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--> 1 Introduction Despite a growing but still limited body of knowledge about the prevalence, diagnosis, etiology, prevention, and treatment of health1 problems among women in general, the health problems of some subgroups of women have continued to receive relatively little attention. Although research on lesbians has increased over the past two decades, there is still relatively little research on their health. Study Process and Report Organization The Institute of Medicine (IOM) Committee on Lesbian Health Research Priorities was established in 1997 to assess the strength of the science base regarding the health problems of lesbians (i.e., women who have sex or primary emotional partnerships with women), to review methodological issues pertinent to lesbian health research, and to suggest avenues for future research. The study was funded by the National Institutes 1 The committee uses the term "health" to indicate a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity. It is a positive concept emphasizing social and personal resources as well as physical capacities. The inextricable link between people and their environment constitutes the basis for a socioecological concept of health. Such a view emphasizes the interaction between individuals and their environment and the need to achieve some form of dynamic balance between the two (World Health Organization, 1998).
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--> of Health (NIH) Office of Research on Women's Health with the Centers for Disease Control and Prevention (CDC) also contributing funding through the NIH. Individuals appointed to the committee brought a wide range of perspectives and professional backgrounds to the workshop study, including expertise in lesbian health issues, mental and addictive disorders, breast cancer, gynecology, epidemiology, adolescence, violence against women, neuroscience, minority health, biostatistics, and sample survey methodology. Names of potential committee members were solicited from a variety of sources, including lesbian health organizations and groups with an interest in lesbian health. The committee met three times—in July, October, and November of 1997. As part of the workshop study the committee conducted an invitational workshop on the physical and mental health concerns of lesbians and the methodological issues involved in conducting research in these areas. At the workshop, information was presented to the committee on the strength of the science base, methodological challenges in conducting research on lesbian health, and gaps in what is known about specific health problems for which lesbians may be at risk. Experts in the biomedical, behavioral, and social sciences; ethics; lesbian health; economics; and research methodology discussed the state of the field and areas in which clarification of the issues is most needed. The two-day workshop featured 21 invited speakers and included public testimony from 14 presenters (see Appendix B). Approximately 50 interested members of the public also attended the workshop and added to the discussion of the issues (see Appendix C). To involve a wider range of people with expertise in lesbian health issues, the committee established an ad hoc public liaison group. The public liaison group included researchers, representatives of government and of community and national organizations, and other individuals interested in the issues. Establishment of the public liaison group reflected the committee's recognition of both the important expertise and knowledge of the issues that rests in the lesbian health community and the diversity therein. Members of the public liaison group were kept informed of the progress of the study and were invited to the public workshop and to submit testimony to the committee.
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--> In addition to the information received through workshop presentations and public testimony, the committee identified and reviewed numerous pieces of published and unpublished literature related to lesbian health. The review included articles in the scientific literature, books, unpublished conference and meeting presentations, reports, and monographs. A listing of selected references is presented in Appendix A. The committee also received written testimony from a number of individuals and organizations unable to attend the workshop (see Appendix D). In addition, the committee's first meeting included presentations from representatives of the Gay and Lesbian Medical Association, the NIH Office of Research on Women's Health, and the CDC Office of Women's Health. This report is the result of the information gathered by and the deliberations of the IOM Committee on Lesbian Health Research Priorities. The report reflects the committee's review and evaluation of the scientific literature on lesbian health and of the testimony presented at the workshop. Selected quotes from workshop speakers are included to more vividly illustrate for the reader some of the issues that emerged during the workshop testimonies as well as the committee's evaluation of the literature. Wherever possible reference to the published literature, surveys, workshop testimony, or other sources of information available to the committee is indicated. Statements not so referenced are those of the committee or from discussions during the