SOCIAL ISSUES IN WOMEN'S HEALTH
| CARING FOR LESBIAN PATIENTS —Kym M. Boyman, MD, Clinical Assistant Professor of Obstetrics and Gynecology,
University of Vermont College of Medicine; Staff Physician, Vermont Women’s Choice and Planned Parenthood, Burlington
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| Introduction: lesbian population has specific health demographic profile and experiences barriers in accessing health
care; health care of lesbian and bisexual patients likely to improve as clinicians improve understanding
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| Definitions and prevalence: no standard definition for “lesbian”; attraction (desire), behavior, and identity components
of sexual orientation; survey suggested 7.5% of women experience same-sex attraction; 5% of women reported
sexual experiences with women; 1.4% of women self-identified as lesbians; 63% of women who engaged in same-sex
sexual behavior did not self-identify as lesbians; sexual orientation continuum; many individuals not exclusively heterosexual
or homosexual, and many develop lesbian orientation over lifetime; average time to “come out” mid-20s;
bisexual—attraction for sexual behavior with both sexes or self-identified as bisexual; gay—generic term referring to all
people with same-sex orientation; queer—used to describe all sexual minorities; American Psychiatric Association reclassified
homosexuality as sexual orientation and expression, and removed connotation of disorder or disease; American
Psychiatric Association and American Psychological Association describe homosexuality as normal variant of human
sexuality and discourage attempts to change individual’s sexual orientation; most researchers agree sexual orientation not
choice; studies do not support Higher prevalence of childhood sexual assault for lesbians; prevalence—2% to 10% of
population; lesbians diverse as general population; represented among all subpopulations; 74% of gay individuals reported
being “out” at work; 39% reported experiencing antigay discrimination or harassment in workplace
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| Barriers to health care: studies show lesbians present late for health care and delay seeking health care until symptomatic
or until symptoms worsen; health maintenance and screening underused; discrimination—lesbian, gay, bisexual,
and transgender (LGBT) individuals experience discrimination and stigma in all aspects of life; studies show LGBT
individuals, on average, have higher educational level, but enjoy lower socioeconomic status than heterosexual peers;
health insurance—27% of lesbians have no health insurance compared to ≈16% of general population; one study
showed 61% of lesbians felt unable to disclose sexual orientation to provider; 27% reported current health care provider
assumed they were heterosexual; ostracism, rough treatment, derogatory comments, and exclusion of life partner from
discussions often reported; 30% to 40% of health care providers reported discomfort providing care to lesbian patients;
>88% of homosexual individuals reported hearing disparaging remarks from colleagues; >67% aware of substandard
care delivery because of orientation; many state legislatures exploring laws to provide protection for health care providers
who do not want to treat LGBT patients, based on religious objections; confidentiality and protection—lack thereof
can make patient feel vulnerable; positive attitude by health care provider beneficial in helping patient disclose relevant
information
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| Medical considerations: lesbian or bisexual status does not inherently affect individual’s health status; data show no hormonal
differences among lifelong lesbians or those who come out later in life, compared to heterosexual women; no definitive
data showing lesbians have higher incidence of chronic diseases; however, as group, lesbians have higher prevalence of
several risk factors, possibly leading to increased risk for heart disease and cancer; recommendations—provide standard
comprehensive care, focusing on risk factors; counsel about family planning and safer sex; most sexually transmitted infections
(STIs) transmissible woman-to-woman; employ broad differential with complaints of vaginitis; studies show more
prevalent bacterial vaginosis among lesbians and same-sex transmission of HIV; higher rate of invasive cervical cancer because
of longer intervals between screenings; data suggest higher incidence of breast cancer among lesbians
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| Mental health and psychosocial considerations: depression—isolation, inferior social status, lack of support,
and internalized homophobia cited as stressors and factors contributing to higher rates of depression; suicidal ideation and
attempts higher; substance abuse—unclear whether more common; adolescents and young adults at high risk for substance
abuse; if counseling indicated, refer to respectful and knowledgeable mental health professional; reparative
therapy—contraindicated; American Medical Association (AMA) states ineffective, unethical, and harmful; social support
key to good mental health and lowering of depression rates; homosexual adolescents and young adults have 3 to 7
times higher risk for mental health issues compared to heterosexual peers; violence—75% of lesbians experienced verbal
abuse; 5% to 10% experienced physical assault; 39% worry about being assaulted; homicides more violent, more often
by strangers and involve higher number of assailants; childhood perpetrators more often family and community authorities;
leads to posttraumatic sequelae, eg, depression, suicide, low self-image; 40% to 44% of street children homosexual;
11% of women in lesbian relationships report intimate-partner violence, compared to 20% in heterosexual relationships;
studies clearly show lesbians and gays not more likely to sexually abuse children
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| Lifespan issues: adolescence—studies show child as young as 10 yr of age can identify same-sex attraction and sexual
