Lesbian health inequalities: a cultural minority issue for health professionals

Many professionals within our healthcare system maintain a position that lesbian health is synonymous with women's health, secure in their belief that it is unnecessary to identify women as lesbian or bisexual within a consultation. Indeed, some well-meaning providers regard enquiry about lesbianism as overly intrusive and to be actively avoided.1 However, being part of a minority sexuality group influences patterns of health and illness and requires specific enquiry within most consultations. International population-based studies indicate a prevalence of lesbian and bisexual identity of around 1.5%, with up to 8% of women reporting homosexual desire or behaviour.2,3 A recent Australian telephone survey that included 9134 women aged between 16 and 59 years, randomly selected from all states and territories, provided a wide range of information regarding sexuality.4 While 0.8% of the women identified as gay and 1.4% as bisexual, 15.1% reported same-sex attraction or sexual experience. It is reported that 8%–11% of young people have a non-heterosexual orientation.5

Differences in health status for non-heterosexual women result from negative attitudes and experiences within society and the healthcare system, which in turn influence patterns of health-seeking behaviour, health-risk factors and specific health issues. For these reasons, sexual orientation was recognised as a social determinant of health in the US 10-year public health plan released in 2000.6 Currently, in Australia, health policy that recognises the health inequalities and specific healthcare needs of sexuality minorities is being developed at a state level.7

Discrimination against non-heterosexual women takes various forms, from overt homophobia to heterosexism. Heterosexism assumes that all people are heterosexual and incorporates mainstream attitudes that value heterosexuality more highly than other types of sexuality.6 This discrimination influences patterns of health seeking, either preventing access to healthcare or reducing openness and trust within the healthcare setting. One of the most significant health risks for non-heterosexual women is avoidance of routine healthcare.8 Repeated consumer research indicates that non-heterosexual women who present to healthcare services would prefer to disclose their sexuality, but are often silenced by the assumption that they are heterosexual.1,9 This silence compromises the development of trust and the ability to reveal complex and relevant life issues to practitioners.10

Compared with heterosexual women, non-heterosexual women access screening less frequently, delay treatment, and are less likely to have a regular general practitioner.10 For example, bisexual women in one study were less likely to have had lipid or mammogram screening than lesbian and heterosexual women.11 Lesbians are less likely to have regular Pap smears,12 despite having similar rates of cervical abnormality.13 Cervical human papilloma virus (HPV) has been reported to occur in 21% of lesbian women with no prior sexual contact with men (dispelling the common myth that lesbians are immune to HPV infection).14 In 1995, the Australian National Cervical Screening Program recognised the need to encourage lesbians to have Pap smears. In the following year, PapScreen Victoria launched its "Lesbians need pap smears too" campaign, and continues to identify lesbians as a target group.15 Despite these policies, lesbians continue to report being discouraged by medical practitioners from having Pap smears, on the grounds that they are unnecessary.16

Research into lesbian and bisexual women's health has progressed considerably over the past decade. Early studies were small, relied heavily on purposive sampling, and often involved predominantly Anglo-Saxon, well educated women, reflecting the difficulty in accessing marginalised subgroups of lesbians.17 A further limitation was the failure of population-based studies to include among the demographic questions a question on sexuality. Australia remains particularly tardy in developing research into lesbian health. Early studies in countries such as the United States and Canada did provide some insights into the specific health needs of lesbians,18 albeit with a limited evidence base. The past decade has seen both increased population-based studies, enabling comparison of sexuality minorities with heterosexuals, and an increased variety of methods (eg, network sampling and various qualitative methods) for attempting to access hard-to-reach subgroups.17 We now have a better understanding of specific risk factors and healthcare needs of non-heterosexual women in areas such as sexual health, reproductive health and parenting, mental health, substance use, and ageing.

