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Institute of Medicine (US) Committee on Lesbian Health Research Priorities; Solarz AL, editor. Lesbian Health: Current Assessment and Directions for the Future. Washington (DC): National Academies Press (US); 1999.

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Lesbian Health: Current Assessment and Directions for the Future.

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2Lesbian Health Status and Health Risks

Identifying the physical and mental health problems for which lesbians are at higher risk is not a straightforward task. Although lesbians share many of the same health risks with women in general, a number of factors act to influence their health risks in unique ways.

In this chapter, several frameworks are presented for examining lesbian health and health risks in order to elucidate some of the unique influences on lesbian health. The first framework considers lesbians in the larger contexts of society, the health care system, and women in general. 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. When examined together, these various approaches provide a more complete picture of the complexity involved in looking at lesbian health.

Framework 1: Lesbian Health in the Larger Context

Lesbian Health in the Context of Society

Historically, lesbians have been the target of prejudice and discrimination, both public and private, and the stigmatization of homosexuality remains widespread in our society (APA, 1997; Perrin, 1996). Although many kinds of abuse of and discrimination against lesbians have been clearly documented, their impact on physical and mental health remains in need of study. Until 1973 the American Psychiatric Association classified homosexuality as an illness or pathological condition. Although no longer classified as an aberrant condition, negative attitudes about gays and lesbians continue to be held by many members of the public, including health and mental health care providers (Bradford et al., 1994b; Garnets et al., 1991; Rothblum, 1994; Wolfe, 1998).

Experience with discrimination or prejudice is common among lesbians. 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. Most of the women (89%) also reported having experienced gender discrimination.

Gay men and lesbians are also at risk of being targets of violence based on their sexual orientation or behavior. Antigay hate crimes accounted for 11.6% of the hate crime statistics collected by the Federal Bureau of Investigation (FBI) in 1996, making this the third largest category following racial hate crimes and crimes based on religion (FBI, 1996).1 More than half of the respondents in the National Lesbian Health Care Survey (NLHCS) reported that they had been verbally attacked because they were lesbian, and 8% said that they had been physically attacked (Bradford and Ryan, 1988). Similarly, nearly half of the women surveyed in the Michigan Lesbian Health Survey (MLHS) reported having experienced a verbal attack because of their lesbian identity, and 5% reported having been physically attacked (Bybee and Roeder, 1990).

Numerous states have in place laws that negatively target gay men and lesbians (NGLTF, 1998; see also Table 2.1). Although some states have laws that ban discrimination on the basis of sexual orientation in employment, housing, credit, and public accommodation, many do not. Passage of such laws remains controversial. For example, in Maine where such legislation passed in 1997, voters subsequently voted to overturn the law (NGLTF, 1998). In some states, laws are in place to prohibit state and county employees from receiving domestic partner benefits. Same-sex marriage is specifically banned in 25 states and is not legal in any state. Efforts are also underway in some states to prevent same-sex couples from adopting children or serving as foster parents. Finally, numerous states ban same-sex sodomy specifically or along with opposite-sex sodomy.

TABLE 2.1. Summary of Legal Status of Lesbians and Gay Men in the United States as of May 1998 .

TABLE 2.1

Summary of Legal Status of Lesbians and Gay Men in the United States as of May 1998 .

We still have many people in many states who can be persecuted by laws, can be put out of work, and even if we have the gold standard (randomized, controlled clinical trials), they are not going to come to our studies because they do not want to be stigmatized any more than they already are.

Donna Knustson, Public Workshop, October 6-7, 1997

Washington, D.C.

Lesbian Health in the Context of the Health Care System2

Lesbian health and risks to health can be examined in the context of the health care system. In other words, are there aspects of the health care system that act to reduce lesbian's access to services, thereby possibly increasing their risk of health problems? Access to health care has been defined as the timely use of personal health services to achieve the best possible health outcomes (IOM, 1993). The three primary types of barriers are (1) structural barriers (e.g., availability of services, organizational configuration of health care providers); (2) financial barriers (e.g., insurance coverage); and (3) personal and cultural barriers (e.g., attitudes of patients and providers) (IOM, 1993). The test of equal access involves determining whether there are systematic differences in use and outcome among groups in society and whether these differences are the result of barriers to care. The committee finds that there is evidence that lesbians may face particular challenges in all three areas.

Structural Barriers to Health Care Access for Lesbians

Structural barriers that affect health care for lesbians include potential barriers presented by managed care systems and the fact that lesbian relationships are often not afforded the same legal standing as heterosexual marriages.

Managed Care. Most Americans indicate that their first choice is to see a physician in the physician's private office. Although some lesbians report that they prefer other types of providers (e.g., naturopaths, chiropractors, nurse practitioners) and to receive care in clinics, the majority report that they receive primary care from a medical doctor (Bradford et al., 1994b; Bybee and Roeder, 1990; Moran, 1996; White and Dull, 1997). 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.
  • It is more difficult for patients to choose a lesbian-friendly medical or mental health care provider. With unrestricted access to providers, as in fee-for-service plans, lesbians have the option of seeking out lesbian or lesbian-friendly providers. Under managed care plans, however, higher levels of coverage of health care services are generally limited to providers who are part of that particular plan. This may make it very difficult for some lesbians to identify any provider who is lesbian or lesbian-friendly, given the limited number of these providers in general. Managed care plans can reduce these barriers by identifying lesbian- or gay-friendly providers in the plan, making a concerted effort to recruit lesbian- and gay-friendly providers, and instituting cultural competency training programs to enhance the ability of their providers to serve lesbians.
  • The general lack of availability of family or household health insurance coverage for members of lesbian households makes it especially difficult for these individuals to see the same providers and enjoy family-focused care and the multiple benefits this can provide. Although domestic partner benefits are now increasingly available through some employers, most lesbians still do not have the option of coverage under their partner's health insurance plan. If two partners are covered under different managed care plans they will have access to the same provider only if that provider is part of both plans. Additional information is needed to determine whether managed care has a differential impact on lesbian health care, and how managed care organizations can best accommodate the health care needs of lesbians.

Lack of Legal Recognition of Partners. Hospitals and health care providers do not always give the partner of a lesbian patient, or the co-parent of a lesbian's child, the same rights to visit and to access information as is provided to a heterosexual spouse. There is also, in some cases, a legal refusal to honor the lesbian partner of a patient as her health care proxy even when so designated by the patient. 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). Among respondents to the NLHCS, 16% stated that they did not receive health care because it was unaffordable (Bradford and Ryan, 1988). In the MLHS, 12.3% of the lesbian sample reported that they did not have health insurance, compared to a state rate of 9.7% of Michigan women in general (Bybee and Roeder, 1990).

Although most middle-aged lesbians surveyed in the NLHCS reported good to excellent health, 27% reported that they lacked health insurance. Analysis indicated that lack of insurance may be more prevalent among lesbians with particularly serious health conditions. 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).

Personal and Cultural Barriers to Health Care Access for Lesbians

Personal and cultural barriers that affect access to care for lesbians include the lack of cultural competency among health care providers, the fear of coming out to providers, and the lack of lesbian focus in preventive and other health care.

Cultural Competency of Health Care Providers. Cultural competency refers to a set of skills that allows providers to give culturally appropriate high-quality services to individuals from cultures different from the providers'. These skills include understanding the culture and values of the group, the ability to communicate in the same language, and understanding the impact of group membership on health status, behavior, and attitudes. Cultural competency typically refers to providing services to people of different racial or ethnic groups. However, it also appropriately captures the skills needed to provide services effectively to lesbians. Providers who are culturally competent with respect to lesbians would be expected to understand the reasons lesbians might be reluctant to seek medical care and the impact of homophobia on the provision of services to lesbians; to be aware of the range of health problems experienced by lesbians as well as their health care risks; to avoid making heterosexual assumptions in the gathering of medical and social health information from patients; and to be willing to involve partners of lesbian patients in discussions about their health care.

Health risks and health-seeking behaviors have been found to be strongly associated with ease of communication with the primary care provider and ease of access to care (White and Dull, 1997). 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 (Bybee and Roeder, 1990).

