Q & A Sexual Health

Queering Sex Ed: What You Need to Know About Sex Between Women

Taja Lindley

Just in time for STD Awareness Month, Dr. Tonia Poteat answers questions about queer sexual health—from the most common sexually transmitted infections among queer women to describing how we can protect ourselves and reduce the risk of transmission.

Editor’s note: A previous version of this article referred to the people this article meant to help as “cisgender women.” We decided to remove the “cisgender” specification because after careful consideration we came to the conclusion it was needlessly exclusive. Throughout the article, when the interviewer and interviewee use the term “woman” or “women” they are referring to people who have female-assigned genitals at birth. We regret any confusion the term “cisgender” may have caused.

This piece is published in collaboration with Echoing Ida, a Strong Families project.

Last month, I wrote an article about the challenges of navigating my sexual health in bedrooms and exam rooms as a queer woman of color. I had lots of questions about safer sex practices as a woman who has sex with other women, but during my gynecological visit, my health provider had very few answers.

It’s frustrating. Queer sex isn’t uncommon. So why is it so challenging to find the information we need to take care of our sexual health? Where can I find accurate and comprehensive information that can address my concerns?

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Just in time for STD Awareness Month, I had an opportunity to interview a culturally competent woman of color health provider and ask all of the questions I had about queer sexual healthnamely, sex between women.

Meet Tonia Poteat, a certified physician assistant and adjunct assistant professor in the Department of International Health at the Johns Hopkins Bloomberg School of Public Health, where she teaches “Introduction to Sexual Orientation, Gender Identity, and Public Health” and conducts research on LGBTQ health disparities. She sits on the editorial board of LGBT Health as well as on the education committee of the Gay and Lesbian Medical Association, and she has worked as a clinician for 18 years, devoting her practice to providing medically appropriate and culturally competent care to LGBTQ communities and people living with HIV. She has worked at nationally recognized LGBT health centers, including the Callen-Lorde Community Health Center in New York and Chase Brexton Health Services in Baltimore.

Basically, she knows what she’s talking about. So let’s get right to it.

Rewire: If you had to give the nitty-gritty, safe(r) sex 101 for women who have sex with women, what would you say?

Tonia Poteat: Sexual behavior among women is so varied. A study was published in 2012 describing the variety and frequency of sex acts between women. This study included over 3,000 women, mostly from the United States and the United Kingdom. The most common sex acts included (in order): genital rubbing, vaginal fingering, cunnilingus (oral-vaginal sex), and genital scissoring.

As a clinician during individual sessions, I work to provide an environment where the woman feels safe, then I ask her to tell me more about the type of sex that she has. Once I have that information, I talk with her about how to make what she enjoys doing safer for her and her partner(s), based on what we know about which fluids transmit what infections.

I have also done safer sex workshops for women. In those workshops, we list sexual fluids that can transmit sexually transmitted diseases (STDs): menstrual blood, vaginal secretions, and fecal matter. Next, we list the places where STDs can enter the body during sex: broken skin, anus, vagina, mouth. Finally, we brainstorm a list of possible sex acts between women, rank them by risk for various infections, and talk about how to make each act safer. For example, when discussing risk for HIV transmission, oral sex on a woman is higher risk than fingering her (assuming there’s no broken skin). While HIV lives in vaginal fluid, it’s harder for it to enter intact skin than the soft mucous membranes of the mouth.

Rewire: What is considered “risky” sex for queer women? And how can we best protect ourselves and reduce the risk of transmission?

TP: “Risk” varies depending on which sexually transmitted infection (STI) you are trying to prevent. For example, herpes is very common, and it can be transmitted by skin-to-skin contact. Because the herpes virus can shed even when there are no sores, the best ways to prevent herpes transmission include: using latex barriers (condoms, gloves, or dental dams) and/or having the partner with herpes take antiviral medications such as valacyclovir as prophylaxis. Other STIs that are transmitted by blood or vaginal secretions (such as HIV) can be prevented by anything that keeps the fluid away from an opening—using latex barriers for oral sex, washing or changing condoms when sex toys are shared, not sharing sex toys, wearing gloves for fingering, etc.

