Attitudes and Knowledge Among Obstetrician-Gynecologists Regarding Lesbian Patients and Their Health

Abstract

Objective:

The lesbian patient population is underserved. Almost no research has examined the knowledge and attitudes of obstetrician-gynecologists toward lesbian health. Our study sought to address this research gap.

Methods:

All 910 obstetrician-gynecologists licensed in Ontario, Canada, were mailed a true–false survey about lesbian health issues, the Homosexuality Attitudes Scale (HAS), and a demographic survey.

Results:

Of the 910 surveys, 271 were returned. The mean HAS score was 87.6 (standard deviation [SD] 11.5), indicating an overall positive attitude. The mean knowledge score was 76.0% (SD 9.5), indicating that respondents had adequate knowledge about lesbian health; 22% described their lesbian health knowledge-base as unaware. Most respondents reported lack of education on lesbian health in residency (81%) or medical school (78%). The majority reported a desire for formal education pertaining to lesbian health. There was no correlation between HAS and knowledge scores.

Conclusions:

Although our results indicate overall adequate knowledge about lesbian health issues, important knowledge gaps were identified. Medical school and residency training curricula should include formal education about lesbian health issues, particularly because most obstetrician-gynecologists report a desire to receive this information.

Introduction

Asubstantial body of literature has demonstrated that lesbian and bisexual women experience significant health disparities across a variety of health outcomes.^1

–9 Numerous health organizations have also acknowledged these health disparities, including the American Public Health Association, (APHA),¹⁰ the American Medical Association (AMA),¹¹ the American College of Obstetricians and Gynecologists (ACOG),^12,13 and the Society of Obstetricians and Gynaecologists of Canada (SOGC).¹⁴

Lesbian health is an important health issue. In 2000, Healthy People 2010, an initiative started by the United States Department of Health and Human Services (USDHHS), recognized sexual orientation as a social determinant of health in a 10-year public health plan.¹⁵ In 1999, the Institute of Medicine (IOM), sponsored by the National Institutes of Health (NIH) and the Centers for Disease Control and Prevention (CDC), published a report documenting the paucity of lesbian-specific research and promoting such research in the future.¹ The IOM went on to recommend that healthcare professional associations and academic institutions disseminate information on lesbian health to healthcare providers, researchers, and the public.¹⁶ The IOM recently released a report that evaluated current knowledge of the health status of lesbians and other sexual and gender minority individuals, identified research gaps and opportunities, and outlined a research agenda to help the NIH focus its research in this field.¹⁷ In response to the 2011 IOM report, the NIH has issued a request for applications for research on the health of sexual and gender minority populations. Ultimately, more research on the health concerns of lesbians will help to decrease health disparities among this population.¹⁷

One potential contributor to health disparities associated with sexual orientation is discriminatory attitudes on the part of healthcare providers.^18
–20 Actual or perceived discriminatory attitudes may cause sexual minority patients to delay or avoid care or not disclose their sexual orientation, leading to inappropriate or suboptimal treatment.^{1,6,20

–24} However, little research has specifically assessed the attitudes of healthcare providers about their sexual minority patients.^19,25

Although obstetrician-gynecologists play an important role in the provision of women's healthcare, we could identify only three studies that assess the attitudes of physicians, including obstetrician-gynecologists, toward homosexuality. A 1986 survey of physicians in one California county revealed that >30% of obstetrician-gynecologists scored in the severely homophobic range.²⁶ Two subsequent studies revealed that obstetrics-gynecology is the third most HIV-phobic specialty²⁷ and that 9.4% of obstetrician-gynecologists had relatively high homophobic scores, scores lower only than those of pathologists and radiologists (9.5%).¹⁸

The primary objective of this study was to assess the attitudes and knowledge of obstetrician-gynecologists working in Ontario, Canada, regarding the care of lesbians during a time when relevant recommendations are available. The secondary objectives of the study were to identify any knowledge gaps related to lesbian and bisexual health and to determine if a correlation existed between medical knowledge and attitudes toward sexual minority patients.