There is a lack of training of health care professionals in addressing the experiences and health needs specific to lesbian and gay clients, such as coming out or the lack of societal and legal recognition of relationships. A recent survey of departments of family medicine found that an average of 2.5 hours was devoted to the study of homosexuality and bisexuality across four years of medical school (Tesar and Rovi, 1998). Half (50.6%) of the 95 schools responding to the survey reported that they did not include these topics in their curricula. Diversity training in health care provider curricula can help students to recognize and overcome their biases toward clients with unfamiliar life styles, including lesbians (Black and Underwood, 1998; Robb, 1996; Robinson and Cohen, 1996).3

Gathering information about sexual behavior history is an essential component of good medical care. However, many physicians feel uncomfortable taking detailed sexual histories from their patients and may be particularly reluctant to inquire about same-sex behavior (Kripke et al., 1994; Merrill et al., 1990; Temple-Smith et al., 1996; Vollmer and Wells, 1989). The committee advocates training of providers to enhance their ability to discuss these issues without embarrassment and in a manner that does not threaten the patient or make her uncomfortable. Health care providers can be taught the importance of and techniques for unbiased sexual history taking (Turner et al., 1992). At the workshop, one of the presenters suggested that rather than asking a woman whether she is married and what birth control she uses, it is preferable to ask whether she is in a sexual relationship, whether her partner is a man or a woman, if she and her partner are monogamous, and when she last had unprotected sex with a man (Waitkevicz, 1997). It is also important that questions be developmentally appropriate in the case of adolescents.

Homophobic Attitudes of Providers. It has been suggested that negative attitudes and responses by some health care providers may lead lesbians to avoid seeking health care (Turner et al., 1992; White and Levinson, 1993). Surveys indicate that like members of society at large, medical faculty have widely divergent views regarding homosexuality (Black and Underwood, 1998). Thus, it is not surprising that discrimination and prejudice against lesbians by both physical and mental health care providers have been reported (Denenberg, 1995; Roberts and Sorensen, 1995). 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. In order to provide high-quality primary care it is important to know a patient's sexual orientation (Geddes, 1994; White and Levinson, 1995). However, the need to disclose one's sexual orientation to a health care provider can present a special barrier to care for lesbians. Fear or embarrassment may make the lesbian patient reluctant to disclose her sexuality, possibly compromising her care (Geddes, 1994; Turner et al., 1992; White and Dull, 1997).5

Someone I will call Valerie came to me last week. She said that her gynecologist had diagnosed her with cervical condyloma and she wanted my opinion about what she should do in term of safe sex with her partner. When she asked her gynecologist this question the gynecologist said to use a condom. The gynecologist had not approacher her about her sexual preference. She said, ''I just don't feel comfortable coming out to my gynecologist."

J. Waitkevicz, Public Workshop, October 6-7, 1997

Washington, D.C.

Several studies have noted that the majority of lesbians (53 to 72%) do not disclose their sexual orientation to physicians when they seek medical care (Bybee and Roeder, 1990; Smith et al., 1985). Sixty percent of the women in the MLHS and 27% of respondents to the NLHCS reported experiences in which health care workers had assumed that they were heterosexual (Bradford and Ryan, 1988; Bybee and Roeder, 1990). Nonetheless, most of the respondents (61%) 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%) in the NLHCS said they would not feel comfortable letting their provider know they were lesbian.

Lack of Lesbian Focus in Preventive and Other Health Care. Primary care for women tends to be organized around reproductive health needs (Denenberg, 1995; Stevens, 1995; White and Dull, 1997). Public funding for women's health has centered on family planning and prenatal care, issues that are less salient for lesbians than for heterosexual women. Counseling for women about sexually transmitted disease, in addition, typically assumes sex with male partners. Furthermore, in many clinical environments the information forms or interviews that include questions about health history, educational materials, and insurance information assume that patients are heterosexually active (Lynch, 1993; Perrin, 1996; Rankow, 1995b; Stevens, 1995; White and Levinson, 1995). Women who are not sexually active with a man or who are not sexually active at all may thus be less likely to believe that health messages about routine care apply to them, may feel unwelcome in the health care setting, or may believe that their health needs will not be understood. In the MLHS, 60% reported that health care workers had assumed they were heterosexual (e.g., providing them with birth control supplies), and 46% reported experiences in which providers assumed they lived in a traditional family (Bybee and Roeder, 1990).

Lesbian Health in the Context of Women's Health in General

Lesbians are first of all women and thus are at risk for the same kinds of health problems as other women. The question is whether they are at the same level of risk or whether their risk is increased or decreased. Any differences in risk might be attributed to a wide range of factors: differences in health behaviors (e.g., cigarette smoking, alcohol use), differences in the stresses to which they are exposed (e.g., homophobia), or differences in the way they interact with the health care system. The major causes of death for women in general are listed in Table 2.2. This provides a backdrop for understanding the subsequent discussion of specific health concerns and the possible factors that influence a lesbian woman's risk for these problems.

TABLE 2.2. Leading Causes of Death and Age-Adjusted Death Rates (per 100,000) for Women, United States, 1995 .

TABLE 2.2

Leading Causes of Death and Age-Adjusted Death Rates (per 100,000) for Women, United States, 1995 .

For women in general, the leading cause of death is major cardiovascular disease including ischemic heart disease, cerebrovascular diseases, and atherosclerosis, followed by malignant neoplasms (cancer). Lung cancer is the most frequent cause of cancer death for women, followed by breast cancer (see Tables 2.2 and 2.3).

TABLE 2.3. Cancer Incidence and Number of Deaths by Selected Sites for Women, United States, 1997 .

TABLE 2.3

Cancer Incidence and Number of Deaths by Selected Sites for Women, United States, 1997 .

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 Health6

This section provides a brief overview of some of the developmental challenges for lesbians that can affect health across the life span. Like all women, lesbians face developmental challenges as they grow from childhood through adolescence to adulthood and old age. In addition, lesbians may encounter special challenges associated with their sexual orientation, such as adverse societal attitudes, family rejection, and internalized homophobia. These special challenges can exist over the life span and depend to a considerable extent on how individual lesbians react to and manage their difference. Addressed separately is the issue of coming out, a critical stage in lesbian development that can occur during adolescence or at any time during adulthood.

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. There are several descriptive models of the stages many lesbians go through during the coming-out process. One such model, proposed by Troiden, describes coming out as entailing four dimensions (Perrin, 1996; Ryan and Futterman, 1997; Sullivan, 1994; Troiden, 1988, 1989):

  1. Sensitization—feel different from same-sex peers, typically before puberty;
  2. Identity confusion—begin to personalize homosexuality, experience same-sex arousal and/or sexual activity, and feel inner turmoil and confusion in confronting the implications of having a homosexual identity;
  3. Identity assumption—recognize homosexual identity, accept one's involvement in same-sex contacts and activities, and explore homosexual subculture; and
  4. Commitment—accept homosexual identity and disclose it to others, experience same-sex intimacy, and are involved in the homosexual community.

It has been suggested that the age at which individuals come out to themselves and to others is falling (Savin-Williams and Rodriguez, 1993). Greater visibility and acceptance of homosexuality in our society may make it possible for young people to recognize and understand their feelings of same-sex attraction more readily, although additional empirical information is needed to confirm this hypothesis.

Managing the coming-out process is one way in which lesbians protect themselves against the negative consequences of living in a homophobic society. It was reported at the workshop that coming out to oneself has been shown to be a precursor to good mental health for lesbians, being associated with increased self-esteem, better psychological adjustment, greater satisfaction, and less depression or stress than experienced by lesbians or gay men who are at conflict with their identity (Savin-Williams and Rodriguez, 1993). However, coming out to others may also have negative consequences, such as being the target of discrimination or violence or experiencing rejection or physical or verbal abuse by family members or peers (Fontaine and Hammond, 1996; Morrow, 1993; Perrin, 1996; Savin-Williams, 1994; Savin-Williams and Rodriguez, 1993). Although 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. More information is needed about what constitutes a psychologically healthy coming-out process. This information should include focus on lesbians from racial and ethnic minority groups, lesbians of different socioeconomic status, and lesbians living in both urban and rural areas.

Ethnic minority lesbians in addition to developing their lesbian identity face the challenge of developing an identity that reflects their racial or ethnic status. This involves developing and integrating their sexual and racial identities in the context of multiple, sometimes conflicting cultures: the dominant American culture and the culture of their racial or ethnic group (or groups) of origin. Although sometimes a source of additional conflict, ethnic minority culture can also be a source of strength and support for ethnic minority lesbians (Liu and Chan, 1996; Savin-Williams, 1996). It has been suggested that having learned to handle their ethnic minority status may better equip lesbians to also handle their status as a sexual minority (Savin-Williams, 1996).

Children and Adolescent Lesbians

Very little information is available about specific developmental issues that might emerge in childhood for lesbians. There is a larger although still limited research base on homosexuality in adolescents. Little of this work, however, has focused exclusively on lesbians. Further, systematic longitudinal studies of development and adjustment are lacking (Savin-Williams and Rodriguez, 1993; Sullivan, 1994). Finally, earlier research, particularly that which focused on pathological behavior, may be of less relevance to understanding the well-being of contemporary lesbian adolescents given the contextual changes in society that have acted to increase the visibility of homosexuality and the availability of support systems for lesbian and gay youth. Nonetheless, the evidence suggests that the following issues are particularly salient for adolescent lesbians.

