Biologically determined health issues
The sexual lives of LBQ women are diverse and fluid, with movement between identities, attractions and behaviours being common (Box 2). Women may have female partners (and may or may not identify as lesbian), partners of both binary genders (and may identify as bisexual), have partners or attractions to gender diverse people (pansexual) or be polyamorous. A disproportionate number of sex workers are LBQ women, and although many are empowered women working in legalised brothels, some are street workers and at risk of violence and coercion. Contraception is needed for some LBQ women, including for those who have sex with men or with gender diverse or transgender people who were assigned male at birth. Young LBQ women are more likely than their heterosexual peers to have an unintended pregnancy, and this is largely due to contraception messaging being targeted to heterosexual people.1
There is a commonly held myth that women who have sex with women (WSW) are not at risk for sexually transmitted infections (STIs). However, this is incorrect. The Second Australian Study of Health and Relationships found that of the female participants aged between 16 and 69 years, 18.4% of lesbians, 20.4% of heterosexuals and 27.7% of bisexuals had ever been diagnosed with an STI; and 2.8%, 2.7% and 7.3% respectively had had an STI in the past year.2
The most common STIs found in WSW are bacterial vaginosis (BV), herpes simplex, vaginal candida and human papillomavirus. Concordance rates of BV between lesbian couples are as high as 80% (both positive or both negative), and this becomes important in the face of recurrent BV (which can be difficult to treat) or when planning pregnancy or gynaecological procedures.3 Bacterial vaginosis in WSW is associated with a greater number of female partners, a female partner with BV symptoms and smoking.4 Current advice is to offer testing and treatment for a female partner of a woman with BV.
Equally, WSW should be offered cervical screening. They are now a specific target group for the national cervical screening program, given evidence that some subgroups of LBQ women are under-screened.5 Safer sex for WSW relates largely to preventing transmission of vaginal secretions between vaginas by using different fingers or toys in different sites and reducing or protecting sexual contact at times of an herpes simplex outbreak.
Resources for LBQ women on sexual health are listed in Table 1.
Reproduction and parenting
Single and coupled LBQ women have been forming families for decades. The increasingly diverse methods of family formation include home insemination with a known donor, clinic-based insemination or in vitro fertilisation with a known or clinic recruited donor, using a partner’s egg and donor sperm to conceive, and parenting through adoption or fostering.6 Most states and territories in Australia legally allow LBQ women to access assisted reproductive technology services and adoption. Despite this access, many LBQ women prefer to have known sperm donors and inseminate at home. This enables more autonomy in conception, and involvement of the donor in the child’s life. The role for the GP in issues around reproduction includes educating women about fertile times in their cycle for insemination, and optimising safety by advising on the appropriate STI and genetic testing for the donor.