Advanced Search Abstract Women who have sex with women WSW are a diverse group with variations in sexual identity, sexual behaviors, sexual practices, and risk behaviors. WSW are at risk of acquiring bacterial, viral, and protozoal sexually transmitted infections STIs from current and prior partners, both male and female. Bacterial vaginosis is common among women in general and even more so among women with female partners. WSW should not be presumed to be at low or no risk for STIs based on sexual orientation, and reporting of same-sex behavior by women should not deter providers from considering and performing screening for STIs, including chlamydia, in their clients according to current guidelines.
Effective delivery of sexual health services to WSW requires a comprehensive and open discussion of sexual and behavioral risks, beyond sexual identity, between care providers and their female clients. Using measures of both self-reported sexual identity and sexual behavior, it was estimated that 1.
Lifetime same-sex behavior is commonly reported by women in large population-based surveys, ranging from Although extensive data are available regarding sexually transmitted infections STIs among men who have sex with men, relatively little has been published about STI prevalence and risks among other sexual and gender minorities, including women who have sex with women WSW. Health care providers and their female clients would benefit from increased knowledge of STI risks and testing guidance for women who have same-sex partners.
Authors of abstracts were contacted for more information if necessary. Key questions were developed based on review of these sources and in consultation with experts in the fields of infectious disease and gender minority health.
Chlamydia trachomatis and Neisseria gonorrhoeae infections among WSW have been considered uncommon. Earlier studies that included women from STD clinics and sexual health centers reported a prevalence of chlamydial infection among WSW ranging from 0. However, no data on C. In , Singh et al [ 7 ] examined chlamydia positivity among WSW aged 15—24 years tested at family planning clinics participating in the Infertility Prevention Project in the northwestern United States from to Chlamydia positivity was 7.
Chlamydia positivity during the same time period for women reporting only male partners in the 12 months prior to testing was 5. Other STIs can be passed between female partners, including trichomoniasis [ 8 ], syphilis [ 9 ], and hepatitis A [ 10 ].
Although it is presumably rare, sexual transmission of human immunodeficiency virus HIV may also occur in this manner [ 11 ]. Prior data suggesting potential HIV transmission between female partners is based on case reports where presumed female-to-female transmission was based on a lack of other identified risk factors [ 12—14 ].
A survey of female blood donors failed to identify any HIV-infected women who identified same-sex contact as their sole risk factor [ 15 ]. Similar results were seen in a much smaller survey of lesbian and bisexual women [ 16 ]. A case report is unique in identifying a woman with no other reported behavioral risk for HIV acquisition other than sexual contact with her sole female partner; she was found to be recently infected with a similar HIV genotype to her known HIV-infected female partner [ 11 ].
More common is the potential for WSW to acquire HIV through other modes, including injection drug use and sexual contact with high-risk male partners [ 17—19 ]. A history of genital herpes or genital warts was reported more frequently by bisexual women Increasing age was predictive of higher seroprevalence of both HSV-1 and 2, and HSV-2 seropositivity was associated with having a male partner with genital herpes.
HSV-1 seroprevalence increased with higher numbers of female partners [ 21 ]. In a separate study of HSV-1 prevalence and acquisition among young women, receptive oral sex was associated with HSV-1 acquisition [ 22 ]. HSV-2 seroprevalence among women self-identifying as homosexual or lesbian was 8. In addition, in a longitudinal study of HSV-2 acquisition among women, the presence of bacterial vaginosis BV was associated with an increased risk of acquiring HSV-2 hazard ratio [HR], 2.
There are no published studies to date to show if the treatment of BV could reduce acquisition of HSV-2 in women. Prior case reports highlighted the presence of cervical neoplasia and HPV among women who had no history of sex with men [ 28 , 29 ].
Despite these findings, WSW, particularly those with a history of having only female partners, are less likely to report having had Pap smear screening and frequently believe they have less need for cervical cancer screening [ 25—27 , 30 ]. WSW are at risk from acquiring HPV both from their female partners and from current or prior male partners, and thus are at risk for cervical cancer.
Some identify women based on self-identified sexual orientation homosexual, lesbian, bisexual, heterosexual whereas others utilize reported sexual behaviors and partner choices over time female partner ever in a lifetime, female partner in the past year, history of male partners , alone or in combination with measures of sexual orientation, making comparability across studies somewhat limited. Use of consistent and expanded methods to detail same-sex behavior that includes measures of sexual identity, sexual orientation, partner choices, and sexual behaviors are needed to better understand the epidemiology and risks for STIs among WSW and to allow comparability across studies over time.
Prior studies have suggested a higher prevalence of BV among WSW, although these studies had previously been limited to specific populations such as STD clinics or sexual health centers [ 3—6 , 35—37 ]. A cross-sectional survey of female community volunteers aged 16—50 years in the United Kingdom conducted from to demonstrated a BV prevalence of In the largest sample to date, the NHANES —, a nationally representative sample of the US civilian population, women who reported a history of a female sex partner had a prevalence of BV of Many studies have also shown a high level of concordance of BV between a woman and her female sex partner both partners with BV and without BV [ 35 , 38 , 40 ].
