Five percent of WSW were diagnosed with a new STD (HPV, anogenital warts, genital herpes, PID) on the day of their visit compared with 17% of WSM (Table 2). Notably, 17% of WSW had a history of 1 or more STDs, compared with 19% of WSM (Table 1).
WSW were significantly more likely to have used alcohol (5+ drinks per week) (OR = 2.41; P = 0.002) relative to WSM (Table 3).
WSW were significantly more likely to have a clinical mental health diagnosis (meet DSM-IV-TR criteria for depression, anxiety, PTSD, substance use disorder, bipolar disorder, adjustment disorder, other (not specified)39) than WSM (OR = 2.58; P = 0.0003). Moreover, being WSW was independently associated with a greater odds of the following: depression (OR = 2.86; P <0.001), anxiety (OR = 2.57; P = 0.002), PTSD (OR = 4.74; P = 0.008), and adjustment disorders (OR = 3.46; P = 0.05). WSW were also more likely to have a personality disorder that met DSM-IV-TR criteria39 (OR = 5.70; P = 0.05) compared with WSM.
Relative to WSM in the sample, WSW were more likely to have a history of sexual abuse (OR = 2.83; P = 0.01), emotional abuse (OR = 2.23; P = 0.03), attempted suicide (OR = 3.93; P = 0.01), and inpatient mental health treatment (OR = 4.50; P <0.001), as documented by a clinician in their medical record.
In multivariable models adjusting for patients' age, race/ethnicity, and health insurance status, WSW were disproportionately affected by mental health and psychosocial issues: any clinical mental health diagnosis (AOR = 3.45; P <0.001), depression (AOR = 3.56; P = 0.004), anxiety (AOR = 3.34; P = 0.008), and PTSD (AOR = 12.34; P = 0.01), history of suicide attempt (AOR = 14.87; P <0.001), and inpatient psychiatric/mental health treatment (AOR = 11.55; P = 0.004) (Table 3). However, WSW were less likely than WSM to engage in high risk HIV/STD sexual behavior (AOR = 0.24; P = 0.03).
WSW diagnosed with a new STD on date of their visit were more likely to have a diagnosis of bipolar disorder (OR = 12.73, P = 0.04), to have a history of outpatient mental health treatment (OR = 23.50; P = 0.003), and to have a STD history (OR = 15.38; P = 0.02) compared with WSW who were not diagnosed with an STD during their clinical screening (Table 4).
Compared with WSW with no STD history, WSW with a history of STDs were more likely to have a history of suicide attempt (OR = 10.00; P = 0.02), inpatient psychiatric/mental health treatment (OR = 12.21; P = 0.002), and outpatient mental health treatment (OR = 6.86; P = 0.01), and to have used injected drugs during their lifetime (OR = 15.09; P = 0.009).
Although STD rates were lower among WSW compared with their WSM counterparts, consistent with prior research,27–37 5% of WSW in this sample were diagnosed with a new STD on the day of their visit and 17% had a history of one or more prior STDs. Although WSW were less likely than exclusively heterosexual women to engage in high risk HIV/STD sexual risk behavior (i.e., sex with men without a condom or latex barrier, condom breakage, anonymous sex partners in the past 3 months), no significant difference was observed in STD diagnosis by sexual orientation after adjusting for age, race/ethnicity, and health insurance. Coupled with the knowledge that many STD infections in women are asymptomatic45–47 and untreated HPV infections can cause Pap smear abnormalities, genital warts, and cervical cancer,28,29 findings from this study suggest that culturally competent screening, diagnostic, and treatment services are indicated for WSW.