The same study that reported on sexual acts between women also looked at safer sex strategies most often used by women. Cleaning sex toys before or after use was most common (70 to 80 percent), using a condom was less common (12 to 21 percent), and using a dental dam was rare (less than 5 percent). While this study provided important information on sexual behavior between women, it did not include the entire repertoire of potential sex acts or safer-sex strategies that could be used between women. For example, it did not include questions about analingus (oral-anal sex) or about the use of finger cots or gloves. This study did not assess why condom and dental dam use were less common than cleaning sex toys. However, other studies have found that women rarely practice safer sex with each other because they are not at risk for pregnancy with a female partner, and they believe that sex between women poses little risk for STI transmission.

Rewire: What are the most common STIs among women who have sex with women?

TP: The most comprehensive review of STIs among women was published in 2011. According to this summary of the evidence, human papillomavirus (HPV) and herpes simplex virus (HSV) are common among women who have sex with women, while gonorrhea and chlamydia are rarer. Studies also suggest that bacterial vaginosis can be transmitted between women as well as trichomonas, syphilis, and hepatitis A. There have been two confirmed cases of HIV transmission between women—one reported in 2003 and the most recent reported this year. However, this data is based on a review of individual studies because no national surveillance tracks HIV or STIs among women who have sex with women.

Rewire: I’m aware that HPV is one of the most common sexually transmitted infections among women, regardless of sexual orientation. Given its prevalence, how can HPV be transmitted between women? Is this something we should be concerned about?

TP: HPV comes in many different types and is transmitted through skin-to-skin contact. Some types cause warts, while other “high-risk” types cause cervical cancer. The types that cause genital warts are not the same as the types that cause cancer. However, it is possible to have more than one strain at a time. Just like other women, women who have sex with women should be tested if they have an abnormal cervical cancer screening test or if they are over the age of 30.

In terms of ranking ease of transmission, it’s easiest for viruses to enter through broken skin; next easiest is mucous membranes (the soft skin inside the mouth, vagina, anus); the hardest is intact skin like what is found on the fingers.

Therefore, HPV is less likely to be transmitted from a vagina to fingers during fingering than vagina to vagina during scissoring. (These are the types of rankings we do in the safer-sex workshops.) Oral sex between women usually involves the mucous membranes of the mouth touching the mucous membranes of the vagina, and HPV can be transmitted that way.

Rewire: The provider I last spoke with during my gynecological exam mentioned that HPV is tested in women under the age of 30 only if abnormal cells are found during the Pap test. Is this true? If so, why is this the case?

TP: Current national guidelines recommend cervical cancer screening at 21 years old and older. These guidelines discourage HPV testing in women younger than 30 years old because HPV often resolves on its own in younger women without intervention. Testing women younger than 30 years old can lead to unnecessary anxiety as well as needless, uncomfortable, and expensive medical procedures. However, if a younger woman has an abnormal result on cervical cancer screening (like a Pap test), then HPV testing may be warranted. The most recent (2012) guidelines for cervical cancer screening and HPV testing can be found here.

Rewire: As you already know, Gardisil is the vaccine that protects against four common strains of HPV. The literature I read usually recommends Gardisil for people up until age 26, but what about for women who are older? A friend once said Gardisil has only been tested on women up to age 26, which is why they only recommend it up until that age. Is that true? And does the HPV vaccine have any particular importance for women who have sex with women?

TP: Vaccination against HPV is not currently recommended for women over age 26 because research studies found that it provided very little protection against HPV-related diseases, specifically cervical cancer, after this age. The HPV vaccine works best when it’s given before someone starts having sex. Because HPV is so common, it’s likely that someone who has been having sex will already have been exposed to at least one of the four types that the vaccine works to prevent. It is just as important for women who have sex with women to be vaccinated as it is for any other woman. More information about the HPV vaccine can be found here.

Rewire: My medical provider told me that the herpes test is unreliable and can give a lot of false positives. She said it’s best to test only if there are visible symptoms, like cold sores. Do you agree? And how reliable is the herpes test? Are there different tests for the disease?

TP: There are several tests for herpes available on the market. One of these tests (HerpesSelect ELISA) has had problems with false positive results. This is not true of other herpes tests. (See this nice explanation of false positive herpes tests in a blog by Dr. Peter Leone in the New York Times.)

The Centers for Disease Control and Prevention (CDC) recommends herpes testing in the following situations:

  1. When someone has genital symptoms that might be related to herpes, to confirm the diagnosis;
  2. When someone has a sex partner with history of genital herpes, to see if they are infected;
  3. When seeking a full STD evaluation, especially when someone has multiple sex partners.

Rewire: Why do medical providers have difficulty providing information about these things? I imagine queer sex is quite common. What’s the disconnect?

TP: Unfortunately, most medical providers receive little to no training in queer sexual health. In addition, many providers have a hard time imagining the variety of sexual acts possible. (Just think of all the people who ask, “What do two women do together, anyway?”) Thus, most providers are unprepared to give culturally competent and medically accurate information. This is slowly changing as more medical, nursing, and physician assistant programs begin to integrate LGBT health into their curricula.

Rewire: A friend of mine mentioned to me that the medical research concerning women who have sex with women is limited and is partly to blame for why providers give wrong or inconsistent information. Is she right? How reliable is the research? And is this population a priority in sexual health research?

TP: While medical research on women who have sex with women is limited, it is not completely absent. Many people are simply not aware that the research is out there.

Or they make assumptions about the sexual behaviors of queer women and respond based on myths rather than data. Research that is published in a peer-reviewed scientific journal is considered the highest standard of evidence. This is the evidence I’ve been citing to respond to your questions. Because the HIV epidemic has had such a dramatic impact on men who have sex with men, sexual health research among that population has been a high priority for institutes that fund sexual health research. However, entities like the Lesbian Health Fund do prioritize studies of lesbian health.

Rewire: Are there any additional resources you can provide for women who have sex with women who are looking for more information about how to navigate their sexual and reproductive health?

TP: These two are my favorite go-to sites: LesbianSTD.com and WomensHealth.gov. I recently found this nice website from Australia that provides some reader-friendly info on the variety of sex that queer women can have, along with STD information.

An additional resource for those who are navigating queer-friendly health plans and providers is Where to Start, What to Ask, developed by Strong Families. And since Dr. Poteat was being modest, I’ll also direct you to the Gay and Lesbian Medical Association’s “Top 10 Things Lesbians Should Discuss With Their Healthcare Provider,” which she authored.

This interview was edited lightly.

Commentary Politics

Milwaukee Officials: Black Youth, Single Mothers Are Not Responsible for Systemic Failings—You Are

Charmaine Lang

Milwaukee has multiple problems: poverty, a school system that throws out Black children at high rates, and lack of investment in all citizens' quality of life. But there's another challenge: politicians and law enforcement who act as if Black youth, single mothers, and families are the "real" reasons for the recent uprising and say so publicly.

This piece is published in collaboration with Echoing Ida, a Forward Together project.

On the day 23-year-old Sylville Smith was killed by a Milwaukee police officer, the city’s mayor, Tom Barrett, pleaded publicly with parents to tell their children to come home and leave protests erupting in the city.

In a August 13 press conference, Barrett said: “If you love your son, if you love your daughter, text them, call them, pull them by the ears, and get them home. Get them home right now before more damage is done. Because we don’t want to see more loss of life, we don’t want to see any more injuries.”

Barrett’s statement suggests that parents are not on the side of their sons and daughters. That parents, too, are not tired of the inequality they experience and witness in Milwaukee, and that youth are not capable of having their own political ideologies or moving their values into action.

It also suggests how much work Milwaukee’s elected officials and law enforcement need to do before they open their mouths.

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Barrett’s comments came after Smith fled a traffic stop and was shot by authorities on Milwaukee’s northwest side. The young Black man’s death sparked an urban uprising in the Sherman Park neighborhood, an area known for its racial and religious diversity. Businesses were burnt down, and the National Guard was activated in a city plagued by racism and poverty.

But Milwaukee parents and families need more than a directive thinly disguised as a plea. And Mayor Barrett, who was re-elected to a fourth term in April, should know well that Milwaukee, the nation’s most racially stratified city, needs racial equity in order for there to be peace and prosperity.

I live in Milwaukee, so I know that its residents, especially its Black parents, do love their children. We want more for them than city-enforced curfews and a simplistic solution of returning to their homes as a way to restore calm. We will have calm when we have greater investment in the public school system and youth services; easy access to healthy food; and green spaces, parks, and neighborhoods that are free from police harassment.

In fact, according to staggering statistics about Milwaukee and Wisconsin as a whole, Black people have been consistently denied their basic human rights and health. Wisconsin has the highest rate of incarceration of Black men nationwide; the Annie E. Casey Foundation has found it is the worst state for racial disparities affecting Black childrenand infant mortality rates are highest among Black women in the state.

What we absolutely don’t need are public officials whitewashing the facts: that Milwaukee’s young people have much to protest, including Wisconsin’s suspending Black high-school students more than any other state in the country.

Nor do we need incendiary comments like those coming from Milwaukee County Sheriff David Clarke, who drew national attention for his “blue lives matter” speech at the Republican National Convention and who is a regular guest on CNN and Fox News. In an August 15 op-ed published by the Hill, Clarke has called the civil unrest “the rule of the jungle,” “tribalism,” and a byproduct of “bullies on the left.”

He went even further, citing “father-absent homes” as a source of what he calls “urban pathologies”—leaning on old tropes used to stigmatize Black women, families, and the poor.

Single mothers are not to be blamed for young people’s responses to a city that ignores or criminalizes them. They should not be shamed for having children, their family structure, or for public policy that has made the city unsafe for parenting.

Creating justice—including reproductive justice—in Milwaukee will take much more than parents texting their teens to come home. The National Guard must leave immediately. Our leaders must identify anti-Black racism as a root cause of the uprisings. And, lastly, creating justice must start with an end to harmful rhetoric from officials who lead the way in ignoring and dehumanizing Milwaukee residents.

Sheriff Clarke has continued his outrageous comments. In another interview, he added he wouldn’t “be satisfied until these creeps crawl back into their holes so that the good law-abiding people that live in the Milwaukee ghetto can return to at least a calm quality of life.”

Many of Milwaukee’s Black families have never experienced calm. They have not experienced a city that centers their needs and voices. Black youth fed up with their treatment are not creeps.

And what hole do you think they should crawl back into? The hole where they face unemployment, underemployment, police brutality, and racism—and face it without complaint? If that’s the case, you may never be satisfied again, Sheriff.

Our leaders shouldn’t be content with Milwaukee’s status quo. And asking the citizens you serve to be quiet in the ghetto is an insidious expectation.

Culture & Conversation Media

Filmmaker Tracy Droz Tragos Centers Abortion Stories in New Documentary

Renee Bracey Sherman

The film arrives at a time when personal stories are center stage in the national conversation about abortion, including in the most recent Supreme Court decision, and rightly so. The people who actually have and provide abortions should be driving the narrative, not misinformation and political rhetoric.

This piece is published in collaboration with Echoing Ida, a Forward Together project.

A new film by producer and director Tracy Droz Tragos, Abortion: Stories Women Tell, profiles several Missouri residents who are forced to drive across the Mississippi River into Illinois for abortion care.

The 93-minute film features interviews with over 20 women who have had or are having abortions, most of whom are Missouri residents traveling to the Hope Clinic in Granite City, Illinois, which is located about 15 minutes from downtown St. Louis.

Like Mississippi, North Dakota, South Dakota, and Wyoming, Missouri has only one abortion clinic in the entire state.

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The women share their experiences, painting a more nuanced picture that shows why one in three women of reproductive age often seek abortion care in the United States.

The film arrives at a time when personal stories are center stage in the national conversation about abortion, including in the most recent U.S. Supreme Court decision, and rightly so. The people who actually have and provide abortions should be driving the narrative, not misinformation and political rhetoric. But while I commend recent efforts by filmmakers like Droz Tragos and others to center abortion stories in their projects, these creators still have far to go when it comes to presenting a truly diverse cadre of storytellers if they really want to shift the conversation around abortion and break down reproductive stigma.

