Women who have sex with women (WSW) are at the same risk for sexually transmitted infections (STI's) as heterosexual women. In a recent study, WSW demonstrated a significantly higher prevalence of bacterial vaginosis (BV), hepatitis C, and HIV risk behaviors compared to non-WSW. "The assumption that women who engage in sex with other women are not at risk of STI's is clearly incorrect," said Katherine Fethers, M.D., lead author of the study from the Sexual Health Unit at Alice Springs Hospital in Australia.

A total of 1,408 women who reported ever having sex with another woman were compared with 1,423 women who had never had sex with a woman. The women had all attended the Sydney Sexual Health Center between 1991 and 1998. Only seven percent of the WSW or 283 women reported no sex with a male in the past 12 months (exclusive WSW) -- 25 percent of these WSW reported never having had sex with a man. Results were published in the October issue of the journal of Sexually Transmitted Diseases.

While genital warts and gonorrhea were found less often in WSW, BV was significantly more prevalent among WSW than controls (eight percent versus five percent), as was hepatitis C (five percent versus less than one percent). BV is a common condition marked by disruption of naturally occurring bugs (flora) in the vagina and is associated with PID (pelvic inflammatory disease), adverse pregnancy outcomes and enhanced HIV sexual transmission. There is no clear explanation as to why the rates are higher among WSW but researchers point to higher rates of smoking among WSW, oral sexual practices or female-to-female transmission as possible factors.

Women should make no assumptions about their risks for STI's. Often, women assume that because they are only sexually active with women they are safe from STI's. "You can't assume anything. You are part of a big chain of sexual transmission. You may think you are choosing your partners carefully but you never know," said Jeanne M. Marrazzo, M.D., the Assistant Professor of Medicine (Infectious Diseases) at the University of Washington in Seattle. "Women who are sexually active with both men and women need to know that they are at the same risk for herpes and other infectious diseases as any heterosexual woman might be. There are many cases of women who have never been sexually active with a man but who get STD's as well," she said.

High-risk behaviors were also noted more frequently in WSW as well as exclusive WSW. "In the Australian study WSW reported more high-risk behaviors, including drug use and sex with a bisexual or gay man, and this is very important," said Dr. Marrazzo. WSW also reported more male sexual partners compared to the control group, and they were significantly more likely to report more than 50 lifetime male sexual partners.* To attribute the high rates of STI's and risky behavior only to the WSW who were also sexually active with men would be simplifying this research. Both the entire WSW group and the exclusive WSW group were compared to the control group. There were some disturbing findings about exclusive WSW, said Dr. Marrazzo. The greatest number of BV cases were found among the exclusive WSW group (10 percent) and hepatitis B was also more common in exclusive WSW.

This is not the only study that points to high risks of STI's for WSW. "We have a study coming out probably in the next month in the International Journal of AIDS and Sexually Transmitted Diseases and the results are the same as the Australian study," she said. "Data for 20,000 women visiting the Seattle clinic were analyzed," she added.

It is a major problem that women don't know their risks and they don't get regular gynecological care. Dr.Marrazzo is still enrolling women in another large study that focuses on HPV and pap smear screening behaviors and results of WSW in Seattle. (If you live in Seattle, see the link for Lesbian STD for more information on how to register.) Findings will be based on a physical exam and questionnaire. Thus far, BV has been highly prevalent and concordant in lesbian couples. One of the disturbing findings is that women still are not reporting good pap screening, said Dr. Marrazzo. Why? "The number one reason women did not get pap exams was because they were not having sex with a man and their provider told them they didn't need pap exams," she said.

What Now? Further studies are needed, according to the researchers, to understand how STI's are transmitted between two women. This will make it possible for better healthcare services and targeted prevention and treatment education to be developed. "Very little is known about female-to-female sexual transmission of STI's and hepatitis C," said Dr. Fethers. "More research is needed to clarify our understanding of woman-to-woman sexual transmission of infections and to establish safe sex practices which may be used by lesbian and bisexual women to protect their health," she added. (See box on Safer Sex for WSW for more information.)

Physicians need to be informed about the risks. "GP's and sexual health physicians should consider all sexually active women at risk of sexually transmitted infections, regardless of the gender of the women's partner. In particular, lesbian and bisexual women should undergo regular pap smears because they are also at risk of abnormal or precancerous cervical cells." Dr. Fethers said. Physicians should also conduct a sexual history and gather information about the patients' past and present sexual life, added Dr. Marrazzo.

[For more information about this study, read the original article in Sexually Transmitted Infections and the accompanying editorial by Dr. Jeanne Marrazzo entitled 'Sexually Transmitted Infections in Women Who Have Sex With Women: Who Cares?' ]

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