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Young Women Who Have Sex with Women: Falling through Cracks for Sexual Health Care

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Health educators often assume that young women who have sex with women (YWSW)* are at little or no risk for HIV, other sexually transmitted infections (STIs), and unintended pregnancy when, in fact, risk behaviors and barriers to health care put YWSW at risk for all three. Health care professionals and researchers often tell YWSW that they are "safe." Moreover, the sexual health needs of young women of color who have sex with women go mostly unrecognized. YWSW need information and programs that specifically address their complex needs and that encourage them to protect themselves.

YWSW Are at Risk for HIV, Other STI, and Pregnancy.

Some women who have sex with women (WSW) are uncomfortable with routine gynecological care, including PAP smears and STI screening.¹ Yet, they are at risk for STIs. In a nationwide study of 6,935 self-identified lesbians, 17.2 percent reported a history of STI.² In another survey of lesbian and bisexual women, 26 percent reported a past STI.³ Human papillomavirus occurred among 30 percent of surveyed WSW, including 19 percent of women who had sex only with other women.⁴ Infection with genital herpes, chlamydia, gonorrhea, and syphilis, while not much studied in WSW, may be likely, depending on the women's sexual practices.⁵ Safer sex information seldom covers protective methods for oral or manual sex, encouraging the myth that YWSW are not at risk for STI. Only the lesbian community receives such health promotion information; and many YWSW, especially young women of color, may not identify with the lesbian community.

"Underreporting of HIV among lesbians seems likely given that many women are reluctant to acknowledge their sexual orientation to their doctor."⁵ The Centers for Disease Control (CDC) does not gather data on the exposure category of female-to-female HIV transmission and, therefore, lacks YWSW epidemiological data. Through December 1998, 109,311 AIDS cases occurred among U.S. women.⁶ Information on female-to-female exposure was missing in half of these cases. At the same time, 98 percent of the 347 women who reported having sex only with other women also reported other risk behaviors, such as injection drug use.⁶

Many YWSW also have sexual intercourse with men, including men who have sex with other men. Unprotected intercourse with men may place YWSW and their female partners at risk for HIV. In a survey of 6,935 self-identified lesbians, 77.3 percent reported sex with one or more male in their lifetime, including vaginal (70.5 percent) and anal (17.2 percent) intercourse.² In a study in New York City, 32 percent of lesbian and bisexual young women reported sex with at least one gay or bisexual man; 51 percent reported having sex with at least one high risk partner.⁷ 

Sexual intercourse with young men also puts YWSW at risk of unintended pregnancy. One study showed that, while bisexual and lesbian teenage females were about as likely as heterosexual peers to have had intercourse, they reported twice the rate of pregnancy (12 percent) as heterosexual and questioning young women (five to six percent). A higher percentage of lesbian and bisexual young women also reported sexual intercourse daily or several times each week and no use of contraception compared to their heterosexual and questioning counterparts.⁸

Health Care Providers and Researchers Overlook YWSW, Despite Risk Factors.

Studies show that adult lesbians, fearing discriminatory and negative responses from health care providers, seek out health care services less often than heterosexual women. When they seek out health care, they may volunteer incomplete or inaccurate information about themselves.⁵ One qualitative study of eight lesbian youth in San Francisco suggested they share many of the fears of adult lesbians and experience ignorance, insensitivity, and heterosexism from health care providers. Some face bias because their gender and gender presentation are incongruent. For YWSW, these problems are compounded by discrimination based on their youth.⁹ 

Moreover, research indicates that health care providers take incomplete sexual histories, assuming (often inaccurately) that YWSW who identify as lesbian have not had sex with men or participated in sexual risk behaviors.⁵ Providers may inaccurately assume that YWSW are "too young" to identify as lesbian or to participate in risk behaviors.⁹ These assumptions cause providers to overlook or ignore the realities of life for YWSW.

Health care providers and researchers often overlook YWSW altogether. For example, the CDC's lack of a formal category for female-to-female transmission of HIV ensures that this potential mode of transmission will remain unevaluated. Little research is conducted around YWSW, and there is a lack of prevention messages targeted towards these youth. Lesbian health research usually addresses the needs of adult women. Research on GLBTQ (gay, lesbian, bisexual, transgender, and questioning) youth usually focuses on gay youth or young men who have sex with men.⁹ Finally, researchers have almost totally ignored the needs of young women of color who have sex with women.

This lack of concern and attention carries inaccurate messages to YWSW. Even though 26 percent of lesbians in a recent survey had an STI at some point in their lifetime, 84 percent of respondents believed that, during the previous year, they were at zero risk for HIV and STI. Only 21 percent had ever suggested safer sex practices to a sexual partner.³ YWSW need accurate, age-appropriate, and culturally sensitive information about sexuality and sexual health.

YWSW Face Complex Mental, Physical and Sexual Health Care Issues.

Providing accurate information about HIV, STI, and pregnancy prevention is only part of the picture for ensuring sexual health among YWSW. Effective programs must address the many factors that contribute to sexual risk behaviors among YWSW.

• Access to Health Insurance—Some YWSW lack health insurance or easy access to publicly subsidized services. For example, lesbians with long term-partners are often ineligible for coverage under a partner's policy,¹⁰ and many YWSW have jobs that offer limited or no health insurance. Demand can be high and lines long at subsidized clinics that serve homeless youth, women, and GLBTQ youth, rendering these clinics less accessible to clients, including YWSW.
• Cultural and Family Attitudes—Many YWSW receive little support at home or in their communities due to cultural and familial attitudes that being GLBTQ is unhealthy or unacceptable.^5,11 Almost three-fourths of respondents in the National Lesbian Health Care Survey (n=1925, including 200 youth) had received counseling; half cited sadness and depression as the reason for seeking therapy.¹² Many GLBTQ youth are kicked out of home because of their sexual orientation. Estimates of GLBTQ youth's homelessness vary, but service providers agree that rates are high and that sexual orientation is the reason for homelessness among 20 to 40 percent of all homeless youth.¹¹ 
• Racism and Homophobia Combined—Youth of color face additional challenges. As within society as a whole, homophobia is common within communities of color.⁹ Young women of color who have sex with women face challenges of sexism, racism, and homophobia from society as a whole, the white lesbian community, and their individual communities of origin. In addition, HIV infection is rising sharply among young women of color; half of new HIV cases occur among people ages 15 to 24; and three-quarters of cumulative AIDS cases among youth are occurring among African American and Latina women.¹³ 
• Assault and Abuse—A history of physical and/or sexual abuse by family members and assault by fellow students, strangers, and acquaintances are frequently reported in studies of young lesbian and bisexual women.⁹ In one survey, 19 percent of bisexual or lesbian respondents reported a history of physical abuse compared to 11 to 12 percent of heterosexual or questioning adolescents. In another study, lesbian and bisexual young women were significantly more likely to report having been sexually abused than were heterosexual or questioning women—22 percent versus 13 to 15 percent, respectively.⁸ 
• Substance Abuse—Substance use is a risk behavior that research has frequently found to cluster with other risk behaviors, including unprotected sexual intercourse.¹⁴ Research also suggests that GLBTQ youth are twice as likely to use alcohol, three times more likely to use marijuana, and eight times more likely to use cocaine/crack compared to heterosexual youth.¹⁵ In one survey, one-third of lesbians reported smoking daily and thirty percent, drinking alcohol more than once a week.¹² 
• Commercial or Survival Sex—One study indicated that lesbian and bisexual teenage women were five times more likely to have exchanged sex for money, food, or other necessities than were their heterosexual or questioning peers (10 percent versus two percent, respectively).⁸ 

Sexual Health Programs Should Target the Health Needs of YWSW.

YWSW need comprehensive health care services and sexual health messages that address their specific needs. One study found that young lesbian and bisexual women are more likely to use health care clinics for routine health and wellness checkups if the clinics are culturally sensitive to young women's needs.⁹ Services and sexual health programs that adequately address the needs of YWSW include the following components:

• Accurate and reliable resources and materials—Brochures regarding the sexual health of YWSW are available to all youth served by the program. Programs offer information about YWSW and are developed specifically for YWSW.
• Culturally competent staff and volunteers—Programs familiarize staff and volunteers with the needs of YWSW and train them to be nonjudgmental, use inclusive language (such as "sexual partner" and "same-gender sexual behavior"), and make no assumptions about youth's behavior.
• Programming developed and led by youth—Programs empower young people to train and develop support groups for other young people, allowing the programs to focus on the needs identified by young women rather than on needs perceived by adults. Peer-led programming limits young women's isolation and encourages them to build leadership skills and provide other YWSW with support.
• Opportunities to build skills—Effective programs promote and encourage skills, such as developing healthy relationships, negotiating safer sex with partners, using condoms and dental dams, communicating with steady and casual partners, and saying "no" to unwanted sex.
• Programs specific to young women of color who have sex with women—Programs support the young women as they deal with decisions and issues regarding sexuality, identity, gender identity, culture, race/ethnicity, and racism.
• Programs for specific populations of YWSW—Programs reach out to homeless youth, including sex workers, first addressing their needs for food, clothing and shelter, and then focusing on health considerations. Versed in issues of gender identity, programs provide support for transgender youth.

Recommendations to Improve the Health of YWSW

More research is needed to discern the sexual health needs of young women—particularly young women of color—who have sex with women. Much completed research has never been published. For example, Boston's Fenway Community Health Center studied the needs of lesbians of color. This and other studies should be published in professional, peer-reviewed journals. Finally, the CDC needs to assess accurately and systematically the risk for HIV infection facing YWSW. The health of YWSW can improve dramatically with support from medical, public health, and education professionals.

* In this paper, YWSW refers to sexual behavior. The terms lesbian and bisexual are used here with reference to studies of women who self-identify in this way.

References

1. Marrazzo JM et al. Papanicolaou test screening and prevalence of genital human papillomavirus infection in women who have sex with women. Am J Public Health 2001; 91:947-52.
2. Diamant AL et al. Lesbians' sexual history with men: implications for taking a sexual history. Archives of Internal Medicine 1999; 159:2730-2736.
3. Morrow KM, Allsworth JE. Sexual risk in lesbian and bisexual women. J Gay & Lesbian Medical Association 2000; 4:149-165.
4. Marrazzo JM et al. Genital human papillomavirus infection in women who have sex with women. J Infectious Diseases 1998; 178:1604-1609.
5. Richardson D. The social construction of immunity: HIV risk perception and prevention among lesbians and bisexual women. Culture, Health & Sexuality 2000; 2(1):33-49.
6. Centers for Disease Control & Prevention. HIV/AIDS & U.S. Women Who Have Sex with Women (WSW). Atlanta, GA: The Centers, 2001. [http://www.cdc.gov/hiv/pubs/facts/wsw.htm]
7. Rosaria M et al. Sexual risk behaviors of gay, lesbian, and bisexual youths in New York City: prevalence and correlates. AIDS Education & Prevention 1999; 11:476-496.
8. Saewyc EM et al. Sexual intercourse, abuse and pregnancy among adolescent women: does sexual orientation make a difference? Fam Plann Perspect 1999; 31:127-131.
9. Scherzer T. Negotiating health care: the experiences of young lesbian and bisexual women. Culture, Health & Sexuality 2000; 2(1):87-102.
10. Denenberg R. Report on lesbian health. Women's Health Issues 1995; 5(2):81-91.
11. Ryan C, Futterman D. Lesbian and Gay Youth: Care and Counseling. [Adolescent Medicine State of the Art Reviews; v. 8, no. 2]. Philadelphia: Hanley & Belfus, 1997.
12. Bradford J et al. National lesbian health care survey: implications for mental health care. J Consult Clin Psychol 1994; 62:228-242.
13. Centers for Disease Control & Prevention. HIV/AIDS among US women: minority and young women at continuing risk. Atlanta, GA: The Centers, 2001. [http://www.cdc.gov/hiv/pubs/facts/women.htm]
14. Alford S. Substance Use among Youth. [The Facts] Washington, DC: Advocates for Youth, 1996.
15. Telljohann SK et al. Teaching about sexual orientation by secondary health teachers. J Sch Health 1995; 65:18-22.

Written by Jessie Gilliam; reviewed by Urooj Arshad, Asha Leong, Jeanne Mazzarro, and Caitlin Ryan.
October 2001 © Advocates for Youth

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