Immunization Issues

Certain high risk Human Papillomaviruses (HPVs) are sexually transmitted infections which can lead to a number of anogenital cancers, including cervical cancer. The recommendation that all females from 11 to 26 years of age be immunized with HPV vaccine was an important public health milestone.

An important—and often overlooked—group of women who should also get this vaccine are women who have sex with other women.

Women who have sex with women (WSW). WSW may comprise as many as 4.5% of sexually active women in the US who are 18-45 years of age.1 However, 43% of WSW identify themselves as heterosexual, 39% as lesbian and 18% as bisexual.1

The majority of WSW do not inform their health provider of their sexual activity with women2, they are less likely to have a health provider1 and they are less likely to utilize preventive health services—such as Pap screening and mammograms.13

About 80% WSW have also previously had sex with men. 245 As a consequence, these women are at the same risk (or higher) of acquiring sexually transmitted infections than exclusively heterosexual women, including HPV.

• Almost a quarter of WSW had sex with a man during the past year—increasing the risk of acquiring sexually transmissible infections, including HPVs—particularly because their male partners were more likely to be
  • Men who have sex with other men6
  • Men were who are intravenous drug users35
• Some WSW have engaged in behaviors that can increase the risk for acquiring HPV infection, such as:
  • Having multiple sex partners.2357
  • Beginning sexual activity at an earlier age.23
  • Practicing oral sex, genital to genital sex, vaginal finger penetration, and/or sharing sex toys.236
  • Using intravenous drugs.5

Approximately 20% of WSW have had sex exclusively with other women. 234 A common misperception is that these women are not at risk of acquiring infection with high risk strains of HPV. Although the risk of acquiring HPV infection in these women may be a bit lower than in exclusively heterosexual women36,

• HPV transmission between women has been demonstrated, including between women who exclusively have sex with other women.46
• Cervical pre-cancers and cancerous changes have been seen in women who exclusively have sex with women.2346

Barriers to preventive healthcare (including Pap screening and HPV vaccine) for those women who have sex exclusively with other women. Perhaps the greatest barrier may be the widespread belief by both these women and their health providers that women who exclusively have sex with women are not at risk of HPV—and therefore, cervical cancer—because they have not been sexually active with men.1234

A number of factors have been identified for why lesbian and bisexual women are an underserved population for preventive health care.

• Health providers often are unaware of the woman’s sexual behaviors.27
• Health providers may have misperceptions about the diversity of health needs of these women.24
• Some women lack healthcare insurance.14
• They may have a lower family income in the absence of a male wage earner.4
• They had prior bad experiences with providers’ attitudes, as well as when undergoing breast and Pap test screening.48

Selected References

• 1. a. b. c. d. e. f. Kerker BD, Mostashari F, and Thorpe L. (2006). Health care access and utilization among women who have sex with women: sexual behavior and identity. J Urban Health 83(5):970-9.
• 2. a. b. c. d. e. f. g. h. i. j. Carr SV, Scoular A, Elliott L, et al. (1999). A community based lesbian health service—clinically justified or politically correct? Br J Fam Plann. 25:93-5.
• 3. a. b. c. d. e. f. g. h. i. Rankow EJ and Tessaro I. (1998). Cervical cancer risk and Papanicolaou screening in a sample of lesbian and bisexual women. J Fam Pract 40:486-92.
• 4. a. b. c. d. e. f. g. h. i. Bailey JV, Kavanagh J, Owen C, et al. (2000). Lesbians and cervical screening. Br J Gen Pract 50; 481-2.
• 5. a. b. c. d. Marrazo JM, Koutsky LA, Kiviat NB, et al. (2001). Papanicolaou test screening and prevalence of genital human Papillomavirus among women who have sex with women. Am J Pub Health 91; 947-52.
• 6. a. b. c. d. e. Fethers K, Marks C, Mindel A, et al. (2000). Sexually transmitted infections and risk behaviours in women who have sex with women. Sex Transm Inf 76;345-9.
• 7. a. b. Marrazzo JM, Koutsky LA, Stine KL, et al. (1998). Genital human Papillomavirus infection in women who have sex with women. J Infect Dis 178;1604-9.
• 8. Fish J and Anthony D. (2005). UK national lesbians and health survey. Women Health 41(3):27-45.