Original articleHealth Status, Health Service Use, and Satisfaction According to Sexual Identity of Young Australian Women
Introduction
Health service use and satisfaction by lesbian and bisexual women is of particular interest because their health status is consistently reported to be poorer than that of heterosexual women. By rights, poorer health status should result in higher use of health services. Herein we have presented a secondary analysis of the young cohort of the Australian Longitudinal Study on Women’s Health (ALSWH) in which we focus on health status, access, and satisfaction according to sexual identity.
Population-based studies show that lesbian and bisexual women have higher rates of depression, anxiety, suicidal ideation, and substance use than their heterosexual counterparts. Such evidence comes from studies conducted with adult samples in the United States (Gilman et al., 2001, McCabe et al., 2009, Wilsnack et al., 2008), The Netherlands (Sandfort et al., 2006, Sandfort et al., 2001), the United Kingdom (Mercer et al., 2007), and Australia (Hillier et al., 2003, McNair et al., 2005), and with youth in New Zealand (Fergusson, Horwood, & Beautrais, 1999). A recent systematic review on mental health and substance use reiterates these findings (King et al., 2008).
Physical health has not been investigated to the same extent as mental health. However, the prevalence of cardiovascular disease, respiratory disease and cancers is posited to be higher among lesbian and bisexual women due to higher risk factors (smoking, alcohol, obesity; Aaron et al., 2001), nulliparity, reduced cancer screening, and reduced contraceptive pill use (Cochran et al., 2001, Dibble et al., 2004). Lower rates of cervical, breast, and cardiovascular screening have been found in population-based studies in the United States (Cochran et al., 2001, Diamant et al., 2000, Valanis et al., 2000) and Canada (Tjepkema, 2008). There is a some evidence suggesting higher rates of sexually transmissible infections among bisexually active women (Mercer et al., 2007), and higher levels of heart disease among lesbians (Diamant et al., 2000). Sandfort et al (2006) found that lesbian and gay adults were more likely than heterosexual adults to report acute physical symptoms and chronic physical conditions, although when mental health status was controlled, only chronic conditions were significantly different. Other investigators have found that higher rates of physical health problems among lesbian and bisexual women were largely mediated by higher levels of distress (Cochran & Mays, 2007).
Health care access varies according to the country and health care system studied. Data from the U.S. National Health Interview Survey (n = 93,418) showed that women in same-sex relationships (n = 614) were about one half as likely as women in heterosexual relationships to have seen a doctor in the previous 12 months or to have a regular source of care (Heck, Sell, & Gorin, 2006). These findings replicate the predominantly U.S.-based literature over the last 2 decades that suggests lower levels of access among lesbians (Banks and Gartrell, 1996, Clark et al., 2001, Mravcak, 2006), and even lower access among bisexual women (Rogers, Emanuel, & Bradford, 2003). Barriers to accessing U.S. health services have been summarized as limited heath insurance and next-of-kin rights, an inadequate number of providers competent in minority sexual orientation issues, a lack of specific prevention services, and a preference not to disclose sexual orientation (Mayer et al., 2008). A Canadian national probability survey compared health care use in 83,723 heterosexual, 695 lesbian, and 833 bisexual women and also found that lesbians were less likely to have seen a GP in the previous 12 months and less likely to have a regular doctor (Tjepkema, 2008). By contrast, lesbian and bisexual women were more likely to see a mental health care provider than were heterosexuals in the Canadian study (Tjepkema, 2008), and this was also found in a population-based Californian study (Grella, Greenwell, Mays, & Cochran, 2009). A large Dutch survey within 104 general practices completed by 9,684 patients, 1.5% of whom were lesbian and 1.2% bisexual, showed that “homosexuals” had a greater usage of physical and mental health care services (Bakker, Sandfort, Vanwesenbeeck, van Lindert, & Westert, 2006). To date, there has been no population-based Australian data published on access to health care among sexual minority women.
Levels of satisfaction with health care are consistently found to be lower for lesbian and bisexual women than heterosexual women, regardless of study location or sampling method (Diamant et al., 2000, Tjepkema, 2008). Reasons for dissatisfaction, particularly among north American samples, often relate to difficulty accessing health care (Diamant et al., 2000, Mathieson et al., 2002), and unmet health care needs (Tjepkema, 2008). Poor communication by providers including assumptions of heterosexuality is also implicated (Bonvicini & Perlin, 2003). Dissatisfaction can result from, or lead to, reluctance to disclose sexual orientation (Meckler, Elliott, Kanouse, Beals, & Schuster, 2006). Conversely, satisfaction with health care is found to be greater when providers and services are more culturally competent regarding minority sexual orientation (Hutchinson et al., 2006, Mayer et al., 2008, Polek et al., 2008).
The primary question addressed in this paper is whether health service usage and satisfaction differ based on sexual identity. We also present analyses of mental and physical health status and their association with differences in health care use and satisfaction. Based on previous literature, we posit two hypotheses: 1) that sexual minority women report greater use of health services than heterosexual women owing to their poorer health status; and 2) that satisfaction with care is lower among sexual minority women than among heterosexual women.
Section snippets
Participants
The study sample is from the third survey of the young cohort of women in the ALSWH. The ALSWH is a prospective, longitudinal study that has collected health data from three age cohorts of women via self-completed questionnaires every 3 years since 1996. The ALSWH sample was selected randomly from the database of Medicare Australia, the universal provider of government funded health insurance for all Australians. The younger cohort of women was 18 to 23 years old at baseline (n = 14,247), and
Sample Demographics
Sociodemographic characteristics differed significantly across the four sexual identity groups (Table 1). Mainly heterosexual women were most similar to heterosexual women in education and income, but most similar to bisexual women with regard to relationship, parental, and residential status. Bisexual women had the lowest levels of education and income (p < .01), were most likely of all four groups to have a Health Care Card (p < .001), and the least likely to have private health insurance (p
Discussion
Our finding of poorer mental health among minority sexual identity women has also been described in several other population-based studies. Conversely, the finding of poorer physical health, higher stress, and lower life satisfaction has not been described for Australian women, and is rarely described elsewhere. Although some observed differences in physical health are small (e.g., general health), we contend that given the young age of the sample and given the consistent pattern of results,
Conclusion
Results of this study have important implications, particularly for primary health care providers. Findings should raise awareness of the risks of health inequalities among sexual minority women, as well as the need for culturally sensitive approaches that encourage continuity of care. Poorer health status among sexual minority women requires further research to more fully understand reasons underlying these health disparities. Apart from the lower need for reproductive services, there is no
Acknowledgments
The research on which this paper is based was conducted as part of the Australian Longitudinal Study on Women’s Health, The University of Newcastle and The University of Queensland. We are grateful to the Australian Government Department of Health and Ageing for funding and to the women who provided the survey data.
We are grateful to the Lesbian Health Fund, USA, for providing us with a grant to enable this analysis and subsequent paper.
Ruth McNair is a Senior Lecturer and Director of Undergraduate Programs at the Department of General Practice, University of Melbourne, Australia. She is Chairperson of the Victorian Ministerial Advisory Committee on GLBTI Health and Wellbeing, and a practicing GP.
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Ruth McNair is a Senior Lecturer and Director of Undergraduate Programs at the Department of General Practice, University of Melbourne, Australia. She is Chairperson of the Victorian Ministerial Advisory Committee on GLBTI Health and Wellbeing, and a practicing GP.
Laura A. Szalacha is a Research Associate Professor at Arizona State University (ASU), College of Nursing & Health Innovation, where she serves as a statistician and methodologist. She also teaches statistics and research methods.
Tonda Hughes is Professor and Interim Department Head of Health Systems Science at the University of Illinois at Chicago (UIC), College of Nursing. She is also Director of Research for the UIC National Center of Excellence in Women's Health.
A grant was obtained from the Lesbian Health Fund of the Gay and Lesbian Medical Association, USA, to support this research.