Development of Sexual Identity. The basic processes involved in the development of sexual orientation remain poorly understood. Although the core feelings and attractions that may form the basis of sexual orientation often emerge by early adolescence, developmental precursors have not been clearly identified for lesbian and bisexual identities (APA, 1997). 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. However, it does appear that awareness of sexual orientation can occur at quite young ages. In a study of 194 lesbian, gay, and bisexual youth aged 21 years or younger, respondents described their first awareness of sexual orientation as occurring at about the age of 10, with about 6 years elapsing before disclosure to another person (D'Augelli and Hershberger, 1993). There is also evidence that this awareness of identity occurs similarly in heterosexuals and lesbians. A study of 358 heterosexual, bisexual, and homosexual women reported that retrospective recall of age of first sexual or romantic attraction and of self-acknowledgment of sexual orientation was very similar in heterosexual and lesbian subjects, except for the difference in object choice (Pattatucci and Hamer, 1995). Although it has been suggested that lesbian sexual orientation may result from early sexual trauma or negative heterosexual experiences, it does not appear that sexual orientation can be largely explained by these factors (Peters and Cantrell, 1991).

Struggling with the Coming-Out Process. Developing a positive sexual identity is a normal part of adolescence. However, this can be a particularly difficult process for gay and lesbian adolescents because of pervasive societal homophobia and the lack of readily identifiable role models for positive gay or lesbian identity to help them understand what it is to be gay or lesbian (e.g., parents of gay and lesbian youth are usually heterosexual) (Ryan and Futterman, 1997; White and Levinson, 1995). Extensive social and emotional isolation (e.g., from family and peers) has been described as a frequent problem for gay and lesbian adolescents (Fontaine and Hammond, 1996; Perrin, 1996). The stigma of having homosexual feelings may make it especially difficult for gay and lesbian adolescents to seek help for their adjustment difficulties (Fontaine and Hammond, 1996; Savin-Williams, 1994).

Negotiating the coming-out process may be particularly challenging for ethnic and racial minority lesbians, who must integrate their sexual identity with their racial or ethnic identity in the face of societal homophobia and racism (Greene, 1994a, b). It has also been suggested that because members of racial and ethnic minority groups have had to learn ways of coping with racism and discrimination, when these coping mechanisms are adaptive they may provide important protective resources for coping with homophobia as well (Greene, 1994a).

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). Although past research on lesbian and gay adolescents has generally reported rates of attempted suicide from 20 to 40%, usually based on retrospective interviews, these data have been criticized on methodological grounds. Studies have been limited by a lack of consensus on definitions of suicide attempt and sexual orientation, nonrepresentative samples, and lack of appropriate comparison groups (Muehrer, 1995). 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 Department of Health and Human Services (DHHS) Secretary's Task Force on Youth Suicide, which suggested that gay and lesbian youth "may comprise up to thirty percent of completed youth suicides annually" (Muehrer, 1995). However, as Muehrer (1995) points out, the essay did not actually cite any published research on completed suicides. Further, there are no nationwide or statewide data on the frequency and causes of completed suicide for gays or lesbians or for the general population. Well-designed research that uses representative samples and appropriate comparison groups and considers a range of contributory factors is needed to better understand the relationships that might exist between suicide and sexual orientation.

Adult Lesbians

Many of the developmental issues that adult lesbians face are the same as those faced by other women: entering the workforce, finding a loving partner and developing a satisfying sexual life, deciding whether to have children, being a parent, and negotiating the aging process with its attendant declines in health and, for some, the death of a life partner. Little information is available, however, about how lesbians face these challenges through adulthood or about the unique challenges they may face. For example, there is a dearth of research on the practice and meaning of sexuality for lesbians throughout their life course. There is evidence that most lesbians have been heterosexually active, and this complicates retrospective and prospective analyses.

There is now a large cohort of lesbians who have lived a decade or two as "out-of-the-closet" lesbians. Midlife issues for this group are likely to be different from previous cohorts, who were less likely to publicly identify as lesbian, and to be different from those faced by heterosexual women or men. For example, many lesbians will most likely continue to struggle with issues related to balancing family and career in ways different from married heterosexual women. 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. An additional area that has received limited attention, which is discussed in greater detail below, is lesbian motherhood. Most research has focused on the effects on children of being part of a lesbian household, rather than on lesbians' decisions to become parents or the process of becoming parents.

Lesbian Motherhood. Deciding whether or not to have children is an important and sometimes difficult issue for all women whether lesbian or heterosexual. In addition to all the usual parenting issues, lesbian parents must cope with the very real fear that they will lose their children in custody battles and other legal situations (CDC, 1997). Nonetheless, lesbians are increasingly choosing to become parents, often through donor insemination, but also through adoption and foster care (Brewaeys et al., 1995; CDC, 1997).

Research has not substantiated fears that children raised in lesbian households might grow up to be homosexual, might develop improper sex role behavior or sexual conflicts, or will have conflicts with peer groups that threaten their psychological health, self-esteem, and social relationships (Brewaeys and van Ball, 1997; Gold et al., 1994; Golombok and Tasker, 1994). There is no evidence that the development of children who have lesbian or gay parents is compromised in any significant respect relative to that of children of heterosexual parents in otherwise comparable circumstances (Golombok and Tasker, 1994; Patterson, 1992). For example, a longitudinal study of a small sample (n = 25) of young adults raised in lesbian families and those raised by heterosexual single mothers (n = 21) showed psychological well-being and evidence of comparable family identity and relationships (Tasker and Golombok, 1995). Furthermore, no differences were reported in the quality of couples' relationships or the quality of mother-child interaction between lesbian mother families and two groups of heterosexual families studied by Brewaeys et al. (1997). These researchers also reported that the quality of the interaction between the social (i.e., non-birth) mother and the child in lesbian families was superior to that between the father and the child in the two groups of heterosexual families studied.

Lesbians and other unmarried women are still sometimes refused donor insemination services.7 One argument made against providing this service is the assertion that growing up in a lesbian household will lead to psychological difficulties for the child (Brewaeys et al., 1995; Englert, 1994; Golombok and Tasker, 1994). Research has not supported this assertion. For example, no differences in emotional and behavioral adjustment are reported for 4- to 8-year-old boys and girls (n = 30) conceived by donor insemination and raised in lesbian mother families, those (n = 38) also conceived by donor insemination but raised in heterosexual families, and those (n = 30) conceived conventionally and raised in a conventional heterosexual family (Brewaeys et al., 1997). Many of these studies have used small sample sizes and hence have low power to detect small differences between groups. 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. These include cancer, hypertension, mental health concerns, sexually transmitted disease, HIV, and substance abuse. The data in these areas relating to lesbians are very limited. It must be further noted that there are few empirical studies of lesbian health that focus exclusively on racial and ethnic minority lesbians or that include a sizable proportion of these lesbians in their samples. Rather, most studies of lesbians have been based on samples that are primarily or exclusively white. Research that has focused on racial and ethnic minority women more generally has also very rarely collected information on sexual orientation (Greene and Boyd-Franklin, 1996). As a result, little is known about specific health care risks and needs of racial and ethnic minority lesbians, and significant caution must be used in generalizing the results of most lesbian health research to these populations.

Risk and Protective Factors for Lesbian Health

General Risk Factors for Health

Numerous factors have been shown to be associated with increased risk for various health problems. Table 2.4 presents general information about some of the factors that put women at higher risk of cancer. As for lesbian health research in general, information is limited on the prevalence of particular health risk factors among lesbians. The Women's Health Initiative (WHI) provides one useful source of data for looking at differences between lesbian and heterosexual women in the study in terms of certain health-related risk variables.8

TABLE 2.4. Selected Risk Factors for Cancer in Women in General .

TABLE 2.4

Selected Risk Factors for Cancer in Women in General .

Preliminary data from the WHI, along with limited data from other studies, indicate the following:

Smoking. In the 1996 National Household Survey on Drug Abuse, 26.7% of women reported use of cigarettes during the past month (SAMHSA, 1997). 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 (6.8% of lifetime lesbians and 7.4% of mature lesbians versus 3.5% of heterosexual women). Also, although almost half of the heterosexual women reported never smoking, only a third of lifetime lesbians (i.e., those whose adult lifetime partners were all women), reported never smoking, and only about a quarter (26.4%) of mature lesbians (i.e., those who reported female sexual partners only after age 50 years), reported never smoking. Reports of tobacco use by lesbians were lower in the NLHCS: 30% of the respondents reported being daily smokers, with another 11% reporting that they smoked occasionally (Bradford et al., 1994b). Current smoking levels were much lower in a more limited survey of lesbians in Oregon (11%) (White and Dull, 1997).

