Why You Should Care About Lesbian Safer Sex (And What To Do About It)

Feature image via shutterstock.

Most sex education doesn’t go beyond a heteronormative p-in-v narrative. According to Autostraddle’s lesbian sex survey (open to all women who have sex with other women), 81.79% of respondents had elementary or high school sex ed that didn’t talk about queer sex (2.71% had never had any safer sex education, not even from the internet).

Many cis women are also unfamiliar with their basic sexual anatomy and asking people to label or draw diagrams of their reproductive systems yields… interesting results.

Drawing on three years of medical school knowledge and an obstetrics-gynecology rotation where I did more pelvic exams than I can count, I’m going to guide you through the research to find out what’s relevant to your interests about safer sex, and what to do about it.

The Patient Is In


wow, you’ve even given timestamps for your sexual history

Queer women tend to underuse health services and come in later for care when compared to straight women. Part of the reason is that queer women are less likely to use reproductive services such as birth control, leading to fewer entry points into the healthcare system. Other reasons include discrimination, as well as a lack of cultural competence and awareness of health issues pertaining to this population. (Not all healthcare providers know what to tell queer women about safer sex, which doesn’t help.)

Although doctors need to be more proactive about creating safe spaces, patients also need to be proactive about their health. You are the most important part of your own healthcare team.

People with vaginas should have their first gynecologic visit between ages 13 and 15. This first visit includes a general physical exam and an external genital exam. There’s usually no need for a pelvic exam unless you have pain, abnormal discharge or bleeding or need certain tests.

The American Congress of Obstetricians and Gynecologists has great resources about what to expect for your first gynecologic visit and annual visits. If you’re seeing a doctor about a specific problem, they may ask you targeted questions about vaginal discharge, abnormal bleeding, urinary problems, pelvic pain, sexual dysfunction or infertility.

When it comes to STIs, the doctor should ask you questions about your sexual behavior — including partners, birth control if applicable, safer sex practices, sexual practices, sexual health history and more — to determine your risks. It’s good to think about these questions in advance — some are even excellent sexual health icebreakers with partners.

Not-So-Risky Business

stock image photographers do not know about the other use for dental dams

stock image photographers do not know about the other use for dental dams

When asked how often they use protection, 59.61% of respondents to Autostraddle’s sex survey report never using it, while 20.41% report using it rarely. Only 6.77% use protection every time they have sex.

Women who have sex with women (WSW, the study’s wording) talk about barrier methods in a way that suggests hypothetical rather than actual use, according to a 2013 study. Many respondents were also confused about the difference between dental dams and female condoms.

A 2010 study surveyed 543 Australian WSW and found that, of the women who had oral sex with other women in the past six months, 9.7% used a dental dam at all and only 2.1% used dental dams “often.” Women who practiced oral-anal contact or had kinky sex involving blood were more likely to use dental dams. However, latex gloves and condoms were used more often than dental dams.

The lack of barrier use is concerning because STIs can be spread by contact involving the skin, genitals, mouth, rectum and bodily fluids. That also includes sex toys that are not protected by barriers between partners.

While some studies suggest that people with vulvas who have sex only with other people with vulvas have a lower STI risk, STIs can still be transmitted. In fact, oral-genital sex, oral-anal sex and sex toys may be more important risk factors for STI transmission than penile intercourse. STI risk also depends on other factors like number of sex partners and sexual practices.

Rather than going from frisky to risky, why not aim for not-so-risky business instead? Scarleteen has great guides on the simple and underrated art of washing your hands and safer sex barriers — including condoms (male/outside and female/inside), dental dams, gloves, and finger cots for both body parts and sex toys.

While it’s best to not share sex toys, plenty of people do. Unfortunately, this means you also could share STIs. That’s why you should know how to properly clean sex toys. Also make sure to use safer sex barriers on toys, wash them after use and sterilize them between partners.

If you’re a do-it-yourself kind of gal, you can make your own dental dams. While you’re at it, you might even want to make a safer sex utility belt to keep all your barriers within easy reach, you sexual health expert, you!

And when it comes to concerns about barriers leading to less intimacy and pleasure, Laurel Isaac sums it up perfectly:

“It’s a horrible misconception that safer sex is somehow less intimate or real than unprotected sex. And for queers, where the sex we have is already always under attack for not being ‘real,’ adding unfamiliar safer sex practices can be uniquely daunting.

But we are very real. Our bodies are real, the sex we have is real, and the risks inherent in our sexual activities are real. So, please, let’s protect each other…

Gloves tend to feel great for the person on the receiving end – they’re soft and smooth and protect delicate tissues from nails. And they tend to feel great for the wearer (I feel pretty powerful and cool wearing them).

For oral sex, too, I appreciate dams even when I don’t ‘have to’ use them. They’re silky and let me appreciate oral sex in a different way. Sometimes when I’m going down on someone, what I want more than anything is to really taste and smell them, to feel as close to their body as possible. Other times, because of my mood or where a partner is in their cycle, it’s just a bit of sensory overload. Dams are great for when you want to go down on your partner, but for whatever reason, want to feel a bit more space.”

Contraceptive methods can be important, too — especially if you’re sleeping with someone with a reproductive system that could lead to pregnancy. And non-barrier contraceptive methods have other benefits like decreasing migraines, pain and bleeding associated with menstruation. They can also reduce acne, body and facial hair growth, and the risk of uterine, ovarian and colon cancer.