Materials and Methods

A survey instrument was designed for the purpose of this study. We are not aware of any validated tools designed to measure a physician's medical knowledge about lesbian and bisexual health issues. In the absence of a well-validated and tested tool, we designed a 19-question true–false survey based on findings of a chapter on primary care of lesbian and bisexual women in a landmark publication by ACOG (Appendix A).¹² Before the knowledge survey was distributed to obstetrician-gynecologists in Ontario, it was pilot tested with ten physicians of various specialties who were also engaged in research at the University Hospitals Case Medical Center in Cleveland, Ohio, where the principal investigator was an obstetrician-gynecologists resident at the time of the study. After completion of the survey, the physicians shared their feedback with the principal investigator, and he adapted the survey accordingly.

To measure obstetrician-gynecologists' attitudes toward sexual minority patients, we used the Homosexuality Attitude Scale (HAS), a 21-item Likert scale that assesses people's stereotypes, misconceptions, and anxieties about homosexuals (Appendix B).²⁸ The measure contains a unidimensional factor representing a favorable or unfavorable evaluation of homosexuals.²⁸ Answer options were 1 for strongly agree, 2 for agree, 3 for neutral, 4 for disagree, 5 for strongly disagree, for a minimum score of 21 and maximum score of 105. Items 1, 2, 6, 8, 13, 14, 15, 18, 19, 20, and 21 are reverse-ordered and scored. In analyses of the results, a score of 1 on any given question would represent a very homophobic attitude, whereas a score of 5 would represent a positive attitude toward sexual minority people. The HAS has been tested and well validated.^29,30 The HAS has excellent internal consistency (alphas=0.93) and a good test-retest reliability (r=0.71).²⁸ We also developed a survey to collect demographic data from participating obstetrician-gynecologists (Appendix C).

All three surveys were approved by the Centre for Addiction and Mental Health Research Ethics Board in Toronto, Ontario (064-2008), and the Institutional Review Board of University Hospitals Case Medical Center in Cleveland, Ohio (EM-08-11).

Data collection

We mailed the surveys as well as a cover letter (available on request from the authors) and a note with the URL of an electronic version of the surveys to all 910 physicians licensed to practice or train in the specialty and subspecialties of obstetrics and gynecology in Ontario, Canada. We sent two reminders after the initial mailing. Postal mailing addresses of practicing obstetrician-gynecologists were obtained online from the Ontario College of Physicians and Surgeons' webpage. Residents' contact information was sought through contact with the six university obstetrics and gynecology residency programs in Ontario. We were successful in connecting with four, who then forwarded the online version of our surveys to their residents and fellows. All training programs in Ontario are university affiliated and academic. Data collection occurred between May and October 2008.

The study was conducted anonymously. No identifying information was collected or retained from the paper or electronic surveys. There was no coding on the surveys that could be used to identify any hard copy returned or electronically filled surveys. We did not collect, store, or have any access to any subject's email address other than those of the program directors, whose email addresses are available online to the public. We did not retain any Internet Protocol (IP) address information or identify any of the subjects who used the electronic submission option. The information letter accompanying the survey indicated to participants that their completion and return of the survey implied their consent to participate and that confidentiality was guaranteed to the extent permitted by law.

Data analysis

Demographic and clinical characteristics of the study sample were calculated using descriptive statistics and frequencies. Descriptive statistics were similarly calculated for scores on the HAS and knowledge survey, as well as individual knowledge survey items. Because of the ordinal nature of the HAS, potential relationships between HAS scores and various participant characteristics were examined using nonparametric tests (Mann-Whitney U test or Kruskal-Wallis one-way analysis of variance [ANOVA], as appropriate). Potential relationships between knowledge scores and various participant characteristics were examined using t tests or ANOVA as appropriate. Finally, the Spearman rank correlation was calculated to examine a potential relationship between HAS and knowledge survey scores. With respect to missing data, all returned knowledge surveys were fully completed. In 12 (4.4%) of the returned HAS, ≥1 items were missing; in each case the entire survey was treated as missing, and these participants were not included in any analysis of HAS scores. All statistical analyses were performed using the statistical software package SPSS 15.0 (SPSS Inc., Chicago, IL).

Results

Participants

After three mailings to all obstetrician-gynecologists licensed to practice (n=792) or train (n=118) in Ontario, 271 surveys were returned, providing a response rate of 30%. Of the 260 respondents who reported their area of practice, 14.2% were in training (residents and fellows) and 85.7% were in practice. Of the practicing obstetrician-gynecologists, 68.2% were generalists and 31.8% were specialized (e.g., maternal-fetal medicine, gynecologic oncology, reproductive endocrinology, and infertility). The response rate from the online version of the surveys alone was only 2% for practicing obstetrician-gynecologists (who had the paper and online options) and 20% for training obstetrician-gynecologists (who had the online version only). Providing an online option to practicing obstetrician-gynecologists increased the response rate from 26% (response rate from obstetrician-gynecologists in practice via the hard copy surveys) to only 28%. Just over half of the respondents identified as female (52.8%). The majority of our obstetrician-gynecologist respondents identified as heterosexual (96.3%) and white/Caucasian (76.4%) (Table 1).

Table 1.

Demographics of Survey Respondents

Variable	n (%)
Gender
Female	143 (52.8)
Male	126 (46.5)
Did Not Specify	2 (0.7)
Age group (years)
<36	63 (23.3)
36–65	173 (64.1)
>65	34 (12.6)
Sexual orientation
Heterosexual	261 (96.3)
Nonheterosexual	8 (3.0)
Did not specify	2 (0.7)
Location
Rural	106 (39.1)
Urban	161 (59.4)
Did not specify	4 (1.5)
Race
White/Caucasian	207 (76.4)
Chinese	17 (6.3)
South Asian	12 (4.4)
South East Asian	9 (3.3)
Black	8 (3.0)
Mixed	6 (2.2)
Arab	3 (1.1)
Other	8 (3.0)
Did not specify	1 (0.3)
Political alignment
Liberal Party	133 (49.1)
Conservative Party	74 (27.3)
New Democratic Party	20 (7.4)
Green Party	14 (5.2)
No affiliation	13 (4.8)
Other affiliation	2 (0.7)
Did not specify	15 (5.5)
Religiosity
Nonreligious	107 (39.5)
Did not specify	5 (1.8)
Religious	159 (58.7)
Christian	91 (57.2)
Jewish	39 (24.5)
Another religion	16 (10.1)
Did not specify	13 (8.2)
Partner status
Partnered	224 (82.7)
Not partnered	46 (17.0)
Did not specify	1 (0.3)

Attitudes

The median score on the HAS was 96 (range 40–105), indicating an overall positive attitude toward sexual minority populations among the obstetrician-gynecologists in our study. There was no significant difference in respondents' HAS scores associated with partner status (partnered vs. not partnered), sexual orientation (heterosexual vs. nonheterosexual), or geographic region (urban vs. rural) (all p>0.05). The score was also not affected by the number of articles read in the past year about lesbian health issues or respondent's self-perception of themselves as expert or very aware vs. average or unaware of lesbian health issues (p>0.05).

HAS scores were significantly higher, however, among women respondents compared to men (U=4838.5, z=−5.70, p<0.001), among those who identified as white/Caucasian vs. nonwhite (U=4701.5, z=−2.57, p<0.05), and among those who were politically aligned with the Liberal Party vs. the Conservative Party (U=2511.5, z=−5.34, p<0.001). Age was also associated with HAS scores, whereby those in younger age categories reported significantly higher scores than those in older age categories (Chi-square (6)=35.4, p<0.001); analysis of HAS scores based on year of graduation yielded similar results, in that age and year of graduation were highly correlated (correlation coefficient>0.9). The HAS score was also significantly higher among those who reported having no religious affiliation (U=5379.5, z=−4.24, p<0.001), those who received education in medical school about lesbian health issues (U=4280.5, z=−2.74, p<0.01), those who reported being aware of resources for lesbians in the community (U=5103, z=−3.72, p<0.001), and those willing to be listed as a lesbian-friendly/-aware practitioner in an official publication listing (U=3350.5, z=−6.00, p<0.001). There was also a significant positive correlation between HAS scores and the percentage of lesbian patients in the respondent's practice (r _s=0.18, p<0.005).

Knowledge

The majority of respondents reported that they did not receive any formal education about lesbian health in residency (81%) or in medical school (78%). A substantial number (59%) expressed that they would like to receive formal education about lesbian health issues. More than two thirds (68%) expressed willingness to be listed as a lesbian-friendly or lesbian-aware provider in an official publication. Only 11% of respondents rated themselves as being expert or well aware of lesbian health issues, and up to 22% rated themselves as unaware.

