Lesbian
Health Care
How
we’re different, how we’re the same as all
women—and how we can take better care of our healthy
selves
By
Pennye Rohde, P.A.C.
 Until
the 1980s, few doctors ever talked about the similarities
or differences between lesbians and other women. However,
in 1985, the National Lesbian Health Care Survey did
a great deal to start focusing attention on the health
needs and concerns of lesbians. Since then, many health
researchers have studied this aspect of women’s
health, and much information has been gathered. In some
ways, lesbians’ health issues and risks are the
same as all women, in some ways they are specialized.
Lesbians have historically been the targets of prejudice
and discrimination, both publicly and privately. Lesbians
may have trouble finding a doctor who understands our
special concerns, or who isn’t operating out of
a veiled homophobia. Also, because most lesbian couples
aren’t provided with spousal benefits, some lesbians
may go without health insurance. Additionally, managed
care systems often limit lesbians’ access to lesbian-friendly
providers. All of these factors can make it more difficult
for lesbians to receive preventative health care.
Lesbians require all routine female health-care maintenance.
Well-established methods of screening for cancers such
as breast, cervical, and colorectal cancers have greatly
decreased the death rate from these diseases. Lesbians,
however, must be aware of the recommended health screening
guidelines and have access to culturally competent providers
for their health-care needs.
Breast
Cancer
According
to recent statistics, breast cancer is the second leading
cause of cancer deaths among women. In the United States,
a woman has a one-in-eight chance of developing breast
cancer in her lifetime. The most important feature in
determining a woman’s likelihood of survival is
the size of the cancer at the time of its discovery.
This emphasizes the need for early detection. The National
Cancer Institute generally recommends that women between
the ages of 40 and 50 should undergo a mammogram and
clinical breast exam every one to two years. Over the
age of 50, a mammogram and breast exam should be performed
yearly. In women with a strong family history of breast
cancer, the frequency of testing should be left up to
the clinical judgment of the care provider. Additionally,
all women should perform self-breast examinations on
a monthly basis.
Women with a significant family history of breast or
ovarian cancer may be prime candidates for genetic testing.
The BRCA 1 and BRCA 2 genes have strongly been associated
with these two cancer types. The chances of carrying
a cancer predisposition gene may be as great as 50 percent
in women with family histories of hereditary breast
or ovarian cancer.
Lesbians may well be at a greater risk for breast cancer
than all other women, because more lesbian women have
never been pregnant or breastfed. Both of these conditions
can decrease a woman’s risk of developing breast
cancer.
Cervical Cancer
The
benefits of screening for cervical cancer with a Pap
smear have been well proven. The human papilloma virus
(HPV) causes 90 percent of cervical cancer cases in
the United States. Not only is HPV transmission between
women possible, but many lesbians have other risk factors
for cervical abnormalities. These risk factors include
multiple male sex partners, heterosexual intercourse
at an early age, and cigarette smoking.
Cervical cancer is rare before the age of 20. The average
age at onset is 47 years. Generally it is recommended
that women get Pap smears yearly, after the onset of
sexual activity or age 18. If a woman is at low risk
for cervical cancer, some clinicians feel that the interval
for Pap-smear testing may be every three years after
three consecutive normal Pap smears.
Colorectal
Cancer
Colorectal cancers are the third leading cause of death
among women. Most cases occur in people over 50 years
of age. Risk factors include a history of breast cancer,
uterine cancer, or ovarian cancer. Additional risk factors
include a family history of colorectal cancer, family
history of adenomatous colon polyps or a history of
ulcerative colitis.
Regular screening is recommended for all women over
age 50. This screening includes annual fecal occult
blood testing. Additionally, flexible sigmoidoscopy
and digital rectal exams are recommended after age 50
at five-year intervals. Colonoscopy or double contrast
barium enemas should be done every 10 years after age
50. Some research studies have shown that eating a diet
rich in fruits and vegetables and supplementing with
antioxidants may help reduce a woman’s risk of
developing not only colorectal cancer, but many other
cancers as well.
Lung
Cancer
Lung
cancer is the leading cause of cancer among women. Because
smoking is the primary cause of lung cancer, it’s
essential that women stop smoking in order to avoid
or minimize damage to the lungs. The prevalence of cigarette
smoking may be higher in lesbians than the general population
of women; the National Lesbian Health Care Survey found
that 30 percent of lesbians smoked cigarettes daily.
Yearly chest X-rays for all women who smoke greater
than 20 packs of cigarettes per year is generally recommended.
Ovarian
Cancer
Ovarian
cancer is the fourth leading cause of cancer death in
women. If caught in its early stages, the five-year
survival rate is 95 percent. Unfortunately, because
ovarian cancer is difficult to detect in its early stages,
most women are not diagnosed until the cancer has already
become advanced.
You’re at greater risk for developing ovarian cancer
as you get older, if there’s a family history of
ovarian cancer, if you’ve had breast or colorectal
cancer, or if you started your menstrual cycle at an
especially early age. A high-fat diet and the use of
talc products can also increase your risk.
