Culturally Competent Care: Primary and Preventive Health Care for Lesbian and Bisexual Women

March 2, 2011

By Elizabeth P.  Gurney, MD

Faculty Peer Reviewed

In the United States, population-based studies estimate that 1-4% of women self-identify as lesbian or bisexual and 4-17% have had same-gender sexual activity since puberty.[1,2] Since the publication a decade ago of the Institute of Medicine report urging investigation of health issues for lesbian and bisexual women, sensitivity to the unique challenges faced by this group has increased.[3] Despite improvements in cultural competence and awareness training for physicians, lesbian and bisexual patients remain at increased risk of not receiving routine preventive health care and consequently have greater risks for adverse health outcomes.[4] Primary care physicians have the opportunity to improve health care for this group by identifying and overcoming common barriers to communication and the provision of routine health care.[5,6]

 Three major barriers inhibit primary and preventive health care delivery to lesbian and bisexual women: (a) lack of physician comfort and knowledge of  health issues specific to lesbian health care, (b) physician reluctance to inquire about sexual orientation, and (c) patient reluctance to disclose sexual orientation.[5] While 25 years ago, only 9.3% of lesbian and bisexual women surveyed had been asked by their physicians about sexual orientation, disclosure rates were 60% in a recent large study.[6,7] This likely reflects widespread change in the social climate over this time interval, with greater cultural acceptance of homosexuality as a normal variant of human sexuality, which may help patients feel more comfortable sharing this intimate information with health care professionals.[8] Additionally, the introduction of lesbian and gay issues into medical school curricula has improved physicians’ ability to discuss sexuality. The use of inclusive language on forms, information handouts, and during patient interviews has become more common, and is supported by the Centers for Disease Control’s “five Ps” method of sexual history taking, which emphasizes a nonjudgmental interview style to inquire about partners, sexual practices, prevention of sexually transmitted diseases (STDs), past history of STDs, and pregnancy prevention.[9]

 By and large, lesbian and bisexual women face the same health issues as heterosexual women. By obtaining a full history, physicians can identify individuals’ health-related practices and appropriately target screening, prevention, counseling, and referrals based upon patients’ needs. Here, we review topics especially relevant to the primary care visit setting.

 Sexual practices and sexually transmitted diseases

Physicians should specifically inquire about their female patients’ sexual practices, which may include intercourse with both women and men, in order to offer appropriate information and counseling about safer sex practices. Transmission between women of herpes simplex virus, trichomoniasis, and human papilloma virus (causing genital warts) has been proven; transmission of other STDs is theoretical but not yet described in the literature.[5,10,11] Furthermore, as many as 77% of lesbians have reported having one or more male sexual partners, placing them at similar risk for male-to-female transmission of STDs as heterosexual women.[12]

 Pregnancy and childbearing

This group of women is more likely to be nulliparous than their heterosexual counterparts, with nulliparity rates about three times greater for lesbians and two times greater for bisexual women.[13] However, homosexual and bisexual women are increasingly choosing to become parents, whether through donor insemination, intercourse with a male partner, or adoption. Such situations are complex, and legal assistance is often recommended to help sort through issues including the legal relationship of the nonbiologic same-sex parent and the sperm donor (who in some areas may have parental obligations), durable power of attorney, and health care proxy status.[14] Physicians should refer patients to a specialist for a full fertility evaluation. Of note, the psychosocial development of children raised by same-sex parents is not different from that of children with heterosexual parents, and the American Academy of Pediatrics supports efforts to legalize adoption for the non-biologic parent in a same-sex couple.[5,14,15]

 Health behaviors

Overweight and obesity are more prevalent among lesbian and bisexual women.[13,16-18] Similarly, lesbian and bisexual women are more likely to drink greater quantities of alcohol, and to be past or current smokers, than heterosexual women.[13,16-8] These are significant potential risk factors for cardiovascular disease as well as cancer, and are modifiable contributors to long-term health outcomes. Simple questions and open discussion of behavior patterns by the primary physician, or via referral to a specialist, can have a lasting impact on quality of life.

Cancer risk and screening

As described above, lesbians have increased rates of cancer risk factors, including nulliparity, obesity, and alcohol and tobacco use. However, this group receives fewer Papanicolaou tests than their heterosexual counterparts despite risk factors for cervical dysplasia.[16-18] Barriers to appropriate screening may include previous negative experiences with health care providers, younger age, lower education, less access to health insurance through a spouse, misperception of risks, and fewer routine gynecologic visits due to the lack of need for contraception.[4,18,19] In contrast, lesbians have been shown to receive mammograms at rates comparable to heterosexual women.[4] This may be explained by the increasing awareness of mammography among the general public. Also, because sexual practices are not as closely tied to mammography recommendations as they are to cervical cancer screening, disclosure of sexual orientation is unlikely to occur in this setting, which may increase patients’ willingness to request a mammogram.

 Psychiatric illness

Social stressors, including homophobia and stigmatization, place lesbian and bisexual women at increased risk for mental distress, psychiatric illness, suicidal ideation, and self-harm. In addition, intimate partner violence occurs among women in same-sex relationships. Physicians should be adept at screening for life stressors, depression, and suicidality. Referral to mental health specialists with experience in homosexual issues is often helpful.[5]

 As physicians, we have the unique opportunity to improve the lives of our patients. Significant patient-physician connections are often made via simple interventions, like turning away from the computer to make eye contact when asking an open-ended question, and maintaining a respectful, compassionate, nonjudgmental manner while the patient replies. Awareness of the issues facing marginalized groups such as lesbian and bisexual women enables us to reach out to these patients in order to provide them with excellent primary and preventive health care.

Commentary by Andrew B. Wallach, MD, FACP

 As noted in Liz Gurney’s article, lesbian and bisexual women confront similar primary care health issues as heterosexual women.  However, based on their sexual practices, they are also at increased risk for specific diseases (eg, breast and ovarian cancer due to their increased prevalence of nulliparity).  Unfortunately, high quality care cannot be provided unless the provider is aware of the specific risks of their individual patient.  Thus, if providers and patients are not comfortable discussing sexuality, health care will be compromised; mutual respect is paramount to the provider-patient relationship and high-quality care.

Dr. Gurney is a former student of NYU School of Medicine

Peer reviewed by Andrew Wallach, MD, Associate Professor of Medicine, NYU School of Medicine

References

 1. Dean L, Meyer IH, Robinson K, et al. Lesbian, gay, bisexual, and transgender health: findings and concerns. J Gay Lesbian Med Assoc. 2000;4:102-151.

2. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA. 1999;281(6):537-544.

3. Solarz AL, ed. Lesbian Health: Current Assessment and Directions for the Future.  Washington DC:  Institute of Medicine, National Academy Press; 1999.

4. Diamant AL, Schuster MA, Lever J. Receipt of preventive health care services by lesbians. Am J Prev Med. 2000;19(3):141-148.

5. Mravcak SA. Primary care for lesbians and bisexual women. Am Fam Physician.   2006;74(2):279-286.

6. AAFP Policies on health issues. American Academy of Family Physicians, 2005. Accessed March 22, 2010 at: http://www.aafp.org/online/en/home/policy/policies.html.

7. Smith EM, Johnson SR, Guenther SM. Health care attitudes and experiences during  gynecologic care among lesbians and bisexuals. Am J Public Health. 1985;75(9):1085-1087.

8. O’Hanlan KA. Health policy considerations for our sexual minority patients. Obstet Gynecol.   2006;107(3):709-714.

9. US Department of Health and Human Services, Centers for Disease Control and Prevention.  Sexually transmitted diseases: treatment guidelines 2006. Accessed March 22, 2010 at:       http://www.cdc.gov/std/treatment/2006/clinical.htm.

10. Marrazzo JM, Koutsky LA, Kiviat NB, Kuypers JM, Stine K. Papanicolaou test screening      and prevalence of genital human papillomavirus among women who have sex with women.  Am J Public Health 2001;91(6);947-952.

11. Marrazzo JM, Stine K, Koutsky LA. Genital human papillomavirus infection in women who have sex with women: a review. Am J Obstet Gynecol. 2000;183(3):770-774.

12. Diamant AL, Schuster MA, McGuigan K, Lever J. Lesbians’ sexual history with men:  implications for taking a sexual history. Arch Intern Med. 1999;159(22):2730-2736.

13. Case P, Austin SB, Hunter DJ, et al. Sexual orientation, health risk factors, and physical functioning in the Nurses’ Health Study II. J Womens Health (Larchmt). 2004;13:1033-1047.

14. Carroll NM. Optimal gynecologic and obstetric care for lesbians. Obstet Gynecol. 1999;93(4):611-613.

15. Committee on Psychosocial Aspects of Child and Family Health. Coparent or second-parent adoption by same-sex parents. Pediatrics. 2002;109(2):339-340.

16. Valanis BG, Bowen DJ, Bassford T, Whitlock E, Charney P, Carter RA. Sexual orientation    and health: comparisons in the Women’s Health Initiative sample. Arch Fam Med. 2000;9(9):843-853.

17. Dibble SL, Roberts SA, Robertson PA, Paul SM. Risk factors for ovarian cancer: lesbian and heterosexual women. Oncol Nurs Forum. 2002;29(1):E1-7.

18. Cochran SD, Mays VM, Bowen D, et al. Cancer-related risk indicators and preventive screening behaviors among lesbians and bisexual women. Am J Public Health.  2001;91(4):591-597.

19. Rankow EJ, Tessaro I. Cervical cancer risk and papanicolaou screening in a sample of lesbian and bisexual women. J Fam Pract. 1998;47(2):139-143.

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