Committee on Health Care for Underserved Women
This information should not be construed as dictating an exclusive course of treatment or procedure to be followed.
ABSTRACT: Lesbians and bisexual women encounter barriers to health care that include concerns about confidentiality and disclosure, discriminatory attitudes and treatment, limited access to health care and health insurance, and often a limited understanding as to what their health risks may be. Health care providers should offer quality care to all women regardless of sexual orientation. The American College of Obstetricians and Gynecologists endorses equitable treatment for lesbians and bisexual women and their families, not only for direct health care needs, but also for indirect health care issues.
Definition and Prevalence
Sexual orientation is an enduring emotional, romantic, or sexual attraction that one feels toward men or women or both 1. Although there is no standard definition of a lesbian, common characteristics may include same-sex attraction, same-sex sexual behavior, or self-identification as a lesbian. For many women, sexual orientation falls along a continuum where a woman may not be exclusively heterosexual or homosexual, or she may develop a lesbian orientation over her lifetime. A bisexual woman is attracted to or engages in sexual behavior with both sexes or identifies herself as bisexual. Sexual orientation has not been conclusively found to be determined by any particular factor or factors, and the timing of the emergence, recognition, and expression of one’s sexual orientation varies among individuals 1.
Although prevalence statistics vary in the United States, data from the National Survey of Family Growth suggest that 1.1% and 3.5% of women identify as lesbian or bisexual, respectively 2. Lesbians and bisexual women are as diverse a population as the population of all women and are represented among all racial, ethnic, and socioeconomic groups. All obstetrician–gynecologists encounter lesbian or bisexual patients, although not all women will disclose their sexual orientation to their health care providers. Additional research is needed to assess the current state of knowledge about the health of this population as well as to identify research gaps and formulate a research agenda as outlined by the Institute of Medicine 3.
Barriers to Health Care
Women who identify as lesbian or bisexual encounter barriers to health care that include concerns about confidentiality and disclosure, discriminatory attitudes and treatment, limited access to health care and health insurance, and often a limited understanding as to what their health risks may be 4. Lesbians who are unemployed or work in a setting that does not offer health insurance are not allowed to participate in their partners’ employment benefits package in most circumstances 4 5. Lesbians and their partners often face additional challenges such as a lack of availability of health care providers offering fertility services to women who identify as lesbian. Obstetrician–gynecologists who elect not to provide fertility services to lesbian couples or individuals should refer them for these services. Sexual orientation should not be a barrier to receiving fertility services to achieve pregnancy. The American College of Obstetricians and Gynecologists (the College) endorses equitable treatment for lesbians and their families, not only for direct health care needs, but also for indirect health care issues; this should include the same legal protections afforded married couples 4.
Routine Health Visits
Comprehensive care, including prevention of cardiovascular disease, obesity, cancer, and sexually transmitted infections (STIs), is recommended for lesbian and bisexual patients. Being a lesbian does not inherently affect an individual’s health status. There are no known physiologic differences between lesbians and heterosexual women. There may, however, be health behaviors or health risk factors that are more common among lesbians and bisexual women that have health consequences.
Several studies have reported higher prevalence rates of obesity, tobacco use, and alcohol use by lesbians 6 7. These factors may increase the risk of type 2 diabetes, lung cancer, and cardiovascular disease. In fact, higher rates of heart attack have been reported in lesbians 6 7. Given these increased risks, routine office visits should include counseling for weight control and smoking cessation, as needed, and screening for cardiac risk factors such as diabetes and lipid status as appropriate for the patient’s age and medical history.
Nulligravidity, low parity, obesity, tobacco use, and less use of oral contraceptives are more common in lesbians than among heterosexual women 6 7. These risk factors are associated with breast cancer and ovarian cancer but more research is needed to determine actual differences in prevalence rates of breast cancer and ovarian cancer. General recommendations for mammography, colorectal cancer screening, hormone therapy, and osteoporosis screening also should be followed for all lesbian and bisexual patients 8.
Routine cervical cancer screening is recommended for all women. The onset and interval for this testing should be based on College recommendations 9. Many health care providers incorrectly conclude that lesbian patients do not require cervical cancer screening because they are at low risk of cervical cancer. This is based on the assumption that the patient has not previously had sex with men, which is not always correct. In addition, cervical dysplasia has been reported in lesbians who have not previously had intercourse with men 10.
Reproductive health care providers and family planning services should consider that any patient, even one who is pregnant, may be a lesbian or bisexual woman. Gynecologic care, including family planning and STI and human immunodeficiency virus (HIV) screening and prevention counseling, is recommended because most lesbians have been sexually active with men at some point in their lives and because some STIs can be transmitted by exclusive lesbian sexual activity 11.
Although less research has been conducted on STIs among lesbians and bisexual women, they may participate in a range of sexual practices with women and men that may put them at risk of acquiring STIs 6 7. Infections, including bacterial vaginosis, candidiasis, herpes, and human papillomavirus infections, can be contracted by lesbians 6 7. Although female-to-female transmission of HIV appears to be possible, there have been no confirmed cases 12. It has been noted that bisexual women have the highest rates of seropositivity in comparison with both lesbians and heterosexual women 7. Lack of knowledge about types of risk-taking behavior and disease transmission also was notable among lesbians and bisexual women. Education about the risks of STIs and dispelling the perception that transmission of STIs between women is negligible will help patients make informed decisions.
