Receipt of preventive health care services by lesbians

doi:10.1016/S0749-3797(00)00192-6

American Journal of Preventive Medicine

Volume 19, Issue 3, October 2000, Pages 141-148

https://doi.org/10.1016/S0749-3797(00)00192-6 Get rights and content

Abstract

Background: We measured receipt of age-appropriate preventive health services by lesbians and assessed whether provider and individual characteristics, including disclosure of sexual orientation, are independently associated with receipt of these services.

Methods: A questionnaire was printed in a national biweekly gay, lesbian, and bisexual news magazine, and self-identified lesbians living in all U.S. states (N =6935) responded to the survey. Main outcome variables were receipt of a Pap smear within the preceding 1 and 2 years and, for women aged ≥50, receipt of a mammogram within the past 1 and 2 years.

Results: Fifty-four percent had Pap smears within 1 year and 71% within 2 years, with increasing rates among older and more educated respondents. Seventy percent of respondents aged ≥50 had a mammogram in the past year, and 83% within 2 years; rates did not vary significantly controlling for education. Sixty percent had disclosed their sexual orientation to their regular health care provider. Controlling for patient and provider characteristics, disclosure was independently associated with receipt of Pap smears, but not mammograms.

Conclusions: It is important for providers to identify their lesbian patients’ unmet needs for preventive health care. Additionally, it is important for providers to provide complete and appropriate preventive health care for their lesbian patients. Further research is needed to determine why lesbians are not receiving Pap smears at the recommended rate and whether this disparity is reflective of aspects of cervical cancer screening or indicates a more general problem with access to health care including receipt of preventive services.

Section snippets

Survey instrument

Three researchers (including MS and JL) developed a 186-item questionnaire and had it printed in The Advocate, a biweekly national news magazine for gay men, lesbians, and bisexual men and women. The questionnaire appeared as a several-page insert in the center of the March 21, 1995, issue and included a postage-paid return-addressed mailer. The questionnaire included items pertaining to sociodemographic characteristics, self-identified sexual orientation, provider/site for health care,

Sample characteristics

The median age for respondents was 34 years. Although ages range from 15 to 93, 85% were aged 25 to 49 (Table 1). The majority of respondents were Caucasian, almost two thirds were college graduates, the median income range was $20,000 to $30,000, and respondents were from urban and rural communities.

Most women (81%) had regular health care providers or sites of care, and 60% of these women had disclosed their sexual orientation to their regular providers (Table 1). Seventy percent of regular

Discussion

The comparison of lesbians’ rates of receipt of Pap smears with rates for American women in general might mislead some readers to believe that currently lesbians are more likely to get this preventive screening test. However, findings from the recent Gallup Poll that allowed us to compare rates after stratifying by age and education, revealed that young lesbians, especially, are at increased risk for not receiving Pap smears relative to their counterparts in the general U.S. population.45 Of

Acknowledgements

This study was supported by grants from the Centers for Disease Control and Prevention and the Lesbian Health Fund, and by the UCLA Robert Wood Johnson Clinical Scholars Program and the University of California, Los Angeles–NRSA Primary Care Fellowship. We thank Carol Edwards for programming, David E. Kanouse for assistance in survey development, Lillian Gelberg MD, MSPH, for her input on early drafts of this manuscript, and the comments of the anonymous reviewers. This work does not

References (79)

S.R Johnson et al.
Factors influencing lesbian gynecologic carea preliminary study
Am J Obstet Gynecol
(1981)
L Zeidenstein
Gynecological and childbearing needs of lesbians
J Nurse Midwifery
(1990)
D.A Grimes et al.
Primary prevention of gynecologic cancers
Am J Obstet Gynecol
(1995)
K.A Oriel et al.
Trends in United States ovarian cancer mortality, 1979–1995
Obstet Gynecol
(1999)
R Denenberg
Report on lesbian health
Womens Health Int
(1995)
E.J Rankow
Breast and cervical cancer among lesbians
Womens Health Issues
(1995)
R.M Andersen
Revisiting the behavioral model and access to medical caredoes it matter?
J Health Soc Behav
(1995)
B.S Hulka et al.
Patterns of utilizationthe patient perspective
Med Care
(1985)
A.L Solarz
Lesbian healthcurrent assessment and directions for the future
(1999)
S.R Johnson et al.
Comparison of gynecologic health care problems between lesbians and bisexual womena survey of 2345 women
J Reprod Med
(1987)

J Bradford et al.

