Health inequalities exist for lesbian and bisexual women, largely related to experiences of discrimination, homophobia and heterosexism. These issues can lead to avoidance of routine healthcare and screening and reduced disclosure of sexual orientation within consultations.
Lesbian and bisexual women have specific healthcare needs in areas of sexual and cervical health, reproductive health and parenting, mental health, substance use, and ageing.
Facilitation of disclosure of sexual orientation, identity and behaviour within the consultation is desired by most lesbians and important for addressing specific health needs.
Healthcare providers should develop "cultural competence" in lesbian issues to enhance their care of lesbian and bisexual women.
Healthcare providers have a role in promoting awareness of lesbian health issues and inequalities in the arenas of healthcare provider education, research and health policy.
Many professionals within our healthcare system maintain a position that lesbian health is synonymous with women's health, secure in their belief that it is unnecessary to identify women as lesbian or bisexual within a consultation. Indeed, some well-meaning providers regard enquiry about lesbianism as overly intrusive and to be actively avoided.1 However, being part of a minority sexuality group influences patterns of health and illness and requires specific enquiry within most consultations. International population-based studies indicate a prevalence of lesbian and bisexual identity of around 1.5%, with up to 8% of women reporting homosexual desire or behaviour.2,3 A recent Australian telephone survey that included 9134 women aged between 16 and 59 years, randomly selected from all states and territories, provided a wide range of information regarding sexuality.4 While 0.8% of the women identified as gay and 1.4% as bisexual, 15.1% reported same-sex attraction or sexual experience. It is reported that 8%–11% of young people have a non-heterosexual orientation.5
Differences in health status for non-heterosexual women result from negative attitudes and experiences within society and the healthcare system, which in turn influence patterns of health-seeking behaviour, health-risk factors and specific health issues. For these reasons, sexual orientation was recognised as a social determinant of health in the US 10-year public health plan released in 2000.6 Currently, in Australia, health policy that recognises the health inequalities and specific healthcare needs of sexuality minorities is being developed at a state level.7
Discrimination against non-heterosexual women takes various forms, from overt homophobia to heterosexism. Heterosexism assumes that all people are heterosexual and incorporates mainstream attitudes that value heterosexuality more highly than other types of sexuality.6 This discrimination influences patterns of health seeking, either preventing access to healthcare or reducing openness and trust within the healthcare setting. One of the most significant health risks for non-heterosexual women is avoidance of routine healthcare.8 Repeated consumer research indicates that non-heterosexual women who present to healthcare services would prefer to disclose their sexuality, but are often silenced by the assumption that they are heterosexual.1,9 This silence compromises the development of trust and the ability to reveal complex and relevant life issues to practitioners.10
Compared with heterosexual women, non-heterosexual women access screening less frequently, delay treatment, and are less likely to have a regular general practitioner.10 For example, bisexual women in one study were less likely to have had lipid or mammogram screening than lesbian and heterosexual women.11 Lesbians are less likely to have regular Pap smears,12 despite having similar rates of cervical abnormality.13 Cervical human papilloma virus (HPV) has been reported to occur in 21% of lesbian women with no prior sexual contact with men (dispelling the common myth that lesbians are immune to HPV infection).14 In 1995, the Australian National Cervical Screening Program recognised the need to encourage lesbians to have Pap smears. In the following year, PapScreen Victoria launched its "Lesbians need pap smears too" campaign, and continues to identify lesbians as a target group.15 Despite these policies, lesbians continue to report being discouraged by medical practitioners from having Pap smears, on the grounds that they are unnecessary.16
Research into lesbian and bisexual women's health has progressed considerably over the past decade. Early studies were small, relied heavily on purposive sampling, and often involved predominantly Anglo-Saxon, well educated women, reflecting the difficulty in accessing marginalised subgroups of lesbians.17 A further limitation was the failure of population-based studies to include among the demographic questions a question on sexuality. Australia remains particularly tardy in developing research into lesbian health. Early studies in countries such as the United States and Canada did provide some insights into the specific health needs of lesbians,18 albeit with a limited evidence base. The past decade has seen both increased population-based studies, enabling comparison of sexuality minorities with heterosexuals, and an increased variety of methods (eg, network sampling and various qualitative methods) for attempting to access hard-to-reach subgroups.17 We now have a better understanding of specific risk factors and healthcare needs of non-heterosexual women in areas such as sexual health, reproductive health and parenting, mental health, substance use, and ageing.
Sexual health. Seventeen per cent of self-identified lesbians in the United States report having a diagnosis at some stage in their lifetime of sexually transmitted infection (STI), the same percentage as that reported for population-based representative samples of women.19 While transmission is partly related to previous or current sexual contact with men (78% had had at least one previous male sexual partner19), STI rates also increase linearly with the number of lifetime female sexual partners. These data contradict the common assumption of low STI risk with female sexual partners, clearly pointing to the need for improved advice regarding "safe sex". Conversely, one comparative study suggested that lesbians were more likely than heterosexual women to practise safe sex.11
Reproductive health. Reproductive healthcare needs of lesbians are highly specific, with a majority electing to achieve pregnancy via self-insemination with a known donor's semen or via clinic-based donor insemination.20 These women require a practitioner who is knowledgeable about appropriate donor-insemination clinics for referral and can provide information, for those using self-insemination, about optimal donor screening, ovulation monitoring and safety during the period of insemination. Australian lesbians wanting to form a family report their key challenges as a lack of access to clinic-based donor insemination in some states, and a lack of social and legal recognition of their family structure and of the non-biological mother as a parent.20 Twenty-seven per cent of Australian lesbian and gay parents report negative experiences with their children's healthcare that relate back to their own sexuality.21 The American Academy of Pediatrics supports coparent adoption by same-sex parents and advocates that paediatricians be knowledgeable about gay and lesbian families.22
Mental health. A higher rate of mental illness among lesbian and bisexual women than women in the general population is one of the most concerning health inequalities. Lesbian and bisexual women report rates of depression, anxiety disorders and suicidal ideation that are two to three times higher than women in the general population.23,24 Although studies usually do not distinguish between lesbian and bisexual women, there is some evidence from an Australian community sample that bisexual people have an even higher prevalence of mental health problems than lesbian and gay people.25 These mental health inequalities are thought to relate to high levels of stress due to homophobia, higher rates of abuse and experiences of victimisation, and lack of social support, rather than to sexuality per se.26 Improved research methods have uncovered an increased risk of "stress-sensitive disorders" attributable to the effects of homophobia.27 Comparison with heterosexual people shows that lesbian and gay people with mental illness have suffered significantly more day-to-day and lifetime discrimination, almost half of which they directly relate to their sexuality.28 Same-sex-attracted young people are also found to have higher rates of depression, drug use and homelessness than the general population of young people.5 This in part relates to the fact that, unlike other cultural minorities, same-sex-attracted young people cannot necessarily rely on support and protection from their family of origin. Conversely, active participation in community support groups and other forms of support improves mental health status.
Substance use. Higher levels of substance use compared with the general population are reported among gay and lesbian people.19,29 Predisposing factors in substance use include increased risk-taking behaviours, higher levels of depression, and a social subculture that incorporates substance use.2 Early studies indicated that lesbians were more likely to drink excessive quantities of alcohol, but the studies tended to be based on convenience samples of lesbians attending bars and other venues.30 The evidence is contradictory, with a New Zealand study indicating low levels of alcohol intake among lesbians31 and a large population study in the United States showing high levels.12 Illicit drug use is consistently reported as higher among lesbians than other women, although the health affects of this use are still not clear.12 An Australian population-based study has shown higher use of all substances, both licit and illicit, among non-heterosexual women.32
Access to sensitive healthcare services. In a Victorian study of gay and lesbian health issues, access to sensitive healthcare services was the most frequently mentioned issue.7 Lesbians have reported low satisfaction with health services because of negative provider attitudes and a lack of cultural understanding of the context in which their health is shaped.10 For example, one of the major issues for ageing lesbians is prejudicial attitudes in aged-care institutions, highlighting the need to train providers and agencies in this area.33 Further issues for ageing lesbians include a lack of recognition of female partners as next of kin, and difficulty accessing superannuation and health insurance benefits as a same-sex couple.
The development of "cultural competence" in lesbian issues includes understanding the reasons lesbians might be reluctant to seek healthcare, the impact of homophobia on physical and mental health, and an awareness of the range of specific health risks and problems experienced by lesbians and bisexual women.10 Lesbian and bisexual women prefer their healthcare provider to be "gay positive" — that is, open-minded, knowledgeable about their healthcare needs, and able to encourage safe disclosure of sexuality.34 Specific guidelines to assist healthcare providers in developing such competence are provided in the Box.
The Australian Medical Association has recently launched a position statement on sexual orientation and gender diversity.37 This gives recommendations for practitioners on providing sensitive individual healthcare and also suggests that doctors have a role in promoting acceptance of sexuality and gender diversity and advancing medical education, research and health policy that addresses sexuality. In responding to the needs of lesbian and bisexual women within individual consultations and at a broader level, healthcare providers can shape a more culturally responsive healthcare system.
Knowledge and understanding
Be aware of the impact of sexuality-based discrimination on health.
Be aware of how health risks and healthcare issues specifically relate to lesbian and bisexual women — sexually transmitted infections, common sexual practices, cervical health, reproductive health, mid-life changes, ageing, mental health, and substance-use patterns.
Be knowledgeable about lesbian-sensitive referral networks.
Be knowledgeable about lesbian-specific support and community groups (eg, relating to lesbian parenting, domestic violence, "coming-out" support and youth support).
Use gender-neutral words such as "partner" and other inclusive terms to facilitate disclosure.
When taking a sexual history, be aware of the fluidity of sexual expression and the "coming-out" process.
Specifically encourage disclosure of sexual identity, orientation and behaviour if they are relevant to the health issues presented.
Give choice regarding documentation of next of kin and sexual orientation in the health record and letters.
Avoid the assumption of heterosexuality.
Avoid common assumptions about lesbians (eg, that lesbians have never had or don't continue to have sexual relationships with men).
Be willing to facilitate disclosure of sexuality.
Be willing to involve lesbian partners in decision-making.
Be aware of additional barriers that increase stigmatisation, including ethnic minority status, disability, age, or economic status.
Train reception staff to be sensitive to lesbian identity.
Have a written practice policy on antidiscrimination, including the issue of sexuality.
Design intake forms to be inclusive of same-sex relationships.
Maintain confidentiality regarding the patient's sexuality.
Display and make available brochures and posters relating to lesbian and bisexual patients.
Advertise practice services through lesbian and bisexual media.
- 1. Stevens PE. Structural and interpersonal impact of heterosexual assumptions on lesbian health care clients. Nurs Res 1995; 44: 25-30.
- 2. Gruskin EP, Hart S, Gordon N, Ackerson L. Patterns of cigarette smoking and alcohol use among lesbians and bisexual women enrolled in a large health maintenance organisation. Am J Public Health 2001; 91: 976-979.
- 3. Michaels S. The prevalence of homosexuality in the United States. In: Cabaj RP, Stein TS, editors. Textbook of homosexuality and mental health. Washington, DC: American Psychiatric Press, 1996.
- 4. Smith A, Rissel C, Richters J, et al. Sex in Australia: sexual identity, sexual attraction and sexual experience among a representative sample of adults. Aust N Z J Public Health 2003; 27: 138-145.
- 5. Hillier L, Dempsey D, Harrison L, et al. Writing themselves in: a national report on the sexuality, health and well-being of same-sex attracted young people. Melbourne: Australian Research Centre in Sex, Health and Society, La Trobe University, 1998.
- 6. Gay and Lesbian Medical Association. Healthy people 2010 companion document for lesbian, gay, bisexual and transgender health. San Francisco, Calif: Gay and Lesbian Medical Association, 2001.
- 7. McNair RP, Anderson S, Mitchell A. Addressing health inequalities in Victorian lesbian, gay, bisexual and transgender communities. Health Promot J Aust 2001; 11: 305-311.
- 8. Harrison AE. Primary care of lesbian and gay patients: educating ourselves and our students. Fam Med 1996; 28: 10-23.
- 9. Roberts SJ. Lesbian health research: a review and recommendations for future research. Health Care for Women International 2001; 22: 537-552.
- 10. Solarz AL, editor. Committee on Lesbian Health Research Priorities, Institute of Medicine. Lesbian health: current assessment and directions for the future. Washington, DC: National Academy Press, 1999.
- 11. Koh AS. Use of preventive health behaviours by lesbians, bisexual and heterosexual women: questionnaire survey. West J Med 2000; 172: 379-384.
- 12. Aaron DJ, Markovic N, Danielson ME, et al. Behavioral risk factors for disease and preventive health practices among lesbians. Am J Public Health 2001; 91: 972-975.
- 13. Fethers K, Marks C, Mindel A, Estcourt CS. Sexually transmitted infections and risk behaviours in women who have sex with women. Sex Transm Infect 2000; 76: 345-349.
- 14. Marrazzo JM, Koutsky LA, Stine K, et al. Genital human papillomavirus infection in women who have sex with women. J Infect Dis 1998; 178: 1604-1609.
- 15. PapScreen Victoria Communications and Recruitment Strategy 1996-99. Final report. Melbourne: Anti-Cancer Council of Victoria, June 2000.
- 16. Brown R. More than lip service: report on the lesbian health information project. Melbourne: Royal Women's Hospital, July 2000.
- 17. Plumb M. Undercounts and overstatements: will the IOM report on lesbian health improve research? Am J Public Health 2001; 91: 873-875.
- 18. Simkin R. Lesbians face unique health care problems. CMAJ 1991; 145: 1620-1623.
- 19. Diamant AL, Wold C, Spritzer K, Gelberg L. Health behaviours, health status and access to and use of health care: a population-based study of lesbian, bisexual and heterosexual women. Arch Fam Med 2000; 9: 1043-1051.
- 20. McNair RP, Dempsey D, Wise S, Perlesz A. Lesbian parenting: issues, strengths and challenges. Fam Matters 2002; 63: 40-49.
- 21. Mikhailovich K, Martin S, Lawton S. Lesbian and gay parents: their experiences of children's health care in Australia. Int J Sex Gender Stud 2001; 6: 181-191.
- 22. American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health. Policy statement: Coparent or second-parent adoption by same-sex parents. Pediatrics 2002; 109: 339-340.
- 23. Gilman SE, Cochran SD, Mays VM, et al. Risk of psychiatric disorders among individuals reporting same-sex sexual partners in the national comorbidity study. Am J Public Health 2001; 91: 933-939.
- 24. Welch S, Collings SCD, Howden-Chapman P. Lesbians in New Zealand: their mental health and satisfaction with mental health services. Aust N Z J Psychiatry 2000; 34: 256-263.
- 25. Jorm AF, Korten AE, Rodgers B, et al. Sexual orientation and mental health: results from a community survey of young and middle-aged adults. Br J Psychiatry 2002; 180: 423-427.
- 26. Otis MD, Skinner WF. Prevalence of victimization and its effect on mental well-being among gay and lesbian people. J Homosex 1996; 30: 93-121.
- 27. Cochran SD. Emerging issues in research on lesbians' and gay men's mental health: does sexual orientation really matter? Am Psychol 2001; 56: 931-947.
- 28. Mays VM, Cochran SD. Mental health correlates of perceived discrimination among lesbian, gay and bisexual adults in the United States. Am J Public Health 2001; 91: 1869-1876.
- 29. Murnane A, Smith A, Crompton L, et al. Beyond perceptions: a report on alcohol and other drug use among gay, lesbian, bisexual and queer communities in Victoria. Melbourne: ALSO Foundation, Australian Drug Foundation and VicHealth, June 2000.
- 30. Hughes TL, Wilsnack SC. Use of alcohol among lesbians: research and clinical implication. Am J Orthopsychiatry 1997; 6: 20-36.
- 31. Welch S, Howden-Chapman P, Collings SC. Survey of drug and alcohol use by lesbian women in New Zealand. Addict Behav 1998; 23: 543-548.
- 32. Hillier L, de Visser R, Kavanagh A, McNair R. The association between drug use and sexuality in young women [letter]. Med J Aust 2003. In press.
- 33. Harrison J. A lavender pink grey power: gay and lesbian gerontology in Australia. Australas J Ageing 1999; 18: 32-37.
- 34. Mathieson CM. Lesbian and bisexual health care. Straight talk about experiences with physicians. Can Fam Physician 1998; 44: 1634-1640.
- 35. Gruskin EP. Treating lesbian and bisexual women: challenges and strategies for health professionals. San Francisco: Sage Publications, 1999.
- 36. Gay and Lesbian Medical Association. Clinical guidelines: creating a safe clinical environment for lesbian, gay, bisexual, transgender and intersex clients. Available at: http://www.glma.org/medical/clinical/lgbti_clinical_guidelines.pdf (accessed Apr 2003).
- 37. Australian Medical Association. Position statement on sexual diversity and gender identity. October 2002. Available at: http://www.ama.com.au/web.nsf/topic/policy-public-health (accessed May 2003).
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