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Objectives To determine whether lesbians and bisexual women are less likely than heterosexual women to use preventive health measures. Design Written, anonymous, self-administered questionnaire. Setting 33 physicians' offices and community clinics mainly in urban areas of 13 states. Participants 524 lesbians, 143 bisexual women, and 637 heterosexual women. Results Bisexual women were less likely than heterosexual women to have had appropriate cholesterol screening (odds ratio 0.29, 95% confidence interval 0.11 to 0.73) or appropriate mammography (0.33, 0.13 to 0.84). Human immunodeficiency virus testing was more common in lesbians (2.38, 1.51 to 3.74) and bisexual women (1.99, 1.17 to 3.38) than in heterosexual women. Illicit drug use was higher in lesbians (2.04, 1.14 to 3.70) and bisexual women (1.96, 1.07 to 3.57) than in heterosexual women. Lesbians were more likely than heterosexual women to practice safer sex (2.60, 1.23 to 5.49) and less likely to have ever been infected with human papillomavirus (0.48, 0.25 to 0.89). Conclusion There were important differences in the preventive health measures taken by lesbians and bisexual women and those taken by heterosexual women. All patients should receive standard health tests, such as cholesterol screening and mammography, regardless of their sexual orientation. Lesbians and bisexual women who report illicit drug use should receive counseling, as appropriate.
Although advances in medical and surgical care have contributed to declines in death and disease for most of the American population, 70% of all illness is caused by preventable factors.1,2 The results of several studies performed without control groups have suggested that lesbians have poorer health than the general population.3,4,5,6,7,8,9,10,11,12 Furthermore, there are no data that compare the use of preventive healthcare services by lesbians, bisexual women, and heterosexual women.
Surveys of lesbians that did not have heterosexual control groups have raised the possibility that morbidity is greater among lesbians than among heterosexual women: lesbians have a higher rate of nulliparity and late parity3,4 (increasing their risks of breast, endometrial, and ovarian cancer) and a higher mean body mass index13 (possibly increasing their risks of breast and endometrial cancer, heart disease, hypertension, and diabetes). In studies that did not use probability samples or heterosexual control groups, lesbians and bisexual women have also had higher rates of cigarette smoking,3,4,5 alcohol consumption,5,6 illicit drug use,3,4,5,6,7 and unsafe sex8,9,10,11 than heterosexual women.
Added to these risk factors is the possibility that lesbians and bisexual women use the healthcare system less often than heterosexual women and then only after they have had more severe symptoms.3,14,15 This may be because they have lower incomes and lower rates of health insurance,3,4 or they may have fewer encounters with the healthcare system because they are less likely to need contraception or prenatal care.3,12
Additionally, lesbians and bisexual women may avoid the healthcare system because they fear or have experienced discrimination because of their sexual orientation.14 Homophobic attitudes and discrimination against lesbians have been documented in a range of healthcare personnel, including physicians, medical students, and nurses.16,17,18,19 People who have experienced discrimination may be discouraged from seeking health care.15 Lesbians may also use complementary healthcare providers if they are seeking more holistic and less discriminatory care.4,15,20
These factors may adversely affect the health of lesbians and bisexual women. Previous surveys have used convenience samples from outside the healthcare setting without comparison groups of heterosexuals. The Institute of Medicine at the National Academy of Science found that more data are needed to determine if lesbians are at higher risk of developing some health problems.21 To explore the use of preventive health measures among lesbians already using the healthcare system, data were collected on lesbian, bisexual, and heterosexual adult women who used outpatient services and analyzed according to the sexual orientation of the patient.
A written survey was developed by a panel of two obstetrician-gynecologists, an internist, an epidemiologist, and a biostatistician. The survey was refined after two pilot tests. It contained 98 questions about the patient's access to health care, use of screening tests, general health, substance use, sexual behavior, and demographic information, such as race and income. The questionnaire did not state that sexual orientation was an issue of interest. Sexual orientation was assessed solely by the patient's self-identification. Patients were asked: “How do you define your sexual orientation?” They could then choose from the close-ended answers: heterosexual/straight, bisexual, lesbian/gay/homosexual, or unsure. The study protocol was approved by the Institutional Review Board of the California Pacific Medical Center in San Francisco.
To include a broad spectrum of women, a variety of practice settings was sought. Private offices and community clinics were contacted in an attempt to achieve geographic distribution across the nation. The participation of sites was sought through letters sent to clinicians known personally to the author, by publicizing the study in newsletters and at the conferences of two national lesbian and gay health organizations, and by the “snowball” technique, in which new participants are recruited through the networks of those already participating.
