The Institute of Medicine Report
To help determine the direction of government funded research into lesbian health, the Institute of Medicine convened a Committee on Lesbian Health Research Priorities in July 1997, funded by the National Institutes of Health (NIH) Office of Research on Women’s Health (ORWH) and the Centers for Disease Control and Prevention (CDC). In January 1999, the Committee released its report, "Lesbian Health, Current Assessment and Directions for the Future". The Committee identified several reasons for directing attention to the study of lesbian health issues; to gain knowledge to improve the health status of lesbian women, to confirm beliefs and counter misconceptions about the health risks of lesbians, and to identify health risks for which lesbians are at risk or tend to be at greater risk than heterosexual women or women in general. The following information comes from the IOM report.
Health Status and Health Risks of Lesbians
Lesbians comprise a subgroup of women whose health status and risks have not been widely researched. One reason for the limited research on lesbian health is the methodological problem of defining what constitutes lesbian sexual orientation, since sexual orientation is commonly described as both behavioral, (i.e., desire or attraction), and cognitive (i.e., identity). Lesbians are found among all subpopulations of women, and are represented in all racial and ethnic groups, all socioeconomic strata, and all ages. There is no single type of family, community, culture, or demographic category characteristic of lesbian women. It is important to note that views about sexual identity and sexual behavior can vary significantly across cultures and among racial and ethnic groups, so it should not be assumed that a lesbian sexual orientation or identity is the same for lesbians of different racial, ethnic, or cultural backgrounds.
Fundamentally, lesbians need access to the same high quality health screening and preventive care that is appropriate for all women throughout the life cycle. Lesbians and their providers often remain uninformed about important health issues, including the need for: cervical and breast cancer screening, reducing the risk of sexually transmitted diseases and HIV; caring for mental health issues including depression; diagnosing and treating substance abuse; pregnancy and parenting assistance; and understanding domestic/intimate violence.
Differences in health risks for lesbians from women in general could be attributed to a number of factors. A woman’s health behavior, stress, and the nature of her experiences with the health care system can all affect her risk for various health conditions.
Health behaviors/characteristics
Pregnancy--- Lesbians appear to be less likely to report having biological children than heterosexual women. However, there are still substantial numbers of lesbian women who are parents, particularly through artificial insemination or adoption. There is little research on how many lesbians are mothers or the number of individuals who have lesbian mothers. In the Women’s Health Initiative sample, lesbians are less likely to ever have 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 89.1% of the heterosexual women. Lesbians are less likely to report having used oral contraceptives between the ages of 25 and 35 (only 16.7%), which may put them at greater risk for breast, endometrial and ovarian cancers.
Smoking---Although data on lesbians’ unique health risks is limited, certain behaviors that can increase heath risks may be more prevalent in lesbians than in heterosexual women.
Preliminary results from the Women’s Health Initiative suggest that approximately twice as many lesbians are heavy smokers compared to heterosexual women. Almost half of heterosexual women report never smoking, compared to one-third of lesbians (6.8% of lifetime lesbians and 7.4% of mature lesbians versus 3.5% of heterosexual women). Smoking can increase a woman’s risk for lung and cervical cancer, as well as cardiovascular disease.
Obesity--- Some studies suggest lesbians are more likely to be overweight than heterosexual women, which can put them at greater risk for cardiovascular disease and some other health conditions. Preliminary information from the Women’s Health Initiative suggests that a greater proportion of lesbians are above the overweight threshold when Body Mass Index (BMI= 27) is calculated (52.3% of lifetime lesbians compared to 45.8% of heterosexual women).
Alcohol Use-- Reviews of lesbian health research suggest a smaller percentage of lesbians (compared to heterosexual women) abstain from alcohol. Even when rates of heavy drinking among lesbians and heterosexual women are comparable, rates of reported alcohol problems are higher in lesbians than in heterosexual women. Similarly, a greater percentage of lesbians describe themselves as being in recovery from alcohol abuse. There is some speculation that lesbians generally have fewer social norms and family responsibilities that limit drinking. However, these theories cannot be fully substantiated without further research.
Substance Abuse--From the limited data on lesbians’ use of illicit drugs, it appears that lesbians report greater use of marijuana, inhalants and cocaine than do women in general. There is evidence that female injection drug users in urban areas identify themselves as lesbians at a higher rate than women in general, however, it is possible that injection drug users as a population sub group might be more willing to disclose their sexual behavior or identity. The IOM Report lists drug abuse among lesbians as an area in need of further research.
Stress
Physiological responses to stress can have many negative health consequences, especially over a long period of time. Lesbians may have additional stresses that compound the everyday stress that everyone experiences.
Identity Issues-- Stress may result from the burden of hiding one’s lesbian identity from family or coworkers.
Legal Issues-- Stress can come from a feeling of legal isolation and lack of cultural acceptance of living situations. Lesbians do not have many of the same legal rights as married couples, and lesbians who are parents may face difficulties with parental rights when partners separate.
Discrimination--- Stress effects may be greatest in lesbians who experience multiple forms of discrimination, such as those who are also members of ethnic or racial minority groups. The combination of homophobia, racism, and sex-based discrimination puts the health of these women in "triple jeopardy".
Interactions with the health care system
Misconceptions about health risks--- Assumptions made by health care providers while taking sexual or social history of lesbian patients can compromise the quality of health care that a lesbian receives, as can overt discrimination or homophobia. Further, past negative health care experiences can discourage a lesbian from seeking care in the future, including preventive and screening measures, which further jeopardizes her health.
Cervical Cancer---Research has shown that lesbians are less likely to receive pap smears than are heterosexual women. Pap smears are one of the most effective methods of cancer prevention for women, yet both lesbian women and their health care providers often overlook the need for cervical cancer screening. Many health care providers and patients share the false assumption that because lesbians are not currently sexually active with men, they are not at risk for developing dysplasia (abnormal cells in the cervix). As a result of this misinformation, lesbians may avoid medical services and health care providers may give incorrect advice and underutilize appropriate health screenings for these patients. It is also possible that lesbians seek obstetrician-gynecologists less frequently than do heterosexual women, and may have less exposure to screening services traditionally offered by these specialists. However, lesbians, like all women, need regular pap smears.
Sexually Transmitted Diseases---Lesbians are at risk for many sexually transmitted diseases. Genital warts, usually associated with the Human Papilloma Virus (HPV), can be transmitted sexually from woman to woman, as can the Herpes virus. Hepatitis B can also be transmitted between women. Any sexually active person should be immunized against Hepatitis B. Similarly, any sexually active person should be considered at some risk for all sexually transmitted diseases, since it is impossible for a health care professional to accurately determine the sexual history of same sex partners.
HIV/AIDS --HIV does occur in lesbians, usually due to two factors 1) sharing of needles and 2) when lesbians have sex with men who have been exposed to HIV. However, because there is also a theoretical risk of HIV transmission between lesbians, safe sex guidelines are recommended. Small studies are currently underway to study the risk of HIV infection in lesbians.
Barriers to Quality Health Care
Elements of the health care system itself, such as managed care, legal rights, and the attitudes and training of health care providers, contribute to negative experiences that can discourage lesbians from seeking appropriate and necessary health screening and treatment.
Insurance---There is also a general lack of availability of family or household health insurance coverage for members of lesbian households. This both restricts lesbians’ access to health insurance through their partners (access they would have through a heterosexual marriage), and makes family-focused care difficult. Lesbians without health insurance are significantly more likely to report heart disease, to smoke, to have eating disorders (either overeating or undereating), to be victims of physical and sexual abuse and anti-gay violence, and to be less likely to have a Pap test. (Bradford et al., 1994).
Legal Issues-- The lack of legal rights for lesbian partners or lesbians as co-parents, such as hospital visitation, access to information, participation in treatment decisions, and health care proxy appointment, can be a barrier to adequate medical care.
Patient-Doctor Communication: 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. However, various studies suggest that few physicians are knowledgeable about or sensitive to lesbian health risks or health care needs (White and Dull, 1997). There is a need for training of health care professionals in addressing the experiences and health needs specific to lesbian clients.
Cultural Competency: Health care for lesbians would improve if physicians could more fully understand why lesbians might be reluctant to seek medical care and the impact of homophobia on the provision of services to lesbians. Similarly, there is a need for an increased awareness of the range of health problems experienced by lesbians as well as their health care risks. Doctors should avoid making heterosexual assumptions in the gathering of medical and social health information from patients; and show a willingness to involve partners of lesbian patients in discussions about their health care.
Research
More research is needed on lesbian health issues for several reasons:
Activities on Lesbian Health
The Department of Health and Human Services have held a series of scientific meetings to evaluate how to most effectively respond to the IOM report. In September 1999, a coalition of offices and institutes at the National Institutes of Health held a research workshop. New Approaches to Research on Sexual Orientation, Mental Health and Substance Abuse was co-sponsored by the National Institute of Mental Health, National Institute on Drug Abuse, Office of Behavioral and Social Sciences Research, and the Office of Research on Women’s Health as well as the American Psychological Association.
On March 23-24, 2000, the Department of Health and Human Services convened the Scientific Workshop on Lesbian Health to consider steps that could be undertaken for implementation of the recommendations from the recent IOM report. The workshop convened ten working groups around specific content noted in the report, including Life Span Development; Cancer; Cardiovascular Disease and Obesity; Service Delivery and Access to Services; Mental Health and Substance Abuse; HIV/AIDS and STDs; Research Methodology; Research Career Development; Health Promotion; and Resiliency/Health Effects of Homophobia.
The seventeen National Centers of Excellence in Women’s Health, sponsored by the Office on Women’s Health, are committed to serving diverse groups of women, including lesbians. A booklet, "Lesbian Health Activities at the National Centers of Excellence in Women’s Health" can be found on the National Women’s Health Information Center website, www.womenshealth.gov or by calling the toll free phone number, 1-800-994-WOMAN (TDD: 1-888-220-5446).
Resources
Office on Women’s Health
U.S. Department of Health and Human Services
200 Independence Ave, SW Room 712E
Washington, DC 20201
(202) 690-7650
Office of Research on Women’s Health
National Institutes of Health
Building 1, Room 201
Bethesda, MD 20892
IOM Report: Lesbian Health: Current Assessment and Directions for the Future. Andrea L. Solarz, Editor. Institute of Medicine. Funded by the National Institutes of Health and the Centers for Disease Control and Prevention, U.S. Department of Health and Human Services.
Institute of Medicine Website: http://www.iom.edu
Last Updated November 2, 2000