LESBIAN PATIENTS

Offering high-quality ob/gyn care to lesbian patients

By Patricia A. Robertson, MD

Most lesbian patients hesitate to reveal their sexual orientation, even though you need that information to deliver targeted health care. Creating a nonjudgmental office environment can encourage trust and disclosure, helping you to better address their unique health needs.

Between 1% and 5% of your patients are lesbian—a group recently recognized by the Institute of Medicine as a minority that's underserved by the medical care system in the United States.¹ It's important that ob/gyns—and all physicians—provide culturally sensitive and effective health care for lesbians, but that usually can't happen unless your lesbian patient feels comfortable revealing her sexual orientation. There is tremendous diversity within lesbian communities as to ethnicity, age, educational level, income, and location (with more lesbians living in urban versus rural areas.) Of women who say their sexual orientation is lesbian, about 85% are sexually active only with other women, while about 15% are bisexual.

Determining if your patient is lesbian is often a challenge, as most do not readily disclose their sexual orientation because they fear the judgmental attitudes of office staff and providers, and are concerned that they'll receive substandard medical care once they're "out." However, most of these patients do want their ob/gyns to know about their sexual orientation, so it is up to you to ferret out this information, either indirectly through office forms that are inclusive for all patients, or directly by asking each patient, "Are you sexually active with men, women, both, or neither?"

Disclosure allows you to order more appropriate screening tests, to know which family members to contact in case of emergency, and to provide appropriate medical care and recommendations. The health concerns of a lesbian patient differ significantly from those of heterosexual patients in some respects, but are the same in others. My goal here is to discuss those differences, which when addressed, often translate into better health care for lesbians.

Addressing primary care issues

For many reasons, lesbians have limited access to medical care.²

Financial barriers, negative feedback. Lesbian women are less likely than heterosexuals to have health insurance, a factor that is usually attributed to their inability to receive spousal benefits. But also because lesbians are "underemployed" for their educational level, they may not have insurance benefits at their own jobs. Additionally, federal and state health services for women often tend to focus on the reproductive aspects of health care, which exclude most lesbians.

About 60% of lesbians have had negative experiences with the health-care system in the past. For instance, a number of lesbians have had birth control methods prescribed to them inappropriately when they were in a monogamous relationship with another woman, as the provider assumed they were heterosexual without specifically asking about the sexual orientation of the patient. Lesbians have reported experiencing disapproval of the health-care provider or staff when disclosing their sexual orientation. It's little wonder that lesbians are less likely to return for preventive care, care for acute health conditions, or worsening chronic conditions.

Many lesbians are also members of ethnic minorities, the disabled, or lower socioeconomic groups, all of whom have encountered barriers when accessing the health-care system. Understandably, adding a lesbian identity further obstructs access.

Young lesbians have special problems to deal with, as adolescents are the most under- or uninsured group. The fear of coming out to their health-care provider when they have not even come out yet to their parents makes it particularly difficult for them. This problem is compounded by the fact that lesbian youths are at higher risk for suicide, substance use, relationship violence, and unintended pregnancy compared to female heterosexual youths.

Fewer lesbians are routinely screened. Because of this limited health-care access, many lesbians have not undergone routine screening tests like TSH, fasting lipid profile, glucose testing, blood pressure measurements, and screening for colon cancer. Lesbians who have relationships with women as well as men are less likely to have mammographic screening than heterosexual women.³ So, when seeing a lesbian patient for the first time, be certain to determine her need for screening tests, as they may not have been done.

Lesbians also have higher body mass indices than heterosexual women, according to recent research.⁴ Although we don't know how higher BMI affects the risk of disease in lesbians, theoretically it could increase the risk of diabetes, heart disease, and a host of other disorders. Another concern is the fact that lesbians are more likely than heterosexual women to have a history of substance abuse, so it's crucial to take the time to carefully screen for cigarette smoking, alcohol use, and the use of other substances, and to order an HIV screen and hepatitis C antibody test if there is a history of IV drug use.

Depression and abuse rates. While depression is more common in lesbians,⁶ unlike their heterosexual female counterparts, lesbians tend to favor psychotherapy over taking anti-depressants (E.P. Gruskin, PhD, written communication, June 2001). On the other hand, when researchers studied the sisters of lesbians as a control group for mental health status, they found no differences in mental health, except that lesbians had higher self-esteem than their sisters.⁷ Lesbians are more likely to be victims of childhood sexual abuse, as well as of parental mistreatment.^8,9 Domestic violence occurs in lesbian relationships, probably at the same rate as in heterosexual relationships, but health professionals often underestimate the severity.¹⁰ Treatment for victims of domestic violence who are lesbian is hampered by lack of shelters for lesbians, as well as by the inadequate patient education in the lesbian community about domestic violence and inadequate training of counselors with cultural sensitivity for lesbian clients.

