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About 10% of the population is lesbian, gay, bisexual, or transgender.1,2 These people face health care risks that are often not addressed because of lack of knowledge of the patient's sexual orientation, ignorance of specific health care issues, or because the patient feels that the health care professional is homophobic. The goals of this article are to educate health care professionals on specific health care issues faced by this community.
Only a limited amount of information is available on health care risks within the lesbian, gay, bisexual, or transgender population. Most studies do not address sexual orientation. Fear of stigmatization prevents many people from identifying themselves as lesbian, gay, bisexual, or transgender. In addition, many do not seek health care (and are therefore excluded from health studies) because of prior negative experience. As many as two thirds of physicians never ask patients about their sexual orientation.3 Some health care professionals assume that their patients are heterosexual. Others may be homophobic and hostile and prefer to avoid the issue.
A MEDLINE search was conducted using “homosexuality” paired with specific health care terms such as “substance abuse,” “breast cancer,” “cervical cancer,” and “suicide.” Because of the paucity of research on the specific health care issues facing the lesbian, gay, bisexual, and transgender population (except for human immunodeficiency virus [HIV] infection or acquired immunodeficiency syndrome in homosexual men), the search was conducted on 1980 to current databases.
In the controversial report of the Secretary of the Department of Health and Human Services, Task Force on Youth Suicide in 1989, Gibson estimated that gay youths account for 30% of completed suicides.4 Forty percent of lesbian, gay, bisexual, or transgender youth have either attempted or seriously contemplated suicide. Gay men are 6 times more likely to attempt suicide than their heterosexual counterparts; lesbians are twice as likely to attempt suicide as heterosexual women.4 In general, suicide attempts by gay men are more severe than those of their heterosexual counterparts.5 Risk factors associated with an increased likelihood of suicide attempts included nonconforming to gender (for example, men in more feminine gender roles), self-identification as gay or bisexual at a young age, first homosexual experience at an early age, history of sexual or physical abuse, and rejection from important social supports.5,6
Adults are also at risk. Some people do not realize their sexual orientation until adulthood and face social isolation, fear of discrimination at work, and loss of loved ones. Suicide prevention awareness and intervention (table) have been shown to decrease the number of suicide attempts and completions.7
Early reports on drug and alcohol use in the lesbian, gay, bisexual, and transgender community suggested that substance abuse affected about a third of the adult gay population (L H Fifield, J D Lathan, C Phillips, “Alcoholism in the Gay Community: the Price of Alienation, Isolation, and Oppression,” a project of the Gay Community Services Center, Los Angeles, 1977). More recent population-based surveys found few differences in drinking patterns and frequency of drug misuse between homosexual and heterosexual men.8 Comparisons of lesbian and heterosexual women showed no differences in alcohol consumption, although lesbians and bisexual women were more likely to report being recovering alcoholics.9,10
Gay men use a wider variety of drugs, such as marijuana, “poppers” (amyl nitrite or butyl nitrite), methylene-dioxyamphetamine (MDA), barbiturates, ethyl chloride, and amphetamines.8 Although causality cannot be determined, a history of consistent use of inhalants, amphetamines, and cocaine is strongly associated with HIV seroconversion, independent of injection drug use.11
About 35% of gay men and 38% to 43% of lesbians reported smoking cigarettes in the past month. This exceeds national averages found in the 1990 National Household Survey on Drug Abuse, which reported current cigarette smoking in 27% of men and 22% of women.12 Health care professionals should actively assess the extent and context of substance misuse in their lesbian, gay, bisexual, and transgender patients. Patients should be referred to treatment and support groups (see box p 405) that are sensitive to this population.
In 41 of 50 states, discriminating against an employee—firing or refusing to hire—based solely on his or her sexual orientation is still legal (www.ngltf.org). In addition, most states do not include sexual orientation under hate crime laws.
In an environment that offers little protection and an abundance of homophobic sentiment, many people are subject to antigay violence and harassment. In a survey of college students and faculty at Yale University, 65% of the lesbian, gay, bisexual, and transgender population had experienced verbal insults. A fourth were threatened with physical violence.13
Health care professionals should create a safe, nonjudgmental environment for battered patients—such as posting sticker-notices to indicate safe zones for the lesbian, gay, bisexual, and transgender population—and take an active role in stopping the perpetration of antigay sentiment among colleagues. In addition, professionals should be aware of community support systems within schools and workplaces.