Overweight. Body mass index (BMI), an indication of overweight, differed significantly between lifetime lesbians and heterosexual women in the WHI, with a greater proportion of lifetime lesbians having a BMI of more than 27 (52.3% of lifetime lesbians compared to 45.8% of heterosexual women).

History of Pregnancy. Probability-based survey estimates are lacking for the proportion of lesbians who are mothers or the number of individuals who have lesbian mothers. Commonly cited estimates of 1 million to 5 million lesbian mothers can be criticized because the estimates are based on possibly incorrect estimates of the number of lesbians in the population (Patterson, 1998). Patterson (1998) recently analyzed data from the NHSLS (Laumann et al., 1994) 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%), and those reporting a heterosexual identity were most likely to have children (73%). Slightly more than half (58%) of those reporting any lesbian same-sex orientation (identity, behavior, or desire) indicated that they had biological children. Thus, although lesbians are less likely to report having biological children than are heterosexual women, there are still substantial numbers of lesbians who are parents, particularly if these figures include adoptive or other nonbiological parents. In the WHI sample, lesbians were much less likely to have ever been pregnant than were heterosexual women. These differences were particularly pronounced for lifetime lesbians of whom 34.1% had previously been pregnant, compared to 61.2% of the mature lesbians and 89.9% of the heterosexual women.

Use of Oral Contraceptives. Not surprisingly, lifetime lesbians in the WHI sample were least likely to report having used oral contraceptives between the ages of 25 and 35 (only 16.7%). Approximately one-third of heterosexual women (32.0%) had used oral contraceptives during this age period as had 42.4% of mature lesbians.

Alcohol Use Among Lesbians. Reviews of lesbian health research have consistently identified alcohol abuse as a problem for which lesbians appear to be at greater risk than are heterosexual women (Cassidy and Hughes, 1997; Eliason, 1996; Haas, 1994; O'Hanlan, 1995; Rosser, 1993). Most studies, however, have had significant methodological limitations, so caution must be used in interpreting the results. Alcohol use among lesbians is described in more detail in a later section of this chapter dealing with substance abuse.

Childhood Sexual Abuse. 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. For example, in a study of 50 lesbians admitted for substance abuse treatment in 1986-1987, Neisen and Sandall (1990) found that nearly 70% of the women reported a history of childhood sexual abuse, a rate comparable to that reported in studies of the general population of women in treatment for substance abuse (Rohsenow et al., 1988).

Like women in general, studies of lesbians who are not in treatment reveal significantly lower rates of childhood sexual abuse. Of the women surveyed in the NLHCS (Bradford et al., 1994b), 21% reported that they had been raped or attacked during childhood. Somewhat different results were obtained in a recent survey of lesbian health conducted in Chicago (Kalton, 1993). In this study, lesbians (n = 284) reported significantly higher overall rates of childhood sexual abuse (29%) than a comparison group of 134 heterosexual work colleagues (14%). However, childhood sexual abuse was not related to level of alcohol consumption or alcohol problems in either group. Finally, in a study of 523 female clients seen at a primary care health center, women who had experienced childhood sexual abuse were more likely than women who had not experienced abuse to report adult sexual experiences with women (8% versus 1%) (Lechner et al., 1993).

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. Likewise, little information is available about the risk or protective effects of lesbian relationships. One factor hypothesized to play an important role in lesbian health is stress. The possible health effects of stress for lesbians are discussed in the following section, beginning with a brief review of stress as a general risk factor for health.

The Health Impacts of Stress. Stress has been characterized as exposure to life events—either good or bad (e.g., divorce, a new job, moving to a new home, holidays, financial difficulties)—that require adaptation, or as a condition that results when an individual perceives demands as exceeding his or her ability to cope with them (Adler et al., 1994). Lesbians, like all people, experience stress as a part of everyday life. Conditions that are threatening to an individual such as physical trauma, exertion beyond one's capacity, and psychologically threatening situations activate certain physiological stress responses (see Box 2.1 for additional information about the response of the body to stress). These responses lead to adaptation and promote survival of the individual, at least in the short run (McEwen, 1998). However, such physiological responses can also have a wide range of negative impacts on health, particularly when they continue over a long term (Adler et al., 1994, McEwen, 1998).

Box Icon

Box 2.1

Physiological Response to Stress. When an organism experiences stress, the body engages in a series of physiological responses. These involuntary responses are sometimes described as ''fight or flight" responses because they prepare an organism either (more...)

Lesbians, similar to other stigmatized individuals, likely experience stress related to the difficulties of living in a homophobic society. Stress may result from the burden of keeping one's lesbian identity secret from family or coworkers, being excluded by physicians from making health care decisions for a gravely ill lesbian partner or, among many other factors, being the target of violence or other hate crimes. Hostility and isolation are very potent forms of stress that contribute to allostatic load by leading to elevated levels of the stress hormones (McEwen, 1998; Powch and Houston, 1996). Although the precise health effects of stress on lesbians have not yet been examined systematically, some hypotheses can be made about their possible health risk based on information about both the stress effects of discrimination on other groups and the stress effects of socioeconomic status.9 It can be hypothesized that lesbians who experience such forms of psychosocial stress sustain negative effects similar to those of other groups that experience discrimination.

It can also be hypothesized that stress effects may be greatest for lesbians who are subject to multiple forms of discrimination, for example, lesbians who are also members of racial or ethnic minority groups. In addition to experiencing racism encountered by members of racial and ethnic minority groups in general, minority lesbians can also encounter racism in the lesbian community (Savin-Williams, 1996). Racism may thus compound the negative effects that homophobia potentially has on health. The combination of homophobia, racism, and sex-based discrimination has been referred to as being in "triple jeopardy" (Greene, 1994b; Greene and Boyd-Franklin, 1996).

A study of depressive distress in a nationally recruited homosexually active sample of African-American men and women showed that lesbians and bisexual women in the sample exhibited higher levels of distress than gay men, except for those with HIV infection (Cochran and Mays, 1994). The authors suggest that individuals who carry multiple lower social statuses (i.e., being lesbian, being a racial or ethnic minority, and being female) may be particularly at risk for stress-induced depression.

Racial discrimination has been found to be a potent source of stress and to be associated with stress-related negative health effects (Krieger and Sidney, 1996). To assess the role of racial discrimination in explaining disparities in elevated blood pressure, a common reaction of people who experience psychosocial stress, Krieger and Sidney (1996) examined associations between blood pressure and self-reported experiences of racial discrimination and unfair treatment in a multisite, multiethnic sample.10 In this study, black individuals who reported that they internalized experiences of discrimination (e.g., accepted these as a fact of life or kept to themselves) had higher blood pressure than both white individuals and black individuals who reacted to experiences of discrimination when they occurred (e.g., did something or talked to others). The researchers concluded that racial discrimination helps to shape patterns of blood pressure among black individuals in the United States and to account for some of the differences in blood pressure observed between white individuals and black individuals.

Socioeconomic status (SES) embodies aspects of stress resulting from different living and working environments as well as economic factors and physical security. There are gradients of health that occur across the full socioeconomic spectrum, and SES, particularly income inequality, has been shown to be predictive of health status (Adler et al., 1993; Kawachi and Kennedy, 1997). These SES relationships are manifest as gradients of mortality and morbidity related to cardiovascular disease and abdominal obesity, with the poorest and least well educated having significantly poorer health and shorter life spans, on average, and the wealthiest and best-educated having significantly better health and longer life spans than those in the middle of the gradient.

Individuals of lower SES are more likely to encounter negative life events than those at higher SES levels and tend to have fewer social and psychological resources for coping with stress (Adler et al., 1994). Both factors can make these individuals more vulnerable to stress. For example, it has been demonstrated that characteristics of the social environment, in particular the presence of social relationships, influence patterns of response to stressful stimuli (Seeman and McEwen, 1996). For lesbians at lower socioeconomic levels the negative effects of stress associated with discrimination may be compounded.

Protective Factors for Lesbian Health

A variety of factors can act to protect individuals from negative outcomes, including a close relationship with a responsive and accepting parent, attachment to external support systems such as schools or churches, and having well-developed social support systems (IOM, 1994). Although research is quite limited, some factors have been suggested to be protective of lesbian health. One of the suggested protective factors is involvement in the lesbian community (White and Levinson, 1993). Although midlife lesbians responding to the NLHCS reported high levels of stress, most reported that they relied on the lesbian community and on lesbian and gay male friends for support and socialization and reported overall satisfaction with their lives (Bradford and Ryan, 1988).

