Both health care professionals and the medical research establishment have historically ignored the so-called sexual minorities, including lesbians. Much of what was known was derived from anecdotal experience and volunteer surveys.^1,2 Over the last decade, empirical studies with more methodological rigor have begun to describe the health status of lesbians more accurately.

As a basic principle, most health concerns of lesbians are no different than those of heterosexual women. However, there are unique factors in four areas. First, the sexual behaviors of the lesbian include all those available to the heterosexual woman except for penile–vaginal intercourse, and she needs to know if these behaviors place her at risk for disease. This question is most urgent regarding human immunodeficiency virus (HIV) transmission risk. Second, if she wants to become a parent, she will have a more difficult time accessing the usual options for achieving that goal. Third, while most research in lesbian health has focused on gynecologic issues, a broader area of research has begun to look primary care issues among lesbians including risks for chronic illness, mental health issues, etc. Finally, lesbians live in a unique psycho-social-economic milieu. There is the possibility that each new clinician from whom she seeks care will be indifferent or hostile simply because of her sexuality; her access to health care and insurance may be limited if partner’s benefits are not available; sources of health care may present their services in a way that is not welcoming or effective for lesbians; and lesbians may view the stages of reproductive life differently than heterosexual women, which may affect the preventive choices they make.

Prevalence

A person’s sexual orientation and preferences are often considered to be unchanging over time, but this is often not the case. Men and women who may identify and behave as heterosexuals early in their lives may later self-identify as gay or lesbian, and a similar switch can occur from early homosexual to exclusively heterosexual behavior; persons who are bisexual may have a much more varied behavioral and relationship history. Thus, the notion of a stable “prevalence” for lesbians is of questionable meaning. Realizing the limitations of this concept, the survey by Laumann and colleagues³ found that between 1% and 4% of adult women in the United States identify themselves as lesbians.

Etiology

The etiology of lesbianism is not known, just as the etiology of heterosexual identity is not understood. Genetic, prenatal, hormonal, and early childhood influences each may have a role. Child abuse and emotionally distant parents have not been found to play a role.

Sexual Practices

Except for activities that require a penis, lesbians have available to them the same potential repertoire of sexual practices as heterosexual couples. The most frequent activities appear to be mutual masturbation and oral–vaginal sex.^3,4,5 The use of sex toys, including vibrators and dildos is common. The prevalence of anal contact varies widely among studies, with a prevalence of 10% in the more recent Diamont survey.⁵

Compared to gay men and heterosexual couples, lesbians as a group appear to have less frequent sex, and fewer lifetime partners.

Research Methodological Issues

Before discussing the various specific health issues, it is important to recognize the challenges inherent in doing research among stigmatized, minority populations such as lesbians and other sexual minorities. One of the major goals of the coming research agenda is identifying methods that will overcome these difficulties. The Institute of Medicine published a landmark report in 1999 that comprehensively details these issues, and that calls for more scientific investigation in these areas.⁶

The primary problem is the difficulty in identifying unbiased, representative samples. The randomly selected population-based sample, the gold standard of epidemiologic research, has been considered impossible to obtain. Consequently, most investigators have used volunteer or convenience samples, despite the unavoidable bias this introduces. The use of convenience samples is preferable to the use of volunteers, and there are several large surveys using this type of sampling.^7,8 This type of study is valuable for generating but not testing specific hypotheses. While larger samples are preferable, size alone does not overcome the inevitable biases. Investigators are therefore obligated to describe the demographic characteristics of the sample, and to avoid generalizing conclusions to other groups.

More recently, the assumption that women will not willingly disclose their sexual orientation to investigators has been tested in a small number of studies in which study participants have been asked to self-identify to investigators. In one large clinical trial of coronary heart disease risk in young adult men and women, 12% reported having had at least one same-sex partner, suggesting that people will provide this type of information on surveys.⁹ Among 96,000 women between the ages of 50 and 79 enrolled in the National Institutes of Health (NIH)-funded Women’s Health Initiative, 0.6% identified as lesbian and 0.7% as bisexuals, confirming that older women will respond to these questions as well.¹⁰ There are other ongoing studies designed to determine if lesbians can be accurately identified using such standard techniques as random digit dialing, household surveys, and the like. If these techniques are proven to be effective, more representative information will be possible.

The disorders of most interest are those for which sexual behavior is related to risk: vaginal infections, sexually transmitted diseases (STDs), cervical neoplasia, and HIV infection. The prevalence of sexually transmitted infections in a group of lesbians will generally reflect the rate of bisexual activity, and the rate of nonmonogamy among women in the group. Although the medical literature contains little information based on the direct study of lesbians, reasonable clinical decisions can be made by combining this limited empirical evidence with theoretical considerations and with extrapolations of information about female-to-male transmission. The recommendations in this chapter reflect this approach.

Vaginitis

BACTERIAL VAGINOSIS.

This infection is common in lesbians, with some studies showing rates of 30% or more among women seeking routine health care. Lesbians who seek care at STD clinics have been found to have approximately twice the rate of bacterial vaginosis compared to heterosexual women attending the same clinics.^11,12 There continues to be controversy as to whether bacterial vaginosis is sexually transmitted. In one study of monogamous lesbian sexual partners, there was a high concordance for the presence or absence of this infection among the pairs, supporting the possibility of sexual transmission between women¹³; other investigators have failed to find evidence for sexual transmission.¹⁴ The mechanism for such transmission has not been established, although one proposed hypothesis is the sexual practice of repetitive cunnilingus, which is common among lesbians.¹⁵ Given the possibility of sexual transmission, it would be reasonable to advise female sexual partners to be examined and treated as appropriate. The treatment of bacterial vaginosis in a lesbian is the same as for a heterosexual woman.