A systematic review and meta-analysis examining the association between BV and female sexual partners found that having a history of female sex partner s conferred a 2-fold increased risk of BV relative risk [RR], 2. Exchange of vaginal fluid or other shared behaviors among female partners may contribute to the initiation of BV.
Among WSW, prior studies have found an association of BV with a higher lifetime number of female sexual partners, a history of receptive oral-anal sex, not always cleaning an insertive sex toy between uses, and smoking [ 38 , 40 ]. No association was seen with age, race, smoking, hormone use, douching, vaginal intercourse, receptive oral or anal sex, or number of partners [ 42 ]. Detailed analysis of behavioral data suggested a direct dose-response relationship with increasing number of episodes of receptive oral-vulvovaginal sex HR, 1.
These studies have thus continued to support, though have not proven, the hypothesis that sexual behaviors that facilitate the transfer of vaginal fluid and possibly exchange of extravaginal microbiota eg, oral bacterial communities between partners may be involved in the pathogenesis of BV.
With the advent of new molecular-based methods, there has been a greater appreciation of the microbial diversity and complex nature of BV [ 44—46 ]. Molecular methods also allow a more detailed analysis of specific vaginal flora shared between partners.
Using both culture methods and strain typing with repetitive element sequence-based polymerase chain reaction rep-PCR fingerprinting, Marrazzo et al [ 47 ] examined Lactobacillus colonization at vaginal and rectal sites and whether unique Lactobacillus strains are shared by female sex partners.
Among women, Within this study, both members of monogamous partnerships were enrolled. No similarities in lactobacilli strains were seen between control partners matched for age and date of enrollment to the study. There was a trend toward an association of reported use of shared vaginal sex toys and shared identical lactobacillus strains OR, 1.
The likelihood of sharing identical lactobacilli was not related to mean age of the couple; number of lifetime male sex partners; or to practice, frequency, or timing of other types of sexual behaviors, including oral or anal sexual practices. Despite an initial treatment response, BV commonly recurs or persists in both the short term [ 48 -- 50 ] and long term [ 51 , 52 ]. One study found that a past history of BV, a regular sex partner throughout the study, and female sex partners were significantly associated with recurrence of BV and abnormal vaginal flora [ 51 ].
A recent study of young WSW with BV treated with vaginal metronidazole gel examined behavioral and microbiologic correlates of persistent BV and abnormal vaginal flora at 1 month after therapy. Vaginal fluid samples at baseline and 1 month after therapy were studied using species-specific 16S recombinant DNA PCR assays targeting 17 bacterial species.
Persistent BV was associated with the presence of specific bacteria in vaginal fluid at baseline including BVAB types 1, 2, and 3; Peptoniphilus lacrimalis; and Megasphaera phylotype 2.
Persistence was not related to any specific sexual activity, including male or female partners, use of sex toys, condom use, receptive oral or anal sex, or a sex partner with BV [ 53 ]. Several prior clinic-based studies have examined the role of treatment of partners of females with BV in reducing persistent or recurrent BV. These trials enrolled women with male sex partners and involved treating women and their male partners with clindamycin [ 54 ], metronidazole [ 55 , 56 ], or tinidazole [ 57 ] with follow-up ranging from 3 to 12 weeks.
None of these trials have shown any benefit in reducing persistent or recurrent BV by treating male sex partners. The only proven interventions that have demonstrated an effect in preventing the development or recurrence of BV are chronic suppressive metronidazole therapy [ 52 ] and circumcision of male partners [ 58 ]. To date there have been no reported trials examining the potential benefits of treating female partners of women with BV, and thus no data on which to base a recommendation for partner therapy in WSW.
Results of a randomized trial utilizing a behavioral intervention to reduce persistent BV among WSW were recently published. Enrolled women were randomized to an intervention designed to reduce sharing of vaginal fluid on hands or sex toys following treatment for BV.
Shared vaginal use of sex toys was infrequent among both groups. In summary, BV is common among women in general and even more so among women with female partners. Current data show that women can share strain-specific genital bacteria with their female partners and that specific bacterial species are associated with treatment failure in BV. In the interim, encouraging awareness of signs and symptoms of BV in women and encouraging healthy sexual practices such as cleaning shared sex toys between uses may be helpful to women and their partners.
WSW are a diverse group with variations in sexual identity, sexual behaviors, sexual practices, and risk behaviors. Sexual identity is not necessarily in concordance with sexual behaviors and gender of sexual partners. It cannot be presumed that women who self-identify as lesbian do not or have not had male partners.
Some women who have both female and male partners may also evidence increased risk-taking behaviors compared with their heterosexual or exclusively same-sex-partner peers. A population-based survey conducted in northern California reported on the prevalence of sexual and drug use behaviors among WSMW ages 18— More recently, surveys of risk behavior among WSW have been extended to community settings, including a survey among self-identified lesbian, bisexual, and heterosexual women attending primary care clinics across 33 sites in the United States.
A stratified probability sample of the British general population in examined behavioral and health-related factors among WSW. WSW including those with exclusively female and both male and female partners were more likely than other women to report STD clinic attendance These associations remained significant even after adjusting for numbers of sexual partners. WSW in this population also reported a higher prevalence of smoking, high alcohol intake, and injecting nonprescribed drugs [ 64 , 65 ].