SUPPLEMENT ARTICLE

Sexually Transmitted Infections Among Women

Who Have Sex With Women
Linda M. Gorgos1 and Jeanne M. Marrazzo2
1Infectious Disease Bureau, Public Health Division, New Mexico Department of Health, Santa Fe; and 2Department of Medicine, Division of Allergy and

Infectious Diseases, University of Washington, Seattle

Women who have sex with women (WSW) are a diverse group with variations in sexual identity, sexual
behaviors, sexual practices, and risk behaviors. WSW are at risk of acquiring bacterial, viral, and protozoal
sexually transmitted infections (STIs) from current and prior partners, both male and female. Bacterial
vaginosis is common among women in general and even more so among women with female partners. WSW
should not be presumed to be at low or no risk for STIs based on sexual orientation, and reporting of same-sex
behavior by women should not deter providers from considering and performing screening for STIs, including
chlamydia, in their clients according to current guidelines. Effective delivery of sexual health services to WSW
requires a comprehensive and open discussion of sexual and behavioral risks, beyond sexual identity, between
care providers and their female clients.

Based on the 2002 National Survey of Family Growth
(NSFG), a nationally representative sample of house-
holds in the United States, 4.4% of women aged 1544
years reported having a female sex partner in the past 12
months and 1.3% reported having exclusively female sex
partners in the past 12 months. Using measures of both
self-reported sexual identity and sexual behavior, it was
estimated that 1.3%1.9% of US women are lesbians
and that 3.1%4.8% are bisexual [1]. Lifetime same-sex
behavior is commonly reported by women in large
population-based surveys, ranging from 11.2% of
women in the 2002 NSFG to 7.1% of women in National
Health and Nutrition Examination Survey (NHANES),
20012006 [1, 2].
Although extensive data are available regarding sex-
ually transmitted infections (STIs) among men who
have sex with men, relatively little has been published
Correspondence: Linda Gorgos, MD, MSc, Medical Director, Infectious Disease
Bureau, Public Health Division, New Mexico Department of Health, 1190 St Francis
Dr, Runnels Bldg - S1157, Santa Fe, NM 87502 (lgorgos@pol.net).
Clinical Infectious Diseases 2011;53(S3):S8491
The Author 2011. Published by Oxford University Press on behalf of the
Infectious Diseases Society of America. All rights reserved. For Permissions,
please e-mail: journals.permissions@oup.com.
1058-4838/2011/53S3-0004$14.00
DOI: 10.1093/cid/cir697
about STI prevalence and risks among other sexual and
gender minorities, including women who have sex
with women (WSW). Health care providers and their
female clients would benefit from increased knowledge
of STI risks and testing guidance for women who have
same-sex partners.
METHODS
In preparation for the 2010 update to the Centers for
Disease Control and Preventions Sexually Transmitted
Diseases (STD) Treatment Guidelines, a systematic
search of the literature on sexually transmitted
infections in WSW was conducted using PubMed
(National Library of Medicine) in October 2008 with
subsequent updates through December 2010. MeSH
(Medical Subject Heading) terms and key words used
included lesbian, women who have sex with
women, homosexuality, female, sexually trans-
mitted disease, gonorrhea, chlamydia, syphilis,
herpes simplex virus, human papillomavirus, and
human immunodeficiency virus. Abstracts from
major STDrelated meetings during the time period
20052009 were also searched using the same search
terms and were considered for inclusion. Authors of
abstracts were contacted for more information if

S84 d CID 2011:53 (Suppl 3) d Gorgos and Marrazzo

necessary. Key questions were developed based on review of
these sources and in consultation with experts in the fields of
infectious disease and gender minority health.
RESULTS
What Is Known About the Current Epidemiology of STIs Among
WSW?