Even though >90% of participating obstetrician-gynecologists reported that at least 1%–10% of their patient population identified as lesbian, 42% reported reading no articles at all about lesbian health in the past year. Only 9% claimed having no patients in their practice identify as lesbian. The majority (69%) indicated that they were not familiar with local organizations or resources to which they could refer their lesbian patients for social support and information. Almost all the respondents (92.3%) believed that lesbian patients should disclose their sexual orientation to their obstetrician-gynecologists.

The mean knowledge score was 76.0% (standard deviation [SD] 9.5), indicating that most responding obstetrician-gynecologists had accurate knowledge about lesbian health issues. The majority of obstetrician-gynecologists who participated in our study were aware that lesbians have similar levels of testosterone and androstenedione as heterosexual women and knew that lesbians have similar indications for routine cervical cancer screening as heterosexual women. Most appeared to be aware that human papillomavirus (HPV) and HIV can be transmitted through female-to-female sexual interactions and that recommendations for safer sex include using condoms on shared sex toys. Respondents correctly identified the increased prevalence of smoking, breast cancer, and depression among lesbians. The majority also correctly reported that studies examining the psychosocial development of children raised by lesbians found no differences in sexual or gender identity, personality traits, development of peer relationships, or intelligence compared to children of heterosexual parents. Most were aware that domestic violence is not rare among lesbian couples, and compared to heterosexual women, lesbians are not more likely to abuse their children. The vast majority knew that reparative psychotherapy directed at changing sexual orientation from homosexual to heterosexual is neither effective nor helpful.

The majority of respondents, however, were not aware that lesbians have higher rates of heart attacks than heterosexual women (88.2% incorrect), that lesbian sexual activity is associated with lower rates of all types of vaginitis than heterosexual sexual activity (78.2% incorrect), and that bisexual women are reported to be at higher risk for testing seropositive for HIV than heterosexual women (75.6% incorrect).

In contrast to HAS scores, there was no significant difference in knowledge scores associated with respondents' gender, age, partner status, religiosity, race, political affiliation, and region. The score was also not affected by the number of articles read in the past year about lesbian health issues or the percentage of patients who identified as lesbian. The score was not associated with willingness to be listed as a lesbian-friendly/-aware practitioner in an official publication or with respondents' self-ratings of awareness of lesbian health issues.

Although knowledge scores were not associated with many demographic variables, they were significantly associated with sexual orientation. The mean knowledge score for heterosexual-identified respondents was 75.8 and was 83.3 among those who did not identify as heterosexual (t=−4.69, p=0.001). Those who reported training on lesbian health issues in medical school also reported a slightly higher knowledge score than those without such training (77.9 vs. 75.6, t=−2.02, p<0.05). However, there was no difference in knowledge scores associated with residency training on this topic. There was no correlation between medical knowledge and attitudes toward lesbian and bisexual patients as measured by knowledge scores and scores on the HAS (r_s=0.04, p>0.5).

Discussion

Our data suggest that the majority of Ontario obstetrician-gynecologists have positive attitudes toward sexual minority women: <2% of respondents had scores in the homophobic range. This is suggestive of a positive shift in attitudes since the 1986 study by Mathews et al.,²⁶ in which >30% of obstetrician-gynecologists surveyed scored in the severely homophobic range. Taken together with our finding and those of other studies^18,26 that younger age (or more recent year of graduation) is associated with less homophobic attitudes, these data are consistent with a generational shift in attitudes toward homosexuality. In addition to positive HAS scores, knowledge scores reveal that the majority of Ontario obstetrician-gynecologists who responded to our survey were well informed about lesbian health issues. Moreover, we found no correlation between knowledge scores and HAS scores. This suggests that among the obstetrician-gynecologists who responded to our survey, attitudes do not affect medical knowledge about sexual minority women.

Despite our positive finding with respect to overall knowledge of lesbian health, our study identified three key knowledge gaps in this regard. First, the majority of respondents were ill informed about the risk of cardiac arrest among lesbians. Although lesbians do not have any intrinsic risk factors for cardiac disease,^1,12 many extrinsic risk factors for cardiac disease are prevalent^{3
–5,7,9,31
–33} and should be considered in preventive screening of sexual minority patients.