orientation; higher likelihood for risky sexual behaviors, substance abuse, tobacco use, and eating disorders; important to
discuss safer sex practices and issues involving substance abuse; offer condoms and emergency contraception; adolescent
reluctant to disclose sexual orientation (important to ask); supportive organizations helpful for individual and family in coming
out process; coming out—process in which person evolves from experiencing same-sex attraction to accepting themselves;
may occur in young adulthood or later in life; associated with good mental health outcomes; aging lesbians—age,
poverty, and health issues can render older lesbians invisible; often have to go back in “closet” as they enter retirement communities
or nursing homes; connection to and activity in lesbian community leads to acceptance of aging process and high
life satisfaction
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| Lesbian family relationships: lesbian parenting—33% of lesbian and gay couples have children <18 yr of age; 6
million children living in lesbian and gay families; study of heterosexual and lesbian couples seeking fertility services
showed no significant differences, except lesbians reported greater family cohesion; studies show children raised in lesbian
and gay households not adversely affected or more likely to become lesbian or gay; many medical societies support
legislative and legal efforts to facilitate same-sex adoption; family of choice—describes close network of friends (especially
if rejected by family of origin); >60% of lesbians involved in long-term relationship; being “out” leads to greater
self-esteem and relationship satisfaction; power of attorney and medical guardianship—encourage lesbian patient to
obtain; without this, risk that same-sex partner cannot make decisions for incapacitated partner; consider chart order naming
partner and granting permission to visit and be involved in consultations
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| Ensuring cultural sensitivity: ensure health care setting more receptive to and appropriately addresses needs of population;
do not assume heterosexuality, even if patient pregnant; ask appropriate questions, and be open and nonjudgmental
about answers; inform employees that lesbian and bisexual patients welcome in practice and should be treated
respectfully; post nondiscrimination policy in reception area; display LGBT posters, brochures, magazines, and newsletters
in reception area; post rainbow flags and pink triangles; make bathrooms unisex; modify office registration forms
and questionnaires to obtain more accurate and useful information; sample questions—are you single, married, domestic
partnered, partnered in civil union, involved with multiple partners, divorced, separated, widowed, other? are you sexual
with anyone (men, women, both) or not active? who are you attracted to (men, women, or both)? do you consider
yourself heterosexual, lesbian, bisexual, transsexual, transgender, asexual, unsure? language—listen to patient and how
she describes her identity, partner, relationship, and reflect choice of language; use inclusive language with patient and
generic terms such as “partner” or “spouse” rather than “boyfriend” or “husband” until you know patient better; focus on
behaviors, rather than how patient self-identifies
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| Clinical issues: discuss extent of “outness” to employers, community, family, and friends; extent of social support and
participation in community; ask patient whether she would like to include anyone in examination room or in discussions
about care; ask who you should speak with after procedures, surgery, critical care admission; discuss safer sex techniques,
eg, avoiding exposure to menstrual blood, use of barriers; do not assume patient never involved with male sexual
partner, has no children, never pregnant, does not plan to conceive, or has little or no risk for STIs; examination
techniques—allow partner or friend in examination room; have female staff person present; ask about patient’s previous
examination experiences; allow patient to direct examination; use small narrow speculum for woman not accustomed to
vaginal penetration; assure confidentiality regarding sexual history
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| ARE WOMEN THE NEW FACE OF AIDS ?—Meg D. Newman, MD, Associate Professor of Clinical Medicine; University
of California, San Francisco, School of Medicine; Director, PHP-HIV Clinical Scholars Program, Positive Health Program,
San Francisco
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| Antiretroviral therapy: patient with high HIV viral load without antiretroviral therapy likely to progress to diagnosis
of AIDS in ≈2 yr; antiretroviral therapy made significant impact on natural history of HIV; patients with HIV or AIDS
using antiretroviral therapy may live close to normal lifespan; HIV and AIDS considered chronic disease
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| Social forces driving epidemic: “on the down-low“—man sexually active with men who does not consider himself
gay or bisexual; often married or has female significant other; men sexually active with other men most common form of
HIV transmission in South Los Angeles; in China, ratio of women with HIV to men currently 2 to 1; being married most
common risk factor for women in India; poverty and inequality of women important factors in spread of HIV—
heterosexual transmission most common mode of transmission outside United States; female patients with AIDS usually
have less chance to get treatment; young girls married to much older men who try to negotiate condom use face violence
or rejection; study data—1 of 5 adolescent girls surveyed reported physical or sexual violence or both in relationship;
being victim of dating violence associated with binge drinking, laxative use or vomiting to lose weight, not using condom
during sexual intercourse, having 3 sexual partners in previous 3 mo, and having been pregnant; data show abuse at ≤10
yr of age associated with more lifetime and recent sexual partners, higher rates of STIs, and more risky sexual behaviors;
odds of having STI >2.5 times greater if abuse occurred at ≤10 yr of age; talking to patient about safer sex practices complex
issue complicated by patient’s possible history of abuse; heterosexual transmission—sex with drug-using men
≈9%; sex with bisexual man ≈3%; sex with HIV-infected person; risk not identified in ≈4000 cases (believed at least 80%
due to heterosexual transmission); 48% of women 20 to 24 yr of age acquired infection through heterosexual transmission,
compared to 8% of men (2001 data); increased cervical ectopy in younger woman places them at greater risk for
HIV transmission
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| Differences in prognosis: women respond equally as well as men to antiretroviral therapy; no significant differences in
natural history of Pneumocystis jiroveci pneumonia (PCP), mycobacterium avium complex (MAC), cryptococcal or cytomegalovirus
(CMV) retinitis; have significantly less Kaposi’s sarcoma; more likely to develop rashes from nevirapine
or efavirenz than men; appear to have more morphologic alterations (abdominal and body fat accumulation); 12- to 18-yr
span before many people have clinical sequelae from HIV (become clinically active when CD4 cell count <200 cells/
mm3 ); always consider HIV or AIDS as part of differential diagnosis, regardless of patient’s age
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| Sex differences in viral load: data show women have 2-fold lower viral load than men; serologic responses to hepatitis
B and A and measles vaccines increased in women; human T-lymphotropic virus type 1 (HTLV-1)-infected women more
likely to retain cell-mediated immune responses to Mycobacterium tuberculosis; progesterone can influence lower genital
tract susceptibility to Chlamydia and simian immunodeficiency virus (SIV); viral load varies with ovulatory cycle from
early follicular to midluteal phase; estrogen may down-regulate tumor necrosis factor (TNF)-α human lymphocytes express
glucocorticoid receptor with distinct progesterone-binding domain; progesterone exerts dose-dependent inhibitory effect on
CC chemokine receptor 5 (CCR5) expression on activated T cells; CCR5 chemokine receptor—host factor playing role in
HIV progression (not expressed in all individuals); lower CCR5 density explains lower viral load; why clinical progression
to AIDS and death equal in men and women still unexplained
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| Women at risk: HIV transmissible woman to woman; reservoir of infection in lesbian community probably low; women
who have sex with women, women who have sex with men, women who use intravenous (IV) drugs, or women who have
sex with partner with high-risk behaviors; use of barrier methods that prevent transfer of bodily fluids critical
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| Gynecologic care: perform careful inspection of entire perianal area; high rates of cervical and anal dysplasia in immunosuppressed
patients; send patient with abnormal cervical or anal Papanicolaou (Pap) test for colposcopy; focus discussion
on safer sex and pregnancy prevention; refer for HIV counseling and testing early and often; focus on health-related
behaviors, eg, smoking, alcohol and drug use; pregnancy and HIV—most HIV transmission occurs at end of pregnancy
or postpartum; breast-feeding source of HIV transmission; antiretroviral therapy usually initiated after first trimester;
efavirenz (Sustiva) contraindicated in pregnancy
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Educational Objectives
| The goal of this program is to educate the listener about caring for lesbian patients and the heterosexual transmission of
HIV. After hearing and assimilating this program, the clinician will be better able to:
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 | 1. Cite barriers to health care that lesbians experience.
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| 2. Discuss medical and psychosocial issues that should be addressed in caring for lesbian patients.
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| 3. Summarize steps health care providers can take to improve care for lesbian patients.
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| 4. Describe social forces driving the heterosexual transmission of HIV.
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| 5. Discuss gender differences in patients with HIV on antiretroviral therapy and the gynecologic care of patients suspected
of having HIV.
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Discussed on This Program
Efavirenz [Sustiva]
Nevirapine [Viramune]
Stavudine (d4T) [Zerit, Zerit XR]
Resources
Gay and Lesbian Medical Association (GLMA): www.glma.org
Suggested Reading
Berger BJ et al: Bacterial vaginosis in lesbians: a sexually transmitted disease. Clin Infect Dis 21:1402, 1995;
Harawa NT et al: Perceptions towards condom use, sexual activity, and HIV disclosure among HIV-positive African
American men who have sex with men: implications for heterosexual transmission. J Urban Health 83(4):682, 2006;
Hutchinson MK et al: Multisystem factors contributing to disparities in preventive health care among lesbian women.
J Obstet Gynecol Neonatal Nurs 35(3):393, 2006; Makadon HJ: Improving health care for the lesbian and gay communities.
N Engl J Med 354(9):895, 2006; Millett G et al: Focusing “down low”: bisexual black men, HIV risk and heterosexual
transmission. J Natl Med Assoc 97(7 suppl):52S, 2005; Mravcak SA: Primary care for lesbians and bisexual
women. Am Fam Physician 74(2):279, 2006; Pinto VM et al: Sexually transmitted disease/HIV risk behaviour among
women who have sex with women. AIDS 19 Suppl 4:S64, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship
with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Dr. Boyman was recorded at Women’s Health Issues, sponsored by the University of Vermont College of Medicine,
held May 17-19, 2006, in Burlington, VT. Dr. Newman was recorded at Controversies in Women’s Health, sponsored
by the University of California, San Francisco, School of Medicine, held Decmember 8-9, 2005, in San Francisco,
CA. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this
program.
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