Some birth control methods last longer than others and are more effective, such as the intrauterine device (IUD). A copper IUD lasts for 10 years and a progestin IUD lasts for five years. Birth control implants last for three years. Other forms — pill (daily), patch (weekly), ring (monthly), injection (every three months) — take more maintenance. Emergency contraception and sterilization can be options in the right circumstances.

The ABCs of STIs


being gay doesn’t mean you don’t have to worry about this shit

Even though my high school sex education class was better than this, the abstinence-plus model focused on the ABCs (“abstinence,” “be faithful,” “correct and consistent condom use”) and a few STIs was incomplete.

I never learned about other STIs, like bacterial vaginosis. In fact, I never even heard of it until medical school. Yet there is an unusually high prevalence of bacterial vaginosis among WSW, especially those who have had more partners. In monogamous relationships where one woman has it, 25 to 50% of their partners are also infected. While bacterial vaginosis is relatively benign — most women are asymptomatic or have vaginal discharge with a fishy odor — it can increase the risk of acquiring other more dangerous STIs.

Human papilloma virus (HPV), which causes cervical cancer and genital warts, has been detected in about one-third of WSW. Because of the false belief that they have a lower risk of acquiring HPV, there is less screening and delayed care. Even though there are vaccines that prevent infection with most types of HPV that cause genital warts and cancer, some patients may not be getting it. This leads to higher cervical cancer rates among bisexual women (2.1%) and lifetime lesbians (2.2%) when compared to straight women (1.3%).

Many STIs are asymptomatic and increase your risk for contracting other STIs. Some STIs like chlamydia can even lead to painful pelvic inflammatory disease and infertility. A study of young women from 1997 to 2005 found that chlamydia rates were higher in those who reported having sex with women (7.1%) versus those who reported having sex with men exclusively (5.3%). In fact, among women at risk (new, multiple or symptomatic partners), those who had sex exclusively with women had higher chlamydia rates than those who had sex with only men or with men and women.

This is why regular testing is so important. Try going on a date with partners or friends to an STI clinic, and grab some free safer sex barriers before heading to brunch. Plus, some company in the waiting room makes the overly dramatic ’90s sexual health videos somewhat bearable.

You can get tested in a lot of free and confidential clinics — use this directory to find a clinic near you. STI testing is quick and simple, with a usual 10-day turnaround for results and only 30 minutes for a rapid HIV test result. During your visit, you may have a pelvic exam to look for signs of infection (ulcers, warts, rashes, discharge, etc.). The doctor may take a fluid, tissue, blood or urine sample for further testing.

And if you want to learn more about STIs, check out my STI cheat sheet with information from UpToDate.

How are you going to change your safer sex behaviors? Do you have any questions that the guide didn’t address? I’d love to hear your experiences and questions in the comments!

NOTE: This article and the accompanying chart are intended to educate, but are in no way substitutes for medical advice or attention. The opinions expressed are those of the author, Christy Duan, and not of the institutions with which she is affiliated. This STI chart was created using information from UpToDate.

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Christy Duan

Christy Duan is a rising fourth-year medical student at Albert Einstein College of Medicine and an award-winning writer who has published in The Detroit Free Press, Quartz, KevinMD.com, and Abaton. In 2012, she graduated from the University of Michigan with a Bachelor of Science in Statistics. Christy is passionate about social justice and global health. Her work has spanned from the Usambara mountain range of Tanzania to the sprawling metropolis of Hong Kong, and from community HIV interventions to data mining. Read more of her work at christyduan.com.

Christy has written 1 article for us.


  1. I went to my first pap smear recently with my girlfriend of five years. The nurse said, “Wow! I’ve never pap smeared a virgin before.


    • Ugh, I’m so so sorry about this.

      I’ve had such varied experiences at GUM clinics (UK sexual health clinics). At one of them, I was treated so wonderfully by everybody and had somebody who read as queer as an advisor to talk to at the end. At another, one of the nurses asked me (after I’d told her that I was a cis woman with another cis woman) whether we used condoms. I knew she meant ‘protection’ and of course condoms are used in vulva-vulva-persons’ sex but it was also so obvious that she was clueless about other forms of protection. It was so frustrating and I feel like, had I been younger or less confident, I would have felt so so alienated.

      I also had a big issue with the way she – and many others from what I can gage – treat(ed) ‘risk.’ When told a woman is a lesbian, so many sexual health advisors, nurses and doctors assume: 1) she’s cis, 2) she’s never had P in V, 3) she’s not going to have any “big risk” STIs/is totally safe.

      It’s perhaps a bit extreme to compare but – during the AIDS crisis – WSW were regarded as a sorta overlooked casualty cos they were so often assumed to be by default “safe” and, therefore, so so rarely catered to.

      Anyway, sorry for the rant. I just wanted to say I’m so sorry for the crappy, queerphobic healthcare you received. It is pants and so endemic.

    • I recently had a physical for a new job and the doctor raised her eyebrows very dramatically and said “you’ve NEVER?!?! been sexually active?”

      At that point I didn’t care to share any details because she wasn’t my regular doctor anyway, but damn.

      • Oh my god i can’t stand the ignorance of some people! This is one of the main reasons I’m fearful of going to the doctor, honestly.