workshop. It is very important to note the limitations of this study and report. Because the study was developed and funded as a workshop study, the committee did not have the resources to undertake the in-depth level of review and analysis that is usual in a full-scale IOM study. In particular, the committee was generally unable to consider issues beyond those that were discussed at the two-day workshop, to conduct in-depth reviews of related areas (e.g., women's health in general or the effects of stress on health), to collect extensive data for analysis, to conduct detailed analyses of specific studies, or to set specific research priorities within fields of study. Nonetheless, the committee was able to conduct a broad workshop and literature review of the field and to assess the general state of knowledge across a wide range of issues for lesbian health. The review and assessment form the substance for this report. The report is organized into five chapters. The first chapter sets the
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--> stage by describing some of the history of the workshop study, its scope, why the committee believes that lesbian health issues present an important area for attention, and how the committee defines being lesbian. Chapters 2, 3, and 4 are based largely on the workshop presentations and public testimony submitted to the committee and directly incorporate many of the presenters' remarks. Chapter 2 provides several frameworks for thinking about lesbian health: lesbians in the context of the greater society, women in general, and the health care system; lesbian health across the life span; and lesbian health with respect to specific health problems. The chapter reviews what is currently known about lesbian health, discusses the limitations of the existing literature base, and suggests health issues that should be targeted for additional research. Chapter 3 describes the methodological challenges faced by researchers studying lesbian health and discusses possible ways of dealing with them. In Chapter 4, some of the contextual barriers to conducting research on lesbian health are described. Finally, the major conclusions and recommendations of the committee are presented in Chapter 5. Why Study Lesbian Health? Why should scientists be interested in studying lesbian health issues? Is there really any reason to think that lesbians have unique health risks or that their health risks are any different from those shared by other groups of women (e.g., heterosexual women, single women, or women who have not had children)? The committee finds several reasons why it is important and worthwhile to direct attention to the study of lesbian health issues. To gain knowledge that is useful for improving the health status and health care of lesbians. Lesbians are a subgroup of all women and so share many health risks and experiences in the health care system with women in general. For the care of lesbians to be both cost-effective and appropriate, the scope of their health problems must be better understood. In addition, knowledge of areas in which the health of lesbians differs from that of other women may provide insights to improve the health of all women.
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--> To confirm beliefs and counter misconceptions that exist about the health risks to lesbians. In the face of little empirical information there are numerous beliefs and misconceptions about the health risks of lesbians that can affect their health outcomes. These beliefs are often shared both by health care providers and by lesbians. Some of the beliefs may be true; others may be or are misconceptions. They include, for example, perceptions that lesbians do not need regular Pap tests or routine gynecological care, that lesbians do not contract HIV/AIDS, and that there is an epidemic of breast cancer in the lesbian community (Council of Scientific Affairs, 1996). To identify health areas in which lesbians are at risk or tend to be at greater risk than heterosexual women or women in general. A large body of epidemiological research has identified factors that place people at risk for health and mental health problems, with gender differences existing for many of these risk factors. However, because information on sexual orientation has not been collected in these studies, it is not possible to draw conclusions about whether lesbians in the samples differed from or were like other women with respect to these risk factors. It is possible that some factors assumed to place women at risk for or to protect them against health disorders may not be present at the same levels or operate in the same ways for lesbians. Also, as discussed later in this report, evidence from some studies suggests that lesbians may be at greater risk than other women for some health-related concerns. In addition to facing many of the same stressors as heterosexual women, women who self-identify as lesbian may also experience stressors not commonly faced by heterosexual women (e.g., stigmatization both in and outside the health care setting). It is important to understand those factors that are unique to lesbians and their impact on lesbians' health. Defining "Lesbian"2 Having a clear definition of "lesbian" is critical for understanding the 2 This section incorporates remarks from workshop presentations made by Meaghan Kennedy, Esther Rothblum, and Lee Badgett.
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--> health implications of being a lesbian woman. Thus, one of the first challenges for the committee was to decide how to define the lesbian population subgroup. Popular definitions are inconsistent. Are lesbians simply women who have sex only with women? What about women whose sexual partners include both men and women? What about women whose primary affiliation is with women, but who have not engaged in sexual relationships with them? There is no standard definition of lesbian. The term has been used to describe women who have sex with women, either exclusively or in addition to sex with men (i.e., behavior); women who self-identify as lesbian (i.e., identity); and women whose sexual preference is for women (i.e., desire or attraction). The lack of a standard definition of lesbian and of standard questions to assess who is lesbian has made it difficult to clearly define a population of lesbian women. In the research literature, definitions of lesbian also vary depending on how and where study samples were obtained. Some researchers have included women who self-identify as bisexual in their definition of a lesbian sexual orientation; others have not. To the extent that lesbian is defined only by sexual activity with other women, bisexual women may then be included in the category of lesbian. If other definitions of lesbian are used, such as self-identification as lesbian or attraction to women, then a different group is identified that may or may not include women who self-identify as bisexual (see Table 3.1 for a summary of how sexual orientation has been assessed across a range of research studies). Most of the literature reviewed by the committee was about lesbians, although it is likely that bisexual women, or even heterosexual women, have been included in some of the research samples. Much less research has been conducted that focuses specifically on bisexual women. Because so little research is available about bisexual women and the degree to which results of research about lesbians also apply to bisexual women is unknown, the committee considers bisexual women to be a different population subgroup for the purposes of this report. Nevertheless some reported data are based on samples that include both lesbian and bisexual women and, when discussed in this report, are so indicated. Some of the committee's conclusions regarding lesbians can also probably
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--> be extended to women who self-identify as bisexual, although other conclusions cannot be generalized. For example, the methodological issues described in this report and the general difficulties of defining the population are clearly also applicable to conducting research focusing on bisexual women. However, some of the committee's other conclusions may not directly or equally apply to bisexual women (e.g., levels of risk for sexually transmitted diseases, interactions with the health care system). It is not known how many lesbians there are in the United States, by any definition of lesbian, or the prevalence of being lesbian although estimates generally range from 2 to 10% of women (Gonsiorek and Weinrich, 1991; Laumann et al., 1994). In research, the category of lesbian is fluid with estimates of membership that vary depending on the way lesbian is defined, the current or past behavior of those sampled, and the degree to which they are willing to disclose very private and perhaps stigmatized behaviors. Lesbians do not constitute an identifiable homogeneous population for research study. Some lesbians may belong to a community of women who self-identify as lesbian and share a culture of values and norms beyond sexual behaviors. Other groups of lesbians may fear identification as lesbian, despite having emotional and sexual partnerships with women, owing to the potential stigma or negative consequence; still others may simply view their sexual behaviors as fluid within a bisexual or heterosexual identity. Diversity among lesbians also occurs along dimensions of race and ethnicity, socioeconomic status, age, whether or not they have children, and so on. Racial and Ethnic Minority Groups Perspectives of Sexual Orientation Views of sexual identity and sexual behavior can vary significantly across cultures and among racial and ethnic groups, so it should not be assumed that a lesbian sexual identity is the same for lesbians of different racial, ethnic, or cultural backgrounds (Liu and Chan, 1996). In particular, it should not be assumed that racial and ethnic minority cultures share views of lesbian sexual orientation identical with the dominant culture. Numerous factors influence views of homosexuality among racial and ethnic minority cultures, including traditional views of family, the predominant religions within the culture, and traditional gender roles.
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--> Other factors to consider include the time and reasons for immigration and the degree of acculturation (Greene, 1994). These factors can vary both across and within racial and ethnic minority groups. Thus, just as the attitudes of African Americans and Asians toward lesbians may differ, so may those among Latinos from Puerto Rico, Mexico, and South America. How their culture views homosexuality influences how lesbians view themselves. Empirical data are limited on attitudes toward lesbians and the differential experiences of lesbians across cultures. However, these data can be supplemented by discussions, often by ethnic minority lesbian or gay authors, about the impact of culture on lesbian experience that illustrate the complexity involved in understanding these influences. In East Asian cultures (i.e., Chinese, Japanese, and Korean), the existence of Asian American lesbians and gay men is sometimes denied and homosexual activity is rarely disclosed to society at large (Liu and Chan, 1996). Collectivism and interdependence are highly valued, and coming out to family is made more difficult by the lack of a cultural framework for homosexuality. Understanding the cultural context for how homosexuality is viewed in these cultures can be greatly enhanced by taking into consideration the influences of Confucianism, Taoism, and Buddhism, religions that have influenced East Asian societies for many hundreds of years (see Table 1.1).3 Similar influences help form attitudes toward being lesbian in other cultural groups. For example, African-American cultures typically have a strong religious and spiritual orientation that sometimes reinforces homophobic attitudes (Savin-Williams, 1996). At the same time, traditionally strong family ties can make it less likely that a family member will be rejected because of sexual orientation, even if the family does not approve of one being lesbian (Savin-Williams, 1996). Strong gender role stereotypes are often found in Latino cultures, with distinct differences between male and female roles (Morales, 1996). Lesbian sexual orientation can be seen as threatening the cultural value of marianismo, which refers to the traditional responsibility of a woman to provide for and nurture her family 3 Confucius lived from 551 to 479 B.C., Taoism was developed in the fifth century B.C., and Buddhism was first introduced into China in the first century A.D. (Liu and Chan, 1996).