The lead clinician at each site was asked to estimate whether the prevalence of lesbians among female patients exceeded 30%. The 30% threshold and the methods of distribution were chosen in an effort to gather approximately equal numbers of heterosexual respondents and lesbian and bisexual women respondents. This estimate was readily available from the clinician. At sites where more than 30% of female patients were known to be lesbians (about half of the sites), surveys were offered to all women. At the remaining sites, surveys were distributed to patients who were known to be lesbians and to the next two female patients. Drop boxes at the sites and individual business reply envelopes were supplied to allow the surveys to be returned anonymously. Because the surveys were self-administered and anonymous, there was neither the intention nor the means to encourage women to complete and return the surveys.
A panel of experts, some from the panel mentioned above, defined appropriate measures of preventive health, based on the literature and their clinical experience. When possible, these measures were standardized to the definitions used in Healthy People 2000, which describes the objectives of the government's health promotion plans.22 A woman 50 years of age or older was classified as having an appropriate level of preventive health care if she had had a cholesterol screening within the past 5 years and a mammogram within the past 2 years. Women of all ages were classified as practicing appropriate preventive health care if they had had a cervical smear within the past 2 years, screening for sexually transmitted diseases within the past 5 years, a breast examination carried out by a clinician within the past 2 years, if they examined their own breasts at least 3 times per year, if they used no illicit drugs in the past 30 days, if they were nonsmokers (defined as no smoking within the past 30 days), if they were not heavy drinkers of alcohol (defined as having 60 or fewer drinks per month, in the absence of binge drinking of 5 or more drinks on one occasion in the past 30 days), if they took regular aerobic exercise (defined as 20 minutes of aerobic exercise per session with at least 3 sessions per week), and if they practiced safer sex (defined by all the following criteria: ≤4 sex partners in the past 12 months; no known or suspected gay or bisexual male sex partners; no known or suspected injection drug use by male or female sex partners; if ≥2 sex partners in the past 12 months, usually or always uses barriers when having sex with men or women, and rarely or never drunk or high when having sex). Thirty-three of the 98 questions specifically measured preventive health care.
Data entry was performed and verified with double-keyed entry using statistical software (SAS, version 6; SAS Institute Inc, Cary, NC). The χ2 test was used to compare categorical variables and sexual orientation. The Kruskal-Wallis test was used to compare numeric variables and sexual orientation. Multivariate logistic regression was used to control for demographic factors and sexual partner history.
Thirty-three sites across the United States agreed to participate; they were predominantly urban, private offices providing primary care services. However, there were also community clinics, two chiropractic practices, and one naturopath's office. We used sites in Alabama, California, Georgia, Louisiana, Massachusetts, Minnesota, New York, Ohio, Oregon, Pennsylvania, Washington, and the District of Columbia.
From May 1, 1996, to February 14, 1997, 2,716 surveys were distributed; 1,362 were completed and returned, yielding a 50% response rate. The principal independent variable was self-identified sexual orientation. After excluding those surveys with incomplete information about sexual orientation, 1,304 surveys (48%) were available for analysis.
Characteristics of respondents are summarized in table 1. Six percent of heterosexual women, 87% of bisexual women, and 54% of lesbians reported having had sex with both men and women during their lifetimes. Respondents' sexual history during the past 12 months more closely reflected their reported sexual orientation: 0.5% of heterosexual women, 23% of bisexual women, and 3% of lesbians reported that they had had sex with both men and women in that time.
Sexual orientation was associated with the health behaviors shown in table 2. Lesbians were about twice as likely as heterosexual women to have used illicit drugs in the past 30 days, and they were more than twice as likely as heterosexual women to have been tested for human immunodeficiency virus. Lesbians were also half as likely as heterosexual women to have ever been infected with human papillomavirus. Of those women not in a committed relationship (defined by respondents answering “yes” or “no” to “Are you currently married or in a committed relationship?”), lesbians were 2.6 times more likely than heterosexual women to practice safer sex. Bisexual women were about twice as likely as heterosexual women to use illicit drugs and to have been tested for human immunodeficiency virus. Bisexual women were about one third as likely as heterosexual women to be classified as having had adequate cholesterol screening and adequate mammography.
All of the other measures of appropriate preventive health care were similar among the three groups (data not shown).
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.box.
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.
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.
The author would like to thank Patricia A Robertson, of the University of California, San Francisco, for her contributions to designing the study; Jeanette S Brown and Peter Bacchetti, of the University of California, San Francisco, and Jocelyn C White, of the Oregon Health Sciences University, Portland, for reviewing the survey instrument; and Jessica J Watson and Amy V Kindrick for assisting in analyzing the data.
See Commentary, p 384.
Funding: Lesbian Health Fund of the Gay and Lesbian Medical Association
Competing interests: None declared