Strong family ties can also have protective effects. Additional research is needed on the relationships between lesbians and members of their families and on the influences of these relationships on mental health. Rejection and disapproval from family members may be major stressors for lesbians, just as acceptance and support may be protective factors (APA, 1997).

Specific Health Concerns for Lesbians

Several potential health concerns for lesbians are discussed in this section because there is some empirical evidence to support the belief that lesbians are at higher risk for a particular problem, because there are widely held assumptions of greater risk, or because possible misconceptions about lesbians' risk for a problem have important implications for health care and health-seeking behavior. 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.

Cancer and Lesbians11

The most common form of cancer in women in the United States is breast cancer, followed by lung cancer, cancer of the colon and rectum, uterine cancer, and ovarian cancer (see Table 2.3). The order of frequency of diagnosis of particular cancers varies somewhat across racial and ethnic groups. For example, although breast cancer is the most commonly diagnosed cancer for both white and black women, the second most frequently diagnosed cancer for black women is cancer of the colon and rectum and for white women lung cancer (American Cancer Society, 1997).

Risk factors have been identified that put women at greater risk for particular cancers (see Table 2.4). For most cancers, risk increases with age or with a family history of that type of cancer. In addition, however, there are behavioral factors, such as smoking, consumption of alcohol, or sexual history, that can increase the risk of cancer. In some cases, the association between a type of cancer and a risk factor is clear and well established (e.g., the link between smoking and lung cancer), in other cases, the data are less clear.

Much attention has been paid to possible increased risk of cancer among lesbians, particularly with respect to breast cancer. The assumption of higher risk for lesbians is based primarily on data from various studies suggesting that certain cancer risk factors occur at higher levels or with greater frequency in lesbians (Turner et al., 1992; White and Levinson, 1993). These factors include higher rates of smoking, alcohol use, poor diet, greater BMI, and differential rates of hormone exposure associated with less use of oral contraceptives and the lower likelihood of bearing children (Rankow, 1995a). To date, however, there are no epidemiological studies supporting a conclusion that lesbians are at increased risk for breast or other cancers.

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 they relate to their health care provider, how the provider relates to them).

Breast Cancer. Excluding skin cancers, breast cancer is the most common cancer among women. According to the National Cancer Institute, approximately one in eight women in the United States will develop breast cancer during her lifetime with most cases occurring after the age of 50 (NCI, 1997). There is some evidence that the prevalence of certain risk factors for breast cancer may be higher among lesbians. Some studies have suggested that lesbians have higher rates of alcohol consumption and being overweight and that they are less likely to have had children than are women in general. However, it is important to state that the appropriate epidemiological research has yet to be done to determine whether lesbians are at greater risk for breast cancer. Thus, the committee concludes. that insufficient data are now available to determine whether lesbians have a higher risk for breast cancer than women in general.

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). Both groups of women, however, perceived their risk to be substantially higher, with lesbians believing that they had a 36% mean lifetime risk and women in the general sample believing they had a 50% mean lifetime risk of breast cancer (i.e., by age 80). When only women with a family history of breast cancer were included ha the sample, the perceived lifetime risk was nearly identical for lesbians and the general sample. From this and other studies it is apparent that women (both lesbian and heterosexual) tend to believe that their risk of breast cancer is much higher than it really is. These misperceptions of risk can have an impact on whether or not one gets a regular mammogram and on one's quality of life (e.g., fear of breast cancer causing increased stress).

Cervical Cancer. Cervical cancer accounts for 6% of all cancers in women and is the ninth most deadly cancer for women in the United States (American Cancer Society, 1997). 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), a common sexually transmitted infectious virus (Price et al., 1996). HPV can cause cervical warts, and some HPV types have a high association with the development of cervical cancers, although after many years of HPV infection. Changes in the cells of the cervix resulting from HPV infection, including early stages of cervical neoplasia as evidenced by squamous intraepithelial neoplasia, can be detected by the Pap test. The Pap test is the most important screening tool used to diagnose and, through subsequent treatment of epithelial abnormalities, to prevent the development of invasive cervical cancer. Early detection of cervical epithelial cell abnormalities through Pap tests has greatly reduced the number of deaths resulting from cervical cancer over the past 20 years.

The important association between female sexual behavior with men and risk of cervical cancer might seem to imply that lesbians are not at meaningful risk for cervical cancer. However, lesbians clearly remain at risk for cervical cancer, albeit probably at less risk than women in general, because the great majority of lesbians report a history of having had heterosexual intercourse (Bevier et al., 1995; Bybee and Roeder, 1990; Ferris et al., 1996; Gómez, 1994; Price et al., 1996; Skinner et al., 1996; White, 1997). Cervical neoplasia associated with HPV infection has been detected in lesbians even in the absence of prior reported sex with men (Marrazzo et al., in press;O'Hanlan and Crum, 1996; Robertson and Schachter, 1981). Genital warts have also been detected in lesbians (Marrazzo et al., in press), including women who deny having had sex with men (Edwards and Thin, 1990).

Some data suggest that lesbians may have routine Pap tests less frequently than is currently recommended (Robertson and Schachter, 1981; Stevens, 1992). For example, 23% of the respondents in the NLHCS reported that their last Pap test was more than two years ago (Bradford and Ryan, 1988), and the mean interval since their last Pap test was 34 months in a sample of 104 lesbians attending a lesbian health clinic in Washington, DC (Biddle, 1993). Evidence is mixed, however, regarding whether lesbians differ from heterosexual women in their frequency of Pap test screening. Some studies (e.g., the WHI; Price et al., 1996) have found no significant differences between heterosexuals and lesbians in Pap test screening behavior. 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). Lesbians without prior male sexual partners may also be less likely to get Pap tests. More than half (57%) of the women in that study who had never had sex with a male partner reported having two or fewer routine Pap smears in the preceding five years compared to 21% of the women with male partners during that time (p ≤ .01). Nevertheless, whether Pap test screening is indeed less frequent among lesbians, particularly those who have not had sex with men, requires further investigation. Conditions that could contribute to less frequent Pap test screening, including perception of low risk for cervical cancer or barriers to health care, need to be defined.

Other Cancers. Less information is available on other cancers among lesbians. If it is indeed true that lesbians have higher rates of smoking, then they are likely at increased risk of lung cancer. However, data are mixed on the prevalence of smoking in the lesbian population as well as on the patterns of smoking. There is some evidence that lesbians tend to have a higher BMI; if this is accompanied by a high-fat diet, they may be at greater risk for colorectal, ovarian, or endometrial cancers. Because lesbians are less likely to have had children and less likely to use oral contraceptives, they may be at increased risk for endometrial or ovarian cancers. However, because the necessary epidemiological data on these health risk factors among lesbians are not available at this point, it is not possible to determine whether lesbians are at increased risk for these cancers.

Cardiovascular Disease and Lesbians

Cardiovascular diseases—heart disease, stroke, and atherosclerosis—represent the leading cause of death for women in general. Risk factors for heart disease include cigarette smoking, high blood pressure (hypertension), high blood cholesterol, excessive weight, use of oral contraceptives, and physical inactivity (NHLBI, 1997). Although stress has been shown to be a possible risk factor for cardiovascular disease in men, this connection has not yet been demonstrated in women. Moderate consumption of alcohol (one or two drinks per day) may have some protective effects against cardiovascular disease as does the use of hormone replacement therapy for menopausal women.

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. On the other hand, lesbians are less likely to use oral contraceptives, which may lower their risk for cardiovascular disease. Based on currently available data, the committee concludes that it is not possible to determine whether lesbians are indeed at higher risk for cardiovascular disease than women in general.

Mental Health Issues for Lesbians12

The most common mental disorders experienced by women in general are anxiety disorders. Data from the National Comorbidity Survey, the first survey to administer a structured psychiatric interview to a probability sample in the United States, indicate that 30.5% of the women surveyed reported experiencing an anxiety disorder at some time in their lives (usually social phobia or simple phobia); 22.6% reported such a disorder during the past year (Kessler et al., 1994). The next most common category of mental disorders experienced by women in general is affective disorders, with depression being most commonly reported. In the National Comorbidity Survey, 23.9% of the women surveyed reported experiencing an affective disorder at some time; 14.1% reported experiencing such an episode during the past 12 months. A previous episode of major depression was reported by 21.3% of the women; 12.9% reported experiencing a major depressive episode during the past year.

Very little is known about the prevalence and incidence of depression, anxiety disorders, psychotic disorders, dissociative disorders, and personality disorders in lesbians (Rothblum, 1994; Trippet, 1994). 13 In general, studies have not found differences in the psychological adjustment of nonclinical samples of lesbians and other women (Rothblum, 1994). Although there is, in general, no reason to expect that most major mental illnesses occur more or less often in lesbians than in heterosexual women, except perhaps owing to the experience of discrimination, not enough information is available to draw definitive conclusions.

