How Doctors' Beliefs Influence Gynecological Health Care for Women Who Have Sex with Other Women

Abstract

Background:

Women who occasionally or regularly have sex with other women (WSW) are rarely identified in primary care. Although we know about their specific health needs, health care professionals still find it difficult to ask questions about sexual orientation (SO) and behaviors, and sometimes, patients may find them difficult to answer. The presumption of heterosexuality still remains a widespread attitude in health care. This study took place in a primary care setting, and aimed to identify differences in gynecological health care and clinical practice for women, according to what their presumed SO and behaviors were.

Methods:

We conducted a cross-sectional observational, descriptive, and comparative study from October 2018 to February 2019. Three hundred thirty-eight general practitioners (GPs) from Rhône-Alpes area (France) received an anonymous questionnaire with clinical case vignettes. The main outcome was the percentage of GPs who perform a different gynecological follow-up for WSW and non-WSW.

Results:

In total, 165 questionnaires were analyzed. Ninety percent of respondents performed a different gynecological follow-up for WSW, compared with other women. They less often addressed topics such as contraception needs, use of barrier protections, and screening of sexually transmitted infections. Ninety-two percent of respondents were aware that they have WSW among their patients, but 2/3 of them never or rarely asked about SO.

Conclusion:

Most GPs know that they manage WSW but may misidentify these patients and their real care needs. Therefore, WSW receive a different and poorer follow-up than non-WSW. Clinical guidelines would be useful to improve and standardize quality and experience of health care for WSW.

Introduction

Four percent of women have experienced at least once in their life, sexual contact with another woman. Approximately 0.5% of women in the general population define themselves as exclusively homosexual (orientation and sexual practices).¹ In primary care settings, women who have sex with other women (WSW), are invisible. Nevertheless, they have specific care needs according to their described lifestyle-associated risk factors, such as alcohol, tobacco consumption,² intranasal and intravenous drug use,³ multiple/different sexual partners (including men), and a higher prevalence of sexually transmitted infections (STI), compared with the general population.³ STI and risk factors are as following: herpes simplex virus, human papilloma virus (HPV), trichomonas, Chlamydia,⁴ syphilis, human immunodeficiency virus, hepatitis B, gonorrhea, as well as possible transmissions of hepatitis A or C that have been described, along with a higher risk of cervix and breast cancer,⁵ a higher prevalence of obesity,² mental health disorders (anxiety, depression, suicide, eating disorders),⁶ and a higher frequency of undesired pregnancies.⁷

To provide the best person-centered global care to WSW, health care professionals (HCP) must be aware of these facts. But there is still a lack of information, research, and training of HCP who are expected to meet WSW's needs. Even during medical training in gynecology, infectiology, and psychiatry, women's homosexuality is never mentioned in theoretical teaching material. In France, no specific national guideline exists for sexual health care of WSW. The French High Authority of Health (HAS) recommends a cervix cancer screening by Pap smear (PS) every 3 years for women between the ages of 25 and 65 years of age (after two normal PS at a 1-year interval),⁸ recently completed by the addition of a HPV test for women over 30,⁹ and screening for HIV is recommended for populations at risk such as sex workers, homosexual men, and people presenting substance abuse.¹⁰ All these guidelines do not take into account women's sexual orientation (SO) or practices. Whereas the French health care system is based on a model of National Health Insurance (NHI), covering all legal residents, according to the French political values: “Liberty, Equality, and Fraternity,” to guarantee free access to equal care for everyone,¹¹ we were interested in WSW's access to gynecological care in a primary care setting. Primary care is a university medical discipline based on clinical practice, research, and teaching.¹² Since 2006, every patient must declare to the NHI a treating general practitioner (GP), who decides, according to one of his/her core competencies (notably care coordination), to eventually refer the patient to other specialists (gynecologists, psychiatrists, ophthalmologists, dentists, surgeons, and so on) if necessary. The French National Academic College of Teachers in General Practitioners (CNGE, Collège National académique des Généralistes Enseignants) formalized the following five core functions of General Practice: First claim, Holistic approach (patient centered), Care coordination/synthesis, Care continuity/long-term care, Public Health: screening and prevention.¹³ According to the EURACT (European Academy of Teachers in General Practice) definition of General Practice: “is normally the point of first medical contact within the health care system, providing open and unlimited access to its users, dealing with all health problems regardless of the age, sex, or any other characteristic of the person concerned.”¹⁴ In this context, French trainees in General Practice are trained during their studies to attend to a spectrum of 11 families of prevalent situations in General Practice. The fifth one of these situations is entitled: “Situations around sexuality and ‘genitality’, including situations of prescription, follow-up, information, and education about all forms of contraception in common situations, situations of risk and emergency; addressing sexuality according to the given context.”¹⁵

Whereas GPs are trained to be person centered and expected to manage women's sexual health, we wanted to explore if real life clinical practice, based on individual beliefs, led to variable clinical practices.

Methods

We conducted a quantitative, cross-sectional, descriptive and comparative case vignette study. This clinical practice survey was suggested to GPs, working in their own office in the French Auvergne-Rhône-Alpes area. An anonymous autoquestionnaire with mostly closed questions (n = 36) and seven case vignettes, was addressed to the randomized GPs by post with an attached prepaid letter to return the answers.

The primary outcome was defined as the percentage of GPs who offered different gynecological care (four most frequent acts in primary care: contraception, screening, prevention of STI, and PS) to a clearly defined WSW compared with a non-WSW (masculine partner, or without any gender specification). The secondary outcome was the percentage of GPs who identified WSW among their patients.

To integrate the described dominant attitude of “presumption of heterosexuality,” we defined, for our case vignettes, as “presumed heterosexual” all women for whom the partners' gender was not clearly mentioned.

We did not create a special vignette for transgender or intersex people, because the questionnaire asked GPs to refer to the gender assigned at birth.

Three current clinical situations were proposed to all participants. (1) First sexual relationship, (2) young woman without any stable partner, (3) change of partner during perimenopause period. Each of them had two variants according to the patient's partners' gender—WSW and non-WSW patient, except for the (2) situation which also had a third variant—WSW who had one explicit male partner, that is, seven vignettes total. For each of the seven vignettes, all GPs had to choose among the four most frequent acts in gynecological primary care: contraception, screening, prevention of STI, and PS. Only the contraception-related question for the (3) situation did not obey the discrete choice modeling, as the options were not mutually exclusive.

Miss Z, 18 years old, informs you about her first sexual relation in her couple.

Miss G, 47 years old, recently divorced from her husband after 20 years of marriage and three children, informs you that she is engaged with a woman now, which is the first time for her. She has had a copper intrauterine device (IUD), for 5 years, and her last menstruation was 4 months ago.

Miss V, 38 years old, has always defined herself as a lesbian woman. She has been sexually active since the age of 17 and has had multiple romantic relationships.

Today she (no. 3) has no long-term partner, but tells you about her recent first experience with a man. She is not yet sure if she wants to renew the experience.

Miss B, 47 years old, recently divorced from her husband after 20 years of marriage and three children, informs you about her new companion. She has had a copper IUD for 5 years, and her last menstruation was 4 months ago.

Miss Y, 37 years old, started her multiple romantic relationships at the age of 19, and has no stable partner today.

Miss K, 21 years old, has a girlfriend and recently began being sexually active with her.

To simplify the reading process, the vignettes included only essential information (age, parity, and patient's relational status), experimental elements (partner's gender), and equivalences between vignettes (four items of identical content and form).¹⁶

With respect to the subject of the chosen items of the Likert scale: “totally agree” and “agree” were considered positive, “disagree” and “totally disagree” as negative. In case of one or more different answers between WSW and non-WSW variants among all equivalent situations, we considered that the GP proceeded to a different gynecological follow-up. The answers were then compared, vignette by vignette and question by question according to the patient's partner's gender.

The third group of questions collected participants' information for a cluster analysis. Some open questions at the end of the survey allowed to explore personal opinions. All returned questionnaires were manually transcribed in an Excel database, followed by a quality control for 10% of the questionnaires, randomly selected.

In case of one different answer for an equivalent vignette, we considered that the GP proceeded to a different gynecological follow-up.

We used Mac Nemar (+correction of Yates if necessary) chi-squared test for data analysis.

The study protocol conforms to the European General Regulation of data protection (May 25, 2018) and reference MR-004 of the National Commission of Digital liberties.

Results

The response rate was 49.7% (168/338). Among the 338 questionnaires addressed to the GPs, 168 were returned, 3 were excluded because they were not completed. One masculine GP returned the questionnaire empty, but in the free text, left a clear homophobic message to the researcher. In total 165 completed questionnaire were included.

Compared with the registered population of GPs in the same French local area in 2018, our population counted significantly more women (61.2% against 48.2%, p = 0.04). Ages were comparable, but GPs between 55 and 65 years of age were underrepresented in our population.

Clinical practice

A total of 148/165 (89.7%) GPs performed a different gynecological follow-up when patients were clearly WSW. A total of 13/165 (7.2%) GPs made no difference, and in four cases, (2.4%) questionnaires were not conclusive. Except for PS realization method and means, all the other questions led to significantly different answers when the patient was WSW, compared with when they were presumed heterosexual. Presumed SO and practices, influenced GP's clinical practice in a significant way (Table 1).

