[*Anya*]

Part II

It is difficult to accurately capture the full effect of marginalization, discrimination, and stigmatization on the mental health of an individual or minority group. LGBT persons "are subject to unique social stressors such as prejudice, stigmatization, and antigay violence that may precipitate mental distress, mental disorders, suicidal ideation, and self-harm."[6] Matthews et al[20] studied the role of sexual orientation in predicting depressive distress in a sample of women. Their sample (N 5 829) showed "51% of lesbians and 38% of heterosexual women reported seriously considering suicide at some point in the past."[20] Also, "more than twice as many lesbians as heterosexual women in this age group (15–19) reported suicide attempts."[20]

Although research is limited, LGBT youth may also be at increased risk for suicide attempts compared to their heterosexual counterparts. Marshal et al[21] found that there is a higher rate of suicidality in sexual minority youth compared with heterosexual youth. However, in the study of LGBT youth by Mutanski et al,[22] there were similar rates of suicidality compared with youth of the same geographical areas. They also noted that mental health disorders were higher among the LGBT youth group compared with national data samples but similar when compared with ethnic/minority urban youth samples. Haas et al[23] said, "Over the last 2 decades, an increasing body of empirical research in the US and other countries has pointed to significantly elevated suicide risk among LGBT compared to heterosexual people."

Although there is limited research describing reasons for increased risk in the WSW population, it may be that many mental health issues are associated with the consequences of being a WSW living in a "heterosexual-oriented society."[7] "Heteronormativity denotes how the social life of Western culture is constructed on the assumption that all people are heterosexual, assuming the heterosexual nuclear family
norm to be natural and universal, and thereby making homosexuality socially invisible and second class."[13] It is important to understand that marginality of any kind can be a risk factor for mental health issues. Lehavot and Simoni[24] suggest screening (and referring as needed) for minority stress and the presence/absence of "coping resources" among sexual minority women.

Substance Abuse

Spinks et al[5] said, "Accurate estimates of the prevalence of substance abuse in lesbians are not available due to the marginalization and hidden nature of the population."[5] The rate of alcohol abuse in WSW is unclear and data are conflicting. Dean et al[1] identify that early studies on the gay and lesbian population recruited subjects in bars "which, not surprisingly, showed higher rates of heavy alcohol and drug use than the general population."

Many reports discussed by Roberts[16] indicate that there is more alcohol use in the lesbian community. "Data from the Women's Health Initiative study and other, smaller studies indicate that tobacco use is higher among lesbians than among the general female population."[6] This finding is in contrast with the Dibble study mentioned above. Roberts[16] said, "Reviews have concluded that smoking rates for adolescent and adult lesbians are higher than their national comparison groups, with adolescents being highest for both groups."

Blosnich and Horn[25] examined discrimination/violence and associated smoking among young adults and found that sexual minorities were more likely to experience discrimination and violence and are twice as likely to smoke when compared with heterosexuals in the same age group. It appears that there may be increased substance abuse among WSW in comparison to heterosexual women, but this, too, needs further research. Many factors may put WSW at higher risk for substance abuse or mental health issues, including social stigma, societal pressures, internalized homophobia, the "coming out" process, and discrimination.[5,6,16]

STDs and Reproductive Health/Services

Women who describe themselves as having same sex orientation may identify themselves as lesbian. However, sexual behavior is not the same as sexual orientation, and these should not be confused.[4] Obtaining an accurate sexual history is important to identify risk factors for STDs and safe sex practices. Sex practices of WSW vary widely and the most important thing a provider can do is refrain from making assumptions.