Chlamydia trachomatis and Neisseria gonorrhoeae infections
among WSW have been considered uncommon. Earlier studies
that included women from STD clinics and sexual health centers
reported a prevalence of chlamydial infection among WSW
ranging from 0.6% to 3.0% and of gonorrhea from 0.3% to 2.8%
[36]. However, no data on C. trachomatis or N. gonorrhoeae
infections in WSW from community-based or population-based
venues were available. In 2008, Singh et al [7] examined chla-
mydia positivity among WSW aged 1524 years tested at family
planning clinics participating in the Infertility Prevention
Project in the northwestern United States from 1997 to 2005.
WSW and women who have sex with both men and women
(WSMW) in the 12 months prior to testing were included.
Chlamydia positivity was 7.1% among both WSW and WSMW
and remained stable over the period of observation in the study.
Chlamydia positivity during the same time period for women
reporting only male partners in the 12 months prior to testing
was 5.3%. Risks for chlamydial infection among WSW and
WSMW were age ,20 years, nonwhite race/ethnicity, new sex
partner, symptomatic sex partner, symptoms, exposure to
C. trachomatis and cervicitis, and did not differ from those
traditionally identified among women who report sex only
with men.
Other STIs can be passed between female partners, in-
cluding trichomoniasis [8], syphilis [9], and hepatitis A [10].
Although it is presumably rare, sexual transmission of human
immunodeficiency virus (HIV) may also occur in this manner
[11]. Prior data suggesting potential HIV transmission be-
tween female partners is based on case reports where pre-
sumed female-to-female transmission was based on a lack of
other identified risk factors [1214]. A survey of 960 000
female blood donors failed to identify any HIV-infected
women who identified same-sex contact as their sole risk
factor [15]. Similar results were seen in a much smaller survey
of lesbian and bisexual women [16]. A 2003 case report is
unique in identifying a woman with no other reported be-
havioral risk for HIV acquisition other than sexual contact
with her sole female partner; she was found to be recently
infected with a similar HIV genotype to her known HIV-
infected female partner [11]. More common is the potential
for WSW to acquire HIV through other modes, including
injection drug use and sexual contact with high-risk male
partners [1719].
Viral STIs including herpes simplex virus type 1 and 2 (HSV-1
and HSV-2) and human papillomavirus (HPV) occur in WSW.
Data from the 2002 NSFG were used to examine self-reported
viral STIs among women aged 1544 years. A history of genital
herpes or genital warts was reported more frequently by bisexual
women (15.0%17.2%) than by lesbians (2.3%6.7%) and their
heterosexual counterparts (8.7%10.0%) [20].
A seroprevalence study of HSV in 392 WSW found that 46%
had antibodies to HSV-1 and 8% had antibodies to HSV-2.
Increasing age was predictive of higher seroprevalence of both
HSV-1 and 2, and HSV-2 seropositivity was associated with
having a male partner with genital herpes. Of the 78 women in
the study reporting never having had a male partner, 3% were
HSV-2 seropositive. HSV-1 seroprevalence increased with
higher numbers of female partners [21]. In a separate study of
HSV-1 prevalence and acquisition among young women, re-
ceptive oral sex was associated with HSV-1 acquisition [22].
More recent data from NHANES conducted in 20012006
among women aged 1859 years demonstrated an HSV-2
seroprevalence of 30.3% among women reporting same-sex
partners in the past year, 36.2% among women reporting same-
sex partners in their lifetime, and 23.8% among women
reporting no lifetime same-sex behavior [2]. HSV-2 seropreva-
lence among women self-identifying as homosexual or lesbian
was 8.2%, similar to a previous clinic-based study of WSW
[2, 21]. In addition, in a longitudinal study of HSV-2 acquisition
among women, the presence of bacterial vaginosis (BV) was
associated with an increased risk of acquiring HSV-2 (hazard
ratio [HR], 2.1 [95% CI, 1.04.5]; P 5 .05). The calculated
population attributable risk of BV for HSV-2 seroconversion
was 21% [23]. Analyses of data from NHANES, 20012004, also
found an association between the presence of BV and the se-
roprevalence of HSV-1 and HSV-2 in women aged 2044 years
[24]. There are no published studies to date to show if the
treatment of BV could reduce acquisition of HSV-2 in women.
Genital HPV infection is common, with certain HPV types
associated with cervical cancer. WSW were once presumed to be
at low risk for HPV acquisition and cervical cancer. Data now
strongly support that HPV infections are common among WSW
and that sexual transmission of HPV likely occurs between
women [2527]. Prior case reports highlighted the presence of
cervical neoplasia and HPV among women who had no history
of sex with men [28, 29]. HPV in WSW has been studied using
both HPV serology and DNA detection methods. In a 1995
study, among WSW who reported never having had a male
sexual partner, 26% had antibodies to HPV-16 and 42% had
antibodies to HPV-6. No difference in the prevalence of HPV-16
and HPV-6 antibodies was found between women with and
women without a history of male partners (P 5 .16). HPV DNA
was detected in genital tract specimens in 30% of the women
enrolled. The presence of HPV DNA was associated with current
STIs Among WSW d CID 2011:53 (Suppl 3) d S85
smoking (odds ratio [OR], 3.4 [95% CI, 1.29.6]) and a shorter
time since last sex with a male partner (P 5 .002). The preva-
lence of squamous intraepithelial lesions on Pap smear was 4%,
similar to that found in heterosexual women [25]. A subsequent
larger study again showed the high prevalence of HPV in WSW,
with 13% having HPV DNA in genital tract specimens (74% of
which were oncogenic types) and 4.4% having either low-grade
or high-grade squamous intraepithelial lesions [26].
Despite these findings, WSW, particularly those with a history
of having only female partners, are less likely to report having had
Pap smear screening and frequently believe they have less need
for cervical cancer screening [2527, 30]. WSW are at risk from
acquiring HPV both from their female partners and from current
or prior male partners, and thus are at risk for cervical cancer.
Studies examining STIs among WSW frequently use differing
methods to reflect female-to-female sexual contact. Some
identify women based on self-identified sexual orientation
(homosexual, lesbian, bisexual, heterosexual) whereas others
utilize reported sexual behaviors and partner choices over time
(female partner ever in a lifetime, female partner in the past year,
history of male partners), alone or in combination with meas-
ures of sexual orientation, making comparability across studies
somewhat limited. Use of consistent and expanded methods to
detail same-sex behavior that includes measures of sexual
identity, sexual orientation, partner choices, and sexual behav-
iors are needed to better understand the epidemiology and risks
for STIs among WSW and to allow comparability across studies
over time.
What Are the Special Issues of BV as It Relates to WSW?
BV is a common cause of vaginal symptoms and is associated with
an increased risk of acquisition of STIs and HIV [23, 3134].
Prior studies have suggested a higher prevalence of BV among
WSW, although these studies had previously been limited to
specific populations such as STD clinics or sexual health centers
[36, 3537]. Prevalence of BV among WSW in these studies
ranged from 8% to 52%. A cross-sectional survey of female
community volunteers aged 1650 years in the United Kingdom
conducted from 2001 to 2004 demonstrated a BV prevalence of
25.7% among self-identified lesbians versus 14.4% among het-
erosexual women (OR, 2.45 [95% CI, 1.254.82]; P 5 .009) [38].
In the largest sample to date, the NHANES 20012004, a nation-
ally representative sample of the US civilian population, women
who reported a history of a female sex partner had a prevalence of
BV of 45.2% (95% CI, 35.5%57.5%) versus 28.8% (95% CI,
26.831.0%; P 5 .003) in those not reporting a female sex partner
[39].
Many studies have also shown a high level of concordance of
BV between a woman and her female sex partner (both partners
with BV and without BV) [35, 38, 40]. A systematic review and
meta-analysis examining the association between BV and female
S86 d CID 2011:53 (Suppl 3) d Gorgos and Marrazzo
sexual partners found that having a history of female sex part-
ner(s) conferred a 2-fold increased risk of BV (relative risk
[RR], 2.0 [95% CI, 1.72.3]) [41]. Exchange of vaginal fluid or
other shared behaviors among female partners may contribute
to the initiation of BV. Among WSW, prior studies have found
an association of BV with a higher lifetime number of female
sexual partners, a history of receptive oral-anal sex, not always
cleaning an insertive sex toy between uses, and smoking [38, 40].
