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--> 2 Lesbian Health Status and Health Risks Identifying the physical and mental health problems for which lesbians are at higher risk is not a straightforward task. Although lesbians share many of the same health risks with women in general, a number of factors act to influence their health risks in unique ways. In this chapter, several frameworks are presented for examining lesbian health and health risks in order to elucidate some of the unique influences on lesbian health. The first framework considers lesbians in the larger contexts of society, the health care system, and women in general. The second framework takes a developmental approach to examining the unique factors that affect lesbian health across the life span. The final framework examines specific physical and mental health concerns for lesbians, and reviews the risk and protective factors that have an impact on their risk for these problems. When examined together, these various approaches provide a more complete picture of the complexity involved in looking at lesbian health. Framework 1: Lesbian Health in the Larger Context Lesbian Health in the Context of Society Historically, lesbians have been the target of prejudice and discrimination, both public and private, and the stigmatization of homosexuality
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--> remains widespread in our society (APA, 1997; Perrin, 1996). Although many kinds of abuse of and discrimination against lesbians have been clearly documented, their impact on physical and mental health remains in need of study. Until 1973 the American Psychiatric Association classified homosexuality as an illness or pathological condition. Although no longer classified as an aberrant condition, negative attitudes about gays and lesbians continue to be held by many members of the public, including health and mental health care providers (Bradford et al., 1994b; Garnets et al., 1991; Rothblum, 1994; Wolfe, 1998). Experience with discrimination or prejudice is common among lesbians. For example, in a multisite longitudinal study of cardiovascular risk factors in black and white adults ages 25 to 37 years, 33% of the black women and 56% of the white women who reported having had at least one same-sex sexual partner reported experience with discrimination on the basis of sexual orientation (Krieger and Sidney, 1997). Eighty-five percent of the black women further reported discrimination based on race. Most of the women (89%) also reported having experienced gender discrimination. Gay men and lesbians are also at risk of being targets of violence based on their sexual orientation or behavior. Antigay hate crimes accounted for 11.6% of the hate crime statistics collected by the Federal Bureau of Investigation (FBI) in 1996, making this the third largest category following racial hate crimes and crimes based on religion (FBI, 1996).1 More than half of the respondents in the National Lesbian Health Care Survey (NLHCS) reported that they had been verbally attacked because they were lesbian, and 8% said that they had been physically attacked (Bradford and Ryan, 1988). Similarly, nearly half of the women surveyed in the Michigan Lesbian Health Survey (MLHS) reported having experienced a verbal attack because of their lesbian identity, and 5% reported having been physically attacked (Bybee and Roeder, 1990). Numerous states have in place laws that negatively target gay men 1 The FBI is mandated to collect data on hate crimes as part of the Uniform Crime Reporting Program, which collects data on crimes from nearly 17,000 voluntary law enforcement agency participants across the country. Of the 8,759 hate crime incidents reported to the FBI in 1996, 5,396 were motivated by racial bias, 1,401 by religion bias, 1,016 by sexual orientation bias, and 940 by ethnicity or national origin bias.
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--> and lesbians (NGLTF, 1998; see also Table 2.1). Although some states have laws that ban discrimination on the basis of sexual orientation in employment, housing, credit, and public accommodation, many do not. Passage of such laws remains controversial. For example, in Maine where such legislation passed in 1997, voters subsequently voted to overturn the law (NGLTF, 1998). In some states, laws are in place to prohibit state and county employees from receiving domestic partner benefits. Same-sex marriage is specifically banned in 25 states and is not legal in any state. Efforts are also underway in some states to prevent same-sex couples from adopting children or serving as foster parents. Finally, numerous states ban same-sex sodomy specifically or along with opposite-sex sodomy. We still have many people in many states who can be persecuted by laws, can be put out of work, and even if we have the gold standard (randomized, controlled clinical trials), they are not going to come to our studies because they do not want to be stigmatized any more than they already are. Donna Knustson, Public Workshop, October 6-7, 1997 Washington, D.C. Lesbian Health in the Context of the Health Care System2 Lesbian health and risks to health can be examined in the context of the health care system. In other words, are there aspects of the health care system that act to reduce lesbian's access to services, thereby possibly increasing their risk of health problems? Access to health care has been defined as the timely use of personal health services to achieve the best possible health outcomes (IOM, 1993). The three primary types of barriers are (1) structural barriers (e.g., availability of services, organizational configuration of health care providers); (2) financial barriers (e.g., insurance coverage); and (3) personal and cultural barriers (e.g., attitudes of patients and providers) (IOM, 1993). The test of equal access involves 2 This section incorporates portions of the workshop presentation by Jocelyn White.
