Monday, July 04, 2011

Lesbian Health Disparities

CONTENTS:

INTRODUCTION
1) BACTERIAL INFECTIONS
          - Bacterial Vaginosis
          - Chlamydia
          - Gonorrhea
          - Syphilis
2) VIRAL INFECTIONS
          - Human Immunodeficiency Virus
          - Hepatitis C
          - Herpes Simplex Virus
          - Human Papilloma Virus
3) CANCERS
          - Cervical Cancer
          - Breast Cancer
4) OTHER GENERAL HEALTH DISPARITIES
          - Life Expectancy
          - Obesity
5) LESBIANS HAVING SEX WITH MEN
6) CONCLUSION




INTRODUCTION

LGBT people are known to suffer from higher levels of distress and some associated mental illnesses due to the heterosexism/minority stress they suffer at the hands of heterosexists (see section 1 of the following link).  In turn, this increases the probability that some will abuse both legal and illegal drugs, likely as a coping mechanism.

Obesity, alcohol and smoking are general risk factors for some cancers, and all three of these disproportionately affect lesbians due to heterosexism (see section 2 of the following link).  Section 3 of the following URL demonstrates the well established link between substance abuse and risky sexual behaviour.  This may place some WSW at increased risk for STIs, though a low biological predisposition towards STI transmission may offset this, as demonstrated in this essay.
http://homoresponse.blogspot.com/2011/06/mental-health-and-substance-abuse.html

Note that the many of the studies below were carried out at STI clinics and were on WSW (women who have had sex with women), rather than lesbians.  This clearly skews the findings towards a higher STI prevalence, both in that those attending STI clinics are far more likely to have an STI than the general population and in that WSW excludes any members of the population that have not yet had sex, unlike general population statistics.  Furthermore, WSW and MSM definitions are often based upon sexual activity within the last year or even 6 months, therefore further excluding less promiscuous participants.  Finally, given that lesbian sexual interactions do likely present a lower risk for STI transmission than heterosexual ones, WSW who have also had heterosexual interactions are likely to be over-represented in STI clinic populations.




1) BACTERIAL INFECTIONS

BACTERIAL VAGINOSIS (BV)

BV is usually the only (supposed) STIs that heterosexists even attempt to suggest is more prevalent among lesbians than the general population.  It appears though that much of this can be explained in terms of the higher smoking prevalence among lesbians that is induced by minority stress.  BV can arise spontaneously in virgins and smoking is a known risk factor.

The CDC:
"It is not clear what role sexual activity plays in the development of BV."
"Women who have never had sexual intercourse may also be affected."
http://www.cdc.gov/std/bv/STDFact-Bacterial-Vaginosis.htm

Fethers et al. 2000, Sex Transmitted Infection, 76:345-349:
"Abnormalities on cervical cytology were equally prevalent in both groups, except for the higher cytological BV detection rate in WSW (OR 5.3, p=0.003)."
http://sti.bmj.com/content/76/5/345.abstract

Evans et al. 2007, Sexually Transmitted Infection, 83:470-475:
"Higher concordance of vaginal flora within lesbian partnerships may support the hypothesis of a sexually transmissible factor or reflect common risk factors such as smoking."
http://sti.bmj.com/content/83/6/470.abstract


Furthermore, the minority stress imposed upon WSW by heterosexists likely also plays a significant role, given that very similar stressors appear to explain the severely heightened prevalence of BV among black women.  It therefore becomes nothing more than a great hypocrisy for any heterosexist to criticise lesbian BV prevalence as it appears to be a direct result of heterosexism itself.

Paul et al. 2008, Social Science and Medicine, 67(5), 824-33:
"A higher number of stressful life events was significantly associated with higher BV prevalence among both African American and White American women."
http://www.ncbi.nlm.nih.gov/pubmed/18573578

Culhane et al. 2002, American Journal Obstetrics and Gynecology, 187(5), 1272-6:
"Black women had significantly higher rates of bacterial vaginosis (64%) compared with white women (35%). Exposure to chronic stressors at the individual level differed by race (eg, 32% of the black women reported threats to personal safety compared with 13% of white women). There were significant racial differences in exposure to stress at the community level (eg, 63% of the black women lived in neighborhoods with aggravated assault rates that were above the citywide mean compared with 25% of the white women)."
http://www.ncbi.nlm.nih.gov/pubmed/12439519



CHLAMYDIA AND GONORRHOEA

Skinner et al. 1996, Genitourinary Medicine, 72(4), 277-80:
"Gonorrhoea and chlamydia infection were infrequent diagnoses in both groups, occurring in four (2%) lesbians and 14 (7%) heterosexuals."
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1195678/

Robertson et al. 1981, Sexually Transmitted Diseases, 8(2), 75-6:
"A screening of 148 sexually active lesbians revealed no cases of syphilis, cervical gonorrhea, herpes simplex virus, or Chlamydia trachomatis infections."
http://www.ncbi.nlm.nih.gov/pubmed/6894808



SYPHILIS

Bailey et al. 2004, Sexually Transmitted Infections, 80(3):244-246:
"There were no cases of HIV, syphilis, or hepatitis B. However, while most subjects were tested for syphilis, a minority were tested for HIV or hepatitis, so we cannot estimate prevalence rates."
http://sti.bmj.com/content/80/3/244.abstract




2) VIRAL INFECTIONS

HUMAN IMMUNODEFICIENCY VIRUS (HIV)

Centers for Disease Control and Prevention, 2005:
"To date, there are no confirmed cases of female-to-female sexual transmission of HIV in the United States database."
http://www.cdc.gov/hiv/topics/women/resources/factsheets/wsw.htm

Petersen et al. 1992, Journal of Acquired Immune Deficiency Syndromes, 5(9), 853-5:
A study on "960,000 female blood donors at 20 large U.S. blood centers during 1990... identified no woman who was infected with HIV from sexual contact with another woman."
http://www.ncbi.nlm.nih.gov/pubmed/1512683



HEPATITIS C (HCV)

Though higher risk of hepatitis is not documented among lesbians, one study did find a higher prevalence but attributed it directly to increased IDU, rather than sexual contact:

Fethers et al. 2000, Sexually Transmitted Infections, 76:345-349:
"The prevalence of hepatitis C was significantly greater in WSW (OR 7.7, p<0.001), consistent with the more frequent history of injecting drug use in this group (OR 8.0, p<0.001)."
http://sti.bmj.com/content/76/5/345.abstract

According to the CDC:
"HCV is not efficiently transmitted sexually".
http://www.cdc.gov/hepatitis/HCV/index.htm



HERPES SIMPLEX VIRUS (HSV)

In the following study, table 2 shows that HSV primary infection was 5 times more prevalent among heterosexuals than lesbians:

Skinner et al. 1996, Genitourinary Medicine, 72(4), 277-80:
"Genital herpes (p = 0.05) and genital warts (p = 0.005) were more common in the heterosexual women."
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1195678/



HUMAN PAPILLOMA VIRUS (HPV)

Genital warts are caused by HPV, as are several cancers (CDC, 2009):
"HPV infections are highly prevalent in the United States, especially among young sexually active women."
http://www.cdc.gov/std/stats09/womenandinf.htm

Fethers et al. 2000, Sexually Transmitted Infections, 76(5), 345-349:
"Genital herpes and genital warts were common in both groups, although warts were significantly less common in WSW (OR 0.7, p=0.001)."
http://sti.bmj.com/content/76/5/345.abstract

In the 1996 Skinner et al. study, table 2 shows that genital warts were 14 times more prevalent among heterosexual women than the lesbians:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1195678/?page=2


A study on HPV transmission also suggests that lesbians sex is less risky than penile-vaginal sex for HPV infection and that smoking is a risk factor for HPV contraction, which we would expect to result in higher smoking-related HPV risk for WSW:

J. M. Marrazzo, 2004, AIDS Patient Care and STDs, 14(8), 447-451:
"In a pilot study of 149 WSW in Seattle, Washington, prevalence of HPV as detected by DNA amplification assay was 30%, and was 19% among women reporting no prior sex with men."
http://www.liebertonline.com/doi/abs/10.1089/108729100416669

CDC 2003-4 statistics show an HPV prevalence of about 30% in the general population around the age range of the above study's participants:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5633a5.htm

Marrazzo et al, 1998 The Journal of Infectious Diseases, 178(6), 1604-9:
"We also found, as have other investigators [17], that current cigarette smoking was associated with an increased risk of HPV DNA detection."


Another study found that exclusive lesbians were again at much lower risk of HPV/cervical cancer and the risk factors it notes as being associated with cervical cancer are predominantly heterosexual:

Bailey et al. 2000, British Journal of General Practice, 50(455), 481–482:
"Cytological abnormalities (borderline, mild, moderate or severe dyskaryosis) were significantly more common in women who had been sexually active with men than in ‘exclusively lesbian’ subjects".
"Early age of first intercourse with a man, number of male partners, smoking, and the presence of cervical HPV infection are all acknowledged factors associated with cervical pre-malignant and malignant change ."
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1313729/




3) CANCERS

CERVICAL CANCER

There are currently no studies known to this author that indicate a greater prevalence of cervical cancers among lesbians.  Given the seemingly lower prevalence of HPV (which causes almost all cervical cancer), it is probably that lesbians have a lower incidence of cervical cancer than heterosexuals.  However, some studies indicate that reduced uptake of Pap tests (which detect cervical cancer) by lesbians due, at least in part, to heterosexism, may put lesbians at greater risk of late detection of cervical cancer.

Mcintre et al. 2010, Culture, Health & Sexuality, DOI: 10.1080/13691058.2010.508844:
"Lesbians are said to feel excluded by sexual health messages that presume heterosexuality, a finding linked to lower levels of Papanicolaou (Pap) testing."
http://www.informaworld.com/smpp/content~db=all~content=a925913140

Tracy et al. 2010, Journal of Women's Health, 19(2), 229-237:
"Many lesbians do not screen for cervical cancer at recommended rates. Nonroutine screeners perceive fewer benefits, more barriers, and more discrimination".
http://www.liebertonline.com/doi/abs/10.1089/jwh.2009.1393



BREAST CANCER

As with cervical cancer, no studies are currently known to this author showing a higher prevalence of breast cancer among lesbians.  However, again, studies indicate a lower uptake of preventative medical care by lesbians, again, due to heterosexism.  Lesbians higher smoking, drinking and obesity rates may also put them at higher risk for various cancers.  Obesity and alcohol intake are risk factors for breast cancer, while smoking may be.  Other risk factors that are incidentally related to lesbianism include; being female, not having children and not breast feeding.  These apply all childless women and it would be insane to advocate having children purely in order to reduce the risk of a specific cancer.  http://www.cancer.org/cancer/breastcancer/detailedguide/breast-cancer-risk-factors

Lauver et al. 1999, Women's Health Issues, 9(5), 264-274:
"Lesbians face unique barriers to health care... some issues identified were particular to lesbians; many issues were common to those identified by general samples of women (which include lesbians)."
http://www.sciencedirect.com/science/article/pii/S1049386799000249




4) OTHER GENERAL HEALTH DISPARITIES

LIFE EXPECTANCY

Women in general have higher life expectancies than men.  MSM life expectancy is only thought to be negatively impacted by HIV and suicide, relative to heterosexuals.  HIV risk appears to be lower in lesbians than heterosexuals, suggesting a potentially higher mean life expectancy.  Suicide rates are still likely higher among WSW than the general population though, due to heterosexism.  The only lifespan studies performed on homosexuals include a massively discredited one, by anti-gay activist Paul Cameron and one that was on MSM, not WSW.  Overall, heterosexism-induced suicide is the only obvious factor that may impact upon WSW mean life expectancy.



OBESITY

Some sources allegedly indicate a higher rate of obesity among lesbians than the general female population, although the specific studies are not currently known to this author.  As with mental illness and substance abuse, obesity is linked to the stress, depression and anxiety such as that caused by heterosexism.

Zigman et al. 2011, Journal of Clinical Investigation, DOI:10.1172/JCI57660:
"The popular media and personal anecdotes are rich with examples of stress-induced eating of calorically dense “comfort foods.” Such behavioral reactions likely contribute to the increased prevalence of obesity in humans experiencing chronic stress or atypical depression."
http://www.jci.org/articles/view/57660

M F Dallman, 2010, Trends in Endocrinology & Metabolism, 21(3), 159–165:
"Stress also induces secretion of both glucocorticoids, which increases motivation for food, and insulin, which promotes food intake and obesity."
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2831158

Richardson et al. 2003, Archives of Pediatric & Adolescent Medicine, 157(8), 739-745:
"Depressed late adolescent girls were at a greater than 2-fold increased risk for obesity in adulthood compared with their nondepressed female peers.  A dose-response relationship between the number of episodes of depression during adolescence and risk for adult obesity was also observed in female subjects."
http://archpedi.ama-assn.org/cgi/content/full/157/8/739


At least one study finds no correlation between sexual orientation and BMI, though this study was on a Dutch population, where heterosexism is not as abundant, therefore diminishing the effects of minority stress that we might expect to see in less accepting cultures.

Sandfort et al. 2006, American Journal of Public Health, 96(6), 1119–1125:
"Obesity was not related to sexual orientation, suggesting that gay/lesbian and bisexual people are not at greater risk than heterosexual people for obesity-related health problems."
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1470639/




5) LESBIANS HAVING SEX WITH MEN

The heterosexist draws attention to lesbian's who have sex with men 1) in an attempt to undermine the legitimacy of their sexual orientation and perhaps 2) to distract from the fact that the WSW STI studies show that WSW generally derive far more of their risk for STI infection from their heterosexual than their homosexual interactions.  The high incidence of lesbian and WSW having at least one lifetime male partner has a couple of explanations:

- The WSW studies include bisexuals and in some cases, heterosexual women who have ever experimented with women.
- Conformity to family and societal expectations and pressure likely explain the bulk of self-identified lesbians who have had sex with men.
- The predominance of heterosexuality in society likely also leaves even the less-pressured lesbians more open to experimentation, at some point in their lives, than the average heterosexual.
- The above two points are particularly probable in that women do not have to get aroused to have sex, unlike men.
- Women are additionally culturally portrayed as not being lustful, far more than men, which likely further contributes to phases of self-denial in young lesbians about their sexual orientation.
- In such cases of self-denial, heterosexual sex may even be used as a means of self-affirmation that "I can't be lesbian because I have had sex with a man".
- Bisexuality can have some additional associated stigma attached to it, even occasionally among homosexuals (bisexuals may be considered "greedy", "confused" or more prone to infidelity) and this may lead some bisexual women, particularly those who lean strongly towards same-sex attraction, to classify themselves as lesbian.
- Even those who were not afraid of bisexuality-associated stigma may have identified as lesbian under the belief that they were primarily lesbian (ignorance of terminology) or purely for simplicity (if you're rarely attracted to men, "lesbian" may be a more pragmatic description).


What we would expect to see, were the above explanations correct (particularly ones such as teenage experimentation, self-denial and conformation to societal pressure), would be a relatively high lifetime incidence of lesbians having sex with men and a very small percentage continuing to do so, even after identifying as lesbian and therefore, presumably, having accepted their sexuality.  This is exactly what we do see:


WSW STUDIES (These include bisexual women):

Note: The Audre Lorde Clinic, which has now closed, was a WSW clinic, not exclusive to lesbians, as confirmed by this author via contact with staff at The Ambrose King Centre, where the Skinner et al. 1996 study was conducted.  Sexual health clinics are also likely to cater to a population that is on average substantially younger than the national mean or median age because the majority of STI transmission occurs among younger people.

