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 Sexual Health

Parents, Educators Can Support Pediatricians in Providing Comprehensive Sexuality Education

Nicole Cushman

While medical systems will need to evolve to address the challenges preventing pediatricians from sharing medically accurate and age-appropriate information about sexuality with their patients, there are several things I recommend parents and educators do to reinforce AAP’s guidance.

Last week, the American Academy of Pediatrics (AAP) released a clinical report outlining guidance for pediatricians on providing sexuality education to the children and adolescents in their care. As one of the most influential medical associations in the country, AAP brings, with this report, added weight to longstanding calls for comprehensive sex education.

The report offers guidance for clinicians on incorporating conversations about sexual and reproductive health into routine medical visits and summarizes the research supporting comprehensive sexuality education. It acknowledges the crucial role pediatricians play in supporting their patients’ healthy development, making them key stakeholders in the promotion of young people’s sexual health. Ultimately, the report could bolster efforts by parents and educators to increase access to comprehensive sexuality education and better equip young people to grow into sexually healthy adults.

But, while the guidance provides persuasive, evidence-backed encouragement for pediatricians to speak with parents and children and normalize sexual development, the report does not acknowledge some of the practical challenges to implementing such recommendations—for pediatricians as well as parents and school staff. Articulating these real-world challenges (and strategies for overcoming them) is essential to ensuring the report does not wind up yet another publication collecting proverbial dust on bookshelves.

The AAP report does lay the groundwork for pediatricians to initiate conversations including medically accurate and age-appropriate information about sexuality, and there is plenty in the guidelines to be enthusiastic about. Specifically, the report acknowledges something sexuality educators have long known—that a simple anatomy lesson is not sufficient. According to the AAP, sexuality education should address interpersonal relationships, body image, sexual orientation, gender identity, and reproductive rights as part of a comprehensive conversation about sexual health.

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The report further acknowledges that young people with disabilities, chronic health conditions, and other special needs also need age- and developmentally appropriate sex education, and it suggests resources for providing care to LGBTQ young people. Importantly, the AAP rejects abstinence-only approaches as ineffective and endorses comprehensive sexuality education.

It is clear that such guidance is sorely needed. Previous studies have shown that pediatricians have not been successful at having conversations with their patients about sexuality. One study found that one in three adolescents did not receive any information about sexuality from their pediatrician during health maintenance visits, and those conversations that did occur lasted less than 40 seconds, on average. Another analysis showed that, among sexually experienced adolescents, only a quarter of girls and one-fifth of boys had received information from a health-care provider about sexually transmitted infections or HIV in the last year. 

There are a number of factors at play preventing pediatricians from having these conversations. Beyond parental pushback and anti-choice resistance to comprehensive sex education, which Martha Kempner has covered in depth for Rewire, doctor visits are often limited in time and are not usually scheduled to allow for the kind of discussion needed to build a doctor-patient relationship that would be conducive to providing sexuality education. Doctors also may not get needed in-depth training to initiate and sustain these important, ongoing conversations with patients and their families.

The report notes that children and adolescents prefer a pediatrician who is nonjudgmental and comfortable discussing sexuality, answering questions and addressing concerns, but these interpersonal skills must be developed and honed through clinical training and practice. In order to fully implement the AAP’s recommendations, medical school curricula and residency training programs would need to devote time to building new doctors’ comfort with issues surrounding sexuality, interpersonal skills for navigating tough conversations, and knowledge and skills necessary for providing LGBTQ-friendly care.

As AAP explains in the report, sex education should come from many sources—schools, communities, medical offices, and homes. It lays out what can be a powerful partnership between parents, doctors, and educators in providing the age-appropriate and truly comprehensive sexuality education that young people need and deserve. While medical systems will need to evolve to address the challenges outlined above, there are several things I recommend parents and educators do to reinforce AAP’s guidance.

Parents and Caregivers: 

  • When selecting a pediatrician for your child, ask potential doctors about their approach to sexuality education. Make sure your doctor knows that you want your child to receive comprehensive, medically accurate information about a range of issues pertaining to sexuality and sexual health.
  • Talk with your child at home about sex and sexuality. Before a doctor’s visit, help your child prepare by encouraging them to think about any questions they may have for the doctor about their body, sexual feelings, or personal safety. After the visit, check in with your child to make sure their questions were answered.
  • Find out how your child’s school approaches sexuality education. Make sure school administrators, teachers, and school board members know that you support age-appropriate, comprehensive sex education that will complement the information provided by you and your child’s pediatrician.

School Staff and Educators: 

  • Maintain a referral list of pediatricians for parents to consult. When screening doctors for inclusion on the list, ask them how they approach sexuality education with patients and their families.
  • Involve supportive pediatricians in sex education curriculum review committees. Medical professionals can provide important perspective on what constitutes medically accurate, age- and developmentally-appropriate content when selecting or adapting curriculum materials for sex education classes.
  • Adopt sex-education policies and curricula that are comprehensive and inclusive of all young people, regardless of sexual orientation or gender identity. Ensure that teachers receive the training and support they need to provide high-quality sex education to their students.

The AAP clinical report provides an important step toward ensuring that young people receive sexuality education that supports their healthy sexual development. If adopted widely by pediatricians—in partnership with parents and schools—the report’s recommendations could contribute to a sea change in providing young people with the care and support they need.

Roundups Sexual Health

This Week in Sex: The Sexually Transmitted Infections Edition

Martha Kempner

A new Zika case suggests the virus can be transmitted from an infected woman to a male partner. And, in other news, HPV-related cancers are on the rise, and an experimental chlamydia vaccine shows signs of promise.

This Week in Sex is a weekly summary of news and research related to sexual behavior, sexuality education, contraception, STIs, and more.

Zika May Have Been Sexually Transmitted From a Woman to Her Male Partner

A new case suggests that males may be infected with the Zika virus through unprotected sex with female partners. Researchers have known for a while that men can infect their partners through penetrative sexual intercourse, but this is the first suspected case of sexual transmission from a woman.

The case involves a New York City woman who is in her early 20s and traveled to a country with high rates of the mosquito-borne virus (her name and the specific country where she traveled have not been released). The woman, who experienced stomach cramps and a headache while waiting for her flight back to New York, reported one act of sexual intercourse without a condom the day she returned from her trip. The following day, her symptoms became worse and included fever, fatigue, a rash, and tingling in her hands and feet. Two days later, she visited her primary-care provider and tests confirmed she had the Zika virus.

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A few days after that (seven days after intercourse), her male partner, also in his 20s, began feeling similar symptoms. He had a rash, a fever, and also conjunctivitis (pink eye). He, too, was diagnosed with Zika. After meeting with him, public health officials in the New York City confirmed that he had not traveled out of the country nor had he been recently bit by a mosquito. This leaves sexual transmission from his partner as the most likely cause of his infection, though further tests are being done.

The Centers for Disease Control and Prevention (CDC)’s recommendations for preventing Zika have been based on the assumption that virus was spread from a male to a receptive partner. Therefore the recommendations had been that pregnant women whose male partners had traveled or lived in a place where Zika virus is spreading use condoms or abstain from sex during the pregnancy. For those couples for whom pregnancy is not an issue, the CDC recommended that men who had traveled to countries with Zika outbreaks and had symptoms of the virus, use condoms or abstain from sex for six months after their trip. It also suggested that men who traveled but don’t have symptoms use condoms for at least eight weeks.

Based on this case—the first to suggest female-to-male transmission—the CDC may extend these recommendations to couples in which a female traveled to a country with an outbreak.

More Signs of Gonorrhea’s Growing Antibiotic Resistance

Last week, the CDC released new data on gonorrhea and warned once again that the bacteria that causes this common sexually transmitted infection (STI) is becoming resistant to the antibiotics used to treat it.

There are about 350,000 cases of gonorrhea reported each year, but it is estimated that 800,000 cases really occur with many going undiagnosed and untreated. Once easily treatable with antibiotics, the bacteria Neisseria gonorrhoeae has steadily gained resistance to whole classes of antibiotics over the decades. By the 1980s, penicillin no longer worked to treat it, and in 2007 the CDC stopped recommending the use of fluoroquinolones. Now, cephalosporins are the only class of drugs that work. The recommended treatment involves a combination of ceftriaxone (an injectable cephalosporin) and azithromycin (an oral antibiotic).

Unfortunately, the data released last week—which comes from analysis of more than 5,000 samples of gonorrhea (called isolates) collected from STI clinics across the country—shows that the bacteria is developing resistance to these drugs as well. In fact, the percentage of gonorrhea isolates with decreased susceptibility to azithromycin increased more than 300 percent between 2013 and 2014 (from 0.6 percent to 2.5 percent).

Though no cases of treatment failure has been reported in the United States, this is a troubling sign of what may be coming. Dr. Gail Bolan, director of CDC’s Division of STD Prevention, said in a press release: “It is unclear how long the combination therapy of azithromycin and ceftriaxone will be effective if the increases in resistance persists. We need to push forward on multiple fronts to ensure we can continue offering successful treatment to those who need it.”

HPV-Related Cancers Up Despite Vaccine 

The CDC also released new data this month showing an increase in HPV-associated cancers between 2008 and 2012 compared with the previous five-year period. HPV or human papillomavirus is an extremely common sexually transmitted infection. In fact, HPV is so common that the CDC believes most sexually active adults will get it at some point in their lives. Many cases of HPV clear spontaneously with no medical intervention, but certain types of the virus cause cancer of the cervix, vulva, penis, anus, mouth, and neck.

The CDC’s new data suggests that an average of 38,793 HPV-associated cancers were diagnosed each year between 2008 and 2012. This is a 17 percent increase from about 33,000 each year between 2004 and 2008. This is a particularly unfortunate trend given that the newest available vaccine—Gardasil 9—can prevent the types of HPV most often linked to cancer. In fact, researchers estimated that the majority of cancers found in the recent data (about 28,000 each year) were caused by types of the virus that could be prevented by the vaccine.

Unfortunately, as Rewire has reported, the vaccine is often mired in controversy and far fewer young people have received it than get most other recommended vaccines. In 2014, only 40 percent of girls and 22 percent of boys ages 13 to 17 had received all three recommended doses of the vaccine. In comparison, nearly 80 percent of young people in this age group had received the vaccine that protects against meningitis.

In response to the newest data, Dr. Electra Paskett, co-director of the Cancer Control Research Program at the Ohio State University Comprehensive Cancer Center, told HealthDay:

In order to increase HPV vaccination rates, we must change the perception of the HPV vaccine from something that prevents a sexually transmitted disease to a vaccine that prevents cancer. Every parent should ask the question: If there was a vaccine I could give my child that would prevent them from developing six different cancers, would I give it to them? The answer would be a resounding yes—and we would have a dramatic decrease in HPV-related cancers across the globe.

Making Inroads Toward a Chlamydia Vaccine

An article published in the journal Vaccine shows that researchers have made progress with a new vaccine to prevent chlamydia. According to lead researcher David Bulir of the M. G. DeGroote Institute for Infectious Disease Research at Canada’s McMaster University, efforts to create a vaccine have been underway for decades, but this is the first formulation to show success.

In 2014, there were 1.4 million reported cases of chlamydia in the United States. While this bacterial infection can be easily treated with antibiotics, it often goes undiagnosed because many people show no symptoms. Untreated chlamydia can lead to pelvic inflammatory disease, which can leave scar tissue in the fallopian tubes or uterus and ultimately result in infertility.

The experimental vaccine was created by Canadian researchers who used pieces of the bacteria that causes chlamydia to form an antigen they called BD584. The hope was that the antigen could prompt the body’s immune system to fight the chlamydia bacteria if exposed to it.

Researchers gave BD584 to mice using a nasal spray, and then exposed them to chlamydia. The results were very promising. The mice who received the spray cleared the infection faster than the mice who did not. Moreover, the mice given the nasal spray were less likely to show symptoms of infection, such as bacterial shedding from the vagina or fluid blockages of the fallopian tubes.

There are many steps to go before this vaccine could become available. The researchers need to test it on other strains of the bacteria and in other animals before testing it in humans. And, of course, experience with the HPV vaccine shows that there’s work to be done to make sure people get vaccines that prevent STIs even after they’re invented. Nonetheless, a vaccine to prevent chlamydia would be a great victory in our ongoing fight against STIs and their health consequences, and we here at This Week in Sex are happy to end on a bit of a positive note.