Lesbian Health

Basics

Description

A lesbian is a woman who has her primary emotional and sexual relationships with women.
Other sexual minorities include bisexual, transgender, and transsexual women.
Sexual behaviors
- May be celibate, sexually active only with women or with both men and women
- ~75% of self-reported lesbians have reported prior sexual experiences with men.
Sexual orientation and gender noncomformity are complex concepts and defining them can be challenging.

Epidemiology

Prevalence

Estimated to be between 1 and 5%
Approximately 1.4 million women living in the United States identify as lesbians. Another 2.6 million women identify as bisexual.
2011 American Community Survey from U.S. Census Bureau reports a total of 321,177 households headed by female same-sex couples.

Risk Factors

Higher incidence for the following risk factors compared to heterosexual women: ‚

Elevated BMI
- Lesbian women have a higher prevalence of overweight/obesity than all other female sexual orientation groups.
Alcohol use
- More common use than reported in heterosexual women
- Age 20 " “34 years is at highest risk for daily use and heavy use of alcohol. Those numbers decline in older age groups.
Tobacco use
- Two times more likely to smoke than heterosexual women
The above factors can increase risks for
- Cardiovascular disease
- Hepatic disease
- Cancers

Commonly Associated Conditions

Cervical cancer
- Lesbians are equally at risk for developing cervical cancer compared to heterosexual women.
- HPV can be transmitted genitally skin to skin, oral to genitals, and digital to genitals.
- Risk of cervical cancer is highest in lesbians:
  - With prior HPV infection/abnormal Pap smear
  - Who have had a history of heterosexual intercourse
- Lesbian and bisexual women are 10 times less likely to have adequate cervical cancer screening compared to heterosexual women.
- Tobacco use influences cervical cell atypia.
Breast cancer
- Risk factors same as heterosexual women
  - Heavy alcohol consumption
  - Obesity
  - Nulliparity or first child born after age 30 years
- Mammogram screening rates lower among lesbians
- New data suggests lesbians have increased mortality rate compared to heterosexual women (1).
Ovarian cancer
- Elevated BMI and tobacco use increases risks.
- Lesbians less likely to have been on hormonal contraception for 5 years or longer.
- Lesbians less likely to have been pregnant or breastfed an infant before age 30 years.
- Lesbians at increased risk for ovarian cancer may want to explore potential benefits of long-term hormonal contraception to reduce risk.
Cardiovascular disease
- Lesbians have higher rates of obesity, smoking, and stress, which increase risks for cardiovascular disease (CVD).
Mental health diagnoses
- Two times more likely to see general physician for mental/emotional complaint
  - Depression
    - Double the rate compared to heterosexual women
    - Discrimination stress proposed factor
  - Anxiety disorders
    - 2 to 4-fold higher rate of generalized anxiety disorder
    - Higher rates of PTSD, panic, phobia
  - Multiple diagnoses
    - Three times risk
  - Alcohol abuse
    - Greatest in lesbians ages 20 " “34 years
    - Bar culture
    - May not feel comfortable in traditional Alcoholics Anonymous environment
    - Alcohol dependency three times more common compared to heterosexual women (2)
Sexually transmitted infections (STI)
- Many lesbians underestimate their STI risks.
- >10% of women with exclusively female partners have a history of at least one STI (3).
- Lesbian sexual practices include the following:
  - High risk: oral-vaginal contact, genital-to-genital contact, oral-anal contact, digital stimulation/penetration, and sharing of sex toys
  - Lower risk: kissing, rubbing genitals to partner 's body
Bacterial vaginosis
- Higher rate than heterosexual women
- Increased incidence with smoking and multiple sexual partners
- Often found in monogamous lesbian couples suggesting it may be sexually transmitted
Chlamydia
- Can be transmitted woman to woman (WTW)
Gonorrhea
- Can be transmitted WTW
Hepatitis B
- Can be transmitted WTW
Herpes
- Can be transmitted WTW
HPV
- Can be transmitted WTW
HIV
- Transmission between women rare but possible
- WSW (women having sex with women) more likely to have sexual contact with MSM (men having sex with men) than heterosexual women
Syphilis
- Can be transmitted WTW
Trichomonas
- Can be transmitted WTW
STI screening and prevention
- Screen based on woman 's history.
- Encourage safer sex practices:
  - Avoid menstrual blood.
  - Dental dams for oral sex
  - Condoms on sex toys and cleaning immediately after use
  - Vinyl/latex gloves for manual sex
Psychosocial considerations
- Sexual abuse
  - Three times more likely than heterosexual women to report having been sexually assaulted
  - 43% of lesbians reported at least one sexual assault in their lifetime.
  - History of childhood sexual abuse can be associated with more complicated and difficult "coming out " ¯ (4).
- Intimate partner violence
  - 17 " “45% of lesbians report at least one act of physical violence at the hands of a lesbian partner.
- Parenthood
  - A reported 41% of lesbians desire to have a child.
  - >30% have biologic children.
    - Usually from previous heterosexual relationship
  - Adoption
  - Assisted reproductive technology/donor insemination
  - Some will engage in high-risk sexual behaviors (MSM, "one-night stand " ¯) in an attempt to get pregnant.
  - Providers should discuss parenting with their lesbian patients.
    - Encourage both partners or nonbiologic parent to adopt child to ensure permanent legal relationship to child.
    - Discuss durable power of attorney for health care and finances in the event of death or separation.
    - Adolescents who have been reared in lesbian mother families since birth demonstrate healthy psychological adjustment (5).

Treatment

General Measures

Healthy People 2010 identified lesbian/gay Americans as 1 of 6 population groups affected by health care disparities.
Create a safe practice environment for lesbian patients.
- Have nondiscrimination policy posted where it is visible to patients.
- Educate staff to be comfortable dealing with the needs of lesbian patients and their families.
- Intake forms should include options for patient to indicate sexual preference and current partnership status.
- Use "gender-neutral " ¯ language.
  - "Do you have a significant other? " ¯
- Avoid heterosexist assumptions ( "What do you use for birth control " ¯?), asking instead "Do you plan to become pregnant or have a child? Do you need birth control? " ¯
Ask about sexual orientation.
- Many physicians do not ask.
- Intake/annual physical forms should include questions about orientation/activity.
Take a detailed sexual history.
- Do not assume sexual activity only with women.
- STI screening based on reported history
- Address contraception when appropriate.
Respect the partner.s
- Treat her as the spouse.
- Assure access if partner hospitalized.
- Recommend durable power of attorney.
Follow same preventive screening guidelines and lifestyle recommendations as for heterosexual women (Pap smear, mammography, colonoscopy screening, safer sex, exercise, diet, alcohol moderation, and tobacco avoidance).
Legal issues " ”United States
- Depending on state of residence, lesbians in committed relationships may not be granted the same legal and financial protection the U.S. laws give to heterosexual couples.
  - Civil marriage contracts exist in 17 states (CA, CT, DE, HI, IL, IA, MA, ME, MD, MN, NH, NJ, NM, NY, RI, VT, WA, and Washington, DC).
  - Civil unions only exist in CO with domestic partnerships in OR and NV (limited domestic partnerships in WI).
  - Thirty-three states have passed laws to prohibit recognition of same-sex marriages, although litigation is pending in many, asserting that such laws are unconstitutional.

References

1.Boehmer ‚ U, Ozonoff ‚ A, Miao ‚ X. Breast cancer mortality 's association with sexual orientation. Sexuality Res Soc Policy. 2013;10:279 " “284.2.Cochran ‚ SD, Mays ‚ VM, Sullivan ‚ JG. Prevalence of mental disorders, psychological distress, and mental health services use among lesbian, gay, and bisexual adults in the United States. J Consult Clin Psychol. 2003;71(1):53 " “61.3.Bailey ‚ JV, Farquhar ‚ C, Owen ‚ C, et al. Sexual behaviour of lesbians and bisexual women. Sex Transm Infect. 2003;79(2):147 " “150.4.Baker ‚ S. Lesbian survivors of childhood sexual abuse: community, identity, and resilience. Canadian J of Commun Ment Health. 2003;22(2):31 " “45.5.Gartrell ‚ N, Bos ‚ H. US National Longitudinal Lesbian Family Study: psychological adjustment of 17-year-old adolescents. Pediatrics. 2010;126(1):28 " “36.

Additional Reading

Ard ‚ KL, Makadon ‚ H. Addressing intimate partner violence in lesbian, gay, bisexual, and transgender patients. J Gen Intern Med. 2011; 26(8):930 " “933.
Boehmer ‚ U, Bowen ‚ DJ, Bauer ‚ GR. Overweight and obesity in sexual-minority women: evidence from population-based data. Am J Pub Health. 2007;97(6):1134 " “1140.
Buchmueller ‚ T, Carpenter ‚ CS. Disparities in health insurance coverage, access, and outcomes for individuals in same-sex versus different-sex relationships, 2000-2007. Am J Public Health. 2010;100(3):489 " “495.
Gates ‚ GJ. How Many People are Lesbian, Gay, Bisexual, and Transgender? Los Angeles, CA: The Williams Institute; 2011.
Gates ‚ GJ, Badgett ‚ GJ, Macomber ‚ JE, et al. Adoption and Foster Care by Gay and Lesbian Parents in the United States. Washington, DC: The Williams Institute; 2007.
Gay and Lesbian Medical Association. Healthy People 2010: Companion Document for Lesbian, Gay, Bisexual, and Transgender Health. San Francisco, CA: Gay and Lesbian Medical Association; 2010. http://www.glma.org.
Institutes of Medicine. The Health of Lesbian, Gay, Bisexual and Transgender People: Building a Foundation for Better Understanding. Washington, DC: National Academies Press; 2011.
The Joint Commission. Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender Community: A Field Guide. Oak Brook, IL: The Joint Commission; 2011. http://www.jointcommission.org/assets/1/18/LGBTFieldGuide.pdf. Accessed October 30, 2014.
Makadon ‚ HJ, Mayer ‚ KH, Potter ‚ J, Goldhammer ‚ H. The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health. Philadelphia, PA: American College of Physicians; 2008.
Ruble ‚ MW, Forstein ‚ M. Mental health: epidemiology, assessment, and treatment. In: Makadon ‚ HJ, Mayer ‚ KH, Potter ‚ J, et al, eds. The Fenway Guide to Lesbian, Gay, Bisexual, and Transgender Health. Philadelphia, PA: American College of Physicians; 2008: 187 " “208.
Valanis ‚ BG, Bowen ‚ DJ, Bassford ‚ T, et al. Sexual orientation and health: comparisons in the women 's health initiative sample. Arch Fam Med. 2000;9(9):843 " “853.

Codes

ICD09

278.02 Overweight
305.1 Tobacco use disorder
305.00 Alcohol abuse, unspecified
V69.2 High-risk sexual behavior
099.9 Venereal disease, unspecified

ICD10

E66.3 Overweight
Z72.0 Tobacco use
F10.10 Alcohol abuse, uncomplicated
Z72.52 High risk homosexual behavior
A64 Unspecified sexually transmitted disease
Z72.53 High risk bisexual behavior

SNOMED

48499001 Increased body mass index (finding)
110483000 tobacco user (finding)
15167005 Alcohol abuse (disorder)
288311000119103 High risk homosexual behavior (finding)
288291000119102 High risk bisexual behavior (finding)

Clinical Pearls

Create a safe health care environment for all patients. Use gender-neutral language.
Do not assume heterosexuality.
Be aware that some patients may openly identify as lesbian but others may only identify when asked directly. Some may be engaging in a same-sex relationship and not identify as a lesbian.
Follow same preventive screening guidelines and lifestyle recommendations as for heterosexual women.
Discuss durable power of attorney for health care needs to ensure partner 's involvement in care.

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