The National Lesbian Health Care Survey Final Report

(1987)

E.J Rankow et al.

Cervical cancer risk and Papanicolaou screening in a sample of lesbian and bisexual women

J Fam Pract

(1998)

S.J Roberts et al.

Health related behaviors and cancer screening of lesbiansresults from the Boston Lesbian Health Project

Women and Health

(1999)

J.H Price et al.

Perceptions of cervical cancer and Pap smear screening behavior by women’s sexual orientation

J Comm Health

(1996)

N.M Carroll

Optimal gynecologic and obstetric care for lesbians

Obstet Gynec

(1999)

Koh A. Use of preventive health behaviors by lesbian, bisexual, and heterosexual women: questionnaire survey. West J...

Diamant AL, Spritzer K, Wold C, Gelberg L. The effect of sexual orientation on health behaviors, health status, and...

L.A Aday et al.

A framework for the study of access to medical care

Health Serv Res

(1974)

J.S Weissman et al.

Delayed access to health carerisk factors, reasons, and consequences

Ann Intern Med

(1991)

L.A Aday et al.

Health sources utilization models

M Millman

Access to health care in America. National Academy of Sciences

(1993)

J.M Lambrew et al.

The effects of having a regular doctor on access to primary care

Med Care

(1996)

J.S Weissman et al.

Delayed access to health carerisk factors, reasons, and consequences

Ann Intern Med

(1991)

L Dardick et al.

Openness between gay persons and health professionals

Ann Intern Med

(1980)

E.M Smith et al.

Health care attitudes and experiences during gynecologic care among lesbians and bisexuals

Am J Public Health

(1985)

S.D Cochran et al.

Disclosure of sexual preference to physicians by black lesbian and bisexual women

West J Med

(1988)

D Bybee

The Michigan Lesbian Health Survey

(1991)

L Warshafsky

Lesbian health needs assessment

(1992)

O’Hanlan K. Lesbian health and homophobia: perspectives for the treating obstetrician/gynecologist. Curr Probl Obstet...

A.L Diamant et al.

Lesbians’ sexual histories with menimplications for taking a sexual history

Arch Intern Med

(1999)

P.M Nardi

The globalization of the gay and lesbian socio-political movementsome observations about Europe with a focus on Italy

Sociological Perspectives

(1998)

It’s normal to be queer. Economist...

Guide to clinical preventive services, 2nd ed

(1996)

Centers for Disease Control and Prevention, National Center for Health Statistics. National health interview survey....

American Cancer Society statement on mammography guidelines

(1997)

National Cancer Institute. Statement from the National Cancer Institute on the National Cancer Advisory Board...

AMA guidelines for adolescent preventive services (GAPS)recommendations and rationale

(1994)

G Ursin et al.

Use of oral contraceptives and risk of breast cancer in young women

Breast Cancer Res Treat

(1998)

Van Os WA, Edelman DA, Rhemrev PE, Grant S. Oral contraceptives and breast cancer risk. Advances in contraception...

Cited by (110)

