Genital human papillomavirus infection in women who have sex with women: a concern for patients and providers

Challenges and Opportunities for Advancing Research and Improving Care for Sexual and Gender Minorities With Inflammatory Bowel Disease

Within the field of gastroenterology and inflammatory bowel disease specifically, there has been little research exploring the healthcare experiences of LGBTQIA+ individuals. This article describes unique clinical challenges and research opportunities that exist particularly at the intersection of inflammatory bowel disease and sexual health.

Cervical screening attendance and cervical cancer risk among women who have sex with women

OBJECTIVES

To describe cervical cancer screening participation among women who have sex exclusively with women (WSEW) and women who have sex with women and men (WSWM) compared with women who have sex exclusively with men (WSEM), and women who have never had sex and compare this with bowel (colorectal) and breast screening participation. To explore whether there is evidence of differential stage 3 cervical intraepithelial neoplasia (CIN3) or cervical cancer risk.

METHODS

We describe cervical, bowel and breast cancer screening uptake in age groups eligible for the national screening programmes, prevalent CIN3 and cervical cancer at baseline, and incident CIN3 and cervical cancer at five years follow-up, among 218,674 women in UK Biobank, a cohort of healthy volunteers from the UK.

RESULTS

Compared with WSEM, in adjusted analysis [odds ratio (95% confidence interval)], WSEW 0.10 (0.08-0.13), WSWM 0.73 (0.58-0.91), and women who have never had sex 0.02 (0.01-0.02) were less likely to report ever having attended cervical screening. There were no differences when considering bowel cancer screening uptake (p = 0.61). For breast cancer screening, attendance was lower among WSWM 0.79 (0.68 to 0.91) and women who have never had sex 0.47 (0.29-0.58), compared with WSEM. There were incident and prevalent cases of both CIN3 and cervical cancer among WSEW and WSWM. Compared with WSEM with a single male partner, among WSEW there was a twofold increase in CIN3 1.91 (1.01 to 3.59); among WSWM with only one male partner, this was 2.25 (1.19 to 4.24).

CONCLUSIONS

These findings highlight the importance of improving uptake of cervical screening among all women who have sex with women and breast screening among WSWM and women who have never had sex.

Dimensions of Sexual Orientation as Predictors of STI-Related Outcomes Among Women: An Examination of 2011-2017 National Survey of Family Growth Data

Background: To estimate sexual orientation associated disparities in sexually transmitted infection (STI)-related outcomes across multiple dimensions of sexual orientation. Methods: Using pooled 2011-2017 National Survey of Family Growth data (N = 16,854), we performed bivariate and multivariable logistic and multinomial regression analyses to estimate associations between sexual identity, behavior in the past 12 months, and attraction, and past-year STI treatment, receipt of the human papillomavirus (HPV) vaccine, and age at first HPV vaccination in cisgender women. Results: Bisexual-identified women (adjusted odds ratio [AOR] = 1.53, 95% confidence interval [CI] = 1.10-2.14) and who were sexually active with both men and women in the past 12 months (AOR = 1.64, 95% CI = 1.03-2.55) had significantly higher odds of past-year STI treatment, compared with their nonsexual minority counterparts. Lesbian-identified women (AOR = 0.44, 95% CI = 0.27-0.75) and women with female partners only (AOR = 0.32, 95% CI = 0.12-0.87) had significantly decreased odds of having initiated the HPV vaccine compared with their heterosexual counterparts. Women with both male and female partners who initiated the HPV vaccine had significantly higher odds of having received the vaccine during the latest age range, 18-25 years old (AOR = 2.32, 95% CI = 1.21-4.45) compared with women with male partners only. Conclusions: Sexual minority women continue to be at risk for poor sexual health outcomes, and these outcomes differ by specific components of sexual orientation.

Maternal Factors and Sexual Orientation-Related Disparities in Cervical Cancer Prevention

OBJECTIVES

Our objective was to explore how mothers' attitudes and relationships with their daughters may impact the cervical cancer prevention behaviors of daughters with diverse sexual orientations.

METHODS

We examined 8,143 mother-daughter dyads from the Nurses' Health Study 2 and Growing Up Today Study. During the daughter's adolescence, each mother reported her beliefs about the importance of regular Pap testing for her daughter, the frequency of communication with her daughter about Pap testing, her beliefs about Pap testing and human papillomavirus (HPV) vaccines, and her acceptance of sexual minorities (e.g., bisexuals, lesbians). Mothers and daughters separately reported relationship satisfaction. Log-binomial models were used to examine the longitudinal association between maternal factors and daughter's receipt of a Pap test and HPV vaccination.