A recent observational study of community-based WSW aged
1635 years found that those with BV were more likely to report
a partner with BV (RR, 2.55 [95% CI, 1.853.49]), sharing
vaginal insertive sex toys (RR, 1.53 [95% CI, 1.102.12]), and
vaginal lubricant use (RR, 1.51 [95% CI, 0.952.40]). No asso-
ciation was seen with age, race, smoking, hormone use,
douching, vaginal intercourse, receptive oral or anal sex, or
number of partners [42]. In a recent study that measured BV
acquisition in a prospective cohort study of 199 WSW over 1
year, risks for incident BV included presentation #14 days since
onset of menses (hazard ratio [HR], 2.3 [95% CI, 1.24.7]),
report of new sex partner with BV history (HR, 3.63 [95% CI,
1.111.9]), change in vaginal discharge (HR, 2.6 [95% CI, 1.3
5.2]), and detection of any of several BV-associated bacteria
(BVAB) in vaginal fluid at enrollment, including BVAB1 (HR,
6.3 [95% CI, 1.428.1]), BVAB2 (HR, 18.2 [95% CI, 6.451.8]),
BVAB3 (HR, 12.6 [95% CI, 2.758.4]), Gardnerella vaginalis
(HR, 3.9 [95% CI, 1.510.4]), Atopobium vaginae (HR, 4.2 [95%
CI, 1.99.3]), Leptotrichia species (HR, 9.3 [95% CI, 3.024.4]),
and Megasphaera-1 (HR, 11.5 [95% CI, 5.026.6]) [43]. De-
tection of Lactobacillus crispatus at enrollment conferred re-
duced risk for subsequent BV (HR, 0.18 [95% CI, .08.4]).
Detailed analysis of behavioral data suggested a direct dose-
response relationship with increasing number of episodes of
receptive oral-vulvovaginal sex (HR, 1.02 [95% CI, 1.001.04])
[43]. These studies have thus continued to support, though have
not proven, the hypothesis that sexual behaviors that facilitate
the transfer of vaginal fluid and possibly exchange of ex-
travaginal microbiota (eg, oral bacterial communities) between
partners may be involved in the pathogenesis of BV.
With the advent of new molecular-based methods, there has
been a greater appreciation of the microbial diversity and
complex nature of BV [4446]. Molecular methods also allow
a more detailed analysis of specific vaginal flora shared between
partners. Using both culture methods and strain typing with
repetitive element sequence-based polymerase chain reaction
(rep-PCR) fingerprinting, Marrazzo et al [47] examined Lacto-
bacillus colonization at vaginal and rectal sites and whether
unique Lactobacillus strains are shared by female sex partners.
Among 392 women, 25.3% had BV and most (58%) reported
only 1 female partner during the prior 6 months. L. crispatus was
the most commonly isolated lactobacilli, followed by Lactoba-
cillus gasseri and Lactobacillus jensenii. Relative to L. crispatus,
the rectum was more commonly the sole site of L. gasseri
colonization (P , .001). Detection of L. gasseri was associated
with recent receptive digital-vaginal sex (P 5 .03) and increased
BV risk (OR, 4.3 [95% CI, 1.413.4]). Within this study, both
members of monogamous partnerships were enrolled. Of 31
couples monogamous for $3 months, strains of genital lacto-
bacilli by rep-PCR fingerprinting were identical in both mem-
bers in 23 couples (74%). No similarities in lactobacilli strains
were seen between control partners matched for age and date of
enrollment to the study. Couples with identical Lactobacillus
strains reported fewer female partners in the prior year
(P 5 .03). There was a trend toward an association of reported
use of shared vaginal sex toys and shared identical lactobacillus
strains (OR, 1.6 [95% CI, 0.942.7]; P 5 .20). The likelihood of
sharing identical lactobacilli was not related to mean age of the
couple; number of lifetime male sex partners; or to practice,
frequency, or timing of other types of sexual behaviors, in-
cluding oral or anal sexual practices .
