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Approach to Health Care for Lesbian and Bisexual Women

Carolyn Delk, DO; Halina Wiczyk, MD

Common Clinical Scenario: A 31-year-old nulligravida woman presents for her annual examination. Her last visit was 4 years ago. She reports a history of menarche at age 10; irregular, heavy periods; and no history of sexually transmitted infections (STIs) or abnormal Pap test results. She has never used hormonal contraception. During your interview, she states she has been exclusively involved with women sexually and asks if she needs to continue getting Pap tests. Additionally, she asks for advice regarding preventive health measures. How might you counsel her?

In the United States, an estimated 2% to 10% of women identify themselves as lesbian or bisexual.1 Lesbian and bisexual women have the same health risks as heterosexual women, but trends and special circumstances within this population may affect individual health outcomes. Homophobia and discrimination negatively affect patients’ health and access to care, but the effects of these may be lessened by practitioner advocacy within health care settings. This article reviews medical and social issues pertinent to health care for lesbian and bisexual women, areas for screening, and interventions that can positively affect patients’ health.

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IDENTIFYING PATIENTS

Many patients may not feel comfortable disclosing their sexuality or identity to a health care provider, often because of concerns regarding homophobia and discrimination. Some offices post a nondiscrimination policy to signal that their practice is a safe space for disclosure. Creating a welcoming environment may involve educating office staff and clinicians, as well as rewording paperwork to be inclusive of same-sex relationships (Table 1).

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TABLE 1. Creating a Safe Space for Lesbian and Bisexual Patients

Maintaining gender-neutral language and a nonjudgmental approach is helpful while screening patients. Asking, “Is contraception a concern?” during screening avoids alienating women in same-sex relationships and acknowledges that heterosexual couples may not be interested in contraception. Inquiring, “Do you have sex with men, women, or both?” offers the opportunity to disclose behaviors that provide useful information for risk assessment. Many practitioners include these and similar questions on a general questionnaire that is administered and reviewed prior to appointments. It may be beneficial to readdress these screening questions at annual visits, as sexual identity and practices may develop or change over time. Patients who elect not to provide written answers to questions regarding sexuality should be asked in person.

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BARRIERS TO HEALTH CARE

Lesbian and bisexual women may have fewer opportunities for accessing health care services than do heterosexual women. Concern about encountering homophobic attitudes or a lack of confidentiality may limit care seeking, particularly for adolescents. Additionally, many women do not have insurance and may not have sufficient income to obtain services they need. In situations where only one woman in a same-sex household is employed, her partner may not have access to coverage under the employer’s insurance. Some women in same-sex relationships may not see a gynecologist regularly if they are unaware they can benefit from annual exams and health care screening, believing such visits are limited to obtaining birth control or pregnancy care.

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CERVICAL SCREENING

All women require regular Pap tests as outlined in the American Society for Colposcopy and Cervical Pathology (ASCCP) Consensus Guidelines. High-risk human papillomavirus (HPV) strains have been identified in approximately 1 in 5 women who have never had heterosexual intercourse.2 Additionally, many lesbians have been in sexual relationships with men or may be in relationships with women who have dated men. As lesbians have higher rates of tobacco use, this may contribute to an increased risk for cervical dysplasia.3 Regular testing as outlined by the ASCCP guidelines should be recommended to all women regardless of their present or past sexual activities. Additionally, patients should be counseled about their HPV vaccination options.

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SEXUALLY TRANSMITTED INFECTIONS

All women are potentially at risk for STIs, including human immunodeficiency virus (HIV), and should be screened and tested appropriately. More than 10% of women with exclusively female partners have a history of STIs, and trichomoniasis, syphilis, and HIV have been documented as sexually transmissible between women.2 Data indicate that bisexual women have the highest incidence case rates for HIV of any female population.4 Additionally, many women who self-identify as lesbians have been sexually active with men during their lives, and some adolescents questioning their sexuality may engage in unsafe sexual activity with same- or opposite-sex partners.

Some women who have sex with women participate in high-risk behaviors for the acquisition of HIV and hepatitis, such as intravenous drug use or unprotected intercourse with men. Un-screened semen from sources other than sperm banks may also facilitate HIV transmission.2

Reviewing safe sex practices remains important. It may be valuable to be inclusive of practices associated with same-sex couples when providing anticipatory guidance to younger patients, as they may not disclose their identities or behaviors and because heterosexual couples may engage in these practices, as well. It is particularly important to review that oral sex can transmit infection. Avoiding contact with menstrual blood and bodily secretions through the use of barrier methods, such as dental dams and gloves, reduces the transmission of STIs. Sex toys should be cleaned with warm soapy water, and condoms should be used when sharing toys.

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PRENATAL COUNSELING

As more lesbians choose to start families, it is important not to assume that patients who are or have been pregnant are heterosexual. Sperm banks require clinician involvement when a woman is interested in either purchasing or processing sperm, and patients may request completion of required paperwork to support there is no medical contraindication to their desired pregnancy. Since fees may total several thousands of dollars, some women may elect to engage in heterosexual intercourse or exposure to untested sperm for the purposes of achieving a pregnancy. Reviewing the importance of having potential partners tested for STIs may be beneficial.

