Lesbian Health Current Assessment and Directions for the Future (1999) / Chapter Skim
Currently Skimming:
2 Lesbian Health Status and Health Risks
2 Lesbian Health Status and Health Risks
Pages 35-96
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From page 35... ...
The second framework takes a developmental approach to examining the unique factors that affect lesbian health across the life span. The final framework examines specific physical and mental health concerns for lesbians, and reviews the risk and protective factors that have an impact on their risk for these problems.
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From page 36... ...
For example, in a multisite longitudinal study of cardiovascular risk factors in black and white adults ages 25 to 37 years, 33% of the black women and 56% of the white women who reported having had at least one same-sex sexual partner reported experience with discrimination on the basis of sexual orientation (Krieger and Sidney, 1997~. Eighty-five percent of the black women further reported discrimination based on race.
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From page 37... ...
structural barriers (e.g., availability of services, organizational configuration of health care providers)
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From page 40... ...
Although data are not yet available to determine the impact of managed care on the quality of health care for lesbians, the committee believes that negative consequences are possible for the following reasons: · Limits placed on the behavior of providers by managed care organizations may introduce barriers to the effective care of lesbians. For example, pressure to keep visits short may compromise building of trust between a provider and a lesbian patient, making it less likely that the patient will disclose her sexual orientation.
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From page 41... ...
In the MLHS, 9% of the respondents reported that health care workers had not allowed their female partners to stay with them during treatment or see them in a treatment facility; 9% also said that providers had not included their partner in discussion about the respondent's treatment (Bybee and Roeder, 1990~. Financial Barriers to Health Care for Lesbians Since insurance coverage is the primary gateway to health care in this country, lesbians are at a distinct disadvantage relative to married heterosexual women because of the common prohibition against spousal benefits for unmarried partners (Denenberg, 1995; Stevens, 1995~.
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From page 42... ...
Lesbians without insurance were significantly more likely to report heart disease, to have Pap tests less often or never, to smoke, to have eating disorders (either overeating or undereating) , and to be victims of physical and sexual abuse and antigay violence (Bradford et al., 1994a)
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From page 43... ...
However, various studies of health care provider experience with and attitudes toward lesbians suggest that few physicians are knowledgeable about or sensitive to lesbian health risks or health care needs (White and Dull, 1997~. Twenty percent of the women responding to the MLHS reported having encounters with health care providers who did not know anything about lesbians )
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From page 44... ...
This discrimination and prejudice can take many forms, including reluctance or refusal to treat, negative comments during treatment, or rough handling during examination (Smith et al., 1985~. It should be noted that a number of provider professional associations have developed statements regarding the care of people of all sexual orientations and have task forces, committees, or other initiatives in place to increase the visibility of lesbian and gay health concerns to their members and to the general public.4 Fear of Coming Out to Health Providers.
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From page 45... ...
to the MLHS reported feeling that they could not disclose their sexual orientation to a health care provider. A much lower proportion of the respondents (16%)
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From page 46... ...
Additional information is presented on what is known about risk factors for various health problems among lesbians in the discussion of specific health concerns for lesbians later in this chapter. FRAMEWORK 2: A DEVELOPMENTAL PERSPECTIVE ON LESBIAN HEALTH: This section provides a brief overview of some of the developmental challenges for lesbians that can affect health across the life span.
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From page 47... ...
10.410.113.2 HIV infection (042 - 044) 5.22.524.0 Chronic liver disease and cirrhosis (571)
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From page 48... ...
Coming Out Acknowledging a lesbian sexual orientation (i.e., coming out) has both internal and external dimensions that lesbians do not negotiate in a consistent manner.
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From page 49... ...
