Testimony of Charlotte Patterson, PhD Department of Psychology University of Virginia

The American Psychological Association (APA) is pleased to have the opportunity to provide testimony on Lesbian Health Research Priorities on behalf of its membership — more than 151,000 researchers, educators, clinicians, consultants and students. Through APA's divisions in 50 subfields of psychology and affiliations with 58 state, territorial and Canadian provincial psychological associations, APA works to advance psychology as a science, as a profession and as a means of promoting human welfare. APA is the largest scientific and professional organization representing psychology in the United States and is the world's largest association of psychologists.

We would like to take this opportunity to express our appreciation to the National Institutes of Health Office of Research on Women's Health and the Centers for Disease Control and Prevention Office of Women's Health for funding the workshop study on lesbian health research being conducted by the National Academy of Sciences Institute of Medicine.

In our testimony we will briefly address each of the three goals of the Committee, as identified in Dr. Solarz's letter of August 6:

• assess the strength of the science base regarding the health problems of lesbians;

• review methodological issues pertinent to lesbian health research;

• suggest possible areas for future research.

Contextual Factors as a Guiding Principle

Before addressing the specific goals, however, we first would like to draw the Committee's attention to APA's Research Agenda for Psychosocial and Behavioral Factors in Women's Health. We believe this report will be helpful to the Committee. In particular we want to reiterate a guiding principle of that report for understanding women's health issues. This guiding principle states that cross-cutting contextual factors must be considered in designing, implementing, and interpreting research. These contextual factors include:

• Relationships: How does being in relationships with others affect women's health status, behaviors and attitudes? In turn, do health behaviors, attitudes and status affect lesbian and bisexual women's relationships?

• Ethnicity: How do lesbian and bisexual women's ethnic backgrounds shape their health, health behaviors and attitudes and how do their ethnic backgrounds influence their health options and status?

• Resources: How do financial and structural resources affect lesbian and bisexual women's health options?

• Status and power: How do lesbian and bisexual women's social status, work status, and social and economic power intersect with health options and status?

• Gender expectations: How is health status affected by gender expectations, such as care giving for others who are sick or in need and expectations to serve as an emotional support system for others?

Lesbian and bisexual women¹ are a distinct minority population within the U.S. population². Little is known about their mental and physical health certainly not enough to answer questions about the incidence and prevalence of mental and physical illness among these women or their access to and utilization of mental and physical health services. This lack of information is due to two factors:

1. the near absence of questions about sexual orientation in health research on the general population; and

2. the very limited amount of health research targeted at the population of lesbian and bisexual women.

The absence of sexual orientation as a variable in mental and physical health research assumes that no significant health issues exist for women who are not exclusively heterosexual. This is an untested assumption.

Opposition to including sexual orientation as a demographic or independent variable in research has been quite potent. The threat of political opposition decreases the likelihood that there will be inclusion of sexual orientation in research by both researchers and research funders. Here we need federal research funders' leadership to encourage the appropriate inclusion of sexual orientation in research and we need their support to address the significant methodological and conceptual issues in this emerging area of research. Some recent federally funded studies³ have laid groundwork for looking at inclusion of sexual orientation in general population research with adults and with adolescents.

In order to address methodological issues, important conceptual challenges that threaten the validity of research including lesbian and bisexual women must be considered. Two such challenges are briefly outlined.

Understanding and Defining Sexual Orientation

Sexual orientation is a complex construct in which the dimensions of sexual identity (I am a lesbian), sexual behavior (I have sex with women), sexual desire (I am attracted to women), and community belongingness and involvement (I am a member of the lesbian community) are all involved. These dimensions may or may not be congruent with one another. For example, a woman may have sex with women but not self-identify as a lesbian or a woman may self-identify as a lesbian though she is equally attracted and sexually active with both women and men. Given the complex dimensions of sexual orientation, how one defines a lesbian or bisexual woman in research is of great importance.