Sexual health. Seventeen per cent of self-identified lesbians in the United States report having a diagnosis at some stage in their lifetime of sexually transmitted infection (STI), the same percentage as that reported for population-based representative samples of women.19 While transmission is partly related to previous or current sexual contact with men (78% had had at least one previous male sexual partner19), STI rates also increase linearly with the number of lifetime female sexual partners. These data contradict the common assumption of low STI risk with female sexual partners, clearly pointing to the need for improved advice regarding "safe sex". Conversely, one comparative study suggested that lesbians were more likely than heterosexual women to practise safe sex.11

Reproductive health. Reproductive healthcare needs of lesbians are highly specific, with a majority electing to achieve pregnancy via self-insemination with a known donor's semen or via clinic-based donor insemination.20 These women require a practitioner who is knowledgeable about appropriate donor-insemination clinics for referral and can provide information, for those using self-insemination, about optimal donor screening, ovulation monitoring and safety during the period of insemination. Australian lesbians wanting to form a family report their key challenges as a lack of access to clinic-based donor insemination in some states, and a lack of social and legal recognition of their family structure and of the non-biological mother as a parent.20 Twenty-seven per cent of Australian lesbian and gay parents report negative experiences with their children's healthcare that relate back to their own sexuality.21 The American Academy of Pediatrics supports coparent adoption by same-sex parents and advocates that paediatricians be knowledgeable about gay and lesbian families.22

Mental health. A higher rate of mental illness among lesbian and bisexual women than women in the general population is one of the most concerning health inequalities. Lesbian and bisexual women report rates of depression, anxiety disorders and suicidal ideation that are two to three times higher than women in the general population.23,24 Although studies usually do not distinguish between lesbian and bisexual women, there is some evidence from an Australian community sample that bisexual people have an even higher prevalence of mental health problems than lesbian and gay people.25 These mental health inequalities are thought to relate to high levels of stress due to homophobia, higher rates of abuse and experiences of victimisation, and lack of social support, rather than to sexuality per se.26 Improved research methods have uncovered an increased risk of "stress-sensitive disorders" attributable to the effects of homophobia.27 Comparison with heterosexual people shows that lesbian and gay people with mental illness have suffered significantly more day-to-day and lifetime discrimination, almost half of which they directly relate to their sexuality.28 Same-sex-attracted young people are also found to have higher rates of depression, drug use and homelessness than the general population of young people.5 This in part relates to the fact that, unlike other cultural minorities, same-sex-attracted young people cannot necessarily rely on support and protection from their family of origin. Conversely, active participation in community support groups and other forms of support improves mental health status.

Substance use. Higher levels of substance use compared with the general population are reported among gay and lesbian people.19,29 Predisposing factors in substance use include increased risk-taking behaviours, higher levels of depression, and a social subculture that incorporates substance use.2 Early studies indicated that lesbians were more likely to drink excessive quantities of alcohol, but the studies tended to be based on convenience samples of lesbians attending bars and other venues.30 The evidence is contradictory, with a New Zealand study indicating low levels of alcohol intake among lesbians31 and a large population study in the United States showing high levels.12 Illicit drug use is consistently reported as higher among lesbians than other women, although the health affects of this use are still not clear.12 An Australian population-based study has shown higher use of all substances, both licit and illicit, among non-heterosexual women.32

Access to sensitive healthcare services. In a Victorian study of gay and lesbian health issues, access to sensitive healthcare services was the most frequently mentioned issue.7 Lesbians have reported low satisfaction with health services because of negative provider attitudes and a lack of cultural understanding of the context in which their health is shaped.10 For example, one of the major issues for ageing lesbians is prejudicial attitudes in aged-care institutions, highlighting the need to train providers and agencies in this area.33 Further issues for ageing lesbians include a lack of recognition of female partners as next of kin, and difficulty accessing superannuation and health insurance benefits as a same-sex couple.

The development of "cultural competence" in lesbian issues includes understanding the reasons lesbians might be reluctant to seek healthcare, the impact of homophobia on physical and mental health, and an awareness of the range of specific health risks and problems experienced by lesbians and bisexual women.10 Lesbian and bisexual women prefer their healthcare provider to be "gay positive" — that is, open-minded, knowledgeable about their healthcare needs, and able to encourage safe disclosure of sexuality.34 Specific guidelines to assist healthcare providers in developing such competence are provided in the Box.

The Australian Medical Association has recently launched a position statement on sexual orientation and gender diversity.37 This gives recommendations for practitioners on providing sensitive individual healthcare and also suggests that doctors have a role in promoting acceptance of sexuality and gender diversity and advancing medical education, research and health policy that addresses sexuality. In responding to the needs of lesbian and bisexual women within individual consultations and at a broader level, healthcare providers can shape a more culturally responsive healthcare system.