In the wake of Texas’ omnibus anti-abortion law, which was at the heart of the Whole Woman’s Health v. Hellerstedt Supreme Court case, Droz Tragos, a Missouri native, said in a press statement she felt compelled to document how her home state has been eroding access to reproductive health care. In total, Droz Tragos interviewed 81 people with a spectrum of experiences to show viewers a fuller picture of the barriersincluding legislation and stigmathat affect people seeking abortion care.

Similar to HBO documentaries about abortion that have come before it—including 12th & Delaware and Abortion: Desperate ChoicesAbortion: Stories Women Tell involves short interviews with women who are having and have had abortions, conversations with the staff of the Hope Clinic about why they do the work they do, interviews with local anti-choice organizers, and footage of anti-choice protesters shouting at patients, along with beautiful shots of the Midwest landscape and the Mississippi River as patients make road trips to appointments. There are scenes of clinic escorts holding their ground as anti-choice protesters yell Bible passages and obscenities at them. One older clinic escort carries a copy of Living in the Crosshairs as a protester follows her to her car, shouting. The escort later shares her abortion story.

One of the main storytellers, Amie, is a white 30-year-old divorced mother of two living in Boonville, Missouri. She travels over 100 miles each way to the Hope Clinic, and the film chronicles her experience in getting an abortion and follow-up care. Almost two-thirds of people seeking abortions, like Amie, are already a parent. Amie says that the economic challenges of raising her other children make continuing the pregnancy nearly impossible. She describes being physically unable to carry a baby and work her 70 to 90 hours a week. Like many of the storytellers in the film, Amie talks about the internalized stigma she’s feeling, the lack of support she has from loved ones, and the fear of family members finding out. She’s resilient and determined; a powerful voice.

The film also follows Kathy, an anti-choice activist from Bloomfield, Missouri, who says she was “almost aborted,” and that she found her calling in the anti-choice movement when she noticed “Anne” in the middle of the name “Planned Parenthood.” Anne is Kathy’s middle name.

“OK Lord, are you telling me that I need to get in the middle of this?” she recalls thinking.

The filmmakers interview the staff of the Hope Clinic, including Dr. Erin King, a pregnant abortion provider who moved from Chicago to Granite City to provide care and who deals with the all-too-common protesting of her home and workplace. They speak to Barb, a talkative nurse who had an abortion 40 years earlier because her nursing school wouldn’t have let her finish her degree while she was pregnant. And Chi Chi, a security guard at the Hope Clinic who is shown talking back to the protesters judging patients as they walk into the clinic, also shares her abortion story later in the film. These stories remind us that people who have abortions are on the frontlines of this work, fighting to defend access to care.

To address the full spectrum of pregnancy experiences, the film also features the stories of a few who, for various reasons, placed their children for adoption or continued to parent. While the filmmakers interview Alexis, a pregnant Black high school student whose mother died when she was 8 years old, classmates can be heard in the distance tormenting her, asking if she’s on the MTV reality show 16 and Pregnant. She’s visibly distraught and crying, illustrating the “damned if you do, damned if you don’t” conundrum women of color experiencing unintended pregnancy often face.

Te’Aundra, another young Black woman, shares her story of becoming pregnant just as she received a college basketball scholarship. She was forced to turn down the scholarship and sought an adoption, but the adoption agency refused to help her since the child’s father wouldn’t agree to it. She says she would have had an abortion if she could start over again.

While anti-choice rhetoric has conflated adoption as the automatic abortion alternative, research has shown that most seeking adoption are personally debating between adoption and parenting. This is illustrated in Janet’s story, a woman with a drug addiction who was raising one child with her partner, but wasn’t able to raise a second, so she sought an adoption. These stories are examples of the many societal systems failing those who choose adoption or students raising families, in addition to those fighting barriers to abortion access.

At times, the film feels repetitive and disjointed, but the stories are powerful. The range of experiences and reasons for having an abortion (or seeking adoption) bring to life the data points too often ignored by politicians and the media: everything from economic instability and fetal health, to domestic violence and desire to finish an education. The majority of abortion stories featured were shared by those who already had children. Their stories had a recurring theme of loneliness and lack of support from their loved ones and friends at a time when they needed it. Research has shown that 66 percent of people who have abortions tend to only tell 1.24 people about their experience, leaving them keeping a secret for fear of judgment and shame.

While many cite financial issues when paying for abortions or as the reason for not continuing the pregnancy, the film doesn’t go in depth about how the patients come to pay for their abortions—which is something my employer, the National Network for Abortion Funds (NNAF), directly addresses—or the systemic issues that created their financial situations.

However, it brings to light the hypocrisy of our nation, where the invisible hand of our society’s lack of respect for pregnant people and working parents can force people to make pregnancy decisions based on economic situations rather than a desire to be pregnant or parent.

“I’m not just doing this for me” is a common phrase when citing having an abortion for existing or future children.

Overall, the film is moving simply because abortion stories are moving, especially for audiences who don’t have the opportunity to have someone share their abortion story with them personally. I have been sharing my abortion story for five years and hearing someone share their story with me always feels like a gift. I heard parts of my own story in those shared; however, I felt underrepresented in this film that took place partly in my home state of Illinois. While people of color are present in the film in different capacities, a racial analysis around the issues covered in the film is non-existent.

Race is a huge factor when it comes to access to contraception and reproductive health care; over 60 percent of people who have abortions are people of color. Yet, it took 40 minutes for a person of color to share an abortion story. It seemed that five people of color’s abortion stories were shown out of the over 20 stories, but without actual demographic data, I cannot confirm how all the film’s storytellers identify racially. (HBO was not able to provide the demographic data of the storytellers featured in the film by press time.)

It’s true that racism mixed with sexism and abortion stigma make it more difficult for people of color to speak openly about their abortion stories, but continued lack of visual representation perpetuates that cycle. At a time when abortion storytellers themselves, like those of NNAF’s We Testify program, are trying to make more visible a multitude of identities based on race, sexuality, immigration status, ability, and economic status, it’s difficult to give a ringing endorsement of a film that minimizes our stories and relegates us to the second half of a film, or in the cases of some of these identities, nowhere at all. When will we become the central characters that reality and data show that we are?

In July, at the progressive conference Netroots Nation, the film was screened followed by an all-white panel discussion. I remember feeling frustrated at the time, both because of the lack of people of color on the panel and because I had planned on seeing the film before learning about a march led by activists from Hands Up United and the Organization for Black Struggle. There was a moment in which I felt like I had to choose between my Blackness and my abortion experience. I chose my Black womanhood and marched with local activists, who under the Black Lives Matter banner have centered intersectionality. My hope is that soon I won’t have to make these decisions in the fight for abortion rights; a fight where people of color are the backbone whether we’re featured prominently in films or not.

The film highlights the violent rhetoric anti-choice protesters use to demean those seeking abortions, but doesn’t dissect the deeply racist and abhorrent comments, often hurled at patients of color by older white protesters. These racist and sexist comments are what fuel much of the stigma that allows discriminatory laws, such as those banning so-called race- and sex-selective abortions, to flourish.

As I finished the documentary, I remembered a quote Chelsea, a white Christian woman who chose an abortion when her baby’s skull stopped developing above the eyes, said: “Knowing you’re not alone is the most important thing.”

In her case, her pastor supported her and her husband’s decision and prayed over them at the church. She seemed at peace with her decision to seek abortion because she had the support system she desired. Perhaps upon seeing the film, some will realize that all pregnancy decisions can be quite isolating and lonely, and we should show each other a bit more compassion when making them.

My hope is that the film reaches others who’ve had abortions and reminds them that they aren’t alone, whether they see themselves truly represented or not. That we who choose abortion are normal, loved, and supported. And that’s the main point of the film, isn’t it?

Abortion: Stories Women Tell is available in theaters in select cities and will be available on HBO in 2017.

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