CANDIDA ALBICANS VULVOVAGINITIS.

Most Candida infections are not the result of sexual transmission. However, Candida can be acquired by direct contact with an infected person. Some heterosexual women with recurrent infections have a male partner who harbors the organism on the genital skin. Transmission between two women could, therefore, also be possible during vulva-to-vulva contact or transmission from fingers to vagina. To minimize the chance of transmission between women, it is prudent to advise the partner of the infected woman to avoid direct contact with the partner’s vulva or vagina during active infection. If fingers or hands come in contact, the partner should avoid placing her hand in her own vaginal area.

TRICHOMONAS VAGINALIS VAGINITIS.

The primary route of transmission for Trichomonas vaginal infection is heterosexual intercourse. Two cases of probable female-to-female transmission have been reported.^16,17 In each case, a Trichomonas infection was diagnosed in both partners, and there was no history of recent heterosexual contact. In each case, transmission was thought to be via mutual masturbation. Although Trichomonas is fairly fastidious, it can survive in the discharge outside the vagina for at least several minutes. Female partners should therefore avoid contact with infected vaginal secretions until treatment is completed.

GONORRHEA, CHLAMYDIA, AND SYPHILIS.

None of these has ever been reported in a lesbian who has never had heterosexual intercourse.^7,18,19 Therefore, the risk of transmission between women must be negligible. Chlamydia and gonorrhea, transmitted via infected semen, primarily infect the cervix, which is not easily accessible to the female partner. Even if a partner’s fingers picked up organisms, direct inoculation onto her own cervix would have to occur quickly. Although infection of a female partner is unlikely, it is again prudent to adhere to vaginal abstinence until treatment is completed.

Viral Sexually Transmitted Diseases

HERPES.

Although herpes type 1 and type 2 are traditionally associated with oral and genital infections, respectively, each viral subtype can infect at either location. Transmission requires direct contact between infected and uninfected mucous or skin. Women with oral herpes may, therefore, transmit this infection to a female partner’s vulva via oral contact. The virus can also be transmitted via an intermediary, such as a finger. Johnson and coworkers⁷ found that 3% of the 1921 lesbians surveyed reported ever having a genital herpes infection, including 1.5% of the women who had never had heterosexual intercourse.⁷ Among lesbians seen in STD clinics, herpes infections are common.^11,12,20 The key to avoiding transmission is to avoid direct contact with any active lesions on either the lips or the external genitalia. Once the lesion is scabbed over, the risk of transmission should be quite low.

HUMAN PAPILLOMAVIRUS AND CONDYLOMA.

Subtypes 6 and 11, which are responsible for most condyloma, infect squamous epithelium and are nearly impossible to eradicate completely. Transmission is poorly understood. Direct contact with infected surfaces, which usually occurs in the context of sexual activity, is probably the most common route of transmission for the human papillomavirsu (HPV) subtypes that cause condyloma.

In theory, transmission of the HPV virus should be as “efficient” between two women as that between a man and a woman. Marrazzo and collegues²¹ found a prevalence of 30% for any kind of HPV type among 149 lesbians, and 19% among the 21 women who had never had heterosexual sexual activity, suggesting that sexual transmission does occur between women. Thus, condyloma are not uncommon among lesbians, although the prevalence may be lower than among comparable heterosexual women.^11,12

CERVICAL NEOPLASIA.

The majority of women who currently identify themselves as lesbian have a history of past sexual contact with men, and thus, are at risk for cervical dysplasia; abnormal Pap smears have been identified among women who have no such history, although the risk in this group is undoubtedly low.^{11,12,22,23,24}

Several small studies have found that lesbians, when compared to heterosexual or bisexual women, are less likely to get regular Pap smear screening.^7,10,25,26 Not all studies have confirmed these results,²⁷ and there is evidence that rates are lower among younger lesbians with less education.²⁸ The urgent concern is the evidence that many lesbians who are at high risk for cervical neoplasia because they engage in heterosexual sex or are HIV infected, fail to recognize their risk, and are not screened appropriately.^29,30

The 1988 consensus recommendation of the American College of Obstetricians and Gynecologists, the American Cancer Society, the National Cancer Institute, the American Medical Association, the American Nurses’ Association, the American Academy of Family Physicians, and the American Medical Women’s Association was that all women who are or who have been sexually active should have an annual Pap smear, and that after three consecutive normal annual smears, further screening should be determined by individual risk factors. This approach is appropriate for lesbians; presence of the usual risk factors (HPV infection, smoking, HIV infection) would justify annual screening.

HEPATITIS.

Hepatitis C was found to be more than seven times more common in the lesbian subjects in a large case control study of women seen in a STD clinic.¹² Risk factors included having had sexual contact with a homosexual or bisexual man or a partner who used intravenous drugs. HIV-infected women are also at higher risk.⁴ There is one well-documented case of probable transmission of hepatitis A between two women, suggesting that any infection that is transmitted via the oral–fecal route can be shared between women.³¹

HIV.

