Papanicolaou test screening and prevalence of genital human papillomavirus among women who have sex with women

Understanding Sexual and Gender Minority Populations and Organ-Based Screening Recommendations for Human Papillomavirus-Related Cancers

OBJECTIVES

Sexual gender minority (SGM) populations are at risk for human papillomavirus (HPV)-related cancers of the anogenital tract and oropharynx and often face barriers to health care. The goals of this document are to clarify language to provide inclusive care for SGM populations and to provide recommendations for screening and prevention of HPV-related cancers in SGM populations.

MATERIALS AND METHODS

An expert committee convened by the American Society for Colposcopy and Cervical Pathology performed a narrative review of the literature through February 2023. A comprehensive MEDLINE database search was performed for relevant studies. The literature review was divided into categories by organ/topic and by SGM population. Given the variability in available data for several of the categories, recommendations were made based on national guidelines where appropriate or expert opinion where there were less data to support risk-based guidelines.

RESULTS

Definitions and terminology relevant to SGM populations are presented. The authors advocate the adoption of sexual orientation gender identity data collection and an organ-based screening approach, which is possible with knowledge of patient anatomy, sexual behaviors, and clinical history. This includes screening for cervical cancer per national recommendations, as well as screening for anal, vulvar, vaginal, penile, and oral cancers based on risk factors and shared clinical decision making. The authors recommend consideration of HPV vaccination in all SGM individuals up to age 45 years old who are at risk.

CONCLUSIONS

An organ-based screening approach is part of a global strategy to create an inclusive care environment and mitigate barriers to screening and prevention of HPV-mediated cancers in SGM populations.

Difference in Pap test uptake between women who have sex with women and other women in France: A comparative survey of 2032 women

The elimination of cervical cancer has been a priority of the World Health Organization since 2018. The number of these cancers induced by the human papillomavirus (HPV) could be drastically reduced through vaccination and regularly screening by Pap tests. Guidelines for cervical cancer screening apply to all women, including those who have sexual relations with women (WSW), as HPV can be transmitted during sex between two women. As far as we know, our study is the first that compare the Pap test rate between WSW and other women in France. We developed an 18-item questionnaire available on the internet for 15 days and finally analyzed the responses of 2032 women. Based on their responses about their self-definition of their sexual orientation and their sexual behavior, we classified them into three groups of women: exclusive WSW, mixed WSW, and non-WSW. For each question, we tested the statistical differences in responses between these three groups. Our study shows in a large sample representative of the French population that exclusive WSW undergo Pap tests significantly less often than either mixed WSW or non-WSW. Among the exclusive WSW, 28.9 % had never had a Pap test, compared with 9 % of the mixed WSW and 3.1 % of non-WSW (p < 0,001). The responses to our questionnaire contribute to an understanding of this disparity and thus help to envision solutions for better care of all women, regardless of their sexual orientation; this point is crucial for prevention of cervical cancer.

The intersection of sexual orientation with race and ethnicity in cervical cancer screening

BACKGROUND

Cervical cancer screening is recommended for those with a cervix who are 21 to 65 years old, with specific timelines being dependent on individual risk. This study compared rates of ever undergoing Papanicolaou (Pap) testing at the intersection of self-reported sexual minority (SM) status and race/ethnicity.

METHODS

Data from the National Health Interview Survey (2015 and 2018) were used to examine cervical cancer screening disparities. Natal females without a history of hysterectomy who were 21 to 65 years old and had reported their sexual orientation and Pap testing history were included. Demographic and health characteristics were summarized with descriptive statistics. To adjust for differences in confounding variables between groups, propensity score-based inverse probability of treatment weighting (IPTW) was performed. IPTW-adjusted multivariable logistic regression models estimated odds of ever undergoing a Pap test by sexual orientation alone and with race/ethnicity (non-Hispanic White, non-Hispanic Black, and Hispanic).

RESULTS

SM persons (n = 877) had significantly reduced odds of ever undergoing Pap testing (odds ratio, 0.54; 95% confidence interval, 0.42-0.70) in comparison with heterosexual persons (n = 17,760). When the intersection of sexual orientation and race/ethnicity was considered, non-Hispanic White SM participants and Hispanic SM participants had reduced odds of ever undergoing Pap testing in comparison with non-Hispanic White heterosexual participants. No significant differences were observed between non-Hispanic White heterosexual participants and participants of non-Hispanic Black SM or Hispanic heterosexual identities.

CONCLUSIONS

SM participants were significantly less likely to have ever undergone a Pap test in comparison with heterosexual participants, with Hispanic SM participants having the lowest uptake. Future studies should further examine the roles of systemic discrimination and other key drivers of these disparities.

Perceived HIV Invulnerability and PrEP Knowledge and Attitudes among Black Sexual Minority Women

Black women have disproportionate rates of HIV compared to women of all other racial groups. The purpose of this analysis was to investigate perceived HIV risk, HIV and STI testing behaviors, and PrEP knowledge and attitudes among Black sexual minority women (SMW) and examine differences based on their history of male sex partners. Secondary data analysis was conducted using data from the Generations Study. This analysis used a sample of N=149 participants who identified as Black cisgender women. Results showed Black SMW with a history of male sex partners reported a higher perceived risk of contracting HIV and significantly more frequent HIV and STI testing than those without a history of male sex partners. Overall, most of the sample was not familiar with PrEP, but one-third had favorable attitudes towards it, and half felt like they did not know enough about PrEP to form an opinion. Implications for culturally relevant public health campaigns and comprehensive sexuality education that integrate PrEP are included.

Experiences of Violence Against Lesbian and Bisexual Women in Brazil

BACKGROUND

Lesbophobia and biphobia are manifestations of homophobic violence directed at lesbian and bisexual women that results in daily violation of rights and social exclusion.

AIM

To describe experiences of the violence against lesbian and bisexual women in Brazil.

METHODS

Sequential mixed methods study was carried out in 2 stages. In the first one, quantitative, an electronic questionnaire was applied to women from all regions, with questions about sociodemographic characteristics, self-identification and lesbophobic and biphobic events. In the second one, qualitative, lesbian, and bisexual women were interviewed face to face about the violence suffered.

OUTCOMES

The chi-square test was applied to compare violence against lesbian and bisexual women (type of violence, place of aggression, gender and age range of the aggressor, bond with the aggressor, repetition of violence, and denunciation of violence) and the content analysis for qualitative data (main categories of analysis were events of violence, denunciation, and consequences of violence).

RESULTS

The report of violence was present in 65% of the answers. There was a predominance of psychological violence (39.8%), in the public environment (63%), practiced by men (73.2%), by strangers (66.2%) and repeatedly (82%). Lesbian women, compared to bisexuals, were more prone to violence in the public environment (59.5% vs 39.5%) and with repetition (84.3% vs 60.6%). The narratives explained intimidating experiences in the family environment (insults, threat of suicide or homicide and false imprisonment) and public (harassment, beatings, and rape). Discriminatory attitudes, insults, and refusal of service in restaurants and bars were recurrent.

CLINICAL IMPLICATIONS

The data provide information that can serve to improve policy initiatives to reduce these episodes.

STRENGTHS AND LIMITATIONS

This is the first study of mixed methods, with national coverage, on lesbophobia and biphobia events in Brazil. Future studies should include women underrepresented in this research as trans women, non-white, less educated, and from the most distant regions of the country.

CONCLUSION

Lesbophobic or biphobic event has harmful repercussions for multiple aspects of these women's lives, including mental health. Rufino AC, Filho CEWBdeC, Madeiro A. Experiences of Violence Against Lesbian and Bisexual Women in Brazil. Sex Med 2021;XX:XXXXXX.

Teaching LGBT+ Health and Gender Education to Future Doctors: Implementation of Case-Based Teaching

Improving the education of medical students and physicians can address the disparities in LGBT+ (lesbian, gay, bisexual, transgender, and others) health care. This study explored how teachers used case-based teaching to teach medical students about gender and LGBT+ health care and discussed the implementation and effectiveness of case-based teaching from the perspective of the teachers and students. This study employed the case study method and collected data through semi-structured interviews. This study used two gender courses in clinical psychiatric education as case studies. Two teachers and 19 medical students were recruited as participants. The findings of this study were as follows: (1) effective cases links theory to clinical practice and competency learning; (2) experience sharing by LGBT+ is highly effective; (3) discussions promote the effectiveness of case-based teaching; and (4) the challenges of case-based teaching included time limitations, the multiplexity of the cases, and multilevel learning. This study also found that using narrative cases is a form of narrative pedagogy, which can help students to integrate medicine, gender, and LGBT+ competency education. A successful narrative case–based teaching strategy involves teachers integrating knowledge related to gender, guiding students through the cases to understand the importance of these cases, and reflecting on the medical profession to make improvements. However, teachers face challenges in this approach, such as changes in the school’s teaching culture and a lack of institutional support.

Sexually Transmitted Infections Treatment Guidelines, 2021

These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11–14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs.

Cross-sectional study of psychosocial well-being among lesbian, gay, bisexual, and heterosexual gynecologic cancer survivors

Background

Delays in care and increased risk for mental health diagnoses put individuals identifying as a sexual minority with cancer at risk for decreased quality of life.

Aim

To assess psychosocial health among sexual minority gynecologic cancer survivors, we compared self‐reported quality of life and psychosocial measures between individuals diagnosed with gynecologic cancers identifying as lesbian/gay/bisexual (LGB) and heterosexual.

Methods and Results

English‐speaking adults with gynecologic cancers were invited to participate in an ongoing cohort survey study. Quality of life and psychosocial measures included the Functional Assessment of Cancer Therapy‐General, Distress Thermometer (distress), Patient Health Questionnaire‐8 (depression), General Anxiety Disorder‐7 (anxiety), and Post‐traumatic Stress Disorder Checklist for DSM‐5 (post‐traumatic stress disorder; PTSD). Measures were compared by self‐reported sexual orientation (heterosexual vs. LGB) using descriptive statistics (frequencies and means) and linear and logistic regression models, adjusting for college education.

Of 814 patients invited, 457 enrolled (56.1%) and 401 (92.6%) completed the survey and provided information on their sexuality. All but one self‐identified as cisgender women and 22 (5.5%) as LGB. LGB participants were more likely to have completed college (68.2% vs. 40.1%, p = .009) but were otherwise similar across demographic and clinical characteristics. Quality of life and distress scores were similar between groups. LGB participants, compared to heterosexual, reported higher rates of depression (31.8% vs. 10.6%, adjusted odds ratio [OR] = 4.1 [95% confidence interval [CI]: 1.6–11.0], p = .004), anxiety (25.0% vs. 7.1%, adjusted OR = 5.4 [95% CI: 1.7–16.7], p= .004), and PTSD (13.6% vs. 3.5%, adjusted OR = 4.2 [95% CI: 1.1–16.3], p = .04).

Conclusion

LGB participants reported poorer emotional health following a gynecologic cancer diagnosis than heterosexual participants. Our data suggest this population may need additional resources and support during and after their cancer diagnosis. Future work is needed to identify additional risk factors and the underlying sources of these disparities in order to improve patient care and wellness in this population.

Cervical cancer screening among sexual minority women: findings from a national survey

PURPOSE

Sexual minority women (SMW; lesbian, bisexual, and other women who have sex with women) are at risk for cervical cancer but less likely than non-SMW to receive regular cervical cancer screening (Pap- and/or HPV-testing). We examined factors contributing to receipt of guideline-based cervical cancer screening among SMW.

METHODS

During October 2019, we conducted an online survey of self-identified SMW aged 21-45 years living in the United States (n = 435). We estimated risk differences (RD) in women's likelihood of being within current cervical cancer screening guidelines by sociodemographic and health-related characteristics.

RESULTS

Overall, 75% of respondents were within current screening guidelines. Adjusting for other factors, SMW were more likely to be within guidelines if they were insured (aRD 0.26, 95% CI 0.13, 0.39), had a partner (aRD 0.18, 95% CI 0.09, 0.28), and were older (aRD 0.12, 95% CI 0.04, 0.20). Overall, the most common reasons for not being screened recently were lack of insurance/cost (42%) and perceiving it was unnecessary (28%).

CONCLUSION

Many SMW are not being screened for cervical cancer according to guidelines. Findings can inform efforts to improve screening among this population.

Dimensions of Sexual Orientation as Predictors of STI-Related Outcomes Among Women: An Examination of 2011-2017 National Survey of Family Growth Data

Background: To estimate sexual orientation associated disparities in sexually transmitted infection (STI)-related outcomes across multiple dimensions of sexual orientation. Methods: Using pooled 2011-2017 National Survey of Family Growth data (N = 16,854), we performed bivariate and multivariable logistic and multinomial regression analyses to estimate associations between sexual identity, behavior in the past 12 months, and attraction, and past-year STI treatment, receipt of the human papillomavirus (HPV) vaccine, and age at first HPV vaccination in cisgender women. Results: Bisexual-identified women (adjusted odds ratio [AOR] = 1.53, 95% confidence interval [CI] = 1.10-2.14) and who were sexually active with both men and women in the past 12 months (AOR = 1.64, 95% CI = 1.03-2.55) had significantly higher odds of past-year STI treatment, compared with their nonsexual minority counterparts. Lesbian-identified women (AOR = 0.44, 95% CI = 0.27-0.75) and women with female partners only (AOR = 0.32, 95% CI = 0.12-0.87) had significantly decreased odds of having initiated the HPV vaccine compared with their heterosexual counterparts. Women with both male and female partners who initiated the HPV vaccine had significantly higher odds of having received the vaccine during the latest age range, 18-25 years old (AOR = 2.32, 95% CI = 1.21-4.45) compared with women with male partners only. Conclusions: Sexual minority women continue to be at risk for poor sexual health outcomes, and these outcomes differ by specific components of sexual orientation.

[Literature review on studies of women who have sex with women]

Women who have sex with other women are a group that has been mostly invisible from public health policies. This category includes the group of lesbians, bisexual women, heterosexual behaviour, and homosexual practices, who have sexual relations with transsexual and transgender (trans) women and trans men who have sex with women. In the absence of a Spanish literature review of a study that addresses women who have sex with other women, a narrative bibliographic review was done using the PubMed/MEDLINE, Scopus, Dialnet, and Taylor and Francis databases. From a universe of 679 articles and after applying the inclusion criteria, 40 documents were analysed, from 1998 to 2019. Three meta-categories were identified (sexual education, the incidence of certain sexually transmitted infections, and aspects related to sexual practices), concerning prevention and risky behaviours. Women who have sex with other women are a particularly vulnerable group when it comes to sexually transmitted infections. These may include bacterial vaginitis, human papillomavirus and acquired immunodeficiency virus. Likewise, there is a lack of specific training and information in health and education professionals, as well as in women who have sex with other women.

Recent Penile Sexual Contact Is Associated With an Increased Odds of High-Risk Cervical Human Papillomavirus Infection in Transgender Men

BACKGROUND

Transgender men (TM) have a male, masculine, or nonfemale gender identity, yet were assigned female sex at birth on the basis of their external genitalia. The majority of TM are at risk of infection with one of several high-risk strains of the human papillomavirus (hr-HPV), acquired primarily through sexual contact, that cause 99.7% of cervical cancers. This study aimed to explore the association between sexual behaviors and current cervical hr-HPV infection in TM with a cervix.

METHODS

The primary aim of this analysis was to test for an association between participant self-report of sexual contact with a penis in the past 1 year and current infection with cervical hr-HPV as measured by provider-collected cervical HPV DNA assay. This is a secondary analysis of a bio-behavioral sexual health study conducted at a health center in Boston, MA from 2015 to 2016. Analysis was conducted using logistic regression with significance level set at P less than 0.05; the primary analysis was adjusted for self-reported age, current tobacco use, years of testosterone use, and HPV vaccination status.

RESULTS

Overall prevalence of hr-HPV was 15.9%. In adjusted analyses, participants reporting receptive penile vaginal sex with any of their most recent 3 sexual partners in the past 12 months had more than 5 times greater odds of current hr-HPV infection than those reporting no penile sex of any kind during this timeframe (odds ratio, 5.23; 95% confidence interval, 1.61-17.02).

CONCLUSIONS

Vaginal-receptive penile sex in the last 12 months was associated with a 5-fold increased odds of cervical high-risk HPV infection among TM. Findings can inform future population level study of associations between sexual behaviors and hr-HPV risk, which could lead to more individualized approaches to screening.

Sexual orientation inequalities during provider-patient interactions in provider encouragement of sexual and reproductive health care

The human papillomavirus (HPV) vaccination, sexually transmitted infection (STI) tests, and Papanicolaou (Pap) testing rates vary by sexual orientation, which may be due in part to healthcare providers (HCP) recommending this care unevenly. Data (N = 17,675) came from the Growing Up Today Study (GUTS) (N = 8039) and Nurses' Health Study 3 (NHS3) (N = 9636). Among participants who met clinical guidelines to receive the care in question, we estimated the probability of an HCP encouraging participants to have the HPV vaccination, STI tests, or Pap test. Regardless of sexual orientation, participants whose HCP knew their sexual orientation were more likely to have been encouraged to get care compared to those whose HCP did not know the participant's sexual orientation. Sexual minority men and women were more likely to be encouraged to obtain HPV vaccination, STI tests, and Pap test than same-gender, completely heterosexuals with no same-sex partners, with some variation by gender and the care in question. Lesbian women were the sole sexual orientation subgroup that was less likely to be encouraged to receive care (HPV vaccination and Pap test) than their same gender, completely heterosexual counterparts with no same-sex partners (odds ratio [95% confidence interval]: 0.90 [0.80-1.00] and 0.94 [0.91-0.98], respectively). The differences across sexual orientation in HCPs' encouragement of care indicate a possible explanation for differences in utilization across sexual orientation. Across the US, HCPs under-encourage HPV vaccination, STI tests, and Pap test for all sexual orientation groups. Lesbian patients appear to be at high risk of under-encouragement for the Pap test.

Atributos da Atenção Primária à Saúde e ferramentas de medicina de família no atendimento às diversidades sexual e de gênero: Relato de caso

Objetivo: Este trabalho objetiva apresentar o médico de família e comunidade como um importante profissional na área da saúde da população de lésbicas, gays, bissexuais e transsexuais. Métodos: Relato de caso ilustrando encontro clínico e uso de ferramentas da medicina de família e comunidade. Conclusões: O médico de família consegue elaborar um projeto comum para o manejo dos problemas dessa população, que, além dos de origem biológica, compreende outros fatores que podem provocar adoecimento: o preconceito que atravessam no mero ato de sair à rua, a pressão de familiares descontentes com sua diversidade, sexual ou de gênero, a dificuldade psicológica da pessoa para se livrar dos seus próprios tabus e preconceitos para se permitir aceitar novas identidades

Clinical Care of Lesbian and Bisexual Women for the Obstetrician Gynecologist

Sexual minority women are more likely to delay care, less likely to have a usual place of care, and more likely to exhibit higher risk behaviors such as smoking, obesity, heavy drinking resulting in a disproportionate number of chronic conditions. It is imperative for obstetrician-gynecologists to be at the forefront of providing comprehensive health care to all women, no matter their sexual orientation. This article seeks to discuss health care disparities as well as health behaviors and outcomes in this population. In addition, it will review the appropriate recommendations for clinical care of sexual minority women for the obstetrician/gynecologist.

Natural history of human papillomavirus and vaccinations in men: A literature review

BACKGROUND AND AIMS

Infection with high-risk (HR) genotypes of the human papillomavirus (HPV) is necessary for and causative of almost all cervical cancers and their precursor condition, cervical intraepithelial neoplasia. These conditions have been sharply reduced by cervical cytology screening, and a further decrease is expected because of the recent introduction of prophylactic HPV vaccinations. While significant attention has been given to gynecologic HPV disease, men can be affected by HPV-related cancers of the anus, penis, and oropharynx. This literature review aims to address disparities in HPV-related disease in men, and certain HR male subpopulations, compared with women.

DISCUSSION

Overall, immunocompetent men are far less likely than women to develop anogenital HPV-related cancers, despite harboring HR HPV infections at anogenital sites. On the other hand, men who have sex with men and men living with human immunodeficiency virus infection are at considerably higher risk of HPV-related disease. Historic rates of prophylactic HPV vaccination in males have trailed those of females due to numerous multilevel factors, although, in recent years, this sex gap in vaccination coverage has been closing. In the absence of routine HPV screening in males, therapeutic vaccinations have emerged as a potential treatment modality for preinvasive neoplasia and are in various phases of clinical testing.

CONCLUSION

Successful reductions in HPV disease morbidity at the population level must acknowledge and target HPV infections in men.

Predicting cervical cancer screening among sexual minority women using Classification and Regression Tree analysis

Cervical cancer screening is a critical preventive healthcare service for all women. Sexual minority women (SMW) in the United States experience multiple health disparities including decreased access to and use of cervical cancer screening. The mechanisms driving these disparities are not clear and SMW with multiple marginalized identities may be more likely to miss recommended cervical cancer screening. This study aimed to identify subgroups of SMW that are more and less likely to be screened for cervical cancer according to American Cancer Society guidelines. We used cross-sectional data from the latest (2010-2012) wave of the Chicago Health and Life Experiences of Women (CHLEW) Study (N = 691). Informed by intersectionality theory, we performed classification and regression tree (CART) modeling to construct a data-driven, predictive model of subgroups of SMW who were more and less likely to receive guideline-recommended screening. Notably, the CART model did not include commonly tested variables such as race/ethnicity or level of income or education. The model did identify subgroups with low likelihood of receiving screening and several novel variables that may be important in understanding SMW's use of cervical cancer screening; lifetime number of sexual partners, age at drinking onset, childhood physical abuse, and internalized homonegativity. Our results point to the importance of early life experiences and identity development processes in shaping patterns of preventive healthcare use among adult SMW. Our analysis also demonstrated the potential value of CART modeling techniques for evaluating how multiple variables interact in complex ways to predict cervical cancer screening.

Do Sexual Minorities Receive Appropriate Sexual and Reproductive Health Care and Counseling?

CONTEXT

Sexual minority women (SMW) are less likely to use sexual and reproductive health care services and receive contraceptive counseling than their heterosexual peers. The role of recent sexual partners and the type of information provided when SMW access health services are unclear.

METHODS

The National Survey of Family Growth 2006-2015 was used to document sexual orientation disparities in the use of sexual and reproductive health services and counseling in clinical settings among 20,703 women. We incorporate data on sexual partners in the past 12 months to investigate whether recent sex with men was associated with health care seeking behavior and reproductive counseling.

RESULTS

Eight-seven percent of the sample reported a male partner in the past 12 months, including 83% of bisexual women and 17% of lesbian women. In clinical settings, 48% of women reported birth control counseling at pregnancy or Pap tests, 49% reported a condom consult at an sexually transmitted diseases (STD) screening, and 9% reported emergency contraception counseling at a Pap test. Logistic regression models show that lesbian women were less likely than heterosexual women to have been given a contraceptive prescription or received contraceptive counseling, but were more likely to have received an STD test. In clinical settings, lesbian women were less likely to receive contraceptive counseling at pregnancy tests, and lesbian women without male partners were less likely to have a counseling about condom use at STD-related visits compared with heterosexual women.

CONCLUSIONS

At least some women and providers adjust health care seeking behaviors and information provided to women based upon recent sexual behavior histories. More work is needed to understand why disparities in reproductive health services and contraceptive use persist among SMW who engage in sex with men.

One in three: challenging heteronormative assumptions in family planning health centers

OBJECTIVES

To estimate the prevalence of sexual-minority women among clients in family planning centers and explore differences in LARC uptake by both sexual identity (i.e., exclusively heterosexual, mostly heterosexual, bisexual, lesbian) and sexual behavior in the past 12 months (i.e., only male partners, both male and female partners, only female partners, no partners) among those enrolled in the survey arm of the HER Salt Lake Contraceptive Initiative.

METHODS

This survey categorized participants into groups based on reports of sexual identity and sexual behavior. We report contraceptive uptake by these factors, and we used logistic and multinomial logistic models to assess differences in contraceptive method selection by sexual identity and behavior.

RESULTS

Among 3901 survey respondents, 32% (n=1230) identified with a sexual-minority identity and 6% had had a female partner in the past 12 months. By identity, bisexual and mostly heterosexual women selected an IUD or implant more frequently than exclusively heterosexual women and demonstrated a preference for the copper T380 IUD. Exclusively heterosexual and lesbian women did not differ in their contraceptive method selection, however, by behavior, women with only female partners selected IUDs or implants less frequently than those with only male partners.

CONCLUSION

One in three women attending family planning centers for contraception identified as a sexual minority. Sexual-minority women selected IUDs or implants more frequently than exclusively heterosexual women.