RESULTS

Nearly all maternal factors predicted the daughter's likelihood to have a Pap test and HPV vaccination. Higher levels of acceptance for sexual minorities and better relationship quality were also positively associated with these cervical cancer prevention behaviors. Yet, after adjusting for the maternal factors, there was little attenuation of the existing sexual orientation-related disparities in Pap tests or HPV vaccination.

CONCLUSIONS

Mothers can play an important role in their daughters' cervical cancer prevention behaviors through novel processes like being more accepting of sexual minorities and having a good relationship quality. However, in this study, maternal factors did not explain much of the sexual orientation-related disparities in cervical cancer prevention. Efforts to ensure a mother is accepting of sexual minorities and has a good relationship quality with her daughter may improve that daughter's reproductive health.

Health Care-Related Correlates of Cervical Cancer Screening among Sexual Minority Women: An Integrative Review

INTRODUCTION

Sexual minority women (SMW; lesbian, bisexual, nonheterosexual women) may have lower rates of cervical cancer screening than heterosexual women. Health care-related factors may explain some of the variation in cervical cancer screening rates among SMW. We aimed to synthesize published evidence of health care-related correlates of cervical cancer screening among SMW.

METHODS

We searched PubMed, CINAHL, and PsycINFO databases for English-language studies published between January 2000 and March 2017 that 1) assessed sexual identity or the sexual partners of female participants, 2) included cervical cancer screening as a main outcome of interest, and 3) measured at least one health care-related variable in addition to cervical cancer screening. We excluded articles that 1) reported on non-US samples or 2) did not report original research. We reviewed the sample, methods, and findings of 17 studies. We then summarized current knowledge about health care-related factors across 3 categories and generated recommendations for clinical practice and future research.

RESULTS

Several health care-related factors such as previous contraception use, having a primary care provider, knowledge of screening recommendations, and disclosing sexual orientation to providers were consistently positively associated with cervical cancer screening. Three groups of factors-previous health care use, health care provider-related factors, and belief-related factors-account for a substantial part of the variation in cervical cancer screening among SMW.

DISCUSSION

Several gaps in knowledge remain that could be addressed by recruiting more diverse samples of SMW with improved generalizability. Clinicians and clinical institutions can address factors associated with low rates of screening among SMW by preventing sexual orientation-based discrimination, inviting sexual orientation disclosure, and offering cervical cancer screening to SMW at a variety of health care encounters. Future research should examine how the location of care and health care provider type affect SMW's cervical cancer screening behaviors and should test the effectiveness of health care interventions designed to address sexual orientation-related disparities.

Comparing self- and provider-collected swabbing for HPV DNA testing in female-to-male transgender adult patients: a mixed-methods biobehavioral study protocol

Background

Cervical cancer, nearly all cases of which are caused by one of several high-risk strains of the human papillomavirus (hr-HPV), leads to significant morbidity and mortality in individuals with a cervix. Trans masculine (TM) individuals were born with female reproductive organs and identify as male, man, transgender man, or another diverse gender identity different from their female assigned sex at birth. Routine preventive sexual health screening of TM patients is recommended, including screening for cervical cancer and other sexually transmitted infections (STIs); however, as many as one in three TM patients are not up-to-date per recommended U.S. guidelines. Among cisgender (non-transgender) women, self-swab hr.-HPV DNA testing as a primary cervical cancer screening method and self-swab specimen collection for other STIs have high levels of acceptability. No study has yet been conducted to compare the performance and acceptability of self- and provider-collected swabs for hr.-HPV DNA testing and other STIs in TM patients.

Methods

This article describes the study protocol for a mixed-methods biobehavioral investigation enrolling 150 sexually active TM to (1) assess the clinical performance and acceptability of a vaginal self-swab for hr.-HPV DNA testing compared to provider cervical swab and cervical cytology, and (2) gather acceptability data on self-collected specimens for other STIs. Study participation entails a one-time clinical visit at Fenway Health in Boston, MA comprised of informed consent, quantitative assessment, venipuncture for syphilis testing and HIV (Rapid OraQuick) testing, randomization, collection of biological specimens/biomarkers, participant and provider satisfaction survey, and qualitative exit interview. Participants are compensated $100. The primary study outcomes are concordance (kappa statistic) and performance (sensitivity and specificity) of self-collected vaginal HPV DNA specimens vs provider-collected cervical HPV swabs as a gold standard.