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--> TABLE 2.1 Summary of Legal Status of Lesbians and Gay Men in the United States as of May 1998 Category Positive Policies Negative Policies Impact Marriage rights Between January and May 1998, antigay marriage bills have been blocked, defeated, or withdrawn in 4 states. Since 1995, 28 states have enacted laws that ban legal recognition of same-sex marriages. In states with antigay marriage laws, lesbian or gay couples who legally marry elsewhere may be denied the legal rights and responsibilities of marriage (e.g., to visit a sick spouse in the hospital or make health care decisions on her behalf. Same-sex marriages are not currently recognized in any state. Hate crimes statutes 19 states, plus the District of Columbia, include bias crimes based on sexual orientation in their hate crime statutes. 19 states do not cover sexual orientation in their hate crime laws. Hate crimes statutes that include sexual orientation make it illegal to commit crimes motivated by the victim's sexual orientation (these laws typically also include crimes motivated by race, religion, or ethnicity of the victim).
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--> Civil fights protection 10 states have civil fights laws that include sexual orientation; at least 8 additional states have executive orders banning discrimination on the basis of sexual orientation. In February 1998, Maine voters repealed a civil rights law, passed in 1997, that would have banned discrimination on the basis of sexual orientation; 3 states had anti-civil rights measures pending as of May 1998. Civil fights protection for lesbians and gays prohibits discrimination with respect to such areas as employment, public accommodation, educational institutions, housing, and credit. Sodomy 30 states do not have antisodomy laws, or existing laws have been overturned by state courts. 5 states continue to have antisodomy laws that apply to same-sex partners only; 15 states have antisodomy laws that apply to both heterosexual and same-sex couples. Antisodomy laws make it illegal for two people of the same sex to engage in sexual activity or prohibit certain forms of sex other than heterosexual intercourse.
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--> determining whether there are systematic differences in use and outcome among groups in society and whether these differences are the result of barriers to care. The committee finds that there is evidence that lesbians may face particular challenges in all three areas. Structural Barriers to Health Care Access for Lesbians Structural barriers that affect health care for lesbians include potential barriers presented by managed care systems and the fact that lesbian relationships are often not afforded the same legal standing as heterosexual marriages. Managed Care. Most Americans indicate that their first choice is to see a physician in the physician's private office. Although some lesbians report that they prefer other types of providers (e.g., naturopaths, chiropractors, nurse practitioners) and to receive care in clinics, the majority report that they receive primary care from a medical doctor (Bradford et al., 1994b; Bybee and Roeder, 1990; Moran, 1996; White and Dull, 1997). Although data are not yet available to determine the impact of managed care on the quality of health care for lesbians, the committee believes that negative consequences are possible for the following reasons: Limits placed on the behavior of providers by managed care organizations may introduce barriers to the effective care of lesbians. For example, pressure to keep visits short may compromise building of trust between a provider and a lesbian patient, making it less likely that the patient will disclose her sexual orientation. It is more difficult for patients to choose a lesbian-friendly medical or mental health care provider. With unrestricted access to providers, as in fee-for-service plans, lesbians have the option of seeking out lesbian or lesbian-friendly providers. Under managed care plans, however, higher levels of coverage of health care services are generally limited to providers who are part of that particular plan. This may make it very difficult for some lesbians to identify any provider who is lesbian or lesbian-friendly, given the limited number of these providers in general. Managed care plans can reduce these barriers by identifying lesbian- or
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--> gay-friendly providers in the plan, making a concerted effort to recruit lesbian- and gay-friendly providers, and instituting cultural competency training programs to enhance the ability of their providers to serve lesbians. The general lack of availability of family or household health insurance coverage for members of lesbian households makes it especially difficult for these individuals to see the same providers and enjoy family-focused care and the multiple benefits this can provide. Although domestic partner benefits are now increasingly available through some employers, most lesbians still do not have the option of coverage under their partner's health insurance plan. If two partners are covered under different managed care plans they will have access to the same provider only if that provider is part of both plans. Additional information is needed to determine whether managed care has a differential impact on lesbian health care, and how managed care organizations can best accommodate the health care needs of lesbians. Lack of Legal Recognition of Partners. Hospitals and health care providers do not always give the partner of a lesbian patient, or the co-parent of a lesbian's child, the same