More than 95% of lesbian, gay, bisexual, and transgender youth feel separated and emotionally isolated from their peers because they feel different. Almost half of gay youth and 20% of lesbians are verbally or physically assaulted in secondary school.4 Lesbian, gay, bisexual, and transgender youth are 4 times more likely to be threatened with a weapon on school property than their heterosexual counterparts.14 Lesbian, gay, bisexual, and transgender youth are 5 times more likely to miss school for fear of their personal safety; 28% of these students drop out of high school.14,15
Nearly 60% of bisexual and gay male youths in 1 study were currently using substances and met psychiatric criteria for substance misuse.16 Lesbian, gay, bisexual, and transgender youths are 9 times more likely to use injectable drugs. They also are more likely to engage in sexual activity, use cocaine, and smoke marijuana and tobacco before age 13.17
Lesbian, gay, bisexual, and transgender resources
It is estimated that lesbian, gay, bisexual, and transgender adolescents are 3 times more likely to attempt suicide than their heterosexual counterparts.14 Of those who are homeless, about half have attempted suicide at least once.18
Many lesbian, gay, bisexual, and transgender youth leave their home because of stresses in the family environment or because they are thrown out by homophobic parents.19 Many foster homes will not accept openly gay, lesbian, bisexual, or transgender youth because of homophobia and fear of predation on other children in the home. About 6% of all runaway youth identify themselves as gay or lesbian.18 In certain locales, lesbian, gay, bisexual, and transgender youths make up a much larger percentage of runaways: 40% of street youths in Seattle and 30% of runaway youths in Los Angeles.15
In a study of lesbian, gay, bisexual, or transgender youth, 40% had experienced violent physical attacks. The Massachusetts Governor's Commission on Gay and Lesbian Youth in their 1993 education report cited numerous anecdotes of physical assaults by both peers and family members.15
Many lesbian, gay, bisexual, and transgender youth have low self-esteem and resort to prostitution to survive and to escape physical, sexual, and emotional abuse in their homes and schools. On the street, they are victims of rape, exploitation, drug misuse, and at risk of contracting HIV.17
In a recent national survey, only 54% of lesbian and bisexual women had been given a cervical smear within the past year, and 7.5% had never had a Papanicolaou smear.20 This is partially due to the misconception of both lesbians and health care professionals that lesbians are not at risk of cervical cancer.21 In one study, 30% of lesbians and bisexual women had a history of sexually transmitted diseases.22 There are several case reports of cervical intraepithelial neoplasia and infection with human papillomavirus in women who admit to sexual activity only with women.23,24 In one study of women with no history of sex with men, 14% had cervical intraepithelial lesions.25 Sexually contracted diseases are thought to be transmitted through vaginal secretions and possibly fomites, such as sex toys.23,26 Physicians should recommend cervical screening according to current guidelines and teach safe sex techniques to prevent the transmission of human papillomavirus between sexual partners.
Lesbian and bisexual women are less likely to use oral contraceptives, more likely to be nulliparous, and more likely to smoke cigarettes than heterosexual women—all risk factors for breast and endometrial cancer.9,27 Studies on the number of lesbian and bisexual women having mammography compared with heterosexual women are contradictory, with 1 national survey showing the former population more likely to have mammography—although most respondents were white and well educated20—and others showing they are less likely to either have mammography or examine their own breasts.27 Health care professionals should recommend annual screening according to guidelines. They should also be aware of local support groups for lesbians with breast cancer.
Recent evidence suggests that it is possible to transmit diseases from woman to woman through sexual activity.23 Although there is no clear evidence of woman-to-woman transmission of HIV, several cases have been reported where the only known risk factor was sexual contact with a woman.26 The virus has been detected in cervical and vaginal secretions throughout the menstrual cycle. Sexual behaviors thought to be associated with increased risk of transmission include vaginal-vaginal contact, cunnilingus, anilingus, digital or manual vaginal or anal contact, and insertion of sexual devices or toys into the mouth, vagina, or anus. Sex toys such as dildos, vibrators, and anal-insertive devices may cause trauma and increase the risk of HIV transmission. The sharing of toys without disinfection between partners may allow exchange of infected fluids.26 Unprotected oral-genital contact can lead to oropharyngeal carriage of gonorrhea. Oral-anal intercourse may transmit gastrointestinal infections such as Giardia lamblia and Entamoeba histolytica.28
Health care professionals should take a detailed sexual history, including the number and sex of previous partners, specific activities engaged in, and the use of preventive measures such as condoms, gloves, and dental dams. Practitioners should educate their lesbian and bisexual female patients on the risks of sexually transmitted diseases and the proper use of protective barriers.
Gay men have higher rates of dieting and binge eating than heterosexual men.29 One study found that clinical eating disorders could be diagnosed in 17% of gay men, 14% of heterosexual women, 4.2% of lesbians, and 3.4% of heterosexual men surveyed.30 Health care professionals should refer patients with eating disorders to community groups and specialists who are sensitive to gay issues.
The association between anal-receptive intercourse and increased risk of HIV transmission has long been established and is thought to be due to HIV entrance at points of mucosal trauma.26 Anal-receptive intercourse is associated with an increased risk of infection with HIV, human papillomavirus, hepatitis B virus, and herpesvirus. Anal- and oral-insertive (during fellatio) intercourse is strongly associated with urethritis, including gonococcal and chlamydial infection. Oral-receptive intercourse increases the risk of HIV and pharyngeal gonorrhea infection.31 Oral-anal intercourse may lead to gastrointestinal infection caused by organisms such as G lamblia; E histolytica; Shigella, Salmonella, and Campylobacter species; and hepatitis A virus.28
Because each sexual behavior carries a separate risk of transmitting disease, health care professionals must assess sexual activity. Physicians must also assess the competency of their patients to use preventive measures. One study of gay men found that more than 80% of them did not know how to use condoms appropriately.32
The risk factors for the development of anal cancer are a history of anal-receptive intercourse; history of genital warts; herpes simplex virus, type 2, infection; hepatitis B virus infection; history of chlamydial infection; and being a current smoker.33
Patients who practice anal-receptive intercourse and are infected with HIV have a greater risk of developing high-grade anal intraepithelial neoplasia and anal cancer.34 Physicians should examine the anal area of patients practicing anal intercourse and search for predisposing diseases and anal cancer.35
Transgender persons are those who maintain a strong and persistent cross-gender identification, not merely a desire for any cultural advantages of being the other sex. Transgender persons are considered by the American Psychiatric Association to have gender identity disorder. Those who are transgender (transsexual) face even greater challenges than lesbians, gays, and bisexuals. They are a minority within a minority group. Therefore, they may be at greater risk for depression, suicide, substance abuse, and antigay violence, although this has not been studied.
Transsexuals may seek gender reassignment surgery. The process of gender reassignment is long and involves psychiatric, endocrinologic, and surgical evaluation. People begin hormone therapy before any surgical procedure. In addition to the risk of thromboembolism and liver abnormalities with estrogen use, there is also the rare possibility of pituitary prolactinoma developing.36 For female-to-male transgender persons, androgen therapy carries an increased risk for heart disease, endometrial hyperplasia, and subsequent endometrial carcinoma.37
Gender reassignment surgery may cause sexual dysfunction, especially with sexual responsivity.38 In addition, although the neovagina in male-to-female transsexuals is relatively resistant to infection, cases of gonococcal urethritis and vaginitis have been reported.39 Those who use hormone therapy but decide not to undergo surgery continue to be at risk for endometrial cancer (female-to-male persons) and prostate cancer (male-to-female persons).37,40
Physicians need to be especially sensitive to the psychosocial and medical status of their transgender patients. Some patients choose to be called by a name that may conform more to their ideal gender.
Lesbian, gay, bisexual, and transgender persons face unique health care risks. Further research is needed to fully evaluate the health care issues facing this population. Community outreach is needed to educate people on their health risks, the need for screening, and preventive measures.
Competing interests: None declared
Dr Lee is a resident in internal medicine at the Cleveland Clinic Foundation. She plans to practice general internal medicine with an emphasis on lesbian, gay, bisexual, and transgender health.