Relatively few data are available to inform estimates of the risk of female-to-female sexual transmission of STDs. The available data come primarily from four sources.
First, review of records from clinics that provide STD services (STD clinics) has provided estimates of some outcomes, including diagnosis of STD syndromes, laboratory results, and risk reporters. Such studies have the advantages of capturing a reproducible population
of women who can be characterized relative to heterosexual women attending the same venue and of relying on clinician-based or laboratory-defined reports of outcomes,
but are limited primarily by the relatively small number of WSW who attend these clinics.
Second, several studies have recruited women who either self-identify as lesbian or who report recent samesex behavior, regardless of stated identity. Although this of WSW and frequently includes laboratory diagnosis of STDs, the sample of women included is likely biased due to self-selection for enrollment.
Third, although population-based surveys attempt to enroll a more representative sample of women, including WSW, because these surveys are generally expensive and complex to undertake, most do not include laboratoryconfirmed assessment of STDs but rely on self-reported STD history.
Finally, case reports of STD transmission between women provide the only documented evidence available for some STDs. Despite their obvious limitations, these reports are valuable in that they can demonstrate the potential for STD transmission between women and, as such, help to emphasize the need for more robust, population-based data to inform WSW patients and their providers about the true risks associated with samesex behavior between women.
Numerous studies have demonstrated that important barriers to health care exist for WSW. These barriers include, but are not limited to, lack of patient educational materials aimed at their specific risks and circumstances, lack of knowledge among providers, low socioeconomic
status, absence of spousal benefits, and impact of negative experiences within the health care system.
Among the latter are included outright instances of homophobia and general invisibility. For example, many office registration materials still list options for marital status as “single” or “married”—terms that do not apply to WSW who may be in domestic partnerships, particularly those that are not recognized by regulatory authorities. Even providers who are comfortable assessing STD-related risks may not be knowledgeable about the sexual practices engaged in
by many WSW, or about the limited disease-specific information in the literature. For these reasons, education of providers in this area is paramount.
Because recent national (USA) surveys indicate that same-sex behavior among women is relatively common, providers should familiarize themselves with information about this patient population, and be aware of referral options for more detailed information. Available information on transmission of specific STDs in WSW is discussed later,
under Laboratory Studies. Risk Assessment Risk assessment in WSW should begin the way all STDrelated risk assessment begins in every patient: with a thorough sexual history. Most importantly, providers should not make assumptions about sexual practices based on the patient’s self-reported identity—in this case, specifically, as a lesbian. Assuming that a self-identified lesbian has not previously been or is not currently sexually
active with men is usually incorrect. In one study, 74% of self-identified lesbians had male partners in the past, and of self-identified bisexual women, 98% had
prior or current male partners. Among lesbians recruited for studies in Seattle, 80–86% reported prior sex with men, 23–28% had had sex with a man in the last year, and the median number of male and female lifetime partners was the same. In a sample of women
evaluated at a London STD clinic, 69% of those identifying as lesbian had prior male partners, and at another London clinic specializing in the sexual health of lesbians,
91% had prior male partners. Heterosexual intercourse transmits the full range of STDs, some of which (notably, chronic viral infections, including HPV, genital
herpes, hepatitis B virus, and HIV) may remain undetected for years.
Important components of the sexual history include number of recent (prior 2 months and 1 year) and lifetime sexual partners, both male and female. Other key components should include types of sexual practices that could pose a risk of transmission of STDs. Some
sexual practices—including oral-genital sex; vaginal or anal sex using hands, fingers, or penetrative sex toys; and oral-anal sex—are practiced commonly between
female sex partners. Practices involving digital-vaginal or digital-anal contact, particularly with shared penetrative sex toys, present a plausible means for transmission
of infected cervicovaginal secretions.
In several studies, women who report sex with both men and women report more sex partners over their lifetimes than women who have sex exclusively with either
men or women. One population-based survey in lowincome neighborhoods found that women who had sex with men only reported a mean of 16 lifetime partners, whereas women reporting sex with men and women reported a mean of 307 lifetime partners.
Similarly, among patients attending an STD clinic in Seattle, women with only female partners in the previous 2 months reported 3.4 partners in the past year; women with only male partners, 5.3 partners in the past year; and women with male and female partners, 16.5 partners in the past year. Women who report sex with both men and women are likely to be at higher risk for STDs than women who report sex with women or men only.
WSW may have male partners who are at higher risk for HIV and STDs than the partners of women who have sex with men only. In one study of patients at an STD clinic, 10% of women who had sex with only women in the previous 2 months had a prior male partner who was gay or bisexual, compared with 6% of women reporting sex with men only. Of women reporting sex with both men and women in the prior 2 months, 29% had a prior gay or bisexual male partner.
Women who reported sex with both men and women in the previous 2 months were also more likely than women who had sex with only men or only women to have had more than four male sexual partners in a year, more likely to exchange sex for money or drugs, and more likely to
have used intravenous drugs. In summary, lesbian and bisexual women may have past or current sex partners at high risk for HIV and other STDs.
Risk Reduction Counseling
No studies have directly addressed the acceptability or efficacy of STD risk reduction interventions among WSW. However, measures that reduce the potential for transmission of cervicovaginal secretions are likely to be effective in reducing STD transmission.
For women who practice digital-vaginal or digital-anal sex (hands or fingers in partner’s vagina or anus), the risk is probably low unless secretions are actually transferred on the hands from the infected partner to the other.
Interrupting this progression by avoiding the behavior or by using and removing gloves after contact is likely effective.
For minimizing transfer of infected secretions associated with insertive sex toys, several approaches are likely effective. These include minimizing sharing of unclean
sex toys (either not sharing toys at all or cleaning them between use by one partner and the other), use of condoms on sex toys, and avoiding use of sex toys anally and
vaginally in succession.
With regard to oral sex and STDs, WSW may be at increased risk of genital herpes infection with herpes simplex virus type 1 (HSV-1) due to a relatively higher frequency of orogenital sex. Serologic screening for HSV-1 is not useful to screen for potential infectiousness, because most adults are infected with HSV-1 orally, and serology does not distinguish between oral and genital infection.
However, women should be counseled to avoid performing oral sex when lesions consistent with an oral herpes outbreak (eg, a cold sore, recurrent ulcer, or vesicle) are evident or if a recognizable prodrome (eg, ear pain or local lymphadenopathy) is underway.
Other important components of complete risk reduction counseling for all patients include a discussion of sex partner selection, sexual network assessment, and the patient’s ability to negotiate safer sex practices.
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