OPTIMAL GYNECOLOGIC AND OBSTETRIC CARE FOR LESBIANS:

Sexual and Gender Minority Patients' First Pelvic Examination Experiences: What Clinicians Need to Know

STUDY OBJECTIVE

The aim of this study was to identify factors that influence the first pelvic exam experiences of sexual and gender minority (SGM) adolescents and young adults who were assigned female at birth (AFAB).

METHODS

Using purposive sampling, we recruited SGM AFAB individuals, ages 18-24, who had had at least 1 pelvic examination. Semi-structured interviews and an iterative approach allowed for the emergence of factors influencing the first pelvic exam experience. Items included in the final code directory had a Krippendorff's alpha intercoder reliability score greater than 0.7. Interviews were analyzed using ATLAS.ti.

RESULTS

Thirty participants completed interviews. Fourteen participants identified as bisexual, 2 as gay, 1 as lesbian, 3 as pansexual, 8 as queer, and 2 as straight/heterosexual. Sixteen participants identified as cisgender, 9 as genderqueer/gender nonconforming, and 5 as transgender. Factors influencing the first pelvic exam experience were organized as patient- or clinician-level factors. The patient-level factors of gender identity, sexual orientation, history of sexual trauma, and participant's relationship to their body were central factors influencing the exam experience. Speculum insertion during the exam induced anxiety and pain for some. The clinician-level factors of gender, age, and race or ethnicity influenced the exam experience. Most participants preferred detailed communication. Participants offered recommendations to ensure gender-affirming, patient-centered care during the first pelvic exam.

CONCLUSION

SGM AFAB individuals identified patient- and clinician-level factors influencing their first pelvic exam experiences. This study underscores the need for changes in medical education and health systems to ensure that SGM AFAB individuals have their needs met and feel comfortable in reproductive health settings.

Contraceptive use by women across different sexual orientation groups

OBJECTIVES

To examine contraceptive methods used across sexual orientation groups.

STUDY DESIGN

We collected data from 118,462 female participants in two longitudinal cohorts-the Nurses' Health Study (NHS) 2 (founded in 1989, participants born 1947-1964) and NHS3 (founded in 2010, born 1965-1995). We used log-binomial models to estimate contraceptive methods ever used across sexual orientation groups and cohorts, adjusting for age and race.

RESULTS

Lesbians were the least likely of all sexual orientation groups to use any contraceptive method. Lesbians in NHS2 were 90% less likely than heterosexuals to use long-acting reversible contraceptives (LARCs; adjusted risk ratio [aRR]; 95% confidence interval [CI]: 0.10 [0.04, 0.26]) and results were similar for other contraceptive methods and in the NHS3 cohort. Compared to the reference group of completely heterosexual participants with no same-sex partners, those who identified as completely heterosexual with same-sex partners, mostly heterosexual, or bisexual were generally more likely to use any method of contraception. Use of LARCs was especially striking across sexual minority groups, and, with the exception of lesbians, they were more likely to use LARCs; as one illustration, NHS3 bisexuals were more than twice as likely to use LARCs (aRR [95% CI]: 2.01 [1.67, 2.42]).

CONCLUSIONS

While certain sexual minority subgroups (e.g., bisexuals) were more likely than heterosexuals to use contraceptive methods such as LARCs, lesbians were less likely to use any method.

IMPLICATIONS

Many sexual minority patients need contraceptive counseling and providers should ensure to offer this counseling to patients in need, regardless of sexual orientation.

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.

Fertility Awareness Counseling for Adolescent Girls; Guiding Conception: The Right Time, Right Weight, and Right Way

STUDY OBJECTIVE

To provide a detailed summary of fertility awareness counseling pearls for healthy teens and those with fertility-relevant comorbidities, and to assist providers in offering such counseling to adolescents and young adult women. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Comprehensive literature review of English-language studies relating to fertility in pediatric and adolescent female patients (ages 13-21 years), and evidence-based dialogue guide.

RESULTS

The literature indicates that although adolescents are interested in discussing sexuality and reproduction, this is commonly overlooked during the standard office medical visit. As a result, adolescents often turn to less reliable sources and hold a variety of reproductive misconceptions and a sense of lack of control over future fertility. We found no studies that examined the routine provision of fertility awareness counseling with healthy adolescents. There are a multitude of specific gynecologic and medical conditions that have ramifications for fertility. We detail these comprehensively, and provide a dialogue guide to assist with fertility awareness counseling for the female adolescent, containing specific information and indications for referral.

CONCLUSION

Providers caring for adolescent girls have the opportunity to enhance fertility awareness as part of a larger reproductive health conversation that adolescents desire, and from which they might benefit. Identifying potential future fertility issues, understanding age-related fertility decline, and aiding in health optimization before future conception might empower the adolescent to make informed reproductive decisions. We provide an algorithm to use with adolescents to discuss the "right time, right weight, right way" to pursue childbearing.

Obstetricians and gynecologists: which characteristics do Israeli lesbians prefer?

AIM

The aim of this study was to explore lesbians' preferences when choosing obstetricians/gynecologists.

MATERIAL AND METHODS

This cross-sectional study included 100 lesbian and 100 heterosexual women. A 40-item questionnaire assessed the correlation between a patient's sexual identity and her specific preferences for obstetricians/gynecologists.

RESULTS

The top five most important parameters for both groups in choosing obstetricians/gynecologists overlapped greatly. Four of those were experience, ability, knowledge and personality. Only one parameter differed: lesbians ranked 'sexually tolerant' as the third most important characteristic while heterosexuals ranked 'availability' as the fifth most important characteristic. Lesbians rated 'sexual tolerance' significantly higher than heterosexuals (P < 0.001). More lesbians (56%) preferred female obstetricians/gynecologists compared to heterosexuals (21%) (P < 0.001). When compared to heterosexuals, more lesbians preferred female obstetricians/gynecologists for intimate and non-intimate procedures (P < 0.001). But within the lesbian population, a higher percentage of subjects showed a preference for female obstetricians/gynecologists only for intimate procedures. Lesbians used the following to describe their preference for female obstetricians/gynecologists: feeling more comfortable; gentle; sympathetic; patient; more understanding of women's health; better physicians in general; and more sexually tolerant (P < 0.001 vs heterosexual). However, when we looked only at the lesbian population, the majority did not exhibit a preference for a female obstetrician/gynecologist for any of these reasons. The main reason given by the 56% of the lesbians who said they prefer female obstetricians/gynecologists was feeling more comfortable.

CONCLUSION

Overwhelmingly lesbians prefer sexually tolerant obstetricians/gynecologists regardless of their gender; however, only a small number of lesbian subjects in this study considered their obstetricians/gynecologists as displaying this characteristic.

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.

What we don't talk about when we don't talk about sex: results of a national survey of U.S. obstetrician/gynecologists

INTRODUCTION

Sexuality is a key aspect of women's physical and psychological health. Research shows both patients and physicians face barriers to communication about sexuality. Given their expertise and training in addressing conditions of the female genital tract across the female life course, obstetrician/gynecologists (ob/gyns) are well positioned among all physicians to address sexuality issues with female patients. New practice guidelines for management of female sexual dysfunction and the importance of female sexual behavior and function to virtually all aspects of ob/gyn care, and to women's health more broadly, warrant up-to-date information regarding ob/gyns' sexual-history-taking routine.

AIMS

To determine ob/gyns' practices of communication with patients about sexuality, and to examine the individual and practice-level correlates of such communication.

METHOD

A population-based sample of 1,154 practicing U.S. ob/gyns (53% male; mean age 48 years) was surveyed regarding their practices of communication with patients about sex.

MAIN OUTCOME MEASURES

Self-reported frequency measures of ob/gyns' communication practices with patients including whether or not ob/gyns discuss patients' sexual activities, sexual orientation, satisfaction with sexual life, pleasure with sexual activity, and sexual problems or dysfunction, as well as whether or not one ever expresses disapproval of or disagreement with patients' sexual practices. Multivariable analysis was used to correlate physicians' personal and practice characteristics with these communication practices.

RESULTS

Survey response rate was 65.6%. Sixty-three percent of ob/gyns reported routinely assessing patients' sexual activities; 40% routinely asked about sexual problems. Fewer asked about sexual satisfaction (28.5%), sexual orientation/identity (27.7%), or pleasure with sexual activity (13.8%). A quarter of ob/gyns reported they had expressed disapproval of patients' sexual practices. Ob/gyns practicing predominately gynecology were significantly more likely than other ob/gyns to routinely ask about each of the five outcomes investigated.

CONCLUSION

The majority of U.S. ob/gyns report routinely asking patients about their sexual activities, but most other areas of patients' sexuality are not routinely discussed.

Health care access and utilization among women who have sex with women: sexual behavior and identity

Past research has shown that women who either have sex with women or who identify as lesbian access less preventive health care than other women. However, previous studies have generally relied on convenience samples and have not examined the multiple associations of sexual identity, behavior and health care access/utilization. Unlike other studies, we used a multi-lingual population-based survey in New York City to examine the use of Pap tests and mammograms, as well as health care coverage and the use of primary care providers, among women who have sex with women and by sexual identity status. We found that women who had sex with women (WSW) were less likely to have had a Pap test in the past 3 years (66 vs. 80%, p<0.0001) or a mammogram in the past 2 years (53 vs. 73%, p=0.0009) than other women. After adjusting for health insurance coverage and other factors, WSW were ten times [adjusted odds ratio (AOR), 9.8, 95% confidence interval (CI), 4.2, 22.9] and four times (AOR, 4.0, 95% CI 1.3, 12.0) more likely than non-WSW to not have received a timely Pap test or mammogram, respectively. Women whose behavior and identity were concordant were more likely to access Pap tests and mammograms than those whose behavior and identity were discordant. For example, WSW who identified as lesbians were more likely to have received timely Pap tests (97 vs. 48%, p<0.0001) and mammograms (86 vs. 42%, p=0.0007) than those who identified as heterosexual. Given the current screening recommendations for Pap tests and mammograms, provider counseling and public health messages should be inclusive of women who have sex with women, including those who have sex with women but identify as heterosexual.

Sexually transmitted disease/HIV risk behaviour among women who have sex with women

OBJECTIVE

To analyse the epidemiological aspects of sexually transmitted diseases (STD) among women who have sex with women (WSW) in São Paulo, Brazil.

METHOD

A cross-sectional study with interviews and analysis of clinical and gynaecological tests in women, by means of a convenience sample. Characteristics were gathered according to age, sociobehavioural profile, reproductive life and sexuality.

RESULTS

The study included 145 women. They started sexual activity at an average age of 16.9 years, and 23.4% of them had had heterosexual relations during the preceding year, with a relatively low frequency of condom use. In sexual relations with women, 54.5% used condoms when they shared sex toys. A previous STD was reported by 38% of them. The following STD were diagnosed: trichomonas (3.8%), bacterial vaginosis (33.8%), fungi (25.6%), Chlamydia (1.8%), hepatitis B (7%), hepatitis C (2.1%), abnormal Pap smear (7.7%), human papillomavirus (6.2%) and HIV (2.9%).

CONCLUSION

In this study, many WSW did not report a single risk behaviour, but often reported a combination of several potential risk factors. Therefore, one cannot speak of high or low-risk behaviour for STD/HIV, but rather of multiple-risk behaviour. It is evident that there is a need for healthcare professionals to be correctly informed and sensitive towards the healthcare of WSW.

Sexuality and safer sex: the issues for lesbians and bisexual women

Nursing interventions to help women reduce their risk of contracting HIV must be designed from an in-depth understanding of the complex sociocultural patterns of sexuality in particular communities and among specific subgroups.

OBJECTIVE

In this data collection phase of a community-based HIV prevention project, the objective was to understand HIV risk-taking and HIV risk-reduction activities of lesbians and bisexual women.

DESIGN

Qualitative field study.

SETTING

Data were collected in women's bars and dance clubs and at selected lesbian/bisexual community events in San Francisco.

PARTICIPANTS

Interviews were conducted with 1,189 racially diverse, socially and sexually active lesbians and bisexual women.

RESULTS

Inductive content analysis produced two themes: realities of sexual behavior and sexual expressions and their meanings. Realities of sexual behavior included an assumption that women who have sex with other women cannot get HIV, a lack of familiarity with HIV prevention strategies, inconsistent practice of safer sex with men and/or women, and the negative effect of alcohol or drug use on safer sex efforts. Sexual expressions and their meaning included trust in monogamy, a sense that safer sex practices detracted from intimacy and eroticism, the difficulty of negotiating sexual behaviors with men or women, and dealing with partner resistance to safer sex practices.

CONCLUSIONS

Specific recommendations for practice are the need for nurses to understand the range and diversity of women's sexual behaviors, to develop skills in conducting inclusive sexual histories, and to develop a comprehensive approach to sexual health.

Papanicolaou test screening and prevalence of genital human papillomavirus among women who have sex with women

OBJECTIVES

The purpose of this study was to examine frequency of and attitudes toward Papanicolaou (Pap) test screening in women who have sex with women (WSW) and to determine prevalence of genital human papillomavirus (HPV).

METHODS

Women were eligible if they reported having engaged in sex with another woman in the preceding year Medical and sexual histories were obtained. Cervical specimens for Pap tests and cervical and vaginal specimens for HPV DNA testing were collected.

RESULTS

HPV DNA was detected in 31 of 248 WSW (13%). Women who had never had sex with men were less likely to have undergone pelvic examinations and had fewer recent Pap tests. Reasons for not undergoing Pap tests included lack of insurance, previous adverse experiences, and belief that Pap tests were unnecessary.

CONCLUSIONS

Despite the occurrence of genital HPV, WSW do not receive adequate Pap test screening. Pap test screening recommendations should not differ for WSW, regardless of sexual history with men.

Cancer-related risk indicators and preventive screening behaviors among lesbians and bisexual women

OBJECTIVES

This study examined whether lesbians are at increased risk for certain cancers as a result of an accumulation of behavioral risk factors and difficulties in accessing health care.

METHODS

Prevalence estimates of behavioral risk factors (nulliparity, obesity, smoking, and alcohol use), cancer screening behaviors, and self-reported breast cancer histories derived from 7 independently conducted surveys of lesbians/bisexual women (n = 11,876) were compared with national estimates for women.

RESULTS

In comparison with adjusted estimates for the US female population, lesbians/bisexual women exhibited greater prevalence rates of obesity, alcohol use, and tobacco use and lower rates of parity and birth control pill use. These women were also less likely to have health insurance coverage or to have had a recent pelvic examination or mammogram. Self-reported histories of breast cancer, however, did not differ from adjusted US female population estimates.

CONCLUSIONS

Lesbians and bisexual women differ from heterosexual women in patterns of health risk. These women would be expected to be at especially greater risk for chronic diseases linked to smoking and obesity.

Receipt of preventive health care services by lesbians

BACKGROUND

We measured receipt of age-appropriate preventive health services by lesbians and assessed whether provider and individual characteristics, including disclosure of sexual orientation, are independently associated with receipt of these services.

METHODS

A questionnaire was printed in a national biweekly gay, lesbian, and bisexual news magazine, and self-identified lesbians living in all U. S. states (N =6935) responded to the survey. Main outcome variables were receipt of a Pap smear within the preceding 1 and 2 years and, for women aged > or= 50, receipt of a mammogram within the past 1 and 2 years.

RESULTS

Fifty-four percent had Pap smears within 1 year and 71% within 2 years, with increasing rates among older and more educated respondents. Seventy percent of respondents aged > or = 50 had a mammogram in the past year, and 83% within 2 years; rates did not vary significantly controlling for education. Sixty percent had disclosed their sexual orientation to their regular health care provider. Controlling for patient and provider characteristics, disclosure was independently associated with receipt of Pap smears, but not mammograms.

CONCLUSIONS

It is important for providers to identify their lesbian patients' unmet needs for preventive health care. Additionally, it is important for providers to provide complete and appropriate preventive health care for their lesbian patients. Further research is needed to determine why lesbians are not receiving Pap smears at the recommended rate and whether this disparity is reflective of aspects of cervical cancer screening or indicates a more general problem with access to health care including receipt of preventive services.