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--> TABLE 1.1 Selected Influences of Religious Heritage on Views of Homosexuality in East Asian Cultures* Selected Influences Cultural View of Lesbians and Gays Confucianism—ordered relationships and roles are emphasized; children are expected to follow parents' rules and demands; concept of saving "face" is important; women are expected to be domestic, family centered, and submissive to males A lesbian or gay sexual orientation does not fit into the Confucian order. Same-sex relationship is unfathomable and tolerated only to the extent that it does not interfere with family duties and eventual marriage. Taoism—ancient principles of yin (the weak, passive, and negative force) and yang (the strong, active, and positive force); harmony of yin and yang is the key to happiness and the rightful order Homosexual relationships violate the natural balance of yin and yang, which is symbolized by the marriage of male and female. Buddhism—the key to salvation is emptying oneself of one's desires, which, after lifetimes of reincarnation, will lead to nirvana or the spiritual heaven Following sexual desires is discouraged and will slow the path to salvation. Homosexuality is seen as resulting from pursuing one's sexual lust and is thus a reflection of impurity. However, there is no concept of homosexuality itself as a sin. * Includes Chinese, Japanese, and Korean East Asians. SOURCE: Liu and Chan, 1996. and to value motherhood (Morales, 1996). Religious influences, primarily Catholicism, are likewise strong in Latino cultures. Historically, Native American cultures appear to have been relatively accepting of varied gender roles, including a lesbian sexual orientation, although contemporary attitudes, which are more influenced by the larger multicultural American culture, may be less accepting (Greene, 1994). How the Committee Defines Lesbian Numerous definitions of lesbian have been suggested, ranging from "someone who identifies as a lesbian" to "a woman-identified woman" or "a woman who has sex with another woman." In general, sexual orientation is most often described as including behavioral, affective (i.e., desire
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--> or attraction), and cognitive (i.e., identity) dimensions that occur along continua (Laumann et al., 1994). That is, women may exhibit differing degrees of same-sex sexual behavior, desire, or identity in combinations that vary from person to person. Table 1.2 presents data gathered in a national study of the sexual behavior of American adults aged 18 or over (Laumann et al., 1994) and illustrates how the estimated percentage of American women who are lesbian varies depending on the definition one selects. In this sample, 3.8% of the women reported having had at least one same-sex sexual partner since puberty, 4.3% indicated that they had engaged in specific sexual activities with another woman, 7.5% reported that they currently experienced desire for a female sexual partner, and 1.4% identified themselves as homosexual or bisexual (Laumann et al., 1994).4 Variations in the way sexual orientation dimensions interact are also illustrated in Figure 1.1. Of the women in the survey who reported some aspect of same-sex orientation, 58.7% reported that although they found sex with another woman to be desirable, they had never had a female sexual partner and did not identify themselves as homosexual or bisexual. Nearly 13% reported that they had engaged in same-sex sexual behavior at some time since puberty, but did not identify as homosexual or lesbian and did not desire a female partner. All who reported that they identified themselves as homosexual or bisexual had engaged in same-sex behavior or found sex with a same-sex partner to be desirable. In other words, in this national sample, virtually everyone (more than 90%) who self-identified as a lesbian also reported both same-sex sexual behavior and desire for another woman. However, many women who reported desire for other women or same-sex behavior did not identify as lesbian. The distribution of the dimensions of sexual orientation in the general population can be graphically represented in a "sexual orientation cube" (see Figure 1.2).5 Women in cell A of the cube are clearly lesbian; 4 When data from the National Health and Social Life Survey are combined with data collected in the General Social Survey since 1988, increasing the sample size to 4,827 women, 4.1% of the respondents reported having had at least one same-sex partner since they turned age 18, 2.2% reported a same-sex partner in the past five years, and 1.3% reported a same-sex partner in the past year. 5 The example of the cube presents one way of measuring the dimensions of identity, behavior, and desire. There are numerous other ways of