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PARITY

Nulliparity has been noted as a relative risk factor for breast cancer. In the Nurses’ Health Study II (NHSII), 76% of lesbians surveyed were nulliparous, contrasting with 22% of heterosexuals. Of parous lesbians and bisexuals, it was noted that significantly more had given birth at age 19 than their heterosexual counterparts (14% lesbians, 13% bisexuals, 6% heterosexuals).5 As part of coping and coming to terms with sexual identity in adolescence, lesbian and bisexual teenagers may engage in sex with men earlier and may be more likely to become pregnant as teenagers.6 Some adolescent girls, both heterosexuals and homosexuals, report pressure to “prove” their sexual identity by having sex with men. Anticipatory guidance and open discussions with adolescent patients may help them make safer sex choices.

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GENERAL HEALTH SCREENING

Comparisons made from the Women’s Health Initiative sample of women ages 50 to 79 suggest there are general health areas in which lesbian and bisexual women may be at higher risk than their heterosexual counterparts (Table 2). The study identified lower use of screening services, higher prevalence of obesity, smoking, and alcohol use, and lower intake of fruit and vegetables when compared with heterosexual women, with similar exercise patterns and rates of hypertension.7 These combined factors may increase the risk for breast cancer, lung cancer, type 2 diabetes, and cardiovascular disease. In fact, higher rates of heart attack have been reported in the lesbian population.7

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TABLE 2. Preventive Health Care Measures for Patients

The rates of current smoking and alcohol use among lesbians are higher than among heterosexual women, and lesbians and bisexuals are more likely than heterosexuals to report current or past smoking.2,5 As smoking is a modifiable risk factor for multiple adverse health conditions, attention should be given to helping patients quit. The NHSII found lesbians (5%) and bisexuals (7%) were significantly more likely than heterosexual women (2%) to report heavy drinking, though other studies have not found an increased incidence.5

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MENTAL HEALTH

The authors of the NHSII found that mental health risk factors are associated with sexual minority status and may increase the frequency of stress-related psychiatric disorders defined as depression, anxiety, panic disorder, and alcohol and drug dependence.5 Adolescent patients struggling with their sexuality are at higher risk for suicide, victimization, sexual risk behaviors, and substance use at an earlier age than their peers.1 Care should be taken to follow up when screening questions for depression and anxiety are positive.

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CANCER RISK

Lesbian and bisexual women may have higher or lower risks for particular cancers than heterosexual women. Higher rates of teenage pregnancy among parous lesbian and bisexual women may reduce their breast cancer risk. However, fewer women who have sex with women have children than heterosexual women, and those who do tend to have them after the age of 30, which may increase that risk. Higher daily alcohol intake may also increase the risk for breast cancer.

Use of oral contraceptive pills and pregnancy protect against ovarian cancer, but these protective factors may be absent in women who have sex with women. In one study, 36% of lesbians reported ever using oral contraceptives, compared with 80% of heterosexual women.7 Women with a family history of ovarian cancer may benefit from prophylactic use of oral contraceptives.

Many risk factors are modifiable, and there is evidence that lesbian and bisexual women are responsive to recommendations regarding smoking cessation, exercise, and increased involvement in screening programs.

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DOMESTIC VIOLENCE

Estimated rates of domestic violence (DV) within same-sex couples are comparable to those of heterosexual couples, with approximately one-fourth to one-half of all same-sex intimate relationships demonstrating abusive dynamics.8 As DV can have significant consequences on patient health and safety, verbally screening all patients is recommended as part of the annual examination.

Conclusion to clinical scenario above: After a thorough examination and discussion, your patient elects to start oral contraceptive pills to regulate her cycles and potentially reduce her risk for ovarian cancer. She elects to undergo STI testing as well as a Pap test and is considering establishing a regular exercise routine. Following the discussion, she reports that she and her partner are interested in having a baby within the next 2 years, and you make plans for further preconception counseling, encouraging her to bring her partner to the appointment if she desires.

The authors report no actual or potential conflicts of interest in relation to this article.

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Carolyn Delk, DO, is Resident, and Halina Wiczyk, MD, is Associate Professor, both in the Department of Obstetrics and Gynecology, Tufts University School of Medicine, Baystate Medical Center, Springfield, MA.

References

1. ACOG. Primary care of lesbian and bisexual women in obstetric and gynecologic practice. In: Special Issues in Women’s Health. Washington, DC: American College of Obstetricians and Gynecologists; 2005: 61-73.
   
2. Hughes C, Evans A. Health needs of women who have sex with women. studentBMJ. 2003;11:393-436.
   
3. 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.
   
4. Institute of Medicine (US). Lesbian Health: Current Assessment and Directions for the Future. Washington, DC: National Academy Press; 1999.
   
5. 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. 2004;13(9):1033-1047.
   
6. Rotheram-Borus MJ, Fernandez MI. Sexual orientation and developmental challenges experienced by gay and lesbian youths. Suicide Life Threat Behav. 1995;25(Suppl): 26-39.
   
7. 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.
   
8. Murray C, Mobley J. Empirical research about same-sex intimate partner violence: a methodological review.
   J Homosex. 2009;56(3):361-386.