rights to visit and to access information as is provided to a heterosexual spouse. There is also, in some cases, a legal refusal to honor the lesbian partner of a patient as her health care proxy even when so designated by the patient. In the MLHS, 9% of the respondents reported that health care workers had not allowed their female partners to stay with them during treatment or see them in a treatment facility; 9% also said that providers had not included their partner in discussion about the respondent's treatment (Bybee and Roeder, 1990). Financial Barriers to Health Care for Lesbians Since insurance coverage is the primary gateway to health care in this country, lesbians are at a distinct disadvantage relative to married heterosexual women because of the common prohibition against spousal benefits for unmarried partners (Denenberg, 1995; Stevens, 1995). Among respondents to the NLHCS, 16% stated that they did not receive health
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--> care because it was unaffordable (Bradford and Ryan, 1988). In the MLHS, 12.3% of the lesbian sample reported that they did not have health insurance, compared to a state rate of 9.7% of Michigan women in general (Bybee and Roeder, 1990). Although most middle-aged lesbians surveyed in the NLHCS reported good to excellent health, 27% reported that they lacked health insurance. Analysis indicated that lack of insurance may be more prevalent among lesbians with particularly serious health conditions. Lesbians without insurance were significantly more likely to report heart disease, to have Pap tests less often or never, to smoke, to have eating disorders (either overeating or undereating), and to be victims of physical and sexual abuse and antigay violence (Bradford et al., 1994a). Personal and Cultural Barriers to Health Care Access for Lesbians Personal and cultural barriers that affect access to care for lesbians include the lack of cultural competency among health care providers, the fear of coming out to providers, and the lack of lesbian focus in preventive and other health care. Cultural Competency of Health Care Providers. Cultural competency refers to a set of skills that allows providers to give culturally appropriate high-quality services to individuals from cultures different from the providers'. These skills include understanding the culture and values of the group, the ability to communicate in the same language, and understanding the impact of group membership on health status, behavior, and attitudes. Cultural competency typically refers to providing services to people of different racial or ethnic groups. However, it also appropriately captures the skills needed to provide services effectively to lesbians. Providers who are culturally competent with respect to lesbians would be expected to understand the reasons lesbians might be reluctant to seek medical care and the impact of homophobia on the provision of services to lesbians; to be aware of the range of health problems experienced by lesbians as well as their health care risks; to avoid making heterosexual assumptions in the gathering of medical and social health information
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--> from patients; and to be willing to involve partners of lesbian patients in discussions about their health care. Health risks and health-seeking behaviors have been found to be strongly associated with ease of communication with the primary care provider and ease of access to care (White and Dull, 1997). However, various studies of health care provider experience with and attitudes toward lesbians suggest that few physicians are knowledgeable about or sensitive to lesbian health risks or health care needs (White and Dull, 1997). Twenty percent of the women responding to the MLHS reported having encounters with health care providers who did not know anything about lesbians (Bybee and Roeder, 1990). There is a lack of training of health care professionals in addressing the experiences and health needs specific to lesbian and gay clients, such as coming out or the lack of societal and legal recognition of relationships. A recent survey of departments of family medicine found that an average of 2.5 hours was devoted to the study of homosexuality and bisexuality across four years of medical school (Tesar and Rovi, 1998). Half (50.6%) of the 95 schools responding to the survey reported that they did not include these topics in their curricula. Diversity training in health care provider curricula can help students to recognize and overcome their biases toward clients with unfamiliar life styles, including lesbians (Black and Underwood, 1998; Robb, 1996; Robinson and Cohen, 1996).3 Gathering information about sexual behavior history is an essential component of good medical care. However, many physicians feel uncomfortable taking detailed sexual histories from their patients and may be particularly reluctant to inquire about same-sex behavior (Kripke et al., 1994; Merrill et al., 1990; Temple-Smith et al., 1996; Vollmer and Wells, 1989). The committee advocates training of providers to enhance their ability to discuss these issues without embarrassment and in a manner that does not threaten the patient or make her uncomfortable. Health care providers can be taught the importance of and techniques for unbiased sexual history taking (Turner et al., 1992). At the workshop, one of the 3 The National Gay and Lesbian Health Association, in partnership with the Mautner Project, has produced a curriculum for training any health care provider across disciplines on addressing and removing the barriers to health care that are faced by lesbian, gay, bisexual, and transgender clients.