Many of our respondents also answered our question about risk for vaginitis associated with lesbian sexual activity incorrectly. The ACOG reports that “exclusive lesbian sexual activity is associated with the lowest rates of all types of vaginitis.”^{12(p. 64)} However, the report also notes that it is important to screen lesbian women, as they may have had male sexual partners in the past and some sexually transmitted infections (STI) can be transmitted by female-to-female sexual activity.¹² More recent research has shown that only a small proportion of lesbian-identified women have never had a male sexual partner.^34

–38 Many lesbian-identified women have penile sexual intercourse with men and transgender women. In other words, sexual identity and sexual behavior are not always congruent. Further, the fact that women who predominantly or exclusively have sex with other women are more likely to experience bacterial vaginosis than women who predominantly or exclusively have sex with men^12,39,40 might have confused our respondents. As a result of these nuances, it is difficult to determine if answering this question incorrectly is truly due to lack of knowledge among the respondents.

Finally, the majority of respondents provided an incorrect response to our item concerning HIV risk among bisexual women. Although this item was developed on the basis of the publication by ACOG,¹² it is possible that incorrect answers may be justified, given the lack of strong evidence to support this statement. Although the ACOG publication¹² suggests that bisexual women are at higher risk for testing seropositive for HIV than are heterosexual women, it does not provide strong evidence to support such a statement. There is only limited evidence to suggest that bisexual women (or those whose nonheterosexual identities or same-sex behaviors place them outside of the heterosexual majority) are at a higher risk for HIV compared to their heterosexual counterparts.^34,41

Our findings may have important implications for obstetrics-gynecology education. A significant percentage of respondents described themselves as unaware about lesbian health issues, and the majority reported that they did not receive any relevant education in residency (81%) or medical school (78%). However, nearly 60% of participants indicated that they would like such training. Healthcare providers surveyed in an earlier study also indicated that they would like more training,⁴² and although 68% of residents in another study indicated that they had received education about lesbian and gay patients in medical school, most reported that this training was inadequate.⁴³ Our study and two others provide further support for this inadequacy. A 1998 study of 116 departments of family medicine at American medical schools revealed that only 2.5 hours for all 4 years of undergraduate medical school were devoted to teaching on homosexuality/bisexuality, and 50.6% of respondents reported that their department spent zero hours teaching about homosexuality/bisexuality.⁴⁴ A recent study published in the Journal of the American Medical Association found that undergraduate medical students in the United States and Canada receive minimal training in sexual orientation or gender identity-related content (median of 5 hours in the entire curriculum).⁴⁵ Further, 33.3% of medical schools who participated in this study reported zero hours of lesbian, gay, bisexual, and transgender (LGBT) content during clinical years.⁴⁵ This study provides evidence of an increase in LGBT content in medical training over the past two decades, but much more needs to be done, given the health disparities that exist among this population as identified by ACOG and other major health authorities.

These data support the inclusion of sexual minority health information within medical school and residency training curricula. Continuing medical education programs for practicing obstetrician-gynecologists could also serve to address the gaps that we observed in medical knowledge, especially the misconception about cardiac risks.

Limitations

Some methodologic limitations must be considered in the interpretation of our data. First, the attitudes scale administered in this study is dated and may not reflect contemporary attitudinal biases against sexual minority women. In particular, the HAS does not assess for heterosexism (i.e., the assumption that heterosexuality is the norm), which has been identified as another barrier to healthcare for sexual minority patients,^46

–50 nor does it specifically assess attitudes toward bisexuals or bisexuality. Further, both the HAS and the knowledge survey we created are limited in that they failed to include a definition for the term, lesbian. In our design and conduct of this study, we employed the term according to that found in ACOG's 2005 publication¹² (also see ACOG's recent Committee Opinion¹³). We do not know which definition our respondents were using when they completed the surveys.

The fact that we created our own knowledge survey might be considered a limitation of our study, particularly given that it consisted of items based on a single American publication¹² and our respondents were training and practicing in Ontario, Canada. We created a knowledge survey because, to our knowledge, no such validated instrument exists, there is no equivalent Canadian publication, and Ontario falls under District Five of the ACOG. The recently published Committee Opinion by ACOG does not significantly differ from the publication we used to develop our knowledge survey; it reconfirms previous findings.¹³ Our procedure for pilot testing the knowledge survey was also limited, in that standardized procedures of scale development were not followed and that physicians other than obstetrician-gynecologists participated in the pilot phase. Additional scale development work may be worthwhile before this instrument is used more widely.

Although our response rate of 30% is as good as or better than most other mail surveys to physicians, response bias is still a concern. For example, more female than male obstetrician-gynecologists (52.8%) responded to our survey, although men make the majority of the obstetrician-gynecologists practicing in Ontario. In comparison, only 22% of Smith and Mathews' respondents were female.²⁷ Research suggests that women are generally less homophobic than men.^51,52

We should note that although our study focused primarily on lesbian health issues, with the inclusion of only one question in our knowledge survey specifically concerning bisexual women, healthcare providers should also be knowledgeable about bisexual women's health. A growing body of literature reveals that bisexual women have poorer health outcomes than both lesbians and heterosexual women^{5,6,53

–56} and that experiences of discrimination and invisibility may be contributing to these poor outcomes.^57,58

Conclusions

Further research is needed to uncover essential factors contributing to the exclusion of sexual minority patients from obstetric and gynecologic healthcare. Results from this study support initiatives designed to improve knowledge about sexual minority women's health among obstetrician-gynecologists and other healthcare providers.

Footnotes

Acknowledgments

We extend thanks to Jennifer Henderson for her assistance with survey dissemination and data collection.

Disclosure Statement

The authors have no conflicts of interest to report.

Appendix A: Knowledge Survey

Please circle True or False | Please DO NOT include any identifying information

Appendix B: Homosexuality Attitudes Scale

Please indicate your level of agreement with the items below using the following scale:

Appendix C: Demographic Survey

Please choose only one answer | Please DO NOT include any identifying information

Gender:

□ Female

□ Male

□ Other

Age group:

□ <25

□ 26–35

□ 36–45

□ 46–55

□ 56–65

□ 66–75

□ ≥76

Marital status:

□ Single

□ Domestic partner

□ Married

□ Divorced

□ Widowed

You identify as:

□ Heterosexual

□ Bisexual

□ Asexual

□ Lesbian

□ Gay

□ Not sure

□ Other: please specify: _________________________

Politically, I feel most aligned with the:

□ Liberal party

□ Conservative party

□ New Democratic party

□ Other: please specify: _________________________

Year of graduation from obstetrics-gynecology residency

□ Still a resident

□ 2001–2007

□ 1991–2000

□ 1981–1990

□ 1971–1980

□ 1961–1970

□ Before 1960

You identify as being from:

□ The Toronto area

□ Another major Canadian city

□ A smaller city/town in Canada

□ A rural area in Canada

□ Outside of Canada

Religious belief:

□ Atheist/Agnostic □ Druze

□ Baha'i □ Hindu

□ Buddhist □ Jewish

□ Catholic □ Muslim

□ Christian □ Protestant

□ Other: please specify ________________________

Race: You can choose more than one

□ Black

□ Latin American

□ Aboriginal/Metis/Inuk

□ East Asian

□ South Asian

□ White or Caucasian

□ Arab □ Lebanese

□ Middle Eastern

Did you receive any formal education about this topic:

In medical school □ Yes □ No

During residency □ Yes □ No

Would you like to receive any formal education about this topic: □ Yes □ No

How aware do you rate yourself about updates on lesbian health issues?

□ Expert

□ Well aware

□ Average knowledge

□ Unaware

Would you be willing to be listed as a lesbian-friendly/aware practitioner in an official publication?□ Yes □ No

Primary area of practice:

□ Resident

□ Fellow

□ General obstetrics and gynecology

□ General obstetrics

□ General gynecology

□ Maternal fetal medicine

□ Gynecology oncology

□ Reproductive endocrinology & infertility

□ Urogynecology

□ Adolescent gynecology

□ Family planning

□ Research/public health

In your practice, in the past year, what percentage of your patients has identified themselves as being lesbian?

□ None

□ 1–5%

□ 5–10%

□ 10–20%

□ >20%

How many articles have your read about lesbian health issues in the past year?

□ None

□ 1

□ 2

□ 2–9

□ >10

Do you know of any local organizations or resources to which you can refer your lesbian patients for social support and information?

□ Yes □ No

In your opinion, should a lesbian patient disclose her sexual orientation to her obstetrician-gynecologist?

□ Yes □ No

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