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Margaret Nichols, Ph.D.
Director
Institute for Personal Growth/IPG Counseling
8 South Third Avenue, Highland Park, N.J. 08904
(732)246-8439 FAX (732)246-8081
email shrnklady@aol.com
Introduction
Since the American Psychiatric Association officially
de-classified homosexuality as a mental illness in 1973, most
healthcare professionals have gradually accepted the view that
being gay or lesbian is a sexual variation rather than a
disease.
Many are also recognizing that gay patients often have
unique needs and concerns. While most doctors and therapists
have at least an occasional homosexual patient, some
practitioners find that gays comprise a noticeable portion of
their patient load. Gays are concentrated more heavily in urban
areas (Laumann et al.,1994)and higher educational groups, and
lesbian activity is common on college campuses (Diamond,2003b).
Lesbians are heavy users of mental health services: a national
survey of lesbian health (Ryan and Bradford,1993) showed that
nearly three-quarters of respondents had at some point been in
therapy or counseling, and two-thirds of this lesbian sample
preferred female practitioners. So, for example, female
gynecologists and sex therapists located near college campuses
or in urban settings may find that a significant number of
their patients are women who have sex with other women.
This chapter outlines some of the unique features of lesbian
sex and lesbian sexual relationships that might concern the
healthcare professional. The material presented here has been
compiled from the relatively meager selection of research
oriented towards lesbian sexuality, from the clinical
experience of the author and colleagues who work with lesbian
clients, and from an internet-based study of lesbian, bisexual,
and heterosexual women's sexual behavior conducted in 2003-2004
at the Institute for Personal Growth, a psychotherapy center in
New Jersey serving the gay, lesbian, and bisexual community.
This latter data, collected by the author and her colleagues,
will be referred to as IPG internet study results (Nichols, et
al., 2004).
Sensitivity: the 'heterosexual assumption'
Before discussing lesbian sexuality, it is worth noting that
it is more important for a doctor or therapist to have an open,
aware attitude towards lesbian patients than for that
professional to have a wealth of knowledge about sexual
minorities. Ryan and Bradford's lesbian health survey
established that the single biggest complaint of the
respondents was that health and mental health practitioners had
an inherent heterosexual bias, an automatic assumption that
everyone is 'straight.' These assumptions are usually
unconscious. For example, when a gynecologist reflexively asks
about birth control; when the office intake form asks for
"marital status: single/married/divorced/widowed;" when the
provider asks "are you sexually active?" and means "are you
having heterosexual sexual intercourse," many lesbians will be
offended and/or conclude that the provider is insensitive or
prejudiced towards gays. In fact, Ryan and Bradford found that
so many lesbians are put off by the perceived insensitivity of
their doctors that 17% would not even reveal their sexual
orientation to their health care practitioner, even though that
information might be critical for treatment. Thus the
'gay-affirmative' health care professional must approach each
female patient as though she may have feelings, history, or
current behavior that is homosexual. The provider must
demonstrate openness to the possibility of female-female sexual
experience in each woman in order to gain the trust of the
lesbian patient.
Special features of lesbian sexuality
Identity versus behavior; sexual fluidity
In a culture that stigmatizes same-sex behavior, as ours
still does, one would expect the incidence of same-sex
attractions to be higher than the incidence of same-sex
behavior, and both should be higher than the number of people
who self-label as gay. Indeed, every study from Kinsey to the
present day has found this. Virtually all studies from the
1950's(Conrad,2001) to the present(Roberts et al.,2000)have
found that the vast majority of self-identified lesbians -
80-90 per cent -have had at least one male sexual partner.
However, the reality is more complicated. Recent evidence
suggests that women may be physiologically 'wired' for
bisexuality (Chivers etal,2002). When presented with lesbian
and heterosexual visual erotica, women of all orientations show
physiological arousal to both, whereas men's arousal is
'targeted:' heterosexual men respond to heterosexual erotica
and gay men respond to gay male erotica. This confirms what a
number of theorists already believe: that women may have a more
fluid sexual orientation than men (Peplau, 2003, 2001, 2000;
Diamond,2000a, Weise,1992). Diamond(2000b)found that a
significant number of lesbian-identified college women change
their self-labeling to bisexual or heterosexual over a five
year period. Moreover, these women do not 'disavow' their
former lesbian identity and are open to the possibility of
sexual change in their futures.
The IPG internet study reveals an even more complex picture.
75% of the 231 self-identified lesbians had had one or more
male sex partners, and 63% report sexual attractions to men;
three of them were in relationships with men at the time they
completed the survey. But 52% of the 132 self-identified
heterosexual women reported sexual attractions to women, 22%
had at least one female sexual partner, and one was currently
in a relationship with a woman. If one were to define sexual
orientation in terms of capacity for sexual attraction, the
majority of these self-labeled lesbian and heterosexual women
would technically be bisexual.
But bisexuality as a personal identity is a relatively new
phenomenon, emerging only within the last twenty years of so
(Nichols,1994; Weise,1992). And women who self-label as
bisexual- as opposed to those who simply exhibit bisexual
attractions - may be a distinct and unique sub-group within
what is now commonly known as the "LBGT (lesbian, bisexual,
gay, and transgendered)" community. The IPG Internet Study
found that the 152 survey respondents who self-labeled bisexual
had some sexual behaviors that set them apart from either
lesbian or heterosexual women. Bisexual women masturbated more
(p<.000), thought about sex more (p<.003),and had nearly
twice the number of lifetime sex partners than their gay or
straight counterparts (p<.02). In addition, they were far
more likely to also identify with the 'kink' community - women
engaging in some form of dominance-submission sex play
(p<.001) - and the 'polyamory' community - women with
multiple concurrent sexual/relationship partners
(p<.000).
