How effective are the current sexual health promotion strategies in the United Kingdom for women who have sex with women?
There are many myths and misconceptions in relation to women who have sex with women (WSW): It is often assumed that WSW cannot contract sexually transmitted diseases, as women do not exchange bodily fluids. Lesbian sex is seen as safe sex, so risk of cervical cancer is small, similar to that of nuns. Lesbians do not have sex with men, therefore there is no need for caution as they cannot catch HIV from each other and sex between women does not really constitute sex. These are just some of the common fallacies associated with WSW.
These beliefs have contributed to considerable controversy as to whether or not lesbians are at risk of sexually transmitted diseases and questions arise around there being a need for sexual health promotion. These mistaken principles appear to have penetrated widely and thus may account for this group being one of the most neglected research areas in health care.
This essay will explore whatschemesif anyare in place for promoting sexual health of women who have sex with women (WSW) / lesbians.The terms lesbian and WSW are used interchangeably in research literature and may be reflected here also (Young & Meyer 2005, Barnes 2012). This essay will look at Sexually Transmitted Infections (STI) and cervical cancer amongst lesbians, exploring the myths and facts that may place this group at risk. The essay will briefly explore same-sex Intimate Partner Violence (IPV) and lesbian reproductive rights. It willexplore risk perception implications for lesbians, as well as what is available in terms of education and promotion of sexual health by the medical profession and within the UK government policies and strategies.
Sexual Health as defined by the World Health Organisation (2002) is a state of physical, emotional, mental and social well-being. In relation to sexuality: It is not merely the absence of disease dysfunction or infirmity, it also requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence.
The implementation of the Human Rights Act 1998 by the United Kingdom Government has enshrined many rights for people, one of these being the Right to Health. The Yogyakarta Principles 2006 also proposed a universal guide focusing on human rights, sexual orientation and gender identity (Fish & Bewley 2010). The right to health principle included; access to health information, participation, equity, equality and non-discrimination for all.
The WHO framework for action 2002 developing sexual health programmes for the promotion of sexual health, encourages Governments to guaranteethe respect, protection and fulfilment of its citizens’ rights to sexual and reproductive health. They proposed a multisectoral approach framework across 5 domains: Laws, policies and human rights to guarantee the promotion, protection and provision of sexual health information and services; Education, to empowercitizens to make healthy decisions about their sexual lives; Social & Cultural involves traditions and cultural values to be reflected upon and encourage change within communities; Economics, interventions can only be effective if a person’s economic need, vulnerability and health outcome are fully understood; Health systems require accessible, affordable and good quality sexual health services in order to achieve a sexually healthy society.
Lesbians along with gay, bisexual and transgendered (LGBT) populations have been subjected to discrimination, violence and other human rights violations over the centuries. However in the western world this is slowly being eradicated on the basis of changes in the laws ensuring legal protection and in people’s perceptions. But discrimination on the basis of sexual orientation and gender identity still exist for lesbian, bisexual women and transgendered women (Hammarberg 2011). However, in other areas of the world LGBT peopleare stigmatised and continue to face abhorrent abuse and discrimination in employment, health and Education. In 2012 Secretary General Ban Ki Moon delivered a speech in New Yorkcalling for the worldwide decriminalization of homosexuality and for other measures to tackle violence and discrimination against LGBT people. “As men and women of conscience, we reject discrimination in general, and in particular discrimination based on sexual orientation and gender identity. Where there is a tension between cultural attitudes and universal human rights, rights must carry the day,”
Bearing all this in mind, lesbians have been unfortunately overlooked over the years within healthcare and particularly since the HIV crisis, in which gay men’s health topped the sexual health agenda. Hughes & Evans (2003) found that lesbian women have been underserved within the health agenda. White & Dull (1998)also report that Gay & Lesbians report dissatisfaction with the health care they receive. This is further confirmed by the minimal data available to confirm lesbian needs and outcomes, thus potentially making them invisible as patients.
There is no hard data on the number of lesbian women in the UK. The Government suggest 5-7% of the population is gay (Stonewall 2013). The Office for National Statistics (ONS) says 480,000 (1%) consider themselves gay or lesbian, and 245,000 (0.5%) bisexual. In the integrated household survey (2011) 1.5% adults defined themselves as gay, lesbian or bi-sexual. These surveys purport lower numbers but evidence suggests some people are reluctant to divulge their sexual orientation for many reasons. There is no national data on STI among WSW (Bailey et al 2004). GUM clinics are now monitoring women’s sexual orientation in order to try to determine STI figures, but this is not available for public (Ripley V 2011).
Stonewall undertook a survey of lesbian and bisexual women which revealed that half of those women who had been screened had an STI and of those who had an STI, one in four had only had sex with women in the previous five years (NHS choices). This confirms and suggests Lesbians are not able to assume that because they do not sleep with men, that they are immune to STI’s. There is difficulty in collating information due to the elusive nature of the lesbian community with women hiding their sexual orientation for fear of discrimination, or reprisal, making random sampling difficult (Fishman & Anderson 2003). Most research studies report methodological limitations in conducting research,such as the concept of definition and with traditional sampling strategies (Fish & Bewley 2010). A number of studies have reported that getting a wide sample has been problematic, most studies have utilised various organisations in order to locate lesbian groups, but this has usually ended with middle class, white ethnic lesbians which is not a full representation of lesbian women (Aaron et al 2001).
Studies have supported more than 90% of women who identify as lesbian, report a sexual history with men (Singh et al 2011). Bailey et al (2004) alsoconfirmed sex with men is likely at some point in a lesbian’s life; this is referred to as women who have sex with women and men (WSWM).
The common belief that Lesbians are not susceptible to Sexually Transmitted Infections (STI) is made more possible due to limited research and visibility. However, a woman who has never had sex with men may still be at risk of acquiring a STI, such as gonorrhoea, herpes and HPV (Power et al 2009). Power et al (2009) pointout that women who identify as lesbian are likely to have had previous sexual relationship with men,likewise women who identify as bisexual have higher risk and prevalence of STI’s (Mercer et al 2007). Thereby confirming it is too easy to assume since there is limited research on lesbian sexual health, this results in limited risk of STI’s.
Lesbian women’s own perception in relation to STI’s suggest lesbian women do not believe they are at risk as it is viewed as safe sex due to limited transfer of body fluids. Some lesbian women believe that STI’s are transmitted via penetrative sex with a penis (Power et al 2009). WSW also based some of their perceived risk on their partner’s sexual history, a woman who has never slept with a man would be considered less likely to have an STI than women who has sex with men.
Marrazzo et al (2005) conclude many lesbians have reported Bacterial Vaginosis (STI) but lack sufficient knowledge on this condition. They found that WSW had higher prevalence of Bacterial Vaginosis than heterosexual women, probably caused by transmission of vaginal secretions through vaginal-vaginal sexual contact. This is the most commonly found infection in WSW (Bailey et al 2004). Other infections in women include gonorrhoea, chlamydia, herpes, genital warts, HPV and pelvic inflammatory disease (Reisner et al 2010). Sexual practices between women, such as digital-vaginal/anal contact, shared penetrative sex toys, do present plausible means of STD transmission (Marrazzo et al 2005. Hutchinson et al 2006).
Lesbians are informed and believe that cervical cancer is due to a virus that comes from having sex with men, not from sex between women. Power et al (2009) found that lesbians did not feel vulnerable to STI’s such as HPV as they believed that sex between women is inherently safe sex, due to the minimal transmission of body fluids. This also limits the likelihood of regular pap testing or considering the HPV vaccine (McNair et al 2009).Marrazzo (2004) states a significant amount of lesbian women have had prior heterosexual relationships thus their risk of cervical cancer due to HPV exposure may not be dissimilar to heterosexual women. Clark et al (2009) suggest Obese and underweight women less likely to have screening.Obese white women have cited embarrassment or discomfort as primary reason for not having screening. Women may delay preventative screening because of perceived negative attitude or judgmental behaviours from health professionals.These beliefs are exacerbated by the lack of availability of sexual health promotionmaterials specifically designed for lesbians (Dolan 2005). The invisibility of lesbian sex in mainstream sexual health promotion and the centrality of penetrative sex around sex and safer sex enforce these attitudes.
Zaritsky & Dibble (2010) discuss risks for reproductive cancer among lesbians, having more nulliparity, obesity, smoking and alcohol use; this suggests that lesbians might have a higher chance of developing these diseases in their lifetime. This confirms the need for the inclusion of sexual orientation in areas of cancer registration. In their study of breast cancer with lesbians and their sisters,they found endometrial cancer risk was higher among lesbians, because of more nulliparity and obesity. Waist hip ratio was higher for older lesbians; however cervical cancer might impact heterosexual women more.
Lesbian women are at risk of STI’s, breast and cervical cancer by their own and their partners risk behaviour, but also through their care seeking behaviours. Compared to heterosexual women, they are less likely to seek preventative care and screening.
Rosenstock’s (1966) health belief model breaks down the problems Lesbian women are facing in regards to their perceived sexual health risks. Perceived susceptibility – seen as low, although WSW do engage in high risk activities, are known to have sex with women whilst drunk or when using drugs,engage in sex toy sharing and practice penetrative sex, vaginal and anal (McNair 2005). Perceived severity – seen as low, as not life threatening, if it were, it would be publicised. Perceived barriers – Women that do perceive risks in their sexual acts, may not feel that they want to practice safe sex as the risks are negligible due to the above. Perceived benefits – without further information, education, promotion and evidence of potential risk, there are no benefits to be gained.
Lesbians’ reproductive needs, having children appears to be on the increase; however there are no accurate figures available. Lesbianism and motherhood are seen as inherently contradicted, thus making it easy for service providers to avoid acknowledging its existence. (Wilton & Kaufman 2001). The needs of lesbian mothers are the same as any. Spidsberg (2007) found pregnant women and living in a lesbian relationship increased visibility, thereby enhancing vulnerability in a heteronormative society (Lee 2004). Lesbians need to be welcomed and understood by the maternity services, if not the quality of care received will be compromised. HCP’s need to be careful with language use and encourage sexual diversity in their unit promotional material.
Same-sex intimate partner violence (IPV) is an issue that faces WSW, at least 41% and 68% of lesbian women experience same sex IPV (Burke et al 2002). It is important that lesbians affected by IPV are given space and support. ‘Lesbian Utopia’ is the idea that lesbian relationships are the ideal relationships (Girshik 2002). However it is important that service providers understand the severity of trauma experienced by victims, are educated to dispel the myths such as a woman cannot rape a woman and establish themselves as inclusive organisations. It is important that this group is supported through the promotion ofthe sexual health agenda in the UK (Duke & Davidson 2009).
The government is trying to reduce the anomalies in the provision of sexual health care for all, irrespective of gender, although the lesbian community remains somewhat under represented. A number of government documents fail to recognise WSW in the prevention of STI’s (Ripley 2011). The national Strategy for Sexual Health and HIV 2001 does not refer to this group. The Equality Impact Assessment for National Sexual Health Policy 2010 aims to reduce inequalities that exist in UK for lesbians and other groups.The government introduced Healthy Lives, Healthy people 2010, for reasons such as;UK most obese nation in Europe, most STI’s, the impact of socioeconomic disadvantage on health, recognised inequalities based on sexual orientation and gender.It introduced local government and local health organisations to promote integrated services,ensuring easy access and non-judgemental sexual health services. April 2013 NHS Commissioning Board now responsible for commissioning services under the GP contract and Local Authorities to be overseen by Public Health England.
The Framework for sexual health in England 2013 is the creation of health & wellbeing boards to develop joint strategic services for the local communities, sexual health has a clear role to play in improving health and reducing health inequalities.
NHS Information Strategy follows on from the Health & Social Care Act 2012, which is how information will be used by all public health and care providers across England. This is to improve access to healthcare information. This will ensure clear records are maintained; information will only need to be given once, which will hopefully help to deliver better care.It is hoped that health care professionals (HCP) will be aware of what health issues to discuss with you, based on this system. Sexual orientation will be monitored, this should safeguard numbers are compiled to monitor and to ensure that providers understand the specific and complex healthcare needs of LGB people (LGF Policy briefing 2012).
Pride in Practice is a tool that identifies GP surgeries that are committed to assuring LGBT are treated fairly and able to discuss their issues openly with the GP or healthcare provider. This is to help surgeries meet their obligations under the equalities legalisation.
The Department of Health has tried to promote services for women and are attempting to reduce inequalities in health care for lesbians.Reducing health inequalities for lesbian sexual healthneeds are not currently being met and a thorough national needs assessment needs to be done.
The NHS has produced a leaflet cervical screening – the facts, however do not mention the word “lesbian” but does encourage all women irrespective of sex with men to at least seek advice. The NHS HPV testing information specifically mentions same sex risk of transmission. Sexual orientation is now being questioned as part of routine history taking in order to promote equality and monitor diversity within the population, (Fish 2007). Fish (2007) describes a concept of heteronormativity, the presumption of heterosexuality by healthcare practitioners. This environment means Lesbian women are obliged to decide whether to disclose their sexuality or not. Having disclosed one’s sexuality may bring health benefits, but it can also bring negative consequences, such as silence, embarrassment, inadequate advice and information due to lack of knowledge. GP’s have expressed concerns, that discussing sexual issues may be seen as confronting or offensive and can be compounded by GP’s lack of specific knowledge and skills in dealing with lesbian women (McNair 2009).It is important that full sexual history is taken in order to support HCP’s ability to consider fully the needs of lesbian women such as contraceptives (Mercer et al 2007).
Lesbians feel HCP lack knowledge about STI’s and STI reduction for them (Marrazzo et al 2005). It is important that provider knowledge and sensitivity is increased. If lesbians find their HCP to be sensitive and knowledgeable of lesbian issues and needs, lesbian women may be more re-active to comply with treatment recommendations. However it is difficult for HCP to discuss issues and matters that they are unfamiliar with. Education of same sex healthcare issues are being added to training modules for HCP’s, however attitude cannot be taught. The Royal College of Nursing (RCN) has written a guide on how to nurse lesbian, gay male patients or clients promoting non marginalisation, as a means of combatting prejudice.
Lesbians have to takesexual health issues seriously, it is imperative that lesbian women are equipped with the tools and the knowledge in order to receive the healthcare and support they need. Research clearly states that Lesbians are receiving less preventative care such as mammography screening, pap screening or STI tests than their heterosexual counterparts (Aaron et al 2001). A number of sexual health clinics have been established in the UK targeting women with an emphasis of meeting the needs of Lesbians / WSW / WSWM.
There are several recommendations for the sexual health care of lesbians: Providing inclusive questionnaires that are gender neutral (Roberts 2006). Being lesbian sensitive and welcoming, in promotional material, such as rainbow flag. Sexual health material primarily aimed at lesbian women has slowly been on the increase; however most of this literature is found on internet sites, such as girl2girl a new website for sexual health information (Ripley 2011). Many lesbian women report reverting to the internet as a means of finding out information relating to their sexual health (Fishman & Anderson 2003).There is limited public information on methods of safer sex. Acquiring safer sex aids is difficult to find, it is perceived that a latex dental dam would reduce sexual transmission of infection (Bailey et al 2004) however, a dental dam cannot be purchased from an average pharmacy like a condom.
This essay confirms WSW / lesbians are at risk of sexually transmitted infections and Reproductive Cancers. WSW / lesbians do not receive all aspects of sexual health protection given to heterosexual women. Therefore it would be prudent to say these women need improved sexual health promotion, prevention and safeguarding. Most literature on sexual health promotion and preventative information has been geared towards other population groups; gay men being one of these key focus groups, especially since the HIV/AIDS crisis. However Lesbian and Bisexual women’s sexual health appears to be less recognised and researched (Formby 2011). Data is limited in connection with transmission of sexually transmitted infection between women in the UK (Bailey et al 2004), and data in areas affecting lesbians / WSW.The uptake of sexual health services for WSW may be low due to belief of minimal risk. HCP may not have correct knowledge and information on the risk potential. Information is not readily available and there is lack of government documentation available for this group. There is much more to be done to reduce the health inequalities that exist for this group.
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