Incapacity and hateful families. Be sure to discuss with your lesbian patient the issue of becoming incapacitated, especially if she has a partner (as do 70% of lesbians). Power of attorney health forms enable her partner to make decisions for your patient in the event she is incapacitated. Otherwise, the decision will default to the family of origin. Frequently, lesbians have "families of choice" instead, as many lesbians are estranged from their family of origin once they have "come out." Many lesbians have been victims of hate crimes from their family of origin (including being asked to leave the home as a teen and verbal and physical abuse). One survey in Philadelphia revealed that 25% of lesbians were victims of such hate crimes perpetrated by their families.¹¹

Narrowing the focus to gynecologic care

All lesbians need Pap smears as frequently as heterosexual patients. The 90% of lesbians who've been sexually active with men in the past are at risk for cervical dysplasia. And even some of the remaining 10% who've never been sexually active with a man do develop cervical dysplasia.¹² Patients should know that the human papillomavirus can probably be transmitted from woman to woman. The Web site www.lesbianstd.com provides information on sexually transmitted diseases and "safer sex" information for lesbians. (Table 1 lists other helpful Web sites.)

TABLE 1
Web site resources for your lesbian patients

Health information from the Lesbian Health Research Center at UCSF:
http://www.lesbianhealthinfo.org

Domestic violence information:
http://www.cuav.org

Legal information (Power of Attorney, parental rights):
http://www.nclrights.org

Information for parents of gay and lesbian children:
http://www.pflag.org

Cancer: The Mautner Project for Lesbians with Cancer:
http://www.mautnerproject.org

Sexually transmitted diseases in lesbians:
http://www.lesbianstd.com

In general, chlamydia and gonorrhea transmission between women are unlikely, but there are case reports of HIV being passed between women and one case of hepatitis B transmission. Because most lesbians are in a monogamous relationship with only women, routine chlamydia and gonorrhea screening in this population is probably not worthwhile. However, 30% of lesbians are not in a monogamous relationship and sometimes are concurrently sexually active with men, so it is important to screen this group for chlamydia, gonorrhea, hepatitis B antibody (and then vaccinate women who are not immune), HIV, and syphilis. Be sure to provide this subset of women with information about safer sex techniques and pregnancy prevention. There's a higher unintended pregnancy rate in both lesbian teens and in female adolescents unsure of their sexual orientation than in female heterosexual youths.¹³

Vaginitis and cancer. If a lesbian patient is diagnosed with vaginitis, you should consider treating her female partner—especially in cases of trichomonas. You may also see bacterial vaginosis in both members of a lesbian couple.¹⁴ If BV recurs in your lesbian patient, screen her partner (treating the partner, if needed) before re-treating your patient. If the patient has vaginal candidiasis, it is unlikely you will need to treat her partner also.

Lesbians are probably at increased risk for breast cancer, ovarian cancer, and endometrial cancer since most are nulliparous.¹⁵ Many lesbians accept routine mammography.

Mothers of gay or lesbian children. On occasion, a gynecologic patient may disclose to you that her child has "come out." This issue may profoundly affect her health. It may, for example, contribute to a depressive episode as she adjusts to the unexpected. It is important to realize that coming to terms with a gay or lesbian child as a parent can be a difficult process in itself. You may want to refer such patients to PFLAG (Parents, Families, and Friends of Lesbians and Gays). Local parent support groups are often available; so is information for parents who are just learning about their child's sexual identity. Talking about these issues in a nonjudgmental way can have a positive influence on your patient's own journey in accepting her child's sexual orientation.

Meeting the patient's obstetrical needs

Fifty percent of lesbians plan to become parents, whether biologically, by adoption, step parenting, co-parenting, or parenting children from a previous heterosexual union. Many studies now show that children raised in lesbian households are no different from children raised in heterosexual households in terms of emotional functioning, sexual preference, stigmatization, gender role behavior, behavioral adjustment, gender identity, and cognitive functioning.¹⁶ The American Academy of Pediatrics' Task Force supports second parent adoption for those children being raised by same-sex parents.¹⁷ Refer lesbian patients planning to parent to an attorney who specializes in alternative families, keeping in mind that laws differ from state to state.

Just as you might ask a heterosexual patient, ask a lesbian patient at her annual exams—especially as she approaches age 30—if she's planning to become a biologic parent. This affords you the opportunity to give her information about fertility rates, birth defects, etc., all of which are affected as a woman grows older.