About three-quarters of all respondents in the NLHCS reported participating in counseling, indicating that they experienced or sought care for the same kinds of mental health issues experienced by women in general (Bradford et al., 1994b).14 These respondents reported depression; anxiety; relationship problems; problems with children, parents, or other family members; work-related problems; substance abuse; loneliness; losses; past or present physical or sexual abuse; other trauma; and major mental illnesses such as bipolar disorder and schizophrenia. 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.15 More than half of the respondents reported thoughts of suicide at some time, and 18% reported that they had attempted suicide. Although these numbers appear high, because there is no reliable source of information about suicide attempts by women in the general population, it is not possible to determine how such figures compare to a similar population of heterosexual women (Muehrer, 1995). The rates of physical abuse, sexual abuse, and incest do not appear to be significantly different from similar reports for all women (Bradford et al., 1994b).

Most of the more recent literature presents data on mental health issues and mental health treatment in self-identified lesbians. As with other areas of lesbian health research, research samples have primarily included self-identified lesbians who are white, middle class, in college or college-educated, urban or suburban, and young to middle aged. Little information is available regarding mental health issues for other groups of lesbians, such as racial and ethnic minority lesbians, poor or working-class lesbians, older lesbians, or lesbians living in rural areas.

Information about the access to or utilization of mental health care services by lesbian women is limited. Although high percentages of lesbians in some surveys have reported that they have used mental health services, the results are not based on probability samples (Bradford et al., 1994b). Additional research is needed to determine the generalizability of these findings. 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 Lesbians16

The high levels of sexually transmitted diseases (STDs) in the United States have been described as a hidden epidemic (IOM, 1997). In 1995, for example, nearly 384,000 women were reported to have chlamydia, nearly 189,000 to have gonorrhea, and more than 34,000 to have syphilis (CDC, 1996). STDs can have numerous negative outcomes for women, including cervical cancer, chronic pelvic pain, infertility, and ectopic pregnancy (IOM, 1997).

The risk of developing STDs depends on several factors. Women are particularly at risk in heterosexual vaginal and rectal intercourse because with penile insertion and ejaculation, the amount of bacteria or virus that is transmitted is much higher than in other kinds of sexual activity. Another important factor is the number of sexual partners. The more partners one has and the more contacts with each individual partner, the higher the risk. Many STDs are transmitted more readily from men to women than from women to men (IOM, 1997).

Although it is well known that women can acquire STDs from male sex partners, the risk of STD transmission between female partners is unclear. Guidelines for safe sex for lesbians are lacking (Denenberg, 1995; Rankow, 1995a). Attempts to use national or local surveillance data to estimate the risk of STD transmission between women are limited by the fact that many risk classification schemes have either excluded same-gender sex among women or subsumed it under a hierarchy of other behaviors viewed as higher risk (Chu et al., 1990, 1992). Moreover, few if any state or local STD reporting systems routinely collect and analyze information on same-sex behavior among women. Nonetheless, lesbians are often perceived to be at very minimal risk for STD. This perception has three apparent sources:

  1. Previous Reports of Low Prevalence. A few studies have reported low prevalence of STD among women who report having sex with women (Robertson and Schachter, 1981) and no risk of transmission of HIV between female sex partners (Raiteri et al., 1994b).17 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. The single prospective study evaluating risk of HIV transmission in HIV-discordant female couples, moreover, was limited by a short follow-up period of six months (Raiteri et al., 1994b; Reynolds, 1994).
  2. Assumptions About Sexual Practices Between Women. It is often presumed that lesbian sex does not involve contact between mu cous membranes, such as that which occurs during vaginal-penile sex, implying a low risk of bacterial STD transmission for anatomic reasons. In fact, data on the specific sexual practices of lesbians are extremely limited and there are no large-scale contemporary studies based on probability samples.18 Limited data on sexual practices among lesbians are presented in Table 2.5. Although caution should be used in generalizing these data, they do give an indication of the range of sexual practices among lesbians.
    The potential exists for transmission of some STDs that require only skin contact (e.g., herpesvirus), and the sharing of vaginal secretions via hands or sex toys could introduce pathogens into the vagina. Perhaps of greater importance, most lesbians have had sex with men, and an estimated 21 to 30% continue to have male sex partners (Einhorn and Polgar, 1994; Ferris et al., 1996; O'Hanlan and Crum, 1996). It is unknown whether the male sexual partners of these women are more or less likely to be infected with one or more STDs. 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.
  3. Assumptions About the Course of Lesbian Relationships. There are numerous assumptions about lesbian relationships and lesbian sexual networks that contribute to the perception that lesbians are at low risk for STD. These include the perception that rates of partner change are low, that monogamous lesbian relationships tend to be long-lasting, and that concurrent sexual relationships outside of monogamous relationships are less common than in heterosexual or male homosexual populations (Kennedy et al., 1995).
TABLE 2.5. Sexual Practices in Selected Samples of Lesbians .

TABLE 2.5

Sexual Practices in Selected Samples of Lesbians .

Classical STDs, such as syphilis, gonorrhea, and chlamydia, are indeed rare in women who have sex only with women, in part because of sexual behavior and in part because of issues related to transmission efficiency. A more complete understanding of the specific sexual behaviors of lesbians is needed because there are few data on the sexual activities in which lesbians actually engage.

Several studies have examined genital infection with HPV and bacterial vaginosis19 (BV) among women who have sex with women. Work by Marrazzo and her colleagues and others suggests that these infections are common among lesbians, including those who have never had sex with men (Marrazzo et al., in press). The prevalence of BV among lesbians has been reported to be 18 to 36% (Berger et al., 1995; Edwards and Thin, 1990; Marrazzo et al., 1996a, b), higher than the 16% prevalence seen in 10,397 pregnant women evaluated in the Vaginal Infections in Pregnancy study (Hillier et al., 1995). A study of 101 lesbians, none of whom had had sex with men during the preceding year, found BV prevalence to be 29%. In that study, 73% of index subjects with BV had partners with BV, whereas BV was documented in only 10% of partners of women without BV. A study conducted in a London genitourinary medicine clinic compared 241 lesbians and 241 matched heterosexual controls and found higher rates of BV in lesbians.

In a recent pilot study to examine the prevalence of STD and cervical neoplasia in a group of lesbians recruited through community advertisements, nearly one-third of the 149 study subjects had experienced at least one episode of BV (Marrazzo et al., in press). Eighteen subjects (18%) had BV at the time of study evaluation. Of the 17 who had had sex with men, the time from last sex with a male partner was greater than three months for 16 of them (91%). 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. With the recent upsurge in herpes type 2 infections among adolescent women and the possibility of transmission by orogenital and hand-genital contact, however, lesbian youth may be at high risk.

HIV and Lesbians

Among the 85,500 U.S. female AIDS cases reported to the CDC as of December 1996 (CDC, 1997), 45% were attributed to injection drug use, 38% to heterosexual contact, and 17% to infection by contaminated blood products or an undetermined route of infection. Undistinguished within these cases of women with AIDS are women who report sexual behaviors with women and women who self-identify as lesbian (Mays, 1996). The prevalence of HIV infection among women who have sex with women (WSW)20 is unknown owing to the methodological barriers in attaining representative samples of these women (Kennedy et al., 1995) and the lack of HIV research studies targeting these populations. The few studies of WSW that assess HIV seroprevalence provide differing estimates of HIV infection rates, possibly attributable to the type of WSW populations sampled. 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; Jose et al., 1993; Mays et al., 1996; Ross et al., 1992; Weiss, 1993; Williams et al., 1996; Young et al., 1992).

HIV-related research on WSW, regardless of sexual orientation, has been scarce yet notable for its unexpected findings:

  • higher HIV seroprevalence rates among women who have sex with both women and men (i.e., behaviorally bisexual women) compared to their exclusively homosexual or heterosexual counterparts;
  • high levels of risk for HIV infection through unprotected sex with men and through injection drug use; and
  • risk for HIV infection of unknown magnitude owing to unprotected sex with women and artificial insemination with unscreened semen.

Although estimates vary, numerous studies have reported HIV positivity among WSW. A study conducted in San Francisco reported a 1% HIV seroprevalence rate in a sample of 498 self-identified lesbian and bisexual women, higher than that reported for childbearing women in California (0.2%) or for women sampled from a San Francisco population-based household survey (0.4%) (Lemp et al., 1995). Behaviorally bisexual women from a predominantly African-American STD clinic population in New York City were reported to have an 18% HIV seroprevalence rate compared to 11% among exclusively heterosexual women (Bevier et al., 1995). 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; Jose et al., 1993; Ross et al., 1992; Weiss, 1993; Williams et al., 1996; Young et al., 1992).

Because WSW have been ignored in most HIV prevention efforts they may perceive their risk of HIV exposure to be lower than it actually is. In a survey of 1,086 WSW, risk perception for HIV acquisition was not as high as would have been expected given the proportion of risk behaviors reported: only 43% of the women with a history of a clear HIV risk factor perceived themselves to be at risk for HIV infection (Einhorn and Polgar, 1994). The perception of little or no risk for HIV infection among WSW reflects continued misconceptions by medical providers and researchers about the sexual behaviors and potential drug use of WSW and may contribute to delays in the diagnosis of HIV-related symptoms and an underestimation of risk of HIV infection among these women.

The explanation for increased HIV seroprevalence rates among certain subgroups of WSW remains uncertain. Some researchers suggest it could be related to the reason (e.g., sensation seeking) that those WSW engage in behaviors that increase HIV risk (Kalichman and Rompa, 1995); substance abuse (Solomon et al., 1996); sexual identity confusion (Gómez 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).

Possible Sources of HIV Infection Among Women Who Have Sex with Women. Although WSW can be found in the same HIV exposure categories as women in general, including injection drug use, heterosexual contact, history of blood transfusions, and ''no identified risk" (Chu et al., 1990; Kennedy et al., 1995), the precise number in each category is unknown, in part because same-sex contact among women is not consistently reported on AIDS case report forms (Doll et al., in press). Nonetheless, unprotected sex with men and sharing of drug injection equipment are believed to account for most cases of HIV infection in WSW, just as they do for women in general. However, the range of sexual and drug-using practices among WSW still remains largely unknown.

Injection Drug Use. A significant risk factor for HIV infection is injection drug use. Female injection drug users (IDUs) who have sex with both women and men (i.e., are behaviorally bisexual) have higher levels of HIV infection and HIV-related risk behaviors than other injectors. The only other major subgroup of injectors consistently reported to have HIV infection rates as high or higher than behaviorally bisexual women are men who have sex with men. This increase in HIV infection and risk is not related in a simple and direct way to women IDUs' sexual behaviors with other women. Thus, the patterns of HIV transmission cannot be accounted for by female-to-female transmission. Nor does HIV infection appear to be accounted for by any increased involvement in prostitution. Some differences in risk, however, may be accounted for by differences in risk networks. For example, women IDUs who have sex with women may be more likely to share needles or have sex with gay men, a particularly high-risk group for HIV infection.

Having Male Sexual Partners. Heterosexual activity among WSW presents a further avenue for entry of HIV into this population. The National Lesbian and Bisexual Women's Health Survey reported that 16% of 6,146 respondents were currently having sex with both male and female partners and that many women reported contracting an STD from a female partner, including 135 with herpes, 102 with chlamydia, 100 with genital warts, 16 with gonorrhea, 9 with hepatitis, and 1 with HIV (Cochran et al., 1996; Gage, 1994). Researchers at the University of Washington analyzed client records from the Harborview STD Clinic in Seattle from 1993 through 1995 to determine the characteristics of WSW seeking care at the clinic. Among all women who reported sex with men (12,307 women; 99% of all subjects), a report of having had sex with women in the prior two months was associated with significantly higher prevalence of HIV-related risk behaviors (Marrazzo et al., 1996b). Finally, female adolescents who have sex with other females are especially likely to engage in unprotected sex with both male and female partners (Hunter et al., 1993). Several other studies on sexual behaviors in WSW have reported a significant percentage (80 to 98%) of women who both identified themselves as lesbian and had engaged in heterosexual intercourse in their lifetime. Of particular concern regarding HIV transmission was the finding across several studies that a significant percentage of women (16 to 34%) reported having had sex with men who had sex with men (Cochran et al., 1996; Gómez et al., 1996; Lemp et al., 1995; Reinisch et al., 1990; Ziemba-Davis et al., 1996). 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.

Female-to-Female Transmission of HIV. Research on female-to-female transmission of HIV has been virtually absent and continues to constitute a gap in the scientific literature on HIV transmission. The only study to date of HIV-serodiscordant lesbian couples (i.e., where one partner is HIV positive and the other HIV negative) was conducted in Italy and found that among the 18 lesbian couples participating in the study there were significant rates of high-risk sexual activities, but there was no evidence of female-to-female transmission of HIV (Raiteri et al., 1994a). Although the validity of these findings has been questioned owing to the small sample size and limited follow-up, they are consistent with the small number of identified cases of potential female-to-female transmission in the United States (Marmor et al., 1986; Monzon and Capellan, 1987; Perry et al., 1989). More systematic attempts to identify cases of female-to-female transmission of HIV are currently underway by the CDC (CDC, 1996). The lack of information about female-to-female transmission of HIV is particularly problematic for serodiscordant couples. 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) 4.2% of women surveyed reported some illicit drug use during the past month (e.g., marijuana, cocaine, hallucinogens, heroin). About 10% of 15- to 44-year-old pregnant women and women with children in the household reported illicit drug use during the previous year; about 19% of women with no children reported such use. Slightly more than 40% of women aged 15 to 44 reported some previous use of illicit drugs during their lifetime. Alcohol use in the past month was reported by 43.6% of women surveyed; 8.7% reported binge alcohol use, and 1.9% reported heavy alcohol use.

Use of Alcohol Among Lesbians.21 Data on the use of alcohol among lesbians are not available from population-based samples or large-scale epidemiological studies focusing on alcohol use, although this area has received some research attention. Nonetheless, reviews of lesbian health research consistently include alcohol abuse as a problem for which lesbians appear to be at greater risk than heterosexual women (Cassidy and Hughes, 1997; Eliason, 1996; Haas, 1994; O'Hanlan, 1995; Rosser, 1993; Skinner and Otis, 1996), and alcohol abuse has been widely viewed as a prevalent and serious problem among lesbians (Cabaj, 1992 Cabaj, 1996; Finnegan and McNally, 1990; Glaus, 1989; Hall, 1993; NGLTF, 1993; Skinner, 1994).

Data across a wide range of non-probability small-sample studies suggest that about 30% of lesbians may have alcohol problems (Bloomfield, 1993; Hall, 1993). However, this estimate may be inflated since these studies have generally had a number of methodological problems, including the fact that subjects have often been recruited using convenience sampling from settings in which alcohol consumption is likely to occur (e.g., bars). Further, it has been suggested that contemporary patterns of alcohol use among lesbians may be lower because bars have become a less important component of the lesbian culture as other options for social gathering have become increasingly available (Hall, 1993).

Despite methodological limitations of the research on alcohol use among lesbians (e.g., the use of samples from bars or other settings likely to attract people who consume higher levels of alcohol), some tentative patterns emerge across studies:

  • A smaller percentage of lesbians compared to heterosexual women abstains from alcohol. Even when rates of heavy drinking among lesbians and heterosexual women are found to be reasonably comparable, rates of reported alcohol problems are higher in lesbians than in heterosexual women.
  • Relationships among some demographic characteristics and drinking behaviors differ for lesbians and heterosexual women, particularly for age-related drinking patterns.
  • A greater percentage of lesbians than heterosexual women describe themselves as being in recovery from alcohol abuse or alcoholism.

Lesbians have the same risk factors for alcohol abuse as other women do, including stress, anxiety, depression, genetic predisposition, and histories of childhood sexual abuse or violence. Some possible reasons for increased alcohol use among lesbians have been speculated; however, as with most research on lesbian health, these hypotheses should be considered tentative, particularly given the lack of attention to issues of social class in much of the existing research, including the following findings from Hughes and Wilsnack (1997):

  • Fewer roles, responsibilities, and social norms that limit drinking . 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.
  • Partner's drinking. Women in general tend to drink like their intimate partners and lesbians are likely no exception. In addition, because lesbian relationships may tend to be characterized by greater intimacy and shared activities than heterosexual relationships, problem drinking of partners may have an even greater impact on lesbians' drinking.

Large-scale studies using probability sampling methods and appropriate non-lesbian comparison groups are needed to better assess and understand the patterns of alcohol use among lesbians.

Use of Illegal Drugs. Very few data are available to document the use of illegal drugs by lesbians. Skinner and Otis (1996) compared data on substance use from a multiple-recruitment source convenience sample of lesbians from two southern metropolitan areas with population-based survey data from similar geographical areas. They found that lesbians reported greater use of cigarettes, marijuana, inhalants, and cocaine than did women in general (Skinner and Otis, 1996). In the NLHCS, 47% of those surveyed reported some marijuana use (14% reporting at least weekly use), 19% reported some cocaine use, and about 1% reported ever using heroin (Bradford et al., 1994b).

