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“‘My doctor told me that I didn't need one because I was a lesbian!’ The first time I heard those words, my heart sank. As a street nurse with the Bute Street Clinic (Vancouver), I wondered why women who have sex with women rarely access STD screening, including Pap smears, at our clinic. What was more alarming was my growing suspicion that screening practices are guided by mythology rather than research–based evidence when it comes to women who have sex with women,” says nurse Kathryn Collister.
During my own latest Pap test, the physician and I debated lesbians' needs for regular smear screening. ‘Do you guys get cervical cancer, too? ’ she asked. Apparently she was told by a cancer authority that women who have never had sex with men don't need Pap smears.
On 13 March 2001, just over forty people attended the launch party for the Queer Women's and Trans Health Series in Vancouver, British Columbia, coordinated by The Centre: A Community Centre Serving and Supporting Lesbian, Gay, Transgendered, Bisexual People and their Allies, in partnership with community groups and health centres, and supported by agencies, businesses and individuals who shared their time, expertise and donated prizes. The series promotes and celebrates health within the queer women and trans communities.
Our definition of 'queer women' and 'women who have sex with women' (WSW) includes women who have sex with women, women who have sex with women and men, and trans individuals. 'Trans' includes Female–to–Male (FTM) and Male–to–Female (MTF), transgender, transsexual and gender–queer individuals.
One of the key features of the series is ‘Papalooza: The Smear Campaign.’ It is a health and education project combining awareness, education and services for STD and Pap test screening. Queer women and trans individuals face significant barriers in accessing appropriate health services, and represent an underserviced and underscreened population.
Despite the confusion among queer women, trans people and health practitioners about who should be tested, how often and why, screening is recommended for all women who are or have been sexually active, or who have reached the age of 18. Pap tests detect changes in the cells of the cervix which are often precursors to cervical cancer. Early detection of these cellular changes facilitates treatment and the prevention of invasive cervical cancer.
Health Canada cites the main risk factors for cervical cancer as: early age at first intercourse; greater number of sexual partners; increasing age; infection with human papilloma virus (HPV); smoking; and low socio–economic status. Research has established a significant association between HPV, a very common STD, and cellular changes in the cervix. While many of these infections resolve spontaneously, some don't. Because of the long lag–time of 15–20 years before invasive cervical cancer becomes evident, most precancerous cells can be detected before significant invasion occurs.
Assumptions about sexual behaviour and how STDs are transmitted influence the health practices, health care and status of queer women and trans people, as well as service providers. Many are misinformed about the need for regular Pap smear screening. The absence of historical research on STD transmission between women has been translated into a health care ‘knowledge’ that assumes low or non–existent transmission rates in these populations. This leads to a misperception that queer women are not at risk for cervical cancer and therefore do not need Pap tests.
HPV can be transmitted by skin–to–skin contact. It has been found in women who report never having had sex with men. It can be detected on human fingertips, and so is transmissible between women. Further, most women who have sex with women have also had sex with men, and many continue to do so. As well, women who have not had sex with men have had sex with women who have had sex with men.
Because the onset of invasive cervical cancer linked to HPV infection is so delayed, it is necessary to educate women and service providers about the need to recognize sexual history and current sexual practices in their discussions about sexual behaviour, STD risk and Pap test screening. The assumption that HPV is not transmissible between female partners, combined with less frequent or non–existent Pap smear screening may place women who have sex with women at increased risk for delayed detection of cervical cancer.
The Queer Women's and Trans Health Series Planning Committee also recognizes a dire need for information about specific transgender health needs. Pap screening for HPV/ rectal cancer for those who engage in penetrative rectal sex is now being researched and considered for future clinics.
Papalooza: The Smear Campaign integrates health services with fun, social and educational activities. Evening clinics have already been held in three different areas of Vancouver with the goal of making tests and screening more accessible to queer women and transgendered people (MTF/ FTM). Each event features activities focused on a particular theme, including Love Your Body, Gender Identity, and Reproductive and Sexual Health. Poetry readings by local artists, art expression workshops, video screenings, and sex toy and sexual health discussions at clinics around the city makes clinics and service providers visible and accessible to members of queer women and trans communities.
Each of the clinics is a three–hour evening event staffed by two female nurses who themselves identify as lesbian, queer or queer–sensitive. Appointments are prebooked with allowances for drop–ins. One–hour appointments provide ample time for gathering thorough sexual/ reproductive health histories, STD screens and Pap testing, as well as for discussion and education to take place between practitioner and client-a vital component of queer women's health. At the end of an appointment, each client receives a “goodies bag”" containing bath bombs, soap, vanilla and berry-flavoured dental dams, condoms and lube, and is eligible to enter a draw for a one–night getaway at a women's B& B on Vancouver Island.
A counsellor is on–site during each clinic for crisis intervention, debriefing and referral because pelvic exams can provoke extreme anxiety for women who have experienced sexual abuse, or have had negative experiences with practitioners. As well, a client's routine presentation at a clinic is often a gateway to disclosure of psychosocial difficulties that may demand immediate attention.
Papalooza: The Smear Campaign and the Queer Women's and Trans Health Series provide a unique model for outreach and education, and encourage community players to collaborate to develop creative methods of promoting health. Although early clinics saw modest attendance, they are receiving overwhelming positive feedback. They are an ongoing commitment of community service providers and consumers who recognize the need for queer-positive health services.
The assumptions that women who have sex with women have done so exclusively all their lives, and that STDs such as HPV cannot be transmitted between women, are false. And, although women who have sex with women are at lower risk, they are not risk–free. Health practitioners need to conduct thorough sexual histories. They must ask, "Do you have sex with men, women or both?" and recognize that sexual behaviours, practices and identities can change over time.
Increased awareness and ongoing dialogue among family physicians, nurses, social service providers and consumers about queer women's and trans health needs is imperative. Papalooza will continue as an ongoing health and education outreach project with clinics being held around Vancouver wherever staff have committed interest, time and space.
Jacquelyne Luce is a medical anthropologist researching queer women's health issues.