A lesbian patient recently asked if she needed to see me less often than straight women since she was at a lower risk for sexually transmitted infections. She figured she needed fewer Pap smears.
Lesbians and bisexual women need to see their doctor with the same frequency as heterosexual women. The Pap smear, breast and pelvic exams, and mammogram screenings are done at the same interval regardless of your sexual orientation.
In speaking with many lesbian and bisexual women in my 22 years as an ob-gyn, I've learned that some have felt apprehensive about getting health care because of discriminatory attitudes, concerns about confidentiality, and uncertainty about their specific health care needs.
The medical community should take the lead by learning sensitive ways of asking necessary medical questions and building trust with all patients. Unfortunately (and understandably), it’s rare for a doctor to ask if someone is straight or gay. While doctors do ask patients if they're sexually active, a lesbian may say yes without disclosing the gender of her partner. She might not feel ready to come out to her doctor.
From a medical standpoint, if a doctor knows whether a patient is gay, straight, or bisexual, the doctor can be more sensitive and thorough with follow-up questions.
For example, if the doctor knows you're a lesbian, she won't ask if your boyfriend wore a condom during sexual intercourse. In that case, the conversation might shift to questions like “Do you share sex toys? Do you use dental dams for protection against STIs?”
If a patient discloses that she is sexually active, it's important that the doctor's next question be, “Is it with a male or female?” Hopefully, everyone will feel comfortable disclosing her sexual preference even if she's not 100% sure of what that is.
Barriers to health care and fertility treatments
Seventeen states (plus Washington, D.C.) have legalized same-sex marriage, and employment rights and benefits have never been so inclusive of gay couples. Last December, CNN reported that 67% of Fortune 500 companies offer health care benefits to same-sex couples.
That said, many states and employers still don’t extend health care benefits to gay partners or spouses. Also, some health care providers will not offer fertility services to women who identify themselves as lesbian. Sadly this could reflect personal prejudices that adversely affect their responsibilities as a physician.
Regardless of sexual orientation, the first step in the lengthy, confusing and costly process of IUI treatments is finding the right doctor who will deliver equitable and complete health care.
The issues of having fertility treatments covered by insurance companies vary between countries, states and different health plans. Some insurance companies, for example, will only define "infertility" as "unprotected sex for at least six months," which excludes lesbians. Others will cover insemination but not the sperm, which can cost around $500. In Arkansas, health insurers are only required to pay for IUI treatments with a spouse's sperm after two years of unprotected sex, which also discriminates against lesbians.
Lesbians do have some higher risks than heterosexual women
While the American Congress of Obstetricians and Gynecologists acknowledges that there are "no known physiologic differences between lesbian and straight women," research shows that lesbians are more likely to engage in some behaviors with negative health consequences:
- Tobacco use
- Alcohol and drug use
- Less use of oral contraception
Lesbians are also more likely to be at risk for certain diseases:
- Type 2 adult onset diabetes
- Lung cancer
- Cardiac disease and heart attacks
Unfortunately, this means that lesbians have a greater risk of having a heart attack, breast cancer, and ovarian cancer compared to a heterosexual women.
Given these increased health risks, lesbian patients need to feel comfortable disclosing their sexual orientation. Why? Because doctors learn to identify certain groups that are higher risk for specific diseases or health concerns. They can then target some of these high-risk habits to give appropriate recommendations for weight control, diabetes, cardiac and smoking screening.
Many gynecologists are not clear as to when Pap smear screening begins and how often it should be done.
Since lesbians aren’t having sex with men, they don’t need Pap smears, right?
While it's true that the Pap smear tests for a variety of sexually transmitted infections (which traditionally result from heterosexual intercourse) the Pap smear is also used to detect cervical pre-cancer or cancer cells. We know cervical cancer is directly related to the number of sexually transmitted diseases you may have, which typically puts lesbians at a lower risk. However, many lesbians have been sexually active with men in their past. One study involving 6,000 lesbians found that 77% have had sex with men in their past and 70% report a lifetime history of vaginal intercourse.
Another thing to consider: Having a history of one normal Pap smear doesn’t mean you'll never have to get a pap again. A case in point is the human papilloma virus (HPV), for which lesbians are at risk. It can show up on future Pap smears as causing pre-cancer cells.
Also, woman-to-woman sexual activity still puts lesbians at risk for sexually transmitted infections (STIs), including bacterial vaginosis, candidiasis, herpes and the human papillomavirus infections (HPV), which increase the risk for abnormal Pap smears.
Current guidelines for pap testing:
- Women should begin pap testing at age 21 year of age.
- Women 21-28 years should have a Pap test every 3 years.
- Women 30-65 years should have a Pap test and HPV test every 5 years. It is also acceptable to have a Pap test alone very 3 years.
- 65 years and older: No screening recommended if adequate prior screening has been negative and high risk is not present
Regardless of your sexual orientation, safe sex practices should be discussed and encouraged to reduce the risk of getting or receiving sexual transmitted infections and HIV. For lesbian and bisexual women, safe sex includes condoms for sex toys, gloves for fisting, and dental dams for oral sex. It is not recommended to share sex toys and dildos. Depression, substance abuse and intimate partner violence are more common in lesbian and bisexual women and should be screened and treated appropriately.
It's essential for everyone to find a health care provider with whom you feel completely comfortable. Not just the health care provider, but the entire office staff should be welcoming and receptive.
What you really need to know is that lesbian and bisexual women need to follow the exact same gynecological guidelines as straight women. Plain and simple.
To learn more:
- Advocates for Youth
- Gay, Lesbian & Straight Education Network (GLSEN)
- GLBT National Help Center
- American College of Obstetricians and Gynecologists
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