Injection Drug Use Among Women Who Have Sex with Women. IDUs are a subgroup of drug users of particular interest because this practice significantly increases risk for transmission of HIV and hepatitis B and C and for other health problems. According to the 1996 National Household Survey on Drug Abuse (NHSDA; SAMHSA, 1997), in the past year less than one-half of 1% of women in general reported using heroin, the illicit drug most often associated with injection drug use.22 It is not known, however, what proportion of these women administered heroin intravenously versus some other means of administration. Nor is it known what percentage of these women are WSW or women who identify as lesbian because probability-based data are not available on the percentage of lesbians who are IDUs. Nonetheless, several studies targeting self-identified lesbians and bisexual women have reported that between 2 and 6% of the women in their samples were injection drug users (Gómez et al., 1996; Lemp et al., 1995; Stevens, 1993).

A number of studies targeting female injection drug users have looked at the percentage of women in their samples who identify as lesbian or bisexual or who report having sex with other women (Friedman, 1998). 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. They may also be useful for exploring whether lesbians or WSW are disproportionally represented among IDUs and thus would be at risk for the consequences of injection drug use.

A significant number of studies of female IDUs have reported WSW in their cohorts (Cheng et al., 1997; Harris et al., 1993; Jose et al., 1993; Ross et al., 1992; Weissman, 1990). In samples from a variety of settings (e.g., drug abuse treatment programs, street settings, and jails), findings suggest that the proportion of WSW among drug-injecting women may be higher than the proportion of WSW in the U.S. population as a whole. 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). In another study, which compared sexual risk behaviors of 39 HIV-positive and 37 HIV-negative inner-city women with a history of injection drug use, 28% reported being lesbian and 48% reported having had sex with a woman at least once in their lives (Ehrhardt et al., 1995).

By way of comparison, in the NHSLS,23 2.6% of women living in the 12 largest central cities reported having a lesbian or bisexual identity, and 6.5% reported that they had ever had sex with another woman (Laumann et al., 1994). These estimates are not, however, based on samples that more closely reflect the populations from whom studies of drug injectors primarily recruit their samples (e.g., working class or poor women, those from racial or ethnic minority backgrounds), so extreme caution should be used in making. comparisons. These data on same-sex sexual behavior among IDUs, moreover, can easily be misinterpreted. That same-sex sexual behavior appears to occur at higher frequency among female IDUs than it does among similar non-injection drug-using women does not necessarily mean that lesbians are at higher risk of being IDUs. Data are not yet available, however, to determine the risk for lesbians.

It is important to consider that the proportion of lesbians, bisexuals, or WSW who are willing to disclose their sexual orientation or same-sex sexual behavior may be considerably higher among IDUs than among those who either are not drug injectors or are unwilling to disclose their drug use behavior. It is also important to note that for some women IDUs, having sex with other women is a situational behavior (e.g., having sex in exchange for drags or shelter or having sex while incarcerated). Such instances of sexual practice may not accurately reflect their sexual identity or desires. In the NHSLS, only 13% of the women who reported any adult same-gender sexuality engaged in same-sex sexual behavior without also having same-sex desires or a lesbian identity (Laumann et al., 1994). It is unknown, however, what percentage of female IDUs fall into this category.

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. In addition, there are significant gaps in what is known about the health of lesbians across the life span and about their access to health services. Further, the committee concludes that it is particularly important that research on lesbian health issues consider how health problems vary along dimensions of race and ethnicity, social class, geographic region, and birth cohort (or age). Both qualitative and quantitative studies, as well as longitudinal studies, are needed.

The committee has identified a number of suggested areas for research on lesbian health, which are presented in Box 2.2. This list is not intended to be exhaustive nor does it set absolute priorities for research. Rather, it illustrates the range of issues in need of attention. The committee strongly believes that in all of these areas studies should be conducted to increase understanding of the health of lesbians of all social classes and racial and ethnic groups.

Box Icon

Box 2.2

Suggested Areas for Further Research on Lesbian Health. General Risk and Protective Factors Risk and protective factors across the life span; coping and resiliency factors

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Footnotes

1

The FBI is mandated to collect data on hate crimes as part of the Uniform Crime Reporting Program, which collects data on crimes from nearly 17,000 voluntary law enforcement agency participants across the country. Of the 8,759 hate crime incidents reported to the FBI in 1996, 5,396 were motivated by racial bias, 1,401 by religion bias, 1,016 by sexual orientation bias, and 940 by ethnicity or national origin bias.

2

This section incorporates portions of the workshop presentation by Jocelyn White.

3

The National Gay and Lesbian Health Association, in partnership with the Mautner Project, has produced a curriculum for training any health care provider across disciplines on addressing and removing the barriers to health care that are faced by lesbian, gay, bisexual, and transgender clients.

4

These groups include (but are not limited to) the American Psychological Association, the American Psychiatric Association, the American Academy of Pediatrics, the American Medical Association, and the National Association of Social Workers.

5

Of course, disclosing behaviors that might be perceived as shameful is an issue not just with respect to a person's sexual behavior, but also in other realms of sensitive or stigmatized behavior, such as drug use or domestic violence, irrespective of a patient's sexual orientation.

6

This section incorporates portions of the workshop presentation by Donna Futterman.

7

Some lesbians use semen from known or unknown donors in the community. The use of semen from untested donors presents a possible risk of HIV infection (White, 1997).

8

Approximately 575 of the nearly 100,000 postmenopausal women now enrolled in the federally funded WHI clinical trial have been identified as lesbians based on data collected about sexual orientation. It must be kept in mind that the sample in the WHI may not be representative of women in the general population. It is not a probability sample; rather, women are recruited into the study using a variety of strategies. Although the WHI represents the largest study of its kind to-date, care must still be taken in generalizing the results from postmenopausal women to all women (or in the case of the lesbian subsample, to all lesbians).

9

A 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. Meaningful analyses of systolic blood pressure in relation to reported experiences of discrimination were precluded by the small number of participants for whom data were available, particularly black women and men (Krieger and Sidney, 1997).

10

Data 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). Participants were 25 to 37 years of age.

11

This section is based largely on the workshop presentation by Dr. Deborah Bowen.

12

This section is based largely on the workshop presentation by Dr. Margery Sved and the public testimony of the American Psychological Association, presented by Dr. Charlotte Patterson.

13

One review of six major psychological counseling journals published from 1978 to 1989 found that only 43 of 6,661 articles addressed gay and lesbian issues (Buhrke et al., 1992).

14

The NLHCS (Bradford and Ryan, 1988) remains the most comprehensive study of the health and mental health of lesbians in the United States. However, although the survey provided valuable information about the health of lesbians, it did not compare lesbians to all women or to heterosexual women.

15

In the National Comorbidity Study, 21.3% of women surveyed were reported to have experienced a major depressive episode at some time during their lives, with 12.9% having experienced a major depressive episode during the previous 12 months (Kessler et al., 1994). In the NLHCS, 37% of the respondents reported that they had experienced a "long depression or sadness" at some point in the past (a broader category than "major depressive episode"), and 11% indicated that they were currently experiencing such feelings.

16

This section is adapted from written testimony submitted by Dr. Jeanne Marrazzo and includes comments from the workshop presentation of Dr. Jonathan Zenilman.

17

Some studies included women who reported having had sex with men as well as women.

18

Although the NHSLS (Laumann et al., 1994) is based on a national probability sample, the sample of lesbians in the study is small, precluding detailed analyses of the data on sexual practices because of the small number of respondents reporting behaviors across categories.

19

Bacterial vaginosis is an ecological disturbance, in the bacterial microflora in the vagina that has been implicated in numerous upper genital tract conditions, including pelvic inflammatory disease and adverse outcomes of pregnancy (Eschenbach, 1993; Hillier et al., 1995).

20

The term "women who have sex with women" is used in this section for several reasons: it captures women who have sex with women but do not otherwise identify as lesbian or feel attraction to women, a group that may possibly be more highly represented among injection drug users, and it allows consideration of whether female-to-female transmission of HIV occurs.

21

This section is based largely on the workshop presentation made by Dr. Tonda Hughes.

22

These figures likely represent an underestimation of the actual level of heroin use in the population, because the NHSDA captures only a small number of heavy drug users, and those who use heroin may fail to disclose this information (SAMHSA, 1997). Nonetheless, the data clearly show that heroin use is a rare behavior among women in general.

23

The NHSLS surveyed nearly 3,500 adults between the ages of 18 and 59, living in the United States, about their sexual practices (Laumann et al., 1994). The study was conducted by the National Opinion Research Center and supported by private funds.

Copyright © 1999, National Academy of Sciences.
Bookshelf ID: NBK45095

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