IMPLICATIONS

Providers should avoid care assumptions based upon sexual identity. Sexual-minority women should be offered all methods of contraception and be provided with inclusive contraceptive counseling conversations.

Health Care-Related Correlates of Cervical Cancer Screening among Sexual Minority Women: An Integrative Review

INTRODUCTION

Sexual minority women (SMW; lesbian, bisexual, nonheterosexual women) may have lower rates of cervical cancer screening than heterosexual women. Health care-related factors may explain some of the variation in cervical cancer screening rates among SMW. We aimed to synthesize published evidence of health care-related correlates of cervical cancer screening among SMW.

METHODS

We searched PubMed, CINAHL, and PsycINFO databases for English-language studies published between January 2000 and March 2017 that 1) assessed sexual identity or the sexual partners of female participants, 2) included cervical cancer screening as a main outcome of interest, and 3) measured at least one health care-related variable in addition to cervical cancer screening. We excluded articles that 1) reported on non-US samples or 2) did not report original research. We reviewed the sample, methods, and findings of 17 studies. We then summarized current knowledge about health care-related factors across 3 categories and generated recommendations for clinical practice and future research.

RESULTS

Several health care-related factors such as previous contraception use, having a primary care provider, knowledge of screening recommendations, and disclosing sexual orientation to providers were consistently positively associated with cervical cancer screening. Three groups of factors-previous health care use, health care provider-related factors, and belief-related factors-account for a substantial part of the variation in cervical cancer screening among SMW.

DISCUSSION

Several gaps in knowledge remain that could be addressed by recruiting more diverse samples of SMW with improved generalizability. Clinicians and clinical institutions can address factors associated with low rates of screening among SMW by preventing sexual orientation-based discrimination, inviting sexual orientation disclosure, and offering cervical cancer screening to SMW at a variety of health care encounters. Future research should examine how the location of care and health care provider type affect SMW's cervical cancer screening behaviors and should test the effectiveness of health care interventions designed to address sexual orientation-related disparities.

Association of Pregnancy History and Cervical Cancer Screening in a Community Sample of Sexual Minority Women

BACKGROUND

Sexual minority women (SMW) face barriers to healthcare that may result in lower utilization of cervical cancer screening. Previous experiences with the healthcare system-specifically reproductive health-related encounters-have the potential to affect future use of screening services. This study aimed to examine the association between pregnancy history and cervical cancer screening in a diverse sample of SMW. Anderson's Behavioral Model of Health Services Use guided the selection of variables included in the study.

METHODS

We performed a secondary analysis of cross-sectional data from the third wave of the Chicago Health and Life Experiences of Women (CHLEW) Study, a longitudinal study of SMW in the Midwestern United States. We performed multivariable logistic regression to address the study aims, restricting the sample to women ages 21-45 (n = 430).

RESULTS

Reporting a previous pregnancy was consistently positively associated with past-year Pap testing. In the multivariable model, bisexual identity and disclosing one's sexual orientation to healthcare providers were also positively associated with past-year Pap test.

CONCLUSIONS

This analysis provides preliminary evidence that SMW who have been pregnant are more likely to receive Pap testing and that multiple sociodemographic factors are likely to impact screening in this population. Clinicians should screen all patients with a cervix for cervical cancer and should encourage screening for all SMW. Future studies should prioritize longitudinal analyses to examine the temporality of reproductive history and healthcare seeking, focus on where SMW seek care, and understand how intersecting components of identity may shape the healthcare utilization of this population.

Health Care of Sexual Minority Women

Sexual minority women may be invisible in health care settings unless practitioners ask every patient about sexual attractions/behaviors and identity. Sexual minority women need to feel comfortable and able to share information about their sexual identity, partners, and lives. No medical diagnoses are found more commonly in sexual minority women, but problems such as overweight/obesity, increased tobacco and alcohol use, increased mental health problems, and a past history of childhood sexual abuse are common. These factors intertwine when treating sexual minority women.

[Barriers to sexual health care in Argentina: perception of women who have sex with women]

Objective The objective is to describe the barriers to sexual health care of Women Who Have Sex with Women (WSW) in Argentina during 2013. Methods A cross-sectional, descriptive and quantitative study. An online survey was conducted using the Internet, in the period of April-July 2013, with homosexual and bisexual women over 18 living in Argentina, making use of the snowball methodology. Results A total of 161 women were surveyed. The results showed that 97.5 % had previously visited a doctor. The doctor did not ask about their sexual orientation in 82.8 % of cases. 93.6 % of the surveyed did not receive information about STDs; 83.8 % perceive little/no risk regarding STDs. 48.4 % are unaware of the methods of protection of STDs among women and 51.6 % obtained this information from websites and friends. 77.5 % reported not using protection methods. The main reasons were: stable partner, discomfort and the inability to acquire them. Discussion The results of this research allow for identifying the low perception among WSW regarding STDs, and the difficulty of approaching health professionals about this subject.

LGBT Cultural Competence and Interventions to Help Oncology Nurses and Other Health Care Providers

OBJECTIVES

To define and give an overview of the importance of lesbian, gay, bisexual, and transgender (LGBT) cultural competency and offer some initial steps on how to improve the quality of care provided by oncology nurses and other health care professionals.

DATA SOURCES

A review of the existing literature on cultural competency.

CONCLUSION

LGBT patients experience cancer and several other diseases at higher rates than the rest of the population. The reasons for these health care disparities are complex and include minority stress, fear of discrimination, lower rates of insurance, and lack of access to quality, culturally competent care. Addressing the health care disparities experienced by LGBT individuals and families requires attention to the actual needs, language, and support networks used by patients in these communities. Training on how to provide quality care in a welcoming and non-judgmental way is available and can improve health equity.

IMPLICATIONS FOR NURSING PRACTICE

Health care professionals and institutions that acquire cultural competency training can improve the overall health of LGBT patients who currently experience significant health care disparities.

The Sexual Health of Women in Lebanon: Are There Differences by Sexual Orientation?

PURPOSE

From studies conducted in Western countries (United States, United Kingdom, and Australia), we know that the sexual health of sexual minority women (SMW) differs in key ways from that of heterosexual women (HSW). To date, the sexual health of SMW living in the Middle East and North Africa region has not been studied. The purpose of this study was to compare the sexual health of SMW and HSW living in Lebanon.

METHODS

SMW and HSW living in Lebanon (N = 95) completed an anonymous, self-administered survey. SMW's risk perceptions and health promoting and sexual behaviors were compared to those of HSW. We examined differences by sexual orientation by using t tests and Fisher's exact tests.

RESULTS

The 45 SMW and 50 HSW had similar demographic characteristics. Significantly more SMW had heard of human papillomavirus, but only 22% of women from both groups knew of its association with abnormal Papanicolaou tests. Cervical cancer screening rates were similar in SMW and HSW, although remarkably low (42%) compared with rates in Western countries. Significantly more SMW (18%) reported difficulty with access to care than HSW (0%). Forty-four percent of SMW reported discomfort in disclosing their sexual orientation to their healthcare provider and 61% reported that healthcare providers lacked sensitivity toward lesbian, gay, bisexual, and transgender needs. Unwanted sexual contact occurred more frequently in SMW (53%) than HSW (23%).

CONCLUSION

The sexual health of women is affected by sociocultural factors. SMW living in Lebanon have unique health needs that should be addressed within their sociocultural context.

Family Planning for Sexual Minority Women

The family planning needs of sexual minority women (SMW) are an understudied but growing area of research. SMW have family planning needs, both similar to and distinct from their exclusively heterosexual peers. Specifically, SMW experience unintended pregnancies at higher rates than their exclusively heterosexual peers, but factors that increase this risk are not well understood. Contraception use is not uncommon among SMW, but lesbian women are less likely to use contraception than bisexual or exclusively heterosexual women. High rates of unintended pregnancy suggest contraception is underused among SMW. Contraception counseling guidelines specific to SMW do not yet exist, but greater adoption of current best practices is likely to meet the needs of SMW. SMW may have unique needs for their planned pregnancies as well, for which obstetrics and gynecology (Ob/Gyn) providers should provide care and referrals. In general, understandings of the distinct family planning needs for SMW are limited and further research is needed, with particular attention to issues of overlapping health disparities related to status as a SMW and other factors such as race/ethnicity that may add additional layers of stigma and discrimination. Clinical resources are needed to help Ob/Gyns make their practice more welcoming to the needs of SMW.

Correlates of Human Papillomavirus Infection Among a National Sample of Sexual Minority Women

BACKGROUND

Many sexual minority women are infected with human papillomavirus (HPV), yet little is known about correlates of HPV infection among this population.

MATERIALS AND METHODS

We analyzed data from a national sample of sexual minority women (i.e., women who either reported a history of female sexual partners or identified as nonheterosexual) aged 20-59 from the 2003 to 2012 National Health and Nutrition Examination Survey (n = 830). Weighted logistic regression identified correlates of infection with any HPV type and infection with a high-risk HPV type.

RESULTS

About 53% of women were infected with any HPV type, and about 37% were infected with a high-risk HPV type. Women who reported five or more sexual partners during their lifetime (adjusted odds ratio [aOR] = 5.07, 95% confidence interval [CI]: 2.26-11.42) were more likely to be infected with a high-risk HPV type. Compared to women aged 20-29, women aged 40-49 (aOR = 0.51, 95% CI: 0.32-0.81) or 50-59 (aOR = 0.27, 95% CI: 0.14-0.53) were less likely to be infected with a high-risk HPV type, as were women who were married or living with a partner (aOR = 0.62, 95% CI: 0.44-0.89). Mostly similar correlates were identified for infection with any HPV type, although infection with any HPV type was also less common among women who identified as lesbian compared to those who identified as heterosexual (aOR = 0.38, 95% CI: 0.21-0.68).

CONCLUSIONS

Demographic and health-related characteristics were associated with HPV infection outcomes. Findings can inform HPV prevention efforts for sexual minority women by providing information about risk factors and subgroups at particular risk for infection.

Interviewing Adolescents About Sexual Matters

To optimally address sex and sexuality, normalize gender and sexual diversities, and attend to adolescents' needs, clinicians will best serve their patients and their families by becoming comfortable initiating confidential, developmentally appropriate discussions with all adolescent patients. The goal is to create a safe, affirming, nonjudgmental space wherein adolescents may learn about sexual matters, discuss concerns, ask questions, and find support to assist them to achieve healthy, positive development. This article provides useful, practical suggestions to begin these conversations, offers specific examples and tips to encourage dialogue, and discusses ways to be a resource to adolescent patients.

Sexual orientation and sexual health services utilization among women in the United States

Although sexual minority women are at risk of sexually transmitted infections (STIs) and cervical cancer, few nationally representative studies have assessed sexual orientation disparities in sexual health care among women. Using data from the 2011-2013 and 2013-2015 waves of the National Survey of Family Growth, which provide a national probability sample of U.S. women aged 15-44years (N=11,300), we used multivariable logistic regression to examine the associations between sexual behavior and sexual identity (modeled separately) and STI testing in the past year, Pap test use in the last 3years, lifetime HIV testing, and lifetime human papillomavirus (HPV) testing. Women with male and female lifetime sexual partners had higher adjusted odds of being tested for STIs ([odds ratio:] 1.61; [95% confidence interval:] 1.37-1.89), HIV (1.66; 1.29-2.14), and HPV (1.79; 1.41-2.25) and similar adjusted odds of obtaining a Pap test (0.98; 0.76-1.27) than women with only male lifetime sexual partners. Self-identified bisexual women had higher adjusted odds of obtaining an STI (1.43; 1.10-1.86) and HIV (1.69; 1.24-2.30) test but lower adjusted odds of obtaining a Pap test in the last 3years (0.66; 0.47-0.93) than heterosexual-identified women. Women with only female lifetime sexual partners had lower adjusted odds of receiving an STI (0.14; 0.07-0.28) and Pap (0.10; 0.03-0.27) test than women with only male lifetime sexual partners. Results comparing self-identified lesbian and heterosexual women were similar. Health care facilities should monitor and address sexual orientation disparities in women's sexual health care and ensure the provision of high-quality sexual health services to all women.

Sexual Orientation and Sexual and Reproductive Health among African American Sexual Minority Women in the U.S. South

BACKGROUND

Research on the sexual and reproductive health of sexual minority women, especially those of color, is limited.

METHODS

Using multivariable Poisson regression, we estimated risk ratios for the association between two dimensions of sexual orientation (sexual identity and sexual behavior) and five sexual and reproductive health indicators (pregnancy, contraceptive use, human immunodeficiency virus [HIV] testing, Pap test use, and sexual assault) among African American sexual minority women in the U.S. South (n = 165).

RESULTS

Lesbians were less likely than bisexual women to have ever been pregnant (risk ratio [RR], 0.64; 95% confidence interval [CI], 0.48-0.85), ever received an HIV test (RR, 0.88; 95% CI, 0.80-0.96), obtained a Pap test in the last 3 years (RR, 0.75; 95% CI, 0.61-0.91), and had an abnormal Pap test result in their lifetime (RR, 0.42; 95% CI, 0.24-0.75). Women with only female past-year sexual partners were less likely than women with male and female past-year sexual partners to have ever been pregnant (RR, 0.58; 95% CI, 0.43-0.78), ever received an HIV test (RR, 0.87; 95% CI, 0.79-0.96), obtained a Pap test in the last 3 years (RR, 0.82; 95% CI, 0.67-0.99), and had an abnormal Pap test result in their lifetime (RR, 0.55; 95% CI, 0.32-0.94). Contraceptive use, receiving an abnormal Pap test result at the time of the study visit, and experiencing sexual assault did not differ by sexual identity or behavior.

CONCLUSIONS

Several sexual and reproductive health indicators varied in relation to sexual identity and sexual behavior among Southern African American sexual minority women. Interventions that facilitate access to sexual and reproductive health services and are tailored to the unique needs of sexual orientation subgroups of sexual minority women are needed.

Sexual orientation identity disparities in human papillomavirus vaccination initiation and completion among young adult US women and men

PURPOSE

To examine the association between sexual orientation identity and human papillomavirus (HPV) vaccination initiation and completion among both women and men.

METHODS

Using data from the 2013 and 2014 National Health Interview Survey, we estimated logistic regression models for the association between sexual orientation identity and HPV vaccination initiation (≥1 dose) and completion (≥3 doses) among US women and men in relation to sociodemographic and healthcare factors. Analyses were restricted to individuals for whom the HPV vaccine was recommended at some point in their lives, namely women aged 18-34 years (n = 9,734) and men aged 18-31 years (n = 6,812).

RESULTS

Among all women, bisexual women had higher adjusted odds of HPV vaccination initiation [(odds ratio) 1.71; (95 % confidence interval) 1.20-2.45] and completion (1.59; 1.05-2.42) than heterosexual women. No difference was observed in the odds of HPV vaccination initiation or completion between lesbian and heterosexual women. Among women who had initiated HPV vaccination, lesbians had lower adjusted odds of completion than heterosexual women (0.41; 0.19-0.90). Among all men, gay men had higher adjusted odds of initiating (2.07; 1.17-3.52) and completing (3.90; 1.68-9.06) HPV vaccination than heterosexual men. No difference was observed in the odds of HPV vaccination initiation or completion between bisexual and heterosexual men. Among men who had initiated HPV vaccination, gay (4.36; 1.28-14.83) and bisexual (20.92; 2.34-186.73) men had higher adjusted odds of completion than heterosexual men, although these results are unreliable and should be interpreted with caution.

CONCLUSIONS

Interventions are needed to promote HPV vaccination among all US women and men, regardless of sexual orientation identity.

Same-Sex Behavior and its Relationship with Sexual and Health-Related Practices Among a Population-Based Sample of Women in Puerto Rico: Implications for Cancer Prevention and Control

This secondary data analysis aimed to estimate the prevalence of same-sex behavior and sexual and health-related practices of a population-based sample (n=560) of women aged 16-64 years in Puerto Rico (PR). Data collection included interviews and biologic samples. Seven percent of the sample had had sex with other women (WSW). Age-adjusted logistic regression models indicated that WSW had higher odds of history of cancer, having ≥ 7 lifetime sexual partners, using sex toys and sharing them, and use of tobacco and illicit drugs. Future research is needed to address the health needs of WSW, including cancer-related risk factors and sexual practices.

Rate and predictors of human papillomavirus vaccine uptake among women who have sex with women in the United States, the National Health and Nutrition Examination Survey, 2009-2012

AIMS AND OBJECTIVES

To examine rates and associated correlates of human papilloma virus vaccine uptake in women who have sex with women in the United States, and to determine whether they differ from those in women who do not have sex with women.

BACKGROUND

Women who have sex with women are at risk for human papilloma virus infection but are less likely to receive preventive gynaecological services. Little research has been carried out to evaluate human papilloma virus vaccination rates and associated predictors of vaccination uptake in this population.

DESIGN

Cross-sectional descriptive study.

METHODS

Data from two consecutive cohorts of the National Health and Nutrition Examination Survey conducted by the United States' Centers for Disease Control were analysed.

RESULTS

The sample (N = 1105) consisted of women aged 18-26 years. There was no difference in human papilloma virus vaccine uptake between women who have sex with women and women who do not have sex with women. Overall, the vaccination rate was low (32·5%). Having health insurance and more education were significant predictors of vaccine uptake in women who have sex with women. Higher education and younger age were predictors in women who do not have sex with women.

CONCLUSIONS

Vaccination rates of women are far lower than the national target of 80%. The predictors of vaccine uptake were different in women who have sex with women than for women who do not have sex with women.

RELEVANCE TO CLINICAL PRACTICE

Women in their 20s (regardless of their sexual orientation) should be recognised as an undervaccinated population and require targeted interventions to improve vaccination uptake.

Lesbian Health Matters: A Pap Test Education Campaign Nearly Thwarted by Discrimination

The Pap test detects cell changes in the cervix that can be treated, preventing cancer from developing. Regular screening reduced cervical cancer deaths by 70% since 1950. Lesbians may not be adequately screened because of a misperception that they do not need Pap tests. The “Lesbian Health Matters” public and provider education campaign was implemented to address this problem. Paid advertisements were placed on two radio stations and in four newspapers. After 1 week, both radio stations cancelled the ads due to listener complaints about hearing the word “lesbian” on the radio. The community responded to this discriminatory action by demanding the campaign be completed, creating publicity that increased the campaign’s reach to 34% of women in the region. A training program was implemented reaching 219 providers. Thirty-two hundred health providers were surveyed regarding lesbianfriendly practice. A database of 293 providers was created and 120 referrals made.

HPV infection among a population-based sample of sexual minority women from USA

OBJECTIVES

Sexual minority women are at risk for infection with human papillomavirus (HPV); yet, relatively little is known about the prevalence of HPV infection among this population.

METHODS

We analysed data from the 2003-2012 National Health and Nutrition Examination Survey among women aged 20-59 (n=7132). We examined two dimensions of sexual orientation (sexual identity and sexual behaviour) and used weighted logistic regression to determine how HPV infection outcomes (any HPV type, high-risk HPV type and vaccine HPV type) vary by dimension.

RESULTS

Similar patterns emerged for sexual identity and sexual behaviour. In bivariate analyses, HPV infection outcomes were more common among non-heterosexual women compared with heterosexual women (any type: 49.7% vs 41.1%; high-risk type: 37.0% vs 27.9%), as well as among women who reported any same-sex partners compared with women who reported only opposite-sex partners (any type: 55.9% vs 41.0%; high-risk type: 37.7% vs 28.2%; vaccine type: 19.1% vs 14.0%) (p<0.05). When we disaggregated measures of sexual orientation into subgroups, bisexual women and women who reported partners of both sexes had greater odds of HPV infection outcomes (p<0.05 in bivariate analyses). Multivariate models attenuated several of these differences, though lesbian women and women who reported only same-sex partners had lower odds of most HPV infection outcomes in multivariate analyses (p<0.05).

CONCLUSIONS

HPV infection is common among sexual minority women, though estimates vary depending on how sexual orientation is operationalised. Results can help inform targeted HPV and cervical cancer prevention efforts for sexual minority women.

Sex of Sexual Partners and Human Papillomavirus Vaccination Among U.S. Girls and Women

INTRODUCTION

Girls and women are at risk of human papillomavirus (HPV) infection and cervical cancer from male and female sexual partners throughout the life course. However, no study has assessed how sex of sexual partners, a dimension of sexual orientation, may relate to HPV vaccination among girls and women.

METHODS

In 2014, data from the 2006-2010 National Survey of Family Growth were used to conduct logistic regression analyses estimating the relationship between sex of lifetime and past-year sexual partners and HPV vaccine awareness and initiation among U.S. girls and women aged 15-25 years (N=3,253).

RESULTS

Among U.S. girls and women aged 15-25 years, the prevalence of HPV vaccine awareness and HPV vaccine initiation was 84.4% and 28.5%, respectively. Adjusting for sociodemographic factors, participants with only female past-year sexual partners had significantly lower odds of initiating HPV vaccination relative to those with only male past-year sexual partners (OR=0.16, 95% CI=0.05, 0.55). Similarly, respondents with no lifetime (OR=0.65, 95% CI=0.46, 0.92) or past-year (OR=0.69, 95% CI=0.50, 0.94) sexual partners had significantly lower adjusted odds of HPV vaccine initiation compared with those with only male sexual partners. No difference was apparent in the odds of initiating HPV vaccination between participants with male and female sexual partners and those with only male sexual partners.

CONCLUSIONS

Medical and public health professionals should ensure that girls and women with only female or no sexual partners are included in HPV vaccine education and promotion efforts.

Primary care of women who have sex with women. Recommendations from the research

Research on women who have sex with women has increased in the last decade. Attention has been brought to this group of women through the IOM report, which noted a lack of research related to their care. Most of the research has not been published in nursing literature. This article reviews this literature with recommendations for primary care practice.

Preventing Cervical Cancer in the United States: Barriers and Resolutions for HPV Vaccination

Human papillomavirus (HPV) vaccination rates for preadolescent and adolescent girls in the United States are far behind those of other developed nations. These rates differ substantially by region and state, socioeconomic status, and insurance status. In parents and young women, a lack of awareness and a misperception of the risk of this vaccine drive low vaccination rates. In physicians, lack of comfort with discussion of sexuality and the perception that the vaccine should be delayed to a later age contribute to low vaccination rates. Patient- and physician-targeted educational campaigns, systems-based interventions, and school-based vaccine clinics offer a variety of ways to address the barriers to HPV vaccination. A diverse and culturally appropriate approach to promoting vaccine uptake has the potential to significantly improve vaccination rates in order to reach the Healthy People 2020 goal of over 80% vaccination in adolescent girls. This article reviews the disparities in HPV vaccination rates in girls in the United States, the influences of patients’, physicians’, and parents’ attitudes on vaccine uptake, and the proposed interventions that may help the United States reach its goal for vaccine coverage.

SCREENING FOR SEXUALLY TRANSMITTED INFECTIONS (STIs) AMONG A HETEROGENEOUS GROUP OF WSW(M)

OBJECTIVES

This study explored predictors of STI screening among a heterogeneous group of women who have sex with women and men.

METHODS

Following bivariate analyses, a multivariate logistic regression model was conducted to assess the relationship between testing and sociodemographic, relationship characteristics.

RESULTS

The majority of participants reported not receiving STI screening in the past year. Gender expression, and not sexual orientation, was a significant predictor of screening. For each increase in masculinity, participants had lower odds of receiving an STI test.

CONCLUSIONS

More research is needed to understand how gender expression of WSW(M) relates to preventative health behaviors.

The Predictive Syndemic Effect of Multiple Psychosocial Problems on Health Care Costs and Utilization among Sexual Minority Women

Previous studies documenting sexual minority women's disproportionate risk for a range of medical, mental health, and substance use disorders have not provided a predictive framework for understanding their interrelations and outcomes. The present study aimed to address this gap by testing the syndemic effect of co-occurring psychosocial problems on 7-year health care costs and utilization among sexual minority women. The sample was comprised of sexual minority women (N = 341) who were seen at an urban LGBT-affirmative community health center. Medical and mental health care utilization and cost data were extracted from electronic medical records. Demographically adjusted regression models revealed that co-occurring psychosocial problems (i.e., childhood sexual abuse, partner violence, substance use, and mental health distress [history of suicide attempt]) were all strongly interrelated. The presence of these indicators had a syndemic (additive) effect on medical costs and utilization and mental health utilization over 7-year follow-up, but no effect on 7-year mental health costs. These results suggest that the presence and additive effect of these syndemic conditions may, in part, explain increased medical costs and utilization (and higher medical morbidity) among sexual minority women.