A1though hiding one's sexual identity or attempting to pass as heterosexual may protect adolescent lesbians from discrimination and abuse, it is also associated with increased stress, negative health and mental health outcomes, and high-risk behaviors such as substance abuse and heterosexual sexual activity, which can lead to unintended pregnancies and sexually transmitted disease (Perrin, 1996~. Many lesbians thus find ways to come out to themselves and to other members of the lesbian and gay community while maintaining secrecy within their families of origin, at work, or in other areas of their lives.
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From page 50... ...
Additional study is needed to better understand the processes of development involved in the acquisition and consolidation of lesbian sexual orientation and identity. Little is known about how sexual identity develops or how the development of a homosexual sexual orientation differs between men and women.
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. It has been suggested that distress related to having a homosexual sexual orientation may lead to increased risk of attempted suicide by gay and lesbian adolescents (Fontaine and Hammond, 1996; Proctor and Groze, 1994~.
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In a study of Minnesota adolescents in grades 7 through 12, which used a population-based sample, bisexual or homosexual sexual orientation was not found to be associated with increased suicide risk in girls although it was in boys (Remafedi et al., 1998~. An oft-cited reference for this supposition is a background essay included in the 1989 report of the Depart ment of Health and Human Services (DHHS)
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From page 53... ...
Little is known about specific physical and mental health concerns of lesbians as they age, particularly about lesbians of color, working-class and poor lesbians, and lesbians who are not connected to an organized lesbian community. Problems typically associated with old age may be exacerbated by poor access to health care, a problem that follows lesbians across the life span.
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From page 54... ...
Nonetheless, the evidence to date is consistent. FRAMEWORK 3: A LOOK AT SPECIFIC HEALTH CONCERNS FOR LESBIANS Lesbians may be at higher or lower risk of certain health problems relative to heterosexual women or women in general.
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From page 55... ...
Data from the WHI indicate significant differences in cigarette smoking status depending on sexual orientation. Approximately twice as many lesbians were reported to be heavy smokers compared to heterosexual women (6.~% of lifetime lesbians and 7.4% of mature lesbians versus 3.5% of heterosexual women)
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to look at relationships between lesbian sexual orientation and parenthood. Women who reported having a lesbian sexual identity were least likely to have children (30%)
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From page 58... ...
Childhood sexual abuse has been associated with a variety of negative outcomes, including alcohol use and mental disorders such as depression (IOM, 1994~. Most studies of lesbians indicate that their experiences of childhood sexual abuse are about the same as those of heterosexual women.
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From page 59... ...
Unique Risk Factors for Lesbian Health The unique effects of health-related risk factors on lesbian health as well as risk factors that may be unique to lesbians have been largely unexplored. There is little information about the social norms of lesbian communities and how these norms might have an impact on health risk.
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From page 61... ...
To assess the role of racial discrimination in explaining disparities in elevated blood pressure, a common reaction of people who 9A very notable and important exception to the lack of research in this area is a recent study by Krieger and Sidney (1997) , which examined associations between self-reported experiences of discrimination based on sexual orientation among black and white women and men participating in a longitudinal multisite study of cardiovascular risk factors.
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From page 62... ...
iOData were collected as part of the Coronary Artery Risk Development in Young Adults (CARDIA) study, which was a multisite community-based study designed to investigate the evolution of cardiovascular risk factors (Krieger and Sidney, 1996)
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From page 63... ...
In reviewing information about the health concerns of lesbians it is important to keep in mind the factors that have been presented thus far; that is, the risk for particular health problems must be considered in the larger contexts of women's health, the health care system, and society. Particular health problems become more salient at different points along the developmental pathway, and there are both risk and protective factors that affect health.
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From page 64... ...
There are several reasons for studying cancer among lesbians. For example, compared to heterosexual women, lesbians may have differences in risk factors, differences in prevalence of risk factors for each of the cancers, and differences in the way that health care is received (e.g., how iiThis section is based largely on the workshop presentation by Dr.
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From page 65... ...