Infertility should probably be defined differently for lesbians. Lesbians who plan to become biological parents often choose donor insemination as the method of conception, although some use intercourse. The donor can be either a friend of the lesbian/couple, or an unknown sperm bank donor. (Some sperm banks have an option that the conceived child can contact the sperm donor at age 18.) Either the sperm bank or the donor's own doctor should screen the donor for STDs, blood type, etc. Of course, your lesbian patient should be taking daily prenatal vitamins or 1 mg of folic acid every day 3 months before conceiving to decrease the risk of birth defects.

Intrauterine inseminations are more effective than intracervical inseminations in lesbians.¹⁸ The definition of infertility for lesbians who are undergoing well-timed inseminations should probably be 6 months, rather than the routine definition of 12 months for heterosexual couples. Use a low threshold for referral to a fertility practice for lesbian patients, as many are older than a comparable heterosexual population when attempting conception.

Most infertility practices now accept lesbian patients.¹⁹ Occasionally lesbians opt for "co-maternity," in which the egg of one partner is aspirated, then mixed in the lab with sperm, and the embryo is then placed into the uterus of the other partner. In this way, both members of the couple participate in the pregnancy. However, for most lesbians, this is not a realistic option because it's costly.

Studies reveal psychosocial issues. Despite the dearth of studies on pregnant lesbians, two investigators in the United Kingdom and US have identified psychosocial issues that concern pregnant lesbian patients and their partners.^20,21 Most pregnant lesbians would like their health practitioners to acknowledge that they are not the only lesbians in the world having a baby and to actually use the word "lesbian." Pregnant lesbians would also like to have as much continuity of care from one provider as is realistic, because it's difficult to continually "come out" to different providers. Furthermore, they ask that childbirth classes use inclusive language (words like "partner" or "spouse" when referring to the partner of a pregnant woman, rather than automatically using the word "husband").

The most negative issue identified by both studies was a provider's frequent failure to acknowledge the presence of a pregnant lesbian's partner in the office or delivery room, resulting in the partner feeling marginalized. Although a substantial number of lesbians have home births (sometimes to avoid the perceived judgmental atmosphere of the hospital), most give birth in the hospital.

Dr. Nanette Gartrell's study of 84 lesbian-parented pregnancies found that on average, three inseminations were needed to achieve pregnancy.²¹ That study also found that 27% of patients had spontaneous abortions during their efforts to conceive, 12 months was the median time for breastfeeding, and 60% of the new lesbian mothers had sought counseling to help them cope with the stress of new motherhood.

In 75% of the 84 families, the birth mother and co-mother shared child-rearing responsibilities equally. In 88% of the families, one mother was called "Mama," while the other was called "Mommie." Overall, the parents perceived the impact of having a child as positive, and said it enhanced their relationships with their own parents. However, only 29% of the grandparents were open with their own friends about their daughter's lesbian-parented family. For 12% of the children, the sperm donor was actively involved as a father, while for another 13%, although the sperm donor was not an active "Dad," he was involved in the child's daily life. Twenty percent of the children conceived by an unknown sperm donor were given the option of meeting the donor at age 18. Most lesbians incorporated male role models into their family life. Postpartum issues for lesbian parents included sexual inactivity for a significant number of the couples, and reduced work hours for 53% of the parents.

Final words of advice

As a physician, you can have a positive impact on the lives and health of your lesbian patients by encouraging them to disclose their sexual orientation to you. Take the time to screen for substance abuse and depression.

Be aware that some lesbians plan to become biologic parents; therefore be sure those patients who are trying to become pregnant are taking prenatal vitamins or folic acid and have been appropriately tested for the rubella antibody, HIV, and so on. If a lesbian patient has not conceived after 3 to 6 months of well-timed inseminations, start an infertility work-up. Once she is pregnant, be sure to include her partner in the office visits and in labor and delivery. Advocate for inclusive language in the childbirth classes. Screen for domestic violence in your lesbian patients as well as in your heterosexual patients. Be aware of resources in your community for lesbians, and urge shelters to offer access to lesbian patients.

We can significantly improve lesbian health only if all physicians help to create nonjudgmental office environments for lesbian patients, so that access to care is secured. Ob/gyns can then deliver targeted care to lesbians—based on each patient's health risks—in a supportive and effective way.

REFERENCES

1. Solarz AL, ed. Committee on Lesbian Health Research Priorities, Neuroscience and Behavioral Health Program and Health Science Policy Program, Health Sciences Section, Institute of Medicine. Lesbian health: Current assessment and direction for the future, Washington, DC: National Academy Press; 1999.

2. 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. 2000;9:1043-1051.

3. Koh AS. Use of preventive health behaviors by lesbian, bisexual, and heterosexual women: questionnaire survey. West J Med. 2000;172:379-384.

4. Aaron DJ, Markovic N, Danielson M, et al. Behavioral risk factors for disease and preventive health practices among lesbians. Am J Pub Health. 2001;91:972-975.

5. Gruskin EP, Hart S, Gordon N, et al. Patterns of cigarette smoking and alcohol use among lesbian and bisexual women enrolled in a large health maintenance organization. Am J Public Health. 2001;91:976-979.

6. Mays VM, Cochran SS. Mental health correlates of perceived discrimination among lesbian, gay and bisexual adults in the United States. Am J Public Health. 2001;91:1869-1876.

7. Rothblum ED, Factor R. Lesbians and their sisters as a control group: demographic and mental health factors. Psychol Sci. 2001;12:63-69.

8. Hughes TL, Johnson T, Wilsnack SC. Sexual assault and alcohol abuse: a comparison of lesbians and heterosexual women. J Subst Abuse. 2001;13:515-532.

9. Corliss HL, Cochran SD, Mays VM. Reports of parental maltreatment during childhood in a United States population-based survey of homosexual, bisexual, and heterosexual adults. Child Abuse Negl. 2002;26:1165-1178.

10. Wise AJ, Bowman SL. Comparison of beginning counselors' responses to lesbian vs. heterosexual partner abuse. Violence Vict. 1997;12:127-135.

11. Herek G. Hate crimes against lesbians and gay men: Issues for research and policy. Am Psychol. 1989;44: 948-955.

12. Marrazzo JM, Koutsky LA, Kiviat NB, et al. Papanicolaou test screening and prevalence of genital human papillomavirus among women who have sex with women. Am J Public Health. 2001;91:947-952.

13. Saewyc EM, Bearinger LH, Blum RW, et al. Sexual intercourse, abuse and pregnancy among adolescent women: does sexual orientation make a difference? Fam Plann Perspect. 1999;31:127-131.

14. Marrazzo JM, Koutsky LA, Eschenbach DA, et al. Characterization of vaginal flora and bacterial vaginosis in women who have sex with women. J Infect Dis. 2002;185:1307-1313.

15. Dibble SL, Roberts SA, Robertson PA, et al. Risk factors for ovarian cancer: lesbian and heterosexual women. Oncol Nurs Forum. 2002;29:E1-E7.

16. Anderssen N, Amlie C, Ytteroy EA. Outcomes for children with lesbian or gay parents. A review of studies from 1978 to 2000. Scand J Psychol. 2002;43:335-351.

17. Perrin EC; Committee on Psychosocial Aspects of Child and Family Health. Technical report: co-parent or second-parent adoption by same-sex parents. Pediatrics. 2002;109:341-344.

18. Carroll N, Palmer JR. A comparison of intrauterine versus intracervical insemination in fertile single women. Fertil Steril. 2002;75:656-660.

19. Stern JE, Cramer CP, Garrod A, et al. Access to services at assisted reproductive technology clinics: a survey of policies and practices. Am J Obstet Gynecol. 2001;184:591-597.

20. Wilton T, Kaufmann T. Lesbian mothers' experiences of maternity care in the UK. Midwifery. 2001;17:203-211.

21. Gartrell N, Banks A, Hamilton J, et al. The national lesbian family study: interviews with mothers of toddlers. Am J Orthopsychiatry.1999;69:362-369.

Dr. Robertson is Professor, Department of Obstetrics, Gynecology, and Reproductive Sciences, and Co-Director of the Center for Lesbian Health Research at the University of California Medical Center at San Francisco, Calif.

Key points

• The health concerns surrounding lesbian patients differ significantly from those affecting heterosexual patients—in some ways. Encourage lesbian patients to disclose their sexual orientation to you. Be sure to include screening for substance abuse and depression.

• During the patient's first visit, assess her need for screening tests that may not have been done. Provide resources on STDs in lesbians and advise her that human papillomavirus can probably be transmitted from woman to woman.

• If a lesbian patient plans to become pregnant, advise her that intrauterine inseminations are more effective than intracervical inseminations in lesbians. Start an infertility workup if she has not conceived after 3 to 6 months of well-timed inseminations.

• Be aware that there's a higher unintended pregnancy rate in lesbian teens than in heterosexual female adolescents—and that young lesbians are at higher risk for suicide, substance abuse, and relationship violence.

Patricia Robertson. Offering high-quality ob/gyn care for lesbian patients.

Contemporary Ob/Gyn

Sep. 1, 2003;48:49-56.