All patients, regardless of sexual orientation, should be encouraged to use safe sex practices to reduce the risk of transmitting or acquiring STIs and HIV. Safe sex practices for lesbians and bisexual women include use of condoms on sex toys, gloves, and dental dams, as well as avoidance of sharing dildos and other sex toys.
Mental Health and Psychosocial Considerations
Health care providers should be alert to the signs and symptoms of depression, substance abuse, and intimate partner violence in all patients and conduct appropriate screening and intervention 8 13. Studies have shown that women who identify themselves as lesbians are more likely to admit to having depression and to taking antidepressants 7. Lesbians report stress caused by isolation, prejudice, stigmatization, a lack of support from peers and family, and a lack of access to health care and mental health care providers 6 14.
Additionally, lesbians are more likely than heterosexual women to abuse alcohol and drugs 15. Reliance on bars as social venues, stress caused by discrimination, and targeted advertising by tobacco and alcohol businesses in gay and lesbian publications all contribute to increased pressures for lesbian, gay, bisexual, and transgender individuals to engage in substance use 16.
Intimate partner violence among lesbians is a serious public health concern. However, true prevalence estimates vary widely because they often are based on studies with varying definitions of violence, time frames, and sampling procedures 17. Women who experience intimate partner violence in their relationships are at risk of repeated assault, increased injuries, chronic health conditions, disabilities, and death 17. Health care providers should be alert to the signs and symptoms of violence in all relationships. For additional information, please refer to Committee Opinion No. 518, Intimate Partner Violence 13.
Mental health concerns also apply to youth who self-identify as lesbian, gay, or bisexual. During adolescence, these youth, who report lack of support from parents and families, are at high risk of depression, suicide, and substance abuse 18. Lesbian or bisexual girls also are at high risk of tobacco use and eating disorders. Counseling may be very helpful for adolescents who are uncertain about their sexual orientation or have difficulty expressing their sexuality and can assist a lesbian or bisexual adolescent in coping with difficulties faced at home, school, or in the community. It should be noted that reparative therapy aimed to change sexual orientation by provoking guilt and anxiety to shame those who do not identify as heterosexual is ineffective and harmful 19. More constructive therapeutic goals for adolescents should be to create and maintain self-confidence and honest relationships with family and friends.
Changes in the Patient Care Setting
In light of the barriers to health care faced by lesbian and bisexual patients, efforts to ensure that the health care setting is receptive and appropriately addresses the needs of this population are warranted. The American College of Obstetricians and Gynecologists’ Code of Professional Ethics states that obstetrician–gynecologists should avoid “discrimination on the basis of race, color, religion, national origin, sexual orientation, perceived gender, and any basis that would constitute illegal discrimination” 20. There are numerous ways obstetrician–gynecologists can better meet the needs of lesbian and bisexual patients in their practices. Specific suggestions for changes in the office setting include the following:
Inform receptionists and other office staff that patients of all sexual orientations and gender identities are welcome in the practice and should be treated with the same respect as other patients.
Modify office registration forms and questionnaires that require patients to identify their relationship and behavioral status to obtain more accurate and useful information 21. Examples include the following:
Are you single, married, widowed, or divorced, or do you have a domestic partner?
Are you or have you been sexually active with anyone—male, female, or both male and female partners—or are you not sexually active?
Who are you sexually attracted to—men, women, or both men and women?
The form can state that response to these questions is optional. If the patient does not answer these questions, she can be asked in person. If the patient has concerns about confidentiality, the health care provider does not need to write down the answer or can code the response.
Have a nondiscrimination policy for your office posted in the reception area. For example: “This office appreciates diversity and does not discriminate based on race, age, religion, disability, marital status, sexual orientation, or perceived gender.”
Use inclusive language with all patients and neutral terms such as “partner” or “spouse” rather than “boyfriend” or “husband” when a patient’s partner status is unknown.
Be a resource for health information about sexual orientation and gender issues for both patients and their families. Provide patients with educational materials that list community resources in the reception area. Concerned families can be encouraged to obtain counseling or contact Parents, Family, and Friends of Lesbians and Gays http://www.pflag.org for information and support.
Additional guidance and recommendations for improving communication, cultural competence, and patient and family centered care is available at: http://www.jointcommission.org/assets/1/18/LGBTFieldGuide.pdf.
American College of Obstetricians and Gynecologists. Lesbian teens. In: Tool kit for teen care. 2nd ed. Washington, DC: ACOG; 2009.
American College of Obstetricians and Gynecologists. Health care for lesbian and bisexual women. Washington, DC: ACOG; 2006.
American College of Obstetricians and Gynecologists Committee on Health Care for Underserved Women. http://www.acog.org/About_ACOG/ACOG_Departments/Health_Care_for_Underserved_Women. Retrieved January 13, 2012.