    • I’m also really sorry that you had such a bad experience. Right now, some medical schools are increasing their training about LGBTQ health issues. My school has a “sex day” where we discuss these issues, as well as others. I hope that this additional training will create more sensitive healthcare providers. But there is more to be done. Thanks again for sharing!

      • Damn, I thought my school was bad. Y’all only have 1 day for human sexuality? I think we had seminars that lasted a couple hours for about a week. The information was pretty outdated and stereotypical, very male-centric, had nothing about trans health, and overall was just not as clinically relevant as it could have been, but they tried I guess…actually maybe just a day of that would have been preferable now that you got me thinking about it. Yikes.

  2. This is amazing, thank you!

    Herpes is also a biiiiig issue for (cis)WS(cis)W; it transfers easily from mouth to genitalia and vice versa, and is asymptomatic in a huge number of sufferers, meaning it’s often not even something that people will know to take account of.

    Is bacterial vaginosis an STI? I had always thought it was a bacterial infection that sexual activity increased the risk of but didn’t transfer? You learn something new everyday!

    I wish we were constantly having inclusive safe(r) sex conversations that talked about all of this and included conversations about consent, boundaries, respect, etc. (Which isn’t a criticism of this article at all; just a reflection on sex ed/conversations around ‘safe(r) sex’ in general.)

    • No, you’re right. Bacterial vaginosis not an STI. Its linked to sex and increases your risk of getting an STI, but its not an STI

    • Thanks for your thoughtful question! I do not think I was clear enough in the article. An STI can be passed among people through intimate sexual contact. According to the CDC, “BV is more common among women who are sexually active, but it is not clear how sex changes the balance of bacteria. BV is not considered an STD, but having BV can increase your chances of getting an STD. BV may also affect women who have never had sex.” Who knows? This may change as we learn more about the disease. Also, when literature sources about WSW discuss STIs, they often include BV under the heading because a lot of research shows an association between BV and a history of vulva-wielding sexual partners. I know — it’s very confusing!

    • That’s what one study reported. If you find different rates in other research, I would love to hear more about it!

    • Well with two females having sex many weren’t taught about safe sex in a homosexual relationship. It’s really frightening honestly because there are so many males and females who have sex with the same gender who know nothing about safe sex outside of heterosexuality. I honestly didn’t know till last year that safe homosexual sex for females was a thing! Im still under knowledged on it.

  3. ‘When it comes to STIs, the doctor should ask you questions about your sexual behavior”
    Yes, they should ask you, but they probably will not know to ask the right questions or they will ask and have no idea what your answers mean. Its not just that women don’t use dental dams and we don’t learn real safe sex in schools, its that doctors and medical students don’t know this stuff either. I think I am one of the few people in my class who is able to give ok counseling about WSW safe sex, but this is using material that I learned in sex ed in middle school. *middle school.* beyond that, there has been no required WSW sex education. I’m finishing my third year of medical school. There is a week each year when we hold optional lectures on sexual issues not included in the medical school curriculum, and that is probably the only time it comes up.
    You should definitely try talking to your doctor. You should ask questions, but have a back-up source of information that is legitimate because they might not know the answer. Ask for STD/HIV screening routinely (even when you don’t have symptoms). Do not ask them if they think you need it.

    • My medical school has a “sex day” where we have lectures on these issues. I believe it was mandatory. Integrating these lectures into the core curriculum at the structural/institutional level can really help. And there are medical students that are pushing for better education in this area. Luckily, we have an administration that is receptive to our concerns.

      You give some great advice. And thank you for doing such a thorough job of educating patients (and hopefully your peers too!). You are very thoughtful and I think you’ll make a wonderful doctor. :)

      • Einstein hospital has a reputation as bring more gay friendly. I am not questioning your education, but it is important to know that it’s not the norm. Especially for older doctors.

  4. Christy, some of your links are to the uptodate website which isn’t going to be accessible to most people. Do you have another way to get to those topics? Like pubmed? My solution is usually to cut and paste uptodate material onto word documents, but that probably isn’t the right solution here.

    • If there are particular citations that you’d like, please let me know and I will try to dig them up. I will definitely keep this issue of access in mind in the future. Thank you!

  5. i feel like i have a pretty good handle on how dental dams are used during sexytimes, but……. how does it work for the dentist? like, are any teeth being cleaned in that image? i am so confused.

    also: thank you for this extremely informative and important article.

    • When I got a root canal done a while back (yuck) they used a dental dam like that. It keeps the area dry and clean. It also prevents the acid they use to flush out the infection in the tooth from getting in your mouth and burning you.

    • During a filling or root canal, they keep saliva from touching the affected teeth. (My dam kept slipping off!) I literally never knew dental dams had a non-sexual use, and wish my first encounter didn’t involve a root canal!

  6. I’ve had ridiculous experiences in discussing my sex life with doctors. My NP in college, despite knowing that I was a lesbian, attributed every ailment to my possibly being pregnant. Broken foot? Pregnant. The flu? Pregnant. You accidentally deeply cut yourself wrapping a present for your girlfriend? MOST DEFINITELY PREGNANT. I went to a women’s college composed of a whole bunch of very sexually active straight girls, so it made sense that she was overly cautious (there were A LOT of unplanned pregnancies…pretty sure our school single handedly funded the local PP), BUT STILL.
    My current PCP really tries, but she’s still pretty lost half the time. I don’t think she knows what to do with someone who has penis-less sex. She just looks like a deer in the headlights every time we talk about it. She told me the last time I saw her that my STI risk was the same as a woman over thirty, so I needed a pap smear every five years instead of three…is that accurate? I mean…I’d like it to be accurate.

    • Check out my STI Cheat Sheet here: http://www.autostraddle.com/wp-content/uploads/2015/04/Duan_Autostraddle_WSWSTI_Table_Final.pdf

      In the United States, it’s every 3 years from age 21-29. At age 30, they give you the option of doing it every 5 years if you also get an HPV DNA test. During the speculum exam, they take a brush to get cells from your cervix in order to test the DNA for high-risk types of HPV. By age >65, it’s possible that you no longer need to be tested for HPV if your other results are negative.

      Oops! I just saw that I have “HPV blood test” in the PDF, which should read “HPV DNA test.” My mistake — I will try to have a corrected PDF posted!

  7. A genital check at 13?? And annually?? Not on the NHS. We have smears every three years after the age of 25, but nothing else routinely.

    • My thoughts exactly. Plus they’re mostly performed by a practice nurse at a GP surgery not by anyone at a GUM clinic or a gynaecologist. I doubt most women in the UK have seen a gyno unless they are pregnant or trying to get pregnant or have an abnormal smear.

    • Yeah, I was surprised by the “genital check” recommendation too. Like none of the reasons they listed on the site seemed like a thing that justified a visit to an ob/gyn in addition to your regular doctor. Everyone over the age of 12 (maybe younger) is going to be asked about their sexual practices by their pediatrician- or is supposed to be. If you have more specific needs, then fine. But that shouldn’t be the standard for everyone. And the vaccine they alluded to is definitely the HPV vaccine, which most people get from their pediatrician. Its like a pulmonologist saying, “you should come in every year for your flu shot because the flu is a respiratory infection.”

    • An initial reproductive health visit from 13-15 is a recommendation from the American Congress of Obstetricians and Gynecologists (they do not specify that it MUST be done by an OBGYN). Part of the reason is to establish a trusting patient–physician relationship and address fears. However, guidelines may vary from organization to organization. If you’d like to read their reasoning, it’s here: http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Adolescent-Health-Care/The-Initial-Reproductive-Health-Visit

      • I read the explanation. Tanner staging is done by pediatricians. It does not require a specialisthe and asking a specialist to do it for everyone is a waste of resources. if someone does have delays, they are routinely referred to a pediatric endocrinologist, who I suppose could recommend seeing an ob/gyn if they needed additional help. All the other stuff could be accomplished at a regular adolescent health clinic with doctors who could take care of all of their medical needs, and of course, refer to an ob gyn if necessary. I’ll believe that these routine processes actually require a gyn when someone outside this specialty agrees. Actually, I doubt the average non-private gyn agrees.

  8. Thank you for this article. It’s been really hard for me to figure out how I should handle my sexual health. I didn’t get my first pap until I was 25 and it was the most humiliating medical experience of my life, mostly because my doctor walked the nurses station asking around if anyone knew if they even needed to give paps to lesbians who had never slept with men. She was pretty adamant even after I had her just do it and give me an STD screening test that I was at barely any risk of STDs and it wasn’t really important for me to be tested regularly as long as I was just sleeping with women and had no sign of infection. I haven’t been back for anything regarding sexual health. It’s been really hard to get clear answers on anything :(

    • I’m really sorry that you had this experience. There’s been a push for medical professionals to be trained better in this area. And medical schools are creating curricula that address these issues. While that doesn’t change the past, hopefully it will change the future by providing more sensitive providers. You should be proud of yourself for taking the effort to figure out how you should handle your sexual health though. It’s not easy, but keep advocating for yourself and demand those services.

  9. OHHH this issue makes me so angry.

    Here are some things gyneacologists and GP:s have said to me or my queer female friends:

    “You don’t need an HIV test. Or have you been fooling around with foreigners?”
    “You don’t need a pap smear because you have only been sexually active for six months.” (I told I had been dating my then-bf for six months.)
    “Your [strange period] symptoms cannot be due to an infection because you’re in a relationship with another woman.”
    “You don’t need any STI tests because you’re a lesbian.”
    “You’re in a relationship with another woman, so I won’t ask you about pain during intercourse.” (when visiting the doctor because of endometriosis)
    “Do you need contraception or are you trying to get pregnant? Oh… Yeah. Sorry.”

    I’ve concluded that many doctors have these assumptions about women’s sex lives:
    – Your current partner is your first partner. Your sexual history is as long as your current relationship and if you are in a lesbian relationship you have definitely never had PIV.
    – Your current primary partner is your only partner. Polyamory does not exist.
    – Lesbians don’t have sex. They probably just hold hands in bed. They DEFINITELY don’t have penetration or genital-to-genital contact.

    I have literally ZERO trust in medical professionals’ knowledge about WSW:s sexual health. I’ve been wondering about this a lot – many of us have a lot of casual sex and practically no-one uses protection. Medical practitioners practically refuse to give us STI tests. I’m sad but not surprised to find out that we have higher incidence of cervical cancer and chlamydia than straight women.

    • Thanks for sharing your experiences. There’s a push for more training, and hopefully future practitioners will be more sensitive about these issues. And you bring up an excellent point about polyamory. I’m very familiar with it, but many practitioners aren’t. I’ll make a point to bring this up more often in the future.

  10. I feel like a lot of the safer sex discourse aimed at queer women is like “we have higher risks of STIs because we’re too stupid to know about these risks and go to the doctor regularly” but, actually, all of this costs money / requires you to have insurance and we’re a population who suffers from systematic employment discrimination and poverty…

    • Yes. This is exactly what I feel. The last time I saw my doctor, she was asking why I hadn’t been to a gynecologist in so long, and I was like “well, this is the first time in my adult life I have ever had health insurance, so…”

  11. A few years ago I got a really disapproving look from my doctor by responding to their question “what protection do you use?” with “none”

    Until I clarified that I meant “none, because I’m not having sex with anyone at the moment”

    Then I got a smile and some free condoms.

  12. I’d love to see where you got your figures for lesbian and bisexual women having a higher lifetime risk of developing cervical cancer but the link seems to be behind a paywall. Could you post an accessible link? I’m kind of surprised to see this as I work for an LGBT org which has carried out research on cervical screening and WSW and also has an ongoing info campaign encouraging these women to screen and I’ve looked in vain many times for figures on cancer prevalence which monitor sexual orientation and never found anything. So a link would be really appreciated.
    The info in this article is really great but it is very US-centric. For example, in the UK they don’t start cervical screening until you’re 25, as there’s quite a lot of evidence that under that age the risks associated with false-positive results outweigh possible gains. It’s a contentious issue though. Also, being able to pay for treatment is obviously not a factor here but WSW are still less likely to screen, probably because until 2009 WSW were routinely told they didn’t need smear tests.
    I also think it’s very unlikely that a 13-year-old would be given a genital exam unless there was a problem and I don’t really understand what would be gained by this, especially if she is not yet sexually active – is it not a bit invasive? Would the possibility of a bad experience at such a young age maybe make a woman less likely to attend in the future? I don’t know. But then, in the UK you’re not going to be visiting a gynaecologist unless you have a specific gynaecological problem.
    The issue of not being able to make informed choices about sexual health is such a huge one. There is currently a campaign to make comprehensive sex and relationship education compulsory in the UK and it really can’t come soon enough. The vast majority of SRE here is completed focussed on heterosexual sex and pregnancy prevention, which means that most queer women (and other women who may have sex with women) assume there is no risk and head off into the world completely uninformed. Great to see this article raising awareness.

    • I think this is the citation that you’re referring to. From UpToDate, “The Women’s Health Initiative Study noted higher rates of cervical cancer among bisexual women (2.1 percent) and lifetime lesbians (2.2 percent) than in heterosexual women (1.3 percent); the higher rate correlated with their having fewer cervical cancer screening tests.”

      And here is the study (hope this helps!):

      Sexual orientation and health: comparisons in the women’s health initiative sample.
      AUValanis BG, Bowen DJ, Bassford T, Whitlock E, Charney P, Carter RA
      SOArch Fam Med. 2000;9(9):843.

      CONTEXT: Little is known about older lesbian and bisexual women. Existing research rarely compares characteristics of these women with comparable heterosexual women.
      OBJECTIVE: To compare heterosexual and nonheterosexual women 50 to 79 years on specific demographic characteristics, psychosocial risk factors, screening practices, and other health-related behaviors associated with increased risk for developing particular diseases or disease outcomes.

      DESIGN: Analysis of data from 93,311 participants in the Women’s Health Initiative (WHI) study of health in postmenopausal women, comparing characteristics of 5 groups: heterosexuals, bisexuals, lifetime lesbians, adult lesbians, and those who never had sex as an adult.

      SETTING: Subjects were recruited at 40 WHI study centers nationwide representing a range of geographic and ethnic diversity.

      PARTICIPANTS: Postmenopausal women aged 50 to 79 years who met WHI eligibility criteria, signed an informed consent to participate in the WHI clinical trial(s) or observational study, and responded to the baseline questions on sexual orientation.
      MAIN OUTCOME MEASURES: Demographic characteristics, psychosocial risk factors, recency of screening tests, and other health-related behaviors as assessed on the WHI baseline questionnaire.

      RESULTS: Although of higher socioeconomic status than the heterosexuals, the lesbian and bisexual women more often used alcohol and cigarettes, exhibited other risk factors for reproductive cancers and cardiovascular disease, and scored lower on measures of mental health and social support. Notable is the 35% of lesbians and 81% of bisexual women who have been pregnant. Women reporting that they never had sex as an adult had lower rates of Papanicolaou screening and hormone replacement therapy use than other groups.
      CONCLUSIONS: This sample of older lesbian and bisexual women from WHI shows many of the same health behaviors, demographic, and psychosocial risk factors reported in the literature for their younger counterparts, despite their higher socioeconomic status and access to health care. The lower rates of recommended screening services and higher prevalence of obesity, smoking, alcohol use, and lower intake of fruit and vegetables among these women compared with heterosexual women indicate unmet needs that require effective interactions between care providers and nonheterosexual women.

      ADKaiser Permanente Center for Health Research, 3800 N Interstate Ave, Portland, OR 97227, USA. [email protected]

    • Haha, sorry it’s so US-centric! It’s because I’m from there. :) And different countries can have some very different ways of approaching screening.

      An initial reproductive health visit from 13-15 is a recommendation from the American Congress of Obstetricians and Gynecologists (they do not specify that it MUST be done by an OBGYN). Part of the reason is to establish a trusting patient–physician relationship and address fears. However, guidelines may vary from organization to organization. If you’d like to read their reasoning, it’s here: http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Adolescent-Health-Care/The-Initial-Reproductive-Health-Visit

  13. Like others, I’ve had to argue with my doctors about STI screening over and over. I have been avoiding the doctor for years because of so many unpleasant and insulting experiences. ..

    • Same thing happened to me – went to a new doctor at the beginning of the year and, as soon as I told her I’m gay, any talk about STI screenings went right out the window. The amount of time between exams went from yearly to every 5 years as well. Overall unpleasant experience…

    • Maybe we should all lie and say that we all sleep with men once a year. “Oh him, yeah no idea who he was really. but we definitely had unprotected sex. Can I have an HIV test now?”

  14. I just wanted to come over and say that I’ve had a great experience with my doctor on this stuff. She’s really fantastic. Just putting it out there as a ray of hope. Maybe we need a giant ladygay network of doctor recommendations…

    • I actually had a great experience too, I just went to the Boro Hall PPH in Brooklyn a couple weeks ago and the NP was fantastic. Their paperwork and stuff was really trans inclusive and as I was leaving she told me if I get a new partner, she recommends gloves and dams. I mean, New York, I know, but I was excited.

  15. Ugh, I had my first Pap smear and genital exam when I was around 25-26 and I cried throughout the whole thing (it felt traumatic, not just the pain). Cannot imagine doing that when I was 13.

    On the other hand, I recently went to Delgado Health Clinic in New Orleans which is sliding scale to get STI tested and they were pretty good – I told them I’d only had sex with people with vaginas and wasn’t looking to get pregnant so they dropped those questions and also used the smallest speculum possible to get a sample. My first Pap smear was incredibly painful; this one was loads better.

  16. WOW, so interesting and shocking to read, how different the health care is depending on the country even if we’re talking about North American and European countries.

    In Germany we get a pap smear once a year from 20 years on, of course by a gynecologist.

    Also, when I’ve had different doctors and when I told them i date women they were just like “oh okay, so you don’t need birth control then” but that didn’t change the treatment I got. Although no one ever talked to me about safe lesbian sex either, so there are still things to be improved.

  17. Cool to see an article written by a u of m and icc alumn and about sex ed at that.
    Guidelines on screening are changing and different organizations are advocating differently for different reasons right now. Outside of the US also there tend to be different guidelines.
    Pretty clear from the comments that there are a lot of opinions and experiences with this in different ways. Hope we hear more!

  18. This is really great information! I always try to read these things because even though I think I know a lot, there’s literally always some statistic or guideline I hadn’t heard of before. Thank you for the reminders!

  19. When I was 17, my guardian decided I needed to go to a gyno because I had had sex (with a girl). She did not stay in the room with me for the exam, the doctor was rude when I answered her questions about sex, said I needed to be tested for different things but didn’t explain, and proceeded with a very rough exam. It was a pretty traumatizing experience. I didn’t get another exam for two years and went to my family doctor for it. I don’t think I mentioned my sexuality with him and neither doctor gave me any safe sex advice. It wasn’t nearly as traumatic but the next time I found the Chicago women’s health center when I moved there. I think I went there twice for exams and didn’t get another until I was pregnant. I felt respected at CWHC but safe sex was not clearly discussed. At 29, I have never had safe sex with a woman but have thankfully never had a STI. I think a lot of us act as if testing is all the prevention we need. When I was single and pregnant my experience with healthcare was hit or miss. I had to leave one hospital midwifery group because they treated me negatively when I explained I am gay and a single mom by choice. They also tested me for things I didn’t consent to as well as not informing me I had a uti. I feel like I had less than stellar experiences with the staff where I delivered but I had bigger things on my mind. I have had one exam since my son was born, did not mention my sexual identity, how I got pregnant, or my then lack of sexual activity. She was rude enough as it was that I had to bring my son with me.

    It got under my skin in this article that all these pros of birth control are mentioned without discussing cons. I feel like if there isn’t the room for both aspects, then just name the different kinds and say discuss them with your doctor.

  20. A recent conversation with my primary care physician:

    “You should call and schedule a ‘well woman visit'”
    “What is that?”
    “A Pap smear”
    “Why don’t you just call it that?”
    “‘Well Woman’ just sounds nicer.”

    How can I trust my doctor to tell me anything when they are too shy to say the REAL WORDS for REAL MEDICAL PROCEDURES?

    • As an openly gay medical student, some of these comments that have been said by healthcare professionals make me cringe. I apologize for their lack of sensitivity, its unacceptable.

      Christy’s right, there has been a push for more training recently. Our medical school has patient labs and lectures devoted to LGBT health, and our training for how to take a history and physical includes LGBT-specific considerations. We work closely with the undergraduate LGBT center for that training as well. There are two physicians who teach at our school that have pioneered transgender medical awareness in our community.

      So, good docs are out there that are knowledgeable about LGBT health. And at the very least, your doctor should be willing to listen and learn, and give you advice from an evidence-based standpoint. If they’re not doing that, find a new doctor :)

  21. Once I went to the doctor with an issue I was having and the whole appointment got bogged down by her being confused about how lesbian sex works. She completely dismissed my concerns.

    I ended up figuring out what was up (scratched cervix) by reading some sort of forum or comment thread or something on After Ellen. It’s a pretty sad state of affairs when you have to check an entertainment site for medical information.

    Information on lesbian sexual health on the internet has gotten better since then, but my doctor hasn’t. I want to find a new doctor, but I don’t have a lot of confidence that the next one will be any better than the one I have.

  22. I live in New Zealand and I recently had a really great experience with the doctor at Family Planning. I explained to her my situation (two male sexual partners and one female) and she was TOTALLY cool about it all. She said that female/female sexual partners still have risks and so she had me tested for all STIs. I’m still quite confused about safe sex for queer women, though :(

  23. Ironically enough, this article showed up on my tumblr dash as I was in the waiting room at the doctor’s for an appointment to talk about safer sex with my first partner. Thank you for this article; it was much more helpful and reassuring than my doctor, who told me to simply use a condom about 3 times throughout my emphasizing female pronouns.

  24. When I let my doctor know that I had “switched sides” (when she asked me if I needed birth control) she said “oh. Wonderful! So, dildoes, eh?”

    That was my safe-sex talk.

    I said “um, sure.” And that was the end of the talk. I really wish more straight doctors would educate themselves about queer sex. I have a feeling they didn’t teach anything about it in med school back when my doctor was there, decades ago…do they at least teach about it now??

  25. I feel like I read a lot about the queer community, esp in queer and indie porn, being really good and pro active about practicing safe sex. However in my real life queer community I never hear references to gloves or dams or condoms being used. It makes me feel like if I were to suggest using any of those in asexual encounter I would be laughed at :/
    Also, now that “truffle butter” is a sexy status thing, sex ed really needs to step up its game!

  26. Just thought I’d give you all a little report from my native country.

    In Sweden, dental dams are neither sold nor distributed freely, and even our healthcare professionals officially tell us that there is no such thing as safe barriers for lesbian sex – because lesbian sex is “already safe”. Swedes in general have no idea that gloves and dental dams even exist. Sexual health clinics are few and far between and only accessible to people with national insurance numbers. They also charge money if you want to get test results for all the STI’s rather than just HIV and gonorrhoea.

  27. I find it funny that I was just reading the CDC STI guidelines prior this article. There is actually a segment regarding screening and most common STI’s among WSW. Accdg to the article, WSW usually get cervicovaginal infections and HIV’s thru digital-vaginal and digital-anal intercourse, and sharing/ using unsterile adult toys. Most common STI among WSW is bacterial vaginosis. However, screening for such disease is unnecessary. But you should go to your doctor (GP or OBGYNE) for proper medication). Chlamydia is uncommon but may be transmitted if partner had previous hetero intercourse. HIV is also transmitted by engaging in high risk behaviours such sharing needles (so it’s not just sex).

    Ladies should get your pap smear at least 3 years from first intercourse or by age 21. I never had mine tho… (but I do pap smears.) Then, you can take cervical shots. i recommend Gardasil that covers the HPV strains for cervical cancer and genital warts. If you’re using a condom, you can use latex or polyurethane. Protection-wise, their “efficacies” are the same; however, polyurethane ones have more cases of slipping. If you are going to use a lubricant, make sure it’s water-based (KY jelly, Astroglide, etc) since oil-based (petroleum jelly) ones break the latex (high chances of getting STI/pregnant).

    True, the WSW population has minimal cases of STI’s as compared to MSM/heterosexuals. However, that doesn’t give us the privilege to be reckless with our health. STI’s should really be treated as a community problem so that we can eventually eradicate them. These should be discussed openly in appropriate venues to help spread awareness, and not the diseases! Most importantly, we should continue to show support to those who have been inflicted by these diseases, and to get rid of the stigma.

    I know some people who have HIV. And, to have it is devastating. They feel like their lives have an expiration date. They just give up. But they shouldn’t. There are specialty clinics that deal with STI’s and HIV holistically (check-ups, blood work, counseling, etc.). And, people should go to those because it’s not just the pills that’ll help you live longer but also the words of encouragement from people whom you can trust can do so much more.

  28. Yikes! Going to the doctor at 13 for a genital inspection?! I was so uncomfortable with my own body and unsure of my sexuality then that I can’t imagine this being anything other than traumatising. I put off going in for a smear test till 27 as it is.

    As others have mentioned, it seems there is a large cultural difference between the US and the UK.

    I’m 31 and have never had safe sex and never had an STI. I’ve always had monogamous relationships with people who have been tested and don’t have STIs though, so don’t get what the point would be? Surely protection is only really relevant if you’re having sex with a bunch of different people in a short period or you don’t trust you partner?

  29. As for the genital inspection, I don’t think it’s advisable because as much as possible we don’t want to break the hymen. Genital inspections are only done once the kid presents with symptoms of STD’s. Otherwise, we dont screen kids for those unless they admit to be sexually active/rape victims. The kids have the right to ask for the std check up (if with symptoms, their partner tested positive or has been active) without their parents’ permission (in some states). But for a screening… I don’t think their parents would consent.

    • I looked at the explanation for the advice and they meant tanner staging. which is a waste because pediatricians/adolescent doctors already do this, but not a pelvic exam. *external genital* inspection

  30. But I think the author meant an external genital exam, which is noninvasive and can be done in a adolescent check-up with consent.

  31. Thanks for this most informative piece! I have over a decade of awkward encounters with medical professionals under my belt. The usual ignorant comments about my virgin status, even after I explained that I had sex with women (which is apparently not *real* sex). Being falsely informed that I was not at risk for STDs. It gets even more fun when you’re dating a trans woman, but you don’t need birth control because you don’t have PIV sex. (It’s inconceivable to most that someone with a penis wouldn’t want to use it during sex.) And my favorite story of all: last year I went to a clinic because of a possible yeast infection, and asked the nurse practitioner to use the smallest speculum available.
    I have a sensitive, tight vagina and most penetration is pretty painful. The NP quipped that I was lucky, because some women will pay thousands of dollars to have a tight vagina. I wasn’t offended, just very amused =P

  32. For all the people who are like “genital exam, what?!?!” From the organization’s explanation of the recommendation, they are referring to an external exam to determine what is called Tanner stages. Tanners stages refer to what someone’s breasts, pubic hair, genitals look like a different stages of puberty. It helps determine where you are developmentally and what other things you would expect at that stage of puberty. Its also really helpful when someone is concerned because they have their period much earlier than normal, or if there is a concern because they have never gotten their period, or anything else similar. It actually takes like less than a minute. Its not a pelvic exam. Its likely that at some point, your pediatrician or adolescent doctor did this. They said something like “is it ok if i check here for just a second?” and they did and it was so short that even if you felt embarrassed for like ten seconds it didn’t become the memorable part of your day.
    On an editorial note: this does not require an ob/gyn visit because as i said, it is already being done by primary care providers and after a certain age, really does not have to be done every year. I personally think that making an appointment for the sole purpose of having someone do that quick exam makes it more awkward. and having to go to the ob/gyn for an HPV vaccine is only going to encourage mom’s who say that their kids shouldn’t have the vaccine yet because its about sex. Its also something that boys should get. And unless we start saying that every boy from age of 12 on has to see a urologist, I don’t really see why we can’t just continue to have pediatricians give them to everyone.

    But to reiterate- genital check ≠pelvic exam. it’s not for STIs. it’s for puberty.

  33. Here is some different information about the HPV vaccine. articles.mercola.com/sites/articles/archive/2013/07/16/hpv-vaccine-effectiveness.aspx

  34. Reading this thread, I’m realizing how lucky I am. I came of age in NYC but had my first gyn exam at 25, after a coercive sexual experience with another cis woman. This happened at Planned Parenthood and the NP who gave me the exam and ran tests was amazing and handled the situation very compassionately while being realistic about the risk involved. My gyn and PCP have also been really good about asking the same questions of me that they do their hetero patients (I just sometimes have to bring them up to speed on terminology, which I am fine doing.) I can give names via a private message if anyone would like.

  35. Alright maybe this is a stupid question but why should people with vaginas have their first gynecologic visit between ages 13 and 15? I mean why is it even a thing? And yes I have read the website linked to that part. But I still don’t see the underlying reason for this measure. It could be a cultural difference though. The reason I’m asking this is because this isn’t normal where I’m from (The Netherlands). And we have a pretty OK health care system. Teenagers (boys and girls) over here get a general physical exam at age 15 but an external genital exam isn’t normal and only happens when something is wrong or when a person with a vagina hasn’t menstruated by the time they are 16 years old.

  36. I think I will add a comment here about India (just for interesting culture info).

    A bit of history: What passed for sex ed (or may be it was menstrual ed) when I was young was a film, exclusive to girls (boys either watched Tom & Jerry or had games), on menstruation and how it happens. There were some bits about uterine lining and all that and no talk of sex. We got sanitary napkins at the end of it.

    That was the case for private/decent schools. I am not sure about state and government schools. I don’t think there was any session on menstruation there. While in a central government school, I remember coming up on the word and asking my bio teacher in class and being ignored (i thought she hadn’t heard me, so I raised my voice and tried again; same result.). Could be her on hangups though because the teacher in a higher grade (age 16/17) who took us through human reproductive system had no such issues (no talk of sex or homosexuality though). In fact, after reading about in the chapter on contagious diseases under AIDS (it said homosexuals where at high risk), I went around asking people what it is and nobody knew. Then I thought may be it was homo + sex, so having sex with one person which didn’t make sense at all; so I gave up. ;-)

    Current situation (18 years later): Not much different in terms of sex ed. None of my younger cousins seem to know much about it although they seem to have learnt stuff when they find books like fifty shades of grey. (They are most definitely more knowledgeable than me at their age; it could also be a personal failing of mine and lack of internet that I didn’t find more).

    There may be a few schools that cover it though.

    Our visits to OBGYN mostly is only in case of abnormalities or if you are married and want to have kids.

    That is urban India, middle class.

    I am not sure about the rural India. (though I have heard that being in rural india doesn’t mean that you have sex only after marriage to the one person who will be your mate for seven lives; so maybe the risk of STDs will be the same).

    Interesting links:



    Note: There may be NGOs and private organisations providing sex ed and such.
    Also, my own information is not comprehensive.
    And talking about homosexuality is not something I have done outside my very close (and limited) circle of friends/cousins, so I don’t have much info there (except that it is at present illegal and considered a shame).

  37. I’m with my first actual girlfriend, I’m 18 and she’s about to be 22, it surprised me when she didn’t know much about safe sex between women, I started teaching her and still am. All because she was surprised I turned down having sex with her for the first time because I didn’t have any protection with me. I really wish it was actually spoken about and taught in sex ed.

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