The Annual Examination for Lesbian, Gay, and Bisexual Patients
2021, Primary Care - Clinics in Office Practice
Contraceptive use by women across different sexual orientation groups
2019, Contraception
To examine contraceptive methods used across sexual orientation groups.
We collected data from 118,462 female participants in two longitudinal cohorts—the Nurses’ Health Study (NHS) 2 (founded in 1989, participants born 1947-1964) and NHS3 (founded in 2010, born 1965-1995). We used log-binomial models to estimate contraceptive methods ever used across sexual orientation groups and cohorts, adjusting for age and race.
Lesbians were the least likely of all sexual orientation groups to use any contraceptive method. Lesbians in NHS2 were 90% less likely than heterosexuals to use long-acting reversible contraceptives (LARCs; adjusted risk ratio [aRR]; 95% confidence interval [CI]: 0.10 [0.04, 0.26]) and results were similar for other contraceptive methods and in the NHS3 cohort. Compared to the reference group of completely heterosexual participants with no same-sex partners, those who identified as completely heterosexual with same-sex partners, mostly heterosexual, or bisexual were generally more likely to use any method of contraception. Use of LARCs was especially striking across sexual minority groups, and, with the exception of lesbians, they were more likely to use LARCs; as one illustration, NHS3 bisexuals were more than twice as likely to use LARCs (aRR [95% CI]: 2.01 [1.67, 2.42]).
While certain sexual minority subgroups (e.g., bisexuals) were more likely than heterosexuals to use contraceptive methods such as LARCs, lesbians were less likely to use any method.
Many sexual minority patients need contraceptive counseling and providers should ensure to offer this counseling to patients in need, regardless of sexual orientation.
Predicting cervical cancer screening among sexual minority women using Classification and Regression Tree analysis
2019, Preventive Medicine Reports
Citation Excerpt :
Other research suggests that “cues to screening” that are common among heterosexual women, such as receiving other sexual and reproductive healthcare services, may be less common among SMW (Charlton et al., 2014; Agénor et al., 2014b, 2015; Greene et al., 2018; Reiter and McRee, 2015; Eaton et al., 2008; Johnson et al., 2016a; Tracy et al., 2010). Healthcare provider- and system-level factors such as provider recommendation of Pap testing (Reiter and McRee, 2015; Johnson et al., 2016a; Marrazzo et al., 2001; Tracy et al., 2013), good communication with providers (Agénor et al., 2015; Johnson et al., 2016a, 2016b; Clark et al., 2003), and disclosing one's sexual minority identity to providers (Reiter and McRee, 2015; Tracy et al., 2013; Clark et al., 2003; Diamant et al., 2000) have been associated with higher rates of screening among SMW. However, the impact of these potential “cues to screening” may vary among groups of SMW with different specific sexual histories, racial or ethnic identities, level of education, and socioeconomic resources (Agénor et al., 2015; Calabrese et al., 2014; Bowleg et al., 2003; Miles-Richardson et al., 2017).
Cervical cancer screening is a critical preventive healthcare service for all women. Sexual minority women (SMW) in the United States experience multiple health disparities including decreased access to and use of cervical cancer screening. The mechanisms driving these disparities are not clear and SMW with multiple marginalized identities may be more likely to miss recommended cervical cancer screening. This study aimed to identify subgroups of SMW that are more and less likely to be screened for cervical cancer according to American Cancer Society guidelines. We used cross-sectional data from the latest (2010–2012) wave of the Chicago Health and Life Experiences of Women (CHLEW) Study (N = 691). Informed by intersectionality theory, we performed classification and regression tree (CART) modeling to construct a data-driven, predictive model of subgroups of SMW who were more and less likely to receive guideline-recommended screening. Notably, the CART model did not include commonly tested variables such as race/ethnicity or level of income or education. The model did identify subgroups with low likelihood of receiving screening and several novel variables that may be important in understanding SMW's use of cervical cancer screening; lifetime number of sexual partners, age at drinking onset, childhood physical abuse, and internalized homonegativity. Our results point to the importance of early life experiences and identity development processes in shaping patterns of preventive healthcare use among adult SMW. Our analysis also demonstrated the potential value of CART modeling techniques for evaluating how multiple variables interact in complex ways to predict cervical cancer screening.
Proportion of patients who disclose their sexual orientation to healthcare providers and its relationship to patient outcomes: A meta-analysis and review
2018, Patient Education and Counseling
Patient-centered care emphasizes the need to form a therapeutic and trusting relationship between patients and providers in which patients feel comfortable disclosing health-relevant and personal information. It is still unknown how many patients disclose their sexual orientation to providers, under what circumstances and what it is related to in terms of outcomes.
The present meta-analysis and review sought to identify the overall proportion of sexual orientation disclosure to healthcare providers, facilitators and barriers of disclosure, patient populations less likely to disclose, and the relationship between disclosure and outcomes. Thirty-five studies met the inclusion criteria yielding 38 independent proportions. Characteristics of patients, providers, location, and disclosure were extracted.
Sexual orientation disclosure proportions to healthcare providers ranged from .29 to .98. The random-effects pooled estimate was .63 (95% CI: .58, .68). Disclosure compared to nondisclosure was related to more positive direct and indirect health outcomes including higher satisfaction, more healthcare seeking and screenings and better self-reported health and psychological wellbeing.
The overall proportion of disclosure to healthcare providers varied by patient, provider, location, and disclosure characteristics.
These findings emphasize the need for future interventions directed at facilitating disclosure among populations identified as less likely to disclose.
Legal and Policy Issues for LGBT Patients with Cancer or at Elevated Risk of Cancer
2018, Seminars in Oncology Nursing
To understand the major legal and policy issues for lesbian, gay, bisexual and transgender (LGBT) cancer patients.
LGBT health policy research.
Major policy issues include discrimination, lack of cultural competency and clinically appropriate care, insurance coverage, family recognition, and sexual orientation and gender identity data collection.
Nurses play a major role in providing affirming and competent care to LGBT cancer patients. Using correct names and pronouns with transgender patients, and collecting sexual orientation and gender identity data can send an affirming message to LGBT patients, as well as inform decision support and preventive screenings, and improve treatment outcomes.
Sexual Minority Women's Satisfaction with Health Care Providers and State-level Structural Support: Investigating the Impact of Lesbian, Gay, Bisexual, and Transgender Nondiscrimination Legislation
2017, Women's Health Issues
Structural discrimination is associated with negative health outcomes among sexual minority populations. Recent changes to state-level and national legislation provide both the opportunity and the need to further explore the impact of legislation on the health indicators of sexual minorities. Using an ecosocial theory lens, the present research addresses the relationship between structural support or discrimination and satisfaction with one's health care provider among sexual minority women.
Data were drawn from an online survey of sexual minority women's health care experiences. Using the Andersen Behavioral Model of Health Services Utilization to operationalize the variables in our model, we examined the relationship between state-level nondiscrimination legislation and satisfaction with provider—a widely used measure of health care quality—through regression analysis.
Participants in structurally supportive states (i.e., those with nondiscrimination legislation) were more likely to disclose their sexual identity to their providers and to report higher satisfaction with their providers. The absence of nondiscrimination legislation was associated negatively with satisfaction with providers.
Results of our study show that the external environment in which sexual minority women seek health care, characterized by structural support or lack thereof, is related to perceived quality of health care.