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--> presenters suggested that rather than asking a woman whether she is married and what birth control she uses, it is preferable to ask whether she is in a sexual relationship, whether her partner is a man or a woman, if she and her partner are monogamous, and when she last had unprotected sex with a man (Waitkevicz, 1997). It is also important that questions be developmentally appropriate in the case of adolescents. Homophobic Attitudes of Providers. It has been suggested that negative attitudes and responses by some health care providers may lead lesbians to avoid seeking health care (Turner et al., 1992; White and Levinson, 1993). Surveys indicate that like members of society at large, medical faculty have widely divergent views regarding homosexuality (Black and Underwood, 1998). Thus, it is not surprising that discrimination and prejudice against lesbians by both physical and mental health care providers have been reported (Denenberg, 1995; Roberts and Sorensen, 1995). This discrimination and prejudice can take many forms, including reluctance or refusal to treat, negative comments during treatment, or rough handling during examination (Smith et al., 1985). It should be noted that a number of provider professional associations have developed statements regarding the care of people of all sexual orientations and have task forces, committees, or other initiatives in place to increase the visibility of lesbian and gay health concerns to their members and to the general public.4 Fear of Coming Out to Health Providers. In order to provide high-quality primary care it is important to know a patient's sexual orientation (Geddes, 1994; White and Levinson, 1995). However, the need to disclose one's sexual orientation to a health care provider can present a special barrier to care for lesbians. Fear or embarrassment may make the lesbian patient reluctant to disclose her sexuality, possibly compromising her care (Geddes, 1994; Turner et al., 1992; White and Dull, 1997).5 4 These groups include (but are not limited to) the American Psychological Association, the American Psychiatric Association, the American Academy of Pediatrics, the American Medical Association, and the National Association of Social Workers. 5 Of course, disclosing behaviors that might be perceived as shameful is an issue not just with respect to a person's sexual behavior, but also in other realms of sensitive or stigmatized behavior, such as drug use or domestic violence, irrespective of a patient's sexual orientation.
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--> Someone I will call Valerie came to me last week. She said that her gynecologist had diagnosed her with cervical condyloma and she wanted my opinion about what she should do in term of safe sex with her partner. When she asked her gynecologist this question the gynecologist said to use a condom. The gynecologist had not approacher her about her sexual preference. She said, ''I just don't feel comfortable coming out to my gynecologist." J. Waitkevicz, Public Workshop, October 6-7, 1997 Washington, D.C. Several studies have noted that the majority of lesbians (53 to 72%) do not disclose their sexual orientation to physicians when they seek medical care (Bybee and Roeder, 1990; Smith et al., 1985). Sixty percent of the women in the MLHS and 27% of respondents to the NLHCS reported experiences in which health care workers had assumed that they were heterosexual (Bradford and Ryan, 1988; Bybee and Roeder, 1990). Nonetheless, most of the respondents (61%) to the MLHS reported feeling that they could not disclose their sexual orientation to a health care provider. A much lower proportion of the respondents (16%) in the NLHCS said they would not feel comfortable letting their provider know they were lesbian. Lack of Lesbian Focus in Preventive and Other Health Care. Primary care for women tends to be organized around reproductive health needs (Denenberg, 1995; Stevens, 1995; White and Dull, 1997). Public funding for women's health has centered on family planning and prenatal care, issues that are less salient for lesbians than for heterosexual women. Counseling for women about sexually transmitted disease, in addition, typically assumes sex with male partners. Furthermore, in many clinical environments the information forms or interviews that include questions about health history, educational materials, and insurance information assume that patients are heterosexually active (Lynch, 1993; Perrin, 1996; Rankow, 1995b; Stevens, 1995; White and Levinson, 1995). Women who are not sexually active with a man or who are not sexually active at
