Gay and Lesbian Health

Lesbian, gay, bisexual, and transgender (LGBT) individuals are as diverse as the general population in terms of race, ethnicity, age, religion, education, income, and family history. A number of health concerns are unique to or shared by the LGBT community, however, including an increased risk of certain cancers, infectious and sexually transmitted diseases (STDs), and mental health disorders; issues relating to nutrition and weight, tobacco use, and substance abuse; and discrimination by health care and insurance providers.

Description

The definitions of different sexual identities have shifted over the years, as have the perceptions and stereo-types of the general population. Because of the wide range of behaviors and identities that exist in the LGBT community, it is difficult to develop an inclusive definition. It is generally accepted, however, that gay men and lesbians are sexually attracted to or participate in sexual behaviors with individuals of the same gender, while bisexual men and women are sexually attracted to or participate in sexual behaviors with individuals of both genders. Transgender individuals live part- or full-time in a gender role opposite to their genetic sex.

It is estimated that approximately 2.8% of men and1.4% of women identify as being gay, lesbian, or bisexual while 9.1% of men and 4.3% of women have participated in sexual behavior with someone of the same gender at least once. The true extent of the transgender community has not been well researched in the United States; one study from the Netherlands in 1993 found that one in 11,900 males and one in 30,400 females are transgender.

There are a number of issues that arise when trying to define sexual orientation. Many gay men and lesbians have participated in or continue to participate in sexual activities with members of the opposite sex but choose not to identify as heterosexuals or bisexuals. Others have never participated in sexual activities at all yet still identify as gay, lesbian, or bisexual. Some men and women identifying as bisexuals are in long-term, monogamous relationships with individuals of the same or opposite sex. Male-to-female (MTF) or female-to-male (FTM) transgender individuals may or may not identify themselves as gay or lesbian.

The implications of these identity issues are farreaching. Misdiagnoses or improper medical recommendations might come from health care providers who have mistakenly assumed sexual behaviors or risks from the patient's stated identity. For example, a provider might incorrectly assume that a lesbian patient has never had sexual intercourse with a male and therefore would not have contracted STDs not normally transmitted by sexual activities between women. It has been difficult to closely estimate the numbers of LGBT individuals in the United States because of varying definitions. Likewise, the statistics in medical or social studies and surveys on LGBT issues might vary widely depending on what definitions were provided for the respondents. Because of this, many researchers have opted for the more inclusive terms of "men who have sex with men" (MSM) and "women who have sex with women" (WSW) to categorize gay, lesbian, and bisexual respondents.

Important health care issues

Many LGBT individuals have difficulty revealing their sexual identity ("coming out") to their health care providers. They may fear discrimination from providers or believe that their confidentiality might be breached. In some cases health care workers have been poorly trained to address the needs of LGBT individuals or have difficulty communicating with their LGBT patient (one study indicated that 40% of physicians are uncomfortable providing care for gay or lesbian patients). In addition, many questions posed in questionnaires or examinations are heterosexually biased (e.g. asking a lesbian which birth control methods she uses or a gay man if he is married, single, or divorced).

Other reasons why LGBT individuals are often hesitant to share their sexual identity are more logistical. Many insurance companies deny benefits to long-term partners on the basis that they are not married. LGBT patients may have inadequate access to health care, either because they live in a remote rural area or in the crowded inner city. Some same-sex partners encounter discrimination in hospitals and clinics when they are denied the rights usually given to spouses of a patient such as visiting, making medical decisions, and participating in consultations with physicians.

Some of the health concerns and risk factors that are relevant to LBGT individuals may be shared by the general population, while others are more specific to the LGBT community, and still others are specific to different subgroups of LGBT individuals. These health concerns may be grouped into the following areas of concern:

• Sexual behavior issues: STDs such as human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS), hepatitis A virus (HAV), hepatitis B virus (HBV), bacterial vaginosis, gonorrhea, chlamydia, and genital warts (human papillomavirus or HPV); anal, ovarian, and cervical cancer.
• Cultural issues: body image, nutrition, weight, and eating disorders; drug and alcohol abuse; tobacco use; parenting and family planning.
• Discrimination issues: inadequate medical care; harassment at work, school, or home; difficulty in obtaining housing, insurance coverage, or child custody; violence.
• Sexual identity issues: conflicts with family, friends, and work mates; psychological issues such as anxiety, depression, and suicide; economic hardship.

CANCER. Cancer is the second leading cause of death in the United States. In 2000, it was estimated that 1,220,100 individuals were diagnosed with cancer and 552,200 lost their lives as a result. LBGT individuals are at an increased risk for certain types of cancers. Some researchers believe that those who do not disclose their sexual identity live with an added stress that suppresses the immune system, thus leaving them with an increased risk of tumor growth.

Several studies have indicated that lesbians have higher risk for developing breast cancer. This is partially related to higher rates of risk factors such as obesity, alcohol use, tobacco use, and nulliparity (not bearing children). It has also been shown that lesbians are less likely to be screened for breast cancer than heterosexual women. Lesbians also have additional risk of developing ovarian cancer, due to inadequate access to health care, nulliparity, and not using oral contraceptives (use of oral contraceptives has been shown to decrease the risk of getting ovarian cancer).

Gay and bisexual men (or more generally, men who have sex with men [MSM]) are at higher risk of developing non-Hodgkin's lymphoma, Hodgkin's disease, and anal cancer. Kaposi's sarcoma, an AIDS-associated cancer, used to be found in the gay community at rates thousands of times more than the general population before more effective antiretroviral drugs became available for people infected with HIV. Anal cancer is associated with transmission of human papillomavirus (HPV); a 1998 study indicated 73% of HIV-positive and 23% of HIV-negative MSM were infected with more than one type of HPV. The risk factors associated with MSM are also associated with increased rates of anal cancer (i.e. smoking, having many sexual partners, and receiving anal intercourse).

AIDS. As of 2000, more than 753,900 individuals have been diagnosed with AIDS in the United States; of total cases, 84% are men, 16% are women, and 1% are children 12 years old or younger. The major risk groups associated with AIDS transmission are MSM who engage in high-risk sexual behaviors, intravenous drug users (IDUs) who share needles, heterosexuals who engage in high-risk sexual behaviors, inmates at correctional facilities, and neonates (newborns) whose mothers are infected with HIV.

Approximately 54% of cumulative AIDS cases are men who have sex with men. MSM also constitute 38% of newly reported HIV cases each year. An annual decrease has occurred in the number of reported AIDS-related deaths, partially attributable to the development of advanced therapies that are extending the life expectancies of AIDS patients. These new treatments, however, have inadvertently caused decreased rates of safe sex practices; one 1998 study revealed that 18% of HIV-positive men were having safe sex less often since advances in treatment.

Few studies have looked at the transmission of HIV in women who have sex with women (WSW). HIV transmission might occur in WSW because of intercourse with males or intravenous drug use. Several small studies conducted in the 1990s found no evidence of HIV transmission from sexual activities between women.

OTHER STDS. It is estimated that 333 million cases of curable STDs occur each year worldwide. Among the most commonly found STDs in the United States are chlamydia, gonorrhea, AIDS, syphilis, and hepatitis B virus (HBV). Over 15 million new infections are estimated to occur each year in the United State, with approximately four million of those occurring in adolescents.

MSM are at most risk of developing urethritis (inflammation of the urethra), proctitis (inflammation of the rectum), pharyngitis (inflammation of the cavity at the back of the mouth), gonorrhea, chlamydia, HAV, HBV, syphilis, herpes, and HPV. HAV and HBV are both vaccine-preventable viruses but rates of vaccination among MSM are low; in 1996 the Centers for Disease Control and Prevention (CDC) found that only 3% of MSM had been vaccinated against HBV. In May 2001 the Food and Drug Administration (FDA) approved a new vaccine that combines the HAV and HBV in one, with hopes that vaccination rates will increase.