Discussion

This study addresses critical gaps in current clinical knowledge of sexual health in TM patients, including comparing alternative strategies for screening and diagnosis of cervical cancer, hr.-HPV, and other STIs. Findings have implications for improving the delivery of sexual health screening to this often overlooked and underserved patient population. Less-invasive patient-centered strategies may also generalize to other at-risk cisgender female populations that face barriers to timely and needed STI and cervical cancer screening.

Trial registration

ClinicalTrials.gov ID: NCT02401867

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-017-2539-x) contains supplementary material, which is available to authorized users.

Addressing Health Care Disparities Among Sexual Minorities

There is evidence of health disparities between sexual minority and heterosexual populations. Although the focus of lesbian, gay, bisexual, and transgender health research has been human immunodeficiency virus/acquired immunodeficiency syndrome and sexually transmitted infection among men who have sex with men, there are health disparities among sexual minority women. Using the minority stress framework, these disparities may in part be caused by individual prejudice, social stigma, and discrimination. To ensure equitable health for all, there is urgent need for targeted culturally sensitive health promotion, cultural sensitivity training for health care providers, and intervention-focused research.

Correlates of Human Papillomavirus Infection Among a National Sample of Sexual Minority Women

BACKGROUND

Many sexual minority women are infected with human papillomavirus (HPV), yet little is known about correlates of HPV infection among this population.

MATERIALS AND METHODS

We analyzed data from a national sample of sexual minority women (i.e., women who either reported a history of female sexual partners or identified as nonheterosexual) aged 20-59 from the 2003 to 2012 National Health and Nutrition Examination Survey (n = 830). Weighted logistic regression identified correlates of infection with any HPV type and infection with a high-risk HPV type.

RESULTS

About 53% of women were infected with any HPV type, and about 37% were infected with a high-risk HPV type. Women who reported five or more sexual partners during their lifetime (adjusted odds ratio [aOR] = 5.07, 95% confidence interval [CI]: 2.26-11.42) were more likely to be infected with a high-risk HPV type. Compared to women aged 20-29, women aged 40-49 (aOR = 0.51, 95% CI: 0.32-0.81) or 50-59 (aOR = 0.27, 95% CI: 0.14-0.53) were less likely to be infected with a high-risk HPV type, as were women who were married or living with a partner (aOR = 0.62, 95% CI: 0.44-0.89). Mostly similar correlates were identified for infection with any HPV type, although infection with any HPV type was also less common among women who identified as lesbian compared to those who identified as heterosexual (aOR = 0.38, 95% CI: 0.21-0.68).

CONCLUSIONS

Demographic and health-related characteristics were associated with HPV infection outcomes. Findings can inform HPV prevention efforts for sexual minority women by providing information about risk factors and subgroups at particular risk for infection.

Sexual Orientation Disparities in Human Papillomavirus Vaccination in a Longitudinal Cohort of U.S. Males and Females

PURPOSE

This study sought to examine how human papillomavirus (HPV) vaccination may differ across sexual orientation groups (e.g., bisexuals compared to heterosexuals)-particularly in boys and men, about whom little is known.

METHODS

Data were from a prospective cohort of 10,663 U.S. females and males enrolled in the Growing Up Today Study followed from 1996 to 2014. Participants were aged 11-24 years when the vaccine was approved for females in 2006 and 14-27 years when approved for males in 2009. In addition to reporting sexual orientation identity/attractions, participants reported sex of lifetime sexual partners. Log-binominal models were used to examine HPV vaccination across sexual orientation groups.

RESULTS

Among females, 56% received ≥1 dose. In contrast, 8% of males obtained ≥1 dose; HPV vaccination initiation was especially low among completely heterosexual males. After adjusting for potential confounders, completely heterosexual (risk ratio [RR]; 95% confidence interval [CI]: 0.45 [0.30-0.68]) and mostly heterosexual (RR; 95% CI: 0.44 [0.25-0.78]) males were half as likely to have received even a single dose compared to gay males. Compared to lesbians, no differences were observed for completely heterosexual or bisexual females, but mostly heterosexual females were 20% more likely to have received at least one dose.