In 1990, the Centers for Disease Control (CDC) first reported on acquired immune deficiency syndrome (AIDS) cases among the newly devised category women who have sex with women (WSW).³² Between 1980 and 1989, 79 cases of AIDS had been reported in this group, and 95% of these cases were intravenous drug users. Subsequent studies have confirmed that for a lesbian, the major risk factors for acquisition of HIV include personal intravenous drug abuse, bisexuality, and having sex with homosexual men.^4,33,34,35 In fact, lesbians who have one or more of these risk factors appear to have higher rates of HIV positivity than heterosexual women matched on the same risk factors.

Most, but not all,³⁶ studies have found that lesbians in these high-risk groups have often been found to be less likely to practice safe sex.^12,37,38,39 For example, in a study of more than 280 HIV-infected women, all of whom had a traditional risk factor for HIV, 44 also reported a main female sexual partner over the preceding 3 years. Cleaning of sex toys before sharing was practiced by all but 1 woman, but the use of a dental dam (the functional equivalent of the condom for oral sex) was half as low, with only 26% who practiced oral sex usually using, and almost half never using dental dams. Overall, the use of barriers by lesbians was half that of infected heterosexual women.⁴⁰

The risk of transmission of HIV between female sexual partners is not known, but is thought to be quite low. The CDC has never reported a case thought to be the result of female-to-female transmission. There were no seroconversions in a prosepective 6-month study of serodiscordant women sexual partners,⁴¹ and no cases identified in a STD clinic survey that included over 130 women who had sex exclusively with women.³⁴

Three possible cases have been reported. The most convincing (and instructive) case is reported by Marmor and coworkers.⁴² They describe a bisexual woman who developed typical acute HIV symptoms 6 weeks after a lesbian relationship with a woman whose AIDS was secondary to intravenous drug use. The sexual encounter included digital and oral contact with the infected partner’s vagina and anus. Both occurred during the menses of the infected woman. Finally, both women had vaginal bleeding from traumatic sexual activity. The infected woman had tested positive for HIV 2 years later, and had no other apparent risk factors. The other two cases rely on symptom history rather than serology for the diagnosis; it is not clear in either case that other risk factors were absent.^43,44

In theory, female-to-female transmission should be the least efficient way to transmit the virus, because female-to-male transmission is thought to be less common than male-to-female or male-to-male transmission. Although the virus has been found in vaginal fluid, there are antibodies in the vagina that may limit transmission. Saliva also contains the virus, but exposure to saliva has not been proven as a route of transmission.

It appears that prevention efforts would be best directed toward lesbians who engage in the behaviors identified as risk factors. In addition to the standard advice to use condoms when having sex with men and avoiding needle sharing, these women should be advised to take measures to minimize exposure to the vaginal secretions of women partners via sex toy use and receptive oral sex.⁴⁰ Avoiding exposure to blood (from menses or genital tract trauma) is also advisable. The barrier methods recommended include the use of dental dams for oral–genital or oral-anal contact; condoms on dildos and sex toys; and latex finger cots during vaginal or anal penetration.

Many lesbians raise children who are the product of previous heterosexual relationships, and an increasing number want to start families in a lesbian relationship. Many books are available that include useful and comprehensive discussions of the many issues involved in this decision.^45,46 Women interested in this course should also be advised to talk to other lesbians who have had children. Johnson and colleages⁴⁷ examined the desirability of several ways of “getting” children: adoption, donor insemination, or intercourse with a known or unknown man. Adoption was found to be highly desirable but can be difficult for lesbians to arrange. Some are successful either by going through international agencies, or by willingness to accept children with special needs. Women who inquire about this option should be advised to consult with persons knowledgeable about the adoption situation locally.

Woman wishing to be biologic mothers overwhelmingly preferred donor insemination to the intercourse options. The essential procedure (placing semen in the vagina) does not require any special medical expertise or equipment and can be arranged without medical or legal consultation, however, this method is not advisable for a number of reasons. First, the donor may later desire involvement with the child beyond the original agreement, and although sometimes this works out well, it often may not. Second, the donor may decide to stop donating semen without notice. Finally, and perhaps most importantly, the woman cannot be sure that the donor is infection-free, particularly from HIV. Seven cases worldwide of HIV transmission via artificial insemination (one in the United States) have been reported.⁴⁸ The authors estimated that the risk of acquiring the virus if insemination with infected semen occurs is between 0.14% and 0.46% per exposure. Eskenazi and colleagues⁴⁹ studied 88 women who were inseminated between 1979 and 1987. Half of the women received fresh semen from gay or bisexual men living in San Francisco before 1982. All women in the study were tested for HIV; none were positive.

Not all medical providers are willing to provide insemination services for lesbians. In fact, some infertility programs limit services to married women. A Canadian survey compared the attitudes of health care providers of artificial insemination by donor toward several types of clients.⁵⁰ Women with specific characteristics would be rejected as applicants by the following proportion of clinics: criminal record (46%); inadequate economic capacity to support a child (54%); no male partner (66%); and, most common, a stable lesbian partner (76%). While another 20% of the clinics would accept women in the first three categories, only 8% would accept a lesbian couple. The basis for these strong feelings is usually said to be concern for the outcome of the children.

A number of studies have specifically focused on role development and social relationships. A meta-analysis of 18 studies concluded that there are no differences between straight and lesbian families in “parenting style, emotional adjustment or sexual orientation of the children.”⁵¹ A review of data regarding children conceived by donor insemination and then raised by two-parent families found no adverse consequences of having homosexual parents.⁵²

Stacey and Biblarz⁵³ present a critical and intriguing view of the childhood outcome and parenting data. After a rigorously review of the literature, they argue that this area is subject to significant bias because of the underlying beliefs of the various authors. They point out that a primary reason for this is that this literature is used as evidence in court proceedings regarding custody decrees, and they “…acknowledge that the political stakes of this body of research are so high that the ideological ‘family values’ of scholars play a greater part than usual in how they design, conduct, and interpret their studies.”