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--> Prevalence of cigarette smoking among lesbians and patterns of tobacco use Prevalence of heavy drug use and injection drug use among lesbians Prevalence of infections related to injection drug use, such as hepatitis B and C Associations between childhood sexual abuse and substance abuse, including alcohol abuse Service Delivery and Access to Services Lesbians' patterns of use of health care services Models of care that act to remove barriers of access to care for lesbians Impact of managed care on quality of care for lesbians Whether cultural competency training of providers on the needs of lesbians will increase sensitive delivery of health care for lesbians Need for prevention and treatment intervention models targeted specifically toward lesbians Barriers to care for lesbians, including adolescent lesbians References Adler NE, Boyce WT, Chesney MA, Folkman S, Syme SL. 1993. Socioeconomic inequalities in health. Journal of the American Medical Association 269(24):3140-3145. Adler NE, Boyce T, Chesney MA, Cohen S, Folkman S, Kahn RL, Syme SL. 1994. Socioeconomic status and health: The challenge of the gradient. American Psychologist 49(1):15-24. American Cancer Society. 1997. Cancer Facts and Figures—1997 [WWW Document]. URL www.cancer.org/statistics/97cff/(accessed December 1 and 3, 1997). Anderson RN, Kochanek KD, Murphy SL. 1997. Report of Final Mortality Statistics, 1995. Monthly Vital Statistics Report 45(11, suppl. 2). DHHS Pub No. (PHS) 97-1120. Rockville, MD: National Center for Health Statistics. APA (American Psychological Association). 1997. Bell AP, Weinberg MS. 1978. Homosexualities: A Study of Diversity Among Men and Women. New York: Simon and Schuster. Berger BJ, Kolton S, Zenilman JM, Cummings MC, Feldman J, McCormack WM. 1995. Bacterial vaginosis in lesbians: A sexually transmitted disease. Clinical Infectious Diseases 21(6):1402-1405.
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--> Bevier PJ, Chaisson MA, Heffernan RT, Castro KG. 1995. Women at a sexually transmitted disease clinic who reported same-sex contact: Their HIV seroprevalence and risk behaviors. American Journal of Public Health 85(10): 1366-1371. Biddle BS. 1993. Health Status Indicators for Washington Area Lesbians and Bisexual Women: A Report on the Lesbian Health Clinic's First Year. Washington, DC: Whitman-Walker Clinic. Black J, Underwood J. 1998. Young, female, and gay: Lesbian students and the school environment. Professional School Counseling 1(3):15-20. Bloomfield K. 1993. A comparison of alcohol consumption between lesbians and heterosexual women in an urban population. Drug and Alcohol Dependence 33:257-269. Bowen D, Hickman KM, Powers D. 1997. Importance of psychological variables in understanding risk perceptions and breast cancer screening of African-American women . Womens Health 3(3-4):227-242. Bradford J, Ryan C. 1988. The National Lesbian Health Care Survey: Final Report. Washington, DC: National Lesbian and Gay Health Foundation. Bradford J, Plumb M, White J, Ryan C. 1994a. Information Transfer Strategies to Support Lesbian Research. Psychological and Behavioral Factors in Women's Health: Creating an Agenda for the 21st Century—Conference Proceedings. Washington, DC: American Psychological Association. Bradford J, Ryan C, Rothblum ED. 1994b. National Lesbian Health Care Survey: Implications for mental health care. Journal of Consulting and Clinical Psychology 62(2):228-242. Brewaeys A, van Ball EV. 1997. Lesbian motherhood: The impact on child development and family functioning. Journal of Psychosomatic Obstetrics and Gynaecology 18:116. Brewaeys A, Devroey P, Helmerhorst FM, Van Hall EV, Ponjaert I. 1995. Lesbian mothers who conceived after donor insemination: A follow-up study. Human Reproduction 10(10):2731-2735. Brewaeys A, Ponjaert I, van Ball EV, Golombok S. 1997. Donor insemination: Child development and family functioning in lesbian mother families. Human Reproduction 12:1349-1359. Buhrke RA, Ben-Ezra LA, Hurley ME, Ruprecht LJ. 1992. Content analysis and methodological critique of articles concerning lesbian and gay male issues in counseling journals. Journal of Counseling Psychology 39(1):91-99. Bybee D, Roeder V. 1990. Michigan Lesbian Health Survey: Results Relevant to AIDS. A Report to the Michigan Organization for Human Rights and the Michigan Department of Public Health. Lansing: Michigan Department of Health and Human Services. Cabaj RP. 1992. Substance abuse in the gay and lesbian community. In: Lowenson J, Ruiz P, Millman R, eds. Substance Abuse: A Comprehensive Textbook. Baltimore, MD: Williams and Wilkins. Pp. 852-860. Cabaj RP. 1996. Substance abuse in gay men, lesbians, and bisexuals. In: Cabaj RP, Stein TS, eds. Textbook of Homosexuality and Mental Health. Washington, DC: American Psychiatric Press, Inc. Pp. 783-799. Cassidy MA, Hughes TL. 1997. Lesbian health: Barriers to care. In: McElmurry BJ, Parker RS, eds. Annual Review of Women's Health, Vol. 3. New York: National League for Nursing Press. Pp. 67-87.
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--> CDC (Centers for Disease Control and Prevention). 1996. Sexually Transmitted Disease Surveillance, 1995. Atlanta, GA: Centers for Disease Control and Prevention, Division of STD Prevention. CDC. 1997. HIV/AIDS Surveillance Report, 1996. Vol. 8 (No. 2). Atlanta, GA: Centers for Disease Control and Prevention. Cheng FK, Ford WL, Weber MD, Cheng S-Y, Kerndt PR. 1997. A probability-based approach for predicting HIV infection in a low prevalent population of injection drug users. AIDS Education and Prevention 7:28-34. Chu SY, Buehler JW, Fleming PL, Berkelman RL. 1990. Epidemiology of reported cases of AIDS in lesbians, United States 1980-89. American Journal of Public Health 80(11): 1380-1381. Chu SY, Hammett TA, Buehler JW. 1992. Update: Epidemiology of reported cases of AIDS in women who report sex only with other women, United States, 1980-1991 [letter]. AIDS 6:518-519. Cochran SD, Bybee D, Gage S, Mays VM. 1996. Prevalence of HIV-related self-reported sexual behaviors, sexually transmitted diseases, and problems with drugs and alcohol in 3 large surveys of lesbian and bisexual women: A look into a segment of the community. Women's Health Research on Gender, Behavior, and Policy 2(1-2):11-33. Cochran SD, Mays VM. 1994. Depressive distress among homosexually active African-American men and women. American Journal of Psychiatry 151 (4):524-529. Cohen H, Marmor M, Wolfe H, Ribble D. 1993. Risk assessment of HIV transmission among lesbians [letter]. Journal of Acquired Immune Deficiency Syndrome 6(10):1173-1174. D'Augelli AR, Hershberger SL. 1993. Lesbian, gay, and bisexual youth in community settings: Personal challenges and mental health problems. American Journal of Community Psychology 21 (4):421-448. Denenberg R. 1995. Report on lesbian health. Women's Health Issues 5(2):81-91. Deren S, Goldstein M, Williams M, Stark M, Estrada A, Friedman SR, Young RM. 1996. Sexual orientation, HIV risk behavior, and serostatus in a multisite sample of drug-injecting and crack-using women. Women's Health: Research on Gender, Behavior, and Policy 2(1-2):35-47. Edwards A, Thin RN. 1990. Sexually transmitted diseases in lesbians. International Journal of STD and AIDS 1:178-181. Ehrhardt AA, Nostlinger C, Meyer-Bahlburg HFL, Exner TM, Gruen RS, Yingling SL, Gorman JM, El-Sadr W, Sorrell SJ. 1995. Sexual risk behavior among women with injection drug use histories. Journal of Psychology and Human Sexuality 7:99-119. Einhorn L, Polgar M. 1994. HIV-risk behavior among lesbians and bisexual women. AIDS Education and Prevention 6(6):514-523. Eliason MJ. 1996. Caring for the lesbian, gay, or bisexual patient: Issues for critical care nurses. Critical Care Nursing Quarterly 19(1):65-72. Englert Y. 1994. Artificial insemination of single women and lesbian women with donor semen. Artificial insemination with donor semen: Particular requests. Human Reproduction 9(11):1969-1971. Eschenbach DA. 1993. Bacterial vaginosis and anaerobes in obstetric-gynecologic infection. Clinical Infectious Diseases 16:S282-S287.
