Childbirth and parenting
Increasingly, lesbians are having children through donor insemination and adoption. Four areas of potential concern for lesbians have been found that are different than for heterosexual women: (a) finding a sensitive birthing provider and worry about coming out to them, (b) making decisions around donors, (c) involving the nonpregnant female partner, and (d) legal issues around parenting (McManus et al., 2006). As noted earlier, lesbians have feared rejection and inadequate care if they "come out" to their provider, and this has been found to be true in pregnancy as well. Lesbians who wish to become pregnant have additional decisions about whether to use a known or unknown donor, how much interaction to have with the donor, and how much to tell the child about their conception (Haimes & Weiner, 2000). Partners may not feel welcome in prenatal groups, the delivery room and hospital environments that are set up for heterosexual couples (Buchholz, 2000). The lesbian partner has no legal responsibility to the child unless the couple lives in a state where marriage or civil unions exist, and the pregnant woman fears that her partner will not be allowed to participate in the birthing process and care of the child (Harvey et al., 1989). The nonbirth partner may need to do a second parent adoption, if allowed in their state, in order to have a legal relationship with the child. A recent focus group study found three major themes of stress in same-sex parenting which they thought might represent unique risk factors for perinatal depression: (a) disappointment over lack of family support, (b) difficulty in negotiating parenting roles, and (c) legal and political barriers (Ross, Steele, & Sapiro, 2005).
Children of lesbians have been found to have challenges due to social stigma, but studies have found that they are comparable to children raised in heterosexual families in social and psychological adjustment and development (Bos, van Balen, & van den Boom, 2004; Gartrell, Rodas, Deck, Peyser, & Banks, 2005; Golombok et al., 2003). The prevalence of physical and sexual abuse was less in these families (Gartrell et al., 2005), and the children were found to be less constrained by gender roles (Stacey & Biblarz, 2001).
Recommendation for lesbian health care
Several recommendations for the health care of lesbians can be made based on this research. Even though studies show that lesbians are now more comfortable in health care settings and are coming out to their health care providers in greater numbers, providers can increase comfort by being welcoming to this population in a variety of ways. Lesbians feel more included if health questionnaires in the office ask about the gender of sexual partners and educational materials use are inclusive or use gender-neutral language. Asking all patients, "Do you have sex with men, women or both?" provides the opportunity for women to discuss their sexuality. If women do disclose that they are lesbian, then determining whether their sexual orientation is creating discomfort in their lives may be useful in determining their need for support. Lesbians find it difficult to know who is lesbian sensitive when choosing a health care provider, and advertisement in gay media or explicit reference to welcoming lesbian women in promotional materials is useful. Lesbians prefer lesbian providers and benefit from knowing how to find them.
Rates of physical examination and pap smears have increased over the past 20 years, but studies show that up to 10% of lesbians still do not have pap smears. Heterosexual women often receive routine screening and health maintenance as part of visits to obtain birth control, but lesbians may not because of their lack of need for birth control. Lesbian women need to know that they may be at risk for cervical cancer and be encouraged to seek care for prevention when they are seen for other services. Specifically, it is now documented that lesbians are at risk for HPV and abnormal pap smears and need to follow the same guidelines. The rate of breast cancer in lesbians is not known, but there are increased risk factors for it among lesbians. Use of sexual behavior/identity as a variable in large breast cancer studies may help to determine the actual rate in this population. Lesbians appear to be aware of their risk for breast cancer, and report frequent mammograms, but still need to be encouraged to comply with guidelines for screening.
A careful sexual history is useful in determining the risk for sexually transmitted diseases as many women who identify as lesbian may have had or currently have male partners. Although chlamydia, gonorrhea, and syphilis have not been frequently identified in WSW, BV is common and can be transmitted from woman to woman. HIV is still uncommon in lesbians, but is found in any woman who uses IV drugs, has sex with high-risk men or are commercial sex workers irrespective of their sexual identity.
Lesbians have increased risk factors for cardiovascular disease, and recent studies suggest also an increased prevalence of cardiovascular diseases. Lesbians have consistently been found to have higher rates of overweight and obesity. There is no research that has explored the reasons for higher weight, but it is commonly thought that resistance to decreasing weight because it implies conformity to the societal norms that women must be thin and only have certain body types may be responsible. Increased weight does put lesbians at increased risk not only for cardiovascular disease but also for diabetes and breast cancer. An emphasis on improving health, rather than primarily on weight reduction may be more successful with lesbians. The research does show that lesbians are active in a variety of forms of exercise, and exercise programs may be an acceptable strategy for decreasing weight and preventing heart disease and other chronic illnesses. Smoking rates have also been shown to be high in lesbians, especially in adolescents. Emphasis on smoking cessation is important in decreasing the multiple health risks associated with tobacco. Further research is needed to explore attitudes and practices of lesbians related toward nutrition, exercise, smoking, and overweight. Clinical trials are needed to explore culturally appropriate and effective programs for this population.
Depression, relationship problems, and heavy alcohol use/abuse are consistent findings in most of the recent research. History of childhood sexual abuse is found in almost half of the lesbians in some studies, and its sequelae may be related to many of the other mental health concerns. The stress of being a sexual minority is also likely to be related to this excess morbidity. Although there is need for further research to understand the relationships between lesbians and these problems, there is also continued need for screening and culturally sensitive treatment programs. Health care providers are key to the recognition and referral for problems and referral to sensitive, and welcoming sources of therapy. The need to have available sensitive services is important to the health care for this population.
Adolescents are especially in need of services. Lesbian adolescents have high rates of smoking, depression, and suicide attempts. Health care providers are key in discussing sexuality, and educating, supporting, and delivering needed services, but broader services are necessary to meet their needs as well. Mechanisms for finding and supporting lesbian youth and those questioning their sexuality are essential to their health. Alliances with schools and agencies that service adolescents are needed to prevent mental and physical impact of discrimination and isolation that may occur.
Increasingly lesbian women are adopting and birthing children and raising families. Prenatal providers need to be sensitive and welcoming to lesbians seeking insemination and care for their pregnancy. Special needs of this population may be family support for the pregnancy, legal issues surrounding parenting, and needs of the nonpregnant partner. Although the children have not been found to have increased psychological or developmental issues, these families are at risk for discrimination and benefit from supportive counseling and services to avoid problems related to stigma.
Health care providers caring for lesbian women may find the following resource useful: Gay and Lesbian Medical Association, 459 Fulton Street, Suite 107, San Francisco, CA 94102, http://www.glma.org/. They may visit www.healthservice.gov.bc.ca/whb/publications/caring.pdf to obtain a copy of "Caring for Lesbian Health."
Research on lesbian health prior to the 1990s primarily explored the experiences of lesbians in health care and found them to be negative. Current research shows that lesbians now have higher rates of preventive care and of coming out to their health care providers. Sexually transmitted diseases, such as gonorrhea, chlamydia, and syphilis are rarely found in lesbians, and when they are, it is related to a history of current or past male partners. All forms of vaginitis, genital herpes, and HPV are found in this population, and BV appears to be especially common. Lesbian women are at risk for abnormal pap smears and should follow current guidelines for screening. There is also evidence that lesbians may be at higher risk for breast cancer and cardiovascular disease. Risk factor reduction programs that are specific to lesbians are needed to promote decreased weight, heavy alcohol use, and cigarette smoking. Multiple studies have found a high utilization of mental health services by lesbians, especially for depression and problems with alcohol. There continues to be need for wide spread availability of culturally sensitive mental health and addiction services to serve the special needs of the lesbian population. Recent research is increasingly available to guide the development of improved care and health promotion of lesbian women. Lesbians are no longer invisible and benefit from sensitive and informed care.