Based on their review, they observe that those who oppose the raising of children by gay men and lesbians have tended to cite theoretical arguments based on a what they refer to as a controversial literature that claims that “fatherlessness” per se adversely affects childhood development, which is largely based on studies of heterosexual women raising children alone. These conclusions are usually further supported by “combining elements of bio-evolutionary theory with social and cognitive learning theories,” all of which presuppose that heterosexual two-parent families are the only ones in which normal children can be raised. On the other side are investigators, often gay or lesbian themselves, who have had as an agenda proving that children raised in lesbian homes are “the same” as those raised in heterosexual families.

While the literature to date does indeed show that children raised in lesbian households are not more likely to have adverse psychological, developmental, or educational outcomes, Stacy and Biblarz⁵³ observe that it seems theoretically implausible that there would be no differences at all. To test this hypothesis, they performed their own analysis of 21 studies published through 1998, and found a number of interesting differences, which they point out are essentially ignored by the authors of the studies. For example, young children being raised by lesbians are less likely to restrict their play to gender stereotypic activities; older girls are more likely to have interest in traditionally masculine occupations; and children of both genders are more likely to report homoerotic thoughts, although there is not a difference in reported sexual orientation. In conclusion, the authors suggest that there might be much to gain in the understanding of families and parenting styles if these differences were examined instead of glossed over.

A model for those who choose to provide lesbians with insemination services is described by Brewaeys and associates.⁵⁴ This clinic in Brussels, which has allowed lesbian insemination since 1982, has a specific clinic screening protocol. Before being accepted as clients, lesbians must: accept their lesbianism; have a supportive social environment; plan to seek male role models for the child; and have a currently stable relationship.

Lesbians who become pregnant appear to be model patients. Harvey and colleagues⁵⁵ surveyed 35 women who became pregnant as a result of artificial insemination All obtained prenatal care within 16 weeks of conception; 90% attended childbirth classes; and 80% breastfed for at least 6 months. Of interest, 90% disclosed their sexual orientation to their provider.

Chronic Diseases

There is growing evidence that lesbians, as a group, have a profile of risk factors that may predispose to cardiovascular disease, diabetes, and various cancers. The factors that have been identified so far include higher rates of tobacco and possibly alcohol use,^10,28,56,57 obesity, lower rates of parity and thus less breastfeeding, and less use of oral contraceptives.¹⁰

This combination of factors could lead to higher rates of cardiovascular disease, diabetes, and cancers of the breast, colon, endometrium, and ovary. However, there are few data examining the relative rates of these diseases between heterosexual and homosexual women. The largest sample to date is from the Women’s Health Initiative Study, in which almost 100,000 women are being followed prospectively to study a variety of postmenopausal health issues.¹⁰ The participants were asked to define themselves as heterosexual (90,578); bisexual (740); lifetime lesbians (264), adult lesbians (309), or never having had sex as an adult (1420). Based on data collected at the time of enrollment, the lesbians and bisexual women were more likely to report the risk factors of obesity, smoking, and had a higher rate of alcohol use.

Overall, there were not significant differences in the rates of any of the disease conditions assessed, and differences described here must be interpreted accordingly. Rates of “any cancer” were highest for the bisexual women, while the rates were similar for the other groups. Breast cancer was reported by each of the nonheterosexual groups more often than the heterosexual women, although the trend was not significant. Interestingly, the highest rates of cervical cancer were reported by the bisexual women, and unexpectedly, lifetime lesbians. Lifetime lesbians also reported the highest rate of colorectal cancer. There were no cases of endometrial cancer among the lifetime lesbians, also unexpected given their higher rate of nulliparity. In the category of cardiovascular disease, adult and lifetime lesbians reported more myocardial infarctions, but had the same rate of hypertension, and fewer strokes as compared to the bisexual and heterosexual women. Although the sample sizes for the nonheterosexual groups are the largest published to date in this age group, they are quite small from an epidemiologic perspective, and a finding of no difference must be interpreted with caution.

Mental Health Issues

ALCOHOL AND SUBSTANCE ABUSE.

The older literature suggested that lesbians have a high rate of alcohol abuse, and indeed, bars had an important place in lesbian cultural. Most recent studies, conducted in general population samples, have found that more lesbians than heterosexual women use alcohol, but the rates of heavy drinking are similar to those of the heterosexual controls.^10,57,58 Two studies found higher rates of heavy drinking among lesbians compared to controls.^56,28

There is very little information about illicit drug use among lesbians. Data from the Trilogy Project, a longitudinal study of more than 1000 young adult gay men and lesbians, found higher rates of marijuana but not cocaine use compared to a general population survey.⁵⁸ Incidence rates of alcohol and drug dependency over 1 year were compared between the exclusive heterosexuality (n = 9714) and men and women reporting same gender partners (n = 194) from the 1996 National Household Survey of Drug Abuse; lesbians were more likely than heterosexual women to report drug or alcohol dependency.⁵⁹

DEPRESSION.