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--> they self-identify as homosexual, have only female sex partners, and find sex with women only to be very desirable. In contrast, those in cell B, at the opposite corner of the cube, would clearly be considered to have a quite different sexual orientation; they find sex with women not desirable, report no same-sex behavior, and self-identify as heterosexual. More difficult to categorize are those women who fall somewhere within the central portion of the cube, such as those who desire sex with women but do not identify as lesbian or engage in same-sex sexual behavior, those who identify as homosexual or bisexual but have never engaged in same-sex sexual behavior, or those women with homosexual or bisexual identity characterized by desire for both female and male partners. As noted throughout this report, no definitive set of data containing information about sexual orientation has been developed from a large probability sample of women; thus, any attempt to represent the distribution of sexual orientation in women is subject to some distortion. The committee has analyzed data from the National Health and Social Life Survey (NHSLS) (Laumann et al., 1994) to illustrate the possible distribution of the dimensions of sexual orientation in the sexual orientation cube. These data are useful for this purpose because the study used probability sampling methods, included women from throughout the country, and included enough women in the sample ( n = 1,719) to support a minimal level of analysis.6 For the purpose of this illustrative analysis, sexual identity was categorized as homosexual, bisexual, or heterosexual, and desire or attraction was measured by the reported appeal of same-sex behavior from not appealing to very appealing.7 As seen later in this report, there are many measuring behavior would include number of lifetime female partners or percentage of sexual events in a given time period that were same-sex partners. Defining and measuring the dimensions of sexual orientation are discussed more fully in Chapter 3. 6 Case-level data from female respondents in the 1995 Inter-University Consortium for Political and Social Research version of the 1992 NHSLS data set (ICPSR: Ann Arbor, Michigan) were analyzed to produce entries in the cells of the sexual orientation cube. Drs. Julie Honnold and Judith Bradford at the Virginia Commonwealth University Survey and Evaluation Research Laboratory analyzed the data on behalf of the committee. Dr. Stuart Michaels of the National Opinion Research Center, a member of the NHSLS research team, provided assistance. 7 Sexual identity was measured by an item asking NHSLS respondents to indicate whether they considered themselves to be "heterosexual, bisexual, homosexual, or something else." Same-sex sexu
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--> TABLE 1.2 Percentage of Women Reporting Various Dimensions of Same-Sex (SS) Sexuality by Selected Social and Demographic Variablesa Any SS Partners Since Pubertyb SS Activity Since Pubertyc Desire SSd Partner Identify as Homosexual or Bisexual Total 3.8 4.3 7.5 1.4 Age 18-29 2.9 4.0 6.7 1.6 30-39 5.0 5.4 9.2 1.8 40-49 4.5 4.6 8.3 1.3 50-59 2.1 1.9 4.6 0.4 Marital status Never married 5.6 5.9 10.4 3.7 Married 2.6 2.8 5.2 0.1 Divorced, widowed, separated 4.1 5.5 9.6 1.9 Education Less than high school 3.3 1.8 3.3 0.4 High school graduate 1.8 2.3 5.3 0.4 Some college or vocational 3.9 5.1 7.3 1.2 College graduate 6.7 7.3 12.8 3.6 Religion None 9.9 11.3 15.8 4.6 Type I Protestant 2.1 2.0 5.2 0.5 Type II Protestant 2.9 3.3 5.5 0.3 Catholic 3.4 4.2 8.4 1.7
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--> Jewish 6.9 12.5 10.3 3.4 Other 18.9 14.7 16.2 5.4 Race or ethnicity White 4.0 4.7 7.8 1.7 Black 3.5 2.8 7.0 0.6 Hispanic 3.8 3.5 7.6 1.1 Place of residence Top 12 central cities (CCs) 6.5 4.6 9.7 2.6 Next 88 CCs 1.6 7.8 7.7 5.7 Suburbs of top 12 CCs 5.7 4.1 9.0 1.9 Suburbs of next 88 CCs 3.3 4.8 9.8 1.6 Other urban areas 2.7 3.4 6.9 1.1 Rural areas 2.1 2.2 2.1 0.0 a Based on data gathered in the National Health and Social Life Survey (n = 1,749). b Percentage of respondents who have had a same-sex partner at any time since puberty. c Percentage of respondents who self-reported ever having engaged in specific sexual activities (e.g., oral sex, sex for pay) with another woman at any time since puberty. d Percentage who reported that they were attracted to women, or that they found sex with women to be appealing, were considered to have some degree of same-sex desire. SOURCE: Laumann et al. (1994).
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--> Figure 1.1 Interrelation of the different dimensions of same-sex orientation (current desire, current or past same-sex behavior, current identity as homosexual or bisexual) for 150 women (8.6% of the total 1,749) who report any adult same-gender orientation. SOURCE: Laumann et al. (1994). ways in which researchers have measured same-sex behavior, usually assessing the gender of sexual partners during a certain period of time (e.g., never, ever, since age 18, during past five years). Because there were so few reports of all same-sex partners among the small number of women in this sample (n = 150) who reported any same-sex identity, behavior, or al behavior was assessed with a combination of questions asking about same-gender partners and cohabitation with a same-sex partner since age 18. Of the two variables in the NHSLS measuring same-sex desire (sex of the people to whom the respondent is sexually attracted and appeal of sex with a person of the same sex), appeal was used in this analysis because it yielded a larger number of cases in the nontypical categories and, like the other variables, could be measured easily using three levels. Although these variables could be measured with a greater number of levels, only three were used to simplify visual presentation of the data and ensure that most cells were not empty. In the NHSLS report, these dimensions were analyzed dichotomously; that is, respondents were classified according to whether or not they reported same-sex behavior, desire, or identity (Laumann et al., 1994).
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--> Figure 1.2 Dimensions of sexual orientation: appeal by sexual behavior and identity. attraction, the committee used a measure of history of cohabitation with a same-sex partner to assess lesbian sexual behavior from no same-sex partners to cohabitation with a same-sex partner. Among a total of 1,719 women represented in Table 1.3,8 1,699 (98.8%) identified themselves as heterosexual, 9 (0.5%) as bisexual, and 11 (0.6%) as homosexual (i.e., lesbian).9 The great majority of self-identified heterosexuals (93.8%; n = 1,594) reported no same-sex desire or behavior (i.e., they would fall into cell B in Figure 1.2). Of the remaining 6.2%, the 8 These represent the female cases for which data were available for all variables in the sexual orientation analysis. 9 These percentages are limited by the extent to which respondents were willing to disclose their sexual identity in the context of the survey. Sexual identity was measured by an item asking NHSLS respondents to indicate whether they considered themselves to be "heterosexual, bisexual, homosexual, or something else." Issues of disclosure are discussed more extensively in Chapter 3.
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--> TABLE 1.3 Sexual Orientation in Adult Women: Appeal and Sexual Behavior by Identity Appeal of Same-Sex Behavior (%) Not Appealing Somewhat Appealing Very Appealing Behavior Identify % Identity % Identity % Same-gender sex A 0.2 A 0.1 A 0.1 with cohabitation B 0.0 B 11.1 B 33.3 C 0.0 C 0.0 C 81.8 Total 0.2 Total 0.2 Total 0.8 Same-gender sex A 1.6 A 0.6 A 0.2 without cohabitation B 22.2 B 22.2 B 0.0 C 0.0 C 0.0 C 18.2 Total 1.7 Total 0.8 Total 0.3 No same-sex behavior A 93.8 A 1.8 A 1.6 B 11.1 B 0.0 B 0.0 C 0.0 C 0.0 C 0.0 Total 92.8 Total 1.7 Total 1.6 NOTE: Total = 1,719; A = heterosexual (n = 1,699); B = bisexual (n = 9); C = lesbian (n = 11). SOURCE: Laumann et al., 1994. largest numbers are found in cells representing heterosexuals who have not had a female partner but who reported that they find sex with a female to be either somewhat or very appealing, and among self-identified heterosexuals who have had a female partner but reported no same-sex desire. Although only 0.6% of the respondents self-identified as lesbian (i.e., their responses would fall into cell A in Figure 1.2), another 6.6% of the respondents reported same-sex behavior or desire. All self-identified lesbians reported that they had had a female sexual partner and that they found sex with females to be very appealing; most (81.8%, or 9 of 11) had cohabited with a female sexual partner. Self-identified bisexuals in the sample appear to occupy an intermediate position between heterosexuals and lesbians, showing less variation than heterosexuals and more than
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--> lesbians both in their sexual behavior and in how appealing they find same-sex sexual behavior. Particularly for lesbian and bisexual women in the sample, but also for some heterosexual women, very low numbers of respondents in the cells make it inappropriate to generalize these patterns to the overall population with confidence. Further, limitations of survey research regarding the collection of valid information on sexual orientation make it likely that these data underrepresent the actual population of women who fit the study definition of lesbian (see Chapter 3). 10 Also, the results reflect an unweighted analysis even though the women in the sample differed in their probability of selection. Nonetheless, this is a useful exercise for illustrating the diversity of expression of sexual orientation in the population as well as the difficulty of grouping sexual orientation into only a few discrete categories. Additional research is needed using probability sampling techniques capable of including greater numbers of women who do not fit into the most common pattern of heterosexually identified women (i.e., those who have not engaged in same-sex behavior and do not find having sex with another woman appealing). The committee strongly believes that there is no one ''right" way to define who is a lesbian. For a researcher designing a study on lesbian health, the recommended course is to develop measures that gather information about the aspects of lesbian orientation that are relevant to the specific project at hand (see Chapter 3). Adopting this approach does not avoid the issue of lesbian definition. Rather, it builds on the need to accept the complexity of sexual orientation and the social context in which it is embedded. In essence, "lesbian" should be defined to meet the needs of specific research studies, interventions, or programs of care within generally accepted conceptual boundaries, with recognition of the three dimensions through which sexual orientation is most often defined: identity, attraction or desire, and behavior. 10 One possible indication that respondents may be underreporting on dimensions of lesbian sexual orientation is the high percentage of self-identified lesbians who reported that they had cohabited with a female sexual partner. It may be the case that these women were most likely to have come out publicly as lesbians and thus were more likely to report their lesbian identity.
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--> References Council of Scientific Affairs, American Medical Association. 1996. Health care needs of gay men and lesbians in the United States. Journal of the American Medical Association 275(17): 1354-1359. Gonsiorek JC, Weinrich JD. 1991. The definition and scope of sexual orientation. In: Gonsiorek JC, Weinrich JD, eds. Homosexuality: Research Implications for Public Policy. Newbury Park, CA: Sage Publications. Pp. 1-12. Greene B. 1994. Ethnic-minority lesbians and gay men: Mental health and treatment issues. Journal of Consulting and Clinical Psychology 62(2):243-251. Laumann EO, Gagnon JH, Michael RT, Michaels S. 1994. The Social Organization of Sexuality: Sexual Practices in the United States. Chicago: University of Chicago Press. Liu P, Chan CS. 1996. Lesbian, gay, and bisexual Asian Americans and their families. In: Laird J, Green R-J eds., Lesbians and Gays in Couples and Families: A Handbook for Therapists. San Francisco: Jossey-Bass. Pp. 137-152. Morales E. 1996. Gender roles among Latino gay and bisexual men: Implications for family and couple relationships. In: Laird J, Green R-J, eds. Lesbians and Gays in Couples and Families: A Handbook for Therapists. San Francisco: Jossey-Bass. Pp. 272-297. Savin-Williams RC. 1996. Ethnic- and sexual-minority youth. In: Savin-Williams RC, Cohen KM, eds. The Lives of Lesbians, Gays, and Bisexuals: Children to Adults. Fort Worth, TX: Harcourt Brace College Publishers. Pp. 152-165. World Health Organization. 1998. WHO Terminology Information System (WHO-TERM)—Health promotion [WWW Document]. URL http://www.who.ch/pll/ter/wt001.html#health (accessed March 11, 1998).
Representative terms from entire chapter: