Preventive screening in women who have sex with women

Case description

A 30-year-old woman who is new to your practice presents for a periodic health assessment. While taking the sexual history, she indicates that she has only been in relationships with other women. She questions the need for cervical cancer screening based on the advice that she had been given by other women and her previous physician. During this discussion, you indicate that the Canadian Task Force on Preventive Health Care guideline recommends women consider starting cervical cancer screening with a Papanicolaou test at age 25, but that there is no specific recommendation for women who have sex with women (WSW). The patient asks for additional evidence and advice on the need for screening her for cervical cancer. You agree to provide additional information on the risks and benefits of cervical cancer screening in WSW at a follow-up visit.

Women who have sex with women are part of the larger group of LGBTQ+ (lesbian, gay, bisexual, trans, queer or questioning, and members of related communities) populations. While the makeup and characteristics of individuals within LGBTQ+ communities may share some similarities, there is substantial diversity,¹ including physical, linguistic, sexual, and cultural distinctions, making it critical for physicians to be aware of these differences. Even though critical health information for some LGBTQ+ members has been available for several years,^2,3 the overall community is much more diverse than originally perceived and their risks are not as well evaluated. Building upon Chronopoulos’ presentation,⁴ Table 1 defines some of the terms associated with LGBTQ+ communities and shows the complexity by outlining important distinctions.

In recent years, societal norms have shifted considerably regarding LGBTQ+ communities, and family physicians are discovering their role in addressing their distinctive health issues. Research on members of this diverse community and guidelines for their care are slowly being recognized as important, but for preventive screening, no specific guidelines are yet available. This article will focus attention on screening guidelines for WSW. Table 2 summarizes the current preventive care data available^5-25; note that evaluations are based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system from the Canadian Task Force on Preventive Health Care.

Participation in preventive screening

The LGBTQ+ communities comprise about 3.5% of the American adult population.¹ Gates notes that approximately 19 million Americans, or 8.2%, indicate same-sex behaviour.¹ When including those who report some same-sex attraction, the number rises to 25 million.¹ Canadian proportions are likely to be similar to these estimates.²⁶ According to a recent study on medical care, sexual minorities continue to encounter barriers to care, even though they are historically at greater risk of obesity, tobacco use, substance use, mental health issues, intimate partner violence, sexually transmitted infections, and cancer.²⁷ Negative experiences with health care professionals generally promote indifferent attitudes toward preventive care. Similar to other marginalized groups, WSW patients may not disclose their sexual orientation to their physicians.^28,29 Patients will, consciously or not, assess the safety of self-disclosure, and it is not unusual for considerable time to pass before patients speak openly about their sexuality and specific sexual practices. Physicians should be aware of this and how it may have a negative effect on screening willingness. Some physicians may also be unsure of the current recommendations for preventive screening in WSW, which makes patients question the effectiveness of screening.³⁰ It is also possible that participation rates may be affected by the gender of the physician.³¹

Gaps in preventive care guidelines

Evidence-based preventive screening for patients identifying as WSW remains elusive.^32,33 Effective guidance may be provided by the GRADE system, but systematic study of all categories of preventive care might not be imminent. At the same time, problem areas, such as stress analysis and mental health issues, are especially problematic for family physicians to adjudicate, given the current state of knowledge.

Considering cervical cancer screening as an example, note that the Canadian Cancer Society indicates that human papillomavirus (HPV) vaccines do not prevent all types of infection and, therefore, recommends regular testing.³³ In addition, information provided by WSW interest groups call for screenings similar to heterosexual women.³⁴ A study on cervical cancer testing in Sweden confirms the importance of the test for all female patients, but does not address sexual minority women.³⁵ The most comprehensive list of screening issues for WSW related to cancer screening is found in Fish’s study,⁶ which included bisexual women, and notes that HPV may be transmitted by a partner who has had sex with a man or from an early sexual encounter with a man. In this same study, HPV diagnosis ranged between 3.3% to 30%; for those with no heterosexual experience, the rate remained at 19%. Women who have sex with women tend to consider themselves at lower risk of cervical cancer than others because intercourse with men for them is regarded as the primary risk factor. The same study of WSW and bisexual women found that they were 10 times less likely to have had a Pap test in the past 3 years, which could mean additional risks.⁶ Given this situation, WSW should follow the recommendations on screening for cervical cancer with Pap tests from the Canadian Task Force on Preventive Health Care.¹⁴ A collaborative assistance model may help alleviate some patient concerns.

Common misinformation and misconceptions

Social environments and what is identified as implicit culture³⁶ also impact willingness to participate in screening. Even so, it is difficult to quantify risks across a spectrum of women because of diversity in age, socioeconomic status, and ethnic identity. However, there seems to be little doubt that public perception of WSW can be very misleading, with resulting discriminatory attitudes. It becomes the case that, in the delicate balance of personal respect required between these patients and their physicians, preventive care is, to some extent, dependent upon intangibles like expressed personal values,^29,37 some of which can be construed as antagonistic to members of this community.

While research on elderly WSW is lacking in the literature, Blair observed relatively low rates of screening in a sample of 201 women 60 years of age and older³⁸; this could mean that physicians incorrectly assume that WSW have traditional monogamous relationships, failing to appreciate the heterogeneity of this population. Age-based preventive screening may seem unclear for WSW, but there is no actionable documented difference in the approach. Despite this, some misconceptions persist among both patients and physicians alike: patients are still sceptical of physicians, information about the reliability and negative aspects of screening are not always conveyed by physicians,³⁹ and there is public confusion about the regularity and effectiveness of some tests, such as cancer screening tests.⁴⁰ The lay population has highly variable views on the value of such testing, implying a need for open discussion and shared decision making on critical issues.⁴¹

Physician responses

There is some evidence that the sex of the health care provider affects assessment participation: female physicians appear to have higher female testing rates,³¹ suggesting that lack of physician comfort with a procedure may also be a constraining factor.⁴² It is crucial that other preventive recommendations about health habits and other forms of screening be consistently applied to all WSW. It would appear, therefore, that physician response is a factor in these statistics.

Women who have sex with women do experience fear and often report negative experiences in their encounters with health care providers.¹³ Physicians may be unaware of the specific problem areas of WSW health, such as the range of health challenges affecting the community.⁴³ For example, in a US study, the percentage of young lesbian and gay women meeting the criteria for major depression (18%) and posttraumatic stress disorder (11.3%) in a 12-month period was much higher than the national averages of 8.3% and 3.9%, respectively.⁴⁴ These women also appear to be at greater risk of partner violence and social rejection.^19,20 Adult WSW also have an increased prevalence of depression and anxiety; Suarez et al point out that “many known risk factors for cancer, such as tobacco, alcohol, nulliparity, and obesity, have higher prevalence among LGBTQ+ persons compared with heterosexual peers,” which leads the researchers to suspect higher rates of breast and cervical cancer in LGBTQ+ populations than in heterosexual populations, and express doubt regarding the accuracy of reported data.⁴⁵

Communication issues

It has been reported that some physicians have difficulty taking a respectful and inclusive sexual history.⁴⁶ Women who have sex with women report that sexual histories are almost inevitably based on heterosexual models that emphasize reproductive health. Consequently, some WSW and their physicians may continue to believe that general health messages for women (eg, folic acid supplementation if contemplating pregnancy, Pap tests, screening for sexually transmitted infections) do not apply to WSW, despite the fact that sexual activity (eg, skin-to-skin contact, use of sex toys, digital insertion) is important to consider in any global sexual health care program. Research also indicates that disparity in preventive care is largely based on sexual assumptions.⁴⁷ Thus, it is assumed that health requirements for WSW are different than for heterosexual women. This may, in fact, not be the case. For example, with cervical cancer screening, it is widely believed that WSW are not at risk of cervical cancer because they do not have sex with men.⁴⁸ Even if some women identify as WSW, it does not mean that they do not have, or have not had, sex with men. Even if they are exclusively sexually active with women, they may still be at risk through genital skin-to-skin contact, etc. The screening discrepancy can be substantial, with fewer than two-thirds of WSW reporting a Pap test within the previous 3 years in 2008, compared with three-quarters of heterosexual women.¹⁴ More recent data show that there is a persistent statistically significant difference in the rate of cervical cancer screening between WSW and heterosexual women (85.7% of heterosexual women, and 78.9% and 80.1% of bisexual and WSW women, respectively, received timely tests).²⁷ This is in contrast to mammography screening in women older than 50 years of age, where there is no disparity between these 2 groups.⁴⁷ Since cervical cancer screening appears to be foundational in today’s preventive recommendations, it is important to determine the proper recommendations for WSW, as there is a weak distinction from a medical standpoint between screening WSW and heterosexual women.¹⁴ Evidence within the LGBTQ+ community indicates that screening preferences are a factor in participation rates.⁴⁹

Sensitive communication for WSW

Health care providers need to realize that WSW face a legacy of antipathy or worse from Canadian institutions and that they often arrive expecting some form of hostility from physicians.^13,14,29-50 There is also some evidence that WSW patients, such as those within certain religious groups, have especially difficult medical experiences,⁵¹ with risks of loss of confidentiality, concern about disclosure, and fear of discrimination predominating.⁵² Awareness of the cultural and social context of WSW is critical when the goal is to provide appropriate preventive care, since addressing the sensitive topic of sexual activity can be very detrimental within some communities. Family physicians are at the front line of issues around sensitive communication.

Strategies

Physicians need to provide screening information in 2 forms: risk information and test effectiveness. The ability of professionals to delineate the risks and make those risks concrete enough to be understood and acted upon is paramount.³⁴ Physicians need to recognize the diversity in WSW women and be able to give appropriate advice. Preventive care of the WSW population is complex; it requires a joint commitment to health betterment by both patients and physicians. Table 3 provides some tools to make encounters more friendly toward WSW.^9,53

Case resolution

At the follow-up appointment, using gender-neutral language, you acknowledge the patient’s reluctance and provide reassurance, first, that sexual orientation is not an issue under discussion, and second, that preventive screening decisions will be made together (shared decision making). You also indicate that there is no evidence to screen WSW differently (ie, the current cervical cancer screening recommendations apply to WSW) and you give her some references for more information about this. You also communicate that trust is an essential element in the doctor-patient relationship and convey the sentiment that you hope to provide her with good-quality care going forward.