It has been hypothesized that gay men and lesbians may have higher rates of depression because of their status as a stigmatized minority. A 1994 large national survey of volunteer participants found that half reported having suicidal ideation at some time in their life, and three quarters had sought counseling for depressive symptoms.⁸ However, most surveys of volunteers have failed to find higher rates of depression or other psychiatric illness.⁶⁰ In the 1996 National Household Survey of Drug Abuse study, gay men had higher rates of depression compared to straight men, but the lesbian and straight women had similar rates.⁵⁹

Of most concern has been the suggestion that homosexual adolescents are at higher risk for depression and suicide than their heterosexual peers. The commonly quote risk for suicide attempts of between 20% and 40% for gay youth, or that 30% of all completed adolescent suicide victims are gay are probably overestimates.⁶¹ However, several small studies have found that gay, lesbian, and bisexual adolescents tend to have more depressive symptoms than heterosexual controls.^62,63,64 There is some evidence that gay male teens are the group at highest risk.^63,65

The postmenopausal lesbians in the Women’ Health Initiative sample had lower mood scores than heterosexual women in that sample. The Trilogy Project investigators looked at factors that are associated with victimization, such as social support, self-esteem, external stress, and internalized homophobia, in their sample of young adults and found that low self-esteem and poor social support were strong predictors of depression.⁶⁶ However, there are no studies comparing the prevalence of anxiety or depressive disorders between lesbians and heterosexual women.

Intimate Partner Violence

Lesbians are at risk for intimate partner violence. The methods required for identification and intervention may differ from those that are effective with heterosexual women.⁶⁷ In a review of 19 studies addressing this issue, Burke and Follingstad⁶⁸ conclude that the rates and risk factors for violence in lesbian and gay male relationships are similar to those in heterosexual ones, and that risk factors, other than gender, are similar. In a national probability sample, the prevalence of intimate partner violence was higher between gay men, and lower between lesbian partners compared to heterosexual couples.⁶⁹

Access

Several factors may keep at least some lesbians from seeking care. In the case of routine gynecologic care, it may be that the lack of need for a yearly contraceptive prescription, coupled with less concern about STDs decreases the motivation for an annual visit. In support of this hypothesis, Johnson and colleagues⁷ found that reporting a recent Pap test was associated with oral contraceptive use and a history of heterosexual intercourse. Stevens² points out three economic circumstances common to lesbians that could make health care less accessible: (1) inadequate insurance coverage because of the inability to be covered by a partner’s health insurance; although this option is now sometimes available, it is far from universal; (2) low family income because women are paid less than men; and (3) inability to take advantage of inexpensive routine gynecologic care, which in many communities is provided by family planning clinics that serve only women who need birth control. Finally, the concern that providers will either be insensitive or hostile may discourage those seeking care for all but urgent problems. An alternative approach used by some lesbians is to seek care from nontraditional (chiropractor, acupuncturist, homeopaths), or nonphysician providers of allopathic care (midwife, nurse practitioner).²⁸ In addition, when given a choice, most surveys report that lesbians prefer a woman physician, and a lesbian, if possible. However, these options are not universally available, nor are these providers appropriate for all medical problems.

The empirical data regarding whether lesbians have poorer access to care, or get appropriate screening less often than heterosexual women are mixed. Two recent studies suggest that screening and access may be a problem. Cochran and colleagues⁵⁷ summarized data from seven controlled studies that comprise data from 11,000 women and found that the rate of mammograms and pelvic examination frequency was lower between the lesbian and bisexuals. Diamant and collegues²⁸ reported the only population-based data, from the 1997 Los Angeles County Health Survey, finding that lesbians were less likely than heterosexual women to have had Pap smears and a clinical breast examination than the heterosexual women in the previous 2 years, and lesbians were less likely than heterosexual women to have health insurance. A problem with this study is the small number of lesbians, 51, in the total sample of 4697 women.²⁸

In contrast, Koh³⁶ compared screening testing among 524 lesbians, 143 bisexual women, and 637 heterosexual women recruited from a clinic setting and found that the rate of cholesterol testing was the same, the rate of HIV testing was higher among the lesbians and bisexuals, and mammography and Pap smear rates were the same. These data may be biased toward good screening rates because the subjects were recruited from the clinical setting. In the Women’s Health Study, the women identified themselves in one of the two lesbian categories had the higher rates of mammography, and same rates of Pap smears, hemoccult, and the same hormone replacement therapy use as the heterosexual women. However, the authors point out that if the women who refused to answer the sexual history question were combined with the lesbian groups, the screening rates were worse than the heterosexuals.

Experiences With Health Care Providers

In her review of 20 years of literature regarding health care providers’ attitudes toward lesbians (9 studies), and lesbians’ experiences in health care encounters (19 studies), Stevens² concludes that despite some progress, problems still exist. Progress has been made in the medical establishment’s efforts to depathologize homosexuality. The American Psychiatric Association removed homosexuality as a disorder from the Diagnostic and Statistical Manual of Mental Disorders in 1973. In 1980, the American Medical Association passed a resolution to encourage learning more about health needs of this population, and to determine ways to educate practitioners and medical students.