In practical terms, it is clear that self-identification is
at best an incomplete description of self-orientation, which
makes it imperative that a sexual health practitioner must not
make any assumptions about the sexual behavior of a client
without the taking of a careful history that includes questions
about contact with both men and women regardless of the
patient's expressed identity.
Gender identity and 'gender bending'
At the peak of the lesbian feminist movement in the 1970's,
it was unacceptable to identify as 'butch' or 'femme;'
androgyny was the only 'politically correct' choice. However,
that has changed dramatically, so much so that female to male
transsexuals are much more visible in the lesbian community
(Bernstein, 2004; Levy,2004). Some of the established
professional definitions of transsexualism are being
challenged, as more and more women identify themselves as being
part of the 'transgender continuum.' For example, 'trannie
boys' are lesbians who take male hormones, may or may not have
'top surgery' on their breasts, and retain their female
genitalia; 'bois' are gay women with completely female bodies
who dress and comport themselves like men, use male pronouns to
identify themselves, and often appear in public 'packing' -
wearing a strap-on dildo under their pants. The IPG internet
study allowed women to identify their gender as 'female' or
'other.' Five percent of lesbians identified as 'other' while
virtually none of the bisexual or heterosexual women did so
(p<.000). Asked to describe "other," these women used words
like "transgendered," "gender queer," "butch" or "ftm." We also
asked women to identify where they fell on a 'butch-femme'
continuum, and while 26% of the lesbians labeled themselves
'butch,' only a handful of bisexual and heterosexual women did
so (p<.000).
The phenomenon described above suggests it may be time for a
paradigm shift in our concepts of gender identity and sexual
orientation. For three decades both gay rights activists and
sexuality experts have encouraged us to think that these two
core self-concepts are separate, in part because sexology was
for a long time dominated by the social constructivist view
that gender identity was socially constructed. Moreover, we
have come to think of 'lesbianism' as a uniform sexual
orientation, rather than as a label describing a broad range of
behaviors and feelings. Increasingly, we are recognizing that
there are substantial differences in sexual behavior among
self-labeled lesbians: some women have never been attracted to
men, others have strong attractions and history of involvement
with men; for some the identity will be constant throughout
their lifetime, for others it may be more fluid. We also notice
the lesbian community itself returning to butch-femme
dichotomies, but with new twists. Perhaps this means it is time
to reconsider a biological basis at least for women who label
themselves butch or bois, as well as for female-to-male
transsexuals, who frequently have identified as lesbian before
coming to a 'trans' identity. Some studies have shown that
girls born with congenital adrenal hyperplasia have more
male-typical behavior as children, more dissatisfaction with
female sex role assignment, and less heterosexual interest than
non-CAH girls (Hines et al. 2004). And at least one study of
lesbians who identify as butch found that butches recalled more
childhood gender-atypical behavior and had higher waist-to-hip
ratios, higher saliva testosterone levels, and less desire to
give birth than either femme lesbians or heterosexual women
(Singh, et al. 1999). The IPG internet study found self-labeled
'butch' women to be less likely to be attracted to males
(p<.03) than other lesbians but with no difference in their
number of male partners.
For the healthcare provider working with lesbian patients,
this implies a need to loosen rigid definitions of gender and
to change the currently marked distinction between
'transsexuals' and 'everybody else.' In the future, the health
care community may be forced to deal with, for example, women
who ask their doctors for hormones without desiring to fully
'transition' to the opposite gender; it is not unrealistic to
think that even the esteemed Harry Benjamin Standards of Care
for transsexuals may need revision.
Sexually transmitted infections
Despite scant research, some of the most consistent findings
regarding lesbian sexuality have been in the area of STI's.
Roberts et al (2000) reviewed ten studies, including their own,
that all showed lesbians having fewer STI's than bisexual or
heterosexual women. In particular, gonorrhea, syphilis, HIV,
and hepatitis B are less common among lesbians, as are abnormal
pap smears. The IPG internet study found significant
differences in the total number of lifetime STI's between
lesbian, bisexual, and heterosexual women, and a strong
correlation (p<.000) between the total number of STI's and
the total number of male sex partners. Looking at individual
STI's (Figure 1), we found lower rates for lesbians for each
STI, but the only significant difference for an individual STI
for the incidence of abnormal pap smears: lesbians had the
lowest rates, then bisexuals, and heterosexual women had the
most abnormal pap smears (p<.01). The data on abnormal pap
smears corroborates the many studies that have shown nuns to
have a low incidence of cervical cancer; the differentiating
variable probably is the male penis and number of different
male partners, not sexual activity alone.
It is important to note that although a number of studies
show lesbians having fewer STI's than heterosexual women, that
finding seems to be related to the number of male partners a
woman has, and we know from a multitude of sources that most
lesbians have had at least one male sex partner. This is yet
another reason why there is no substitute for the taking of a
detailed sexual history; one cannot rely upon self-identification
alone.
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