Lesbian Health Care
Lesbian Health Issues in a Heterosexual Society
The additional burdens placed on the lives of minorities as a result of social exclusion can lead to health disparities. Social exclusion theory has been used in previous research to investigate the health disparities that exist between socioeconomic classes and individuals of different ethnic backgrounds living in the United States, but it has not yet been applied to another important minority group: sexual minorities. This review of the literature has sought to apply social exclusion theory to the examination of health issues and health disparities within the lesbian community. Lesbian women face the health concerns common to all women, but also face a number of additional health care related challenges as a result of their sexual minority status living in a predominantly heterosexual society. Many of the challenges that they face with respect to their access to health care, the health care risks specific to their community and their health status are a result of their stigmatized social status. This review of the literature has sought to examine what is presently known concerning lesbian health status, their health risk behaviors, as well as their utilization and access to health care. The review also examines issues of relevance to the future of health care within this community by examining the specific and unique needs of aging lesbians.
Table of Contents
Lesbian Health in Heterosexual Society 6
Social Exclusion Theory 7
Overview of Topics Covered 8
Literature Review 10
Social Exclusion Theory 10
Social exclusion from society through legal sanctions. 13
Failure to provide for the needs of particular groups. 15
Exclusion from social production. 16
Economic exclusion from social consumption. 17
Social exclusion and health outcomes. 18
Methodological Issues in Studying Lesbian Health 20
Definition & Measurement of Sexual Orientation & Identity. 20
Studying a Marginalized Population. 23
Funding for Research. 26
Current Health Status of Lesbians 27
Health Risks and Health Behaviors. 28
Alcohol Use & Abuse. 33
Substance Use. 33
Cancer & Major Illnesses. 34
Reproductive Cancers. 34
Chronic Illnesses. 38
Sexual Health. 40
Mental health. 42
Minority Stress & Health 45
Stress associated with hiding sexual identity. 46
Experiences of prejudice and victimization. 48
Social support and minority stress. 50
Social Support, Relationships & Health 53
Access to & Experiences with Health Care Services 56
Unequal access to health benefits. 57
Negative experiences and disclosure of sexual orientation. 61
Social exclusion. 63
The Experience of Aging for Lesbians 65
Summary & Conclusions 73
Recommendations for Future Research 76
Lesbian Health in Heterosexual Society
North American society is based upon the ideals of equality and opportunity, despite the long history of failing to provide these ideals to all members of society. Throughout various times in history, different minority groups have been restricted in their access to the rights and opportunities afforded to the majority. African-Americans in the U.S.A. have had a long struggle for equality, and similarly, Jewish-Americans and Japanese-Americans have faced periods of blatant discrimination and unequal treatment. Today, these transgressions are generally looked upon with the benefit of hindsight, offering apologies and recognizing these ‘past’ situations as being unjust, unfair, and immoral. Despite the common acknowledgement that differential treatment based on race, ethnicity, or gender is wrong and contrary to the ideals upon which our society is founded, discrimination continues for a number of minority groups. Sexual minorities, generally considered anyone who is not heterosexual, are at the forefront of their own ‘civil rights’ movement in the U.S.A. today, battling for equal rights within a country that has found far too many ways to curtail the rights and opportunities of those who do not conform to heteronormativity. While progress has been made, with the decriminalization of same-sex sexual activity (2003), the recognition of same-sex relationships and marriages in some states, and the federal repeal of the Don’t Ask Don’t Tell policy banning gay men and lesbians from serving openly in the military (2010), the playing field is far from even and there are many battles still to be fought. In challenging the courts and legislatures to provide equal rights, an important issue that must be addressed is the examination of the consequences of inaction. Failure to move forward in providing equal rights to sexual minorities is not just a matter of failing to make changes to the law, it is also a failure to provide for and protect sexual minorities. When that status of a particular group of individuals is set below the status of another, the demoted, or marginalized group suffers in a variety of ways, not least of which include mental and physical health deficits. Marginalization can restrict access to health care, restrict access to rights under the law that can impact an individual’s health, and can create psychological consequences that can reduce an individual’s ability to function to their potential and to adequately care for themselves. The focus of the present research examines how systematic social exclusion impacts the health care needs and behaviors of lesbian women. What are the specific health care deficits, both psychological and physical, faced by lesbians living in a heterosexual society? What is the status of knowledge concerning lesbian health and what specific methodological issues impede research on sexual minorities and health care issues? How do the mechanisms of social exclusion, discrimination and minority stress impact the quality of life for lesbians as compared to heterosexual women and what do we know about relative mortality rates for these two groups? These questions have guided this research towards a goal of greater understanding concerning the current health status of lesbians as a marginalized group. The highlighting of the current health deficits and obstacles to health care access is intended to serve as a catalyst for those working to promote positive change and meaningful progress with respect to the creation of equality in the healthcare field.
Social Exclusion Theory
Elements of social exclusion theory, as it can be applied to health and social inequalities, will be used as a guiding framework for analyzing the current health status of lesbians and the challenges and deficits this group faces as a whole with respect to health care. According to White (1998), there are four aspects of social exclusion that relate to and diminish health status in marginalized groups, such as sexual minorities. This theory has predominantly been applied to racialized groups, but it is equally applicable to the study of other marginalized groups, such as sexual minorities, and lesbians in particular. The four aspects relevant to the current analysis of lesbian health and access to health care are: 1) Social exclusion from society through legal sanctions; 2) Failure to provide for the needs of particular groups; 3) Exclusion from social production and the denial of opportunity to contribute to and participate actively in society’s social and cultural activities; and 4) Economic exclusion from social consumption. These four aspects of social exclusion theory will be applied to the various topics explored in this review of the existing literature concerning lesbian health and lesbian access to health care. In some cases, only a selection of these points will be relevant for a given topic, but more often than not, all four aspects will prove fruitful in analyzing the topics at hand.
Overview of Topics Covered
One of the key challenges to understanding lesbian health and issues surrounding access to health care among lesbians as a group relates to methodology and the ability of researchers to accurately and effectively study lesbians. The first challenge in this area is the ability of researchers (and sexual minorities themselves) to agree upon and utilize a shared definition of the term lesbian. Sexual identity itself is a fluid and complicated concept, and thus it can only be expected that the term would be defined differently between individuals and groups for whom the term holds relevancy (Diamond, 2000). Beyond the challenges of finding and operationalizing the terms required to actively pursue research in this area, researchers must also overcome the challenges associated with studying a group that, by its very definition, is often marginalized and hidden from mainstream society. As such, there can be difficulties in reaching adequate numbers of participants when conducting a study, and when participants are found, there are additional challenges related to the expectations of participants (Rothblum et al., 2002). Given psychology’s tumultuous history with its treatment of sexual minorities, many sexual minorities are skeptical of the research being conducted and are eager to determine the motives of researchers prior to committing their time and efforts to participate in ongoing research (Fish, 2009). Finally, effective research requires funding, and funding for sexual minority research fluctuates as a function of the politics involved in the agencies providing funding. As a result, given the varying political climates, funding for sexual minority research can often be sparse and researchers are often required to use funding from more mainstream research projects to fund fringe projects related to sexual minority issues. The final consequence of such circumstances is that the research quality and generalizability is sacrificed in the face of affordability. Despite these challenges, researchers have indeed conducted fruitful and important research on the health status and experiences of sexual minorities, allowing for a thorough review of the literature concerning lesbian health, lesbian access to health care and lesbian experiences with health care services and professionals.
After reviewing the methodological issues relevant to studying lesbian health, the exiting knowledge concerning the current health status of lesbian women will be reviewed. A great deal of research has established the various risk factors that are unique to lesbians with respect to health care concerns, such as being at an increased risk for various forms of cancer, substance use, tobacco use and obesity (Roberts, 2006). Very few of the differences found between lesbian women and heterosexual women in health status and health risks are not related to sexual identity itself, but rather to the consequences of sexual identity, such as minority stress and the consequences of persistent discrimination (Cochran, 2001; Meyer, 2003). Many of the sources of minority stress and discrimination experienced by sexual minorities unfortunately begin at home, with the families of origin of sexual minorities, thus after reviewing the issues concerning discrimination and minority stress, the review will move on to examine the family experiences of lesbians and sexual minorities as they relate to issues of mental and physical health. Social support from friends and family plays an important role in determining mental and physical health, and a lack of social support has been linked to health deficits (Blair, 2008). Beyond dealing with the consequences (or benefits) of issues related to family of origin, matters related to chosen families, a concept whereby sexual minorities build social networks of close friends who are not kin, will be reviewed. It is also important to understand the desires of lesbians to build their own families and to understand how the structures of these families influence their experiences with health care access and professionals. This will lead into a discussion of the actual issues concerning health care access and lesbian experiences with health care. This topic ranges from an understanding of the health care education targeted at sexual minority women and the battles of myths concerning sexual health within this community. Health care access issues will be addressed, reviewing the various barriers to access and the issues that lead to negative experiences, or the expectation of negative experiences, when accessing health care services as a sexual minority. Finally, the review will examine a pressing and growing issue related to lesbian health access and experience, the issue of the experiences of aging lesbians. As the population ages, more and more sexual minorities are finding themselves in need of long-term care, nursing home placement and palliative care, an experience that for many has resulted in having to return to the closet or dealing with discrimination within the health care system.
Social Exclusion Theory
In order for any particular group to experience systematic discrimination, there needs to be a mechanism through which such unequal treatment can be dispensed. While there are a number of factors at play that contribute to the marginalization of sexual minorities, this review of the literature will focus on how social exclusion plays a key role in influencing the experiences of lesbians within the health care system, and how these experiences have direct consequences for the mental and physical health of lesbians living in a predominantly heterosexual society.
Social exclusion, as a theory used to explain inequality, has predominantly been applied to racialized groups of minorities (Galabuzi, 2006). The concept of social exclusion refers to both a process and an outcome, such that systemic practices of inequality and discrimination cumulate as a process into the consequences of social exclusion for minority groups. As a theory, social exclusion can explain marginalization of minority groups through an examination of the structural inequalities that consistently produce an environment of substandard access to opportunity and services and unequal treatment. By examining marginalization as a result of social exclusion, the emphasis is placed on society as a whole with respect to assigning responsibility for existing social inequalities (Galabuzi, 2006). This focus on society as opposed to the individual makes social exclusion theory useful for examining marginalization in a variety of contexts, not just those related to race. In the past, sexual diversity, or even sexual deviance as it would have more likely been conceived, was viewed as a failure or flaw of an individual, thereby leaving the individual with full responsibility for dealing with the consequences of their supposedly ‘chosen’ sexual identity. The past decades have seen this view begin to change, beginning with the removal of homosexuality from the American Psychological Association’s list of mental disorders in 1973 (Blair & Holmberg, 2008). Since then, sexual identity and sexual orientation have come to be increasingly viewed as an inherent trait, not chosen, and not indicative of a mental defect or physical ailment. This transition in public attitude, albeit tenuous at times, allows social exclusion theory to be aptly applied to the inequalities experienced today by sexual minorities. As such, the theory holds that society must be held responsible for such social inequities, and can therefore be applied to mean that sexual minorities themselves should not be left to suffer the consequences alone and to seek remedy of such inequities without the assistance of society at large.
Through Galabuzi’s (2006) conceptualization, social exclusion theory can be applied to a wide variety of social institutions, ranging from education to criminal justice to spatial isolation and to health care, the area in which this review will apply the theory. It is important to understand though, that while social exclusion is well applied to the experiences of lesbians within the health care system, part of what generates the widespread systemic social exclusion of sexual minorities overall is the fact that this exclusion takes place across all aspects of social and societal life. In other words, while social exclusion theory may specifically explain why lesbians have unequal access to health care, other aspects of social exclusion experienced over the lifespan, such as discrimination in the educational system, or negative experiences with the criminal justice system, all play a contributing role in determining the actual health outcomes for sexual minorities.
Galabuzi (2006) has identified four aspects of social exclusion that contribute to the inability of marginalized groups to access cultural, social, political and economic resources through an ongoing process of oppression and discrimination, both through the marginalization of the group as well as the individual experiences of discrimination, inequality and isolation. The four aspects are as follows:
1) Social exclusion from society through legal sanctions;
2) Failure to provide for the needs of particular groups;
3) Exclusion from social production, or the denial of opportunity to contribute to, or participate actively in society’s social and cultural activities; and
4) Economic exclusion from social consumption, or unequal access to normal forms of livelihood and economy.
These four aspects can all be applied to the lived experiences of sexual minorities in North America, especially those living in the United States. Previous research and theory has predominantly applied social exclusion theory to racial minorities, immigrants, and individuals of lower socio-economic status. Lip service has been paid to the applicability of social exclusion theory to sexual minorities (Galabuzi, 2006), but no previous reviews of have systematically applied this theory to the understanding of health inequities among sexual minorities, or the experiences of lesbian women specifically.
Social exclusion from society through legal sanctions.
The first aspect of social exclusion theory, as identified by Galabuzi (2006), refers to the disconnection of from civil society as well as reduced or limited political participation as a function of both material and social isolation due to continued and systemic discrimination. In the case of lesbian women, this discrimination can be based on both gender and sexual orientation or identity. Wilson (1987) has referred to the collective effects of social exclusion, with respect to the experience of inequality over a wide spectrum of life experiences, as the creation of an underclass culture. In many respects, sexual minorities can be seen to form an underclass, or second-class culture within the mainstream society of North America. In the United States, a number of legal sanctions have inhibited the lives sexual minorities. Same-sex sexual activity in the United States was only completely decriminalized on a nation-wide basis in 2003, and there is still no federal recognition of same-sex marriage or relationships (Dysart-Gale, 2010). The “Don’t Ask Don’t Tell” policy prohibiting the openly acknowledged service of gay men and women in the military has just recently been repealed (December 18, 2010), and access to hospital visitation rights is a recent change in United States health care policy. While the United States prides itself on being built on a foundation of equality for all citizens, in the area of sexual minority rights, the country falls far behind its other civilized Western siblings. By example, Canada decriminalized same-sex sexual activity in 1969, allowed gay men and lesbians to serve openly in the military in 1992, provided spousal rights in 1999, and nation-wide federal and provincial recognition of same-sex marriage in 2003 (Dysart-Gale, 2010). Thus, by comparison, sexual minorities living in the United States today can be seen as being even more marginalized than other groups of sexual minorities living in other countries around the world.
