Abstract

Objective:

To know the characteristics of the studies that have paid attention to women who have sex with women (WSW) and to identify possible gaps in the interest of comprehensive sexual health in WSW.

Method:

A scoping review on sexual health on WSW was conducted from 2000 to 2019. Papers with lack of focus on sexual health on WSW were excluded and a web tool was used to guarantee blindness. Information was extracted on the key characteristics of the studies and the quality of the evidence. The sexual health categories were comprehensive sexual health, specification of sexual practices in WSW, and recommendations provided.

Results:

39 studies were included, mostly cross-sectional. The gaps identified were the lack of evidence on sexual health, confusion about sexual orientation and sexual practices, lack of specific interest in comprehensive sexual health and the life cycle approach. Recommendations focused on WSW self-care; interventions aimed at clinical practice, research, education and prevention; and contributions of a feminist approach on sexual health of WSW.

Conclusions:

There are several gaps about in the knowledge about sexual health among WSW. Self-care improvement and specific strategies addressed to the unique characteristics of these women and their different and specific situation and health determinants are highlighted.

Keywords:
Sexual health; Women who have sex with women; Feminist approaches; Sexually transmitted infections

Resumen

Objetivo:

Conocer las características de los estudios centrados na mujeres que tienen sexo na mujeres (MSM) e identificar posibles lagunas na el interés sobre la salud sexual integral de las MSM.

Método:

Revisión sistemática exploratoria sobre salud sexual na MSM entre los años 2000 y 2019. Se excluyeron los estudios no centrados na salud sexual de MSM y se utilizó na herramienta web para asegurar el enmascaramiento. Se extrajo información sobre las características de los estudios y la calidad de la evidencia. Las categorías de análisis fueron: salud sexual integral, especificidad de prácticas sexuales na MSM y recomendaciones aportadas.

Resultados:

Se incluyeron 39 estudios, la mayoría transversales. Las lagunas identificadas fueron la falta de evidencia na salud sexual, la confusión entre orientación sexual y prácticas sexuales, la falta de interés específico na salud sexual integral y el enfoque de ciclo vital. Las recomendaciones se centraron na autocuidados de las MSM; intervenciones enfocadas a la práctica clínica, investigación, educación y prevención; y contribuciones desde na enfoque feminista sobre la salud sexual de las MSM.

Conclusiones:

Existen varias lagunas de conocimiento na la salud sexual de las MSM. Se destaca la necesidad de intervenir na la mejora del autocuidado y también de incluir estrategias específicas dirigidas a las características de estas mujeres, de acuerdo na sus realidades.

Palabras clave:
Salud sexual; Mujeres que tienen sexo na mujeres; Enfoques feministas; Infecciones de transmisión sexual

Introduction

Several studies have identified some diseases, such as sexually transmitted infections (STI), to be more prevalent among women who have sex with women (WSW), including heterosexual women.¹1. Blondeel K, Say L, Chou D, et al. Evidence and knowledge gaps on the disease burden in sexual and gender minorities: a review of systematic reviews. Int J Equity Health. 2016;15:1-9. Little is known regarding the sexual health of WSW.²2. Tat SA, Marrazzo JM, Graham SM. Women who have sex with women living in low- and middle-income countries: a systematic review of sexual health and risk behaviors. LGBT Health. 2015;2:91-104. Indeed, several researches have highlighted the lack of studies investigating STIs in WSW suggesting that there are other factors apart from the biological determinants that should be considered, such as the difficulties in accessing to diagnosis and treatment in WSW.³3. Massad LS, Xie X, Minkoff H, et al. Abnormal pap tests and human papillomavirus infections among HIV-infected and uninfected women who have sex with women. J Low Genit Tract Dis. 2014;18:50-6.

Studies that have been carried out in specific countries such as Brazil⁴4. Pinto VM, Tancredi MV, Neto AT, et al. Sexually transmitted disease/HIV risk behaviour among women who have sex with women. Aids. 2005;19:64-9. or Poland⁵5. Kowalczyk R, Nowosielski K. Impact of social factors and sexual behaviors on the knowledge of sexually transmitted infections among women who have sex with women/women who have sex with women and men. Int J STD AIDS. 2019;30:163-72. also have emphasized other barriers such as the lower visibility of health situations concerning WSW and the lack of opportunities to carry out this research in specific areas. For example, the risk of infection the human immunodeficiency virus (HIV) is still unknown in WSW, particularly in those more socioeconomically disadvantaged,⁶6. Arend ED. The politics of invisibility: HIV-positive women who have sex with women and their struggle for support. J Assoc Nurses AIDS Care. 2003;14:37-47. as this disease has been globally studied more in men who have sex with men (MSM) than in WSW.⁷7. Zaidi SS, Ocholla AM, Otieno RA, et al. Women who have sex with women in Kenya and their sexual and reproductive health. LGBT Health. 2016;3:139-45. The spread of some of these diseases is the result of lifestyles and stigmatization due to sexual orientation⁸8. Gil-Borrelli CC, Velasco C, Iniesta C, et al. Towards a public health system with pride: equity in health in the lesbian, gay, bisexual and trans community in Spain. Gac Sanit. 2017;31:175-7.. Furthermore, there are studies that suggest WSW receive less medical attention than the rest of the population.⁹9. Clift JB, Kirby J. Health care access and perceptions of provider care among individuals in same-sex couples: findings from the Medical Expenditure Panel Survey (MEPS). J Homosex. 2012;59:839-50.

Other studies have showed that health providers assume that lesbian identity prevents sexual activity with men or that transmission of STIs among women is unlikely.¹⁰10. Elliott MN, Kanouse DE, Burkhart Q, et al. Sexual minorities in England have poorer health and worse health care experiences: a national survey. J Gen Intern Med. 2015;30:9-16. Little literature exists on safe sex messages aimed at promoting healthy sexuality among lesbian women, which in turn leads to na absence of studies that analyze sexual behaviors within this group.¹¹11. Marrazzo JM, Coffey P, Bingham A. Sexual practices, risk perception and knowledge of sexually transmitted disease risk among lesbian and bisexual women. Perspect Sex Reprod Health. 2005;37:6-12. This is the reason why precise risk associated with certain sexual practices cannot be defined and therefore, be able to design prevention campaigns.

International Organizations such as the United Nations as well as different studies, have highlighted the need to investigate about WSW and sexual and reproductive health,¹²12. Larson EL. United Nations Fourth World Conference on Women: Action for Equality, Development, and Peace (Beijing, China: September 1995). Emory Int'l L Rev. 1996;10:695. and have claimed the right of WSW to be treated equally and with non-discrimination.¹³13. Cabral Grinspan M, Carpenter M, Ehrt J. The Yogyakarta Principles plus 10. J. Geneva. 2017;27.

In this context of disparities in the sexual health of WSW that can potentially worsen their health and well-being, it is worth to investigate what studies have focused on STIs and sexual health of WSW and what are their characteristics. The research question intends to be answered by knowing the characteristics of the studies that have paid attention to WSW and by identifying possible gaps in the interest of comprehensive sexual health in WSW. Since MSM is a topic that has been further investigated compared to WSW, the present investigation aimed to focus on WSW.

Method

A scoping review is carried out, following the recommendations for this type of studies¹⁴14. Levac D, Colquhoun H, O'Brien KK. Scoping studies: advancing the methodology. Implement. Sci. 2010;5. and adapting to the recommendations of PRISMA¹⁵15. Shamseer L, Moher D, Clarke M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-p) 2015 elaboration and explanation. BMJ. 2015;349:1-25. guide.

Search strategy

The search included the empirical literature published from 2000 to 2019 in five electronic databases: PubMed, Scielo, LILACS, Embase and CINAHL. These databases were chosen with the help of na informant from the Health Science library to provide the most comprehensive coverage of relevant studies conducted in this area.

The present scoping review followed the systematic review methodology proposed in the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement.

The search terms were combined into two categories: the population of interest (WSW, lesbians, bisexual women, WSW or WSW/M) and the topic of interest (sexual health). The search terms for WSW and WSW/M included various phrases used to describe this population in health science research (for example lesbian, bisexual women, WSW or WSW/M). Search terms for health issues included STD, STD risks factors, sexual health, sexual habits, prevention, barriers and risk behaviours.

The search terms within each category were combined using the Boolean operator “or”. Then, the search results in all two categories were combined using the boolean operator “and”. Search syntax included: ((”lesbian“OR”bisexual women“OR”WSW“OR”WSW/M“) AND (”STD“OR”STD risk factors“OR”sexual health“OR”sexual habits“OR”prevention“OR”barriers“OR”risk behaviours”)).

Na ancestry and descent search of the retrieved studies was performed to identify additional articles.

Inclusion criteria were studies about sexual health of WSW published in peer reviewed journals in English, Spanish, French and Portuguese. The following types of publications were included: original articles, reviews, clinical trials, books, documents, consensus conference, editorials, comparative studies, electronic supplements, guidelines, meta-analysis, government documents, multicenter studies. We excluded articles with health professional's opinions on sexual minorities, prevalence estimations of sexual minority populations, studies with migrants or refugees, conference abstracts, case studies, and reports in the gray literature.

A total of 3569 articles were obtained. After this first phase, duplicates and those articles the title and/or abstract of which included the terms health (and non-sexual health), treatment or diagnosis were eliminated, as well as those in which the keywords used for the search did not appear. After applying these criteria, a total of 115 articles were obtained. All titles and abstracts were reviewed after completing the ancestry and descent search. Then, four researchers reviewed the full text of each article in pairs. The data was summarized if the article met the inclusion criteria, yielding a result of 49 selected works.

The review was carried out by the Rayyan QCRI¹⁶16. Ouzzani M, Hammady H, Fedorowicz Z, et al. Rayyan - a web and mobile app for systematic reviews. Syst Rev. 2016;5:1-10. web tool, which allowed for a blind review throughout the process. Any disagreement between these two authors was discussed with a third author until consensus was reached. Thus, 20 conflicting documents appeared, on which a third review was applied by na additional researcher, from which na were excluded (Fig. 1).

The selection of the results of each article was examined by the researchers, so that each one read and reviewed the results and the positions found were discussed, thus allowing na analysis of the results in pairs.

Data analysis

Data extraction matrices were created to summarize the key characteristics of the studies, including country, study populations, and sample characteristics, year, study design, STIs studied and quality of evidence according to the type of study. The quality of the scientific evidence of the selected articles was classified according to the Scottish Intercollegiate Guidelines Network (SIGN)¹⁷17. Scottish Intercollegiate Guidelines Network. Sign Grading System 1999-2012. Edimburgo: SIGN 2; 2012. Available: https://www.sign.ac.uk/assets/sign_grading_system_1999_2012.pdf.
https://www.sign.ac.uk/assets/sign_gradi... criteria.

Regarding comprehensive sexual health, the categories of extraction were created: areas of interest in sexual health, specification of sexual practices in WSW and recommendations of the studies from a comprehensive sexual health point of view.

Additionally, statements were identified that showed a feminist approach focused on sexual health in WSW within the studies, when applicable. Gender was considered as a health determinant that increases the knowledge of women's health, or that indicates changes in gender structures impacting on women's health equality¹⁸18. Ariño MD, Tomás C, Eguiluz M, et al. ¿Se puede evaluar la perspectiva de género en los proyectos de investigación? Gac Sanit. 2011;25:146-50..

Results

Out of 3569 publications identified, a total of 39 were finally selected. The methodology used was mainly cross-sectional (64.1%). Four cohort studies were applied and one of them was multicentric.³3. Massad LS, Xie X, Minkoff H, et al. Abnormal pap tests and human papillomavirus infections among HIV-infected and uninfected women who have sex with women. J Low Genit Tract Dis. 2014;18:50-6. Qualitative methodology included interviews (7.7%) and focus groups (10.25%). Two systematic reviews were also retrieved.²2. Tat SA, Marrazzo JM, Graham SM. Women who have sex with women living in low- and middle-income countries: a systematic review of sexual health and risk behaviors. LGBT Health. 2015;2:91-104.^,1919. Forcey DS, Vodstrcil LA, Hocking JS, et al. Factors associated with bacterial vaginosis among women who have sex with women: a systematic review. PLoS One. 2015;10:1-16. Table 1 shows the characteristics of the studies and the evidence level according to the SIGN classification. Populations sampled in the studies varied from 16 to 5714 people. Nine studies focused on comparing WSW and WSWM. In addition, seven studies were addressed specifically to African American WSW and two specifically identified only lesbians in their study population,²⁰20. Fish J, et al. UK National Lesbians and Health Care Survey. Women Health. 2005;41:27-45.^,2121. Fishman SJ, Anderson EH. Perception of HIV and safer sexual behaviors among lesbians. J Assoc Nurses AIDS Care. 2003;14:48-55. 23 studies (59%) were focused on specific STIs and 17 (43.6%) were interested in other aims or included STIs in general, as added information.

Regarding STIs specifically in WSW, eight studies were interested on Bacterial Vaginosis, with proportions varying from 14,4% to 43%. They were cross-sectional or qualitative studies, so that evidence less than 3 was not achieved. Forcey's¹⁹19. Forcey DS, Vodstrcil LA, Hocking JS, et al. Factors associated with bacterial vaginosis among women who have sex with women: a systematic review. PLoS One. 2015;10:1-16. systematical review found a previous prevalence between 5.9% and 56.2% and other found a proportion of 43% in lesbian women. Other authors focused their work on specific diseases such candidiasis, Chlamydia, human papilloma virus or herpes simplex virus, among others. Nine studies were focused on HIV, finding frequencies from 0% to 42% of HIV in WSW and two of these researches were addressed to HIV positive people.

Some studies provided claims related to a comprehensive sexual health vision of WSW.

A total of 25 general contributions were extracted from the different studies in which any of these statements were observed (64.1%), pointing at certain factors that could determine the sexual health of the WSW from a holistic point of view such as the type of partner,²²22. Muzny CA, Kapil R, Austin EL, et al. Lower sexually transmissible infection prevalence among lifetime exclusive women who have sex with women compared with women who have sex with women and men. Sex Health. 2014;11:592-3. generally referring to male partners.

Thirteen (33.3%) studies specified or exemplified types of sexual practices according to the objectives of their study. As can be seen in Table 2, in these research participants were asked about sexual practices that included external genital contact, but in most cases the interest was focused on asking about the type of penetration in the intercourse, which shows no specific interest in real sex practices of WSW.

Discussion

The present scoping review aimed to assess the research gaps in the WSW considering the life cycle, prevention, recommendations for health teams and feminist approaches.

The included studies approached from multiple disciplines, providing future fields of research covering the entire life cycle, diverse sexual practices, and socially focused interventions in public health prevention from health teams. It is noteworthy that in studies focused on other populations such as MSM, in sexual health, the type of partners referred to are usually stable couples, friends, colleagues, which is not the case for women.²³23. Goodreau SM, Anthony D. What drives the US and Peruvian HIV epidemics in men who have sex with men (MSM)? PLoS One. 2012;7:e50522. It would be worth considering whether the former perpetuates the heteronormative model of health care for this group of women, hence placing them on a level of inequality within the rest of the population.²⁴24. Silberman P, Buedo PE, Burgos LM. Barreras en la atención de la salud sexual en Argentina: percepción de las mujeres que tienen sexo con mujeres. Rev Salud Publica. 2016;18:1-12. The studies that referred to comprehensive sexual health were focused on the perception of risk in safer sex behaviours.²⁴24. Silberman P, Buedo PE, Burgos LM. Barreras en la atención de la salud sexual en Argentina: percepción de las mujeres que tienen sexo con mujeres. Rev Salud Publica. 2016;18:1-12. Interests was found in structural factors (inter-personal, intra-personal and psychosocial), which sheds more light on possible factors that can determine comprehensive sexual health²⁵25. Logie CH, Navia D, Loutfy MR. Correlates of a lifetime history of sexually transmitted infections among women who have sex with women in Toronto. Canada: results from a cross-sectional internet-based survey. Sex Transm Infect. 2015;91:278-83. and health inequalities.²⁶26. Singh D, Fine DN, Marrazzo JM. Chlamydia trachomatis infection among women reporting sexual activity with women screened in family planning clinics in the Pacific Northwest, 1997 to 2005. Am J Public Health. 2011;101:1284-90.

Surprisingly, only slightly over half of the selected studies contribute ideas of sexual health from na integral point of view and that it tends more to approach it from a negative point of view (deficit, pathology). Indeed, when the analysis of information related to psychosocial aspects is incorporated these are considered risk factors for the appearance of diseases.²⁷27. Reisner SL, Mimiaga MJ, Case P, et al. Sexually transmitted disease (STD) diagnoses mental health disparities among women who have sex with women screened at an Urban Community Health Center Boston M.A, 2007. Sex Transm Dis. 2010;37:5-12.

On the other hand, no studies focused on older WSW have been found, being the limit age 55 years old. This restriction can lead to the invisibility of health problems in these women, risks and limitation of access to social and health services.

When analyzing the populations that are part of the studies, it was observed that there is no impact on sexual health in childhood and adolescence either, which leads to ignore at what age WSW understand the risk of STIs or why they choose not to use barriers when they have sexual relations.²⁸28. Doull M, Wolowic J, Saewyc E. Why girls choose not to use barriers to prevent sexually transmitted infection during female-to-female sex. J Adolesc Health. 2018;62:411-6.^,2929. Muzny CA, Harbison HS, Pembleton ES, et al. Misperceptions regarding protective barrier method use for safer sex among African-American women who have sex with women. Sex Health. 2013;10:138-41.

The constant equation of sexual orientation with sexual practices is also observed, concepts that are very rarely differentiated.³⁰30. Logie CH, Navia D, Loutfy MR. Correlates of a lifetime history of sexually transmitted infections among women who have sex with women in Toronto. Canada: results from a cross-sectional internet-based survey. Sex Transm Infect. 2015;91:278-83. This fact supposes na error already described in the health literature which leads to problems in the way in which the results of the epidemiological studies are provided, but also in prevention and health promotion interventions and that is reflected in healthcare practice.³¹31. Dahan R, Feldman R, Hermoni D. The importance of sexual orientation in the medical consultation. Harefuah. 2007;146:626-30. In this sense, Muzny et al.²⁹29. Muzny CA, Harbison HS, Pembleton ES, et al. Misperceptions regarding protective barrier method use for safer sex among African-American women who have sex with women. Sex Health. 2013;10:138-41. underline the need for a greater research on the effectiveness of recommendations about the use of barrier methods for STIs transmission reduction in WSW.

Other recommendations aimed at health providers, research and prevention, include taking into account female partners,¹⁹19. Forcey DS, Vodstrcil LA, Hocking JS, et al. Factors associated with bacterial vaginosis among women who have sex with women: a systematic review. PLoS One. 2015;10:1-16. the need for a change in care approaches,³²32. Rufino A, Madeiro A, Trinidad A, et al. Disclosure of sexual orientation among women who have sex with women during gynecological care: a qualitative study in Brazil. J Sex Med. 2018;15:966-73. taking into account psychosocial factors,²⁷27. Reisner SL, Mimiaga MJ, Case P, et al. Sexually transmitted disease (STD) diagnoses mental health disparities among women who have sex with women screened at an Urban Community Health Center Boston M.A, 2007. Sex Transm Dis. 2010;37:5-12. or integrating in the curricula of health sciences degrees the specificity of WSW sexual health needs.²⁴24. Silberman P, Buedo PE, Burgos LM. Barreras en la atención de la salud sexual en Argentina: percepción de las mujeres que tienen sexo con mujeres. Rev Salud Publica. 2016;18:1-12. Na important aspect highlighted is that sexual health must be addressed from childhood, thus underlining the importance of the life cycle approach in lesbian, gay, bisexual, trans and intersex people and the need to include sexual orientation in studies.³³33. Gasch-Gallén Á, Gregori-Flor N, Hurtado-García I, Suess-Schwend A, Ruiz- Cantero M. Diversidad afectivo-sexual, corporal y de género más allá del binarismo en la formación en ciencias de la salud. Gaceta Sanitaria. 2021;35(4):383-388.

Regarding the existence of a feminist approach in studies, we found some works criticizing the approach to certain sexual health problems, such as the transmission of HIV mainly in men.³⁴34. Logie CH, James L, Tharao W, et al. 'We don't exist': a qualitative study of marginalization experienced by HIV-positive lesbian, bisexual, queer and transgender women in Toronto, Canada. J Int AIDS Soc. 2012;15:1-11. These works also show the need for keeping in mind the application of specific health care and specific sexual practices of WSW independently considered avoiding studies from a pathologizing pathological point of view or in comparison with other population groups and other women,³⁰30. Logie CH, Navia D, Loutfy MR. Correlates of a lifetime history of sexually transmitted infections among women who have sex with women in Toronto. Canada: results from a cross-sectional internet-based survey. Sex Transm Infect. 2015;91:278-83. as well as the importance of na intersectional vision, which accounts for the diversity of WSW.³⁵35. Cox P, McNair R. Risk reduction as an accepted framework for safer-sex promotion among women who have sex with women. Sex Health. 2009;6:15-8.

To the best of our knowledge this is the first scoping review examining the gaps in sexual health research about WSW. Nonetheless, as a limitation we have to state that the present study did not consider other types of documents beyond scientific journals, such as those mentioned above or doctoral theses, therefore articles with health professional's opinions on sexual minorities, prevalence estimations of sexual minority populations, studies with migrants or refugees, conference abstracts, case studies, and reports in the gray literature were excluded.

Conclusions

Several shortcomings about sexual health in WSW still exist. Due to the heterogeneity of the studies, mostly cross-sectional and without a follow-up for the specification of indicators such as incidence, as well as the diversity of populations recruited (WSW and WSWM), it is difficult to draw a general conclusion about the STIs in WSW.

Recommendations from a comprehensive sexual health approach in WSW should consider the improvement of specific self-care for WSW, education of health providers, and a life cycle and diversity centered perspective. These findings contribute to future research about sexual practices and sexual health care in WSW.

The absence of published data on the health problems affecting WSW sexual health perpetuates the heteronormative model of health care for this group of women, which places them on a level of inequality compared to other populations.

Transparency declaration

The corresponding author on behalf of the other authors guarantee the accuracy, transparency and honesty of the data and information contained in the study, that no relevant information has been omitted and that all discrepancies between authors have been adequately resolved and described.

Acknowledgements

In memoriam of Concepcion Tómas Aznar (Professor of the Department of Physiatrics and Nursing, Nursing Area, Faculty of Health Sciences, University of Zaragoza), for the inspiration space.

References

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