counseling practitioner, we identified seven themes: age, context, knowledge and expertise, medical specialty, qualities, relationship and rapport, and sex and gender and sexual orientation. These themes are presented in Figure 2, showing the number of participants in each sexual practice group who cited each theme. Most women of all sexual practices discussed “qualities” of the medical practitioner that would make them more or less comfortable being counseled on this topic. Important qualities of a medical practitioner, weighted by the number of participants who discussed each, are presented in Figure 1. Overwhelmingly, women discussed the importance of being nonjudgmental. Some discussed previous judgmental interactions with a medical professional; one woman who has sex with women and men was asked by the practitioner if there was a sex toy used during intercourse, to which she responded yes. The practitioner asked follow-up questions, including, “Well, if you're with a guy, why is there a dildo involved?” The participant said, “…from that moment on, [they] seemed distant or withdrawn, which made me feel extremely uncomfortable because, as my health care practitioner, I feel like I should be able to be open and honest with you.” Similarly, a woman who has sex with men described an interaction in which she felt shamed. “[He judged] the number of partners that I had, and why I hadn't stayed a virgin until marriage, and then when I brought up that I didn't want to get married, then he makes some off-handed moral comment about loose women and my children. And then when I said I didn't want children, he made a comment like, that made complete sense because I probably wouldn't make a good mother…” Finally, a woman who has sex with women said she would assume that medical practitioners are not coming from a place of judgment, “…but because we are a same sex couple, I know that some people might ask questions [about sex toy use] just out of curiosity…” instead of to provide high-quality health care. One woman who has sex with women and men explained that she is worried about being judged because, “…there are some really puritanical attitudes about women and sex toys in our culture…” Another woman who has sex with women and men expressed, “It's very upsetting to encounter someone who you think is supposed to give you information and help you, to make you feel like they think you're gross.”
The second most discussed theme was that of sex and gender and sexual orientation of the medical professional. Most women preferred female practitioners. Some preferred female practitioners in general; for others, preference of sex or gender was linked to their practitioner's specialty. Women said that they expect to discuss this topic with an obstetrician–gynecologist (ob-gyn) and would prefer a woman, because they prefer their ob-gyn to be female. Women stated that they would prefer a woman because, “…I don't trust men down there…”; “because of the anatomy comparison…”; and “It would feel weird to me to have a straight guy to be like, ‘Yeah, you should have sex this way…’” A summary of the remaining five themes related to preferred practitioner qualities is presented in Table 3.
Overall, women expressed comfort being counseled about safe sexual enrichment aid use and hygiene by a medical practitioner. One woman who has sex with men shared, “In terms of health care professional, just listening to women, supporting them, and giving us space to feel empowered and to feel like…we are allowed to use these toys and we're allowed to feel good and normalize it a bit more.”
Although medical practitioners feel comfortable and qualified, the majority do not currently counsel patients on safe sexual enrichment aid use. Despite most women feeling comfortable being counseled by a medical practitioner, most medical practitioners do not counsel women on this subject. Of the medical practitioners surveyed, only 27.0% (52/192) stated that they counsel patients on safe sexual enrichment aid use and hygiene when discussing safe sex, and 21.4% (41/192) reported that this topic is included when counseling women after an STI diagnosis. The RR of counseling patients on safe sexual enrichment aid use and hygiene during safe sex practices counseling (1.53 RR, 95% CI 0.97–2.42) or during STI diagnosis counseling (1.03 RR, 95% CI 0.59–1.81) was not significantly different for ob-gyns or midwives compared with other practitioner types (eg, family medicine, internal medicine, pharmacists), indicating that ob-gyns and midwives are not more likely to counsel on this topic.
Although most practitioners reported not incorporating sexual enrichment aid use and hygiene into counseling, 45.2% (84/186) stated that they felt comfortable and qualified to counsel patients on this topic. The RR of feeling comfortable and qualified to counsel patients on this topic for ob-gyns or midwives compared with other practitioners was 1.58 (95% CI 1.16–2.14). With almost half of practitioners feeling comfortable and qualified to counsel on this topic, only 7.4% (14/188) and 6.4% (12/188) had received training on this topic and were aware of any professional guidelines or recommendations, respectively. The RR of being trained on how to counsel patients on safe sexual enrichment aid use and hygiene for ob-gyns or midwives compared with other practitioners was 4.41 (95% CI 1.44–13.53), and the RR of being aware of professional guidelines or recommendations on this topic for ob-gyns or midwives compared with other practitioners was 3.53 (95% CI 1.10–11.29).
Regardless of specialty, medical practitioners who counsel patients on safe sexual enrichment aid use and hygiene are also more likely to be aware of professional guidelines or recommendations, with an RR of 3.76 (95% CI 1.25–11.31). Surprisingly, only 15.9% (7/44) of practitioners who counsel patients on safe sexual enrichment aid use and hygiene were also aware of professional guidelines. However, those who provide counseling were not statistically more likely to have been trained (RR 2.62, 95% CI 0.96–7.09). Likewise, practitioners who felt comfortable and qualified to counsel patients on this topic were more likely to be aware of professional guidelines (RR 3.6, 95% CI 1.00–12.90), with 10.7% (9/84) knowing the guidelines. We were unable to determine whether practitioners who felt comfortable and qualified to provide counseling were also those who were trained to do so due to insufficient sample size, but 15.5% (13/84) indicated such.
Medical practitioners were also surveyed about barriers they perceived to counseling patients on this topic. Regardless of medical specialty, the most cited reasons were the lack of training (57.8%, 111/192) or knowledge of the literature (45.3%, 87/192). Indeed, in response to an open-ended question, many practitioners made comments such as they, “know little” about this topic; they, “…desperate[ly] need info!!”; and questioned, “Is there any literature [on this topic]?” Others said they perceive it to be an uncomfortable situation (16.2% [20/123] of other practitioner types compared with only 2.9% [2/69] of ob-gyns or midwives). One person stated, “Probably because of my own discomfort in bringing it up. I can count on one hand the number of times I have discussed it. I feel a little let down in myself that I haven't discussed more often, as I know this is something that should be normalized.” Finally, 2.0% (4/192) of practitioners stated that they do not perceive safe sexual enrichment aid use and hygiene to be a medical issue, including two ob-gyns or midwives. The RR of perceiving no barriers regarding counseling patients on safe sexual enrichment aid use and hygiene for ob-gyns or midwives compared with other practitioners was 1.96 (95% CI 1.16–3.33).
Many practitioners expressed that they had not previously considered counseling on this topic. One person stated, “…I'm embarrassed about the inadequacy of my knowledge/care in this area!” Others wrote, “I never thought about this,” and, “Thank you for bringing this topic to my awareness; I will include a discussion regarding sex toy use when appropriate in the future.”
We investigated a growing topic in women's health care—the use of sexual enrichment aids. Our data indicate that women are eager to receive evidence-based information on safety, risk, and hygiene associated with sexual enrichment aid use. Medical practitioners, in particular ob-gyn or midwife practitioners, are ideally suited to provide this counseling, and, indeed, women prefer this. By investigating both women's experience and preferences and medical practitioner counseling behaviors, we can begin to elucidate guidance for practitioners in broaching the subject of sexual enrichment aids with their patients.
It is important to women how medical practitioners interact with them when approaching this sensitive topic. Overwhelmingly, women expressed the need for a nonjudgmental practitioner. Women also stated that they would prefer practitioners who are open, listen to their patients, and are professional. Despite the eagerness expressed among women for counseling on safe sexual enrichment aid use and hygiene, medical practitioners may not be fully equipped to provide such counseling. Reasonable barriers identified by clinicians within this study were lack of training and unfamiliarity with the literature on this topic.
It is unsurprising that many medical professionals do not know of guidelines on the subject; a review of professional medical societies (eg, the American College of Physicians, the American College of Obstetricians and Gynecologists, and the American Academy of Family Physicians) confirms they are largely lacking on the topic of sexual enrichment aid use and hygiene. Indeed, guidelines can be difficult to find, lack detail, target only subsets of women or men, are noninclusive, or reference no primary research associated with the guidelines.8–13 Further, these guidelines do not recognize the barriers women may face when implementing them, such as how to clean sexual enrichment aids with electrical components, how to use barrier protection with sexual enrichment aids that are not phallic in shape, and preferences in sexual activities, such as the pleasure obtained when sharing sexual enrichment aids with partners.3 Such guidelines may need to be revised to be more in-depth, evidence-based, inclusive of all patients who may engage in sexual enrichment aid use, and better advertised to practicing clinicians and taught to trainees. More research is needed to guide evidence-based counseling practices, particularly surrounding hygiene of sexual enrichment aids of varying materials. It is also important that clinicians feel comfortable asking in-depth questions of their patients when counseling on this behavior, because different terminology, such as “sharing,” could hold different meanings to different patients.3
Finally, it is essential that practitioners counsel all patients on safe sex and sexual enrichment aid use. Women who have sex with women, in particular, may be undercounseled on such topics. Unfortunately, these findings reflect what others have documented: women who have sex with women have reduced access to reproductive health services and often have poorer health outcomes.9,17 Yet, women who have sex with women should not be considered at low or no risk for STIs based on sexual orientation alone and should still be provided STI and cervical cancer screening.11,18,19 In fact, women who have sex with women have similar or higher prevalence of STIs and bacterial vaginosis prevalence as high as 52%, compared with women who have sex with men.20–23 Further, some women who have sex with women may be at higher risk for negative health outcomes due to their preferred sexual enrichment aid use.3
With sexual enrichment aid use increasing among women of all sexual practice groups,1–3 it is imperative that women are provided evidence-based guidance on safe sexual enrichment aid use and hygiene. Our findings support the eagerness of women to be counseled on this topic by informed and compassionate medical professionals. Additionally, we have identified educational opportunities and a need for evidence-based recommendations for medical practitioners so that they can best counsel their patients. Research needs to be undertaken and shared to empower women to engage in their chosen sexual behaviors safely, including laboratory-based techniques to determine STI transmission through sexual enrichment aids, best cleaning practices for sexual enrichment aids of varied materials of differing porosities, and investigating sexual behaviors of other groups, including men who have sex with men and noncisgender individuals. Indeed, our current study has the limitation of including primarily cisgender women instead of all patient groups who may engage in sexual enrichment aid use. There are certainly other patient perspectives missing from our current understanding of these topics, because only those women who were comfortable sharing their sexual behaviors may have participated and historically marginalized groups may have very different experiences with approaching health care topics. Further research should be undertaken to specifically understand the perspective of women who have sex with women, because they are already at risk for poorer health outcomes and our current study was able to include only 27 participants. This relatively small subset of women who have sex with women made it difficult to draw generalizable comparisons for any nonsignificant findings in this study. Further development of strong evidence-based guidelines is needed for all patients on safe sexual enrichment aid use and hygiene, to creat an environment for people to explore sexual behaviors safely and with knowledge and confidence.
1. Herbenick D, Reece M, Sanders S, Dodge B, Ghassemi A, Fortenberry JD. Prevalence and characteristics of vibrator use by women in the United States: results from a nationally representative study. J Sex Med 2009;6:1857–66. doi: 10.1111/j.1743-6109.2009.01318.x
2. Wood J, Crann S, Cunningham S, Money D, O'Doherty K. A cross-sectional survey of sex toy use, characteristics of sex toy use hygiene behaviours, and vulvovaginal health outcomes in Canada. Can J Hum Sex 2017;26:196–204. doi: 10.3138/cjhs.2017-0016
3. Collar AL, Fuentes JE, Rishel Brakey H, Frietze KM. Sexual enrichment aids: a mixed methods study evaluating use, hygiene, and risk perception among women. J Sex Res 2021;1–10. doi: 10.1080/00224499.2021.2015568
4. Rowen TS, Breyer BN, Lin TC, Li CS, Robertson PA, Shindel AW. Use of barrier protection for sexual activity among women who have sex with women. Int J Gynecol Obstet 2013;120:42–5. doi: 10.1016/j.ijgo.2012.08.011
5. Marrazzo JM, 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 2002;185:1307–13. doi: 10.1086/339884
6. Marrazzo JM, Coffey P, Bingham A. Sexual practices, risk perception and knowledge of sexually transmitted disease risk among lesbian and bisexual women. Perspect Sex Reprod Health 2005;37:6–12. doi: 10.1363/psrh.37.006.05
7. Anderson TA, Schick V, Herbenick D, Dodge B, Fortenberry JD. A study of human papillomavirus on vaginally inserted sex toys, before and after cleaning, among women who have sex with women and men. Sex Transm Infect 2014;90:529–31. doi: 10.1136/sextrans-2014-051558
8. Addressing health risks of noncoital sexual activity. Committee Opinion No. 582. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;122:1378–82. doi: 10.1097/01.AOG.0000438963.23732.80
9. Mravcak SA. Primary care for lesbians and bisexual women. Am Fam Physician 2006;74:279–86
10. Sobel JD. Bacterial vaginosis: treatment. In: Barbiere RL, editor. UpToDate. Accessed April 22, 2021. https://www.uptodate.com/contents/bacterial-vaginosis-treatment
11. Health care for lesbians and bisexual women. Committee Opinion No. 525. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;119:1077–80. doi: 10.1097/AOG.0b013e3182564991
12. Carroll NM. Lesbian, gay, bisexual, transgender, and other sexual minority women: medical and reproductive care. In: Barbiere RL, editor. UpToDate. Accessed April 22, 2021. https://www.uptodate.com/contents/sexual-minority-women-lesbian-gay-bisexual-transgender-plus-medical-and-reproductive-care
13. Knight DA, Jarrett D. Preventive health care for women who have sex with women. AFP 2017;95:314–21
14. LeFevre ML. Behavioral counseling interventions to prevent sexually transmitted infections: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med 2014;161:894–901. doi: 10.7326/M14-1965
15. Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377–81. doi: 10.1016/j.jbi.2008.08.010
16. Saunders B, Sim J, Kingstone T, Baker S, Waterfield J, Bartlam B, et al. Saturation in qualitative research: exploring its conceptualization and operationalization. Qual Quant 2018;52:1893–907. doi: 10.1007/s11135-017-0574-8
17. Diamant AL, Wold C, Spritzer K, Gelberg L. 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;9:1043–51. doi: 10.1001/archfami.9.10.1043
18. Workowski KA, Bachmann LH, Chan PA, Johnston CM, Muzny CA, Park I, et al. Women who have sex with women (WSW) and women who have sex with women and men (WSWM). In: Sexually transmitted infections treatment guidelines, 2021. Morbidity and mortality weekly report. Centers for Disease Control and Prevention; 2021. p. 19–22. doi: 10.15585/mmwr.rr7004a1
19. Workowski KA, Bachmann LH, Chan PA, Johnston CM, Muzny CA, Park I, et al. In: Sexually transmitted infections treatment guidelines, 2021. Morbidity and mortality weekly report. Centers for Disease Control and Prevention; 2021. p. 100–6. doi: 10.15585/mmwr.rr7004a1
20. Fethers K. Sexually transmitted infections and risk behaviours in women who have sex with women. Sex Transm Infections 2000;76:345–9. doi: 10.1136/sti.76.5.345
21. Singh D, Fine DN, Marrazzo JM. Chlamydia trachomatis
infection among women reporting sexual activity with women screened in family planning clinics in the pacific northwest, 1997 to 2005. Am J Public Health 2011;101:1284–90. doi: 10.2105/AJPH.2009.169631
22. McCaffrey M, Varney P, Evans B, Taylor-Robinson D. Bacterial vaginosis in lesbians: evidence for lack of sexual transmission. Int J STD AIDS 1999;10:305–8. doi: 10.1258/0956462991914168
23. Skinner CJ, Stokes J, Kirlew Y, Kavanagh J, Forster GE. A case-controlled study of the sexual health needs of lesbians. Genitourin Med 1996;72:277–80. doi: 10.1136/sti.72.4.277