View all citing articles on Scopus

¹: The full text of this article is available via AJPM Online at http://www.elsevier.com/locate/ajpmonline.

View full text

Research articleReceipt of preventive health care services by lesbians1

Abstract

Section snippets

Survey instrument

Sample characteristics

Discussion

Acknowledgements

Am J Obstet Gynecol

J Nurse Midwifery

Am J Obstet Gynecol

Obstet Gynecol

Womens Health Int

Womens Health Issues

Revisiting the behavioral model and access to medical caredoes it matter?

J Health Soc Behav

Patterns of utilizationthe patient perspective

Med Care

Lesbian healthcurrent assessment and directions for the future

Comparison of gynecologic health care problems between lesbians and bisexual womena survey of 2345 women

J Reprod Med

The National Lesbian Health Care Survey Final Report

Cervical cancer risk and Papanicolaou screening in a sample of lesbian and bisexual women

J Fam Pract

Health related behaviors and cancer screening of lesbiansresults from the Boston Lesbian Health Project

Women and Health

Perceptions of cervical cancer and Pap smear screening behavior by women’s sexual orientation

J Comm Health

Optimal gynecologic and obstetric care for lesbians

Obstet Gynec

A framework for the study of access to medical care

Health Serv Res

Delayed access to health carerisk factors, reasons, and consequences

Ann Intern Med

Health sources utilization models

Access to health care in America. National Academy of Sciences

The effects of having a regular doctor on access to primary care

Med Care

Delayed access to health carerisk factors, reasons, and consequences

Ann Intern Med

Openness between gay persons and health professionals

Ann Intern Med

Health care attitudes and experiences during gynecologic care among lesbians and bisexuals

Am J Public Health

Disclosure of sexual preference to physicians by black lesbian and bisexual women

West J Med

The Michigan Lesbian Health Survey

Lesbian health needs assessment

Lesbians’ sexual histories with menimplications for taking a sexual history

Arch Intern Med

The globalization of the gay and lesbian socio-political movementsome observations about Europe with a focus on Italy

Sociological Perspectives

Guide to clinical preventive services, 2nd ed

American Cancer Society statement on mammography guidelines

AMA guidelines for adolescent preventive services (GAPS)recommendations and rationale

Use of oral contraceptives and risk of breast cancer in young women

Breast Cancer Res Treat

Research article
Receipt of preventive health care services by lesbians¹