Whether or not lesbians are at higher risk of breast cancer than heterosexual women, there is a common perception in the lesbian community that they are. In a controlled clinical trial of breast cancer risk, when lifetime risk of breast cancer was calculated for a sample of lesbians and for a general sample of women, women in the general sample were found to have a 13% mean risk of breast cancer by age 80 whereas women in the lesbian sample were found to have an 11% mean risk (Bowen et al., 1997~.
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From page 66... ...
Cervical cancer risk in women in general is highly associated with sexual behavior (e.g., multiple male sexual partners or partners who have had multiple sex partners, early age at first intercourse, unprotected sex) and with the presence of certain genotypes of human papillomavirus (HPV)
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From page 67... ...
A randomized controlled trial of counseling for breast cancer risk, however, which included more economically disadvantaged women, found that lesbians were less likely than women in general to get a Pap test at least once a year (Bowen et al., 1997~. In another community study, the mean interval between routine Pap smears was longer for lesbians than for age-matched heterosexual women attending the same clinic (21 months versus 8 months, Marrazzo et al., 1996a)
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From page 68... ...
There are no population-based data on cardiovascular disease among lesbians or on the factors that increase their risk for cardiovascular disease. There is some evidence that lesbians may have higher rates of smoking and higher BMI, two risk factors for cardiovascular disease.
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From page 69... ...
However, whether any of these issues, themes, or illnesses occur more often or differently in lesbians than in other women is not known. The reported rates of depression for lesbians responding to the NLHCS appear to be somewhat similar to those reported for heterosexual women.l5 More than half of the respondents reported thoughts of suicide 130ne review of six major psychological counseling journals published from 1978 to 1989 found that only 43 of 6,661 articles adressed gay and lesbian issues (13uhrke et al., 1992)
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From page 70... ...
Research is also needed to examine the experiences that lesbians have in mental health care settings and the effectiveness of various therapeutic approaches with lesbians. Sexually Transmitted Diseases Among Leshians76 The high levels of sexually transmitted diseases (STDs)
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From page 71... ...
.~7 However, these studies evaluated small numbers of women and did not employ newer diagnostic tests including amplified DNA probes and serologic techniques, particularly for viral STDs. They also did not provide complete information on sexual behaviors.
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From page 72... ...
Acquisition of chronic STDs from male partners thus presumably occurs with the same frequency for these women as for heterosexual women. Because viral infections such as herpes and HPV can result from previous exposure unrelated to current sexual activity, it is particularly important to consider the sex of past sexual partners.
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From page 73... ...
All subjects with BV reported receptive oral sex and mutual digital-vaginal sex. There are no specific data about the prevalence of STDs in lesbian teenagers.
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From page 74... ...
Raiteri et al., 1994b HIV seroprevalence, behavioral risks, and attitude toward HIV infection among selfidentified lesbians in Turin, Italy (`n= 181) 74 General health and HIV risk of lesbians across the state of Michigan (`n= 1,681)
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From page 75... ...
Most studies, however, suggest higher HIV seroprevalence among WSW compared to exclusively heterosexual women (Bevier et al., 1995; Cheng et al., 1997; Cohen et al., 1993; Ehrhardt et al., 1995; Harris et al., 1993; lose et al., 1993; Mays et al., 1996; Ross et al., 1992; Weiss, 1993; Williams et al., 1996; Young et al., 1992)
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From page 76... ...
Also, a study of injection drug-using women in drug treatment in King County, Washington, reported that women who identified as lesbian or bisexual had 8% HIV seroprevalence rates compared to 1.5% among heterosexual women (Harris et al., 1993~. Several other studies corroborate the findings that WSW, specifically behaviorally bisexual and drug-injecting WSW, seem to have higher HIV seroprevalence rates than exclusively heterosexual women (Cheng et al., 1997; Cohen et al., 1993; Ehrhardt et al., 1995; lose et al., 1993; Ross et al., 1992; Weiss, 1993; Williams et al., 1996; Young et al., 1992~.