Table 1.

The Different Clinical Practice According to the Presumed Sexual Orientation (n = 165)

Clinical situation no. 1: young woman who starts sexual life, n (%)
Question	WSW Non-WSW	Yes	No	p^a
Propose a contraception mean	Yes	36 (22.4)	112 (69.5)	<0.001
	No	0 (0)	13 (8.1)
	Missing: 4
Inform about prevention of STI	Yes	120 (74.1)	40 (24.7)	<0.001
	No	0 (0)	2 (1.2)
	Missing: 3
Screen for STI	Yes	127 (78.0)	17 (10.4)	<0.001
	No	10 (6.1)	9 (5.5)
	Missing: 2
Perform Pap smear according to French Guidelines	Yes	148 (89.7)	8 (4.8)	1
	No	7 (4.3)	2 (1.2)
	Missing: 0

Clinical situation no. 2: fertile woman without a fixed partner, n (%)
Question	WSW Non-WSW	Yes	No	p^a
Discuss personal needs of contraception	Yes	80 (48.5)	82 (49.7)	<0.001
	No	1 (0.6)	2 (1.2)
	Missing: 0
Inform about prevention of STI	Yes	127 (77.0)	35 (21.2)	<0.001
	No	1 (0.6)	2 (1.2)
	Missing: 0
Perform Pap smear according to French Guidelines	Yes	150 (90.9)	11 (6.7)	0.061
	No	3 (1.8)	1 (0.6)
	Missing: 0
Screen for STI	Yes	116 (70.7)	32 (19.5)	<0.001
	No	8 (4.9)	8 (4.9)
	Missing: 1

Clinical situation no. 3: Woman in perimenopausal period, n (%)
Question	WSW Non-WSW	Yes	No	p^a
Inform about prevention of STI	Yes	120 (74.5)	36 (22.4)	<0.001
	No	3 (18.6)	2 (1.2)
	Missing: 4
Screen for STI	Yes	133 (82.1)	21 (12.3)	<0.001
	No	2 (1.2)	6 (3.7)
	Missing: 3
Perform Pap smear according to French Guidelines	Yes	158 (98.1)	0 (0)	1
	No	1 (0.6)	2 (1.2)
	Missing: 4

p-Values were obtained using the Mac Nemar test on dependent data, with Yates correction when necessary.

STI, sexually transmitted infections; WSW, women who have sex with other women.

GPs had to choose a course of action regarding the IUD. A replacement of an IUD was more frequently proposed to presumed heterosexual women than to WSW. A removal of an IUD, sometimes followed by the suggestion of an alternative way of contraception was more frequently proposed to WSW. The two most frequently chosen propositions in the free text were, the discussion with the patient and complementary biological exams.

A presumption of heterosexuality

In two vignettes, the patient's partner's gender was not specified, nevertheless we found significantly different answers compared with the equivalent vignette, where the partner was a woman. Only one GP (woman) specified: “I suppose that a heterosexual relation is described.”

Vignettes, which presented a patient without a stable partner, described three cases: partners' gender was not specified, lesbian patient, patient who had one sexual relation with a masculine partner. Despite the significant differences in answers (except the PS), between a presumed heterosexual woman and a lesbian woman, the simple fact that a single masculine partner was mentioned, modified the answers, which then became identical to those for the case of the presumed heterosexual woman. Risks for undesired pregnancy and STI were minimized for WSW.

Awareness of the WSW population in primary care

Among the 165 GPs, 10 (6.1%) declare not to know if they manage WSW and 4 of them (2.4%) think that they do not acknowledge them. A GP said: “LGBT patients are probably extremely rare among my patients… proportion in general population?.”

Those who think they know how many WSW they follow were convinced that: “women talk about their sexual orientation or practices spontaneously,” or GPs had asked an explanation “in case of a doubt.”

Among the 151 (91.5%) GPs who thought that they cared for WSW, 37 (24.5%) of them never, and 65 (42.4%) of them rarely asked for SO during the consultation.

No difference was found in the primary outcome according to GPs gender or whether they had a same-gender relationship or not. GPs who declared same-gender relationships were significantly more aware than others that they manage WSW among their patients (100% vs. 91%, p < 0.001). No difference was found according to GPs' gender. The number of GPs in each age; county; type of environment that is, rural, semirural, or urban; level of gynecological experience; and frequency of asking about SO subgroup was insufficient to perform a statistical cluster analysis.

Discussion

To the best of our knowledge, this type of clinical practice survey was the first in France. The study highlights that 89.7% of the GPs performed a different gynecological follow-up according to the presumed SO of women (heterosexual women, compared with WSW), except for the screening of cervix cancer by PS.

Information to prevent STI was significantly less frequently delivered to WSW than to presumed heterosexual women. Possible protective measures between women, such as gloves, finger cots, dental dams, and cling films are not very well known by WSW or gynecologists.^17,18 Our free text answers suggest that the GPs in our study do not know about them either.

The most important differences were observed regarding contraception management. In the case of a patient without a stable relationship, only half of the GPs declared evaluation of her personal needs of contraception (54.5%, n = 90). Recent North American studies showed that WSW were more frequently confronted to undesired pregnancies than non-WSW, which underlines the importance of an individual evaluation of personal contraception needs.^7,19 Among the 91.5% GPs (n = 151) who think that they occasionally or regularly follow WSW in their practice, less than 1/3 “often” or “always” tackle the question of SO.

Our study confirms the widespread attitude of “presumption of heterosexuality”: we can assume that some patients talk spontaneously about their own, or their partner's SO. However, we must be aware of the risk that HCP's own beliefs about sexual stereotypes may lead to false-positive identifications of WSW, and vice versa, false-negative identification of WSW who do not fit in those stereotypes. According to a German study, only 40% of WSW are clearly “out” in view of their GP. According to a national French survey, 4% of women declared to have had at least one homosexual relation, and about 1% in the last 12 months.²⁰ A GP probably unconsciously faces one WSW a week.

A Swedish study showed that only 37% of GPs were aware that they followed lesbian women.²¹

This result was expected, because a Parisian study among gynecologists showed that their clinical practice was heteronormative,¹⁸ which led them to underestimate the WSW proportion among their patients and in the general population.

These facts confirm WSWs' reported health care experiences. They describe a heteronormativity in gynecological consultations in echo to general social tendencies, and the feeling of being invisible.^22,23

A study among American gynecologists showed that screening for depression, substance abuse, and cervix cancer, was equal for lesbian bisexual transgender (LBT) and non-LBT patients, but gender identity was rarely asked.²⁴

The “ideal” of a standardized gynecological consultation, is not yet met today. Less than 10% of women in the general population benefit from an adequate screening of cervix cancer, recommended since 2010 by the French High Authority of Health (HAS).²⁵ Therefore, the frequency of PS was not a pertinent criteria to find differences in gynecological follow-up of WSW and non-WSW by the same GPs. The American association of family physicians and the Royal College of general practitioners of Northern Ireland recommends the same gynecological care for all women.^26,27 According to the “sexual minority,” HCP are expected to create an open and friendly environment, and to ask direct and inclusive questions. According to Maragh-Bass et al., LGBT people find it important that providers, and especially GPs collect data about SO and gender identity to guarantee a person-centered health care and meet their real needs. The same study highlights that providers appeared less comfortable asking the patient about SO and gender identity.²⁸

Strengths and limitations

The strengths of our study were its originality and medical, social, and political concerns. The study is useful to optimize patient-centered management in gynecological primary care. The autoadministered anonymous short questionnaire in paper form, attached to a prepaid return letter, and the Likert scale of four items, encouraged many of the GPs to answer freely and clearly, which limited the bias to answer according to social desirability. In the absence of pre-existing measurement tools, we created a reusable questionnaire for our study. Case vignette studies allow an estimation of the quality of health care.²⁹

The limitations of our study are the small number of participating GPs. Our data must be confirmed by wider, international and interdisciplinary populations of HCP treating women. Recruitment, information, and comprehension bias are possible. Our results show trends of bias among GPs according to the patient partners' gender. This should be confirmed by wider studies with an appropriate sample sizing.

Conclusion

Research focusing on LGBT population in a primary care setting is still underrepresented, despite the fact that the GP is often a woman's first contact with the care system, and it is the HCP, who intimately knows a person in his/her global life context, which favors a trustful and emphatic relationship.

Although the French health care system is thought to be one of the best worldwide, we observed in this study important health disparities regarding WSW in a primary care setting and an urgent need for information about WSW. HCP must become aware of their specific needs to guarantee optimal care and to avoid that WSW fall through the screening crack. We may progress through an elaboration of national Guidelines and more literature out of primary care settings, in which we can estimate a big portion of WSW.

Providers must be trained in health communication to get comfortable to discuss this important topic. They should remind patients the principle of medical secrecy to create a warm and safe atmosphere.

To reduce disparities in health care for WSW through real person centeredness, GPs and other providers may simply ask women and men: “Do you have, one or more partners in your life?” to open a respectful and professional discussion.

Footnotes

Acknowledgments

The authors wish to thank all the GPs for their participation and Miss Rebecca Roussel and Rachel Litke for her English proofreading.

Disclaimer

This research was never presented elsewhere.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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