Social exclusion from society through legal sanctions generates a variety of consequences for the day-to-day experiences of sexual minorities and lesbians. The inability to marry creates social stigma, reduces the ability of same-sex couples to form families, denies same-sex couples the benefits of marriage, including increased longevity and increased barriers to relationship dissolution, and also denies same-sex couples the protections available to married couples in the face of separation and divorce (King & Bartlett, 2006). Unequal access to marriage can also infringe upon a couple’s financial circumstances, their access to health care and health care insurance, and impact the mobility of a couple. Bi-national couples are particularly hurt by unequal access to marriage, as same-sex relationships are not viewed as legal grounds for immigration, thus preventing gay and lesbian United States citizens from sponsoring their international partners for immigration to the United States (King & Bartlett, 2006). Other aspects of social exclusion related to legal sanction include the lack of policy and law against discrimination based on sexual orientation and identity within the United States. Laws prohibiting employment discrimination, housing discrimination, or discrimination within many other aspects of life are varied across the nation, with many states having absolutely no laws or sanctions against discrimination directed towards sexual minorities. As a result, sexual minorities in some states can be legally fired from their employment on the basis of their sexual identity, can be denied housing, denied the right to adopt, and can have their sexual identity used against them in custody disputes (Fish, 2010). Thus, in the current legal and political climate of the United States, lesbians, along with all sexual minorities, face discrimination on a daily basis that is supported by legal sanctions and they are denied equal protection and equal access under the law, thus making this aspect of social exclusion theory quite applicable to the understanding of sexual minority experiences.
Failure to provide for the needs of particular groups.
The second aspect of social exclusion that Galabuzi (2006) refers to is the failure of society to provide for the needs of a particular minority group, in this case, the needs of sexual minorities. This aspect refers to the ability of society to meet specific needs of a group, as well as the policies in place that prevent systemic denial of such needs being met. For example, failure to provide adequate protections under the law, such as anti-discrimination policy, would qualify as a failure to provide for the needs of sexual minorities.
The recent teen suicides of young Americans who were bullied based on their known or presumed sexual identity speaks volumes to the nation’s failure to provide for the needs of sexual minority youth. Bullying and harassment are tools through which social exclusion is systematically enacted upon individuals, and the failure to address the rampant bullying of sexual minority youths is a blatant disregard for the rights of sexual minorities. According to research, a large number of sexual minority adults report experiencing bullying and harassment within the workplace based on their sexual orientation (Fish, 2010). Additionally, research has consistently linked the experience of bullying among sexual minority youth to increased mental health issues, including depression and suicide (Rivers, 2000). So long as adequate sanctions against informal and formal harassment and discrimination are absent from the legal doctrine of the United States, the needs of sexual minorities will not be met.
With respect to health care specifically, there are a number of areas in which the needs of sexual minorities have been overlooked. Funding is limited for research on sexual minorities, making it difficult for researchers and health professionals to develop targeted health care strategies or to even gain an accurate understanding of the health care needs of sexual minorities. The research that has been conducted consistently points to areas in which the needs of sexual minorities with respect to health care are not being met, such as the lack of education concerning safer sex for lesbians, the lack of options available to lesbian couples seeking to build a family, the lack of sensitive, knowledgeable and understanding health care professionals with respect to treating lesbians, and the lack of services and policies to address the needs of aging sexual minorities.
Exclusion from social production.
The third aspect of social exclusion refers to the denial of opportunities to marginalized groups to participate fully in society’s cultural and social activities (Galabuzi, 2006). This aspect is relevant to the lives of sexual minorities in that many feel that they find themselves exiled to the fringes of society, and not fully welcome to participate in the rituals of mainstream society and culture. Once again, the denial of equal marriage rights plays a large role in this form of social exclusion, as marriage, intimate relationships and family are focal points of American society, and the inability to participate in these aspects of life creates social exclusion from social production. Even when sexual minorities seek to participate fully in the cultural and social traditions of their society they are often rejected or faced with hurdles, which make their participation more difficult or less enjoyable. For example, when contemplating the process of building a family, a lesbian couple must determine how to have the child, navigate the legal hurdles involved in both being recognized as the legal guardians (often having to pay legal fees for one parent to adopt the child), and must weigh the pros of cons of having a child that might face additional life burdens as a result of being a member of a family that deals with systemic discrimination and reduced legal protections. It is easy then to see how the processes of social exclusion can reduce participation in social and cultural activities. Reduction in such activities can have direct consequences for mental and physical health, with reduced social support being a predictor of mental and physical health challenges (Blair & Holmberg, 2008).
Economic exclusion from social consumption.
The final aspect of social exclusion addressed by Galabuzi (2006) refers to economic exclusion, or unequal access to normal forms of livelihood and economy. As already mentioned, many states in the U.S.A. do not offer protection from employment discrimination based on sexual orientation or identity, thus placing sexual minorities in a position where they can be fired from their employment without cause solely based on their sexual orientation. Having one’s employment placed in jeopardy based on one’s sexual identity can create stress and additional economic burdens. Sexual minority individuals may take these factors into consideration when selecting employment and may consequently choose a position that might have fewer financial benefits, but which offers greater protection and acceptance based on their sexual identity. There are a number of other ways in which the current legal and political systems infringe upon the ability of sexual minorities to experience economic equality. Legal recognition of marriage comes with a variety of benefits, including tax credits, which are not available to unmarried individuals, including same-sex couples. Married individuals often also enjoy spousal benefits from their employer, something that is not available to all same-sex couples in the United States at an equal rate because it is not currently regulated or mandated by the Federal Government. In a country where health care is not socialized, health insurance benefits can make a large difference in the health outcomes of an individual, and failure to provide equal access to spousal health benefits places sexual minorities at a disadvantage both with respects to their economic equality and their health status.
Social exclusion and health outcomes.
Social exclusion has been directly linked to negative mental and physical health outcomes in a variety of populations (Campbell & Jovehelovitch, 2000; Culley, 2010; Fish, 2010; Marmot, 2005; Weik, Maroof, Zoller & Dinzer, 2010; Zoller, Maroof, Weik & Deinzer, 2010). From a theoretical standpoint, researchers have shown that social exclusion can lead to self-defeating behavior (Twenge, Catanese & Baumeister, 2002) and impair self-regulation (Baumeister, DeWall, Ciarocco & Twenge, 2005). In a study on self-defeating behavior and social exclusion, researchers manipulated the experience of social exclusion and found that experiencing social exclusion was a causal factor in predicting self-defeating behavior, including making unhealthy choices (Twenge, Catanese & Baumeister, 2002). Another study directly linked social exclusion to impaired self-regulation, showing that individuals in the social exclusion group showed reduced self-regulation when faced with making a healthy decision, or in other words, they were more likely to choose the unhealthy option (Baumeister et al., 2005). Furthermore, participants in the same study were less likely to engage in health promoting behaviors after being socially excluded (Baumeister et al., 2005). What is interesting about these two studies is that the participants experienced social exclusion within the context of an experiment, not as a reoccurring, daily feature of their life experience, and yet this singular experience of social exclusion still had causal and significant effects on both self-defeating and self-regulating behaviors, especially in the areas of health promotion and healthy decision making. Additional research supports these findings, showing that the experience of social exclusion in real life can reduce access to health knowledge, and reduce the belief in one’s ability to take control of their health, thereby making socially excluded individuals less likely to engage in health promoting behaviors (Campbell & Jovehelovitch, 2000).
Other research linking social exclusion to health outcomes has found that members of socially excluded groups experience more adverse health outcomes (Zoller et al., 2010), including links to depression, anxiety, fibromyalgia, cardiovascular disease and even cancer (Fish, 2010; Weik et al., 2010). Julie Fish (2010) argues that examining health from a social exclusion standpoint is an important step in fully understanding the social determinants of health and states that it is important to incorporate an understanding of how living and working conditions contribute to health outcomes. Researchers in this area are consistently calling for the examination of social exclusion as a predicting factor in health outcomes, as opposed to solely focusing in specific healthcare interventions (Culley, 2010; Fish, 2010; Marmot, 2005). One study, using brain imaging techniques, found that the experience of social exclusion, or social pain, activates the same brain structures as actual physical pain, indicating that physical and social pain share a common neuroanatomical basis (Eisenberger, Lieberman & Williams, 2003). With respect to lesbians in particular, research has indicated that women are more vulnerable to social predictors of health outcomes, and thus lesbians may be especially vulnerable to the adverse health effects of social exclusion (Weik et al., 2010; Zoller et al., 2010).
Methodological Issues in Studying Lesbian Health
Reliable and valid research requires strong methodologies that implement sound designs with well-selected research samples. One of the greatest challenges to developing a thorough and accurate understanding of lesbian health issues is the lack of adequate research methodology. This is by no means a criticism of the quality of researchers conducting investigations into lesbian health issues, but rather a consequence of the nature of human sexual identity and the politics that surround sexual minorities. In order to properly investigate a specific population it is important for researchers to be able to define that population and then draw representative samples from which to generalize about the population as a whole. With sexual minorities, this concept is challenged in a variety of ways, including the lack of consensus on defining sexual identities, the difficulty in studying a marginalized and hidden, or invisible, community, and the willingness of sexual minorities to participate in research. Even if one can surmount a reasonable response to these challenges, research on sexual minority issues continues to be plagued by political concerns that limit the availability and quantity of funding available to conduct such research. Despite these significant and real methodological challenges, high quality research has been conducted, but when reviewing such research it is important to keep in mind the challenges that researchers of sexual minorities face, and how these challenges can influence the interpretation of the results that have been published in the literature.
Definition & Measurement of Sexual Orientation & Identity.
The first challenge that sexual minority researchers must address is the definition of the population they wish to examine, and which definitions of sexual orientation and identity to use in designing their study and recruiting their participants. Researchers in the field have not reached a consensus on defining important terms, such as lesbian, gay, bisexual, even though one has a sense that they understand what these terms imply colloquially (Diamond, 2000; Savin-Williams, 2001). Even when researchers do pick a particular definition for the purposes of their study and their sample recruitment, if this definition is not shared by other research studies, this makes comparisons between studies rather difficult. For example, if one study defines their population by looking at women who have sexual contact with other women, while another study defines their population by looking at women who self-identity as bisexual, the results of these two studies may be very different, and the populations addressed may not be similar at all. This leaves a rather disjointed literature on the topic, which one study reporting that women who have sex with women engage in high risk behaviors while another study reports that lesbians do not engage in high risk behaviors, while yet another reports that bisexual women are the ones that engage in high risk behaviors. Within these three studies it is entirely possible that some of the samples overlap with each other based on the variations in individual definitions of sexual identity, let alone the definitions used by various researchers. The consensus that has been growing among sexual minority researchers is that it is important to measure various dimensions of sexual identity (Brown & Alderson, 2010). For example, Brown and Anderson (2010) encourage researchers to measure sexual orientation using a variety of measures, including measures of past and present behavior, measures of past and present attraction and measures of self-reported identity. The notion of measuring past and present dimensions of sexual identity is reflected in other research that has shown that sexual identity is not necessarily a stable trait across the lifespan (Diamond, 2000; Savin-Williams, 2001). In a longitudinal investigation of sexual identity and attraction in sexual minority women, Diamond reports finding that half of the sample changed their identity label twice during a 2-year period and that one third of the sample changed their label at least once during a 2-year period. Within this same sample, reported attractions remained relatively stable across the time span, but identities (labels) and behaviors fluctuated, indicating that sexual identity is more complex than simply selecting a term, and that a reported identity does not always correspond with the expected behavior (Diamond, 2000). Such fluidity in identity and behavior has been found to be especially prevalent among women, making measurement of sexual identity particularly challenging when seeking to understand issues of relevance to lesbian health. The possibility of identity and behavior changing over time leads to additional questions with respect to lesbian health. For example, if lesbians as a group are found to be at higher risk for specific disease or cancers, what happens to the risk level of an individual who previously identified as a lesbian but now identifies as bisexual or as a heterosexual? Does the increased risk remain with them due to past lesbian identity, or does it become diminished with their new identity? What if their reported identity does not fully correspond with their actual behavior or attractions? In other words, what aspects of being a lesbian are associated with the health outcomes that have been identified in the literature? Is it the nature of being attracted to the same-sex, or is it the act of having sex with members of the same-sex, or is it the embodiment of adopting a lesbian identity and living a “lesbian life” that holds relevancy for the health outcomes in the literature? Without assessing identity from various perspectives (behavior, attraction, identity), research has difficulty answering these questions and gaps remain in creating a complete understanding of lesbian health (Brown & Alderson, 2010; Sell, 1997).
In addition to the challenges associated with selecting a definition of sexual identity or orientation and then selecting an appropriate method of measurement, there also exists the challenge of getting researchers to include sexual orientation in their studies in the first place. Despite the relative ease of including sexual orientation in a demographics section of a study, the majority of public health research and psychological research fails to include this question in their demographics (Fish, 2009; Dilley, Simmons, Boysun, Pizacani & Stark, 2010). Even when sexual orientation is included in demographics, often it is done so only as a means for ruling out non-heterosexually identified participants. There appears to be a consensus among researchers who do not specifically study sexual minority issues that it is impossible to recruit a sample with sufficient numbers of sexual minorities to make the inclusion of such participants worthwhile (Fish, 2009). This is an erroneous assumption, especially given the advanced statistical methods available today to address issues of unequal sample sizes and missing data. In one review of a major public health study that did include sexual orientation in the demographics, researchers found that this inclusion provided a wealth of information concerning sexual minority health disparities, and the inclusion of the demographic variable added no cost to the conduction of the study (Dilley et al., 2010). As a result, the researchers concluded that more public health studies need to include sexual orientation in their demographics variables in order to add an additional dimension to the analysis of their data and to provide additional information about the health profiles of sexual minorities.