Despite these efforts, even recent studies report that a substantial number of providers still consider homosexuality pathologic. Many physicians continue to hold negative views toward gays and lesbians that, in turn, may affect the care provided. Randall⁷⁰ found that 24% of the respondents in a national survey of nurse educators believed that homosexuality was wrong, immoral, or perverted, and 28% felt that laws outlawing relevant sexual practices should not be repealed. A 1986 survey of 1000 San Diego physicians found that 30% reported homophobic attitudes, and that gynecologists and family physicians were among the specialists most likely to hold this attitude.⁷¹ In a 1996 survey of 2000 physicians, obstetrician-gynecologists were found to be the specialty most opposed to gay and lesbians seeking careers as physicians, which might be seen as an indirect measure of attitudes toward gay patients.⁷²

These attitudes are detectable by lesbian patients. Dardick and Grady⁷³ reported in their mail survey that approximately one third of the lesbians reported an encounter with at least one prejudiced primary care physician. Smith and associates⁷⁴ surveyed 1921 lesbians and found that 30% reported experiencing an obvious negative attitude on the part of at least one physician providing them with gynecologic care. The gay and lesbian young adults who were enrolled in a larger study of cardiovascular risk factors reported a high rate of discrimination in the health care setting.⁹ These attitudes can affect clinical care directly if the provider inappropriately focuses on sexual orientation as an explanation for the presenting problem. Diamant and colleagues,⁷⁵ based on a survey of almost 7000 lesbians, reported that disclosure of lesbian status to the health care professional was associated with a higher likelihood of getting a Pap smear, supporting the notion that openness is associated with better health care.⁷⁵

Given this high rate of homophobia, a lesbian may have a difficult choice to make about whether or not to disclose her orientation to a new provider. Stevens² points out that there are substantial personal costs to continually maintaining nondisclosure. If disclosure to a new person is considered, a complex monitoring process must occur to determine if the disclosure is safe. Despite the risks, many lesbians do choose to disclose to health care providers. In two large surveys, half of the lesbian respondents had disclosed to at least one physician. Smith and colleagues⁷⁴ provide additional details. When asked what effect disclosure would have on their care, 38% said it would “hinder,” 31% thought “no effect,” and only 22% said it would improve their care. Yet, disclosure was usually unsolicited; only one fourth of the women who disclosed did so in response to a direct question from the physician.

In summary, there is both theoretical and empirical evidence to suggest that disclosure to health care providers (perhaps especially physicians) is considered risky, yet it appears that a large number of lesbians do so despite the risk. Why? Johnson and Guenther⁷⁶ suggest three possible reasons: a need for appropriate health care; a desire for an enhanced relationship with the provider; or apolitical belief that society’s attitudes will change only if gay persons “come out.”

A need for appropriate health care might overcome fear of adverse interpersonal consequences. A lesbian with a vaginal infection will want to know if she can transmit it to her female partner, and if so, during what specific sexual activities. More urgently, she may want to discuss her risk of acquiring HIV infection and how to reduce this risk. Many lesbians now want to have children, and must successfully negotiate the process for insemination, and later, prenatal care and childbirth. The lesbian with a life-threatening illness needs to include her partner in discussions with the provider, and to make known the power-of-attorney to be used should she be unable to speak for herself.

The other two motivations for disclosure are less obvious but no less important. An honest, respectful, mutually satisfactory relationship between the provider and the patient leads to better health outcomes. Sexual orientation and intimate relationships are each integral parts of a person’s identity. When it is necessary to withhold these aspects of the self from the provider, trust cannot develop. Finally, individuals who are comfortable being “out” may disclose purely for political purposes. This strategy may, in fact, be useful. Physicians who have knowingly treated homosexual patients have been shown to be less likely to be homophobic

The literature is unanimous in its recommendations to health care providers who choose to improve services to lesbians:

1. Educate yourself about the medical aspects of problems relevant to lesbians. This chapter provides a starting point for that task.
   
2. Use inclusive language. Questions about marriage, sexual activity, and birth control are often asked in a way that assumes the respondent is heterosexual. Instead of “Are you married?” try “Do you have an ongoing relationship?” Rather than “What do you use for birth control?” ask “Are you in need of birth control?” By allowing an opening for the nontraditional answer to these questions, you create an atmosphere in which the lesbian can more confidently disclose.
   
3. Keep the patient’s disclosure of her sexual orientation confidential. Some clinicians use a personal code in the medical record so that they remember from visit to visit. If there is need to write the sexual orientation in the record, or if another provider should be informed, inform the woman why.
   
4. Include the significant other or other support system of the patient in the same way you would the partner of a heterosexual woman. This is easy to do in your own office; it may still occasionally be necessary to arrange exceptions to “family only” policies in the hospital setting.
   
5. Finally, examine your own attitudes, and if you are not comfortable caring for lesbians, refer to another physician.
   

1. Good RS: The gynecologist and the lesbian. Clin Obstet Gynecol 19:473, 1976

2. Stevens PE: Lesbian health care research: A review of the literature from 1970 to 1990. Health Care Women Int 13:91, 1992

3. Laumann EO, Gagnon JH, Michael RT, et al: The Social Organization of Sexuality: Sexual Practices in the United States. Chicago, University of Chicago Press, 1994

4. Raiteri R, Fora R, Gioannini P, et al: Seroprevalence, risk factors and attitude to HIV-1 in a representative sample of lesbians in Turin. Genitourinary Med 70:200, 1994

5. Diamant A, Lever J, Schuster MA: Lesbians’ sexual activities and efforts to redue risks for sexually transmitted diseases. J Gay Lesbian Med Assoc 4:41, 2000

6. Solarz AL: Lesbian Health: Current Assessment and Directions for the Future. Washington, D.C., National Academy Press, 1999

7. Johnson SR, Smith EM, Guenther SM: Comparison of gynecologic health care problems between lesbians and bisexual women. A survey of 2,345 women J Reprod Med 32:805, 1987

8. Bradford J, Ryan C, Rothblum ED: National Lesbian Health Care Survey: Implications for mental health care. J Consult Clin Psychol 62:228, 1994

9. Krieger N, Sidney S: Prevalence and health implications of anti-gay discrimination: A study of black and white women and men in the CARDIA cohort. Coronary Artery Risk Development in Young Adults Int J Health Serv 27:157, 1997

10. Valanis BG, Bowen DJ, Bassford T, et al: Sexual orientation and health: Comparisons in the women’s health initiative sample. Arch Fam Med 9:843, 2000

11. Skinner CJ, Stokes J, Kirlew Y, et al: A case-controlled study of the sexual health needs of lesbians. Genitourinary Med 72:277, 1996

12. Fethers K, Marks C, Mindel A, et al: Sexually transmitted infections and risk behaviours in women who have sex with women. Sex Transm Infect 76:345, 2000

13. Berger BJ, Kolton S, Zenilman JM, et al: Bacterial vaginosis in lesbians: A sexually transmitted disease. Clin Infect Dise 21:1402, 1995

14. McCaffrey M, Varney P, Evans B, et al: Bacterial vaginosis in lesbians: Evidence for lack of sexual transmission. Int J STD AIDS 10:305, 1999

15. Tchamouroff SE, Panja SK: The association between receptive cunnilingus and bacterial vaginosis. Sex Transm Infect 76:144, 2000

16. Sivakumar K, De Silva AH, Roy RB: Trichomonas vaginalis infection in a lesbian. Genitourinary Med 65:399, 1989

17. Kellock D, O’Mahony CP: Sexually acquired metronida-zole-resistant trichomoniasis in a lesbian couple. Genitourinary Med 72:60, 1996

18. Robertson P, Schachter J: Failure to identify venereal disease in a lesbian population. Sex Transm Dis 8:75, 1981

19. Ernst RS, Houts PS: Characteristics of gay persons with sexually transmitted disease. Sex Transm Dis 12:59, 1985

20. Edwards A, Thin RN: Sexually transmitted diseases in lesbians. Int J STD AIDS 1:178, 1990

21. Marrazzo JM, Koutsky LA, Stine KL, et al: Genital human papillomavirus infection in women who have sex with women. Journal of Infectious Diseases 178:1604–9, 1998

22. O’Hanlan KA, Crum CP: Human papillomavirus-associated cervical intraepithelial neoplasia following lesbian sex. Obstet Gynecol 88:702, 1996

23. Bailey JV, Kavanagh J, Owen C, et al: Lesbians and cervical screening. Br J Gen Pract 50:481, 2000

24. Diamant AL, Schuster MA, McGuigan K, et al: Lesbians’ sexual history with men: Implications for taking a sexual history. Arch Intern Med 159:2730, 1999

25. Buenting JA: Health life-styles of lesbian and heterosexual women. Health Care Women Int 13:165, 1992

26. Rankow EJ, Tessaro I: Cervical cancer risk and Papanicolaou screening in a sample of lesbian and bisexual women. J Fam Pract 47:139, 1998

27. Roberts SJ, Sorensen L: Health related behaviors and cancer screening of lesbians: Results from the Boston Lesbian Health Project. Women Health 28:1, 1999

28. Diamant AL, Wold C, Spritzer K, et al: Health behaviors, health status, and access to and use of health care: A population-based study of lesbian, bisexual, and heterosexual women. Arch Fam Med 9:1043, 2000

29. Price JH, Easton AN, Telljohann SK, et al: Perceptions of cervical cancer and Pap smear screening behavior by women’s sexual orientation. J Commun Health 21:89, 1996

30. Moran N: Lesbian health care needs. Can Fam Phys 42:879, 1996

31. Walters MH, Rector WG: Sexual transmission of hepatitis A in lesbians. JAMA 256:594, 1986

32. Chu SY, Buehler JW, Fleming PL, et al: Epidemiology of reported cases of AIDS in lesbians, United States 1980–89. Am J Public Health 80:1380, 1990

33. Harris NV, Thiede H, McGough JP, et al: Risk factors for HIV infection among injection drug users: Results of blinded surveys in drug treatment centers, King County, Washington 1988–1991. J Acquir Immune Defic Syndr 6:1275, 1993

34. Bevier PJ, Chiasson MA, Heffernan RT, et al: Women at a sexually transmitted disease clinic who reported same-sex contact: Their HIV seroprevalence and risk behaviors. Am J Public Health 85:1366, 1995

35. Kral AH, Lorvick J, Bluthenthal RN, et al: HIV risk profile of drug-using women who have sex with women in 19 United States cities. J Acquir Immune Defic Syndr 16:211, 1997

36. Koh AS: Use of preventive health behaviors by lesbian, bisexual, and heterosexual women: Questionnaire survey. West J Med 172:379, 2000

37. Shotsky WJ: Women who have sex with other women: HIV seroprevalence in New York State counseling and testing programs. Women Health 24:1, 1996

38. Perry SM: Lesbian alcohol and marijuana use: Correlates of HIV risk behaviors and abusive relationships. J Psychoactive Drugs 27:413, 1995

39. Lemp GF, Jones M, Kellogg TA, et al: HIV seroprevalence and risk behaviors among lesbians and bisexual women in San Francisco and Berkeley, California. Am J Public Health 85:1549, 1995

40. Kennedy M, Moore J, Schuman P, et al: Sexual behavior of HIV-infected women reporting recent sexual contact with women. JAMA 280:29, 1998

41. Raiteri R, Fora R, Sinicco A: No HIV-1 transmission through lesbian sex. Lancet 344:270, 1994

42. Marmor M, Weiss LR, Lyden M, et al: Possible female-to-female transmission of human immunodeficiency virus. Ann Intern Med 105:969, 1986

43. Monzon OT, Capellan JM: Female-to-female transmission of HIV. Lancet 2:40, 1987

44. Sabatini MT, Patel K, Hirschman R: Kaposi’s sarcoma and T-cell lymphoma in an immunodeficient woman: A case report. AIDS Res 105:969, 1984

45. Martin A: The Lesbian and Gay Parenting Handbook: Creating and Raising Our Families. New York, Harper Perennial, 1993

46. Pies C: Considering Parenthood. 2nd ed.. San Francisco, Spinsters Ink, 1988

47. Johnson SR, Smith EM, Guenther SM: Parenting desires among bisexual women and lesbians. J Reprod Med 32:198, 1987

48. Chiasson MA, Stoneburner RL, Joseph SC: Human immunodeficiency virus transmission through artificial insemination. J Acquir Immune Defic Syndr 3:69, 1990

49. Eskenazi B, Pies C, Newstetter A, et al: HIV serology in artificially inseminated lesbians. J Acquir Immune Defic Syndr 2:187, 1989

50. Freedman B, Taylor PJ, Wonnacott T, et al: Non-medical selection criteria for artificial insemination and adoption. Clin Reprod Fertil 5:55, 1987

51. Allen M, Burrell N: Comparing the impact of homosexual and heterosexual parents on children: Meta-analysis of existing research. Journal of Homosexuality 32:19, 1996

52. Brewaeys A: Review: parent-child relationships and child development in donor insemination families. Hum Reprod Update 7:38, 2001

53. Stacey J, Biblarz TJ: (How) does the sexual orientation of parents matter? Am Sociol Rev 66:159, 2001

54. Brewaeys A, Olbrechts H, Devroey P, et al: Counselling and selection of homosexual couples in fertility treatment. Hum Reprod 4:850, 1989

55. Harvey SM, Carr C, Bernheine S: Lesbian mothers. Health care experiences J Nurse-Midwifery 34:115, 1989

56. Gruskin EP, Hart S, Gordon N, et al: Patterns of cigarette smoking and alcohol use among lesbians and bisexual women enrolled in a large health maintenance organization. Am J Public Health 91:976, 2001

57. 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 91:591, 2001

58. Skinner WF, Otis MD: Drug and alcohol use among lesbian and gay people in a southern U.S. sample: Epidemiological, comparative, and methodological findings from the Trilogy Project J Homosex 30:59, 1996

59. Cochran SD, Mays VM: Relation between psychiatric syndromes and behaviorally defined sexual orientation in a sample of the US population. Am J Epidemiol 151:516, 2000

60. Sorensen L, Roberts SJ: Lesbian uses of and satisfaction with mental health services: Results from Boston Lesbian Health Project. J Homosex 33:35, 1997

61. Muehrer P: Suicide and sexual orientation: A critical summary of recent research and directions for future research. Suicide Life-Threatening Behav 25(suppl):72, 1995

62. Safren SA, Heimberg RG: Depression, hopelessness, suicidality, and related factors in sexual minority and heterosexual adolescents. J Consult Clin Psychol 67:859, 1999

63. Fergusson DM, Horwood LJ, Beautrais AL: Is sexual orientation related to mental health problems and suicidality in young people? [see comments] Arch Gen Psychiatry 56:876, 1999

64. Lock J, Steiner H: Gay, lesbian, and bisexual youth risks for emotional, physical, and social problems: Results from a community-based survey. J Am Acad Child Adolesc Psychiatry 38:297, 1999

65. Remafedi G, French S, Story M, et al: The relationship between suicide risk and sexual orientation: Results of a population-based study. Am J Public Health 88:57, 1998

66. Otis MD, Skinner WF: The prevalence of victimization and its effect on mental well-being among lesbian and gay people. J Homosex 30:93, 1996

67. Pitt E, Dolan-Soto D: Clinical considerations in working with victims of same-sex domestic violence. J Gay Lesbian Med Assoc 5:163, 2001

68. Burke LK, Follingstad DR: Violence in lesbian and gay relationships: theory, prevalence, and correlational factors. Clinical Psychology Review 19:487, 1999

69. Tjaden P, Thoennes N, Allison CJ: Comparing violence over the life span in samples of same-sex and opposite-sex cohabitants. Violence Victims 14:413, 1999

70. Randall CE: Lesbian phobia among BSN educators: A survey. J Nurs Educ 28:302, 1989

71. Mathews C, Kessler L, Booth MW, et al: Physicians attitudes toward homosexuality. West J Med 140:290, 1984

72. Ramos MM, Tellez CM, Palley TB, et al: Attitudes of physicians practicing in New Mexico toward gay men and lesbians in the profession. Acad Med 73:436, 1998

73. Dardick L, Grady KE: Openness between gay persons and health professionals. Ann Intern Med 93:115, 1980

74. Smith EM, Johnson SR, Guenther SM: Health care attitudes and experiences during gynecologic care among lesbians and bisexuals. Am J Public Health 75:1085, 1985

75. Diamant AL, Schuster MA, Lever J: Receipt of preventive health care services by lesbians. Am J Prev Med 19:141, 2000

76. Johnson SR, Guenther SM: The role of “coming out” by the lesbian in the physician-patient relationship. Women Ther 6:231, 1987