Address health needs of lesbians, bisexual women
As a clinician, you may be comfortable with providing care to lesbians and bisexual women. But does your office environment and the forms used in your practice reflect your open approach?
Take a moment to look at your front waiting room. If there’s no printed statement that your office appreciates the diversity of women and does not discriminate on the basis of race, age, religion, ability, marital status, or sexual orientation, and your intake forms offer no listing for "domestic partner" or "significant other," then those female patients who have sex with women may not get the message that they are welcome in your care.
Displaying such a sign and using forms that recognize domestic partnerships or significant others give an important message to patients, says Katherine O’Hanlan, MD, attending gynecologic oncologist at Stanford Medical Center and partner in Gynecologic Oncology Associates of Portola Valley, CA. O’Hanlan led a clinical seminar on lesbian health at the May 2002 annual meeting of the Washington, DC-based American College of Obstetricians and Gynecologists.
"No. 1, it tells the 97% of women that your office would respect and has a place for the lesbian and bisexual and transgender patient, but no. 2, it tells that 3% of women who are lesbian, bisexual, or transgender that you welcome them," she says.
About 75% of doctors polled in a 2001 national survey say they would be very comfortable treating an openly gay or lesbian patient, and 19% say they would be somewhat comfortable.1 One in 20 physicians (5%) say they would be somewhat uncomfortable treating an openly gay or lesbian patient, and 1% say they would be very uncomfortable.
If clinicians are comfortable with providing care to lesbian, bisexual, and transgender patients, they need to do a little extra to reverse the negative and false messages that their patients get from society so that the patients will feel comfortable in the office, says O’Hanlan.
"When the patient feels comfortable, you’re going to get a better history, you’re going to have a better clinician/patient relationship, and you’re going to have more successful outcomes in your medical and surgical care, because you’ll have a higher quality of relationship with your patient," she states.
Some shun care
Many lesbians delay seeking health care because they feel alienated by providers, says Ellen Kahn, director of the lesbian services program at the Whitman-Walker Clinic in Washing-ton, DC. A needs assessment survey conducted by the program found that even though 87% of survey respondents had health insurance, many delayed seeking health care for reasons that included "homophobia, whether real or perceived, on the part of the health care providers."2
This avoidance of health care may have important medical implications, since an analysis of data from several lesbian health surveys shows that lesbians and bisexual women in the United States have above-average prevalence rates of several risk factors for breast and gynecologic cancers.3 In comparison with adjusted estimates for U.S. women, lesbians/bisexual women exhibited greater prevalence rates of obesity, alcohol use, and tobacco use and lower rates of parity and birth control pill use, the findings indicate. These women also were less likely to have health insurance coverage or to have had a recent pelvic examination or mammogram.
Some programs, such as the Whitman-Walker Clinic, are reaching out to the community with targeted information on special areas of care, such as breast health. The Washington clinic’s Breast Health Initiative provides breast examinations, mammograms, and information on breast cancer to lesbians and bisexual women throughout the Washington, DC, metropolitan area, and sponsors "Breast Health Days" when women can receive clinical breast exams and mammograms regardless of their ability to pay.
Be sure to dispel the misconception that lesbians and bisexual women have little or no risk for sexually transmitted diseases (STDs). This myth is fueled by the lack of reliable studies of STD transmission in these communities, according to information provided at www.lesbianstd.com, an informational web site maintained by Jeanne Marrazzo, MD, MPH, an assistant professor of medicine, and other researchers at the University of Washington in Seattle.
Human papillomavirus can be sexually transmitted between women.4 The prevalence of bacterial vaginosis among lesbians has been reported to be 18%-36%.5 Several studies indicate that HIV-related risk behavior is not uncommon among some lesbians, particularly those seen at STD clinics and who report concurrent sex with men.4
Clinicians should assume that lesbians and bisexual women have the same risks for STDs as do heterosexual women, says O’Hanlan. Many lesbians and bisexual women have had intercourse with a male partner5; clinicians should approach screening for each woman on an individual basis without any assumptions, she notes.
References
1. Kaiser Family Foundation. National Survey of Physicians. Part I: Doctors on Disparities in Medical Care. March 2002. Accessed at: www.kff.org/content/2002/20020321a/Physician_SurveyPartI_disparities.pdf.
2. Lesbians, bisexual women have special OB/GYN needs. ACOG Today 2002, 4:11.
3. 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 2001; 91:591-597.
4. Marrazzo JM. Sexually transmitted infections and gynecologic health in lesbians: Research update. Presented at the 2002 National STD Prevention Conference. San Diego; March 2002.
5. Institute of Medicine. Solarz AL, ed. Lesbian Health: Current Assessment and Directions for the Future. Washington, DC: National Academy Press; 1999.
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