Primary Care for Lesbians and Bisexual Women - July 15, 2006

July 15, 2006 Table of Contents

Primary Care for Lesbians and Bisexual Women

SALLY A. MRAVCAK, M.D., University of Medicine and Dentistry of New Jersey–Robert Wood Johnson Medical School, New Brunswick, New Jersey

� Patient Information Handout

For the most part, lesbians and bisexual women face the same health issues as heterosexual women, but they often have difficulty accessing appropriate care. Physicians can improve care for lesbians and bisexual women by acknowledging the potential barriers to care (e.g., hesitancy of physicians to inquire about sexual orientation and of patients to disclose their sexual behavior) and working to create a therapeutic physician-patient relationship. Taking an inclusive and nonjudgmental history and being aware of the range of health-related behaviors and medicolegal issues pertinent to these patients enables physicians to perform relevant screening tests and make appropriate referrals. Some recommendations, such as those for screening for cervical cancer and intimate partner violence, should not be altered for lesbians and bisexual women. Considerations unique to lesbians and bisexual women concern fertility and medicolegal issues to protect familial relationships during life changes and illness. The risks of suicidal ideation, self-harm, and depression may be higher in lesbians and bisexual women, especially those who are not open about their sexual orientation, are not in satisfying relationships, or lack social support. Because of increased rates of nulliparity, the risks of conditions such as breast and ovarian cancers also may be higher. The comparative rates of alcohol and drug use are controversial. Smoking and obesity rates are higher in lesbians and bisexual women, but there is no evidence of an increased risk of cardiovascular disease. (Am Fam Physician 2006;74:279–86, 287–8. Copyright � 2006 American Academy of Family Physicians.)

An estimated 1 to 4 percent of women identify themselves as lesbian or bisexual.1 Preferred terminology varies among different demographic groups. In this article, the term “lesbian” refers to women whose primary sexual and emotional partnerships are with women, and the term “bisexual” refers to women whose primary sexual and emotional partnerships are with men or women. These terms do not fully describe sexual orientation, which encompasses gender and biological sex; sexual identity, behavior, and fantasy; other aspects of sexuality such as social, cultural, and political affiliations; and familial relationships (biological, legal, and chosen). Aspects of sexual orientation are not always consistent and may change over time—for example, a person who identifies as heterosexual may have same–sex sexual experiences, or vice versa.

Knowledge of a patient’s sexual orientation should direct preventive and health maintenance strategies, as well as enhance understanding of patients’ health in the context of their families and communities. Physicians can be important resources for lesbians and bisexual women by assisting with medicolegal issues to protect their health and relationships during life events such as births, deaths, and marriage or domestic partnership. Policy statements from the American Academy of Family Physicians relevant to lesbians and bisexual women are listed in Table 1.2

BARRIERS TO HEALTH CARE

Lesbians and bisexual women face three major barriers to receiving quality health care: (1) hesitancy of physicians to inquire about sexual orientation; (2) hesitancy of lesbians and bisexual women to disclose their sexual behavior; and (3) lack of knowledge, comfort, and research regarding health issues specific to lesbians and bisexual women.1,3–5 In a survey4 of 424 bisexual women and 1,921 lesbians receiving gynecologic care, only 9.3 percent of participants had ever been asked by their physician about their sexual orientation. In the same survey, more than one third of participants believed that disclosure of their sexual orientation to their physician would adversely affect their health care. Of the participants who disclosed their sexual orientation, 30 percent experienced a negative response from their physician.4 Research on health care in lesbian, gay, bisexual, and transgender persons is one of the health objectives in the Healthy People 2010 initiative.1,3,6

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendation	Evidence rating	References
A sexual history should be taken using the “five Ps”: partners, practices, prevention of STDs, past history of STDs, and prevention of pregnancy.	C	8
Physicians should provide lesbians and bisexual women with education about STDs and should offer STD testing.	C	12,16
Physicians should advise patients to use barrier protection when engaging in oral–genital contact or vaginal penetration with the fingers or a latex sex toy.	C	10,12–15
Screening for cervical cancer in lesbians and bisexual women should be carried out according to the recommendations for women in general.	C	23,25–27
Physicians can reassure parents that children who grow up with one or two gay or lesbian parents do not differ in emotional, cognitive, social, or sexual functioning compared with children whose parents are heterosexual.	B	30,31
Physicians should screen lesbians and bisexual women for intimate partner violence.	C	35
Physicians should identify life stressors in lesbians and bisexual women and screen for depression and suicidal ideation.	C	39,40

STD = sexually transmitted disease.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see page 215 or http://www.aafp.org/afpsort.xml.

