Primary Care of Lesbians

From WiserWiki

[edit] Primary Care of Lesbians

Jocelyn C. White

The care of lesbians and women who have sex with women (WSWs) has received little attention, and medical literature rarely addresses the needs of this group. Lesbians and WSWs may compose up to 15% or more of the female population depending on demographic characteristics such as geographic area, religion, and education.^[1] These women are a large group of patients with unique medical, psychologic, and social needs.^[2] According to current theories, sexual orientation is most likely determined by a combination of biologic and environmental factors.^[3] Contemporary researchers define “lesbian” in ways that include self-definition, women as sexual partners, and sexual attraction to or desire of women. For primary care purposes the aspects of self-identification and sexual partners are most relevant. Identification as a lesbian is based on emotions and psychologic responses, societal expectations, and the individual's own choices in identity formation. Therefore some women call themselves lesbians but are not sexually active with women or exclusively with women; conversely, some are sexually active with women but do not identify as lesbians. The specific identity and sexual practices of an individual patient determine her risks of particular conditions and are important in developing individual medical recommendations.

Lesbians and WSWs are a diverse group of women from all racial, economic, geographic, religious, cultural, and age populations. Despite this diversity, lesbians have formed a culture and community of their own that often provides an alternative family or kin group to its members. Many older women who developed their lesbian identity before the modern gay and lesbian era feel less connected to this culture and community. These older women may be more reluctant to reveal their identity because of experiences with or fears of discrimination. Community resources may be helpful to physicians looking for lesbian-sensitive referrals for social services, counseling, or peer support.

Although the body of research is growing, scientific information is limited about the lesbian and WSW populations. The studies available are often methodologically flawed by sample bias or small sample size, and physicians may not be able to generalize from these results. In other areas, such as cancer risks and screening, specific information about lesbians and WSWs is unavailable, but inferences can be drawn from larger epidemiologic studies of women.

[edit] PHYSICIAN-PATIENT INTERACTION

Many lesbians are reluctant to share their sexual orientation with physicians for fear of negative judgments and homophobic responses. Some lesbians do not share this information even when asked. Negative experiences with health care professionals make lesbian patients more likely to terminate care and avoid routine screening and other care. On the other hand, physicians may feel inexperienced in dealing with lesbian health issues or uncomfortable deciding what language to use to elicit information sensitively. Because of both patient and physician discomfort, important information is often not shared.

An effective physician-patient interaction has three functions: information gathering, rapport building, and patient education. The physician needs to communicate with all women in ways that will (1) elicit information needed to identify lesbian and WSW patients and provide appropriate medical care, (2) demonstrate a nonjudgmental attitude that conveys a sense of acceptance, and (3) provide educational information, resources, and referrals sensitive to the needs of lesbians and WSWs.

Gathering information from female patients about sexual orientation and sexual practices may be the first pitfall. Typical patient interview questions often lead to inaccurate or incomplete information and set up barriers for the lesbian and WSW patient because they assume she is heterosexual; “What form of birth control do you use?” is a common example. Questions that facilitate communication include “Have you ever had sex with men, women, or both?” and “How do you identify your sexual orientation?” (Box 39-1). Physicians should ask these questions of all women from adolescence through old age. It is important to recognize elderly lesbians because of their risk of social isolation. Physicians may be a significant source of support to these patients.

Sensitivity to important concerns of the lesbian patient improves rapport (Box 39-2). For example, offering to include a partner in discussions and ensuring that she has access to patient care areas (e.g., delivery room, intensive care unit) demonstrate acceptance. The physician also builds rapport by discussing the stresses of homophobia and exploring the patient's perceptions of the health care system. In addition, physicians can ensure that all next-of-kin policies and discussions of advance directives include the possibility of a female partner and that office and hospital forms use wording that recognizes alternative family structures, such as “living with a partner” or “living as a couple” in addition to “spouse.”

Providing education for lesbian patients involves physician self-education and access to reference materials and brochures with information specific to lesbians. Verbal instruction in preventing the transmission of sexually transmitted diseases (STDs), including human immunodeficiency virus (HIV), should be clear and specific to sexual practices between women. Physicians should be able to counsel or refer patients for counseling about such issues as parenting, coming out, battery, and hate crimes. Referrals should include other providers and community-based resources sensitive to the needs of lesbians.✢✢For further information and referral sources for lesbian and gay health issues, contact Gay and Lesbian Medical Association, 273 Church St, San Francisco, CA 94114; 415-255-4547. Hotlines, book stores, and bibliographies can help educate. Youth groups and senior groups, community centers, lesbian and gay religious organizations and retirement centers, substance abuse support groups, and counselors who deal with lesbian issues can provide support.

Finally, it is important for physicians to discuss explicitly with lesbians the documentation of sexual orientation and sexual partners in the chart. Because the information is integral to providing high-quality health care, physicians may consider using a coded entry in the chart if a patient does not want her lesbian identity documented. This provides physicians with a record to remind them about the patient's sexual orientation but prevents inadvertent breaches of confidentiality through use of the chart.

[edit] SEXUALLY TRANSMITTED DISEASES

STDs, except for HIV, appear to be less common in lesbians and WSWs than in other populations. Sexual practices between women include kissing, breast stimulation, manual and oral stimulation of the genitals and anus, friction of the clitoris against the partner's body, and penetration of the vagina and anus with fingers and devices. No gynecologic problems are unique to lesbians or WSWs, and none occurs more often than in other populations. Human papillomavirus (HPV), the cause of genital warts and cervical dysplasia, has been shown to be sexually transmitted between women.^[4] Therefore female partners of infected women should also be evaluated.

Nonspecific vaginitis, more recently called bacterial vaginosis, often occurs in lesbians. According to recent research the female partners of infected women are most likely infected. Physicians should inquire about vaginal discharge in lesbians and evaluate those partners of infected patients who have symptoms. Although bisexual women report vaginal candidiasis more often than do lesbians, probably because of heterosexual contact, transmission between women is possible. Partners of lesbians with vaginal candidiasis should be evaluated.

Trichomonas vaginalis bacteria have been found in women sexually active exclusively with women, women with no sexual contact at all, and lesbians with a bisexual woman as contact. Physicians should include T. vaginalis infection in the differential diagnosis of vaginal discharge in lesbians. Sexual partners of lesbians diagnosed with Trichomonas infection should also be evaluated.

Screening and testing for STDs is appropriate in the setting of risk factors based on specific sexual history. Chlamydial and herpes organisms are found infrequently in lesbians who have been sexually active exclusively with women. Herpes can be transmitted between women, but the prevalence in the lesbian population seems to be low. Pelvic inflammatory disease (PID) also appears to be rare among lesbians. Unlike in the gay male population, enteric infections caused by hepatitis A, Amoeba, Shigella, and helminths have a low prevalence in lesbians. Hepatitis B and C occur when risk factors are present.

[edit] Human Immunodeficiency Virus

Of the Centers for Disease Control and Prevention (CDC) reported cases of acquired immunodeficiency syndrome (AIDS) in lesbians, about 93% were intravenous drug users. To date, transmission of HIV between women as a result of sexual contact only may have occurred in up to nine cases, likely related to exposure to menstrual and traumatic bleeding. However, HIV has been cultured from cervical and vaginal secretions and cervical biopsies taken throughout the menstrual cycle and may theoretically be transmitted by infected women who are not bleeding.^[5] Because of the low rate of transmission from infected women to men in the general population, however, the rate of transmission between women is probably also low.

Physicians should counsel lesbians to avoid contact with cervical and vaginal secretions, menstrual blood, and blood from vaginal and rectal trauma in partners whose HIV status is unknown.^[6] Methods believed to protect against transmission for oral-genital contact include latex squares known as dental dams, latex condoms or gloves cut open and laid flat, and odor-impermeable brand-name plastic wrap. For vaginal penetration, latex gloves used on hands and condoms on sexual toys are appropriate. Recommendations for HIV testing should be based on individual risk factors.

Lesbians who undergo artificial insemination with either fresh semen from donors in the community or frozen semen from sperm banks are also at risk for HIV infection. Sperm banks routinely test donors for HIV infection at the time of donation and 6 months later before releasing the sample for use. Because of delays in seroconversion, however, it is possible for lesbians to be exposed to HIV through fresh semen from a seronegative donor. Lesbians should avoid using fresh semen for insemination.

[edit] CANCER

There are no population-based studies of gynecologic and breast cancer risk in lesbians. As a result, cancer screening decisions in lesbians should be based on individual risk factors using standard screening guidelines for women. Based on their sexual and reproductive histories, however, the incidence of certain cancers in lesbians may differ.

Cervical cancer appears less common among lesbians than other women, as suggested by lower rates of dysplasia. HPV is transmissible between women, however, and cervical cancer occurs in women sexually active exclusively with women. Current American Cancer Society (ACS) recommendations and other preventive health guidelines give no guidance for cervical cancer screening in women who are sexually active with women only. Physicians need to screen these women according to current guidelines.

Little information exists on breast cancer in lesbians.^[7] However, many lesbians are nulliparous, older with the first birth, have never breastfed, or have a higher body mass index. Physicians should adhere to current guidelines for breast examination and mammography.

Ovarian cancer has been reported to occur more frequently in women who have not used oral contraception and those who have not given birth. Endometrial cancer is also more common in nulliparous women. Based on these risk factors, some lesbians may be at a slightly higher risk for ovarian and endometrial cancers, and physicians should follow current guidelines on screening for these cancers where available.

[edit] SPECIAL ISSUES

[edit] Parenting and Reproduction

Lesbians may have children from previous heterosexual relationships, from adoption, by artificial insemination, or by being a foster parent. Although some members of society oppose motherhood for lesbians, studies have not demonstrated differences between children raised by lesbians and those raised by heterosexuals.^[8] Open communication with children about parents' lesbianism appears important in family function.

Most lesbians who want to conceive find artificial insemination, also called alternative insemination or therapeutic insemination, the preferred method. Some physicians are uncomfortable performing artificial insemination for lesbians, whereas others believe it is ethically justifiable but should not be mandated. A physician who is unable to comply with a patient's wishes should refer the patient to another provider for the service.

A pregnant lesbian may find it more difficult than other women to find social or family support for her pregnancy. The development of her identity as a mother may also be more complex. Primary care physicians can support the pregnant lesbian by demonstrating nonjudgmental attitudes, encouraging acceptance of lesbian motherhood among members of the obstetric team and childbearing classes, and including partners in the process of conception, prenatal care, and delivery.

[edit] Psychosocial and Psychologic Issues

In general, psychologic illness is no more common in lesbians than in heterosexual women. Lesbians do experience unique psychosocial stressors, however, that often affect their physical and emotional health. The issues most relevant for primary care physicians include homophobia, coming out, alcohol and substance abuse, suicide, lesbian battery, and hate crimes.

Stress experienced by lesbians may result from a conflict between their chosen identity and the identity they express to the outside world. Although lesbians' self-esteem is similar to that of heterosexual women, lesbians often find it difficult to act in accordance with their identity because of society's negative attitudes, known as homophobia. Societal attitudes may be compounded by the lesbian's own internal homophobia developed from years of living in an intolerant society.

Evaluation of a lesbian patient's support network is necessary to determine her ability to cope with these and other stressful life events. Lesbians most often derive support from partners, friends, and lesbian and gay community organizations. The quality of the relationship with a partner can be particularly important to a lesbian's psychologic well-being. Discord in a lesbian couple can be even more stressful than for a married heterosexual couple because of a lack of traditional social support.

The process of discovering one's sexual orientation and revealing it to others, known as coming out, may begin at any age and may be associated with significant emotional distress. The process of coming out has been well described. It involves a shift in core identity that takes place in four stages: (1) awareness of homosexual feelings, (2) testing and exploration, (3) identity acceptance, and (4) identity integration and disclosure to others. Internalized and societal homophobia cause the lesbian to perform a fatiguing cost-benefit analysis for each situation in which she considers coming out. If the costs are high, she may ultimately become socially isolated or deny the identity.^[9] Lesbian adolescents are particularly vulnerable to the emotional distress of coming out, and this distress often confounds their developmental tasks. Parental acceptance during this process, especially maternal, may be the primary determinant of the development of healthy self-esteem in adolescent lesbians. Signs of sexual orientation confusion in adolescents may include diminished school performance, alcohol and substance abuse, acting out, depression, and suicidal ideation and attempt. It is important for the primary care physician to screen adolescents for these signs and to consider sexual orientation confusion in the differential diagnosis of depression and substance use.^[10]

As part of a comprehensive clinical evaluation, primary care physicians should screen all women, including their lesbian patients, for alcohol and substance abuse, depression, and violence. Lesbians are less likely to abstain from alcohol than other women, more likely to be moderate drinkers, especially in middle decades of life, equally likely to be heavy drinkers, and more likely to report an alcohol problem. A recent national mail survey from a lesbian publication reported that 59% of subjects had used alcohol to cope with stress and 42% had considered suicide. Marijuana and cocaine use also appear to be higher in lesbians. Violence is an issue in lesbian as well as heterosexual relationships. One small study reported that among lesbians aged 22 to 52 years, about 38% had experienced battery by a partner, and alcohol or drug use was involved in 64% of these incidents.

Hate crimes against lesbians, including verbal abuse, threats of violence, property damage, physical violence, and murder, are increasing each year. Lesbians at universities report being victims of sexual assault twice as frequently as heterosexual women. According to a study for the U.S. Department of Justice, lesbians and gay men may be the most victimized group in the nation. About 25% of lesbians in a Philadelphia study reported being the victim of a crime committed by a family member. Many gay and lesbian adolescents may leave home because of abuse related to their sexual orientation. The primary care provider should be aware of the possibility that a patient has been a victim of violence, particularly when patients present with symptoms of depression or anxiety.

[edit] End of Life

Advance directives are necessary for lesbians who want to appoint their partners as surrogate health care decision makers. Completing this document is the best way to avoid a tragic conflict between a partner and a legal next of kin in a time of crisis. As with all patients, a discussion of advance directives should be included in the preventive care evaluation.

Caregiving issues for lesbians can be different than those for other women. Lesbians caring for partners with breast cancer report unique considerations that are best addressed in support groups for lesbian caregivers. Physicians should refer caregivers to local lesbian cancer projects or cancer centers with groups for lesbians.

[edit] SUMMARY

Many primary care physicians are caring for lesbian patients without recognizing their sexual orientation or their unique medical and psychologic needs. Enhanced knowledge and skills allow these physicians to provide optimal and sensitive patient care for lesbians. Clearly, much more research on this group is needed to provide appropriate guidelines for physicians.^[11]

[edit] REFERENCES