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--> FBI (Federal Bureau of Investigation). 1996. Uniform Crime Reports: Hate Crime Statistics 1996. Clarksburg, WV: U.S. Department of Justice, Federal Bureau of Investigation. Ferris DG, Batish S, Wright TC, Cushing C, Scott EH. 1996. A neglected lesbian health concern: Cervical neoplasia. Journal of Family Practice 43(6):581-584. Finnegan DG, McNally EB. 1990. Lesbian women. In: Engs RC ed. Women: Alcohol and Other Drugs. Dubuque, IA: Kendall/Hunt Publishing Company. Pp. 149-156. Fontaine JH, Hammond NL. 1996. Counseling issues with gay and lesbian adolescents. Adolescence 31(124):817-830. Gage S. 1994. Preliminary findings: The National Lesbian and Bisexual Women's Health Survey. Lesbian Health Project of Los Angeles. New York: National Lesbian and Gay Health Conference. Garnets L, Hancock KA, Cochran SD, Goodchilds J, Peplau LA. 1991. Issues in psychotherapy with lesbians and gay men. A survey of psychologists. American Psychologist 46(9):964-972. Geddes VA. 1994. Lesbian expectations and experiences with family doctors. How much does the physician's sex matter to lesbians? Canadian Family Physician 40:908-920. Glaus KO. 1989. Alcoholism, chemical dependency and the lesbian client. Women and Therapy 8(2):131-144. Gold MA, Perrin EC, Futterman D, Friedman SB. 1994. Children of gay or lesbian parents. Pediatrics in Review 15(9):354-358. Golombok S, Tasker F. 1994. Donor insemination for single heterosexual and lesbian women: Issues concerning the welfare of the child. Human Reproduction 9(11):1972-1976. Gómez CA. 1994. Lesbians at risk for HIV: An unresolved debate. In: Greene B, Herek GM eds. Psychosocial Perspectives on Lesbian and Gay Issues, Vol. I: Lesbian and Gay Psychology: Theory, Research, and Clinical Applications. Thousand Oaks, CA: Sage. Gómez CA, Garcia DR, Kegebein VJ, Shade SB, Hernandez SR. 1996. Sexual identity versus sexual behavior: Implications for HIV prevention strategies for women who have sex with women. Women's Health: Research on Gender, Behavior, and Policy 2(1-2):91-109. Greene B. 1994a. Ethnic-minority lesbians and gay men: Mental health and treatment issues. Journal of Consulting and Clinical Psychology 62(2):243-251. Greene B. 1994b. Lesbian women of color: Triple jeopardy. In: Comas-Díaz L, Greene B, eds. Women of Color: Integrating Ethnic and Gender Identities in Psychotherapy. New York: Guilford Press. Pp. 389-427. Greene B, Boyd-Franklin N. 1996. African American lesbians: Issues in couples therapy. In: Laird J, Green RJ, eds. Lesbians and Gays in Couples and Families: A Handbook for Therapists. San Francisco, CA: Jossey-Bass. Pp. 251-271. Haas AP. 1994. Lesbian health issues: An overview. In: Dan AJ, ed. Refraining Women's Health: Multidisciplinary Research and Practice. Thousand Oaks, CA: Sage Publications. Pp. 339-356. Hall JM. 1993. Lesbians and alcohol: Patterns and paradoxes in medical notions and lesbians' beliefs . Journal of Psychoactive Drugs 25(2): 109-119.
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Representative terms from entire chapter: