The Whole Lesbian Sex Book (45 page)

More troubling, those who research STD transmission may not know much about lesbian sex either. They may use terms like
oral sex
and
vaginal intercourse
in safer-sex guidelines without defining them. Does oral sex refer to cunnilingus? Or just fellatio? Does penetration with a dildo count as intercourse? How do you know what’s safe?

Relatively few clinical studies have been conducted of woman-to-woman transmission of STDs. Can chlamydia be transmitted by sharing a dildo with an infected partner? Can you give your partner herpes or trichomoniasis through frottage? Can you get HIV by going down on a menstruating woman who has the virus? What about hepatitis? A cautious physician will tell you that, yes, all of these scenarios are quite possible—but that not enough studies have been done to offer conclusive answers.

Since women who have sex with women are often left out of health research, our health-care needs are neglected. Jeanne Marrazzo, of the Lesbian-Bisexual Women’s Health Study at the University of Washington, says that because “lesbians do not fit the very narrowly and poorly defined risk profile, they are being told that as lesbian/bisexual women they do not need Pap smears or STD screenings.”
¹

None of which inspires confidence when you’re sitting on the examination table in a paper gown and your health-care practitioner cheerfully asks whether you’re sexually “active” and what kind of birth control you use. No wonder few of us feel comfortable speaking candidly about our sexual histories and practices.

But if medical research skirts the issue of woman-to-woman transmission of STDs, and if you don’t feel comfortable coming out to a physician, how will your gynecologist know what to look for?

Talking to Your Doctor About Sex

As Tristan Taormino says, “Your gynecological visit is no time to play ‘Don’t Ask, Don’t Tell.’ If they don’t ask, it’s your responsibility to tell.”
²
It’s important for your health that you come out to your health caregiver. Find a physician you feel comfortable with. Look for someone you think you can talk to. Even a lesbian gynecologist can’t guess what you do in bed.

You can’t rely on your health-care practitioner to make you feel comfortable talking about sex. Physicians trained in the United States receive less instruction in human sexuality than volunteers at some sex-information hotlines. Your doctor may be even less comfortable than you discussing the details of your sex life—especially if your physician sees few other lesbian, bisexual, or transgendered patients.

Charles Moser, author of
Health Care Without Shame: A Handbook for the Sexually Diverse and Their Caregivers,
recommends that you come out to your physician during your first visit—if not sooner. Don’t wait until you suspect you have an STD. What should you tell your health-care practitioner about your sex life? Here are some of the points Moser suggests you cover:

• The sexual activities you typically engage in—such as oral sex, vaginal or anal penetration with fingers or a dildo, or fisting.

• The safer-sex precautions you employ.

• The number of partners with whom you have sexual contact.

• Whether you engage in activities that might involve bruising or breaking the skin (such as caning or play piercing).

• The family structures or relationships you wish to have taken into account for hospital visitation or decisions regarding your care.
³

Finally, if you don’t feel comfortable following Moser’s recommendations, some health advocates suggest you simply say that you are sexually active and want to be tested for the full spectrum of STDs.

Gynecological Care

All sexually active females should get annual gynecological exams, including Pap smear, pelvic exam, and breast exam. Whether you have sex with one partner or many, with women only or with both women and men, you need regular gynecological care. Regardless of your gender identity—stone butches (and many FTMs)
⁴
require gynecological care, too.

If you engage in unprotected sexual activities, ask to be screened for STDs. If you engage in anal sex, ask for a rectal exam—some STDs can infect you rectally as well as genitally. As you’ll see below, STDs often occur without any symptoms—or with symptoms you could easily mistake for the flu. A Pap smear, blood test, or culture may be the only way you know you’ve been exposed to an STD.

If you’re diagnosed with an STD or have had an abnormal Pap smear, your physician will recommend treatment. It’s important that you follow up on recommended procedures and return visits. Your annual Pap smear can prevent cervical cancer
only
if you treat any dysplasia or other conditions revealed by the test.

Consult a gynecologist if you experience pain during penetrative sex or if you experience spotting after deep thrusting with a dildo, fingers, or fist. You may have a small tear or abrasion on your cervix.

If you notice a rash or sore on your genitals or anus, unusual discharge, or irregular bleeding, or if you experience genital itching or irritation, painful urination, abdominal or pelvic pain, nausea, fatigue, or fever, consult a physician. Don’t ignore these symptoms.

STDs and Gynecological Concerns

Many gynecological problems can be cleared up easily. Left untreated, they can lead to very serious health problems. Bacterial STDs can be treated with antibiotics. Viral STDs can’t be “cured”—but there are medications to alleviate out-breaks, as with herpes, as well as new treatment protocols for HIV that have been effective for many people.

Butches and Gynecological Care

Many butches feel profoundly uncomfortable in the pastel pink-and-blue world of the ob-gyn’s office. The presumptions of mainstream health-care providers about female bodies and gender are painful to bear. Even “feminist” and “lesbian-friendly” health-care providers may not necessarily be sensitive to the needs of butches.

For a butch who does not engage in receptive vaginal penetration, putting your feet in the stirrups can be hell. For many butches who don’t identify as women,
per se
—stone butches, transgendered butches, butches who view “butch” as a third gender—a gynecological exam is an experience of dysphoria.

Numerous butches have a simple solution to the problem: they don’t go. They don’t receive regular Pap screenings, mammograms, or well-woman exams.They don’t see a gynecologist unless something’s wrong.And since many STDs are asymptomatic—well, you get the picture.

FTMs aren’t exempt either. “For the FTM specifically, dealing with the female reproductive organs can be a nightmare. Most of us do not have regular Pap smears.The procedure is invasive. And again, finding a gynecologist who is sympathetic is difficult.”
⁵
FTMs need access to appropriate gynecological health care. Some health-care providers serving the transgendered community advocate pelvic exams after age 40 for “people assigned a female sex at birth.”
⁶
Others say health maintenance routines should be determined by the organs present. “Health maintenance for transgender patients should be based on age, family and personal health risk factors, and the organ systems present. Physical exams should be structured based on the organs present rather than the perceived gender of the patient…. If the uterus and cervix are present, pelvic exams and Pap smears need to be done on a regular basis.”
⁷

Wherever we fall on the gender spectrum—from butch to transgendered—we need health care. What can we do?

• Use local and regional email lists and discussion boards to find referrals. Some national organizations and websites also offer local referrals. (See the resources section.)

• Educate your doctor.
Butch-femme.net
posts an informational brochure for gynecologists and other health-care professionals, “Female = Woman, Right? Not Always …”
⁹

• Is there a butch-friendly physician in your area? Spread the word. Even a single queer staff person in a medical practice can be a support.

• Tell your health-care provider how you wish to be addressed. Likewise, health-care providers can ask patients if they prefer “he” or “she.”

• Tell your health-care provider what you do sexually, with whom, and whether or not you use latex barriers.

• Take a friend or partner with you to your exam. Tell the office staff that she (or he) will be accompanying you for the exam.

• If you are partnered, you may feel more comfortable getting your health care in the same office as your partner. You can support each other.

• Take care of yourself. Learn about gynecological health, do breast self-exams, get tested for STDs, and practice safer sex.

“Latex provides protection on whatever surface it is covering,” according to the researchers on
LesbianSTD.com
.
⁸
Use of latex or polyurethane barriers on insertive sex toys such as dildos and vibrators prevents transmission of bacterial STDs like chlamydia and gonorrhea. Use of plastic wrap or latex or nitrile gloves on skin prevents transmission of viruses like herpes and HPV. Plastic wrap is considered a better barrier for oral sex than conventional dental dams, which are too small. Of course, if you do have sex with men (penis-vagina, penis-anus, or fellatio), use a condom. (See chapter 5, The Road to Heaven Leads to You, for a complete list of safer-sex guidelines.)

Here are some STDs and other gynecological conditions you should know about:

Allergies and Chemical Sensitivity

While allergies aren’t sexually transmitted conditions, they certainly will affect your sex life. The vaginal discharge, itching, and irritation they cause may lead you to mistake allergic vaginosis for a yeast infection—or even new-onset genital herpes. You may be sensitive to latex, the powder used on latex gloves, glycerin in a particular brand of lubricant, spermicides or microbicides like nonoxynol-9, or other products. The best treatment is to discontinue use of the irritant. (See chapter 17, Sex Toys and Accoutrements, for information on lubricants, latex allergies, and alternative safer-sex supplies.)

Nonoxynol-9 is a detergent that’s added to some lubricants (including some lubricated condoms) to kill the HIV virus. Many women find nonoxynol-9 irritating to the mucous membranes of the vagina and rectum. There has been much debate regarding the use of nonoxynol-9. While some sex educators still recommend nonoxynol-9 for use with condoms during penis-to-vagina and penis-to-anus penetration as added insurance against HIV transmission, most do not. They argue that the irritations caused by nonoxynol-9 outweigh the benefits. Especially regarding anal sex, they recommend that you
not
use nonoxynol-9.
¹⁰
Irritating the delicate rectal tissue, they argue, can encourage HIV transmission by providing the virus with an accessible route to the bloodstream. As of June 2001, the CDC recommended that nonoxynol-9
not
be used as a microbicide or lubricant during anal intercourse.
¹¹

LesbianSTD.com

When I first logged onto
LesbianSTD.com
, I wanted to leap out of my chair. Finally, a website addressing
our
safer-sex concerns. Here are some things I learned:

• Human papillomavirus (HPV), one of the most common STDs, can cause genital warts and abnormal Pap smears, and in some women can lead to cervical cancer.

• HPV can be transmitted from one woman to another.

• Bacterial vaginosis (BV) is strongly associated with preterm labor and low birth weight.

• BV is often diagnosed in both partners in lesbian couples.

• Both HPV and BV have been seen in many lesbian and bisexual women, even those with no prior sexual history with men.

• Medical literature contains case reports of woman-to-woman transmission of HIV. The most likely sources of transmission are menstrual blood, vaginal discharge when there is vaginitis (because more white blood cells containing HIV may be present then), and traumatic sex practices.

Bacterial Vaginosis

This condition may be transmitted sexually between women with such frequency that one researcher calls BV an “STD among lesbians.”
¹²
One study of lesbian health reported an 80 percent concurrence rate for bacterial vaginosis among monogamous lesbian couples.
¹³
Yet, it has not been medically proven that bacterial vaginosis, caused by an imbalance of bacteria normally found in the vagina, is, in fact, sexually transmitted at all.
¹⁴
Still, partners should be evaluated. If you notice a yellowish vaginal discharge, vaginal itching or irritation, or a strong odor, you may have a vaginal infection. Bacterial vaginosis is treated with antibiotics. Use only water-based lubricants in the vagina; oil-based lubes are difficult to wash out. Do not allow anal bacteria entry into the vagina. Change gloves when you move from anal to vaginal penetration—or wash your hands with an antibacterial soap. Use condoms on shared sex toys. Change condoms when you change activities or partners.