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Both health care professionals and the medical research establishment have historically ignored the so-called sexual minorities, including lesbians. Much of what was known was derived from anecdotal experience and volunteer surveys. As a basic principle, most health concerns of lesbians are no different from those of heterosexual women. However, there are unique factors in four areas. First, the sexual behaviors of the lesbian include all those available to the heterosexual woman except for penile—vaginal intercourse, and she needs to know if these behaviors place her at risk for disease. This question is most urgent regarding human immunodeficiency virus HIV transmission risk.

Second, if she wants to become a parent, she will have a more difficult time accessing the usual options for achieving that goal. Third, while most research in lesbian health has focused on gynecologic issues, a broader area of research has begun to look at primary care issues among lesbians including risks for chronic illness, mental health issues, etc. Finally, lesbians live in a unique psycho-social-economic milieu. Men and women who may identify and behave as heterosexuals early in their lives may later self-identify as gay or lesbian, and a similar switch can occur from early homosexual to exclusively heterosexual behavior; persons who are bisexual may have a much more varied behavioral and relationship history.

The etiology of lesbianism is not known, just as the etiology of heterosexual identity is not understood. Genetic, prenatal, hormonal, and early childhood influences each may have a role. Child abuse and emotionally distant parents have not been found to play a role. Except for activities that require a penis, lesbians have available to them the same potential repertoire of sexual practices as heterosexual couples. The most frequent activities appear to be mutual masturbation and oral—vaginal sex. Compared to gay men and heterosexual couples, lesbians as a group appear to have less frequent sex, and fewer lifetime partners.

Before discussing the various specific health issues, it is important to recognize the challenges inherent in doing research among stigmatized, minority populations such as lesbians and other sexual minorities. One of the major goals of the current research agenda is identifying methods that will overcome these difficulties.

The Institute of Medicine published a landmark report in that comprehensively details these issues, and that calls for more scientific investigation in these areas. The primary challenge is the identification of unbiased, representative samples. The randomly selected population-based sample, the gold standard of epidemiologic research, has been considered impossible to obtain. Consequently, most investigators have used volunteer or convenience samples, despite the unavoidable bias this introduces.

The use of convenience samples is preferable to the use of volunteers, and there are several large surveys using this type of sampling. While larger samples are preferable, size alone does not overcome the inevitable biases. Investigators are therefore obligated to describe the demographic characteristics of the sample, and to avoid overgeneralizing their conclusions.

The assumption that women will not willingly disclose their sexual orientation to investigators has been tested in a small of studies in which study participants have been asked to self-identify. The disorders of most interest are those for which sexual behavior is related to risk: vaginal infections, sexually transmitted diseases STDs , cervical neoplasia, and HIV infection. A majority of lesbians have a past history of heterosexual activity, and many have used oral contraceptives and have been pregnant. The recommendations in this chapter reflect this approach. Lesbians who seek care at STD clinics have been found to have approximately twice the rate of bacterial vaginosis compared to heterosexual women attending the same clinics.

In one study of monogamous lesbian sexual partners, there was a high concordance for the presence or absence of this infection among the pairs, supporting the possibility of sexual transmission between women 21 and a cross sectional study found that bacterial vaginosis risk was associated with an increasing of female partners.

The treatment of bacterial vaginosis in a lesbian is the same as for a heterosexual woman. Most Candida infections are not the result of sexual transmission, and the prevalence of this infection is similar in lesbians. However, Candida can be acquired by direct contact with an infected person, and the risk of acquiring Candida increases in lesbians with more female partners.

Transmission between two women could, therefore, also be possible during vulva-to-vulva contact or transmission from fingers to vagina. If fingers or hands come in contact, the partner should avoid placing her hand in her own vaginal area. The primary route of transmission for Trichomonas vaginal infection is heterosexual intercourse. Two cases of probable female-to-female transmission have been reported. In each case, transmission was thought to be via mutual masturbation.