Research examining issues of health for lesbian and bisexual women need to make distinctions between these two groups of women rather than treating them as one homogenous group. Whether lesbian and bisexual women have similar or different health issues is unknown since research has tended to treat them as one and the same. These issues of definition are critical in research on lesbian and bisexual health.

Validity Issues in Health Research That Excludes Sexual Orientation

Research on women's health has not generally included sexual orientation as a variable for analysis. Nonetheless, research samples do include lesbian and bisexual women though their presence in research samples has been ignored. How the validity of this research is affected is not well understood.

In considering future research, two distinct perspectives should be kept in balance. The first perspective recognizes the benefits for the health of lesbian and bisexual women in conducting both targeted research examining their needs and including them in larger health research studies. The second perspective recognizes the benefits to the scientific understanding of women's health issues generally by including sexual orientation and lesbian and bisexual women in research. We offer two examples of this second perspective. First, one risk factor associated with breast cancer is nulliparity. Women may have physical and/or social reasons for not giving birth to children. If breast cancer research included sexual orientation, then data linking breast cancer risk to underlying physical and/or social bases for not bearing children would potentially help in elucidating the etiology of breast cancer. Second, violence, and particularly domestic violence, is a major cause of morbidity and mortality among women. If research on domestic violence included sexual orientation, results could offer an understanding of domestic violence that would help isolate the effects of gender and differentiate the role of power differences in abusive relationships.

Although our current knowledge about lesbian and bisexual women's health is limited, based on the expertise of psychologists that have conducted work in this area, we identify the following areas as research priorities.

Prejudice, Discrimination, and Violence

Historically, lesbians and bisexual women have been subject to prejudice and discrimination, both public and private, and prejudice against them remains prevalent in contemporary American society. Verbal abuse, employment and housing discrimination, and high rates of specifically anti-lesbian violence have been empirically documented. The effect this has on the health of the lesbian and bisexual women needs explication.

Minority Stress

Stigma, discrimination, and violence are stressors. The effects can include depressive distress, a persistent sense of vulnerability, and efforts to rationalize the experience by viewing one's victimization as just punishment. Like members of other groups that are subject to social prejudice, lesbian and bisexual women may also hold negative stereotypes about themselves. Of particular concern is the role that stigma may have in adolescent development. There are some indicators of a stress response, such as higher rates of suicide attempts, AODA, and mental health services utilization have been reported in studies using convenience samples of lesbians, gay men and bisexual persons, but these data have limited generalizability to the population as a whole. Greater understanding of these processes could have important preventive potential.

The Development of Lesbian and Bisexual Orientation

The basic biopsychosocial process of development of same-gender or even opposite-sex sexual orientation is poorly understood. Although the core feelings and attractions that form the basis for adult same-gender sexual orientation typically emerge by early adolescence, developmental precursors have not been consistently identified for lesbian or bisexual women and the subsequent developmental process of sexual orientation and identity are unclear.

Issues Related to family Relationships

The impact of lesbian and bisexual women's family roles and relationships on their mental health, as well as on the mental health of people around them, is in need of study. Lesbian and bisexual women's relationships with parents, with romantic and sexual partners, with children, and with other family members are likely to be significant influences on mental health, but are as yet little studied. Rejection and disapproval from family members may be major stressors for lesbian and bisexual women, just as acceptance and support may be protective factors. Conditions that affect the degree to which issues related to sexual orientation may unite or divide families, and resulting effects on physical and mental health among lesbians and bisexual women, and their family members are not well understood.

Age as An Important Factor of Consideration

As outlined in our guiding principle, contextual factors are critical to developing an understanding of lesbian and bisexual health. As lesbians age they are faced with a host of new challenges as well as benefits. Economic security and the availability of people to care take become central issues, especially for women who have never had children. The specific health needs of aging lesbian and bisexual women need to be examined. In addition, given the typical stressors associated with adolescence, coming out can be a difficult and vulnerable experience. Young lesbians may be at increased risk for psychological distress from negative reactions from families, anti-lesbian harassment, and social isolation. Understanding the specific health needs across the developmental spectrum is important.

The Intersection of Gender and Sexual Orientation

It is not atypical for research on sexual orientation to miss or ignore the role of gender. As a result some theories developed without taking gender into account may not appropriately apply to lesbians (e.g., essentialist models of identity development) and overlook important gender specific information. Research examining lesbians and bisexual women's health could profit from examining the unique intersection of sexual orientation and gender.

Service Utilization

Mental Health: Large percentages of lesbians surveyed to date report use of mental health services4. Because studies of this topic typically employed convenience samples, research is needed to extend these findings, and to examine their generalizability to the population at large. Moreover, research is needed about the actual experiences of lesbian and bisexual women when they do seek mental health care, and about the effectiveness of various therapeutic approaches with this population.

Physical Health: Although rates of utilization for physical health care for lesbian and bisexual women is unknown it has been hypothesized for various reasons that they underutilize the health care system. One reason may be that some lesbians perceive health care providers as insensitive to their unique needs offering inappropriate advice (e.g., indiscriminant advice to use birth control). Others may fear coming out to their health care provider. Research to address health care utilization issues as well as provider preparedness is a priority. As with mental health professionals, physical health care providers need to understand the health issues of lesbian and bisexual women in order to care effectively for this population.

Lesbian and bisexual women may also be an important sentinel population for monitoring the negative affects of new forms of health care delivery. Provider choice and confidentiality, both threatened by current changes in the health care system, have long been seen as the cornerstone of lesbian health care. Negative effects from health care changes may appear sooner in this population.

Specific Recommendations

• We recommend the committee take into account psychosocial and behavioral factors that have often been neglected in health research. We refer the committee to the APA Research Agenda for Psychosocial and Behavioral Factors in Women's Health as an important resource for its work.

• We recommend that the committee acknowledge in its assessment of the science based research the critical barriers that have severely limited research.

• We recommend the committee consider how the research policy of the National Institutes of Health (NIH) and the Centers for Disease Control (CDC) should be modified to encourage the appropriate inclusion of sexual orientation and of lesbian and bisexual women in clinical, services, and prevention research.

• We recommend that the committee address the conceptual issues that underlie the methodological challenges of studying the health issues of lesbian and bisexual women.

• We recommend that the committee strive to maintain a proper balance between emphasizing the benefits of research for the health of lesbian and bisexual women and the benefits of research in general from including lesbian and bisexual woman, explicitly, in research.

• We recommend that the committee include the experience of prejudice, discrimination, and violence, minority stress, the development of lesbian and bisexual orientation, issues related to family relationships, special needs based on age, the intersection of gender and sexual orientation, and service utilization among its research areas.

• We recommend the committee advocate for further funding for researchers to examine the unique health needs of lesbian and bisexual women and for funding levels adequate for meaningful research conclusions, e.g., population sampling and longitudinal research as appropriate.

1. We use the term "lesbian and bisexual women" to include all women with an orientation toward erotic and affectional relationships with women whether that orientation is primary or not and regardless of whether the women have a psychological identity build around that orientation.

2. In one recent national study (Laumann, Gagnon, Michael, & Michaels, 1994), 1.4% of female respondents identified themselves as "homosexual" or "bisexual." , 4.1% reported same gender sex partners since age 18, and 7.5% reported sexual desire directed towards same gender. In the 12 largest U.S. metropolitan areas, 2.6% of the women in the central cities self-identified as "homosexual" or "bisexual", 6.2% reported same-gender partners since age 18, and 9.7% reported sexual desire directed towards the same gender. For a number of reasons, these estimates must be considered as lower bounds.

3. The NIH Women's Health Initiative and the National Institute of Child Health & Human Development (NICHD) Adolescent Health Project.

4. National Lesbian Health Care Study found 73% of respondents had sought out professional mental health counseling at some time in their lives. High rates were found among white, Latino, and African American women.