Creating a Therapeutic Relationship

Building trust with lesbians and bisexual patients is paramount to overcoming the barriers to quality care. Physicians can create an environment that is conducive to candid communication. Posters, patient education materials, and plaques with relevant information in the waiting room help set a tone of acceptance. Using inclusive language on intake forms and training office staff to use inclusive language also may increase patients’ comfort (Table 2).7

TABLE 1
AAFP Policies Regarding Care for Lesbians and Bisexual Women

Area	Policy
Children’s health	The AAFP establishes policy and supports legislation that promotes a safe and nurturing environment, including psychological and legal security, for all children, including those of adoptive parents, regardless of the parents’ sexual orientation. (2002) (2003)
Discrimination, patient	The AAFP supports the principle that family physicians should not discriminate against patients on the basis of race, color, religion, gender, sexual orientation, ethnic affiliation, health or economic status, body habitus, or national origin. The AAFP supports the principle that family physicians provide quality medical care for all patients and their families, including gay, lesbian, bisexual, and transgender patients and families. (1996) (2002)
Family, definition of	The family is a group of individuals with a continuing legal, genetic, and/or emotional relationship. Society relies on the family group to provide for the economic and protective needs of individuals, especially children and the elderly. (1984) (2003)
Health benefits	The AAFP supports the equality of health benefits to all individuals within the context of the AAFP definition of family. (1996) (2002)The AAFP supports domestic partner benefits for same-gender couples. (2002)

AAFP = American Academy of Family Physicians.

Information from reference 2.

TABLE 2
Examples of Inclusive Language

Instead of:	Use:	Comment
Are you married?	Do you have a spouse or domestic partner?	Does not assume sexual orientation or gender of sexual partners
Boyfriend/girlfriend	Partner	As above
Are you the mother/father?	Are you the parent or guardian?	More inclusive of different types of families
Who is the real father/mother?	Who is the biological father/mother?	Describes the genetic parent and is useful if genetic information is needed

Adapted with permission from Laret M. Inclusive language policy. San Francisco, Calif.: University of San Francisco Medical Center, 2004.

In the examination room, it is important to ask patients open-ended questions about all aspects of sexuality. For example, in addition to asking about sexual behavior, a physician might ask whom a person lives with, who should be informed about health care issues, and how a patient prefers to be addressed. Phrasing these questions in a way that demonstrates openness to a variety of answers allows a trusting therapeutic relationship to develop.

TAKING A SEXUAL HISTORY

Asking, without judgment, about specific sexual practices enables physicians to identify potential health risks and needed screening tests. One example of such a question is “Let’s review your risk factors for cervical cancer, sexually transmitted diseases, and ovarian cancer. Have you had sex with men, women, or both?” The Centers for Disease Control and Prevention recommends asking about the “five Ps”: partners, practices, prevention of sexually transmitted diseases (STDs), past history of STDs, and prevention of pregnancy (Table 3).8

Health Issues in Lesbians and Bisexual Women

Caution should be used in interpreting epidemiologic research on lesbians and bisexual women because of the methodologic problems with identifying a suitable study population (e.g., research participants may not disclose full information about their sexuality, terminology is not standardized). However, some research exists that can be used to guide clinical decision making.

SEXUAL PRACTICES AND STDS

Lesbians and bisexual women may participate in a range of sexual practices with women and men, including oral–genital contact, genital manipulation, and vaginal penetration with fingers or a latex sex toy. Transmission of some STDs between women is known to occur; for other STDs, transmission between women is possible in theory but has not been proven (Table 4).9–15 One survey showed a 20 percent increased likelihood of STDs per 500 sexual exposures with female partners in women who had such exposures compared with those who had not, supporting the need for STD screening in women who have sex with women.12 According to the Institute of Medicine’s Lesbian Health report,3 there are no national data to identify rates of STDs among lesbians.

TABLE 3
Questions to Ask When Taking a Sexual History

Are you having or have you ever had sex with men or women?
How many partners have you had in the past six months?
	In the past five years?
Does your partner have sex with someone other than yourself?
What kind of sexual contact do you have?
	Oral, including mouth on vagina, anus, or penis?
	Vaginal penetration, including with hands, latex sex toy, or penis?
	Anal penetration, including with hands, latex sex toy, or penis?
Have you had sexual contact with someone who uses injection drugs or a man who has sex with other men?
Do you use barrier protection like condoms or gloves during sexual contact? What kind?
Do you use another method of birth control? (if also sexually active with men)
Do you have any questions about sexually transmitted diseases?
Do you have any questions or concerns about sex?

Information from reference 8.

TABLE 4
STDs That May Be Transmitted Between Women

Disease	Mode of transmission
Proven transmission
Herpes simplex	Oral–genital or skin–skin contact
Genital warts associated with HPV	Oral–genital or skin–skin contact
Trichomoniasis	Genital–genital contact
Theoretical transmission
Chlamydia*	Oral–genital contact
Gonorrhea*	Oral–genital contact
Syphilis*	Oral–genital or genital–genital contact
Hepatitis B†	Blood or body fluid contact
HIV†	Oral–genital contact‡

STD = sexually transmitted disease; HPV = human papillomavirus; HIV = human immunodeficiency virus.

*—Not studied.

†—Case reports of transmission between female partners exist.

‡—Most likely sources are menstrual blood, vaginal discharge, and blood from traumatic sex practices.

Information from references 9 through 15.

TABLE 5
Safer Sex Recommendations for Women Who Have Sex with Women

Avoid contact with a partner’s menstrual blood and with any visible genital lesions.

Cover sex toys that penetrate more than one person’s vagina or anus with a new condom for each person; consider using different toys for each person.

Use a barrier (e.g., latex sheet, dental dam, cut-open condom, plastic wrap) during oral sex.*

Use latex or vinyl gloves and lubricant for any manual sex that might cause bleeding.

*—No barrier methods have been evaluated by the U.S. Food and Drug Administration for use during oral sex.

Adapted with permission from Waitkevicz HJ. Lesbian health in primary care. Part 2: sexual health care and counseling for women who have sex with women. Women’s Health Prim Care 2004;7:231, with additional information from reference 13.

It should not be assumed that lesbians have never been sexually active with men. In a survey of 6,935 lesbians, 77 percent of respondents reported having had one or more male sex partners, and 6 percent of respondents had had a male sex partner within the preceding year.16 Another survey showed a 7 percent increased likelihood of reported STDs per male partner in women who had sex with men compared with those who did not.12 It has been reported in some studies that lesbians and bisexual women may be more likely than women who have never had sex with another woman to engage in unprotected vaginal or anal intercourse with a male partner, sexual contact with homosexual or bisexual men, and sexual contact with an injection drug user, putting them at a greater risk for human immunodeficiency virus infection and hepatitis B and C infections.17,18

Lesbians are less likely than bisexual or heterosexual women to be tested regularly for STDs.12 Educating lesbians and bisexual women about the risks of STDs and dispelling the perception that the transmission of STDs between women is negligible will help patients make informed decisions. In one survey, 85 percent of lesbians stated that their physicians knew they had sexual relations with women, but only 15 percent reported receiving education from their health care providers about safer sex.19� Recommendations for safer sex among women who have sex with women are listed in Table 5.13,20

Bacterial vaginosis, although not clearly an STD, is prevalent in lesbians and bisexual women.20 Some investigators have found associations between bacterial vaginosis and increasing numbers of female sex partners, implying possible sexual transmission between women.21

CERVICAL CANCER

Many physicians incorrectly think that lesbians are at low risk for cervical dysplasia and need less frequent Papanicolaou (Pap) smears than heterosexual women,22 and several studies23,24 indicate that lesbians receive fewer Pap smears than heterosexual women. Human papillomavirus–associated squamous intraepithelial lesions have occurred in lesbians who have never had sex with men.25 Recommendations for cervical cancer screening in lesbians and bisexual women, regardless of their sexual history with men, should not differ from screening recommendations for women in general.23,25–27

PREGNANCY AND CHILDREN

Lesbians increasingly are choosing to have children.1,28 Physicians should refer lesbians and bisexual women who wish to become pregnant to a health care professional who performs donor insemination. Donor insemination involves ovulation tracking and timed insemination with semen from a known donor or from a commercial sperm bank.29 Intrauterine insemination has a higher success rate than intracervical insemination.29 STDs can be transmitted through donor insemination, but sperm bank donors generally have been tested.

Women considering donor insemination should be referred for legal counseling because this method of becoming pregnant can affect legal relationships with the child. For example, in some localities, if insemination is not performed by a physician or if the donor is known, the donor may have legal parental rights and responsibilities.

An estimated 6 to 14 million children in the United States have gay or lesbian parents.1,21 These children may have been conceived through donor insemination or a relationship with a man, or they may be adopted or within the foster care system.1 Children who grow up with one or two gay or lesbian parents do not differ from children of heterosexual parents in emotional, cognitive, social, or sexual functioning.30,31 The American Academy of Pediatrics supports legislative and legal efforts to provide the nonbiological parent in a same-sex couple the option to adopt a child being parented by the couple.32 The adoption of a child by the biological parent’s same-sex partner is legal in some states.33

MEDICOLEGAL ISSUES

Family law for same-sex couples is evolving rapidly and varies considerably among localities. Legal relationships may be recognized by employers and local or state governments but not by the federal government. Depending on the locality, same-sex couples can attain some medicolegal rights and responsibilities through marriage, domestic partnership, civil union, adoption, or reciprocal beneficiary relationships. However, these relationships may not be available or recognized in all localities. In most states, hospital visitation, notification, durable power of attorney, and parental rights for nonbiological partners are not automatically granted to a same-sex couple without legal action. Regardless of informal agreements, known sperm donors have parental rights in many jurisdictions. If contested, legal agreements with known donors may not be upheld or recognized.

Physicians should address medical decision making with lesbians and bisexual women and encourage them to take the legal action necessary to carry out their wishes. They should be encouraged to establish a durable power of attorney and appoint a health care proxy to clarify their wishes.34 Lesbian and bisexual couples, especially those with children, should be referred to an estate or family lawyer with expertise in family law for same-sex couples. When a same-sex relationship ends through separation or death, the persons involved are at risk of losing possessions; housing; parental rights; immigration status; medical and disability insurance; and Social Security, welfare, and life insurance benefits.

Because of the lack of legal recognition for same-sex couples, life events such as disability, childbirth, or losing a job can create extra hardships for lesbians and bisexual women and their families, who may not be able to take advantage of employer or government benefits. These hardships can have a significant impact on health. Depending on the locality, some, but not all, of these losses and hardships can be avoided through estate planning and drafting legal documents.

VIOLENCE

Many lesbians and bisexual women are victims of hate crimes and often fear for their safety. Also, intimate partner violence may occur between women in same-sex relationships. Responses to the National Violence Against Women survey35 involving 8,000 U.S. women indicate that more than 11 percent of women in same-sex relationships have been raped, physically assaulted, or stalked by a female partner. In heterosexual women, the rate of intimate partner violence was 21.7 percent.35� More research is needed to define rates of intimate partner violence between female partners, but current data suggest that domestic violence screening should not be omitted based on sexual orientation. Questions that may be used to screen for domestic violence are listed in Table 6.36

SUICIDAL IDEATION, SELF-HARM, AND DEPRESSION

Most lesbians and bisexual women are emotionally healthy and well-adjusted. In the Women’s Health Initiative study, lesbian and bisexual participants had quality-of-life and emotional well-being scores similar to those of heterosexual participants.37 However, lesbian, gay, bisexual, and transgender persons are subject to unique social stressors such as prejudice, stigmatization, and antigay violence that may precipitate mental distress, mental disorders, suicidal ideation, and self-harm. Available social support can be lower in this population, with friends providing more support and families providing less support compared with the heterosexual population.38

TABLE 6
Questions to Screen for Domestic Violence

How does your partner treat you?

Have you ever been or are you currently being physically, emotionally, or sexually abused?

Have you been hit, kicked, punched, or otherwise hurt by someone in the past year?

Do you feel safe in your current relationship?

Is there a partner from a previous relationship who is making you feel unsafe now?

Adapted from Ebell MH. Routine screening for depression, alcohol problems, and domestic violence. Am Fam Physician 2004;69:2422.

In interviews of men and women 26 years of age, women who have had same-sex attraction were significantly more likely to have engaged in deliberate self-harm or to have had suicidal ideation compared with women who have not had same-sex attraction.39,40 Rates of depression in lesbians were found to be lower among women with social support, those involved in a satisfying relationship, and those more open about their sexual orientation.41,42 Physicians should identify life stressors and screen lesbians and bisexual women for depression and suicidal ideation. Referral to mental health professionals who have experience with lesbian, gay, bisexual, and transgender patients often is helpful.

BREAST AND OVARIAN CANCERS

The risk of breast cancer in lesbians is debated.43 Reported prevalences of breast cancer in lesbian populations are conflicting, but rates of mammogram screening in lesbians and bisexual women are similar to those in heterosexual women.24,37,44,45

Risk factors for ovarian cancer (e.g., low parity, less exogenous hormone use, smoking, higher body mass index [BMI]) are more prevalent in lesbians than in the general population.46 However, no studies have been performed to determine the actual risk of ovarian cancer in lesbians compared with heterosexual women. Results from a Danish study44 showed no increased occurrence of ovarian cancer in 1,614 women in homosexual partnerships who were followed for four years.

SMOKING, ALCOHOL, AND DRUG USE

Data from the Women’s Health Initiative study37 and other, smaller studies45,46 indicate that tobacco use is higher among lesbians than among the general female population. Rates of alcohol use among lesbians and bisexual women have been disputed. The Women’s Health Initiative data showed no difference in current alcohol use between lesbian and heterosexual respondents, but a higher percentage of lesbian respondents than heterosexual respondents reported being recovering alcoholics (13 versus 3 percent, respectively).37 Early studies showing an increased rate of alcoholism in lesbians were flawed because researchers recruited participants in bars.1

Data about rates of drug use among lesbians are limited and conflicting.1 Two trials18,47 studying the rates of injection drug use in lesbians and bisexual women who attended STD clinics found higher rates among lesbians and bisexual women than heterosexual women, but this group is not representative of the general population.

Like all patients, lesbians and bisexual women should be screened for tobacco, alcohol, and drug use and referred appropriately. Physicians can offer substance abuse resources specific to the lesbian, gay, bisexual, and transgender population if desired by the patient.

OBESITY AND CARDIOVASCULAR DISEASE

Lesbians are more likely than heterosexual women to have a high BMI, waist circumference, and waist-to-hip ratio; however, they also are more likely to engage in regular exercise.37,43,45,48 There is no proven increase in the risk of cardiovascular disease among lesbians and bisexual women. The Women’s Health Initiative data showed a higher prevalence of myocardial infarction in lesbians, but a lower prevalence of hypertension and stroke.37

The Author

SALLY A. MRAVCAK, M.D., completed a women’s health fellowship at the University of Medicine and Dentistry of New Jersey–Robert Wood Johnson Medical School and is now a staff physician at the University of Medicine and Dentistry of New Jersey working at a federally qualified health center in New Brunswick, N.J.

Address correspondence to Sally A. Mravcak, M.D., University of Medicine and Dentistry of New Jersey–Robert Wood Johnson Medical School, Department of Family Medicine, 1 Robert Wood Johnson Place, CN 19, New Brunswick, NJ 08903 (e-mail: mravcak@umdnj.edu). Reprints are not available from the author.

Author disclosure: Nothing to disclose.

The author thanks Jeffrey P. Levine, M.D., M.P.H., for assistance in the preparation of the manuscript.

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