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Objectives To determine whether lesbians and bisexual women are less likely than heterosexual women to use preventive health measures. Design Written, anonymous, self-administered questionnaire. Setting 33 physicians' offices and community clinics mainly in urban areas of 13 states. Participants lesbians, bisexual women, and heterosexual women. Results Bisexual women were less likely than heterosexual women to have had appropriate cholesterol screening odds ratio 0.
Human immunodeficiency virus testing was more common in lesbians 2. Illicit drug use was higher in lesbians 2. Lesbians were more likely than heterosexual women to practice safer sex 2. Conclusion There were important differences in the preventive health measures taken by lesbians and bisexual women and those taken by heterosexual women. All patients should receive standard health tests, such as cholesterol screening and mammography, regardless of their sexual orientation.
Lesbians and bisexual women who report illicit drug use should receive counseling, as appropriate. Surveys of lesbians that did not have heterosexual control groups have raised the possibility that morbidity is greater among lesbians than among heterosexual women: In studies that did not use probability samples or heterosexual control groups, lesbians and bisexual women have also had higher rates of cigarette smoking, 3 , 4 , 5 alcohol consumption, 5 , 6 illicit drug use, 3 , 4 , 5 , 6 , 7 and unsafe sex 8 , 9 , 10 , 11 than heterosexual women.
Added to these risk factors is the possibility that lesbians and bisexual women use the healthcare system less often than heterosexual women and then only after they have had more severe symptoms. Additionally, lesbians and bisexual women may avoid the healthcare system because they fear or have experienced discrimination because of their sexual orientation. These factors may adversely affect the health of lesbians and bisexual women. Previous surveys have used convenience samples from outside the healthcare setting without comparison groups of heterosexuals.
The Institute of Medicine at the National Academy of Science found that more data are needed to determine if lesbians are at higher risk of developing some health problems. A written survey was developed by a panel of two obstetrician-gynecologists, an internist, an epidemiologist, and a biostatistician.
The survey was refined after two pilot tests. It contained 98 questions about the patient's access to health care, use of screening tests, general health, substance use, sexual behavior, and demographic information, such as race and income. The questionnaire did not state that sexual orientation was an issue of interest.
Sexual orientation was assessed solely by the patient's self-identification. To include a broad spectrum of women, a variety of practice settings was sought. Private offices and community clinics were contacted in an attempt to achieve geographic distribution across the nation.
This estimate was readily available from the clinician. At the remaining sites, surveys were distributed to patients who were known to be lesbians and to the next two female patients. Drop boxes at the sites and individual business reply envelopes were supplied to allow the surveys to be returned anonymously. Because the surveys were self-administered and anonymous, there was neither the intention nor the means to encourage women to complete and return the surveys. A panel of experts, some from the panel mentioned above, defined appropriate measures of preventive health, based on the literature and their clinical experience.
When possible, these measures were standardized to the definitions used in Healthy People , which describes the objectives of the government's health promotion plans. Women of all ages were classified as practicing appropriate preventive health care if they had had a cervical smear within the past 2 years, screening for sexually transmitted diseases within the past 5 years, a breast examination carried out by a clinician within the past 2 years, if they examined their own breasts at least 3 times per year, if they used no illicit drugs in the past 30 days, if they were nonsmokers defined as no smoking within the past 30 days , if they were not heavy drinkers of alcohol defined as having 60 or fewer drinks per month, in the absence of binge drinking of 5 or more drinks on one occasion in the past 30 days , if they took regular aerobic exercise defined as 20 minutes of aerobic exercise per session with at least 3 sessions per week , and if they practiced safer sex defined by all the following criteria: Thirty-three of the 98 questions specifically measured preventive health care.
The Kruskal-Wallis test was used to compare numeric variables and sexual orientation. Multivariate logistic regression was used to control for demographic factors and sexual partner history.
Thirty-three sites across the United States agreed to participate; they were predominantly urban, private offices providing primary care services. However, there were also community clinics, two chiropractic practices, and one naturopath's office.
The principal independent variable was self-identified sexual orientation. Characteristics of respondents are summarized in table 1.
Respondents' sexual history during the past 12 months more closely reflected their reported sexual orientation: Sexual orientation was associated with the health behaviors shown in table 2. Lesbians were about twice as likely as heterosexual women to have used illicit drugs in the past 30 days, and they were more than twice as likely as heterosexual women to have been tested for human immunodeficiency virus.
Lesbians were also half as likely as heterosexual women to have ever been infected with human papillomavirus. Bisexual women were about twice as likely as heterosexual women to use illicit drugs and to have been tested for human immunodeficiency virus.
Bisexual women were about one third as likely as heterosexual women to be classified as having had adequate cholesterol screening and adequate mammography. All of the other measures of appropriate preventive health care were similar among the three groups data not shown. Many studies have found an association between a failure to conform with preventive health measures and an increased risk of preventable chronic diseases.
It has been proposed that being bisexual or lesbian is associated with poorer use of preventive health measures. In this study, after controlling for standard demographic factors and gender of sexual partners in a person's lifetime, sexual orientation was associated with some preventive health behaviors such as practicing safer sex and having cholesterol screening and mammography that have important long-term health consequences.
The finding that lesbians and bisexual women have higher rates of drug use in the past 30 days is worrying. The use of illicit drugs may be associated with unsafe sex practices and having poorer judgment while under the influence of drugs, although this was not confirmed in this study. In this study, rates of cigarette smoking In this study, lesbians had had fewer human papillomavirus infections than the other two groups of women.
However, infection with human papillomavirus and cervical dysplasia has been documented in women who have had only female sexual partners. Bisexual women were the least likely to have been appropriately screened for cholesterol and to have had mammography. This is a potentially serious problem considering the low threshold used to define appropriate screening in this study. As shown in previous studies, a person's lifetime sexual history correlates poorly with sexual orientation.
Because of the variability of sexual behavior among people of all sexual orientations, taking an accurate social and sexual history is important. Recommendations for obtaining such a history and the appropriate counseling of patients are given in the box.
This study has several strengths. It is the first study to compare the health of lesbian, bisexual, and heterosexual women in the same setting and after adjusting for important covariates. It is also the first large study to describe lesbian, bisexual, and heterosexual women who use the healthcare system.
The study had a large sample size of heterosexual women and bisexual and lesbian women and many variables covering a wide range of health-related topics. The respondents came from different geographic areas and were recruited from a range of outpatient settings. There are, however, several limitations to this study. Biases in sampling limit the generalizability of the results. The respondents were predominantly young to middleaged, white, insured, and of high socioeconomic and educational status.
Future research using a different methodology might enable more women from racial minorities and women with poorer literacy skills to participate. Characteristics of the sites and the physicians involved might also introduce bias. Although an effort was made to include a wide spectrum of practices, most of the respondents came from urban primary care practices.
About half of the sites had a substantial proportion of lesbian and bisexual women as clients. These sites may be less biased toward providing care for heterosexuals than is generally the case. The practitioners at these sites are interested in research on women and preventive health and may be attuned to health issues that are important to lesbians.
Thus, multiple selection biases were introduced by respondents, sites, and practitioners. Reporting bias may have occurred, such as the underreporting of diseases and behaviors with negative associations, because of the sensitive nature of some of the questions.
However, all of these biases should have been corrected by the use of an internal control group at each site. Our findings apply to a group of women already seeking care. Similar problems of a larger magnitude may exist among women who do not have regular contact with the healthcare system. These findings suggest that there are some specific targets for interventions among women already seeking care.
Programs focusing on decreasing the use of illicit drugs by lesbians and bisexual women may be needed. Further studies are needed to understand why patients do not use preventive health services, how being a lesbian or bisexual woman is related to not observing guidelines on preventive health, and to address the vulnerability to avoidable diseases of certain groups of women who do not use healthcare services.
Bisexual and lesbian women seemed to be less likely to engage in preventive health behavior than heterosexual women. Given the current weight of evidence that supports an association between illicit drug use and suboptimal cholesterol and mammography screening with a variety of acute and chronic illnesses, encouraging women to make use of preventive health measures may significantly improve health outcomes in the population. See Commentary, p National Center for Biotechnology Information , U.
Journal List West J Med v. Audrey S Koh 1. Author information Copyright and License information Disclaimer. This article has been cited by other articles in PMC. Abstract Objectives To determine whether lesbians and bisexual women are less likely than heterosexual women to use preventive health measures. METHODS Questionnaire A written survey was developed by a panel of two obstetrician-gynecologists, an internist, an epidemiologist, and a biostatistician.
Survey sites To include a broad spectrum of women, a variety of practice settings was sought. Use of preventive health measures A panel of experts, some from the panel mentioned above, defined appropriate measures of preventive health, based on the literature and their clinical experience.
Open in a separate window. Data are missing for some of the characteristics because some respondents did not answer all questions. Table 2 Relation between sexual orientation and health behaviors. Table 3 Recommendations for providing inclusive care for patients. Strengths and weaknesses of the study This study has several strengths.
Targets for intervention These findings suggest that there are some specific targets for interventions among women already seeking care.
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