Although Trichomonas is fairly fastidious, it can survive in the discharge outside the vagina for at least several minutes. Female partners should therefore avoid contact with infected vaginal secretions until treatment is completed. None of these has ever been reported in a lesbian who has never had heterosexual intercourse. Chlamydia and gonorrhea, transmitted via infected semen, primarily infect the cervix, which is not easily accessible to the female partner. Although infection of a female partner is unlikely, it is again prudent to adhere to vaginal abstinence until treatment is completed.

Although herpes type 1 and type 2 are traditionally associated with oral and genital infections, respectively, each viral subtype can infect at either location. Transmission requires direct contact between infected and uninfected mucous or skin.

The virus can also be transmitted via an intermediary, such as a finger. Once the lesion is scabbed over, the risk of transmission should be quite low. Subtypes 6 and 11, which are responsible for most condyloma, infect squamous epithelium and are nearly impossible to eradicate completely. Transmission is poorly understood. Direct contact with infected surfaces, which usually occurs in the context of sexual activity, is probably the most common route of transmission for the human papillomavirus HPV subtypes that cause condyloma. In theory, transmission of the HPV virus should be as 'efficient' between two women as that between a man and a woman.

Thus, condyloma are not uncommon among lesbians, although the prevalence may be lower than among comparable heterosexual women. The majority of women who currently identify themselves as lesbian have a history of past sexual contact with men, and thus, are at risk for cervical dysplasia; abnormal Pap smears have been identified among women who have no such history, although the risk in this group is undoubtedly low.

Several small studies have found that lesbians, when compared to heterosexual or bisexual women, are less likely to get regular Pap smear screening. This approach is appropriate for lesbians; presence of the usual risk factors HPV infection, smoking, HIV infection would justify annual screening.

Hepatitis C was found to be more than seven times more common in the lesbian subjects in a large case control study of women seen in a STD clinic. HIV-infected women are also at higher risk. Subsequent studies have confirmed that for a lesbian, the major risk factors for acquisition of HIV include personal intravenous drug abuse, bisexuality, and having sex with homosexual men. Most, but not all, 45 studies have found that lesbians in these high-risk groups have often been found to be less likely to practice safe sex. Overall, the use of barriers by lesbians was half that of infected heterosexual women.

The risk of transmission of HIV between female sexual partners is not known, but is thought to be quite low. The CDC has never reported a case thought to be the result of female-to-female transmission. There were no seroconversions in a prospective 6-month study of serodiscordant women sexual partners, 49 and no cases identified in a STD clinic survey that included over women who had sex exclusively with women. Three possible cases have been reported. The most convincing and instructive case is reported by Marmor and coworkers. Both occurred during the menses of the infected woman.

Finally, both women had vaginal bleeding from traumatic sexual activity. The infected woman had tested positive for HIV two years later, and had no other apparent risk factors. The other two cases rely on symptom history rather than serology for the diagnosis; it is not clear in either case that other risk factors were absent.

In theory, female-to-female transmission should be the least efficient way to transmit the virus, because female-to-male transmission is thought to be less common than male-to-female or male-to-male transmission. Although the virus has been found in vaginal fluid, there are antibodies in the vagina that may limit transmission. Saliva also contains the virus, but exposure to saliva has not been proven as a route of transmission. It appears that prevention efforts would be best directed toward lesbians who engage in the behaviors identified as risk factors.

In addition to the standard advice to use condoms when having sex with men and avoiding needle sharing, these women should be advised to take measures to minimize exposure to the vaginal secretions of women partners via sex toy use and receptive oral sex.

The barrier methods recommended include the use of dental dams for oral—genital or oral-anal contact; condoms on dildos and sex toys; and latex finger cots during vaginal or anal penetration. Many lesbians raise children who are the product of heterosexual relationships, and an increasing want to start families in a lesbian relationship.

