• Sexual Health Shanghai



Women who have sex with women (WSW) are a diverse group with variations in sexual identity, sexual behaviors, sexual practices, and risk behaviors. Recent studies indicate that some WSW, particularly adolescents and young women as well as women with both male and female partners, might be at increased risk for STDs and HIV based on reported risk behaviors. Certain studies have highlighted the wide diversity of sexual practices and examined use of protective/risk reduction strategies among populations of WSW. Use of barrier protection with female partners (gloves during digital-genital sex, condoms with sex toys, and latex or plastic barriers [also known as dental dams for oral-genital sex]) was infrequent in all studies. Despite this, few comprehensive and reliable resources of sexual health information for WSW are available.

Few data are available on the risk for STDs conferred by sex between women, but transmission risk probably varies by the specific STD and sexual practice (e.g., oral-genital sex; vaginal or anal sex using hands, fingers, or penetrative sex items; and oral-anal sex). Practices involving digital-vaginal or digital-anal contact, particularly with shared penetrative sex items, present a possible means for transmission of infected cervicovaginal or anal secretions. This possibility is most directly supported by reports of shared trichomonas infections and by concordant drug resistance genotype testing and phylogenetic linkage analysis identifying HIV transmitted sexually between women. Most self-identified WSW (53%–97%) have had sex with men in the past and might continue this practice, with 5%–28% of WSW reporting male partners within the past year.

HPV, which can be transmitted through skin-to-skin contact, is common among WSW, and sexual transmission of HPV likely occurs between female sex partners. HPV DNA has been detected through polymerase chain reaction (PCR)-based methods from the cervix, vagina, and vulva in 13%–30% of WSW. Among WSW who reported never having had a male sexual partner, 26% had antibodies to HPV-16, and 42% had antibodies to HPV-6. High- and low-grade squamous intraepithelial lesions (SIL) have been detected on Pap tests in WSW who reported no previous sex with men . WSW are at risk for acquiring HPV from both their female partners and from current or prior male partners, and thus are at risk for cervical cancer. Therefore, routine cervical cancer screening should be offered to all women, regardless of sexual orientation or sexual practices, and women should be offered HPV vaccine as per current guidelines.

Genital transmission of HSV-2 between female sex partners is inefficient, but can occur. A U.S. population-based survey among women aged 18–59 years demonstrated an HSV-2 seroprevalence of 30% among women reporting same-sex partners in the past year, 36% among women reporting same-sex partners in their lifetime, and 24% among women reporting no lifetime same-sex behavior. HSV-2 seroprevalence among women self-identifying as “homosexual or lesbian” was 8%, similar to a prior clinic-based study of WSW. The relatively frequent practice of orogenital sex among WSW might place them at higher risk for genital infection with HSV-1, a hypothesis supported by the recognized association between HSV-1 seropositivity and previous number of female partners among WSW. Thus, sexual transmission of HSV-1 and HSV-2 can occur between female sex partners. This information should be communicated to women as part of a larger sexual health counseling and evaluation effort.

Less is known regarding transmission of bacterial STDs between female partners. Transmission of syphilis between female sex partners, probably through oral sex, has been reported. Although the rate of transmission of C. trachomatis between women is unknown, infection also might be acquired from past or current male partners. More recent data suggests that C. trachomatis infection among WSW might be more common than previously believed. Reports of same-sex behavior in women should not deter providers from offering and providing screening for STDs, including chlamydia, according to current guidelines.

BV is common among women in general and even more so among women with female partners. Sexual behaviors that facilitate the transfer of vaginal fluid and bacteria between partners may be involved in the pathogenesis of BV. A study including monogamous couples demonstrated that female sex partners frequently share identical genital Lactobacillus strains. Within a community-based cohort of WSW, extravaginal (i.e., oral and rectal) reservoirs of BV-associated bacteria were a risk factor for incident BV. Several new studies have examined the impact of specific sexual practices on the vaginal microflora and on recurrent or incident BV among WSW and non-WSW. These studies have continued to support, though have not proven, the hypothesis that sexual behaviors, specific BV-associated bacteria, and possibly exchange of vaginal or extravaginal microbiota (e.g., oral bacterial communities) between partners might be involved in the pathogenesis of BV in WSW.

Although BV is common in WSW, routine screening for BV is not recommended. Results of a randomized trial using a behavioral intervention to reduce persistent BV among WSW through reduced sharing of vaginal fluid on hands or sex toys has been published. Although women randomized to the intervention were 50% less likely to report receptive digital-vaginal contact without gloves than controls and reported sharing sex toys infrequently, these women had no reduction in persistent BV at 1 month post-treatment and no reduction in incident episodes of recurrent BV. To date, no reported trials have examined the potential benefits of treating female partners of women with BV; thus, no recommendation can be made regarding partner therapy in WSW. Increasing awareness of signs and symptoms of BV in women and encouraging healthy sexual practices (e.g., avoiding shared sex toys, cleaning shared sex toys, and barrier use) might benefit women and their partners. WSW are at risk for acquiring bacterial, viral, and protozoal STDs from current and prior partners, both male and female. WSW should not be presumed to be at low or no risk for STDs based on sexual orientation. Report of same sex behavior in women should not deter providers from considering and performing screening for STDs and cervical cancer according to current guidelines. Effective screening requires that care providers and their female patients engage in a comprehensive and open discussion of sexual and behavioral risks that extends beyond sexual identity.

Useful Resource

  • Shanghai Public Health Clinical Center | shaphc.org
  • Shanghai Municipal Center For Disease Control & Prevention | scdc.sh.cn
  • Shanghai Skin Disease and STD Hospital | shskin.com

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