It appears that STDs are less common in women who have sex only with women than in bisexual or heterosexual women. Genital warts, trichomoniasis, and bacterial vaginosis are transmittable during sexual activity between women. Chlamydia, herpes, syphilis, gonorrhea, and HAV are also able to be transmitted between women, although at lower rates.

MENTAL HEALTH. Forty million Americans are estimated to be diagnosed with a mental disorder, a condition in which abnormalities in thought, feeling, and/or behavior cause distress or impair function. Of these, only 25% seek and obtain care from mental health professionals.

Homosexuality was labeled as a mental disorder until 1973 when it was declassified by the American Psychiatric Association; in 1986 "ego-dystonic homosexuality" was removed from the Diagnostic and Statistical Manual of Mental Disorders (DSM-III). More recently, studies have shown that LGBT individuals are at increased risk of depression, panic attacks, substance abuse, and suicide. MSM have been shown to have higher rates of depression, anxiety, and conduct disorder than heterosexual males, although not much study has been done in this area. WSW have been shown to have increased rates of alcohol and drug abuse.

Gender identity disorder is defined as "a strong and persistent cross-gender identification…manifested by symptoms such as a stated desire to be the other sex, frequently passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she as the typical feelings and reactions of the other sex" (DSM-IV, 302.85). Transvestic fetishism is defined as involving "recurrent, intense sexually arousing fantasies, sexual urges, or behaviors involving cross-dressing" (DSM-IV, 302.3). Both disorders lead to a "disturbance that causes clinically significant distress or impairment in social, occupational, or other important areas of functioning." This last point iterates that transgender individuals not automatically considered under DSM-IV to have a mental disorder.

NUTRITION AND WEIGHT. Diet and nutritional factors are associated with a number of diseases including cancer, stroke, diabetes, heart disease, and osteoporosis. It has been shown that lesbians are more likely than heterosexual women to be obese, have a higher body mass index (BMI), and have higher rates of smoking, but are also more likely to have a healthier body image (42% compared to 21% of heterosexual women). Gay men and adolescents, on the other hand, have been shown to have increased rates of eating disorder behaviors than heterosexual men; examples are binge eating (25% compared to 11%), purging behaviors (12% to 4%), and poor body image (28% to 12%).

SUBSTANCE AND TOBACCO USE. Marijuana and cocaine use has been shown to be higher among lesbians than heterosexual women. The incidence of the use of some drugs is higher in gay men than heterosexual men; these include marijuana, psychedelic drugs, ecstasy, barbituates, and stimulants such as amyl or butyl nitrate ("poppers"). There is some indication that the use of some illicit drugs speeds up the replication of HIV, although more research needs to be done in this area.

Cigarette smoking is responsible for 430,000 deaths a year in the United States, with an estimated 3,000 nonsmokers dying as a result of exposure to secondhand smoke. In 1997 the rate of smoking among all adults was 25%. In contrast, 36% of gay men and lesbians were noted to be smokers. Lesbians are more than two times as likely to become heavy smokers than heterosexual women.

Prevention

There are numerous ways that health care providers can improve the access to and experience of health care services for LGBT individuals. These include:

• rewording questionnaires and examinations to be inclusive of LGBT patients
• providing referrals to social service agencies and counseling services that are LGBT-friendly
• taking educational courses that are sensitive to the needs of LGBT patients
• treating the families of LGBT patients as one would the families of heterosexual patients
• maintaining the strictest code of confidentiality
• developing and maintaining health care centers or clinics that address LGBT-specific needs
• asking non-threatening questions to determine if a person is at risk of an STD
• educating patients of risk factors associated with STDs, possible vaccines, and treatments available
• providing services to individuals in the process of disclosing their sexual identity and, if applicable, their families