Sexually transmitted infections (STIs) occur in lesbian and bisexual women in all countries, but little population-based data are available to delineate precise risks. Asking about sexual behaviors rather than only sexual identity is key to identifying STI risk and advising appropriate testing since risk may vary by specific sexual practice (eg, digital-vaginal, vaginal-vaginal, digital-anal, oral-vaginal, oral-anal contact) and the specific pathogen. WSW are noted by the Centers for Disease Control and Prevention (CDC) to have diverse sexual practices and that use of barrier protection in examined studies (eg, use of gloves, dental dams) was ubiquitously low. Chlamydial infections were higher in 14- to 24-year-old women who reported same-sex behavior when attending family planning clinics in the US Pacific Northwest compared to women who reported exclusively heterosexual behavior. Possible explanations for this observation include differences in these groups' use of reproductive health care services, infrequent use of barrier methods to prevent STI transmission with female partners, trends toward higher-risk behaviors, and different characteristics of their sexual networks. Untreated chlamydial infection places a woman's future fertility at risk due to potential tubal occlusion. Some women who have a chlamydial infection do not have symptoms. Secondary sequelae of chlamydia include intra-abdominal abscesses, chronic pain, and the need for multiple surgeries. Regardless of sexual orientation, the CDC recommends annual Chlamydia trachomatis (and Neisseria gonorrheae) screening from the age of first sexual activity to the age of 25 years for all women.
It is important to ask lesbian and bisexual women about specific sexual practices, as some practices may carry a higher risk of STIs than others, although there has been little research on sexual practices and the risk of STIs in this population. Thus, inferences are drawn from heterosexual prevention of these infections. "Safer Sex Kits" have occasionally been distributed to WSW and WSWM to decrease the risk of STIs but the effectiveness of this preventive measure has not been studied. These kits often include dental dams to prevent transmission of bacteria and viruses from oral sex, but the efficacy of dental dams for this function has not been studied. Female latex condoms and latex gloves may provide better protection against infectious transmission from oral sex since latex has been studied as a barrier for prevention of HIV. Exchange of blood should be avoided as much as possible, especially in HIV-discordant lesbian couples. HIV can be transmitted sexually between women; this was confirmed by viral genotype analysis. The clinician should encourage both partners in new lesbian couples to have HIV screening prior to sexual contact, recommend the use of barrier protection for 6 months until the couple is again screened to verify that their HIV status is still negative. If the couple is monogamous, barrier precautions do not need to be continued. However, very few lesbian and bisexual women follow this advice, as many feel they are at low risk for HIV, which may be correct, but data are lacking as is good questioning about sexual practices and sexual orientation. About 20–50% of lesbian women use sexual aids (eg, vibrators, dildos, or other sexual toys); these should not be shared with partners and should be cleaned after use. The HPV can remain on these sexual aids for up to 24 hours after use, even after standard cleaning. Some lesbian and bisexual women are sex workers or have had sexual relationships with high-risk male sexual partners (sometimes their gay male friends) and are at increased risk for STIs. Current CDC guidelines recommend that all women should be tested once in their lifetime for HIV, and then repeated according to risk factors.
The herpes simplex virus (HSV) can be transmitted sexually between women. The same precautions regarding the transmission of HSV should be provided to lesbian, bisexual, and heterosexual women; there should be no sexual contact during any prodromal symptoms that may precede a genital herpes outbreak or during the blister stage of the outbreak. Suppression of lesions can usually be accomplished with antiviral medications, such as acyclovir or valacyclovir, if the lesions are recurrent (see Chapter 6).
There is evidence of HPV transmission between female sexual partners. Ten percent of lesbian women have never had sex with men, yet cervical dysplasia and cervical cancer develop in some of these women. All women need Papanicolaou smears, including lesbian women, according to timetables provided by professional society guidelines. The rate of HPV vaccination in lesbian women (8.5%) is less than in heterosexual women (28.4%) and bisexual women (33.2%), which contributes to health disparities. Administration of the HPV vaccine is critical to the prevention of cervical cancer.
Trichomonas vaginalis can be easily transmitted between female sexual partners. One study of African American women attending an STI clinic in the United States noted that T vaginalis was the most common curable STI found in this population with a prevalence of 17% in WSW and 24% in WSWM. Accessing medical evaluation early when symptoms of excess or foul-smelling vaginal discharge first appear is important in the treatment of trichomoniasis in order to prevent transmission of the infection, which can survive on towels and in hot tubs.
Bacterial vaginosis is common among women and according to the CDC, even more common among WSW. It is unknown whether bacterial vaginosis can be transmitted between women. A study from Australia found a 27% prevalence of bacterial vaginosis in women and their female partners; risk factors for bacterial vaginosis were four or more lifetime female sexual partners, a female partner with bacterial vaginosis symptoms, and smoking at least 30 cigarettes weekly. Routine screening for bacterial vaginosis, though, is not currently recommended and testing should be performed in response to symptoms. One approach for a WSW who has symptoms and a diagnosis of bacterial vaginosis is to treat her and not her female sexual partner. If symptoms recur, her female sexual partner should be evaluated and treated with consideration of re-treating the index woman. This strategy may also be used for treatment of recurrent or hard to treat vulvovaginal candidiasis, which technically is not considered to be sexually transmitted, but anecdotally, improvement has occurred with index patient and female partner treatment.
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