Studying a Marginalized Population.
Putting aside the challenges associated with defining and measuring sexual orientation, researchers are also faced with the challenge of recruiting sexual minorities to participate in research. Recruitment of sexual minority samples proves to be a challenge in a number of ways. While it is unknown exactly what the size of the sexual minority population is, it is known that the size is significantly smaller than the heterosexual population, thereby making it more difficult to recruit substantial samples. Additionally, because the population is not well defined, it is impossible to recruit a “random” or “representative” sample. Without knowing the makeup of the actual population, it is impossible to know to what extent any sample of sexual minorities accurately reflects the population of sexual minorities as a whole (Rothblum, Factor & Aaron, 2002). It is also difficult to recruit a random sample because if one were to use traditional methods of random sampling (for example using birth records or school enrollments), the resulting number of sexual minorities would prove to be too small for many research purposes. As a result, the majority of research on sexual minorities has relied on convenience sampling methods whereby researchers recruit from community organizations and events known to be associated with the sexual minority community (Rothblum et al., 2002).
While convenience sampling may be acceptable for a number of the questions addressed concerning sexual minorities, when conducting public health studies or studies directed at understanding population-based mortality and risk rates, the use of a convenience sample can severely hamper the validity of the study. Some researchers have attempted to get around this issue by conducting population-based studies that are large enough to provide a decent sample size of sexual minorities. Given the size of a study required to generate a random sampling of sexual minorities large enough for analysis, these studies are quite large are therefore rarely designed with studying the health of sexual minorities, but rather the analyses are done post-hoc on data that happened to include information about sexual orientation and identity (Diamant, Wold, Spritzer & Gelberg, 2000). As an example, Diamant and colleagues analyzed data from a population-based study that yielded 4610 heterosexual women but only 51 lesbians and 36 bisexual women. While statistical methods can compensate for unequal sample sizes to some extent, sample sizes such as these ones severely limit the nature of the statistical analyses that can be conducted with the resulting data.
Regardless of the sampling method used, research on sexual minorities is also challenged by the willingness of sexual minority individuals to participate in research. Given the longstanding history of abuse, pathologizing and medicalization of homosexuality by the medical and psychological communities, many sexual minority individuals are rightfully skeptical of the methods and motives of research being conducted on sexual minorities (Fish, 2009). In addition to skepticism, willingness to participate can also be influenced by the extent to which an individual is open about their sexual identity. If participation requires visiting a laboratory or any form of public acknowledgement of their sexual identity, individuals who are not yet ‘out of the closet’ or comfortable with their sexual identity may be more reluctant to participate. The consequence of this challenge is that the research that has been conducted can only be said to generalize to individuals who were willing to participate, and therefore may not generalize to individuals who are not living their lives openly. Given the stress known to be associated with hidden identities, it is precisely the individuals who are unwilling to participate in research whose health may stand to benefit the most from an increased understanding of the interconnections between sexual identity and health (Blair & Holmberg, 2008). One method that has been used to address this issue is the use of online surveys, which allow participants a considerably greater level of anonymity and may therefore conceivably reach a more diverse section of the sexual minority population (Blair & Holmberg, 2008).
In addition to using research methods that may be conceived as less invasive of the privacy of sexual minority participants, researchers may also consider the usefulness of openly identifying their motives and goals associated with their research projects. Despite the fact that sexual minorities are skeptical and untrusting of the medical establishments that have treated them poorly in the past, they are also very interested in their health and well-being and in the promotion of their rights as full and equal citizens (Fish, 2009). Positive discourse and inclusive language has been seen to go a long way in reducing the anxiety of sexual minorities in medical settings (McIntyre, Szewchuk & Munro, 2010) and therefore may be just as useful in the research setting for putting participants at ease and making them more willing to participate in research aimed at improving their access to and experiences with health care services.
Funding for Research.
The final significant challenge to conducting fruitful research on lesbian health issues is the lack of funding available to conduct such research. Quality research requires funding in order to provide compensation to participants and to make use of the most up-to-date methods and technologies available. Health research can be particularly expensive given the time periods of interest (sometimes an entire lifetime), and methods required to adequately measure health outcomes. Without adequate funding, research can suffer by being limited to the use of smaller sample sizes, the lack of longitudinal follow-ups and a reduction in the sophistication of measurement tools. Funding for a health study could make the difference between using self-report measures of mental and physical health and being able to collect biophysiological data that provides an objective measure of physical health functioning. It is also difficult to draw useful conclusions about health status by taking one-time measurements, as health outcomes often take years to develop. Longitudinal research is required in order to accurately assess the health outcomes of various predicting variables, but this type of research requires large sample sizes to deal with participant attrition and often the best way to keep participants is through the provision of substantial compensation (Plumb, 2001). Unfortunately, funding for research is often linked to politics, and if the political climate is not in favor of advancing research on sexual minority issues, then researchers will have difficulty obtaining the funding required to conduct the research that will advance the health of sexual minorities. Perhaps Plumb worded it best when he described the vicious cycle of needing funding to produce quality research that is capable of influencing medical outcomes:
Without funding we cannot do quality research, without quality research we cannot get published in medical journals, without being published in medical journals we cannot convince medical experts that a health need exists, without proving a health need exists, we cannot get funding for research, prevention or programs (Plumb, 2001, p. 873).
Despite these significant challenges to producing quality research on sexual minority issues, including investigations of lesbian health, a wealth of valuable information has been created through the efforts of resourceful and creative researchers inspired to improve the health status of lesbians. The remainder of this paper reviews the literature on lesbian health issues, covering what is known about current lesbian health status, the impact of minority stress on health experiences, the role that family experiences play in the health of lesbians, lesbian access to and experiences with health care services and the aging process. While there are still significant gaps to be filled, the literature that exists provides a great deal of information that can be useful to health care practitioners and policy makers interested in learning how to improve the health status and experiences of lesbians in North America and abroad.
Current Health Status of Lesbians
The last couple of decades, especially the most recent decade, have seen an increase in the amount of research addressing the specific health disparities experienced by sexual minorities, including lesbians. The results of this research have painted a picture in which lesbians are characterized by a number of physical and health disparities when compared to their heterosexual counterparts. Despite these findings, very few factors have been found to be inherent to one’s sexual identity and rather are more likely to be a result of social and societal differences in the lived experiences of sexual minorities. For example, lesbians are found to be at an increased risk for mental health issues, especially those related to depression and anxiety, but this is not seen as being a result of their sexual orientation, but rather as a result of dealing with the constant stigma associated with their sexual orientation and the inherent stress that comes along with such a burden (Austin & Irwin, 2010; Hutchinson, Thompson & Cederbaum, 2006; Fish, 2009). This section will review the literature concerning what is known about the current health status of lesbians with respect to physical and mental health, including cancers, major illnesses, sexual health and mental health.
Health Risks and Health Behaviors.
One factor that contributes significantly to many of the different health disparities experienced by lesbians is the different occurrence of specific health risks and health behaviors. Specifically, lesbians are more likely to be overweight or obese (Struble, Lindley, Montgomery, Hardin & Burcin, 2010), to smoke (American Lung Association, 2010; Coker, Austin & Schuster, 2010; Lee, Griffin & Melvin, 2009; Steele, Ross, Dobinson, Veldhuizen & Tinmouth, 2009; Tang et al., 2004), use alcohol excessively (Dilley, Simmons, Boysun, Pizacani & Stark, 2010; Mayer, Bradford, Makadon, Stall, Goldhammer & Landers, 2008) and to have substance use issues (Coker et al., 2010; Drabble & Trocki, 2005; Gillespie & Blackwell, 2009). All of these represent important health risks or risky healthy behaviors that serve to compromise the health of lesbians in a serious manner and subsequently places lesbians at a greater risk for other serious illnesses, including cancer and cardiovascular disease.
Struble and colleagues (2010) conducted a study in which they compared the prevalence of being overweight or obese among lesbian, bisexual and heterosexual college women. The study found that lesbians and bisexuals were significantly more likely to be overweight or obese as compared to heterosexual women. Conversely, lesbians were significantly less likely than heterosexual women to report being underweight, indicating that there are greater issues for lesbians in terms of eating disorders leading to excess as opposed to eating disorders related to excessive restriction (Struble et al., 2010). This finding corresponds with a qualitative focus-group-based study that found that lesbians were significantly less likely to express concerns about being thin or achieving ‘ideal’ body images as dictated by society or media outlets (Roberts, Stuart-Shor & Oppenheimer, 2010). The same study did, however, find a difference in views on body image between older and younger lesbians. Younger lesbians who were overweight were more likely to report wanting to lose weight than were older overweight lesbians (Roberts et al., 2010). Furthermore, the older lesbians were more likely to explain the large numbers of overweight and obese lesbians by stating that lesbians are more likely to reject social norms related to appearance and body type for women, and to be more accepting of all body types within their community (Roberts et al., 2010). Despite the differences in opinions between younger and older lesbians dealing with weight issues, all of the participants in the study, regardless of age, did report having significant concerns related to their health and wishing to have their consequent health concerns addressed by their medical care professionals (Roberts et al., 2010). Many of the lesbians in this sample also attributed their difficulties with weight to dealing with minority stress on a daily basis, and they also felt that this stress contributed to other unhealthy behaviors such as increased drinking and smoking. Finally, the participants felt that there was a link between their experience of depression as a result of the stigma associated with their sexual orientation and their weight gain (Roberts et al., 2010). The results of this study further emphasize the notion that increased health risks among lesbians are not inherent to their sexual orientation, but rather are a resulting consequence of the stigma associated with their sexual orientation and the additional social stresses that this creates within their daily lives.
The study by Roberts and colleagues (2010) raises questions about whether or not the trend of lesbians being overweight when compared to their heterosexual counterparts is a trend that will dissipate with greater social acceptance of sexual diversity. A recent study by Coker and colleagues (2010) attempted to address this question by examining the views of sexual minority adolescents with respect to body image and health. The study found that lesbian and bisexual girls were significantly happier with their body image than were heterosexual girls, which is more in accordance with the views expressed by the older lesbians in the Roberts and colleagues (2010) study than by the younger lesbians, who expressed an interest in losing weight and being thin. One important difference between these two studies, however, is that the Coker and colleagues (2010) sample was not limited to participants who were overweight, but rather collected opinions from participants across the spectrum of weight categories. This could indicate that for lesbian and bisexual youth, concerns about weight are not as present for individuals who are already a health weight, but that once overweight, the younger lesbians of today are more likely than their older lesbian counterparts to express a desire to become thin or to reduce their weight for health reasons.
The consistent results of research pointing to weight issues within the lesbian community underscores the importance of directing specific weight related health interventions towards this population. The participants in the Roberts and colleagues (2010) study expressed a desire for such interventions, but also emphasized that they wanted health interventions directed at the lesbian community to be focused on overall health, and not specifically on weight issues. Regardless, any campaigns directed at weight for women should consider the specific needs of lesbians, or at least make an attempt to make their campaign accessible and approachable to a lesbian audience. Weight concerns have in the past been explained by the supposed rejection of societal norms by lesbians as a group (Fish, 2009; Roberts et al., 2010), as well as a result of dealing with additional social stresses related to homophobia, heterosexism and discrimination (Fish, 2009), but regardless of the causes of weight issues for lesbians, it is important that these issues be addressed given their dangerous links to other serious health concerns. Mayer and colleagues (2008) point out that being overweight or obese places lesbians at a greater risk for cardiovascular disease, lipid abnormalities, glucose intolerance and increased morbidity.
Research has consistently found that lesbians are more likely to smoke and more likely to smoke more than heterosexual women. Smoking itself has been consistently linked to a variety of health concerns and negative health outcomes, making smoking one of the most serious health risk behaviors that contributes to health disparities between lesbians and heterosexual women. The American Lung Association (2010) reports that a lesbian is between 1.2 and 2 times more likely to be a smoker than a heterosexual woman, with this being even more exaggerated among younger lesbians. The number of studies that have found lesbians to be more likely to smoke is excessive (Cochran, Mays, Bowen et al., 2001; Coker et al., 2010; Dilley et al., 2010; Lee et al., 2009; Mayer et al., 2008; Roberts, 2006; Steele et al., 2009), with only a few studies reporting no significant differences in smoking between lesbians and heterosexual women (Zarisky & Dibble, 2010) or reverse effects with heterosexual women smoking more than lesbians (Dibble, Roberts, Robertson & Paul, 2002). These contrary results, however, are grossly outnumbered by the results indicating that lesbians do smoke more than heterosexual women. The one study that found no significant differences between lesbians and heterosexuals used a sample of lesbians and their heterosexual sisters, thus not quite using representative studies. This study was interesting though in that it incorporated familial predictors of smoking and health risk behaviors, suggesting that these factors may in some cases be better predictors of smoking behavior than sexual orientation. Further research in this area would be required to determine whether or not this discrepancy with the remaining literature holds true across multiple samples, or whether it represents an anomaly among a general consensus of research that strongly suggests that smoking is a serious concern within the lesbian community.
Data from the National Health Interview Survey analyzed by Lee and colleagues (2009) found that 18% of U.S. women were smokers, compared to 25 to 37% of lesbian smokers, based on a review of 46 different studies investigating sexual minorities and smoking behavior. In one study of adolescent girls, girls with one or more same-sex sexual encounter were 6.3 times more likely to smoke than heterosexuals (Lee et al., 2009). One of the contributing factors to the increased levels of smoking within the lesbian community has been suggested to be the prevalence of socializing within bar scenes in which smoking is common (American Lung Association, 2010; Fish, 2009). Another potential factor suggested to be one of the causes of increased levels of smoking is the additional stresses experienced by sexual minorities, resulting in greater seeking of coping behaviors (Roberts et al., 2010). Once again, researchers do not consider the increased levels of smoking to be necessarily inherent to sexual orientation, but rather a subsequent consequence of being enmeshed within a community that either emphasizes smoking through social practices or that uses smoking as an outlet for coping with the social stresses related to a sexual minority status. Despite the fact that sexual orientation and smoking are not inherently linked, the increased level of smoking within the lesbian community does contribute to a number of increased health risks, including increased risks cardiovascular disease, lung cancer, reproductive cancers, reduced life expectancy and increased morbidity (American Lung Association, 2010).
Alcohol Use & Abuse.
In addition to increases in smoking behavior, lesbians are also more likely to use alcohol and to use alcohol excessively in comparison to heterosexual women. A number of research studies have found that lesbians tend to drink alcohol more often than heterosexual women, both in older and younger lesbians (Coker, 2010; Dilley et al., 2010; Kavanaugh-Lynch et al., 2002; Mayer et al., 2008; Steele et al., 2009). In addition to being more likely to drink alcohol, research also shows that lesbians are more likely than heterosexual women to use alcohol excessively or to have problem drinking behaviors (Coker et al., 2010; Dilley et al., 2010; Steele et al., 2009). Problem drinking behaviors are known to be associated with mental health issues, including stress, depression and anxiety, all of which are reported more frequently among sexual minorities (King et al., 2007), thus offering a potential explanation for the increased alcohol use among lesbians. Additionally, increased and excessive alcohol use is associated with negative health outcomes and reduced life expectancy, further contributing to the health disparities between lesbians and heterosexual women.
The research on substance use in lesbians, with respect to illicit substances other than alcohol and tobacco, the research is less conclusive. Studies with sexual minority youth have reported increased substance use by lesbians as compared to heterosexual youth, but for the most part substance use appears to be more common among sexual minority males than females (Coker et al., 2010). Some research has pointed to increased drug misuse in lesbians as compared to heterosexual women (Drabble & Trocki, 2005), but the majority of research does not find significant differences between heterosexual women and lesbians with respect to substance use and abuse. Gillespie and Blackwell (2009) found that substance use problems were much more prevalent in sexual minority men than they were in sexual minority women, but the study did not include a heterosexual comparison group and thus could not provide information comparing lesbians to heterosexual women. Another study, investigating sexual risk behaviors found that lesbians reported higher rates of injection drug use than both heterosexual and bisexual women (Koh, Gomez, Shade & Rowley, 2005) which places individuals at greater risk for sexually transmitted diseases, including HIV.
Cancer & Major Illnesses.
Overall, research consistently paints a picture of lesbian health that includes increased rates of smoking, alcohol use and abuse, and increased likelihood of being overweight or obese, all of which place lesbians at greater risk for a number of serious illnesses and increased morbidity.
One of the areas in lesbian health research that has received the greatest amount of attention is the relative risk associated with reproductive cancers in lesbian women. Research has sought to determine whether or not there are discrepant rates of cancer between lesbian women and heterosexual women, and more often, investigated whether there are greater risks within one community or the other associated with potential for developing reproductive cancer. In addition to the elevated risk associated with health risk behaviors, such as smoking and alcohol use, lesbians have been found to be at increased risk for some of the reproductive cancers for reasons associated with discrepancies in detection, screening and prevention practices.
A study of 370 lesbians and their heterosexual sisters compared the risk factors for reproductive cancers (Zarisky & Dibble, 2010). All of the participants were over the age of 40, and the sisters were compared based on their levels of education, pregnancies, breast feeding experience, number of children, birth control use, weight, exercise habits, smoking and drinking habits, as well as their preventative health practices, such as self-breast examinations. The results of the analysis found that lesbians scored significantly higher than their heterosexual sisters on education and weight (body mass index), while the heterosexual sisters were more likely to have had more pregnancies, more children, more experience with breast feeding, increased exercise levels, and increased practice of self-breast examinations. The authors concluded that based on these results, the lesbian sisters were at an increased risk for breast, ovarian and endometrial cancer, but at a decreased risk for cervical cancer (Zarisky & Dibble, 2010). Null parity, lack of breast feeding, obesity, and reduced exercise are all associated with greater risk for development of breast cancer, and these risks added to the lack of birth control use are predictive of increased occurrence of ovarian and endometrial cancers (Zarisky & Dibble, 2010). Cervical cancer was the only reproductive cancer for which the study concluded that lesbians were at a decreased risk for as compared to their heterosexual sisters. This finding was based on the heterosexual sisters reporting a greater number of risks associated with cervical cancer, including pregnancy, use of birth control, and increased sexual activity with men. The only risk factor for cervical cancer on which lesbians scored higher than their heterosexual sisters was obesity (Zarisky & Dibble, 2010).
Another study focused on the risks associated with developing ovarian cancer and found that lesbians were at an increased risk for ovarian cancer even after controlling for age, ethnicity, employment, and disability status (Dibble et al., 2002). The majority of the participants in this sample were white, poor, lacking in health insurance and over the age of 40. The study compared lesbians and heterosexual women recruited from health care practitioner offices and found that lesbians had higher BMIs than heterosexuals, fewer pregnancies, fewer children, fewer miscarriages, fewer abortions and less use of birth control, all of which placed them at a higher risk for developing ovarian cancer than heterosexuals. The only risk factor on which heterosexuals scored higher than lesbians was on smoking, and this finding is in contrast to the majority of the research on sexual minority women and smoking which consistently finds lesbians to be more likely to smoke than heterosexual women.
A study focusing on risk for developing breast cancer found that lesbians were at an increased risk for developing breast cancer as a result of reduced parity, reduced breast feeding, higher BMIs, and increased alcohol use (Kavanaugh-Lynch et al., 2002). In addition to the number of studies indicating that lesbians appear to be at a higher risk for developing a number of reproductive cancers, there is also concern within the literature that lesbians are less likely to engage in the protective and preventative health behaviors that are likely to lead to early detection of a reproductive cancer. A number of research studies have reported that lesbians experience more discomfort with accessing medical services than do heterosexual women (Cochran et al., 2001; Hutchinson et al., 2006; Mayer et al., 2008; Roberts, 2006), leading to a reduction in the frequency with which lesbians receive gynecological examinations or mammograms. Mayer and colleagues (2008) found that lesbian women reported significantly less frequent screening for breast and cervical cancer than did heterosexual women, making them less likely to benefit from early detection. Additionally, there appears to be a great deal of misinformation concerning the health risks associated with reproductive cancers for lesbians, with many doctors assuming that lesbians have not had sexual contact with men and are therefore not at risk for developing cervical cancer, and therefore not in need of pap tests (Fish, 2009; Fish & Wilkinson, 2000). This misconception can lead to a delay in the detection of cervical cancer and also in a lack of gynecological examinations which can be useful in monitoring the overall reproductive health of a woman and the early detection of other forms of cancer. Lesbians also report experiencing barriers to accessing care, such as negative experiences with insensitive medical professionals or experiences of heterosexism that make them unlikely to seek medical treatment. Cochran and colleagues (2001) reported that lesbians were significantly less likely than heterosexuals to have health insurance and also significantly less likely to have had a recent pelvic examination or mammogram, thereby increasing their risk of developing a reproductive cancer and not having it detected at an early and treatable stage. Additionally, one of the very few population-based studies also found that lesbians were significantly less likely than heterosexual women to have participated in preventative or screening behaviors, and that specifically lesbians were significantly less likely to have had a pap test or breast examination in the previous two years (Diamant, Wold, Spritzer & Gelberg, 2000).
Although a considerable amount of research has been conducted to assess the relative risks of lesbians as compared to heterosexual women with respect to developing reproductive cancers, very little research has been conducted that has focused on the actual experiences of sexual minority women with cancer, or the treatment and progression of the disease (Brown & Tracy, 2008). Brown and Tracy criticize the literature for focusing solely on prevention and screening barriers and not investigating any potential discrepancies with respect to treatment, survival, morbidity and mortality between lesbians and heterosexual women with cancer. In fact, the present literature review only found one study that had compared the diagnosis, treatment and prognosis of breast cancer in lesbian and heterosexual women. Dibble and Roberts (2002) compared lesbians and heterosexual women diagnosed with breast cancer and found no differences in their demographics, diagnostic procedures, surgical procedures, chemotherapy regimens or use of radiation therapy. The only significant difference found in the study was with the reported side effects of chemotherapy. Lesbian women in the sample reported significantly more side effects associated with chemotherapy than did the heterosexual women, but the researchers were unable to explain why this may have been the case (Dibble & Roberts, 2002). Dibble and Roberts (2002) stated that additional research was needed in the area to fully appreciate the differences in the diagnosis, treatment and progression of reproductive cancers in lesbian and heterosexual women. It is possible that the existing barriers to screening and preventative care may also spread into the treatment stage of a lesbian’s experience with cancer, with continued negative experiences with health care professionals potentially predicting a worse prognosis and progression of the disease than found in heterosexuals. Further research is needed in this area to investigate whether or not such differences may exist (Brown & Tracy, 2008; Dibble & Roberts, 2002; Hutchinson et al., 2006).
Research has also found links between sexual orientation and other chronic illnesses within the lesbian population, but considerably less research has been conducted in this area as compared to the research that has examined the links between sexual orientation and risks for developing reproductive cancers.
A recent population-based study that investigated the links between sexual orientation and chronic illness found that lesbians were significantly more likely than heterosexual women to have poor physical and mental health (Dilley et al., 2010). Specifically, the study found that lesbians were significantly more likely to have asthma, to be overweight, to be smokers, to drink excessively and to have reduced access to health care services (Dilley et al., 2010). In a review of the literature, Mayer and colleagues (2008) concluded that lesbians were at a significantly increased risk for cardiovascular disease, lipid abnormalities, diabetes and increased morbidity as a result of their increased likelihood to be overweight or obese. In a Canadian population-based study that used a community health survey, sexual orientation was found to be significantly associated with health status disparities and health risk behaviors (Steele et al., 2009). Lesbians in the sample were significantly more likely to report daily smoking risky drinking behaviors, and bisexual women were significantly more likely to report poor or fair mental health, mood and anxiety disorders, lifetime STD diagnosis and lifetime suicidality (Steele et al., 2009).
It is logical that given the increased incidence of obesity, smoking and alcohol abuse within the lesbian community that there would also be an increase in the associated health consequences of these conditions, including diabetes and cardiovascular disease. Despite this logical and obvious connection, very little research has actually examined the experiences of lesbians with chronic illnesses or compared disease progression in lesbians vs. heterosexual women. This is an area of lesbian health research that requires a great deal more investigation and the final conclusion concerning the health disparities related to chronic illnesses in lesbians are far from being drawn at this stage in the research process. Given the known disparities in health access and utilization of health care services, as well as the known barriers to accessing health care or being satisfied with health care services within the lesbian community, there is a high likelihood that disease progression, treatment and prognosis may differ between lesbians and heterosexual women, making this a crucial area for future research.
Lesbians, and the medical professionals who treat them, often assume that lesbians are at a reduced risk for contracting sexually transmitted diseases and infections, including HIV and HPV. While lesbians may be at a reduced risk in some aspects, as a general assumption it is dangerous for lesbians and health care professionals to simply dismiss the risks of sexually transmitted diseases and infections when considering lesbian sexual health (Fish, 2009). Bisexual women have been found to have significantly higher numbers of lifetime STD diagnoses (Steele et al., 2009), and although bisexuals and lesbians form two separate groups, research has shown that sexual identity is not always a stable trait (Diamond, 2000) and thus assumptions should not be based on current labels when considering appropriate health care provisions. Additionally, the reduced access to care and the reduced comfort with accessing medical care among lesbians places lesbians at a greater risk for leaving their sexual health unchecked, thus creating a risk of increased spread of disease between partners and a delay in receiving proper treatment (Koh, Gomez, Shade & Rowley, 2005).
A study investigating the sexual risk behaviors of lesbians, bisexual and heterosexual women compared a variety of different behaviors between the three groups of women (Koh et al., 2005). Within the sample examined, heterosexual women were found to have the highest risk of HIV infection as a result of having a greater likelihood of sex without a condom with men. Lesbians, however, were not absent of sexual risk behavior. Lesbians were more likely to report having had sex with bisexual men, a behavior that is considered to be high risk with respect to contracting HIV. Despite this, lesbians were most likely to report having used a condom when having sex with a man. Lesbians in the sample also reported higher rates of injection drug use than the bisexual or heterosexual women, additionally adding to their risk of HIV contraction. For a group that is often assumed to have very low to zero risk of contracting HIV, this study highlights the importance of not relying on assumptions and understanding how the fluidity of sexual identity and behavior can alter the risk profile of any individual (Koh et al., 2005).
Another important aspect of sexual health is sexual satisfaction. Henderson, Lehavot and Simoni (2009) reported that sexual satisfaction in lesbians and heterosexual women appears to subject to the same predictor variables, and to be strongly linked to relationship satisfaction. The only differences the researchers reported between lesbians and heterosexual women were the relative impacts of internalized homophobia and social support. The researchers found that social support was a positive predictor of relationship satisfaction in lesbian, but not heterosexual women, and that this in turn predicted sexual satisfaction in the lesbian sample. Similarly, internalized homophobia, which is not a relevant variable to heterosexual women, was found to be negatively correlated with relationship satisfaction, and in turn, sexual satisfaction, in lesbian women (Henderson, Lehavot & Simoni, 2009). Other research in this area has also found important links between relationship satisfaction and sexual orientation (Blair & Holmberg, 2008; Holmberg, Blair & Phillips, 2009). In one study, the relationship was reversed and sexual satisfaction was found to be a significant predictor of relationship satisfaction, and in turn, to also predict mental and physical health for women in same-sex and mixed-sex relationships (Blair, Holmberg, & Phillips, 2009). This study, in particular, emphasizes the importance of investigating issues related to sexual satisfaction when examining the health of women, as it demonstrates that health is predicted not only by variables directly linked to physical health, but also by those associated to health through other variables, such as relationship satisfaction and functioning, which can be impacted by a wide variety of social factors.
The topic of sexual minority mental health is one that has been consistently associated with controversy in the literature. Historically the higher incidence of mental health issues within the sexual minority community was used as justification for classifying homosexuality as a mental disorder itself, and as a basis for discrimination against sexual minorities (Cochran, 2001; Fish, 2009). More recent perspectives, however, have acknowledged that it is more likely that the higher incidence of mental health issues within this community are a result of the stigma and discrimination that individuals within the community face on an ongoing basis in their daily lives (Fish, 2009). Regardless of the debates concerning etiology, research does consistently find disparate rates of mental illness in sexual minority populations, and this finding extends to lesbians.
King and colleagues (2007) found that lesbians were at a significantly higher risk for experiencing psychological distress, engaging in self-harming and suicidal behaviors and reporting higher levels of generalized anxiety disorder. Research in this area has been conducted with a wide variety of sample types, ranging from population-based studies to sibling comparisons to community health surveys. Some studies have found more differences within the bisexual community, indicating that it is bisexuals who suffer from the greatest number of disparities in mental health, being more likely to have mood and anxiety disorders and higher levels of lifetime suicidality (Steele et al., 2009). Despite this finding, many other studies have indicated that sexual orientation continues to explain a significant portion of the variance in mental health issues for lesbians even after bisexuals have been removed from a sample for analysis. In their review of the literature, Mayer and colleagues concluded that lesbians have significantly higher levels of depression and anxiety, and they explain this as being a result of living marginalized lives in which they constantly deal with the stress of hiding their identity and the in some cases, also endure on going emotional and physical abuse based on their sexual identity. This conclusion is supported by reports of lesbians themselves, who indicate that a number of their physical and mental health concerns are direct consequences of dealing with societal reactions to their sexual identity on an ongoing basis (Roberts et al., 2010). According to Cochran (2001), mental health is strongly influenced by social stress, which contributes greatly to the reduction in mental health status for lesbians, who deal with a great deal of social stress based on their marginalized status and often rejected sexual identity. Cochran (2001) points out that dealing with such stress contributes directly to increased incidence of anxiety and affective disorders, and that the existence of these disorders within the lesbian community should not be interpreted as being inherent to sexual minority status, but rather are inherent to being a sexual minority living in a heterosexual and heterosexist society.
Despite the general improvement in acceptance of sexual minorities within society, there continues to be a great deal of concern about the mental health of sexual minorities, especially as it relates to issues of depression and suicide. These concerns are most present in the research examining sexual minority youth, who are statistically more likely to attempt suicide than their heterosexual peers. Roberts (2006) found that lesbian youth were at an increased risk for suicide and depression and this finding has been echoed by many other researchers, with Coker and colleagues (2010) recently highlighting the consistency with which lesbian youth have been found to be at an increased risk for suicide attempts and suicidal behavior and ideation. Knowledge that sexual minority youth are at a higher risk for suicide has been within the literature on sexual minority health issues for nearly two decades, and yet the issue continues to be prevalent. A study by Safren and Heimberg in 1999 found that sexual minority adolescents reported greater levels of depression, hopelessness and past and present suicidality than their heterosexual peers. Even after controlling for other predictors of psychological distress, suicidality remained a significantly higher risk for sexual minority youth (Safren & Heimberg, 1999). Mayer and colleagues (2008) conclude that despite the improvements in societal acceptance of sexual minorities, the ‘coming-out’ process is still a very stressful period in a sexual minority’s life, and they conclude that this is a contributing factor to the continued higher rates of suicide and suicidal behavior among sexual minority youth today.
Suicide and depression are not only issues of concern for sexual minority youth. In a study of sexual minority adults and their siblings, sexual orientation was found to predict suicidal ideation, suicide attempts, self-harming behavior, use of psychotherapy and use of psychiatric medications (Balsam, Beauchaine, Mickey & Rothblum, 2005). This study highlights that suicidality and depression remain considerable concerns for sexual minority adults, and that the challenges of living in a heterosexual and heterosexist society create great levels of stress for sexual minorities, in some cases enough that it lead to suicidal behavior.
The mental and physical health status of lesbians is one in which there are clear disparities on a variety of factors, in which lesbians suffer from higher levels of obesity, risky health behaviors (e.g. smoking, drinking), increased risks for reproductive cancers and decreased access to preventative screening and detection, chronic illness related to obesity and health risk behaviors, higher rates of mental illness, and neglected sexual health concerns. What ties the majority of these issues together is their link to minority stress, or the stress experienced by lesbians on a day-to-day basis living in a heterosexual society that is not always accepting or accommodating of their lives, loves and families. The stress of having to navigate the extent to which they live their lives openly, and the constant monitoring of the ‘coming out’ process, as well as dealing with both implicit and explicit forms of discrimination take their toll on the health behaviors and health conditions of lesbians. While the information about the current health status of lesbians can be seen in some respects to be disheartening, it can also be seen in a more promising light, in that the majority of the health disparities that exist for this community are the result of societal imbalances and injustices, rather than anything inherent to actually being a lesbian. The implications for this mean that as societal acceptance continues to improve, and as the rights of sexual minorities continue to be advanced and respected, the existing health disparities will eventually dissipate. Societal change is, however, slow, and the health transformations that will follow will be even slower, thus necessitating a response from health care providers at present that recognizes the unique health care needs of lesbians and the specific areas in which they are at greater risk.
Minority Stress & Health
As the review of the literature on the health status of lesbians has demonstrated, many of the health disparities experienced by lesbians living in a heterosexual society are the result of living with the consequences of minority stress. As a result of research indicating greater disparities in health among sexual minorities, especially in the areas of mental health, researchers began to investigate potential explanations for such discrepancies, and the most supported explanation to date has been the investigations of minority stress. Meyer first applied the term minority stress to the lives of sexual minorities in 2003, and he described minority stress as the excess stress that sexual minorities live with and deal with as a consequence of being part of a stigmatized social group and as a result of that group’s social position. According to Meyer (2003), minority stress explains the higher prevalence of mental disorders among sexual minority adults, emphasizing that sexual minorities deal with a great amount of excess stress as a result of experiencing prejudice, expectations of rejection, the stress associated with hiding and concealing efforts, as well as internalized homophobia. The consequence of these repeated life experiences is that sexual minorities live with a much higher amount of stress than heterosexuals, and consequently it should not be surprising that they then suffer from higher rates of mental disorders and physical ailments, as stress is known to be a causal factor in both mental and physical health.
Stress associated with hiding sexual identity.
One of the contributing factors to minority stress is the experience of hiding one’s sexual orientation or negotiating the ongoing process of disclosure. Although many sexual minorities are open about their lives, heterosexuality remains the assumed norm, and thus even though a sexual minority may live their life entirely out in the open, the process of ‘coming out,’ or disclosing one’s sexual orientation continues to be a life long process. King and Cortina (2010) have reported that the degree to which sexual minorities hide their sexual orientation in their day-to-day lives, especially in the workplace, is closely associated with their experiences of decreased mental and physical health. This finding is further supported by research that indicates that hiding one’s sexual orientation requires an immense amount of energy that depletes the cognitive resources available for other stress management and daily living tasks (Madera, 2010).
The process or necessity of hiding one’s sexual orientation is also relevant to the discussion of social exclusion. The lack of legal sanctions to protect sexual minorities from employment discrimination based on sexual orientation often leads to many individuals feeling that they have no choice but to ‘pass’ as heterosexual within the workplace in order to protect their job security. The failure to have federal employment protection for sexual minorities and the consequent necessity of hiding one’s sexual identity is relevant to all four aspects of social exclusion. Social exclusion through legal sanctions applies due to the lack of legal protections for sexual minorities in the workplace. There is also a failure to provide for the needs of sexual minorities, in that they cannot live their lives openly, thereby contributing to additional minority stress, which has its own consequences for mental and physical health. There is also social exclusion from social production and the ability to fully participate in society’s activities. The work environment for most Americans constitutes the location where individuals spend the majority of their waking hours, and thus such an environment plays a large role in the cultural and social activities that individuals participate in. Being unable to be open about one’s sexual identity limits the extent to which one can fully participate in these environments, and thus sexual minorities often experience social exclusion within the workplace, either through hiding their sexual orientation, or through being open but facing negative attitudes and stigmatizing behaviors. Finally, economic exclusion is relevant, as the ability to earn a living can be compromised by individuals losing their jobs based on sexual identity, or underperforming at their jobs due to extending excessive cognitive efforts to hiding their sexual orientation in the workplace (Maderna, 2010).
In a study that investigated the experiences of lesbian women in the Canadian Military who had been discharged for homosexuality prior to the legislation changes that allowed open gay military service in Canada in 1992, a number of health consequences were reported as a result of the ongoing process of having to hide one’s sexual orientation (Poulin, Gouliquer & Moore, 2009). Having to hide one’s sexual orientation at the workplace may involve simply appearing single or using generic pronouns when discussing a significant other, but hiding one’s sexual orientation in the military can be quite a different experience (Poulin et al., 2009). During the period before homosexuals were allowed to serve openly in the Canadian Military (prior to 1992), sexual minorities in the military were subjected to constant scrutiny and special investigations that sought to identify potential sexual minorities within the armed forces (Poulin et al., 2009). Thus, lesbians serving in the Canadian Military during this time were subjected to much higher levels of stress associated with concealing their identity than the average individual hiding their identity within the workplace. The study found that many of the women reported negative physical and mental health consequences as a result of the stress they experienced, and in fact the researchers concluded that the stress experienced by these women was remarkably similar to the nature and magnitude of stress experienced by stalking victims (Poulin et al., 2009).
Experiences of prejudice and victimization.
Another mechanism through which minority stress can infringe upon the mental and physical health of sexual minorities is through the process of internalized homophobia or homonegativity (Newcomb & Mustanski, 2010). Internalized homophobia refers to the process through which sexual minorities adopt the negative views held by society of their sexuality and interpret these views as being accurate and consequently having a reduced sense of self and self-esteem. A meta-analysis of 31 studies that investigated the links between internalized homophobia and mental and physical health found moderate effect sizes for the association between internalized homophobia and mental and physical health (Newcomb & Mustanski, 2010). Specifically, higher levels of internalized homophobia were associated with increased levels of depression and anxiety, which are considered to be internalizing mental health problems. This relationship was found to be even stronger among older lesbians and gay men. Additionally, the relationship between internalized homophobia and depression was found to be higher than the relationship between internalized homophobia and anxiety (Newcomb & Mustanski, 2010). Internalized homophobia is one of the contributing factors to minority stress, according to Meyer (2003), and its direct links to mental health help to contribute to the understanding of why sexual minorities as a group experience higher rates of mental illness and disorders than their heterosexual counterparts.
In addition to the stresses associated with hiding one’s sexual identity and the internalizing of society’s views concerning sexual diversity contributing to internalized homophobia, minority stress is also influenced by experiences of prejudice and harassment (Meyer, 2003). The bullying literature consistently reports negative mental and physical health outcomes for individuals who have been victims of bullying (Smith, 2004). In particular, youth who experience bullying at school are more likely to report higher levels of depression and anxiety and lower levels of self-esteem than their peers who have not been victims of bullying (Smith, 2004). Bullying has been reported to be a particularly common experience for sexual minority youth, and has been considered to be one of the main contributing factors to the increased rates of suicide and suicide attempts within this population (Smith, 2004; Williasm, Connolly, Pepler & Craig, 2005). In a study of 97 sexual minority high school students and a heterosexual comparison group, sexual minority youth reported significantly higher experiences of sexual harassment, bullying, and less companionship with their best friends (Williams et al., 2005). Furthermore, experiences of victimization were found to mediate the link between sexual orientation and psychosocial symptoms, such that sexual minority youth who were also victims of bullying and harassment were significantly more likely to report negative psychosocial symptoms, such as depression, anxiety and low self-esteem (Williams et al., 2005). Social support, however, was found to also mediate this relationship, such that youth who had higher levels of social support experienced better mental health than those who suffered from lower levels of social support (Williams et al., 2005).
Another study of youth and minority stress found that chronically stressful events lead to negative health outcomes, especially within the realm of mental health (Kelleher, 2009). In a sample of 301 Irish LGBTQ youth, minority stress was found to be a significant predictor of psychological distress. The authors concluded that one of the main contributing factors to the experience of minority stress for sexual minority youth was a negative social environment (Kelleher, 2009). This study provides further evidence for the link between bullying, harassment and psychological distress in sexual minority youth (Kelleher, 2009).
Social support and minority stress.
Some researchers have suggested that as the legal status of sexual minorities improve, the connections between sexual orientation and negative health outcomes might reduce (Dysart-Gale, 2010). One study sought to investigate this hypothesis by examining the experiences of lesbian, gay and bisexual youth in Canada, a country that has removed many of the social and legal barriers still experienced by sexual minorities in the United States today. Despite the liberal and progressive political climate in Canada with respect to sexual minority rights and freedoms, the researchers found that the youth in the study still reported negative social attitudes towards sexual minorities and that these attitudes continued to have a negative impact on the experiences of exclusion, isolation and fear of lesbian, gay and bisexual youth living in Canada (Dysart-Gale, 2010). Consequently, even as social and legal barriers are removed, challenges still exist for sexual minorities facing the continued negative social attitudes held towards sexual diversity. This finding points to the importance of not only enacting change within the political and legal systems, but also ensuring that social change occurs to ensure that negative attitudes are eradicated. The finding also highlights the fact that change takes time, and that even though Canada has greatly improved the status of sexual minorities, the lived realities for LGBTQ individuals still varies greatly based on the actual attitudes of individuals within their lives and social networks (Dysart-Gale, 2010).
The importance of social attitudes is highlighted in the links that have been well established in the literature between social support and health (Cassel, 1976; Cobb, 1976; House, Umberson & Lnadis, 1988; Uchino, Cacioppo & Kiecolt-Glasser, 1996). Social support has been shown to have a variety of health implications, ranging from improved mental health (Dean, Kolody & Wood, 1990; Dew & Bromet, 1991; Reisen & Poppen, 1999; Ross, Lutz & Lakey, 1999) to better immune system functioning (Uchino et al., 1996) and increased longevity (Billings & Moos, 1982; Blazer, 1982; Hendersons, Bryne & Duncan-Jones, 1981; Turner, 1981). Given the strong links between general social support and health, researchers have sought to investigate the impact of specific forms of social support and health outcomes. In a recent study of sexual minority youth, levels of support available from friends and family for dealing with minority stress were compared with levels of support from the same sources for dealing with other forms of stress (Doty, Willoghby, Lindahl & Malki, 2010). The results of the study found that support for dealing with minority stress and its consequences was less available from friends and family than was support available for dealing with other forms of stress unrelated to sexuality or sexual identity (Doty et al., 2010). The researchers found that it was the friends who were also sexual minorities themselves who provided the greatest levels of support for sexuality related stress, or minority stress. Furthermore, having support for dealing with stress associated with one’s sexuality or sexual orientation was associated with decreased levels of emotional distress and was also found to buffer the effects of minority stress on emotional distress (Doty et al., 2010). This study is important as it shows the importance of social support, not just in general, but specifically relate sexual identity and sexual orientation, in improving the mental health of sexual minorities. It also emphasizes the fact that general support is not sufficient to compensate for the experiences of minority stress, and that the negative mental health consequences of minority stress in sexual minority individuals can be best combated by providing improved levels of social support related to sexuality. The findings of this study fit well with social exclusion theory, as the opposite of social exclusion is social inclusion, and social inclusion is essentially a form of social support.
The literature has consistently demonstrated that minority stress is linked to negative mental and physical health outcomes. As such, it is important that minority stress be taken into consideration when examining the existing health status of lesbians, as it provides a context for understanding the disparities that exist between lesbians and heterosexual women. Although a number of serious health disparities do exist, the story is somewhat positive in that there is a clear pathway to improvement. The improvement of lesbian health care, access and status does not lie in solving some grand mystery about something inherent to being a lesbian or a sexual minority, but rather lies in the processes of social change and increased societal acceptance. Achieving social change is no small order, and it is not something that will contribute to improvements in health overnight, but it is at least a clear mandate for society, and one that can be successfully achieved.
Social Support, Relationships & Health
Although minority stress can have negative consequences on the mental and physical health functioning of sexual minorities, social support has been shown to function as an effective buffer variable, ameliorating the effects of minority stress and improving well-being (Doty et al., 2010). One of the most important sources of social support is family, including intimate partners or spouses. Partly for this reason, marriage is quite closely linked to improved health. Good relationships are associated with reduced levels of depression (Tolpin, Cohen, Gunthert & Farrehi, 2006), lower anxiety (Campbell, Simpson, Boldry & Kashy, 2005), lower stress levels (Waite, 1995) and improved immune system functioning, contributing to improved physical health (Kiecolt-Glaser & Newton, 2001). Additionally, married individuals have been shown to have increased longevity in comparison to single individuals or even coupled cohabiting individuals (King & Bartlett, 2006).
Although it is known that marriage confers mental and physical health benefits to those who are married, legislation continues to prohibit same-sex couples from legally marrying each other in many states and countries around the world. This has lead researchers to question whether or not same-sex couples are potentially being denied the health benefits associated with marriage. According to King and Bartlett (2006), denying same-sex couples the right to marry or engage in civil unions is placing the mental and physical health of gay men and lesbians at a disadvantage compared to their heterosexual peers. The authors argue that legal and social recognition of same-sex unions would increase the stability of same-sex relationships by increasing the barriers to dissolution and improving the sources of social support available to same-sex couples. Consequently, the authors argue that this would reduce the discrimination and social stigma associated with same-sex relationships, eventually leading to improvements in the mental and physical health of gay men and lesbians (King & Bartlett, 2006).
A recent study compared 282 gay and lesbian couples to a variety of other couple times, including heterosexual, legally married couples, unmarried cohabiting single heterosexuals and single gay men and lesbians (Wienke & Hill, 2009). The results of the study found that gay men and lesbians in cohabiting couples (i.e. those who may be married if marriage were an available legal option), experienced lower levels of happiness and mental well-being than married heterosexuals, but they also experienced greater levels of happiness in comparison to single individuals, regardless of sexual orientation (Wienke & Hill, 2009). This supports King and Bartlett’s (2006) argument that same-sex couples may be at a disadvantage with respect to reaping the benefits provided to couples through the institution of marriage. The study failed to find any significant pattern of results with respect to associations between physical health and relationship status, however this may very well be due to the fact that the study only utilized a single self-report item to measure health status (Wienke & Hill, 2009). The study simply asked participants to rate their health on a scale ranging from poor to excellent, and there are often a number of limitations to using single item self-report measures of physical health.
One study to date has examined the associations between social support, relationship well-being, mental and physical health (Blair & Holmberg, 2008). The study used multiple measures of all variables and used structural equation modeling to evaluate the links between each latent variable (Blair & Holmberg, 2008). The authors hypothesized a model in which increased levels of social support (or approval) for a relationship would predict improved relationship well-being (satisfaction, love, and trust), which would in turn predict greater mental and physical health (Blair & Holmberg, 2008). The study included a large sample of both same-sex and mixed-sex (heterosexual) couples and utilized multiple measures of physical and mental health. The results of the study supported the hypothesis of the authors, indicating that social support for a relationship does indeed predict greater relationship well-being, as indicated by higher levels of relationship satisfaction, higher levels of reported love, and stronger reports of interpersonal trust within the relationship (Blair & Holmberg, 2008). This association was, in turn, predictive of higher levels of mental and physical health for the individuals within the relationship, and the associations held true for both individuals in same-sex and individuals in mixed-sex relationships (Blair & Holmberg, 2008). The only difference between same-sex and mixed-sex couples was a stronger relationship between relationship well-being and mental health in same-sex couples, perhaps underscoring the importance of support from within an intimate relationship for sexual minorities (Blair & Holmberg, 2008). The study did not differentiate, however, between married and cohabiting couples and thus was not able to provide further evidence concerning whether married individuals have improve mental and physical health over and above cohabiting individuals. Despite this, the demonstration that social support specifically for a relationship was an important contribution to the literature, as it highlights the role that societal acceptance can play in increasing and improving the mental and physical health of sexual minorities.
As legalized same-sex unions and marriages become more commonplace around the world, additional research will need to investigate whether or not same-sex couples do indeed share in the same mental and physical health benefits as heterosexuals as a result of being legally married, or whether simply being in a relationship maximizes the physical and health benefits available to same-sex couples. The issue is, however, closely related to social exclusion theory, as it represents an important area in which sexual minorities experience the process of social exclusion. The denial of equal marriage rights enacts social exclusion through legal sanctions that prohibit same-sex marriage and also social exclusion that that prevents sexual minorities from participating fully in the cultural and social activities that are important. A great deal of North American culture is based on marriage, relationships and family, and thus having unequal access to socially recognized relationship statuses excludes sexual minorities from many of the commonplace day-to-day activities that contribute to a sense of belonging and well-being.
Access to & Experiences with Health Care Services
Despite the fact that research has identified a number of lesbian specific health care needs, lesbians still, as a group, access preventative health care services less often than their heterosexual counterparts (Austin & Irwin, 2010; Diamant, Wold, Spritzer & Gelberg, 2000; Fish, 2009; Heck, Sell & Gorin, 2006; Hitchcook & Wilson, 1992; Polek, Hardie & Crowlery, 2008; Steele, Tinmouth & Lu, 2006). There are a variety of reasons for this discrepancy in access, ranging from misinformation (McIntyre, Szewchuck & Munro, 2010) to lack of insurance (Diamant et al., 2000; Heck et al., 2006) to avoidance of negative experiences (Fish, 2009). The majority of barriers creating unequal access to health care for lesbians can be reviewed within the four aspects of social exclusion, with access to health care having the potential to be greatly improved for lesbians through social, political and legal advancements. Unlike the massive challenges of providing equal access to care across all socio-economic statuses in the United States, providing equal access across sexual orientations can be seen as a problem that has a relatively simple solution, albeit one that will still require effort and time.
Unequal access to health benefits.
A number of research studies have found that one of the main barriers creating unequal access to health care for lesbians is the unequal access to health care benefits and insurance. In a study that compared lesbians living in Southern USA to heterosexual women across the country, southern lesbians were found to have significantly less access to health care and health care insurance than their heterosexual counterparts across the nation, as well as being less likely to have a regular source of medical care (Austin & Irwin, 2010). Other studies have echoed this finding, including a population-based study conducted in 2000 by Diamant and colleagues, in which they found that lesbian and bisexual women were less likely than heterosexual women to have health insurance and were more likely than heterosexuals to report having had difficulty obtaining necessary medical care and to have been uninsured in the previous year. Other nationally-based studies, including one based on the National Health Interview Survey (Heck et al., 2006) have found that women in same-sex relationships are significantly less likely to have health insurance, less likely to have seen a doctor or medical professional in the previous year, less likely to have regular access to a physician or primary care practitioner, and significantly more likely to have unmet medical needs as a result of not being able to afford the associated costs. One of the more interesting findings of this study was that these inequities were only found between women in same-sex relationships as compared to women in mixed-sex relationships, and that no differences in access to health care were found when comparing men in same-sex relationships to men in mixed-sex relationships (Heck et al., 2006). This finding emphasizes the specific barriers to health care access experienced by lesbians in comparison to other segments of society, including gay men.
One of the most commonly cited reasons for unequal access to health care benefits and insurance is the lack of spousal rights or same-sex partner benefits (Fish, 2009; Heck et al., 2006). At present in the United States, the provision of health care (and other) benefits to same-sex partners is left to the discretion of individual employers and is not federally mandated, as it is in other countries (e.g. Canada, the United Kingdom, the Netherlands). As a result, in couples where only one partner has access to health benefits, the health care costs of the other partner become a burden on the couple and can contribute to health care needs being left unmet. Lesbians are at a particular disadvantage in this situation as they are dually discriminated against based on their sexual orientation and their gender (Fish, 2009). The feminist movement in the 1960s and 1970s highlighted a number of gender inequalities with respect to health care access and treatment, and while a number of these aspects have been remedied, inequities between the genders do exist, especially with respect to employment equity, which can have a direct link on health equity through creating unequal access to health insurance and benefits (Fish, 2009).
Unequal access to health insurance and benefits signifies a failure to provide for the needs of lesbians as a group, and thereby is one of the key processes through which social exclusion is enacted and sustained. Legal changes that would require employers to provide equal access to health care benefits on the basis of legally recognized same-sex relationships would significantly reduce the inequities experienced by lesbians in the United States with respect to access to health care insurance. Such a measure would not create access for every individual, but it would remove one of the most significant barriers currently preventing lesbians from having health insurance.
Another barrier to creating equal access to health care services for lesbians is the existence of misinformation, both among lesbians themselves and within the medical community. Misinformation can take the form of the propagation of health myths, the lack of education provided to lesbians concerning their specific health needs, and the lack of education concerning lesbian health provided to health care professionals during their training programs.
The historical pathologizing of homosexuality and same-sex sexual behavior has contributed considerably to an atmosphere of mistrust among sexual minorities when it comes to the medical profession (Fish, 2009). In the past, the majority of medical professionals viewed lesbianism as something that required remedy and research was directed towards developing a ‘cure’ or finding the ’cause’ (Fish, 2009). Since the removal of homosexuality from the APA’s Diagnostics and Statistical Manual in 1973, the view of homosexuality being a mental illness has slowly dissipated, but the medicalization of its treatment has continued informally and the issue of lesbian health is often approached in terms of determining what might be “wrong” with lesbians as a result of their alternative sexuality (Fish, 2009). As an example of the failure of research to take into consideration the study of lesbians, less than one percent of the published work in the field of psychology is related to the lives of lesbians, gay men and bisexuals, and within that one percent, the large majority of research that has been conducted has focused on gay and bisexual men, leaving issues relevant to lesbians far behind (Fish, 2009).
Although homosexuality was removed as a diagnosable disorder in 1973, many lesbians still reported their dealings with medical professionals in the following decades to be hostile and humiliating (Hitchcook & Wilson, 1992; Fish, 2009). In more recent years, lesbians continue to report experiences of heterosexism, uncomfortable doctors, anxiety over the disclosure of their sexual orientation and a constant battle against misinformation (Fish, 2009). A number of lesbian women have reported receiving mixed messages from public health information and from their own medical professionals. For example, public health ads directed at women often emphasize the importance of annual pap testing and clinical breast exams, yet when lesbian women visit their doctors they are informed that as lesbians, they do not require annual pap tests and breast exams, which is in fact a myth (Fish, 2009; McIntyre et al., 2010). Research conducted in Canada has found that lesbians report having a lack of knowledge concerning their specific health needs, especially with respect to their sexual health (McIntyre et al., 2010). In particular, the women in the study reported having a lack of reliable information with respect to pap testing, HPV, cervical cancer, and the risks associated with sexually transmitted infections and diseases as they relate to sexual activity between women (McIntyre et al., 2010). Within the study, many of the participants reported having received mixed messages from their doctors, which they identified as a contributing factor to their own confusion over understanding exactly what their health care needs were (McIntyre et al., 2010).
The endorsement of health myths by medical professionals is disturbing, yet not entirely surprising when one examines the level of education medical professionals receive with respect to lesbian health care issues. In a survey of 184 residents and physicians, over 50% of the respondents indicated that they did not feel that they had the skills necessary to discuss issues related to sexual orientation or sexuality with teen patients (Kitts, 2010). Another study, which examined the curriculum content of obstetrics and gynecology residency programs in Canada and the United States found that the average number of hours devoted to lesbian health issues over the course of a four-year residency program was only 1.86 hours, with more than half of the programs reporting that they did not include any amount of education on lesbian health issues (Amato & Morton, 2002). The deficiency in medical education is not even one that educational institutions are unaware of, as 73% of the program directors surveyed in the same study indicated that they felt their program did not provide sufficient or adequate coverage of lesbian health issues (Amato & Morton, 2002). Despite the fact that there is a general acknowledgement that physicians and other medical professionals in the United States lack the education and knowledge necessary to adequately provide treatment to sexual minorities (Makadon, 2006), little has been done to rectify this situation. Once again, this signifies the failure to provide for the needs of a particular group, and in fact places the responsibility of ensuring that such needs are met on the members of that disadvantaged group.
Negative experiences and disclosure of sexual orientation.
With the plethora of misinformation that exists both among lesbians themselves and within the medical profession, it is not surprising that many lesbians anticipate negative experiences when accessing health care services. Research has found that lesbians consistently report feelings of discomfort and anxiety when accessing health care services and that they feel they must cautiously navigate a labyrinth of decision making choices with respect to disclosing their sexual orientation to medical professionals (Hitchcook & Wilson, 1992). The process of disclosing one’s sexual orientation is a familiar experience for most sexual minorities, yet it is one that continues to generate anxiety each time one must determine whether to disclose their identity (Polek et al., 2008). Hitchcook and Wilson conducted a qualitative study (1992) with lesbians in which they asked them to discuss their experiences with disclosing their sexual orientation to medical professionals. The experiences reported were ripe with anxiety and detailed the process of navigating the pros and cons of disclosing, determining the appropriate time to make such a disclosure, and constantly monitoring the interactions with physicians in an attempt to make predictions about what the reaction to a disclosure might be (Hitchcook & Wilson, 1992). Considering that medical encounters can be anxiety provoking enough for any individual faced with dealing with their health concerns, having to navigate additional anxieties concerning one’s identity can act as a considerable barrier to accessing health care services.
In fact, research has found consistently that concerns about disclosing one’s sexual identity are in fact some of the greatest barriers to accessing health care services for lesbians (Hitchcook & Wilson, 1992; Fish, 2009; McIntyre et al., 2010; Polek et al., 2008; Steele et al., 2006). To further complicate the issue, there can be significant consequences to not disclosing one’s sexual identity, including inappropriate questioning, inaccurate diagnosis and further marginalization (Fish, 2009). Polek and colleagues (2008) found that lesbians tend to avoid disclosure when they encounter insensitive health care personnel, which then further leads them to avoid continued health seeking behaviors. Anxiety over disclosing one’s sexual orientation to a medical professional is not unfounded, as a study of sexual minorities in New Zealand reported that 88% of lesbians had their sexual orientation wrongly assumed to be heterosexual by their physicians and 11% of those who did disclose their sexual orientation felt that their doctor was uncomfortable with their disclosure and ill equipped to deal with the information (Nursing Standard, 2006). Despite the anxiety associated with disclosing one’s sexual orientation, research has consistently found that doing so can lead to better health outcomes, including increased satisfaction with care (Polek et al., 2008; Steele et al., 2006) and increased continued health care access (Fish, 2009; McIntyre et al., 2010; Polek et al., 2008). Thus, when it is considered that one of the main challenges for providing sufficient health care to lesbians is the inequities in access to health care, and that anxiety over disclosing sexual orientation is one of the greatest barriers to accessing health care, but that actual disclosure of sexual orientation is a predictor of increased health care access, it becomes obvious that the solution lies in increasing disclosure of sexual orientation among lesbians. Yet the onus should not be placed on lesbians themselves, as it has already been shown that disclosure is an anxiety inducing situation. One study of lesbians in Canada reported that 100% of the lesbians in their sample who had had a physician inquire as to their sexual orientation had disclosed their sexual orientation and had consequently reported increased satisfaction with their care and continued to access health care services more regularly than the individuals whose physicians had not inquired about their sexual orientation (Steele et al., 2006). This finding demonstrates that minor changes to health care protocols can make significant differences in promoting health care access and use among lesbians. Atmospheres that promote positive and inclusive discourse concerning sexuality and sexual diversity, as well as health care personnel who are comfortable discussing and asking questions about sexual orientation are all conducive to increased disclosure among lesbians (McIntyre et al., 2010; Polek et al., 2008; Steele et al., 2006), a goal which should be encouraged within the health care field in an effort to improve the use of preventative health care services by lesbians and sexual minority women.
Three of the four aspects of social exclusion theory, as identified by Galabuzi (2006), can be applied to the issues concerning lesbian access to and experiences with health care services. The effects of social exclusion from society through legal sanctions can be seen in the denial of spousal benefits to same-sex couples, thereby reducing the number of sexual minorities, especially lesbians, who have access to health insurance. The failure of the federal government to provide legislation that recognizes same-sex relationships is a failure to provide legal sanctions against discrimination that prevents same-sex couples from sharing the same health benefits as their heterosexual counterparts. This failure has extensive consequences for the health and well-being of sexual minorities through decreasing their access to and use of health care services. A number of research studies have found that one of the main reasons lesbians fail to access health care when needed is because of the costs associated with such care and their lack of access to health insurance (Diamant et al., 2000; Heck et al., 2006). The unequal access to health care insurance also impacts the economic lives of lesbians, thereby making this issue relevant to economic social exclusion. When lesbians have unequal access to health care insurance and benefits, this means that they also have an unequal burden of health care costs that could otherwise be covered were they in a heterosexual relationship as opposed to a same-sex relationship. This creates unfair economic burdens on one segment of society as compared to another, further diminishing the quality of life and health status of the individuals within this group.
In addition to social exclusion through legal sanctions and economic exclusion, the failure to provide equal access to health care services and health insurance, as well as the failure to promote education concerning lesbian health issues constitutes a failure to provide for the needs of a particular group. The medical establishment is failing to provide for the needs of lesbians as a whole by failing to address the gaps in educational curricula that leave physicians unprepared to provide quality service to lesbian patients. Significant amendments to the educational programs of all health professionals must be made, both in the early stages of education and in the field of professional development so that new and established practitioners alike may have the opportunity to fill the existing gap in knowledge and being to provide acceptable levels of well-informed and considerate care to lesbian patients.
The Experience of Aging for Lesbians
Some of the most pressing health concerns facing lesbians as a whole are those related to the process of aging. As the population in general continues to age with the baby boomers reaching their senior years, one of the greatest challenges to providing equal access to health care concerns creating the necessary education and awareness required to provide dignified and welcoming care for aging sexual minorities. A study conducted by Brotman, Ryan and Cormier (2003) examined the health and social service needs of sexual minorities and their families living in Canada, a country where sexual minorities on the whole experience considerably greater levels of equality and protection under the law than sexual minorities living in the U.S.A. The researchers found that aging sexual minorities reported experiences of invisibility, barriers to care and a lack of necessary service options that suited their personal needs from the health care system. One of the most troubling findings reported in the study, which was qualitative in nature, was that many elders who had previously been ‘out’ to their friends and family, went back into ‘the closet’ when accessing health care services in their senior years. This issue can be especially problematic when looking at the needs of lesbians entering long-term care facilities, where if their sexual identity is not disclosed, accepted or understood, their relationships may become invisible and neglected. Furthermore, researchers have suggested that sexual minority elders may be especially vulnerable to the stressful experiences of having to come out in environments, which are perceived to be hostile, and as a result they may avoid doing so, or may suffer more severe consequences when they do come out (Brotman, Ryan, & Cormier, 2003). As a result, the needs of aging sexual minorities, including lesbian women, need to be placed at the forefront of health care reform in order to ensure equal access to dignified and respectable care that is understanding of the lives and experiences of sexual minorities.
An important factor, which must be considered when addressing the needs of aging lesbians, is the need for an understanding of the context in which these individuals have lived their lives. Being over the age of 65 in 2010 indicates that an individual has been alive since at least 1945, and has therefore lived through an historical era that has seen significant changes in the lives of sexual minorities. As an example, a 75-year-old lesbian today has lived during a time when rounded up, sterilized, imprisoned and even murdered, not only by extremists such as the Nazis, but also closer to home (Daley, 1998; Peterson & Bricker-Jenkins, 1996). Prior to the 1960s and 1970s, it was not uncommon for young lesbian women to be institutionalized for treatment of their ‘mental disorder,’ and in fact, homosexuality was not removed from the American Psychology Association’s list of mental disorders (included in the DSM) until 1973 (Daley, 1998). Such an individual would have lived the majority of her life facing severe social, medical and even legal consequences for living their lives openly and publicly acknowledging their sexuality. At the same time, these individuals have lived to see change, and may have played a significant role in promoting change and fighting for equal rights during the 1970s, 80s and 90s. A 75-year-old lesbian today, if they have been out for the majority of their adult life, may have a very different life story than a 75-year-old heterosexual woman. It may be more common that the lesbian woman would have needed to be self-sufficient for most of her life; she may not have had a husband or children, and may not be accustomed to asking for help or being taken care of. At the same time though, it is important that health care workers not too widely apply stereotypes to treating individuals, as there may be many elderly lesbian women who came out later in their lives, and therefore did have husbands and do have children (Barranti & Cohen, 2000; Fish, 2006). The important bottom line is that work needs to be done to address the needs and concerns of aging sexual minorities, including lesbians, and that much of this work needs to be targeted on the attitudes and education of health care providers. The sexual minority elders today are the individuals predominantly responsible for the changes in civil rights for the generations of sexual minorities who have followed, they have lead the charge of promoting change and fighting discrimination and they deserve to not have to continue that battle in the final stages of their lives. Unfortunately, according to research, this is all to often not the case, and sexual minority elders are faced with the choice of continuing to be the one educating those around them about their needs and lives or going back into the closet and retiring from a long life in which they have battled discrimination around every corner (Brotman, Ryan & Cormier, 2003). Research has reported that sexual minority elders report greater levels of fear and anxiety than heterosexuals going into long-term care facilities, and that their greatest concern is that of increased invisibility throughout their final years (Brotman, Ryan & Cormier, 2003). The burden of change needs to be placed on the institutions providing change, not on the elderly individuals themselves. There is a distinct and urgent need for improved education concerning sexual minority issues for health care professionals, and sexual minority elders would benefit greatly from added policy initiatives that seek to incorporate homophobia and heterosexism as grounds for elder abuse (Brotman, Ryan & Cormier, 2003).
One particular area in the care of sexual minority elders that is particularly easy to address is an increased understanding of the concept of family and chosen family within the sexual minority community (Barranti & Cohen, 2000; Brotman, Ryan & Cormier, 2003; Fish, 2006). The majority of care facilities available to elderly individuals place a great deal of emphasis on biological family members, both at a formal and legal level, and at a more informal level with respect to individual institution policies. The concept of ‘chosen’ family is common within the sexual minority community and refers to the practice of generating one’s own social network of close and important people who may not be related biologically (Barranti & Cohen, 2000). Often times sexual minorities have become estranged from their biological families, having been disowned or shunned based on their sexual orientation and/or identity. As a result, sexual minorities have become adept at building auxiliary families, or ‘chosen’ families, and in fact, research suggests that the concept of the ‘lonely gay or lesbian elder’ is in fact a myth, and that many sexual minority seniors have well developed and large social networks (Barranti & Cohen, 2000; Brotman, Ryan & Cormier, 2003). Despite having these communities, often times heterosexist institutions fail to recognize the importance of these non-biological family ties and restrict a patient’s access to their most important sources of social support. One example of such a situation might entail a care facility that provides greater access to a patient to that patient’s children, but denies that patient access to their long-term partner or close friends. It is possible that the children may have at some point disowned their parent, or not been supportive their parent’s sexuality, and thus they may not be the people that the patient would choose first to be in charge of their care and to have the greatest access to them while they age (Brotman, Ryan & Cormier, 2003). These problems are further compounded by the legal system that does not recognize same-sex marriages or common-law relationships, thereby denying many long-term partners the legal access required to be in charge of their loved one’s care. While individual institutions may not be able to circumvent the law when it comes to issues of power of attorney or other legal matters, they can be more understanding and knowledgeable about the lives, wishes and needs of their sexual minority patients and endeavor to ensure that they are doing everything in their power to allow an individual’s wishes to be followed and respected. Sadly, one of the greatest fears of sexual minority elders is that they will be separated from their beloved partners, not by death or illness, but by institutional insensitivity and discrimination under the law (Fish, 2006).
With respect to social exclusion theory (White, 1998), all four aspects of social exclusion can be applied to the process of aging among lesbians. Aging lesbians face social exclusion from society through legal sanctions, in that they are discriminated against, homophobia and heterosexism are rampant in hospitals and long-term care facilities, and the law does not recognize their long-term relationships, thereby overriding their wishes concerning which individuals should be in charge of making decisions for their health and lives once they are no longer capable of making such decisions themselves. Social exclusion is also enacted upon aging lesbians through the failure to provide for the needs of a particular group (sexual minorities). This is perhaps the most applicable of the four aspects of social exclusion theory, as the long-term care facilities, retirement homes and seniors’ resources consistently fail to provide an adequate understanding of the lives needs of sexual minority individuals. Social activities are often heterosexist, living arrangements deny couples the ability to remain together and have their relationships be openly acknowledged, and very few opportunities exist for sexual minority elders to forge their own form of community with other sexual minorities, and thus they are thereby forced to assimilate into a heterosexual environment that they may have spent the majority of their lives circumventing and avoiding.
The third aspect of social exclusion theory, according to White (1998) is exclusion from social production, or the denial of opportunities to contribute to society’s cultural activities. The aging process is in fact a social process. Very few individuals can manage this stage of their life on their own, and even the most reclusive must rely on the assistance of others. Yet, at present, the social activities that exist for seniors in many cases do not take into consideration sexual diversity. In fact, it can be argued that sexuality in general is a neglected area when it comes to the care of seniors, with heterosexuals and non-heterosexuals suffering alongside each other in many respects, having been assumed by society to no longer have a stake in the world of sexuality (Gott, 2005). The rise in sexually transmitted infections and diseases within retirement communities and nursing homes suggests that this quite the erroneous assumption and that the sexual needs of seniors are not being adequately provided for in a way that allows dignity and continued enjoyment (Gott, 2005). If sex among seniors is a taboo subject, one that adult children and health care professionals do not seem ready or capable of accepting, understanding or managing, then one can only assume that the already stigmatized nature of same-sex sexual relationships must be even more marginalized for sexual minority elders. In this sense, social exclusion theory can be seen to be acting on sexual minority seniors at two levels; first, seniors themselves are being excluded from the world of healthy sexuality, and second, sexual minority seniors are experiencing this exclusion twofold, as both sexuality itself, and ‘alternative’ sexuality are being denied.
The final aspect of social exclusion theory that applies to aging sexual minorities is economic exclusion from social consumption (White, 1998). At first, it may be more difficult to see how this aspect applies to sexual minority seniors, as often seniors are retired and no longer engaging with the workforce. There are other aspects to economy though, and an important aspect in which many sexual minority elders may be at a disadvantage to their heterosexual counterparts is with respect to access to funds, savings, and pensions. So long as the United States Federal Government denies the recognition of same-sex relationships, most seniors do not have legal access to their partner’s pension funds, savings, or old age security. When a gay or lesbian partner dies, all to often the estate passes along to the next of kin, not recognizing the living partner as the rightful holder of that title. As a result, seniors can be left penniless, or with a significantly deteriorated living condition, especially if they happen to have been dependent upon their partner’s income or savings. Furthermore, it should be considered that the sexual minority elders today have suffered a lifetime of discrimination, including economic discrimination, and thus the effects of this economic disparity might be exacerbated or cumulative. While many private companies today offer benefits to same-sex partners, the majority of sexual minority seniors today did not work during a time when such benefits were available, and thus they have been paying out of pocket their entire lives for savings and benefits that heterosexual married couples were provided by nature of their legally recognized marriage. For example, a couple of 70-year-old lesbians today may have been retired for 15 to 20 years, and likely never received any form of partner benefits during their lifetime, whether those be from employment or from taxes. As a result, if one received health care benefits from their employment and the other did not, the couple would have had to pay for the additional health benefits out of their own funds. Such a couple would also have been denied any available tax savings or deductions based on one partner being the dependent of the other. Year after year, these discrepancies in costs add up, thus depleting the potential savings and retirement savings available to the couple, as compared to a heterosexual couple that may have had health benefits provided by an employer and would have benefited from years of spousal tax deductions. Specifically with respect to lesbians, often lesbian couples have a much lower earning potential than heterosexual or gay male couples as a function of their gender, and this element can only be expected to be exaggerated among the lesbian seniors living today who would have had to navigate a world that did not encourage or equally compensate female workers. The end consequence of the years of imbalance and economic exclusion can result in an inability to pay for the care that one desires, and may leave lesbian seniors (and other sexual minority seniors) without the resources required to determine their own aging experience and journey and may leave them at the hands of public services and charity. From a legal and economic standpoint, these longstanding disadvantages need to be considered, acknowledged and in someway accommodated for, perhaps by providing special grants, funding or retroactive tax credits to help sexual minorities recover the “costs” of having been financially discriminated against for decades.
The failure to address these important deficiencies in providing for the health care needs of sexual minority elders will only contribute to an exacerbation of suffering and the increase in health problems experienced by sexual minority elders. Research in many different areas has consistently shown that the stress of dealing with social exclusion can lead to prolonged psychological effects which can have a negative impact on an individual’s physical and mental functioning (Wilkinson, 1996; Kawachi & Kennedy, 2002). What is particularly concerning is the continued neglect of incorporating the existing social networks of sexual minority elders into their daily lives, a concept that is repeatedly strapped with the hurdle of overcoming existing institutional barriers based on heterosexist policies and a discriminatory legal system. The links between diminished social support and mental health are well established (Dew & Bromet, 1991; Reisen & Poppen, 1999; Ross, Lutz & Lakey, 1999), especially among the elderly (Dean, Kolody & Wood, 1990). Furthermore, social support has been shown to be an important causal contributor to physical health (Cohen & Syme, 1985; Wallston, Alagna, Devellis & Devellis, 1983), which underscores the importance of finding ways of incorporating existing social networks into the lives of sexual minority seniors.
Summary & Conclusions
This review has attempted to examine the existing knowledge within the literature concerning the health of lesbians living in a heterosexual society. To this end, social exclusion theory has been used as an organizing principle within which to examine individual topics of relevance to the health care needs, health status, and health care access of lesbians. Galabuzzi (2006) identified four aspects of social exclusion theory that have been applied to the issues reviewed in this paper. The first aspect of social exclusion theory is exclusion through legal sanctions, which in the context of the literature reviewed, applies to the lack of legal sanctions to protect sexual minorities from a variety of forms of discrimination as well as legal sanctions that do not allow for the legal recognition of same-sex relationships. The second aspect of social exclusion theory is closely related and refers to the failure of society to provide for the specific needs of a particular group, in this case, the needs of lesbians with respect to safeguarding and promoting their mental and physical well-being. This aspect also applies to the failure to provide policy and sanctions to deter discrimination, and also refers to the lack of research investigating important aspects of lesbian health and health care access, as well as the actual barriers in place to equal access of health care by lesbians. The third aspect of social exclusion refers to exclusion from social production, through which a specific group is denied equal opportunities to contribute to or participate actively in society’s social and cultural activities. Once again, unequal access to marriage severely limits the extent to which sexual minorities can participate in social and cultural norms, which hampers the extent to which this group can achieve a sense of belongingness, which consequently has implications for both physical and mental health outcomes. The final aspect of social exclusion refers to economic exclusion from social consumption, and this has been seen in a variety of ways within the review of the literature on lesbian health and health care needs. One of the most obvious examples of economic exclusion within this topic is the unequal access to and distribution of health care benefits and health care insurance. Lesbians are significantly more likely than their heterosexual peers to be uninsured and to have unmet medical needs as a result of unaffordable medical costs. One of the reasons for this discrepancy in access to health care insurance is the lack of federal legislation requiring all employers to offer equal access to medical benefits to same-sex spouses as they do to opposite-sex spouses. The additional financial burdens placed on same-sex couples, especially lesbian couples, contributes to a lifelong financial discrepancy that can impact the lives and health care of lesbians to a great extent, even influencing the type of health care that can be afforded by lesbians in their later years of life. Thus, social exclusion theory has been very applicable to creating an understanding of the health care and health status discrepancies experienced by lesbians.
One of the major challenges highlighted in this paper to developing a thorough and accurate understanding of the health care needs of lesbians is the issue of methodology. Researchers come up against a number of methodological challenges, including how to define sexuality, how to find funding for sexuality-based research, and how to find and retain sexual minority participants for research studies. Without adequate funding researchers have difficulty conducting valid and reliable research that can provide accurate information concerning health care status issues related to sexuality. Population-based studies are very important in health care research, but they are also very expensive, and the lack of funding earmarked for research on the health of sexual minorities severely limits the quality and nature of research that can be conducted in this field. Researchers must also determine how to handle the fluidity of sexual identity and determine which aspects of sexuality they believe to be most relevant to health: self-labeled identity, behavior, or attractions. One of the challenges for this field in the future will be to obtain more funding and to build consensus concerning definitional issues, allowing for more valid research that will be better received within the medical community, and therefore have a better chance of contributing to positive change with respect to the health care needs of lesbians.
This review has also brought together research from various areas to help understand the specifics of health care discrepancies experienced by lesbians living in a heterosexual society. Lesbians are at higher risk for three of the four reproductive cancers, are more likely to be overweight or obese, more likely to drink excessively and more likely to be current users of tobacco. These increased health behavior risks contribute to the increased risks of cardiovascular disease and other chronic illnesses for lesbians. One of the significant contributing factors to these discrepancies has been identified as chronic stress that lesbians and sexual minorities endure as a result of being part of a socially stigmatized group. Minority stress is the term used to refer to the excess stress experienced by sexual minorities as a result of their sexual orientation, and research has linked minority stress to a variety of mental and physical health outcomes. The consensus within the literature is that many of the health status discrepancies found in lesbians, especially with respect to mental health, are in someway associated with the effects of minority stress. On the bright side, social support has been shown to be an important buffering variable with respect to the effects of minority stress on health. Improved levels of social support, specifically social support related to sexuality and social support specifically for a particular relationship, has been shown to predict greater levels of relationship well-being, mental and physical health. While this also means that lower levels of social support contribute to negative health outcomes, it provides an avenue through which policy makers and health care providers can seek to promote change and work towards improved health status for sexual minorities, including lesbians.
One final area that this review has touched on is the experience of aging lesbians, a relatively new area of research that is rapidly growing with respect to relevancy and importance. As the population as a whole ages, more and more sexual minorities will be encountering the medical care system as an elderly individual. At present, the health care needs of elderly sexual minorities appear to be poorly understood by health care providers and elder care institutions. This is an area that requires great attention in future research and medical practice, as sexual minorities who have lived through the social changes and battles for rights do not deserve to spend their final years once again being marginalized, stigmatized and having their sexuality become invisible.
Recommendations for Future Research
Although the size of the literature relevant to issues pertaining to lesbian health and health care has grown considerably over the last couple of decades, there is still quite a bit of research left to be done. A number of recommendations for future research on lesbian health status, lesbian health care and lesbian access to health care services are discussed here, and will hopefully provide inspiration to readers to become involved in this important area of research.
One of the interesting areas for future research involves replication studies of existing research on younger generations of lesbians. It is important to learn whether or not the existing research on lesbian health status and specifically health risks remains true for the younger generations of lesbians who are growing up in a society that is considerably more accepting and in which there are far fewer legal sanctions curtailing the lives and well-being of sexual minorities. For example, lesbians are at a higher risk of being overweight or obese, which contributes to their higher risks for cardiovascular disease and other chronic illness, including reproductive cancers. One of the reasons that has been suggested for why lesbians tend to have higher BMIs than heterosexual women is that the subculture is more accepting of multiple body types and that it rejects the societal norms concerning how a woman should look. As sexual diversity becomes more mainstream, and more and more media outlets incorporate lesbians into pop culture, one relevant question for future research is whether or not these rejections of societal norms continue, or whether lesbians will become more like heterosexual women with respect to their adherence to such norms (for better or for worse). Another explanation that has been offered for weight discrepancies is related to the emotional coping mechanisms associated with minority stress. Overeating is often associated with mental health issues, such as depression or anxiety, and lesbian women who have been subjected to minority stress, discrimination and prejudice may have turned to eating as a form of comfort, ultimately leading to higher rates of obesity within the population. As sexual diversity gains greater acceptance, minority stress will hopefully reduce, and as a result fewer coping mechanisms would theoretically be needed. This could reduce the number of lesbians struggling with weight issues, and consequently change the health risk profile for lesbians as a group. Regardless of how this issue may change in the future, it is important for researchers to continue to assess the health risk behaviors and statues of lesbians by conducting research on each new generation and not simply assuming that what applied to previous generations will continue to ring true for future generations.
Another area in which research on different generations of lesbians will be relevant is the health risks for reproductive cancers. Nulliparity, or not being pregnant and giving birth to children, is one of the main contributing risk factors that places lesbians at a higher risk for developing breast, ovarian, and endometrial cancer. As acceptance of family diversity grows, and as medical technology provides greater fertility options to lesbian couples, more and more lesbian couples are choosing to have families of their own. This may significantly change the rates of parity among lesbians, and may therefore change the risk levels for reproductive cancers. It may become that it is better to view risk for reproductive cancer on an individual basis by examining actual risk factors as opposed to examining risk factors associated with groups. It should not be assumed that because a woman is in a same-sex relationship that she does not have an interest in having children, or that she will not carry a child herself, thus health care providers must be thorough and avoid making assumptions if they wish to provide the most accurate and comprehensive health care possible to lesbian patients.
The issue of family building is also relevant for another area of future research. At present, fertility treatment is often reserved for individuals who have difficulty conceiving, and lesbians have been placed under this umbrella simply because there is no other place for them to fit. The fertility issues experienced by lesbians, however, are likely to be very different than the fertility issues experienced by heterosexual women, as their access to sperm is different as a function of their relationship with another woman. Future research needs to investigate more closely the specific fertility needs of lesbian women to determine how best to help lesbians achieve their family goals, while not exposing them to unnecessary treatments that may otherwise only be relevant for women who have actual fertility problems.
Given what is known about current health status of lesbians, their health risk behaviors and their access to health care, future research should also focus on determining what kinds of health care and health promotion interventions are most successful and effective within the lesbian community. Previous research has shown that when lesbian women feel excluded from the medical discourse on prevention or treatment, they are less likely to access health care. Thus researchers need to determine how best to include lesbians within health promotion campaigns, and how best to ensure that accurate health care information is provided to lesbians and their medical care professionals. One area in which this can be accomplished is through the education training of medical professionals. This review has shown a great number of deficiencies with respect to the education provided to medical professionals concerning lesbian health issues, and if improvements are expected within this area, then improvements to the educational process must be considered one of the most important areas for change and reform. Additionally, efforts must be made to determine how best to eradicate the existing myths concerning lesbian health, specifically that lesbians are not in need of routine cervical screening or breast examinations.
Finally, research must shift from focusing on the problem, which is negative health outcomes, to focusing more on the causes, which have already been identified as often being linked to societal acceptance of sexual diversity. If a large number of the health discrepancies experienced by lesbians are associated with their experiences of discrimination and prejudice, as well as reduced access to care through elements of social exclusion, then research must focus on how to change these societal predictors of health, as opposed to focusing on the health outcomes themselves. Research must address questions concerning how minority stress can be ameliorated or eliminated, how can social support for sexual minorities be improved, and how can negative societal attitudes be changed? The answers to these questions hold the key to generating true and genuine change with respect to lesbian health status, health care provisions and access to health care. If research continues to ignore the causes of health care discrepancies, then little progress will be made in actually changing the health care outcomes for lesbians. Although social change is far from easy, this aspect of changing lesbian health discrepancies should be seen in a positive light. Instead of being faced with the challenge of solving a health care discrepancy based on something inherent to being a lesbian, the medical field and society itself is faced with a challenge of solving a health care discrepancy that is based on societal and social inequities, and in fact has nothing to do with the inherent medical nature of a particular group of individuals. This needs to be seen as an opportunity for change that can be tackled with enthusiasm and that has high prospects for success in the decades to come.
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