Lesbians are at an increased risk of ovarian cancer
simply due to the fact that most lesbians have no prior
history of pregnancy or breast-feeding. Also, since
oral contraceptives can decrease the incidence of ovarian
cancer if used for more than five years, most lesbians
will not receive this benefit.
Unfortunately, there are no effective screening methods
for detecting ovarian cancer. The CA-125 serum marker
is a blood test that may play a role in early detection.
The sensitivity of the test is limited, and only 60
percent of women with early disease will have an elevated
CA-125 level. There is also a high incidence of false-positive
CA-125 results in pre-menopausal women. After detection
of an elevated CA-125 level, a transvaginal or transabdominal
ultrasound is necessary to detect any ovarian enlargement.
Sexually
transmitted diseases (STDs)
Lesbians
have the common misconception that they have a much
lower risk for catching STDs with a female partner than
with a male sexual partner. Indeed, some health-care
providers do not recommend routine screening of lesbian
women for STDs unless there has been recent heterosexual
contact or specific symptoms are present. And it’s
true that recent findings have shown that lesbians have
the lowest incidence of gonorrhea and syphilis of any
group, except for those who have never had sexual relations.
But because sex between women can include deep kissing,
oral-genital contact, vaginal or anal penetration with
fingers or devices, and oral-anal contact, disease transmission
is still possible. For instance, herpes simplex virus,
human papilloma virus, chlamydia, trichomonas, and syphilis
can all be transmitted between women. Additionally,
hepatitis B or C and HIV can potentially be shed through
vaginal secretions, especially during menstruation.
Human immunodeficiency virus (HIV)
It is a myth that lesbians do not contract or transmit
HIV infection through exclusively homosexual activity.
AIDS has become the sixth leading cause of death for
women between 25 and 44 years of age in the United States.
While the risk of female-to-female transmission of HIV
appears to be small, there may still be some risk. Some
lesbians have a history of intravenous drug abuse or
prior sexual relations with a male. These activities
greatly increase a lesbian’s risk of HIV infection.
In addition, many lesbians may be unsure about their
sexuality and therefore engage in sexual “experimentation”
with men. These men are often young gay and bisexual
men who are among those most at risk for HIV infection.
Coronary
Heart Disease
Coronary
heart disease remains the number-one killer of women
(and men)—it is therefore likely the leading cause
of death among lesbians. Prevention of heart disease
is a major health issue for lesbians. Over a lifetime,
women are 10 times more likely to develop heart disease
than breast cancer.
The incidence of heart disease in women ages 35 to 44
years is one per 1,000 increasing to four per 1,000
in women ages 45 to 54. One in four women over the age
of 65 have heart disease. African-American women have
the highest incidence. You should consider yourself
at risk if a close female relative has developed heart
disease or died unexplainedly before she was 65. Family
related issues in women such as cultural habits, low
socioeconomic status, education level, and availability
of insurance coverage may also play a role in the development
of heart disease.
Smoking cigarettes increases the risk for an early heart
attack, and lesbians may smoke more than the general
female population, according to the National Lesbian
Health Care Survey. Cigarette smoking lowers the HDL
cholesterol level and serum estrogen levels in women,
the presence of both helping protect women against developing
heart disease.
High blood pressure (greater than 140/190) strongly
increases the risk of heart disease in women. Reducing
blood pressure with medications or lifestyle modifications
can greatly reduce this risk. Weight loss, avoidance
of alcohol, smoking cessation, sodium restriction, adequate
potassium, calcium and magnesium intake, and regular
exercise are important approaches to control high blood
pressure.
If you have a high cholesterol level, especially a high
HDL, you may develop heart disease as you get older,
as elevated cholesterol can increase the number of deaths
or strokes. An HDL level greater than or equal to 60
mg/dl is considered protective against heart disease.
LDL cholesterol levels should be under 160 mg/dl in
women with fewer than two risk factors for developing
heart disease. In women with at least two risk factors
for heart disease but without evidence of disease, the
target LDL level should be below 130md/dl. In women
with established heart disease, the goal for LDL cholesterol
should be under 100 mg/dl. Also, women with diabetes
should have LDL levels below 100 mg/dl. Normal triglyceride
levels should be below 200 mg/dl.
Diet and exercise are the cornerstones of lipid-lowering
therapy. Women with high blood lipid levels should reduce
dietary cholesterol and saturated fats, replacing them
with monounsaturated and polyunsaturated fats. If you’re
overweight, weight loss may also help to reduce lipid
levels.
Physically
active women have a significantly lower risk for heart
disease as compared to sedentary women. Increasing the
level of physical activity can raise HDL cholesterol
levels. Every woman in the United States should engage
in at least 30 minutes of moderate-intensity physical
activity (brisk walk) on most if not all days of the
week. If diet, weight loss, and exercise do not lower
LDL cholesterol to desirable levels in three to six
months, drug therapy should be initiated.
Pennye
Rohde is a physician’s assistant at the Southampton
Medical Group, working with Dr. Shannon Schrader.
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