Addressing the Lifetime Healthcare Needs of Lesbian Patients

Feature |
August 24, 2017

Addressing the Lifetime Healthcare Needs of Lesbian Patients

  1. Jordan E. Rullo, Phd, ABPP and
  2. Stephanie S. Faubion, MD, FACP, NCMP, IF

Creating an inclusive, nonjudgmental healthcare environment can improve patient-centered care for lesbian women.

  1. Jordan E. Rullo, Phd, ABPP and
  2. Stephanie S. Faubion, MD, FACP, NCMP, IF

Lesbian women have the same healthcare needs as all women; however, unlike their heterosexual counterparts, they are at higher risk for obesity, certain cancers, substance use or abuse, and depression. Also, issues relevant to all women (e.g., intimate partner violence [IPV], sexually transmitted infections [STIs]) may affect lesbian women differently. These health disparities are perpetuated by social stigma and discrimination, which inhibit access to healthcare.

Lesbian Identity

The term “lesbian” refers to a sexual identity, a label used to recognize that a woman has physical, emotional, or sexual attractions toward other women.1 This label does not provide information about sexual behaviors or romantic relationships, which are often incongruent with sexual identity. Although 2% of U.S. adult women identify as lesbian,2 >7% report same-sex sexual behaviors.3 If a patient identifies as lesbian, this is merely a starting point for a focused assessment of sexual history and practices.

Behavioral Health Considerations

Compared with heterosexual women, lesbian women are more likely to live in poverty,4 delay seeking healthcare,5 and be at higher risk for obesity, alcohol use, and tobacco use.1 These factors, in conjunction with nulliparity, place lesbian women at higher risk for breast cancer. Given that lesbian women are less likely to undergo cervical cancer screening, they are also at higher risk for this form of cancer.5 Lesbian women are more likely to report experiencing depression,1 in part due to stigma and discrimination. Further, IPV is as common in same-sex relationships as in heterosexual relationships, but may go unassessed in women in same-sex relationships.

The American Medical Association recommends IPV screening for everyone. Screening questions include:6

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

  • Do you feel safe in your current relationship?

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

Healthcare screening recommendations for lesbian women are the same as for all women.1 Age, lifestyle behaviors, and health-related practices should guide screening rather than sexual identity. However, given the health disparities unique to lesbian women, it is important to pay special attention to weight and use of alcohol and tobacco, and to conduct regular screening for depression4 and IPV.1,6

Sexual Health Considerations

Lesbian women are at risk for STIs. As many as 70% of women who identify as lesbian have engaged in penile-vaginal penetration in their lifetimes.7 Additionally, >86% of women who have sex with women use, or have used, a sexual device.8 Sharing sexual devices can increase risk for bacterial vaginosis and transmission of human papillomavirus (HPV). Like all women, lesbian women should be counseled about using a barrier (condom or dental dam) during sexual activity, not sharing sexual devices between partners or orifices, and washing sexual devices with soap and water after use.4

Sexual Identity in Adolescence

Adolescents are more likely to identify as queer, no label, or sexually fluid than to identify specifically as lesbian. Sexual identity may also change over time — even between healthcare visits.9 Although sexual minority adolescents have the same healthcare needs as their peers, they are at higher risk for depression, suicide, and substance use or abuse due to stigma and discrimination. Because of the vulnerability associated with the coming-out process, bullying and victimization by peers and other adults, and parental rejection, lesbian adolescents are at higher risk for depression and suicide than their heterosexual counterparts.1,9 Sexual minority adolescents should be screened for mental health concerns, substance use, and sexual risk-taking. Protective factors, including level of parental support and family connectedness, should also be assessed.9 Youth at high risk, including those with inadequate family support, may benefit from referral to a lesbian, gay, bisexual, transgender (LGBT)-affirming therapist or online resources (The Trevor Project) and the Trevor Lifeline (866-488-7386), a 24/7 suicide prevention hotline.

Lesbianism in Older Adulthood

Older lesbian women are more likely to struggle with obesity, have higher risk for cardiovascular disease, and are 1.3 times more likely to have a physical disability than their heterosexual counterparts. Perhaps more striking than these physical health disparities is that 26% of lesbian adults have reported that their greatest concern about aging is fear of discrimination,10 potentially leading to a delay in seeking assisted living or residential care. Additionally, older lesbian couples are less financially equipped to handle healthcare costs. Services and Advocacy for GLBT Elders (SAGE) has developed a National LGBT Housing Initiative to help older LGBT adults secure LGBT-friendly housing and residential care (information available at www.sageusa.org or 1-888-234-SAGE).

Providing Inclusive Care

Healthcare providers are in a unique position to reduce the stigma and discrimination experienced by lesbian patients by promoting an inclusive healthcare environment. This includes creating a visually welcoming space and intake questionnaires that do not assume heterosexuality. The American College of Obstetricians and Gynecologists recommends that relationship and sexual behavior status be assessed with the following questions:1

  • 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?

  • To whom are you sexually attracted — men, women, or both men and women?

Healthcare providers can model inclusivity by asking questions without judgment, minimizing reactions and facial expressions, and using gender-neutral language (e.g., “partner,” “significant other”). Resources for creating an LGBT-inclusive environment can be found online at the American Medical Association. Online education is also available through the National LGBT Health Education Center.

Conclusion

Although lesbian women are not inherently different from their heterosexual counterparts, they are at greater risk for obesity, certain cancers, substance abuse, and depression, in part because of social stigma and discrimination. Adolescence and older age are particularly vulnerable times for lesbian women. Creating an inclusive healthcare environment with nonjudgmental patient–provider interactions can improve patient-centered care for lesbian women.

Dr. Rullo is Assistant Professor, Board Certified Clinical Health Psychologist, and American Association of Sex Educators, Counselors and Therapists (AASECT) Certified Sex Therapist, Women's Health Clinic, Division of General Internal Medicine, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota.

Dr. Faubion is Director, Executive and International Medicine and Office of Women's Health and Associate Professor of Medicine, Women's Health Clinic, Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota.

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