Skinner et al. 1996, Genitourinary Medicine, 72(4), 277–280:
"Of the lesbians, 218 (91%) had experienced heterosexual intercourse but in only four (2%) had this occurred in the lst 90 days and none within the last 60 days.  In 34 (14%) of the lesbians, heterosexual intercourse had not occurred within the last 10 years."
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1195678/

Baley et al. 2003, Sexually Transmitted Infections, 79(2), 147-150:
"85% of the sample reported sexual activity with men; for most (70%) this was 4 or more years ago."
http://sti.bmj.com/content/79/2/147.abstract


SELF-IDENTIFIED LESBIAN STUDIES (These exclude bisexual women):

Diamant et al. 1997, Archives of Internal Medicine, 159(22), 2730-2736:
"Our data showed that 5.7% of respondents reported having had 1 or more male sexual contacts within the preceding year."
"Younger women were more likely to have had a male sexual partner during the preceding year. By contrast, older women were more likely than younger women to have engaged in vaginal intercourse".
"Data suggest that individuals who answer surveys about sexual issues tend to hold more liberal sexual attitudes and be more sexually active than nonrespondents."
http://archinte.ama-assn.org/cgi/content/full/159/22/2730

In Koh et al. 2005, (Sexually Transmitted Diseases, 32(9), 563-569), only 3% of the lesbians reported sex with men in the last year (see table 2). 
http://journals.lww.com/stdjournal/Fulltext/2005/09000/Sexual_Risk_Factors_Among_Self_Identified.8.aspx


Only a tiny portion (~4%) of the self-identified lesbians have had recent (past year) sex with men.  These 4% are likely made up of those predominantly bisexual women who identify as lesbian and those young members of the study populations who only recently accepted their sexual orientation.  That the older women in the Diamant 1997 study were more likely to have had lifetime vaginal intercourse is consistent with the point that heterosexism, which used to be even more prevalent, is the cause behind a lot of the lesbian heterosexual interactions.  Studies on the prevalence of homosexuality and bisexuality repeatedly show more people claiming to have engaged in homosexual interactions than the number that identify as something other than heterosexual.  This does not undermine heterosexuality.




6) CONCLUSION

BV and obesity appear to both be linked quite closely with stress.  Substance abuse may put lesbians at increased risk of STIs and some cancers, with fears of discrimination and feelings of exclusion also potentially contributing to lack of preventative medical care.  However, current research does not generally indicate a higher incidence of STIs among lesbians, except for BV, the sexual transmission of which is controversial and the prevalence of which is linked to (minority) stress.

One study showed a markedly higher prevalence of hepatitis C, though the study was not representative, did not have a properly matched control population and the study authors attributed the HCV prevalence to injecting drug usage (IDU), which correlated with it.  All of these disparities are clearly established as being caused by heterosexism, rather than homosexuality itself.

The potential for HIV transmission is known to be significantly lower between two women than WSM or MSM.  There is insufficient research on nationally representative populations to draw firm conclusions about the prevalence of other STIs, though current studies appear suggestive of a lower prevalence of many STIs among WSW than WSM.

In a study on 708 WSW patients attending two London-based STI clinics, Bailey et al. (2004, Sexually Transmitted Infections, 80(3):244-246) found that:
"Bacterial vaginosis and candida species were commonly diagnosed (31.4% and 18.4% respectively). Genital warts, genital herpes, and trichomoniasis were infrequently diagnosed (1.6%, 1.1%, and 1.3% respectively). Chlamydia, pelvic inflammatory disease, and gonorrhoea infections were rare (0.6%, 0.3%, and 0.3% respectively) and diagnosed only in women who had histories of sex with men."
http://sti.bmj.com/content/80/3/244.full

Cochran et al. 2007, American Journal of Public Health, 97(11), 2048–2055:
"Our findings indicate that minority sexual orientation alone is not associated with poorer physical health."
"Lesbians and bisexual and homosexually experienced heterosexual women reported a greater variety of health conditions and limitations compared with exclusively heterosexual women; however, these differences mostly disappeared when distress levels were taken into account."
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2040376

Note that Candida (mentioned in Bailey, 2004) causes yeast infection/thrush, which affects the majority of women at least once in their lifetime and is similar to BV.  An analogous quotation to the above one can be found at the end of the "African American Health Disparities" conclusion:
http://homoresponse.blogspot.com/2011/06/african-american-health-disparities.html#5

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