Adoption is a desirable option, but domestic adoptions of healthy newborns are difficult for lesbians to arrange. As a result, many lesbian families pursue international adoption, or children with special needs. Women who inquire about this option should be advised to consult with persons knowledgeable about the adoption situation locally.

Women wishing to be biologic mothers should be advised that donor insemination through a medical or other d facility is optimal. The essential procedure placing semen in the vagina does not require any special medical expertise or equipment and can be arranged without medical or legal consultation; however, this method is not advisable for a of reasons. First, the donor may later desire involvement with the child beyond the original agreement, and although sometimes this works out well, it often may not.

Second, the donor may decide to stop donating semen without notice. Finally, and perhaps most importantly, the woman cannot be sure that the donor is infection-free, particularly from HIV. HIV transmission via artificial insemination one in the United States has been reported, with an estimated risk of less than 0. Half of the women received fresh semen from gay or bisexual men living in San Francisco before All women in the study were tested for HIV; none were positive.

Ross et al surveyed a group of lesbians and bisexual women, and shared their suggestions with assisted reproductive services who were interested in being more lesbian-friendly. Not all medical providers are willing to provide insemination services for lesbians.

The basis for this policy is sometimes stated as concern for the outcome of the children born into a lesbian household. A of studies have specifically focused on role development and social relationships. While the literature to date shows that children raised in lesbian households are not more likely to have adverse psychological, developmental, or educational outcomes than those raised by heterosexual parents, 62 Stacy and Biblarz 63 observed that it seems theoretically implausible that there would be no differences at all.

To test this hypothesis, they performed their own analysis of 21 studies published through , and found a of interesting differences, which they point out are essentially ignored by the authors of the studies. For example, young children being raised by lesbians are less likely to restrict their play to gender stereotypic activities; older girls are more likely to have interest in traditionally masculine occupations; and children of both genders are more likely to report homoerotic thoughts, although there is not a difference in reported sexual orientation. In conclusion, the authors suggest that there might be much to gain in the understanding of families and parenting styles if these differences were examined instead of glossed over.

A model for those who choose to provide lesbians with insemination services is described by Brewaeys and associates. Before being accepted as clients, lesbians must: accept their lesbianism; have a supportive social environment; plan to seek male role models for the child; and have a currently stable relationship.

Lesbians who become pregnant appear to be model patients. Harvey and colleagues 65 surveyed 35 women who became pregnant as a result of artificial insemination. There is growing evidence that lesbians, as a group, have a profile of risk factors that may predispose to cardiovascular disease, diabetes, and various cancers.

The factors that have been identified so far include higher rates of tobacco and alcohol use, 12 , 37 , 66 , 67 , 68 obesity; 69 lower rates of parity and thus less breastfeeding, and less use of oral contraceptives. This combination of factors could lead to higher rates of cardiovascular disease, diabetes, and cancers of the breast, colon, endometrium, and ovary.

However, there are few data examining the relative rates of these diseases between heterosexual and homosexual women. Based on data collected at the time of enrollment, the lesbians and bisexual women were more likely to report the risk factors of obesity, smoking, and had a higher rate of alcohol use. Overall, there were no ificant differences in the rates of any of the disease conditions assessed, and differences described here must be interpreted accordingly.

Rates of 'any cancer' were highest for the bisexual women, while the rates were similar for the other groups. Breast cancer was reported by each of the nonheterosexual groups more often than the heterosexual women, although the trend was not ificant.

Interestingly, the highest rates of cervical cancer were reported by the bisexual women, and unexpectedly, lifetime lesbians. Lifetime lesbians also reported the highest rate of colorectal cancer. There were no cases of endometrial cancer among the lifetime lesbians, also unexpected given their higher rate of nulliparity. In the category of cardiovascular disease, adult and lifetime lesbians reported more myocardial infarctions, but had the same rate of hypertension, and fewer strokes as compared to the bisexual and heterosexual women.

Married women i Cochrane wanting sx

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Married women i Cochrane wanting sx