Many studies have found an association between a failure to conform with preventive health measures and an increased risk of preventable chronic diseases. It has been proposed that being bisexual or lesbian is associated with poorer use of preventive health measures. In this study, after controlling for standard demographic factors and gender of sexual partners in a person's lifetime, sexual orientation was associated with some preventive health behaviors (such as practicing safer sex and having cholesterol screening and mammography) that have important long-term health consequences.22
The finding that lesbians and bisexual women have higher rates of drug use in the past 30 days is worrying. The use of illicit drugs may be associated with unsafe sex practices and having poorer judgment while under the influence of drugs, although this was not confirmed in this study.24
The frequency with which lesbians and bisexual women have sex with both men and women may also contribute to the spread of sexually transmitted diseases.9
In this study, rates of cigarette smoking (16.5%) and heavy drinking (13.1%) were equal among groups of women of different sexual orientations, in contrast with findings from studies that used convenience samples without control groups and that reported higher rates of cigarette and alcohol abuse by lesbians.5,6
The only large study examining the amount of alcohol consumed by lesbians and a heterosexual control group also identified equal rates of heavy drinking in lesbians and heterosexual women (albeit markedly lower at 2% in each group).25
In this study, lesbians had had fewer human papillomavirus infections than the other two groups of women. However, infection with human papillomavirus and cervical dysplasia has been documented in women who have had only female sexual partners.26,27
Thus, screening measures and recommendations about safer sex should be determined by sexual behaviors and other factors related to the risk of developing cervical dysplasia, rather than by perceptions of sexual orientation.
Bisexual women were the least likely to have been appropriately screened for cholesterol and to have had mammography. This is a potentially serious problem considering the low threshold used to define appropriate screening in this study.
As shown in previous studies, a person's lifetime sexual history correlates poorly with sexual orientation.6,10,11,20
This is the first comparative study to evaluate the sex of current sexual partners and the sex of those in the participant's lifetime: 23% of the bisexual women and 3% of the lesbians reported having had sex with both men and women in the preceding 12 months. Surveys without control groups done in the late 1980s found that 8% (141 of 1,681) of lesbians who were surveyed in Michigan, most of whom were white, and 17% (101 of 605) of African American lesbians recruited nationally had had sex with men in the preceding 12 months.3,6
This study found that during their lifetimes, 54% of the lesbian participants had had sex with both men and women compared with findings of 78% to 91% in all previous similar studies.3,4,6,9,20
It is unclear whether the difference between this and earlier studies of patterns of sexual behavior is caused by sampling differences or demographic differences (women in the healthcare setting compared with women attending lesbian community events) or actual changes in the sexual practices of lesbians as the gay and lesbian liberation movement has developed.
Because of the variability of sexual behavior among people of all sexual orientations, taking an accurate social and sexual history is important. Recommendations for obtaining such a history and the appropriate counseling of patients are given in the box.
Recommendations for providing inclusive care for patients
Strengths and weaknesses of the study
This study has several strengths. It is the first study to compare the health of lesbian, bisexual, and heterosexual women in the same setting and after adjusting for important covariates. It is also the first large study to describe lesbian, bisexual, and heterosexual women who use the healthcare system. The study had a large sample size of 637 heterosexual women and 667 bisexual and lesbian women and many variables covering a wide range of health-related topics. The respondents came from different geographic areas and were recruited from a range of outpatient settings. The overall response rate of about 50% was high for an exploratory, descriptive study using a written, anonymous questionnaire distributed at different sites. Data were missing from less than 4% of the questionnaires even when questions of a sensitive nature had been asked.
There are, however, several limitations to this study. Biases in sampling limit the generalizability of the results. The respondents were predominantly young to middleaged, white, insured, and of high socioeconomic and educational status. Future research using a different methodology might enable more women from racial minorities and women with poorer literacy skills to participate.
Characteristics of the sites and the physicians involved might also introduce bias. Although an effort was made to include a wide spectrum of practices, most of the respondents came from urban primary care practices. About half of the sites had a substantial proportion of lesbian and bisexual women as clients. These sites may be less biased toward providing care for heterosexuals than is generally the case. The practitioners at these sites are interested in research on women and preventive health and may be attuned to health issues that are important to lesbians.
Thus, multiple selection biases were introduced by respondents, sites, and practitioners. Reporting bias may have occurred, such as the underreporting of diseases and behaviors with negative associations, because of the sensitive nature of some of the questions. However, all of these biases should have been corrected by the use of an internal control group at each site.
Our findings apply to a group of women already seeking care. Similar problems of a larger magnitude may exist among women who do not have regular contact with the healthcare system.
Targets for intervention
These findings suggest that there are some specific targets for interventions among women already seeking care. Programs focusing on decreasing the use of illicit drugs by lesbians and bisexual women may be needed. All patients should receive standard health tests, such as cholesterol screening and mammography, regardless of their sexual orientation. Further studies are needed to understand why patients do not use preventive health services, how being a lesbian or bisexual woman is related to not observing guidelines on preventive health, and to address the vulnerability to avoidable diseases of certain groups of women who do not use healthcare services.
Bisexual and lesbian women seemed to be less likely to engage in preventive health behavior than heterosexual women. Given the current weight of evidence that supports an association between illicit drug use and suboptimal cholesterol and mammography screening with a variety of acute and chronic illnesses, encouraging women to make use of preventive health measures may significantly improve health outcomes in the population.