CONCLUSIONS

HPV vaccination rates in the U.S. are strikingly low and special attention is needed for boys and men, especially those who do not identify as gay. Vaccinating everyone, regardless of sex/gender and/or sexual orientation, will not only lower that individual's susceptibility but also decrease transmission to partners, females and/or males, to help eradicate HPV through herd immunity.

Rate and predictors of human papillomavirus vaccine uptake among women who have sex with women in the United States, the National Health and Nutrition Examination Survey, 2009-2012

AIMS AND OBJECTIVES

To examine rates and associated correlates of human papilloma virus vaccine uptake in women who have sex with women in the United States, and to determine whether they differ from those in women who do not have sex with women.

BACKGROUND

Women who have sex with women are at risk for human papilloma virus infection but are less likely to receive preventive gynaecological services. Little research has been carried out to evaluate human papilloma virus vaccination rates and associated predictors of vaccination uptake in this population.

DESIGN

Cross-sectional descriptive study.

METHODS

Data from two consecutive cohorts of the National Health and Nutrition Examination Survey conducted by the United States' Centers for Disease Control were analysed.

RESULTS

The sample (N = 1105) consisted of women aged 18-26 years. There was no difference in human papilloma virus vaccine uptake between women who have sex with women and women who do not have sex with women. Overall, the vaccination rate was low (32·5%). Having health insurance and more education were significant predictors of vaccine uptake in women who have sex with women. Higher education and younger age were predictors in women who do not have sex with women.

CONCLUSIONS

Vaccination rates of women are far lower than the national target of 80%. The predictors of vaccine uptake were different in women who have sex with women than for women who do not have sex with women.

RELEVANCE TO CLINICAL PRACTICE

Women in their 20s (regardless of their sexual orientation) should be recognised as an undervaccinated population and require targeted interventions to improve vaccination uptake.

The estimated lifetime probability of acquiring human papillomavirus in the United States

BACKGROUND

Estimates of the lifetime probability of acquiring human papillomavirus (HPV) can help to quantify HPV incidence, illustrate how common HPV infection is, and highlight the importance of HPV vaccination.

METHODS

We developed a simple model, based primarily on the distribution of lifetime numbers of sex partners across the population and the per-partnership probability of acquiring HPV, to estimate the lifetime probability of acquiring HPV in the United States in the time frame before HPV vaccine availability.

RESULTS

We estimated the average lifetime probability of acquiring HPV among those with at least 1 opposite sex partner to be 84.6% (range, 53.6%-95.0%) for women and 91.3% (range, 69.5%-97.7%) for men. Under base case assumptions, more than 80% of women and men acquire HPV by age 45 years.

CONCLUSIONS

Our results are consistent with estimates in the existing literature suggesting a high lifetime probability of HPV acquisition and are supported by cohort studies showing high cumulative HPV incidence over a relatively short period, such as 3 to 5 years.

HPV, cervical cancer risks, and barriers to care for lesbian women

The purpose of this article is to identify Pap testing rates among lesbians and identify reasons for lack of recognition of cervical cancer risks in lesbians. Articles that reported cervical cancer screening rates among lesbians were searched. Between 48% and 81% of lesbians reported recent Pap smears. The lesbian community requires better education, and healthcare providers should promote regular Pap smears for all women.

Cervical cancer screening (Pap testing) behaviours and acceptability of human papillomavirus self-testing among lesbian and bisexual women aged 21-26 years in the USA

OBJECTIVE

Lesbian and bisexual women are at risk for human papillomavirus (HPV) infection and cervical disease. We examined cervical cancer screening (Pap testing) behaviours among these women and their acceptability of HPV self-testing at home, a potential cervical cancer screening strategy.

METHODS

We analysed data from a national sample of lesbian and bisexual women aged 21-26 years (n=418) who completed our online survey in Autumn 2013. Logistic regression identified correlates of (1) having had a Pap test in the last 3 years and (2) willingness to use an HPV self-test at home.

RESULTS

About 70% of women had undergone a Pap test in the last 3 years. Pap testing was more common among women who had disclosed their sexual orientation to their health care provider [odds ratio (OR)=2.01, 95% confidence interval (CI) 1.02-3.95] and less common among women who self-identified as lesbian (OR=0.48, 95% CI 0.25-0.93). Just over half the women (51%) were willing to use an HPV self-test at home. Women were more willing to use an HPV self-test at home if they were older (OR=1.16, 95% CI 1.03-1.30) or reported higher levels of worry about getting an HPV-related disease (OR=1.28, 95% CI 1.01-1.63). The most common concerns about HPV self-testing at home were using the test incorrectly (70%) and test accuracy (64%).

CONCLUSIONS

Many young lesbian and bisexual women have not had a recent Pap test. HPV self-testing at home may be a promising future strategy for reaching and screening these women. Findings highlight beliefs and concerns that could be addressed by self-test programmes.

Influence of hormonal contraceptive use and health beliefs on sexual orientation disparities in Papanicolaou test use

OBJECTIVES

Reproductive health screenings are a necessary part of quality health care. However, sexual minorities underutilize Papanicolaou (Pap) tests more than heterosexuals do, and the reasons are not known. Our objective was to examine if less hormonal contraceptive use or less positive health beliefs about Pap tests explain sexual orientation disparities in Pap test intention and utilization.

METHODS

We used multivariable regression with prospective data gathered from 3821 females aged 18 to 25 years in the Growing Up Today Study (GUTS).

RESULTS

Among lesbians, less hormonal contraceptive use explained 8.6% of the disparities in Pap test intention and 36.1% of the disparities in Pap test utilization. Less positive health beliefs associated with Pap testing explained 19.1% of the disparities in Pap test intention. Together, less hormonal contraceptive use and less positive health beliefs explained 29.3% of the disparities in Pap test intention and 42.2% of the disparities in Pap test utilization.

CONCLUSIONS

Hormonal contraceptive use and health beliefs, to a lesser extent, help to explain sexual orientation disparities in intention and receipt of a Pap test, especially among lesbians.

Understanding cervical cancer screening among lesbians: a national survey

Background

Lesbians have low rates of cervical cancer screening, even though they are at risk of developing the disease. The aim of this study was to examine cervical cancer screening behaviors in a national sample of lesbians.

Methods

A standardized internet survey was sent to 3,000 self-identified lesbians to assess cervical cancer screening behaviors and barriers to screening. The sample consisted of 1,006 respondents.

Results

Sixty-two percent of the weighted sample of respondents were routine screeners. Lack of a physician referral (17.5%) and lack of a physician (17.3%) were the most commonly-cited top reasons for lack of screening. Adjusting for age, education, relationship status, employments status, and insurance status, women who had disclosed their sexual orientation to their primary care physician (adjusted odds ratio [OR] 2.84 [95% confidence interval 1.82-4.45]) or gynecologist (OR 2.30 [1.33-3.96]) had greater odds of routine screening than those who did not. Those who knew that lack of Pap testing is a risk factor for cervical cancer were also more likely to be routine screeners (OR 1.95 [1.30-2.91]), although no association with screening was apparent for women who had more knowledge of general cervical cancer risk factors. Physician recommendation appeared to be a potent determinant of regular screening behavior. Routine screeners perceived more benefits and fewer barriers to screening, as well as higher susceptibility to cervical cancer.

Conclusions

Some women who identify as lesbian are at a potentially elevated risk of cervical cancer because they are not routinely screened. Evidence-based interventions should be developed to address critical health beliefs that undermine participation in screening. Given the value placed on physician recommendation, patient-provider communication may serve as the optimal focus of effective intervention.

Barriers to cervical cancer screening among lesbians

OBJECTIVE

To evaluate cervical cancer screening practices and barriers to screening in a sample of lesbians.

METHODS

Cross-sectional survey data were collected from 225 self-identified lesbians who completed an online questionnaire.

RESULTS

Of the respondents, 71% reported receiving a Pap screening test in the past 24 months (routine screeners), and 29% reported receiving a Pap screening test >24 months ago or never (nonroutine screeners). Routine screeners were more likely to be older (p < 0.01), white (p = 0.04), and college graduates (p < 0.01) than nonroutine screeners. Nonroutine screeners were more likely to delay seeking healthcare because of fear of discrimination (p < 0.01) and were less likely than routine screeners to disclose orientation to their primary care physician (p < 0.01). After adjusting for age, race, and education, nonroutine screeners perceived fewer benefits from (p < 0.01) and more barriers (p < 0.01) to Pap screening tests and were less knowledgeable about screening guidelines (p < 0.01) than routine screeners, but there was no difference in perceived susceptibility (p = 0.68), perceived seriousness (p = 0.68), or risk factor knowledge (p = 0.35) of cervical cancer.

CONCLUSIONS

Many lesbians do not screen for cervical cancer at recommended rates. Nonroutine screeners perceive fewer benefits, more barriers, and more discrimination and are less knowledgeable about screening guidelines than routine screeners.

Reproductive health screening disparities and sexual orientation in a cohort study of U.S. adolescent and young adult females

PURPOSE

To examine sexual orientation group disparities in the Papanicolaou (Pap) and sexually transmitted infection (STI)/human papillomavirus (HPV) tests among adolescents and young adult females.

METHODS

Survey data from 4,224 adolescents and young adults aged 17-25 years who responded to the 2005 wave questionnaire of the Growing Up Today Study were cross-sectionally examined with multivariate generalized estimating equations regression. We examined associations between sexual orientation and reproductive healthcare utilization as well as abnormal results with completely heterosexual as the referent group, controlling for age, race/ethnicity, geographic region, and sexual history.

RESULTS

After accounting for sociodemographics and sexual history, mostly heterosexual/bisexual females had 30% lower odds of having a Pap test within the last year and almost 40% higher odds of being diagnosed with an STI, as compared with the completely heterosexual group. Additionally, lesbians had very low odds of having a Pap test in their lifetime (odds ratio = .13, p ≤ .0001) and having a Pap test within the last year (odds ratio = .25, p = .0002), as compared with completely heterosexuals.

CONCLUSIONS

Our study demonstrates that sexual minority adolescent and young adult women underutilize routine reproductive health screenings, including Pap smears and STI tests. Providers and health educators should be aware of these disparities so that they can provide appropriate care to young women and their families and ensure that all young women receive reproductive health screening. Further research is needed to explore reasons sexual minority females are not accessing care as recommended because this may suggest opportunities to improve reproductive health screenings as well as broader healthcare access issues.

Sexual behaviors and sexually transmitted infections among self-identified lesbian and bisexual college women

Sexually transmitted infections (STIs) are a significant health issue for lesbian and bisexual women. Older age and having a history of sexual intercourse with males are primary risk factors for STIs among this population. However, little research has been conducted to assess sexual risk among lesbian and bisexual college women exclusively. A cross-sectional Internet survey was conducted with 230 self-identified lesbian and bisexual female college students to examine their sexual risk and to determine with which, if any, STIs they had ever been diagnosed. Eight percent of lesbian and bisexual college women reported ever being diagnosed with an STI; the human papillomavirus, bacterial vaginosis, and genital herpes accounted for 84% of STI cases. Number of lifetime sex partners was significantly associated with an STI diagnosis among this population. Older age, engaging in penile-vaginal intercourse with a male (lifetime), and younger age at first same-sex experience were significantly associated with a greater number of lifetime sex partners. Results may be useful to sexual health programs targeting lesbian and bisexual college women and/or their providers.

STDs among sexually active female college students: does sexual orientation make a difference?

CONTEXT

Research addressing sexual health or STD risk among lesbian and bisexual college women is scarce.

METHODS

Data on 29,952 sexually active females aged 18-24 who completed the 2006 National College Health Assessment were examined to assess differences in sexual risk factors and recent STD incidence by sexual orientation. Comparisons were analyzed at the bivariate level and through multivariate logistic regression.

RESULTS

Bisexual students were the most likely to have had an STD during the past year (9%); lesbians were the least likely (2%). However, lesbians were also the least likely to have had a routine gynecologic examination (46%, compared with 64-73% of others). Among students who had had multiple partners in the past year, those who had had partners of both sexes were more likely to have had an STD (16%) than were students who had had only male partners (9%) or only female partners (6%). Students who had binged on alcohol the last time they partied, had had multiple partners or had had a routine gynecologic examination in the past year, had been tested for HIV or had not used condoms at last vaginal intercourse were at increased odds of having had an STD (odds ratios, 1.3-4.0).

CONCLUSIONS

Sexual health programs targeting female college students, regardless of sexual orientation, must focus on behavioral risks associated with STDs. In addition, the importance of regular gynecologic exams should be emphasized, especially among lesbians. Further research is needed on risk-taking among female college students who are sexually active with both sexes.

Lesbians and cancer: an overlooked health disparity

OBJECTIVE

To evaluate the breast, cervical, ovarian, lung, and colorectal cancer literatures using a novel application of the cancer disparities grid to identify disparities along domains of the cancer continuum focusing on lesbians as a minority population.

METHODS

Computerized databases were searched for articles published from 1981 to present. Cumulative search results identified 51 articles related to lesbians and disparities, which were classified by domain.

RESULTS

The majority of articles identified were related to breast and cervical cancer screening. Barriers to adequate screening for both cancers include personal factors, poor patient-provider communication, and health care system factors. Tailored risk counseling has been successful in increasing lesbian's mammography and Pap screening. Ovarian, lung, and colorectal cancer have been virtually unexplored in this population. An "Adjustment to Illness/Quality of Life" domain was added to capture literature on psychosocial aspects of cancer.

CONCLUSIONS

This review revealed a lack of research for specific cancers and for specific aspects of the cancer continuum. The limited number of studies identified focused on issues related to screening/prevention in cervical and breast cancers, with almost no attention to incidence, etiology, diagnosis, treatment, survival, morbidity, or mortality. We present implications for social and public health policy, research, and prevention.

Is physical examination required before prescribing hormones to patients with gender dysphoria?

INTRODUCTION

A genital examination can have psychologic effects on a patient, particularly when the source of their sexual medicine complaint is a body part. How necessary is a physical exam before prescribing hormones in cases of gender dsyphoria?

METHODS

Five people with expertise and/or interest in the area of gender dysphoria and endocrinology were asked to contribute their opinions.

MAIN OUTCOME MEASURE

To provide food for thought, discussion, and possible further research in a poorly discussed area of sexual medicine.

RESULTS

Of the five experts writing on the topic, one believes that a physical examination should always be performed before prescribing hormones for gender dysphoria, one believes it is not a prerequisite, and three believe a physical examination is recommended, but is not necessary in cases where the patient objects despite an explanation of the purpose of the exam. As long as this was documented, it would not present a medicolegal problem.

CONCLUSIONS

It is not clear whether or not a physical examination must be performed on all gender dsyphoric patients before prescribing hormones; however, an examination would be helpful in revealing a significant health management issue.

Human papillomavirus: the burden of infection

Vaccines for preventing human papillomavirus (HPV) infection are far along in clinical development and testing, and hold great promise for reducing HPV infections and HPV-associated disease. HPV is the most common sexually transmitted infection in the United States, affecting an estimated 75% of the U.S. population. HPV infection is highly prevalent in sexually active adolescents and young adults. Sexual activity is the most important risk factor for infection, with 64% to 82% of sexually active adolescent girls testing positive for HPV. Clinical manifestations of HPV infection include genital warts, cervical intraepithelial neoplasia (CIN), and invasive cervical cancer, all of which cause significant morbidity and, in the case of cervical cancer, mortality. The majority of HPV-associated disease is caused by 4 HPV types: HPV 6 and 11 are responsible for low-grade genital lesions and more than 90% of genital warts, and HPV 16 and 18 both account for approximately 70% of all high-grade CIN or dysplasia and invasive cervical cancer. Although current screening methods have proven effective in reducing cervical cancer incidence and associated mortality, more than 10,000 women are diagnosed annually and 4000 U.S. women die from the disease each year.

Multisystem Factors Contributing to Disparities in Preventive Health Care Among Lesbian Women

Lesbians experience significant health disparities in preventive care utilization and health outcomes compared to heterosexual women. In this study, a multisystems ecologic approach is taken to identify barriers to access, treatment, and preventive care among lesbian women. Recommendations include increasing knowledge of lesbian health care needs, developing cultural sensitivity and competence in communication and care for lesbian women, and creating practice environments that convey respect, acceptance, and welcome to all women, regardless of sexual orientation.

Nuances and shifts in lesbian women's constructions of STI and HIV vulnerability

This study examines the subjective side of vulnerability as a social construct rooted in interpersonal relationships and community membership. Analysis is based on a survey of an especially diverse sample of 162 lesbian women, 67 of whom also participated in depth interviews. Another 24 of the original sample also participated in transcribed focus groups. One third were African American, Latina, and Asian, and two thirds were white. This sample reported an overall infection rate of 23%. Three subjective stances, or risk frames, are identified: essentially invulnerable, socially inoculated, and fundamentally vulnerable. Some women describe shifts in their interpretations of their own vulnerability, moving from one stance to another in response to obtaining information, becoming infected, having friends or acquaintances who become infected, and becoming involved with new partners. It is suggested that these shifts comprise a subjective "vulnerability career". The significance of lesbian women's constructions of vulnerability is examined, and the implications of this study for a better understanding of their risk for STIs are discussed.