Theoretical writings and research suggest that the onset, course, treatment, and prevention of mental disorders among lesbians and gay men differ in important ways from those of other individuals. Recent improvements in studies of sexual orientation and mental health morbidity have enabled researchers to find some elevated risk for stress-sensitive disorders that is generally attributed to the harmful effects of antihomosexual bias. Lesbians and gay men who seek mental health services must find culturally competent care within systems that may not fully address their concerns. The affirmative therapies offer a model for intervention, but their efficacy and effectiveness need to be empirically documented. Although methodological obstacles are substantial, failure to consider research questions in this domain overlooks the welfare of individuals who may represent a sizable minority of those accessing mental health services annually.
Individual health risks are shaped by many factors beyond sexual orientation and sexual behavior, including family history and age. But it's important for lesbians and other women who have sex with women to understand the following health issues and take steps to stay healthy.
Violence can affect anyone in an intimate relationship. And research has shown that lesbians and other women who have sex with women experience intimate partner violence at a higher rate than do other people. But they might be less likely to report this kind of violence due to:
During the strike, the Thatcher government sequestered the funds of the National Union of Mineworkers (NUM), meaning that it was pointless for supporters of the strike to send donations to the national union. Instead, support groups in Britain were encouraged to "twin" with the various mining communities in England, Scotland and Wales. Among these organisations, the LGSM was formed by Communist Party of Great Britain activist Mark Ashton and his friends, after they collected donations for the miners at the 1984 Lesbian and Gay Pride march in London. The London LGSM group met and fundraised in numerous locations, including the Gay's the Word bookshop. The group grew rapidly and moved out of Gay's The Word to a larger venue: The Fallen Angel, a gay pub in Graham Street, Islington. The London group was twinned with the Neath, Dulais and Swansea Valleys Miners Support Groups. In November 1984, a group of lesbians broke away from LGSM to form a separate group, Lesbians Against Pit Closures, although some lesbians remained active in the LGSM campaign rather than joining the women-only group.
Identifying the physical and mental health problems for which lesbians are at higher risk is not a straightforward task. Although lesbians share many of the same health risks with women in general, a number of factors act to influence their health risks in unique ways.
In this chapter, several frameworks are presented for examining lesbian health and health risks in order to elucidate some of the unique influences on lesbian health. The first framework considers lesbians in the larger contexts of society, the health care system, and women in general. The second framework takes a developmental approach to examining the unique factors that affect lesbian health across the life span. The final framework examines specific physical and mental health concerns for lesbians, and reviews the risk and protective factors that have an impact on their risk for these problems. When examined together, these various approaches provide a more complete picture of the complexity involved in looking at lesbian health.
Historically, lesbians have been the target of prejudice and discrimination, both public and private, and the stigmatization of homosexuality remains widespread in our society (APA, 1997; Perrin, 1996). Although many kinds of abuse of and discrimination against lesbians have been clearly documented, their impact on physical and mental health remains in need of study. Until 1973 the American Psychiatric Association classified homosexuality as an illness or pathological condition. Although no longer classified as an aberrant condition, negative attitudes about gays and lesbians continue to be held by many members of the public, including health and mental health care providers (Bradford et al., 1994b; Garnets et al., 1991; Rothblum, 1994; Wolfe, 1998).
Experience with discrimination or prejudice is common among lesbians. For example, in a multisite longitudinal study of cardiovascular risk factors in black and white adults ages 25 to 37 years, 33% of the black women and 56% of the white women who reported having had at least one same-sex sexual partner reported experience with discrimination on the basis of sexual orientation (Krieger and Sidney, 1997). Eighty-five percent of the black women further reported discrimination based on race. Most of the women (89%) also reported having experienced gender discrimination.
Gay men and lesbians are also at risk of being targets of violence based on their sexual orientation or behavior. Antigay hate crimes accounted for 11.6% of the hate crime statistics collected by the Federal Bureau of Investigation (FBI) in 1996, making this the third largest category following racial hate crimes and crimes based on religion (FBI, 1996).1 More than half of the respondents in the National Lesbian Health Care Survey (NLHCS) reported that they had been verbally attacked because they were lesbian, and 8% said that they had been physically attacked (Bradford and Ryan, 1988). Similarly, nearly half of the women surveyed in the Michigan Lesbian Health Survey (MLHS) reported having experienced a verbal attack because of their lesbian identity, and 5% reported having been physically attacked (Bybee and Roeder, 1990).
Numerous states have in place laws that negatively target gay men and lesbians (NGLTF, 1998; see also Table 2.1). Although some states have laws that ban discrimination on the basis of sexual orientation in employment, housing, credit, and public accommodation, many do not. Passage of such laws remains controversial. For example, in Maine where such legislation passed in 1997, voters subsequently voted to overturn the law (NGLTF, 1998). In some states, laws are in place to prohibit state and county employees from receiving domestic partner benefits. Same-sex marriage is specifically banned in 25 states and is not legal in any state. Efforts are also underway in some states to prevent same-sex couples from adopting children or serving as foster parents. Finally, numerous states ban same-sex sodomy specifically or along with opposite-sex sodomy.
Lesbian health and risks to health can be examined in the context of the health care system. In other words, are there aspects of the health care system that act to reduce lesbian's access to services, thereby possibly increasing their risk of health problems? Access to health care has been defined as the timely use of personal health services to achieve the best possible health outcomes (IOM, 1993). The three primary types of barriers are (1) structural barriers (e.g., availability of services, organizational configuration of health care providers); (2) financial barriers (e.g., insurance coverage); and (3) personal and cultural barriers (e.g., attitudes of patients and providers) (IOM, 1993). The test of equal access involves determining whether there are systematic differences in use and outcome among groups in society and whether these differences are the result of barriers to care. The committee finds that there is evidence that lesbians may face particular challenges in all three areas.
Structural barriers that affect health care for lesbians include potential barriers presented by managed care systems and the fact that lesbian relationships are often not afforded the same legal standing as heterosexual marriages.
Managed Care. Most Americans indicate that their first choice is to see a physician in the physician's private office. Although some lesbians report that they prefer other types of providers (e.g., naturopaths, chiropractors, nurse practitioners) and to receive care in clinics, the majority report that they receive primary care from a medical doctor (Bradford et al., 1994b; Bybee and Roeder, 1990; Moran, 1996; White and Dull, 1997). Although data are not yet available to determine the impact of managed care on the quality of health care for lesbians, the committee believes that negative consequences are possible for the following reasons:
Since insurance coverage is the primary gateway to health care in this country, lesbians are at a distinct disadvantage relative to married heterosexual women because of the common prohibition against spousal benefits for unmarried partners (Denenberg, 1995; Stevens, 1995). Among respondents to the NLHCS, 16% stated that they did not receive health care because it was unaffordable (Bradford and Ryan, 1988). In the MLHS, 12.3% of the lesbian sample reported that they did not have health insurance, compared to a state rate of 9.7% of Michigan women in general (Bybee and Roeder, 1990).
Although most middle-aged lesbians surveyed in the NLHCS reported good to excellent health, 27% reported that they lacked health insurance. Analysis indicated that lack of insurance may be more prevalent among lesbians with particularly serious health conditions. Lesbians without insurance were significantly more likely to report heart disease, to have Pap tests less often or never, to smoke, to have eating disorders (either overeating or undereating), and to be victims of physical and sexual abuse and antigay violence (Bradford et al., 1994a).
Personal and cultural barriers that affect access to care for lesbians include the lack of cultural competency among health care providers, the fear of coming out to providers, and the lack of lesbian focus in preventive and other health care.
Cultural Competency of Health Care Providers. Cultural competency refers to a set of skills that allows providers to give culturally appropriate high-quality services to individuals from cultures different from the providers'. These skills include understanding the culture and values of the group, the ability to communicate in the same language, and understanding the impact of group membership on health status, behavior, and attitudes. Cultural competency typically refers to providing services to people of different racial or ethnic groups. However, it also appropriately captures the skills needed to provide services effectively to lesbians. Providers who are culturally competent with respect to lesbians would be expected to understand the reasons lesbians might be reluctant to seek medical care and the impact of homophobia on the provision of services to lesbians; to be aware of the range of health problems experienced by lesbians as well as their health care risks; to avoid making heterosexual assumptions in the gathering of medical and social health information from patients; and to be willing to involve partners of lesbian patients in discussions about their health care. 041b061a72