by Virginia Apuzzo
Lesbian health care, in the course of the past fifteen years, has progressed from a state of total neglect to a state of almost total neglect. Like the medical problems of women in general, and such specific groups as older women and women of color, health care for lesbians is a subject long overdue for recognition.
It is a tribute to the diligence of those women health care practitioners – lesbian and heterosexual – who have founded and maintained clinics providing supportive settings for the care of lesbians, that some awareness of lesbianism as one aspect of the diversity of women has been achieved within the medical establishment. But it is also true that in many localities such clinics are simply unavailable, and in every locality lesbians who require treatment may encounter prejudice and misinformation. Lack of information and lack of sensitive treatment are typical of women’s health care issues in general – but for lesbians the problems are more acute, and, in a sense, comparable to the state of women’s health care in the early 1970s.
Conducting research into lesbian health issues is an exercise in frustration. The dearth of scientific information is astounding, and reflects a lack of basic research, which in turn reflects a failure to commit resources to the study of lesbians.
The scope of lesbian health care issues encompasses gynecological concerns, other medical concerns specific to women, alcoholism and other substance abuse, mental health, health insurance and occupational hazards.
There are no known gynecological ailments specific to lesbians; those affecting heterosexual women affect lesbians as well, whether it be vaginitis, cervicitis, cystitis, pelvic inflammation diseases, endometriosis or herpes. What is not known is whether the incidence or modes of transmission are the same or different for lesbians.
Certain trends, however, are evident. For example, the incidence of sexually transmitted disease appears to be lower among gay women, according to the few attempts to systematically study sexually active lesbians. Cervical cancer may appear less frequently, and the same appears true for pelvic inflammatory diseases, the latter probably due to the correlation of such ailments with certain forms of contraception. On the other hand, lesbians who have not borne children, like other women who have have not borne children, may be more susceptible to breast cancer and endometriosis.
Without an understanding grounded on sound epidemiologic research rather than anecdotal evidence (which is largely the case today), it is impossible to make an accurate determination of the relative risks to lesbians of sexual and nonsexual activities. Sound epidemiologic research would not only impact favorably on the quality of health care delivered to gay women, but could have significant implications for the health of women generally.
For example, if research confirmed that cervical cancer does indeed occur at a lower incidence among lesbians, crucial insights might be gained that would contribute to risk reductions guidelines, resulting in lower incidence overall.
To the extent that research focuses on women in general, the failure to consider lesbians as a discrete subpopulation among women can have a negative impact. The assumption of heterosexuality among all female research subjects – a practice that is rife in medical literature – can compromise the quality of methodology and result in distorted interpretations of research data.
It is frequently and inaccurately assumed that motherhood is incompatible with lesbianism, or that it is so rare as to be a curiosity. In fact, a significant percentage of lesbians have borne or will bear children, through heterosexual means or by alternative insemination. The need on the part of lesbians for obstetric services requires recognition from the health care establishment.
Sexism has contributed to a high level of substance abuse among women in our society. For lesbians, who must face heterosexism and homophobia as well, the level of affliction is probably higher. But, again, there is a lack of data. One study of the gay male and lesbian population of a major urban center indicated an alcoholism rate between 25 to 30 percent. While lesbians were not differentiated in the study, that figure is more than twice the rate reported among women generally.
Throughout most of this century, the legitimate mental health concerns of lesbians were obscured by a preoccupation with determining the cause of homosexuality, and remedial therapies to achieve sexual orientation reversal. The removal of homosexuality from the list of recognized illnesses by the American Psychiatric Association in 1973 allowed for a less judgemental approach. Still, much research is marred by false assumptions about lesbian lifestyles – as well as a failure to appreciate the diversity of lifestyles among lesbians – and by lingering allusions to medical pathology
Recently, thanks to the movement towards a feminist approach to therapy, .more constructive analyses have begun. It is interesting to note that in the psychological research that has attempted to characterize personality traits among women, lesbians have scored high in terms of autonomy, resilience, self-acceptance and goal direction.
Nevertheless, many years of unenlightened psychiatry deserve redress. Indeed, it might prove significant to examine how psychiatric treatment has impacted negatively on the mental health of lesbians.
The inadequacies of the system of health care insurance in this country affect lesbians as they do other women. There is an additional area of discrimination – spousal benefits – that affects lesbians to the same extent that it affects people who have chosen to enter relationships without a legal conjugal bond. That legal bond, of course, is not an option for lesbians (or gay men); therefore, spousal benefits from insurance companies and the Social Security Administration are unavailable. To the extent that, as single women in this society, lesbians probably experience a higher rate of poverty, private insurance may be beyond their means, thereby forcing dependence on government programs (which are themselves underfunded) in cases of disability.
If, as may be the case, lesbians are more likely to work in nontraditional jobs than other women, they may collectively experience a greater degree of job-related health hazards. Similarly, stress related health problems may be greater among lesbians due to prejudice.
Since the principal obstacle to addressing lesbian health needs is a lack of basic medical and sociological information, the National Gay Task Force has proposed that the Public Health Service allocate funding for a comprehensive assessment of lesbian health care needs, similar to the one currently being undertaken by the National Lesbian and Gay Health and Education Foundation. This is a necessary first step, but the PHS, as the largest funding agency for health care research in this country, must be prepared to take the results of such a survey seriously, and to make an appropriate commitment of funds to address the needs outlined in the survey
Equally important is the need for attitudinal changes on the part of health care providers. In most cases, it is still unfortunately true that lesbians seeking treatment or routine examinations are confronted with a presumption of heterosexuality (and must sometimes fend off prescriptions for contraceptives, particularly if they are viewed as “public dependents”). If they decide to inform the doctor or nurse of their sexual orientation, lesbians must contend with a profound ignorance and/or hostility.
Such attitudes inevitably detract from the quality of care provided. Health care practitioners may view lesbianism as an illness in itself and attribute physical symptoms to some aspect of the patient’s homosexuality. An even more insidious effect of nonsensitive treatment is that it may discourage lesbians from seeking routine check-ups, thus missing out on opportunities to detect such serious illnesses as breast and cervical cancer. One San Francisco study indicated that lesbian subjects had Pap smear tests an average of every 21 months, as opposed to an average of 8 months for heterosexual women.
A great deal can be accomplished in providing better informed, lesbian-sensitive health care. One of the simplest steps would be for the Secretary of Health and Human Services to issue a policy statement acknowledging the need and requesting verifiable improvements in the procedures followed by primary health care workers in the public sector, with a recommendation for the same in the private sector. Medical and nursing schools could incorporate lesbian-sensitizing information into their curricula.
But in some respects, such procedural reforms bypass a larger issue, one which inevitably impacts negatively on the quality of health care provided to lesbians: the absence of civil rights protections for lesbians (and gay men) at the federal level. Combined with an executive order or the passage of the federal lesbian and gay civil rights bill by Congress, the improvements in training mentioned would have a vastly greater impact on improving health care for lesbian Americans.
VIRGINIA M. APUZZO is executive director of the National Gay Task Force. For assistance in the preparation of this article she wishes to thank Lesbians in Health Care, Bernice Goodman. Dr. Mary Jo Kennedy, Dr. Grace Lawrenson. Frances Hanckel. Carol Robin. Pat Maher. Audrey Block, and John Boring.