Despite an initial treatment response, BV commonly recurs or
persists in both the short term [4850] and long term [51, 52].
One study found that a past history of BV, a regular sex partner
throughout the study, and female sex partners were significantly
associated with recurrence of BV and abnormal vaginal flora
[51]. A recent study of young WSW with BV treated with vaginal
metronidazole gel examined behavioral and microbiologic cor-
relates of persistent BV and abnormal vaginal flora at 1 month
after therapy. Vaginal fluid samples at baseline and 1 month
after therapy were studied using species-specific 16S recombi-
nant DNA PCR assays targeting 17 bacterial species. Persistent
BV was associated with the presence of specific bacteria in
vaginal fluid at baseline including BVAB types 1, 2, and 3;
Peptoniphilus lacrimalis; and Megasphaera phylotype 2. After
adjustment for treatment adherence, detection of either BVAB3
(RR, 2.6 [95% CI, 1.45.45]) or P. lacrimalis (risk ratio, 2.8 [95%
CI, 1.213.3]) at baseline remained associated with the likeli-
hood of BV persistence. Persistence was not related to any
specific sexual activity, including male or female partners, use of
sex toys, condom use, receptive oral or anal sex, or a sex partner
with BV [53].
Several prior clinic-based studies have examined the role of
treatment of partners of females with BV in reducing persistent
or recurrent BV. These trials enrolled women with male sex
partners and involved treating women and their male partners
with clindamycin [54], metronidazole [55, 56], or tinidazole
[57] with follow-up ranging from 3 to 12 weeks. None of these
trials have shown any benefit in reducing persistent or recurrent
BV by treating male sex partners. The only proven interventions
that have demonstrated an effect in preventing the development
or recurrence of BV are chronic suppressive metronidazole
therapy [52] and circumcision of male partners [58]. To date
there have been no reported trials examining the potential
benefits of treating female partners of women with BV, and thus
no data on which to base a recommendation for partner therapy
in WSW.
Results of a randomized trial utilizing a behavioral in-
tervention to reduce persistent BV among WSW were recently
published. Enrolled women were randomized to an intervention
designed to reduce sharing of vaginal fluid on hands or sex toys
following treatment for BV. Shared vaginal use of sex toys was
infrequent among both groups. Despite the fact that women
randomized to the intervention were 50% less likely to report
receptive digital-vaginal contact without gloves than controls,
there was no reduction in persistent BV at 1 month after
treatment or incident episodes of recurrent BV among women
randomized to the intervention arm versus controls [59].
In summary, BV is common among women in general and
even more so among women with female partners. Current data
show that women can share strain-specific genital bacteria with
their female partners and that specific bacterial species are as-
sociated with treatment failure in BV. Sexual behaviors that
facilitate the transfer of vaginal fluid and/or bacteria between
partners may be involved in the pathogenesis of BV, but more
research needs to be done to understand the relationships be-
tween the transmission of BV-associated bacteria, BV patho-
genesis, outcomes, and potential behavioral and medical
interventions to reduce the occurrence, persistence, and re-
currence of BV among WSW. In the interim, encouraging
awareness of signs and symptoms of BV in women and en-
couraging healthy sexual practices such as cleaning shared sex
toys between uses may be helpful to women and their partners.
What Are the Risk and Protective Factors Related to STIs Among
WSW?
WSW are a diverse group with variations in sexual identity,
sexual behaviors, sexual practices, and risk behaviors. Sexual
identity is not necessarily in concordance with sexual behaviors
and gender of sexual partners. Past and current studies affirm
that the majority of women (up to 87%) who report same-sex
behavior have had male partners in the past and may continue to
do so in the present (6%23%) [20, 6062]. It cannot be pre-
sumed that women who self-identify as lesbian do not or have
not had male partners.
Some women who have both female and male partners may
also evidence increased risk-taking behaviors compared with
their heterosexual or exclusively same-sex-partner peers. Surveys
in an STD clinic in 19881992 found that women who reported
same-sex contact (93% of whom also had male partners) were
more likely to report high-risk behaviors, including exchanging
sex for money or drugs and having partners who were injection
drug users (IDUs), bisexual men, or HIV positive [19].
A population-based survey conducted in northern California
reported on the prevalence of sexual and drug use behaviors
STIs Among WSW d CID 2011:53 (Suppl 3) d S87
among WSMW ages 1829. Compared with women who re-
ported exclusively male partners, WSMW were more likely to
report having ever had prior sex with MSM (30% vs 3%;
P , .001), sex with an IDU (38% vs 8%; P , .001), and both
past and current injection drug use [63].
More recently, surveys of risk behavior among WSW have
been extended to community settings, including a survey among
self-identified lesbian, bisexual, and heterosexual women at-
tending primary care clinics across 33 sites in the United States.
Lesbians and bisexual women were more likely to report sex with
MSM in the past year (36% and 22%, respectively) than het-
erosexual women (3%; P , .001) and to report sex with a male
IDU (6% and 4% vs 2%, respectively; P , .02). Of interest,
lesbians were more likely to use condoms with male partners in
the past year (94%) than both their bisexual (74%) and het-
erosexual (46%) peers (P , .001). The bisexual women were
more likely to perceive themselves as at risk for HIV, to have ever
had an HIV test (77%), and to have had STD testing in the past
2 years (66%). While reporting having riskier male partners,
the lesbian and bisexual women were more likely to engage in
protective behaviors such as condom use and to recognize their
risk of STDs and HIV with subsequent care seeking for testing
[61].
A stratified probability sample of the British general pop-
ulation in 2000 examined behavioral and health-related factors
among WSW. Nearly 10% of women reported any sexual ex-
perience(s) with women and 2.8% reported $1 female sexual
partners in the past 5 years (median, 1 partner). WSW (in-
cluding those with exclusively female and both male and female
partners) were more likely than other women to report STD
clinic attendance (23.5% vs 6.2%), HIV testing (21.6% vs 8.2%),
and STI diagnosis (14.7% vs 3.7%) in the past 5 years. These
associations remained significant even after adjusting for num-
bers of sexual partners. WSW in this population also reported
a higher prevalence of smoking, high alcohol intake, and
injecting nonprescribed drugs [64, 65].
Issues of sexual identity and behavioral risks also extend to
adolescents and young adults. The inconsistency between sexual
identity and choice of sexual behaviors and sexual partners was
demonstrated in adolescent women in grades 9 through 12 who
were surveyed as part of the Massachusetts Youth Risk Behavior
Survey from 1995 to 2001. Among women who reported having
only female sexual partners, 82% identified as heterosexual, 14%
as lesbian or bisexual, and 4% as not sure. Young women in STIs, including C. trachomatis, in their clients according to
this study who identified as other than heterosexual (lesbian,
bisexual, or unsure of their sexual identity) and those who re-
ported same-sex partners (either exclusively or in addition to
male partners) were more likely than heterosexual participants
to report multiple lifetime and recent sexual partners, illegal
drug use, having been pregnant, having had any STD, and
having been coerced into sexual contact [62].
S88 d CID 2011:53 (Suppl 3) d Gorgos and Marrazzo
Among the 14 000 US college students enrolled in the 1997
College Alcohol Study, women who had sex with both men and
women reported $2 sexual partners (11.1%) more frequently
than their peers with opposite-sex (4.9%) or same-sex-only
partners (5.4%; P , .01) [66]. Among the nearly 30 000 female
students surveyed in the Spring 2006 National College Health
Assessment, female students who reported having both male and
female sex partners during the past year were 3.64 (95% CI,
2.285.83) times more likely to report being diagnosed with an
STD during the past school year than students who had only
male partners and 4.04 (95% CI, 2.576.35) times more likely
than students who had only female partners [67]. An urban
householdbased survey of women ages 1824 years found that
women describing themselves as mostly heterosexual (at-
tracted to both sexes, but mostly to persons of the opposite sex)
were more likely to report an earlier age of first sexual in-
tercourse and a higher number of lifetime sexual partners than
women who described themselves as 100% heterosexual [68].
In summary, many early studies of risk behaviors among
WSW were based on convenience samples or on women at-
tending STD clinics and are not necessarily generalizable to all
WSW. However, it does appear that some WSW, particularly
adolescents and young women as well as WSMW, may be at
increased risk for STIs and HIV based on reported risk behav-
iors. Health care providers assessing any woman for her risk of
STIs must incorporate an open discussion of all aspects of
sexuality, and not just those limited to preconceptions or ster-
eotypes on the part of providers. Sexual and reproductive health
services that are sensitive to gender-minority women across
a wide range of ages and populations are needed, including
adolescents and college-aged women.
What Recommendations Should Be Made Regarding Testing for
STIs Among WSW?
WSW are at risk of acquiring bacterial, viral, and protozoal
STIs from both female and male partners. WSW should not
be presumed to be at low or no risk for STIs based on stated
sexual orientation. Effective screening requires a comprehensive
and open discussion of sexual and behavioral risks, beyond
sexual identity, between health care providers and their female
clients.
Report of same-sex behavior in women should not deter
providers from considering and performing screening for
current guidelines. Sexual transmission of HSV-1 and HSV-2
can occur between female sex partners, and this information
should be included in the counseling and evaluation of womens
sexual health. Routine cervical cancer screening should be
offered to all women, regardless of sexual orientation or partner
choice, and women should be offered HPV vaccine according to
current guidelines. Although BV is common among WSW,
routine screening for BV is not currently recommended, nor is
the treatment of partners of women with BV. Encouraging
awareness of signs and symptoms of BV in women and en-
couraging healthy sexual practices such as cleaning shared sex
toys between uses may be helpful to women and their partners.
The evaluation of WSW who present with symptoms concern-
ing for STIs is no different than that for women with male-only
partners.
Future Research
Much remains to be understood about sexual health and STIs
among WSW. More accurate information from future research
on population health and STIs among women could be obtained
by routinely examining measures of sexual orientation including
sexual behaviors, sexual attraction, and sexual identity, partic-
ularly as they relate to participation in sexual networks [69].
Larger population-based studies are needed to more clearly
define the epidemiology and transmission risks for STIs among
the diverse group of WSW, including adolescents and young
women. Specifically, further research is needed to identify risks
that may predispose to the acquisition and transmission of
C. trachomatis in this group and to better quantify the epide-
miology of chlamydial infection among WSW in the United
States. WSW have a higher prevalence of BV, and more research
needs to be done to understand the relationships between the
transmission of BV-associated bacteria, the pathogenesis of BV,
and treatment outcomes. In addition, future research is needed
to identify behavioral and medical interventions that can reduce
the occurrence, persistence, and recurrence of BV among WSW.
An improved understanding of the dynamics of the health
care interaction between WSW patients and providers would be
extremely useful. Little is known about the knowledge, attitudes,
and behaviors that contribute to STI screening and health care
access among WSW, either from the perspective of women
themselves or from the providers who serve them. Valuable
research could provide information on womens perceptions of
STI risk, reproductive health needs, and patterns of seeking
preventive sexual health care. These data are essential to inform
both women and their health care providers about STI risks and
prevention and to foster a dialogue that could support sexual
health in general.
Notes
Acknowledgements. This publication/project was made possible
through a cooperative agreement between the Association for Prevention
Teaching and Research(APTR) and the Centers for Disease Control and
Prevention (CDC), award number 3U50CD300860; its contents are the
responsibility of the authors and do not necessarily reflect the official views
of APTR or CDC.
Supplement sponsorship. This article was published as part of a sup-
plement entitled "Sexually Transmitted Disease Treatment Guidelines
sponsored by the Centers for Disease Control and Prevention.
Potential conflicts of interest. All authors: No reported conflicts.
All authors have submitted the ICMJE Form for Disclosure of Potential
Conflicts of Interest. Conflicts that the editors consider relevant to the
content of the manuscript have been disclosed.
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