Why are lesbians missing from sexual health discussions?

My routine smear test at the GP was the latest (but not the first!) time the very confusing fact that I am sexually active, but not at risk of pregnancy, finally got straightened out when I said I have a girlfriend. The GP gave me a disapproving look that said "You shouldn’t really be here", and asked “…but you have had sex, right?”

The depressing limitations of the heterosexual imagination aside, it made me think about whether I actually did need to be there – are women who have sex with women immune to STIs? Is that the reason why we are invisible in sexual health discourse? Let’s find out!

How are STIs actually transmitted during sex?

Bacterial infections or viral infections such as warts and herpes like the specific environment of the genitals, so if these come into close contact, the bacteria and viruses can transfer from one person to the other.

"If you are sharing sex toys, they can also be transmitted from one person’s genitals to the other via the sex toy” says our Sexual Health Nurse, Charlotte. STIs such as chlamydia, HPV and gonorrhoea don’t like to live outside of their cosy, moist environment for long, so using a toy someone else used a week ago should be safe from STIs (but please wash it anyway!)

There is a myth that you must have had sex with someone with a penis to contract HPV (which can lead to cervical cancer – the reason I went for my smear!)…but this isn’t true.

"HPV can be passed on during any genital contact (including sharing toys). Most people will have HPV at some point in their lives, and the majority will clear it without symptoms and without needing treatment” says nurse Charlotte. “Some may develop warts and very rarely some types of cancer.

"If you or your partner have visible warts, don’t have sex if you are not comfortable, or use some form or barrier like a dental dam. Although it’s more likely to pass on HPV when you have active warts, it can still happen when you are symptom-less”. So go for your smears! Ignore the ignorant GP…

STIs can also be passed on through body fluids via hands and fingers. BAASH (British Association for Sexual Health and HIV) guidelines states that non-penetrative contact carries the lowest risk, but no sexual contact is without risk. For penetrative sex (including fingering, using sex toys and fisting) the risk of transmission is related to the degree of trauma – i.e if there is friction or aberration (tiny cuts).

To be safe use a condom on your sex toy or fingers, or a latex glove for your hand, and change this every time you move from one person to the other. Using the elusive dental dam (or more easily accessible – a cut up condom!) will help stop the spread of STIs during oral sex or scissoring (if you can get it to stay in place…)

What about HIV?

In contrast to the above stated STIs, HIV is a bloodborne infection, meaning it needs to get into your bloodstream for you to contract it. Transmission is more likely during receptive anal sex or receptive, penetrative, vaginal sex.

“There is a high quantity of white blood cells in the rectum and on the cervix as well, and if the virus gets there, it is very close to where it needs to be. The skin in the rectum also tears more easily, which adds another way for the virus to come in contact with your blood stream during anal sex” says nurse Charlotte. However HIV cannot survive outside of the body for more that a few seconds, so transmission rates of HIV via sex toys are much lower, but notably have been reported in one case study (source: https://academic.oup.com/cid/article/36/3/e40/354816).

Menstrual blood can carry HIV, so sex which involves menstrual blood can be of higher risk of transmission although this risk will still be low. The exact rate of transmission of HIV for WSW (women who have sex with women) is unknown.

The way HIV transmission is documented may mask the true transmission rate between women, besides the obvious fact that it is seldom documented at all. WSW are more likely to engage in what is called high-risk behavior (such as having sex with men who have sex with men) than heterosexual women, and are therefore often exposed to other traditionally recognised modes of transmission (like substance abuse and heterosexual intercourse) which are then presumed to be how they contract the infection.

Testing regularly for HIV and other STIs is a good way to stay on top of your sexual health. Many STIs (including HIV!) are treatable and early detection is key. We recommend testing once a year or every time you change a partner, whichever comes first.

2 in 5 WSW said that (in the last year) healthcare practitioners had assumed that they were heterosexual

Lesbians need to be more visible in sexual health discussions!

It is clear that STIs can be passed on during sex between women, yet lesbians are conspicuously invisible in sexual health promotion and discourse. A 2018 study from Stonewall found that 34% of Lesbians had experienced a lack of understanding from healthcare staff and because of that did not receive the appropriate advice. These assumptions were most routinely made in sexual health (sexual history taking, contraception and cervical screening). Source.

As a consequence, lesbians are much less likely to practice safe sex, go for smear tests and test for STIs. Historically, WSW are considered to be at low risk for STIs, including HIV. However, data from case reports, small prevalence studies, and surveys of self-reported history of STI among WSW have suggested that this generalization may not be correct (Source).

It’s about time we start making lesbians and women who have sex with women more visible in sexual health!