INTRODUCTION — We are choosing to define the term "sexual minority women" (SMW) in the broadest sense of women with a nonheterosexual sexual orientation who may be self-identified as lesbian, gay, bisexual, transgender, queer, or other. This can also be inclusive of racial/ethnic minorities. SMW are a heterogeneous group of women from a multiplicity of backgrounds with regard to race, ethnicity, education, socioeconomic status, etc, and they represent a small segment of the general population throughout the United States.

For clinicians, how to provide best practices of care to SMW is constantly changing as it relies on a variety of inputs, including patient feedback directly, focus groups and surveys, meta-analyses, and an increasing volume of research from a variety of disciplines. By keeping informed of the nuanced differences in the medical and mental health risk factors and outcomes of SMW, health care providers can best meet patients' expectations without judgment, prejudice, or bias.

Knowing and understanding a patient's sexual identity, orientation, and behavior improves health care providers' abilities to provide inclusive quality care and recognize areas of disproportionate risk [1]. There is no stereotypical profile that identifies SMW (eg, lesbian, gay, bisexual, transgender, queer, and other women, or LGBTQ+); therefore, when providing care, clinicians are encouraged never to make assumptions about a patient's identity. Taking an adequate sexual and gender history to recognize SMW (and other sexual and gender minority orientations and identities) is important on many levels, including affirming a patient's identity, being able to discuss topics relevant to SMW health, and identifying disparities and risks that should be addressed, such as mental health issues, tobacco and substance use, and decreased preventive screening such as mammography.

This topic will address issues related to the medical care of SMW. Detailed reviews of related topics are presented separately.

●(See "Lesbian, gay, bisexual, and other sexual minoritized youth: Primary care".)

●(See "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns".)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. However, we encourage the reader to consider the specific language preferences as well as counseling and treatment needs of each individual.

LANGUAGE AND TERMINOLOGY — Language and terminology are continuously evolving, and there are numerous terms in use. It is always best to ask patients how they prefer to be identified regarding their gender identity, pronouns, and sexual partner. In our practice, we have found that it is important to repeat this conversation over time as gender identity and sexual orientation, and behaviors, can change. We find it useful to refer to the publicly available resources through the University of California San Francisco Center of Excellence for Transgender Health and the Fenway Institute Glossary of LGBT Terms for Health Care Teams. A multidisciplinary group of clinicians and researchers has described barriers to sexual and reproductive health care and proposed detailed "Recommendations for Building Gender-Inclusive Clinical Settings" and "Recommendations for Conducting Gender-Inclusive Research" in 2020 [2].

Some commonly used terms include:

●Gender – Gender refers to the socially constructed characteristics of men and women, such as roles, norms, and behaviors, that are labeled by a society as male or female [3]. The concept of gender can vary by society and can change over time [4,5].

●Gender identity – Gender identity is one's innermost concept of self from the perspective of one's gender [6]. It can be described as an internal self-label. Gender is often thought of as a male/female binary, meaning that individuals identify as either male or female. However, gender is an umbrella term, and many identify outside of this construct, including no gender [7]. Gender identity encompasses transgender identities (trans women and trans men), nonbinary, gender-queer, intersex, etc [7,8]. An individual's gender identity can be the same or different from their sex assigned at birth [7]. Furthermore, since identity is an internal perception, it can be unrecognized by others.

●Transgender – Transgender is an umbrella term, sometimes shortened as "trans" or "trans*," and refers to a person whose gender identity differs from their sex assigned at birth [7,9]. Transgender individuals may be referred to as transwomen or transgender women or transmen or transgender men. Transgender individuals may choose to receive hormone therapy and/or undergo various gender affirmation surgeries. Transgender is a gender identity and should not be confused with sexual orientation.

●Nonbinary – The term nonbinary includes identities such as gender-queer, agender, androgynous, etc.

●Gender expression – How that gender identity is lived constitutes gender expression. In other words, "The outward manner in which an individual expresses or displays their gender" [9]. This can include characteristics such as clothing, hairstyle, mannerisms, and speech and may differ from one's gender identity.

●Sex – An individual's sex refers to the biology they are born with, including genetic, hormonal, anatomic, and physiological characteristics [7]. Related terms include "sex assigned at birth," "natal sex," "biologic sex," or "birth sex." Sex characteristics result in being labeled as female or male gender at birth.

●Sexual orientation – Sexual orientation refers to one's inherent emotional, romantic, and sexual attractions to other people [6,8,9]. Historically, sexual orientation has been thought of with three main categories including heterosexual, homosexual (lesbian or gay), and bisexual. However, many perceive their attractions as more fluid (readily reshaped) than this and do not identify within these categories. Once a derogatory label, the term "queer" has been adopted as a positive self-label and is recognized to be more fluid (less limiting) than choosing one of the three above categories. Other categories of sexual orientation that have emerged are pansexual, asexual, and omnisexual.

Sexual orientation is self-defined. Thus, a single sexual event or desire does not define one's sexual orientation. Also, the phrase "women who have sex with women" describes a behavior and is not a sexual orientation.

●Sexual behavior – Sexual behavior embraces a complex spectrum of romantic and/or sexual activities and therefore is not so clearly categorized. Sexual behavior can also change over time. Studies surveying self-identified lesbians show a wide range of sexual behaviors (eg, same-sex partners, opposite or different sex partner, or both) [10]. Additionally, a current partnership may not reflect an individual's previous sexual behavior, and behavior is not always concordant with self-identification. [7]. For example, a self-identified lesbian can also be attracted to, and engage in, sex with men and/or individuals who identify as nonbinary, transgender, etc.