The risk for STD transmission in WSW changes based on sexual practices and the STD organism.[4] Little is known about transmission of STDs between 2 women. "Transmission of some STDs between women is known to occur; for other STDs, transmission between women is possible in theory but has not been proven."[6] Mravcak[6] provides a table in her article showing known transmission of STDs between women to include herpes simplex, genital warts associated with HPV, and trichomoniasis. Included in the table is the description of theoretical STD transmission between WSW: chlamydia, gonorrhea, syphilis, hepatitis B, and HIV.[6] Bacterial vaginosis, while not an STD, is commonly found in the WSW and their female partners[6,16] and is believed to be transmitted between women.[16]

As identified earlier in this article, most WSW have a history of male sexual partners. This fact increases STD risk for these women and their partners. However, Mravcak[6] said, "Lesbians are less likely than bisexual or heterosexual women to be tested regularly for STDs."[6] Many WSW may not believe that they are at risk for acquiring STDs and may even delay treatment when symptoms arise.[4] In addition, NPs may have inaccurate information about the risks of STDs for WSW and assume that they are not engaging in heterosexual intercourse.[4] This assumption may result in the provider choosing to omit needed routine screening for these patients.[4]

NPs need to teach safe sex practices for WSW. Some recommendations given by Mravcak[6] are to avoid contact with any visible genital lesions, cover sex toys that penetrate more than one person's vagina or anus with a new condom for each person, use a barrier during oral sex, and use latex or vinyl gloves and lubricant for any manual sex that might cause bleeding. The Centers for Disease Control and Prevention[26] (CDC) determined, "No barrier methods for use during oral sex have been evaluated as effective by the Food and Drug Administration. However, natural rubber latex sheets, dental dams, condoms that have been cut and spread open, or plastic wrap may offer some protection from contact with body fluids during oral sex and thus may reduce the possibility of HIV transmission."

The CDC[26] also suggests the importance of knowing a partner's HIV status since there is a potential for HIV transmission through menstrual blood. For WSW at this time, oral sex does not require barrier methods if performed with a monogamous partner whose HIV status is negative and has no lesions or other risk factors.[26] Jeanne Marrazzo, MD, MPH, is a leader in infectious diseases and STD prevention and epidemiology. She and her colleagues[27] said WSW should be educated about possible STD transmission between women and education should be centered on common sex practices between WSW.

Reproductive health services are important topics to discuss with WSW patients. In the US, approximately 6 to 14 million children have parents who are lesbian or gay.[6] WSW may have children from previous relationships with men or may choose to become pregnant through a sperm bank, known donor, or heterosexual intercourse. Adoption and foster care are also options for WSW in many states. Other than dealing with societal stigma, studies have shown that children of lesbians have comparable development and life skills adjustment to children in heterosexual families.[16] "The American Psychological Association, the American Academy of Pediatricians, and the North American Council on Adoptable Children have each endorsed foster parenting, adoption, and parenting by same-gender couples, with the reassurance that their review of all the research on these children show that they develop normally."[28]

Even so, the process of starting a family can be emotionally, mentally, and financially challenging for WSW because of social stigma, discrimination, legal issues, and isolation. Zeidenstein[29] said the birth mother has unique challenges as she may have to "come out" again after becoming pregnant and once again as a lesbian mother. Zeidenstein[29] also identified that the comother can experience pain when her role as a parent is not recognized by the people in her life. Furthermore, state laws vary greatly. Legal action is required in most states for the nonbiological parent to be granted parental rights.[6] While legal implications are not within the scope of this article, it is important for NPs to encourage WSW to seek assistance from lawyers to ensure their wishes are granted and to ensure the comother has the rights of parenting she deserves. As an NP, referring WSW to agencies that are known to be nondiscriminatory can also be very helpful.[5]

Improving Practice Through Cultural Safety

NPs are responsible for creating a safe and caring atmosphere for each patient. A "safe" environment is defined by the patient. Key factors to a safe and caring context are reflection, environment, language, and knowledge. Context includes all the "in-betweens" of these 4 key factors. Most of context is made up of what is not said with words or language. A truly safe and caring health care context cannot be achieved by omitting any of the 4 elements. For example, a clinician who provides a safe environment but does not use inclusive language is not providing safe care.

Reflection of one's own feelings and possible biases about the WSW population is the first step in establishing a caring and safe patient-provider relationship. Acknowledging these feelings and examining personal biases is a necessary part of providing a safe and caring environment. McManus[30] said, "Awareness of how one's own attitudes affect clinical judgment and the development of a non-homophobic attitude are important steps in providing culturally competent care."[30] Reflection is an ongoing assessment of one's own feelings, reactions, and motivations. It cannot be done once as a single exercise; it is always evolving based on new experiences and interactions. The process of self-reflection is a personal mission of growth and development that requires continual self-evaluation.

Environment is the first factor that a WSW patient will experience. The waiting room can be a significant indicator of the level of acceptance a WSW patient can expect. The presence/absence of a posted nondiscriminatory policy, the art/pictures displayed, and the kinds of reading material available are all examples of environmental factors that a WSW patient will notice immediately. An example of a nondiscriminatory statement is: "This office appreciates the diversity of women [and men] and does not discriminate based on race, age, religion, ability, marital status, sexual orientation, gender, or perceived gender."[7]

The environment will likely affect the WSW patient's openness about her sexuality. "If the environment is perceived as completely unsafe, questioning by the provider will elicit an inaccurate history."[29] Many waiting rooms and clinics have brochures, posters, and educational materials that "reflect heterosexual experience."[29] Including posters or pictures depicting same-sex couples, brochures available that include same-sex experiences, a visible nondiscriminatory policy, and a visible symbol that the WSW population will recognize as a sign of safety are all ways to make an environment more welcoming to them.[4-6,16,30]

McManus[30] gives examples of symbols that health care providers can display to demonstrate a safe environment for the LGBT population:

**pink triangle (symbol of homosexuality in the concentration camps of Nazi Germany)
**A rainbow flag (an icon for the LGBT community since 1978, when it was first used in the San Francisco Gay Pride Parade)
**The Human Rights Campaign's equality symbol (a blue square with a yellow equal sign [5], which is well known to LGBT persons as a sign of acceptance)

Language used by the provider, staff, and in brochures and history/intake forms is also a strong indicator of safety for the WSW patient. Using inclusive, nonjudgmental, and open-ended questions are important to convey caring and safety. This provides a space for each patient to be as open as she chooses to be. A few examples of open-ended and nonjudgmental language include, "Do you have a partner or a spouse?" instead of "Do you have a husband?" or "Are you married?" Also asking, "Do you, or have you had, sexual relations with men, women, both, or none?"[4–6,16,30] This question is more likely to end with an honest response in comparison to simply asking the patient if she is sexually active.[30] "By taking a little time and asking a few sensitive questions, health care providers can create an environment of trust and inclusion."[5]

Knowledge and competency are associated with caring practice.[31] Understanding the health risks for WSW that are different than heterosexual women is valuable and necessary to provide quality care. The ability to refer patients to other providers who are known to be open and nondiscriminatory is helpful[6] and will enable patients to further trust their provider. The availability of information and resources ( Table 1 ) on WSW-specific health considerations is essential when providing care to this population.

Implications for NPS

In a qualitative study by Bjorkman and Malterud[13] on lesbian experiences with health care, 3 essential qualities were described as necessary for the health care provider: awareness, attitudes, and medical knowledge. This study reinforces the importance of personal attributes that play a role in developing a safe and caring patient-provider relationship.

Some suggestions given in the literature for providing a safe and caring health care context for the WSW population include health questionnaires that are inclusive of same-sex relationships or sexual practices, educational materials or brochures that are inclusive of same-sex relationships and sexual practices, open-ended questions from providers, a nonjudgmental approach to questions, images or posters with same-sex couples, and a nondiscriminatory statement.[6,16,30] While it is important to understand the common health disparities found in the WSW population, the population itself is full of unique individuals from every walk of life. Each individual will present a unique set of health issues and needs. Understanding the uniqueness and diversity of each woman allows the opportunity to provide individually tailored health care and best practices for this population.

In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest.