I LESBIANS AND BISEXUAL WOMEN ^451 ^677
Lesbians and bisexual women are as diverse as the general population of all women. They are represented among all ages, racial and ethnic groups, and socioeconomic strata. Given this diversity, obstetrician-gynecologists will encounter lesbian and bisexual patients, although not all will disclose their sexual orientation.
Practitioners have the responsibility to provide quality care to all women regardless of sexual orientation.Finding accepting, supportive, and culturally competent health and mental health practitioners may be difficult for lesbians and bisexual women. For this reason, lesbians may forgo needed health care or may not disclose their sexual identity to health care providers. To address more fully the health care needs of lesbians, clinicians should educate themselves and examine their own biases, developing responses to disclosure that are positive, respectful, and therapeutic.
Barriers to Health Care
Lesbians and bisexual women may experience barriers to health care, including the following:
• Confidentiality and disclosure concerns, especially in the adolescent population
• Lack of insurance coverage, because many are not able to participate in their partners’ employment benefits package as would a married spouse
• Caregiver attitudes that cause them to hesitate in obtaining health care
• Limited understanding as to what their health risks may be
Routine Health Visits
Providers of reproductive health care and family planning services should not assume that patients, even if pregnant, are heterosexual. Likewise, they should not assume that women who say they are lesbians or bisexual are not in need of routine gynecologic care, including family planning and sexually transmitted infection (STI) and human immunodeficiency virus (HIV) screening and prevention counseling. Being a lesbian or bisexual woman does not inherently affect an individual’s health status.
There are no known physiologic differences between lesbians and heterosexual women. Standard comprehensive obstetric and gynecologic care is recommended for lesbians and bisexual women.Many practitioners incorrectly presume that lesbian patients do not require screening for cervical cancer because they are at low risk. However, most lesbians have been sexually active with men at some point in their lives, and human papillomavirus transmission and cervical dysplasia may occur even with sexual contact exclusively among women. The usual recommendations from the American College of Obstetricians and Gynecologists should be followed to determine the onset and interval for cervical cancer screening (see also the “Well-Woman Annual Health Assessment” section earlier in Part 3).
Lesbians and bisexual women should be screened for STIs and HIV based on the same risk factors as other women (see also the “Sexually Transmitted Infections” section earlier in Part 3). Again, because most lesbians have been sexually active with men at some point in their lives and because some STIs can be transmitted by sexual activity exclusively among women, it should not be assumed that STI screening is unnecessary. All patients, regardless of their sexual orientation, should be encouraged to practice safer sex. Safer sex practices for lesbians include using gloves and dental dams, using condoms on sex toys, avoiding sharing of sex toys, and avoiding contact with a partner’s menstrual blood and any visible genital lesions.
Psychosocial Concerns
Clinicians should be alert to the signs and symptoms of depression, substance abuse, and violence (including intimate partner violence) in all patients and conduct appropriate screening and intervention. Lesbians and bisexual women may be at greater risk of depressive disorders and drug or alcohol dependency. Violence and fear of violence because of sexual orientation can confer emotional sequelae, including depression, diminished self-esteem, and suicidal thoughts.
Mental health concerns also apply to youth who self-identify as lesbian, gay, or bisexual. Counseling may be very helpful for adolescents who are uncertain about their sexual orientation or have difficulty expressing their sexuality and can assist a lesbian or bisexual adolescent in coping with difficulties faced at home, school, or in the community (see also the “Adolescents” section earlier in Part 3).Legal Considerations
Most lesbians are in long-term relationships. Lesbians and their partners would be well advised to contact an attorney to keep abreast of legal decisions in their state regarding health care powers of attorney for each other. Sexual orientation should not be a barrier to receiving fertility services to achieve a pregnancy. Lesbians should have equal access to co-parenting and second parent adoption rights. This view also is supported by the American Academy of Pediatrics and the American Medical Association. Lesbians in same-sex parent families should be encouraged to confer with an attorney because the laws on adoption vary by state and continue to evolve. The American College of Obstetricians and Gynecologists supports equitable treatment for lesbians and their families, not only for direct health needs but also for indirect health issues, which include the same legal protections afforded married couples.
Creating a Welcoming Patient Care Environment
Obstetrician-gynecologists can make their practices more receptive to lesbian and bisexual patients by offering the following:
• Education and appropriate training of office staff to ensure a welcoming and respectful environment
• Registration forms and questionnaires that give patients the opportunity to identify sexual relationships and behaviors (see the “WellWoman Annual Health Assessment” section earlier in Part 3 and the “Sexual Function and Dysfunction” section in Part 4)
• Posted nondiscrimination policies
• Use of inclusive language such as partner or spouse
• Use of nonjudgmental methods for inquiring about sexual orientation and behavior:
— “Are you single, partnered, married, widowed, or divorced, or do you have a domestic partner?”
— “Are you or have you been sexually active with anyone—male, female, or both—or are you not sexually active?”
— “Who are you sexually attracted to—men, women, or both?”
• Reassurances regarding confidentiality, including the offer not to record information about sexual orientation in writing in the patient’s records or to code the information
• Display of educational materials about sexual orientation and gender issues for patients and their families (see Resources)
• Referrals to counseling and support groups for patients and their families (see Resources)
Bibliography
Addressing health risks of noncoital sexual activity.
Committee Opinion No. 582. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013; 122:1378-83. [PubMed] [Obstetrics & Gynecology]Health care for lesbians and bisexual women. Committee Opinion No. 525. American College of Obstetricians and Gynecologists. Obstet Gynecol 2012;119:1077-80. [PubMed] [Obstetrics & Gynecology]
Marriage equality for same-sex couples. Committee Opinion No. 574. American College Obstetricians and Gynecologists. Obstet Gynecol 2013;122:729-32. [PubMed] [Obstetrics & Gynecology]
Resources
Gates GJ. How many people are lesbian, gay, bisexual, and transgender? Los Angeles (CA): The Williams Institute, UCLA School of Law; 2011. Available at: http://wil liamsinstitute.law.ucla.edu/wp-content/uploads/Gates-How-Many-People-LGBT- Apr-2011.pdf Retrieved July 31, 2013.
Gay and Lesbian Medical Association. Available at: http://www.glma.org. Retrieved July 31, 2013.
Parents, Family, and Friends of Lesbians and Gays. Available at: http://community. pflag.org. Retrieved July 31, 2013.
Whitman-Walker Health. Mautner Project of Whitman-Walker Health. Available at: http://www.whitman-walker.org/mautnerproject. Retrieved April 10, 2014.