PREVALENCE — Obtaining accurate information about the prevalence of SMW is challenging because gender, sex, and behavior are not the same, and national census surveys have historically not asked about sexual orientation or gender identity. In the United States, gay and lesbian individuals were first recognized as a subpopulation on the 1990 census. The 2018 United States National Health Interview Survey, an annual survey of over 34,500 adults aged 18 years and older, reported that 97.0 percent of adults identified as heterosexual, 1.6 percent identified as gay or lesbian, 1.3 percent identified as bisexual, and 1.1 percent were not identified (ie, responded as "something else," "I don't know," or declined to answer) [11]. A reason for this may be that, due to stigma, individuals do not feel comfortable identifying, or that their identity or sexual behaviors have not been accurately represented in these surveys.

Rates of same-sex sexual behavior are higher than rates of self-identification as lesbian or bisexual. As an example, analysis of the 2011 to 2013 National Survey of Family Growth reported that 1.3 percent of women identified as "homosexual, gay, or lesbian" but 17.4 percent of women reported sexual activity with individuals of the same sex, which includes a single or frequent encounters [12].

IMPACT OF SEXUAL ORIENTATION ON HEALTH

●Disparities – When individuals do not conform to established heteronormative gender definitions, relations, or roles, their access to and control over resources that contribute to health can also be reduced [4]. This can lead to disparities and health risks that could be mitigated by health care provider awareness and education. (See "A patient-centered view of the clinician-patient relationship".)

A longitudinal cohort survey study including nearly 1000 US adolescents and young adults reported that, in multivariate analysis compared with completely heterosexual peers, sexual minority men and women were approximately twice as likely to be unemployed and uninsured, and all sexual minority subgroups reported worse health-related quality of life [13]. Additionally, societal stigma, discrimination, and denial of civil and human rights can result in altered health care and other disparities [14]. Studies have reported an association between the discrimination and stigma LGBTQ people face and higher rates of mood disorders, reported mental stress, high-risk sexual behaviors, substance misuse, and suicide [15-21]. A study of nationally representative surveillance data reported that women in same-sex relationships were less likely to have health insurance, less likely to have preventive screening such as mammograms, and more likely to have untreated health problems compared with women in heterosexual relationships [22]. These inequities highlight the importance of identifying SMW, addressing their unique health care needs, and reducing barriers to care [14].

●Barriers to care – Prior to 1973, "homosexuality" was included in the Diagnostic and Statistical Manual of Mental Disorders. This historical pathologic paradigm greatly contributed to isolation and stigmatization of sexual minority individuals by the health care community [7]. Additional barriers to care can include lack of health insurance, prior judgmental or insensitive encounters with health care providers, and assumption of heterosexuality [23,24]. These barriers contribute to regional differences in patients' willingness to disclose sexual orientation [25]. A systematic review of 12 studies reported factors associated with improving a patient’s ability to enter care included a welcoming environment, clinicians with knowledge of LGBTQ needs, and medical confidentiality [26].

Due to the disparities mentioned above, SMW can have fewer points of contact and lower rates of accessing health care because they may lack adequate insurance coverage (eg, unable to access partner's insurance), have lower total family income compared with men, and are less likely to take advantage of low-cost gynecologic care, frequently provided by family planning clinics [27].

●Impact on health – As a result of disparities, stigma, discrimination, and prior negative experiences with the health care community, SMW often underutilize clinical care services and present later for health care than heterosexual women [28,29]. In addition, differential risks for disease can arise because of behaviors that may be more common among SMW. For example, SMW have reported higher rates of current smoking, alcohol consumption, obesity, heavy drinking, and substance use disorders [30-34]. Information on smoking cessation and screening for substance use is presented separately. (See "Overview of smoking cessation management in adults" and "Screening for unhealthy use of alcohol and other drugs in primary care".)

●Exposure to sexual violence – Compared with heterosexual women, SMW have reported more severe victimization and higher rates of sexual revictimization [35]. In a study of over 7600 women undergoing abortion in 2014, women who identified as bisexual, lesbian, or something else were two to nine times more likely to report physical violence by the man involved in the pregnancy compared with heterosexual women [36]. In addition, lesbian women were 18 times more likely than heterosexual women to report sexual abuse by the man involved in the pregnancy, and 10 percent of lesbian women noted the pregnancy was a result of forced sex.

RESILIENCY — Historically, LGBTQ+ research has focused on poor health outcomes or risk behaviors within the LGBTQ+ community due to minority stressors. However, researchers and the sexual minority community themselves are increasingly turning attention toward individual and community resilience. Resiliency is defined as one's ability to adjust, recover, or overcome adversity or significant stress in one's life [37]. This term can be further defined as the "dynamic process encompassing positive adaptation within the context of significant adversity" [38]. This important shift in perspective allows health care providers, as well as patients, to consider a strength-based approach, rather than just focusing on one's deficits, when considering health needs and outcomes [39]. Characteristics that can positively impact one's individual resiliency are positive self-esteem, self-efficacy, cognitive ability to mediate stress, self-acceptance, proactive coping, self-care, shamelessness, and spirituality. Larger community and environmental factors include social support and connectedness, positive LGBTQ+ role models, positive representation of LGBTQ+ populations in the media, family acceptance, positive school and/or work environments, having access to safe spaces, and social activism.

CULTURAL COMPETENCY — Cultural competency focuses on the ability to communicate effectively and provide quality health care to patients from diverse backgrounds and, in practice, can include an individual's and organization's cultural competency. The delivery of routine primary health care to SMW can be complicated by the health care provider's or organization's lack of cultural competence [40,41]. Not making assumptions about a patient's sexual orientation or behaviors is a fundamental principle in offering culturally competent care, as is acknowledging that we may have implicit biases that inform our diverse behaviors as clinicians. Educating ourselves about SMW can change our awareness and cultivate new patterns of thinking, communications, and actions to replace prejudices, which may be subtle or unconscious, with an informed understanding about the different types of patients we may encounter [42]. Furthermore, professionalism, confidentiality, being mindful of one's internal assumptions, and an unbiased approach are key components for enabling patients to identify themselves as well as for better interactions between these patients and their health care providers and staff [1,43,44]. These issues are explored in greater detail elsewhere:

●(See "The patient’s culture and effective communication".)

●(See "Racial and ethnic disparities in obstetric and gynecologic care and role of implicit biases", section on 'Mitigation of implicit bias'.)

Understanding a patient's sexual orientation is important on many levels. Research shows that many health care providers do not ask about sexual orientation, yet patients generally report that they want to be asked [43]. In a 2017 United States questionnaire study, 78 percent of Emergency physicians felt that patients would refuse to disclose if asked about sexual orientation; in contrast, only 10 percent of patients reported they would refuse to disclose [45]. Asking about sexual orientation allows a patient's identity to be affirmed and seen by their provider. Secondly, understanding a patient's identity will help providers recognize potential health disparities that should be addressed [46]. Lastly, patients who disclose their sexual orientation to their health care providers may feel safer discussing their health and risk behaviors as well [47].

Sexual history-taking — Health care providers should never assume a patient has a particular gender or sexual identity or engages in particular sexual behaviors. Therefore, it is extremely important for a comprehensive, inclusive sexual history to be obtained. The Institute of Medicine and the Joint Commission recommend routine documentation of a patient's sexual orientation; however, it is not always comfortable for patients to disclose this information. First and foremost, in our practice, it is important to normalize this question and let patients know why you are asking, such as to better understand sexual risk and safety or to better understand if contraception needs to be discussed. Patients may also be concerned that disclosing this information could impact the care that they receive. It is very important for patients to be aware that this information is asked without judgment and is always kept confidential, as with all other health information. If patients are told why these questions are being asked and that this is safe and confidential, most will be more forthcoming with this disclosure [48].

Information on sexual orientation and behavior should be obtained using open-ended questions, gender-neutral questions and terms, and with nonjudgmental acceptance [49-51]. Providing a welcoming clinical environment, with inclusive resource material and intake forms, can aid in this as well.

Clinicians can also provide multiple opportunities for disclosure of sexual orientation and sexual behaviors including medical intake forms with SMW-inclusive questions and language and face-to-face discussions. Intake forms that do not offer binary choices can be helpful (eg, rather than offering male or female as gender options, provide the heading "gender" and a blank space for the patient to complete). One cohort study of 540 patients, with a mean age of 36 years, who were evaluated in an emergency department reported greater patient comfort and improved communication when sexual orientation and gender identity information was collected by nonverbal registration form compared with nurse verbal collection [52]. Lastly, training frontline staff regarding care of sexual and gender minority patients can aid in creating inclusive and affirming health care environments.

When obtaining a sexual history, the appropriate level of detail depends on what is applicable for the patient's medical evaluation. The United States Centers for Disease Control and Prevention (CDC) Guide to taking a sexual history offers information on taking a nonjudgmental sexual history, including frank questions about partners, sexual practices, prevention and history of sexually transmitted diseases, and prevention of unintended pregnancy [53]. For example, the CDC advises starting with a statement such as, "I am going to ask you a few questions about your sexual health and sexual practices. I understand that these questions are very personal, but they are important for your overall health…I ask these questions to all of my adult patients, regardless of age, gender, or partnership/marital status. These questions are as important as the questions about other areas of your physical and mental health. Like the rest of our visits, this information is kept in strict confidence. Do you have any questions before we get started?" [53]. (See "The gynecologic history and pelvic examination", section on 'Gynecologic history'.)

ISSUES WITH ADDITIONAL RISK — While there are no diseases specific to SMW, the health disparities that result from identification with a minority group and the risks associated with specific health behaviors require attention and consideration. Several issues that warrant discussion with SMW include mental health stressors, obesity and body image, gynecologic cancer risk and screening, risk for sexually transmitted infections, potential desire for pregnancy, substance and alcohol misuse, protection from unplanned pregnancy, and intimate partner violence [1,14,54].

Mental health — It is important for clinicians to recognize the impact that pervasive stigma and discrimination due to one's sexual orientation can have on an individual's mental health [50,55]. Sources of stress for SMW include stigmatization and non-acceptance by family members, peers, and friends [56]. Higher rates of suicidality and depression are most common in SMW who have not disclosed their sexual orientation [57]. Conversely, when same-sex couples are in legally recognized relationships, they report having more meaning in their lives, fewer symptoms of depression, and less overall stress [58]. A systematic review of 25 studies comparing mental health in LGBTQ and heterosexual individuals reported that LGBTQ individuals had a 1.5-fold increased risk of depression and anxiety and a 2.5-fold increased risk of suicide attempt [59]. We advise asking SMW about their mental health, their support networks, and individuals in their lives who may not be supportive.

Detailed information on suicide, depression, and substance misuse are presented separately.

●(See "Suicidal ideation and behavior in adults".)

●(See "Screening for depression in adults".)

●(See "Lesbian, gay, bisexual, and other sexual minoritized youth: Primary care".)

Obesity — A study of the 2013 and 2014 National Health Interview Survey data comparing SMW with heterosexual women reported SMW had a 20 percent higher prevalence of obesity (defined as a body mass index of ≥30 kg/m²) [60]. This study is consistent with prior data noting that obesity is more prevalent among SMW than among heterosexual women [30,61-63]. The relationship between sexual minority stress and obesity is layered and complex. There is some evidence that chronic minority stress, depression, and alcohol use contribute to a high prevalence of obesity among sexual minority woman [64,65]. There is some evidence that weight gain and having a higher body mass index may be more culturally acceptable to lesbians. The reason for this is unknown; however, one reason may be that the lesbian community may not share the mainstream media-driven goal of low body weight as the ideal [66]. Therefore, in addressing weight with SMW, it is important to emphasize the health implications of being either overweight or obese, including diabetes, cardiovascular disease, and hypertension. (See "Overweight and obesity in adults: Health consequences" and "Screening for coronary heart disease" and "Screening for type 2 diabetes mellitus".)

Cancer risk, screening, access, and conduct of care — A 2019 study of over 1900 cancer survivors (female and male) reported that SMW not only had challenges to screening for cancers but also reduced access to care once diagnosed with a cancer [67].

●Breast cancer – SMW are advised to undergo breast cancer screening according to guidelines published for the general female population. (See "Screening for breast cancer: Strategies and recommendations".)

SMW appear to have an increased risk and incidence of breast cancer, which may result from their greater incidence of high-risk health patterns (eg, overweight, obesity, nulliparity, and excessive alcohol intake) [22,62,68-70]. In a study of over 400 women, being SMW was independently associated with 1.43 percent higher lifetime Gail scores for breast cancer risk [69]. (See "Screening for breast cancer: Strategies and recommendations", section on 'Breast cancer risk determination'.)

●Cervical cancer – Cervical cancer screening and human papillomavirus (HPV) vaccination should be offered according to established guidelines regardless of a woman's sexual orientation or practices [71]. (See "Human papillomavirus vaccination", section on 'Importance of cancer screening' and "Screening for cervical cancer in resource-rich settings".)

•HPV infection risk – SMW are at risk for HPV infection from both male and female partners [72]. In a study of 149 SMW, HPV DNA was detected in 30 percent of the entire group and in 19 percent of women who reported no prior male sexual partners [73]. For comparison, a United States National Health and Nutrition Examination Survey study on HPV reported that up to 40 percent of women in the general population were infected with any genital HPV during 2013 to 2014 [74].

•Cervical cancer screening – Despite their risk for HPV infection, SMW have lower rates of screening for cervical cancer compared with heterosexual women [75]. The Women's Health Initiative Study reported fewer cervical cancer screening tests and higher rates of cervical cancer among bisexual women (2.1 percent) and lifetime lesbians (2.2 percent) than in heterosexual women (1.3 percent) [61]. In a study of nearly 250 SMW, reasons given by women for not having cervical cancer screening included lack of health insurance, prior negative health care experiences, and belief that Pap tests were unnecessary [76,77]; thus, it is essential to offer age-appropriate cervical cancer screening to natal women (ie, born with a cervix) regardless of sexual orientation or behavior.

●Ovarian cancer screening and risk reduction – We discuss ovarian cancer risk factors with all patients. Screening and preventive measures for women who are carriers for hereditary and/or familial breast and ovarian cancer syndromes are discussed in detail separately. (See "Screening for ovarian cancer" and "Overview of hereditary breast and ovarian cancer syndromes associated with genes other than BRCA1/2" and "Lynch syndrome (hereditary nonpolyposis colorectal cancer): Screening and prevention of endometrial and ovarian cancer".)

SMW have higher theoretical risks of developing ovarian cancer compared with heterosexual women because of increased rates of nulliparity and decreased hormonal contraceptive use [78]. While SMW may have risk factors for ovarian cancer, sexual behavior/orientation is not a factor considered in formal ovarian cancer risk assessment. There are no formal guidelines for ovarian cancer prevention for SMW with potential reproductive risk factors for ovarian cancer (eg, early menarche, nulliparity, and infertility). However, clinicians can discuss the potential benefits of using estrogen-progestin hormonal contraception to reduce the risk of ovarian cancer with these women [79,80]. Ovarian cancer screening is generally not recommended for women at average risk for ovarian cancer, including women with a family history of ovarian cancer who do not have a confirmed ovarian cancer syndrome.

Sexually transmitted infection

Screening — A few studies suggest that some SMW, particularly younger women and women who also have sex with men, may be at increased risk for sexually transmitted infections (STIs), including human immunodeficiency virus (HIV) [81-84]. However, it is not yet clear if SMW should have distinct STI screening guidelines, in part because the data on risk of female-to-female STI transmission are limited [71]. Screening for STIs should be performed in women with symptoms or in those with risk factors [71]. (See "Screening for sexually transmitted infections".)

Behavioral risk factors include [71]:

●New sex partner in the past 60 days

●Multiple sex partners or sex partner with multiple concurrent sex partners

●No or inconsistent condom use for any penetrative item (eg, sex toys) outside a mutually monogamous sexual partnership

●Trading sex for money or drugs

●Sexual contact (oral, anal, penile, or vaginal) with sex workers

●Meeting anonymous sex partners on the internet

Risk groups are demographic groups identified as having a high prevalence of STIs [71].

●Young age (15 to 24 years old)

●History of a prior STI

●Lower socioeconomic status, or high school education or less

●Admission to correctional facility or juvenile detention center

●Illicit drug use

SMW with STIs should be encouraged to inform their sexual partner(s) regarding the need for screening, diagnosis, and treatment. Sexual transmission between women has been reported for trichomoniasis, HIV, HPV, herpes simplex virus, hepatitis C, syphilis, chlamydia, and bacterial vaginosis (BV) [71,85-87]. Infectious agents can be transmitted through sexual behaviors that result in the exchange of vaginal secretions on hands or objects (eg, finger-to-vagina contact, genital-to-genital contact, or sharing objects such as sex toys without condom use or cleaning between partners) [88]. Sex toys, oral-genital contact, and fingers can also transmit bacteria from the anal region to the vagina. STIs can be acquired from female sexual partners even when there is a remote or no history of male sexual partners [73,89-95].

Bacterial vaginosis — Although BV is common in SMW, routine screening is not advised [71]. SMW in monogamous relationships are usually concordant for the presence or absence of BV; this has led some investigators to believe that BV, which is not considered a STI in heterosexual women, is probably transmitted between female sexual partners through exchange of vaginal secretions [91,96]. A systematic review of 14 studies that assessed risk factors for BV among SMW reported an association between BV and higher numbers of female sexual partners, both lifetime and in the prior three months [97]. Sexual contact with men, ethnicity, douching, and hormonal contraception use were not associated with an increased risk of BV in SMW, although hormonal contraception use was low. (See "Bacterial vaginosis: Clinical manifestations and diagnosis".)

For reasons that remain unclear, oral-genital sex, oral-anal sex, and sex toys may be more important risk factors for infection than penile penetrative sex. Screening asymptomatic female partners is not recommended, but women with BV should encourage their female partners to be aware of the signs and symptoms of BV, given the high risk of concordant infection (25 to 50 percent) [98]. Treatment of confirmed infection is indicated for relief of symptoms. Although it has been hypothesized that behavioral interventions that reduce transfer of vaginal fluid between female sex partners may be helpful (eg, cleaning sex toys between use, use of gloves during digital-vaginal sex), a small randomized trial evaluating this approach reported no reduction in BV persistence [85]. Further study is needed.

Prevention of sexually transmitted infections — Studies report that sexual activity among SMW frequently occurs without prophylaxis against STIs [86,99,100]. Options for STI prevention include the following:

●Hepatitis A and B vaccination and HPV vaccination are indicated for SMW by specialty care groups [51]. Of note, the United States Centers for Disease Control and Prevention (CDC) do not include SMW as one of their high-risk groups [101]. (See "Hepatitis A virus infection: Treatment and prevention" and "Hepatitis B virus immunization in adults".)

Education regarding the benefits of HPV vaccination is particularly important for SMW, as the perceived need for vaccination has been reported to be lower for SMW than for heterosexual women [102,103]. In one study of over 12,000 United States women from 2006 to 2010, of women who were aware of the HPV vaccine, 8 percent of lesbian women had initiated vaccination compared with 28 percent of heterosexual women and 32 percent of bisexual women [104]. In an English population-based survey of over 790,000 men and women, SMW were over-represented among women with oropharyngeal cancer, which is typically HPV related [105]. These studies highlights the need to discuss HPV vaccination and modes of transmission with all women. (See "Human papillomavirus vaccination".)

●Pharmacologic prophylaxis – Pharmacologic prophylaxis (pre-exposure prophylaxis or PrEP) is offered to those at high risk of HIV transmission. There are no formal guidelines for starting Truvada (PrEP) for SMW. However, CDC guidelines do state that PrEP can be considered for HIV-negative individuals who are at substantial risk for HIV transmission. This includes people who are in a sexual relationship with a partner living with HIV (sero-discordant couples), who have penetrative intercourse with male-bodied individuals and do not regularly use condoms and who do not know the HIV status of their sexual partner(s), are engaged in commercial sex work, have had a recent bacterial STI, or use injections drugs and (1) share drug equipment, or (2) were recently in a drug treatment program [106]. In these situations [106], PrEP with tenofovir disoproxil fumarate-emtricitabine can reduce the risk of HIV transmission by more than 90 percent [107]. (See "Administration of pre-exposure prophylaxis against HIV infection".)

Similarly, couples who are sero-discordant for herpes simplex virus can use valacyclovir (500 mg once daily) to help prevent transmission of herpes simplex virus-2 to an uninfected sexual partner. (See "Prevention of genital herpes virus infections", section on 'Chronic suppressive therapy in discordant couples'.)

●Safer sex – "Safer sex" refers to strategies for avoiding mucous membrane contact with a partner's blood or secretions. Examples include using male or female condoms, placing a dental dam or latex barrier over affected areas during oral sex, and washing sex toys with hot soapy water between uses (or covering the toy with a fresh condom). Couples who are mutually monogamous should still practice "safer sex" to limit possible transmission of BV. (See 'Bacterial vaginosis' above.)

Prevention of unintended pregnancy — Since SMW can have sex with men or male-bodied individuals, we inquire about and address each woman's need for contraception as appropriate to their history and needs [7]. A focus group study of 22 individuals who identified as SMW revealed that SMW, especially adolescents, are at higher risk of having an unintended pregnancy than heterosexual women [108]. In a survey study of nearly 400 SMW, 16 percent reported having been pregnant, and of those who had been pregnant, 63 percent reported having one or more induced abortions [86]. (See "Contraception: Counseling and selection".)

Substance misuse — As SMW report higher rates of tobacco use, exposure to secondhand smoke, and alcohol and drug use, we ask all patients about their substance use habits [59,109-111]. A systematic review of 25 studies comparing LGBTQ and heterosexual individuals reported that lesbian and bisexual women had nearly fourfold increased risk of substance misuse [59]. The Population Research in Identity and Disparities for Equality (PRIDE) study, which asked over 1700 participants about substance use behaviors, reported different substance use patterns among different gender and sexual minority groups [112]. For example, asexual individuals had reduced likelihood of reporting binge alcohol or marijuana use within the past year while queer participants had an increased odds of marijuana use in the same time period. With varied and potentially increased prevalence of substance use in sexual and gender minority populations, it is important that providers and organizations offer inclusive material and resources for substance use education and treatment. Information regarding smoking cessation that is specific to LGBTQ tobacco users can be found at LGBT HealthLink. Limited research suggests that there is some association between higher rates of anxiety, substance abuse, and depression due to gender minority stressors [113].

Screening and treatment for substance use disorders can be found separately.

●(See "Screening for unhealthy use of alcohol and other drugs in primary care".)

●(See "Clinical assessment of substance use disorders".)

●(See "Substance use disorder in adolescents: Epidemiology, pathogenesis, clinical manifestations and consequences, course, assessment, and diagnosis".)

Intimate partner violence — Intimate partner violence (IPV) refers to actual or threatened psychological, physical, or sexual harm by a current or former partner or spouse. IPV can occur among heterosexual or same-sex couples and does not require sexual intimacy. The CDC National Intimate Partner and Sexual Violence Survey 2010 reported that IPV (rape, physical violence, and/or stalking) was experienced by 61 percent of bisexual women, 44 percent of lesbian women, and 35 percent of heterosexual women [114]. Thus, we screen all women for IPV. Women who screen positive are assessed for safety and referred for counseling and help with intervention.

●(See "Intimate partner violence: Diagnosis and screening".)

●(See "Intimate partner violence: Intervention and patient management".)

PHYSICAL EXAMINATION — The components of the physical examination of SMW are the same as for non-SMW. As with any patient, the clinician should be alert for signs of physical or emotional discomfort that can indicate a history of trauma or abuse. A trauma-informed care approach can reduce the potential to trigger or retraumatize a patient. (See "Intimate partner violence: Diagnosis and screening", section on 'Clinical presentation' and "Human trafficking: Identification and evaluation in the health care setting", section on 'Trauma-informed care'.)

Prior to starting the physical examination, we discuss whether or not a speculum examination is indicated and explain the rationale. For women who have had prior negative experiences or who have not had penetrative vaginal sexual activity, we discuss options including application of topical lidocaine to the introitus, use of topical lubricant, selection of a narrow/small speculum, and asking the woman if she would prefer to insert the speculum. Additionally, we discuss bringing a support person, distractions such as music, or use of anxiolytic medication to reduce the stress of a visit and aid muscle relaxation. A detailed discussion of the pelvic examination for all women is presented separately. (See "The gynecologic history and pelvic examination".)

Lastly, for transgender men or nonbinary/gender-queer individuals it is helpful to ask if they have any particular terminology they use for their genital anatomy prior to the examination. Using gender neutral language, such as genital examination versus vaginal examination, etc can also be helpful.

PREGNANCY AND PARENTING

Medical and legal issues — SMW encounter special obstacles in fulfilling their desires to become parents, including homophobic stigmatization; potential rejection by family; and limited access, finances, and availability of resources such as sperm banks and insurance coverage. These obstacles exist despite evidence from studies that have examined the psychosocial development of children raised by SMW and found no differences in sexual or gender identity, personality traits, or intelligence compared with children of heterosexual parents [115-118]. The National Longitudinal Lesbian Family Study: Mental Health of Adult Offspring reported no significant differences in the mental health status of children conceived through donor insemination compared with a normative sample of the United States population [119].

SMW who choose to have children have some needs similar to those of heterosexual couples and other needs unique to their circumstances [2,120].

●Issues for the clinician – Clinicians should not assume that individuals in same-sex relationships do not desire pregnancy [118]. A 2017 meta-analysis of 28 studies reported that, compared with heterosexual women, the likelihood of having ever been pregnant was lower for lesbian women but higher for bisexual women [121]. We inquire about plans for family building and discuss optimizing reproductive health (eg, screen medications for teratogens, educate about alcohol and substance use, and discuss folate supplementation) with our patients who are planning pregnancy. Additionally, topics the clinician might need to address with patients include the logistics, safety, effectiveness, and family/legal ramifications of various parenting options as well as referral to appropriate providers of fertility and parenthood services. The goal is to optimize fertility and minimize pregnancy complications. Due to health disparities recognized within the SMW community, it is important, much like with heterosexual patients, to screen and discuss risks, such as age at conception, chronic stressors, body mass index, as well as substance use [122].

●Issues that SMW woman will need to consider regarding parenting – Depending on one's route to parenthood, there are specific issues that patients will need to address. Issues that SMW must address include contracts regarding parenting, durable power of attorney, health proxies, second parent (or co-parent) adoption, custody issues in the event of death or separation, as well as issues regarding either known or anonymous sperm donor's rights [123,124]. In the United States, the 2015 Supreme Court ruling in the case of Obergefell v. Hodges stated that fundamental right to marry is guaranteed for same-sex couples under the 14^th Amendment of the United States Constitution [125]. The ability of individuals in same-sex couples to adopt varies by state. Advising patients to seek consultation with an attorney knowledgeable in this area is recommended.

Parenting options — SMW have several possible paths to parenthood including conception through known or anonymous donor insemination or in vitro fertilization (IVF), use of a surrogate, foster parenting, adoption, or raising children from prior heterosexual relationships [126].

●Fertility treatment – Both the Ethics Committees of the American Society for Reproductive Medicine and the American College of Obstetricians and Gynecologists have affirmed the right of single or coupled gay and lesbian persons to have access to fertility services [122,127]. For women who desire parenthood, we provide information regarding preconception care, prenatal care, and fertility services. The patient's female partner is included in all discussions if she is present. Issues concerning legal relationships with both the sperm donor and the nonbiologic same-sex parent should be addressed before starting fertility treatment.

Fertility services typically used by lesbian couples include intrauterine insemination (IUI) and IVF with donor sperm. Patients can elect fertility treatment for one partner (single partner), both partners (dual partner), or comaternity, in which the egg of one partner is aspirated, fertilized as in an IVF procedure, and then transferred to the uterus of the other partner, who is the gestational carrier [128]. Although this allows both partners to biologically participate in the pregnancy, it is more costly and risky than simple insemination.

In a retrospective chart review of 306 lesbian couples who sought reproductive assistance with either IUI or IVF, 85 percent attempted single-partner conception and 68 percent had a live birth [129]. An additional 15 percent of couples elected dual-partner conception, and 89 percent had a live birth. An average of 3.0±1.1 cycles were completed for women who conceived with IUI and an average of 6.0±1.4 IUI cycles plus 1.7±0.3 IVF cycles for women who conceived with IVF. Both IUI and IVF are presented in detail separately. Not surprisingly, lesbians using assisted reproductive health services are more likely to be successful than heterosexual women who typically use these services after a diagnosis of infertility [121,130]. (See "Donor insemination" and "In vitro fertilization: Overview of clinical issues and questions".)

●Adoption – Issues related to adoption are reviewed in detail separately. (See "Adoption".)

●Foster parenting – Foster care is reviewed in detail separately. (See "Epidemiology of foster care placement and overview of the foster care system in the United States".)

Prenatal care, childbirth, and hospitalization — Prenatal care of SMW is the same as for heterosexual women. As with heterosexual couples, the presence of her partner is welcomed at antenatal visits, childbirth preparation classes, during labor, and postpartum. (See "Prenatal care: Initial assessment".)

A study was conducted using data from the 2014 to 2016 Behavioral Risk Surveillance System, and Gonzales et al found that SMW had more frequent issues with depression, mental distress, chronic health issues, and poorer quality of health when pregnant compared with pregnant heterosexual women, and they were more likely to be daily cigarette smokers [130].

SPECIAL POPULATIONS

Adolescents — LGBTQ youth issues are presented separately.

●(See "Adolescent sexuality".)

●(See "Gender development and clinical presentation of gender diversity in children and adolescents".)

●(See "Management of transgender and gender-diverse children and adolescents".)

●(See "Lesbian, gay, bisexual, and other sexual minoritized youth: Primary care".)

●(See "Lesbian, gay, bisexual, and other sexual minoritized youth: Epidemiology and health concerns".)

Older women — While there are no medical guidelines unique to the care of older SMW, clinicians should be aware of the potential impact of lifelong stigmatization, victimization, and discrimination on older SMW and inquire about these issues [131]. A population-based study in Washington affirmed that, when compared with heterosexual women, older LGBTQ individuals have higher rates of obesity, mental health issues, smoking and alcohol use, and cardiovascular disease [132]. In addition to these mental and physical health challenges, older LGBTQ patients can face significant life-changing issues, including sexual issues; isolation and lack of social support; problems with financial security; end-of-life issues with housing, long-term care, and palliative care; and the experience of discrimination and mistreatment in these situations [133]. These health disparities, estrangement from family, and lower rates of parenting and/or partnering result in a group that can require more access to health and human services as they age [132,134,135]. The long-term care issues of older LGBTQ women requires more study. SAGE (Services and Advocacy for GLBT Elders) is a national organization that has many resources for LGBTQ elders and caretakers.

Transgender individuals — The care needs specific to transgender individuals is presented separately. (See "Primary care of transgender individuals" and "Transgender women: Evaluation and management" and "Transgender men: Evaluation and management".)

Immigrants, political refugees, and other disenfranchised sexual minorities — The safety and health care of sexual minority persons varies around the globe. Sexual minority persons may be subjected to sexual assault, "corrective rape" [136], imprisonment [137], abuse, and torture. This marginalization and stigmatization, combined with higher rates of poverty and abuse, are major chronic stressors that can lead to mental health disorders and significant health morbidity [138]. Detailed information on the health care needs of immigrants and refugees is presented separately. (See "Medical screening of adult immigrants and refugees".)

RESOURCES FOR PATIENTS AND CLINICIANS

●Websites

•National LGBTQIA+ Health Education Center – Provides free online training, including videos and webinars, and education on many LGBT health topics.

•United States Department of Health and Human Services

•Centers for Disease Control and Prevention

•GLMA – Formerly known as the Gay & Lesbian Medical Association, the GLMA is an association of LGBT health care professionals that provides free resources for patients and providers.

•Fenway Health – "The mission of Fenway Health is to enhance the well-being of the LGBTQIA+ community and all people in our neighborhoods and beyond through access to the highest quality care, education, research, and advocacy."

•HealthyPeople.gov

•Institute of Medicine

•National Alliance on Mental Illness

•American Academy of Pediatrics

•SAGE (Services and Advocacy for LGBT Elders)

•Centers for Medicare and Medicaid Services, Office of Minority Health

●Books

•Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health, 2^nd ed, Makadon HJ, Mayer KH, Potter J, Goldhammer H (Eds), American College of Physicians, Philadelphia 2015.

•Lesbian, Gay, Bisexual, and Transgender Healthcare: A Clinical Guide to Preventive, Primary, and Specialist Care, 1^st ed, Eckstrand KL, Ehrenfeld JM (Eds), Springer, 2016.

•Lesbian Health 101: A Clinician's Guide, 1^st ed, Dibble SL, Robertson PA (Eds), UCSF Nursing Press, 2010.

•LGBT Health: Meeting the Needs of Gender and Sexual Minorities, Smalley KB, Warren JC, Barefoot KN (Eds), Springer, New York 2017.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Health care for lesbian, gay, and other sexual minority populations".)

SUMMARY AND RECOMMENDATIONS

●Sexual orientation refers to one's innermost emotional, romantic, and sexual attractions to other people. Historically, sexual orientation was thought of with three main categories including heterosexual, homosexual (lesbian or gay), and bisexual. However, many perceive their attractions as more fluid than this, and do not identify within these binary categories and instead identify as queer, pansexual, etc. Sexual behavior embraces a complex spectrum of patterns of romantic and/or sexual activities and therefore may not be so clearly categorized. Studies surveying self-identified lesbians show a wide range of sexual behaviors (eg, celibacy, opposite or different sex partners, same sex partners, or both). (See 'Language and terminology' above.)

●Obtaining accurate information about the prevalence of sexual minority women (SMW) is challenging because gender, sex, and behavior are not the same, and national census surveys have historically not asked about sexual orientation or gender identity. In the United States, gay and lesbian people were first recognized as a subpopulation on the 1990 census. Rates of same-sex sexual behavior are higher than rates of self-identification as lesbian or bisexual. (See 'Prevalence' above.)

●Societal stigma, discrimination, and denial of civil and human rights can result in health care and other disparities. When individuals do not conform to established heteronormative gender roles, their access to and control over resources that contribute to health can also be reduced. Recognizing women who identify with sexual minority groups is important because it allows patients to be known and affirmed by their provider, and it allows the provider to be aware of potential health disparities such as SMWs' increased risk for adverse health outcomes, including mood disorders, tobacco and substance use, and sexually transmitted infections. (See 'Impact of sexual orientation on health' above.)

●Cultural competency focuses on the ability to communicate effectively and provide quality health care to patients from diverse sociocultural backgrounds. Not making assumptions about patient's sexual orientation identity or behaviors is fundamental in providing inclusive care. Professionalism, confidentiality, being aware of internal assumptions, and an unbiased approach are key components for enabling women to identify themselves as well as for better interactions between them and their health care providers. (See 'Cultural competency' above.)

●While there are no diseases specific to SMW, the health disparities that result from identification with a minority group and the risks associated with specific health behaviors require additional consideration. Specific issues that warrant discussion with SMW include mental health and support systems, cancer screening and prevention, sexually transmitted infections, obesity, protection from unplanned pregnancy, plans for pregnancy, substance use, and intimate partner violence. (See 'Issues with additional risk' above.)

●The components of the physical examination and age-appropriate screening guidelines for SMW are the same as for non-SMW. As with any patient, the clinician should be alert for signs of physical or emotional discomfort that may indicate a history of trauma, and be aware of how to provide trauma-informed care. (See 'Physical examination' above.)

●SMW encounter special obstacles in fulfilling their desires to become parents, including homophobic stigmatization, potential rejection by family or communities, and limited access to and availability of resources such as sperm banks and insurance coverage. SMW have several possible paths to parenthood including conception through donor insemination or in vitro fertilization, use of a surrogate, foster parenting, adoption or raising children from prior heterosexual relationships. Both the Ethics Committee of the American Society for Reproductive Medicine and the American College of Obstetricians and Gynecologists have affirmed the right of single or coupled, gay, and lesbian persons to have access to fertility services. (See 'Pregnancy and parenting' above.)

●Within the diverse group of women who identify as SMW, subpopulations with specific health care needs include adolescents, older individuals, transgender individuals, and immigrants and refugees. (See 'Special populations' above.)