WSW were more than three times as likely to have a clinical mental health diagnosis relative to the WSM women in this sample. Consistent with prior research, WSW were especially disproportionately affected by depression, anxiety, and PTSD.7–14 Consistent with prior research on psychosocial health disparities, WSW were more likely to have a history of past suicide attempt(s)13,48 and increased mental health utilization (e.g., inpatient psychiatric/mental health treatment).17,49 Prior research suggests that stressors associated with being WSW, such as leading a marginalized life, hiding one's sexuality, facing verbal, emotional, or physical abuse, or stigma, may contribute to increased rates of mental health diagnoses among women.2–6,50
However, contrary to previous research on psychosocial health disparities, no significant differences on alcohol use,9,13,16–20,22,23 tobacco use,15,23–26 and history of sexual abuse or emotional abuse51 were found in this sample between WSW and WSM women after adjusting for age, race/ethnicity, and health insurance. Due to the documented co-occurrence of mental health diagnoses and alcohol use among lesbians,8,26 and PTSD and history of sexual or emotional abuse,52 it could be that mental health diagnoses are the domain of greatest concern among WSW. Additional research is warranted to examine the pathways to psychosocial disparities, in particular to understand the influence of factors salient to WSW status such as disclosure, stigma, and stress which may affect mental health.5
Prior research with women has documented significant associations between a variety of psychosocial factors and STDs53–58; however, to date this association has not been adequately documented among WSW specifically. In the current study, WSW diagnosed with a new STD on the date of their visit were at increased odds of having bipolar disorder, utilizing outpatient mental health services, and having an STD history. WSW with a history of STDs had an increased odds of having attempted suicide in the past, utilizing both outpatient and inpatient mental health treatment services, and having a history of injection drug use. Findings suggest that future research examining “intertwined syndemics”59–61 with larger samples of women by sexual behavior may provide valuable data to guide the development of behavioral and sexual health interventions with WSW. In particular, future studies would benefit from examining whether greater numbers of psychosocial health problems are associated with high-risk sexual behavior and STD acquisition, similar to prior research studies among men who have sex with men.59
This study has limitations to consider when interpreting findings. First, symptom status was only determined for patients who were screened for an STD. We could not determine if some symptomatic patients were empirically treated without testing. Ideally, all symptomatic patients would be screened for an STD, but this could not be ascertained by the retrospective chart review used in this study. Second, 15% of women in the FH population did not report gender of their sexual partners, and this “unknown” sexual behavior group had the highest STD rates but were excluded from the study (N = 58). The categorization of sexual behavior by WSW and WSM is consistent with the literature suggesting that health disparities are less likely to be related to the gender of one's sexual partner, but may be more related to stigma and/or homophobia that WSW experience, irrespective of whether they have sex with both women and men.3,5 However, future studies with larger samples might benefit from examining differences by WSW, WSW/M, and WSM, differentiating exclusively lesbian and bisexually active women. Third, the primary reasons that women presented for care at FH were not captured (i.e., primary care, mental health, HIV testing specifically). Those patients who received outpatient mental health treatment at Fenway had more information in their medical chart, especially concerning psychosocial history (e.g., history of abuse, suicide attempt) due to the extensiveness of mental health intake form. Thus, since Fenway is known to provide culturally competent care to sexual and gender minority persons, it is possible that a disproportionate percent of female clients seeking mental health services were WSW. Fourth, data are constrained by the study design itself (i.e., retrospective chart review), which has several limitations including incomplete documentation, missing charts, information that is unrecorded, difficulty interpreting information found in the documents (e.g., jargon, acronyms), problematic verification of information and difficulty establishing cause and effect, and variance in the quality of information recorded by medical professionals.62–66 Lastly, but importantly, lack of statistical power remains a major limitation given the small cell sizes present in bivariate logistic regression procedures used to assess whether WSW diagnosed with an STD on their date of visit and WSW with a history of STDs were more likely to have psychosocial issues, as compared to WSW who were not diagnosed with an STD on the date of their visit and those with no STD history. However, given the dearth of research on this topic, we felt that it was important to take a preliminary look at the psychosocial issues associated with STD diagnosis and history among WSW despite the small sample size and resulting statistical imprecision. Additional research is warranted with larger samples of women.
Limitations notwithstanding, results suggest that all sexually active women, regardless of sexual orientation and behavior, should be routinely screened for STDs. Assumptions that WSW are at low or negligible risk for STDs and other gynecological infections may be premised upon infrequent screening, ignorance of lesbian sexual practices, and/or the discomfort that WSW may feel concerning the disclosure of their sexual identity and behavior.27,35,67 Although some patient charts did not document sexual behavior or sexual identity, the majority (85%) of the sample had known gender of sexual partners, suggesting that clinicians are both talking to women about their sexual behaviors and documenting these interactions in patient charts, though this may be biased since the sample came from Fenway Health, a clinic specializing in LGBT care. Continued provider training is warranted to ensure appropriate screening, diagnosis, and care screening for STDs and other gynecologic infections among WSW. Moreover, research with larger samples is warranted to look more carefully at sexual behavior and sexual health among women, including disease prevalence rates, reasons for screening, and treatment. Future studies would benefit from examining a broad range of health disparities among WSW, especially mental health and psychosocial issues.
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