In late 2008, in association with the Gay and Lesbian Equality Network (GLEN), the Irish College of General Practitioners (ICGP) published an important quality document, Gay, Lesbian and Bisexual Patients: the Issues for General Practice.¹

This guide was written for GPs to advance their understanding of what they need to know when treating lesbian, gay and bisexual (LGB) people in primary care settings.

Four years later, in the context of this series on women’s health, it is timely to review the specific health issues that we, as GPs, need to be aware of for our lesbian and bisexual patients.

The first step is to be aware which of our patients are lesbian or bisexual. It is estimated that over 50% of lesbian and bisexual women never disclose this to their GP, which means that they do not get the opportunity to discuss their specific sexual and general health needs.

Introduction

Being comfortable using open, non-judgemental questions during the consultation, may open the door for lesbian and bisexual women to disclose their sexual orientation in safety:

• Are you in a sexual relationship?

• Have you been sexually active recently?

• Is your partner male or female?

• Do you have sex with men, women or both?

• Do you need birth control?

• Is there any chance you could be pregnant?

While for the most part, lesbian and bisexual women have the same health needs as the heterosexual population, the ICGP document identified three broad health areas that should be borne in mind when working with this population:

• Mental health

• Sexual health and fertility

• General health/screening.

Mental health

While homosexuality itself is not indicative of psychopathology, lesbian and bisexual woman have been shown to be at risk of more mental health problems that their heterosexual peers.

Reasons for this include the stresses associated with initial confusion over sexual orientation, worries about being accepted by family, peers and society, and the high incidence of bullying, often a problem in the school or workplace.

There is also evidence of an increased risk of suicide at the time of ‘coming out’, if there is poor support from family and friends.

As a consequence of these extra stresses in life, lesbian and bisexual women may be at increased risk of alcohol and/or drug abuse. They are also at increased risk of assault and violent attack.

However, if a woman has not disclosed her sexual orientation to her GP, how can she express her fears and anxieties during the consultation?

And how can the GP help her to access the appropriate supportive care she may need?

Being aware of a woman’s sexual orientation is a vital piece of information needed in any consultation relating to mental health issues.  

Sexual health and fertility

It must not be assumed that lesbian and bisexual women are at lower risk of sexually transmitted diseases. Bisexual women are, of course, at the same risk as their heterosexual peers and need to take the same precautions. Lesbian women often assume that they are at no risk. However, some lesbian women will have had sex with men, before they were secure in their own sexuality, hence putting themselves at risk of sexually transmitted infections (STIs). 

Even those who have only had sex with women do run a risk of STIs (human papillomavirus [HPV] and herpes are both spread by skin-to-skin contact) so they should be encouraged to use adequate protection, such as dental dams, and also access routine screening. 

Bacterial vaginosis, however, can be a more prevalent issue for some lesbian and bisexual women and may be related to use of sex toys. General hygiene advice, and also advising against using scented soaps and douches, will help to resolve this problem. Encouraging the regular use of lubrication during sex, especially if using fingers and toys, will also be of benefit.

Just as many heterosexual women can have problems with sexual dysfunction, lesbian and bisexual women are no different in this regard. However, they may have more problems in discussing this with their doctor, if they sense any reticence or disapproval. It is therefore important again to be comfortable talking about sex and sex practices in a practical, non-judgemental manner.

As technology and the law have advanced, the issue of lesbian couples planning pregnancy has become common. In discussing pregnancy with a lesbian couple, there are two important questions that need to be addressed:

• Who will carry the foetus? 

• Who will provide the sperm?

In my experience, by the time the couple have come to the doctor to discuss a pregnancy, they will have already decided on the first question. In counselling them, however, each woman’s menstrual cycle, age and general health should be reviewed, so as to give them the greatest chance of success during the fertilisation process. 

Some couples will decide that the older partner will try first, allowing the other partner to try later on, should they want a second pregnancy.

Again, the question of who will supply the sperm will usually have been discussed. 

The simplest method is to employ the services of a male friend, who will provide a semen sample, for self-insemination. However, this can be quite random and success depends on the recipient woman being very aware of her ovulation. There may also be many potential legal minefields down the road, regarding custody, parental rights, inheritance etc.

Most couples will opt to attend one of the private fertility clinics throughout the country which provide a high-standard aid service for lesbian couples.

General health and screening

Although lesbian and bisexual women often have pregnancies, in general they have fewer pregnancies than their heterosexual peers. They will have had many more menstrual cycles in their lifetime and are unlikely to have used the oral contraceptive pill for an extended period of time. All of these factors can put them at increased risk of ovarian cancer.

Unfortunately, however, there is no adequate screening tool as yet for the early detection of ovarian cancer. As always, a high level of suspicion, especially in the middle-aged woman presenting with vague abdominal symptoms, is the best approach to this problem, and knowing her sexual orientation and potential increased risk may be important.

The link between HPV exposure and cervical cancer has been well documented. It is often assumed, especially among the lesbian population, that as they do not have sex with men, they are at little or no risk of cervical cancer. Unfortunately this is not true. 

As mentioned previously, many lesbian women will have had penetrative heterosexual sex in the past. Also, genital HPV is transmitted by skin-to-skin contact, so the risk is present in homosexual relationships also, although the risk is increased if there is local skin irritation, as can occur with penetrative sex.

The lesson from this, for both lesbian women and their doctors, is that regular smear testing is just as important for them as it is for their heterosexual peers.

Similarly, regular mammograms, as per the BreastCheck protocol, are also recommended for lesbian women. 

While there is evidence that the incidence of breast cancer in lesbian women is higher than expected, the reason for this is not clear. It may be related to another health issue, obesity, which is again higher in lesbian women. Again, why this should be so is not clear.

As mentioned earlier, the LGB population as a whole have a higher incidence of alcohol and recreational drug use than would be expected compared to their heterosexual peers, and similarly they smoke more than would be expected. 

Flagging these health issues for lesbian and bisexual women in the consultation may open the way for the GP to use brief intervention techniques to help modify behaviour.

Conclusion

In summary, lesbian and bisexual women, as with any minority group, have health needs outside of the common issues seen in the heterosexual population. In order to provide comprehensive care to this group, it is important to be aware of what these specific needs may be. But until we are comfortable and skilled in knowing the sexual orientation of our patients, we cannot be in a position to provide this extra level of care.  

Reference

1. Allen O, ICGP Quality in Practice Committee, Gay and Lesbian Equality Network (GLEN). Gay, lesbian and bisexual patients: the issues for general practice. Irish College of General Practitioners: Dublin, 2008