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From page 77... ...
that those WSW engage in behaviors that increase HIV risk (Kalichman and Rompa, 1995~; substance abuse (Solomon et al., 1996~; sexual identity confusion (Gomez et al., 1996~; or childhood sexual abuse (Widom and Kuhns, 1996~. Other explanations are more closely linked to the fact that some WSW may be more likely to have sex or share needles with men who have sex with men or to be part of other social networks with high HIV seroprevalence rates (Deren et al., 1996; Turner et al., 1998~.
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From page 78... ...
Other research on heterosexual behaviors in lesbians has reported that as many as 21% of subjects reported anal intercourse during sexual activity with a man (Bell and Weinberg, 1978~. These patterns of heterosexual behavior may put WSW at increased risk for HIV infection.
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From page 79... ...
Understanding the relationship of self-defined sexual identity, sexual behaviors, and risk of HIV infection is critical for all populations of WSW. Substance Use Among Lesbians In the 1996 National Household Survey on Drug Abuse (SAMHSA, 1997)
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From page 80... ...
· A greater percentage of lesbians than heterosexual women describe themselves as being in recovery from alcohol abuse or alcoholism.
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From page 81... ...
Although increasing numbers of lesbians are having children and many are in long-term committed relationships, lesbians are still less likely than heterosexual women to have children and to engage in other social and family roles that serve to limit drinking among heterosexual women. In addition, although this too is changing, there are fewer social norms against drinking in some lesbian communities and lesbians in general are likely less constrained by traditional gender role norms for women that serve to limit drinking.
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From page 82... ...
Research questions about WSW were not the primary purpose of these drug use studies and drug-using women were recruited without regard to sexual orientation. Although data from these studies do not tell us what percentage of WSW are also IDUs, they are useful for establishing the fact that injection drug use is a problem that exists for these women just as it exists to some degree for women in general.
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From page 83... ...
However, reported figures vary widely, in part because studies have sampled different populations and in part because they have used different measures to assess sexual orientation. For example, in a study of 6,667 women injection drug users participating in a multisite national study of IDUs and crack users, 12.5% reported that they identified as lesbian or bisexual or indicated that they had engaged in same-sex behavior during the past 30 days (Deren et al., 1996~.
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From page 84... ...
SUGGESTED AREAS FOR RESEARCH The committee believes that the following dimensions should be considered when determining the priority of lesbian health research areas: burden of disease, public health risk, theoretical underpinnings, and presence of conflicting findings in areas with significant clinical consequences. The committee concludes that there are significant gaps in what is known about lesbian health with respect to numerous health conditions, including possible risk and protective factors.
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Lesbian Health Status and Health Risks 85
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From page 87... ...
1995. Bacterial vaginosis in lesbians: A sexually transmitted disease.
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1995. Women at a sexually transmitted disease clinic who reported same-sex contact: Their HIV seroprevalence and risk behaviors.
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From page 89... ...
1996. Prevalence of HIV-related self-reported sexual behaviors, sexually transmitted diseases, and problems with drugs and alcohol in 3 large surveys of lesbian and bisexual women: A look into a segment of the community.
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From page 90... ...
1996. Sexual identity versus sexual behavior: Implications for HIV prevention strategies for women who have sex with women.
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From page 91... ...
1993. Risk factors for HIV infection among injection drug users: Results of blinded surveys in drug treatment centers, King County, Washington 1988-1991.
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From page 92... ...
1996a. Epidemiology of sexually transmitted diseases and cervical neoplasia in lesbian and bisexual women.
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From page 93... ...
1996. Perceptions of cervical cancer and Pap smear screening behavior by women's sexual orientation.
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1992. Differences across sexual orientation on HIV risk behaviors in injection drug users.
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1996. HIV testing behaviors in a population of inner-city women at high risk for HIV infection.
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From page 96... ...
1992. Assessing the risk in the absence of information: HIV risk among women injection drug users who have sex with women.
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