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SYNOPSIS OF

HOUSTON AREA HEALTH CARE NEEDS ASSESSMENT FOR LESBIAN, GAY, BISEXUAL, AND TRANSGENDER WOMEN

A Project of Lesbian Health Initiative with technical assistance from Montrose Counseling Center
prepared by Barbara L. Becker, MPH, and Ann J. Robison, MPA

INTRODUCTION

From June to October, 1994, a 94-question survey was distributed to lesbian, gay, bisexual, and transgender women in the Houston area. The survey was designed to yield results which could be compared to results of similar studies which have been conducted throughout the United States, and which could provide descriptive information concerning issues such as sexual identity and behaviors; relationship patterns; history of sexual assault and domestic violence; health history and status; access to, barriers to, and gaps in health care services; health services utilization; levels of health promotion awareness; and sources of information and referral.

This study can serve as an example of how grass roots activists and members of affected groups can work with researchers and members of the health care services to determine the needs of the community. The idea for the survey began with a small group of activists who organized the Lesbian Health Initiative in Houston ( a local non-profit created to promote health and well-being in the lesbian community) and contracted with Montrose Counseling Center (a community based non-profit agency which serves the lesbian and gay community), to jointly complete the study. This study represents hundreds of hours of LHI volunteer time and agency staff time to design and distribute the questionnaire, and analyze and report on the results. It also reflects the support of over 20 local lesbian and gay organizations and businesses, as well as constructive feedback from faculty and students at the University of Texas-Houston Health Sciences Center's School of Public Health.

The Houston study was consistent with other studies performed throughout the country, including the National Lesbian Health Care Survey (NLHCS) (1984-85); the San Francisco Lesbian, Gay, and Bisexual Substance Abuse Needs Assessment (1990); the Michigan Lesbian Health Survey (1991); and the Los Angeles Lesbian Health Needs Assessment (1992). The similarities in the studies include study design (purposive, non-probability studies), distribution methods, questions asked, and results obtained.

In the NLHCS study, completed written questionnaires (10 pages in length) were received from 1,925 lesbians in all 50 states. In this study, the questionnaires were distributed through women's centers, lesbian and women's organizations, bookstores, professional associations, lesbian and gay newspapers, and lesbian and gay events.

The San Francisco study includes data gathered using a written questionnaire. There were 318 lesbian and bisexual women, as well as 416 gay and bisexual men who participated in the study. A further part of this study was to interview service providers and policy makers.

The Michigan study was a written survey of 1,681 lesbians across the state of Michigan. Questionnaires were distributed through mailing lists of lesbian and gay organizations, locations such as businesses or community centers, and at community events.

In the Los Angeles study, there was both a full-length survey distributed in ways similar to the distribution methods used for the Houston study, and a short-form survey published in a lesbian-focused newspaper. There were 267 completed full-length surveys returned, as well as 63 of the short-form newspaper surveys. Thus, the total number of respondents in the Los Angeles study is 330.

Completed surveys were received from 614 Houston-area women from June to October, 1994. Of the 614 responses, 2 were from self-identified heterosexual women. These 2 surveys were excluded from the analysis, resulting in a study group of 612 women. Comparing the number of participants in Houston to that of the other study which was a city-wide effort, this number is almost twice the number who participated in the Los Angeles study in 1992.

RESULTS

In the following paragraphs, a brief outline of the results of the Houston survey are provided.

SELF DESCRIPTION: Almost three-fourths of the respondents identified themselves as lesbians, with 14% identifying as gay women, 11% as bisexuals, and less than 1% as transsexuals. The average length of time for which the respondents had identified themselves with these sexual orientations was 15.42 years. Ninety-nine percent of the respondents self-identified as females, while one percent identified as transgenders.

AGE: The average age of the respondents was 38 years. The range in age was 15 to 78 years of age.

RACE/ETHNICITY: Over 81% of the respondents identified as White/Caucasian, with 6% identifying as Black/African American, less than 8% identifying as Hispanic/Latina/Mexican, and less than 1% Asian/Pacific Islander.

HEIGHT AND WEIGHT: The average height was 5 feet 5 inches, with the average weight being 156 pounds. Almost 14% of the respondents weigh 200 pounds or more. Twenty-eight percent met the definition of being overweight. (For women, the term "overweight" as applied to this study would mean weighing more than 160 pounds if you are a 5 feet, 5 inch female.) Compared to national averages for all women, a slightly lower percentage of the study group could be classified as overweight.

INCOME: Approximately one-quarter have incomes less than $20,000 per year. Almost half have annual incomes from $20,000 - $40,000.

EDUCATION: Over 87% of the respondents have at least some college education, with almost one-third having master's or doctoral degrees.

RELATIONSHIPS: Over half are in committed relationships, with one-third of those relationships being from 2-5 years in length. Almost 5% of the relationships have been on-going for more than 15 years. When asked who they talked to about personal problems, the respondents reported they most often talked to friends (81%), spouse/partner (55%), and family (36%). Three percent reported they talked to no one about personal problems. Given a hypothetical situation in which they were no longer able to care for themselves, the respondents were asked who would take care of them. The most frequent caregivers were spouse/partner (52%) , family (51%), and friends (36%). Five percent reported they had no one to take care of them in such a situation.

COMING OUT: Over half of the respondents hide their sexual orientation from people at work or school. Only 30% percent reported not hiding their sexual orientation from anyone. Sixty percent are not "out" as lesbians to their health care providers.

SEX: Twenty-one percent reported they are uncomfortable with their sex lives. One quarter reported they had not been sexually active in the past year. When asked how the respondents would improve their sex lives, the most frequent responses included having sex more often, increasing the passion and spontaneity of sex, finding a partner, and improving communication with their partner.

SAFER SEX: Sixty percent reported they know enough about safer sex to practice it with their partners. However, only 30% of the respondents report they practice safer sex always or mostly. Over 30% of the respondents reported they never practice safer sex. Of those reporting they do not practice safer sex, 92% indicated they are monogamous, 30% believe they are not at risk, 26% believe that only having sex with women is safer sex, and 18% did not know what to use for safer sex.

HEALTH STATUS: Only 2% of the respondents reported their health status as poor, while 48% reported their health status as fair and 47% as excellent. The most frequently identified health conditions are allergies/asthma/respiratory problems (37%), constant tiredness/fatigue (35%), and muscle/bone/joint problems (27%). Over 30% of the respondents report a health condition which restricts their activities.

TOBACCO: Twenty-four percent of the respondents are smokers, with 19% of those smoking at least 2 packs per day. The average length of time the respondents have been smoking is 17 years.

ALCOHOL: Seventy-three percent consume alcoholic beverages, with 16% of those consuming at least one drink per day. Four percent of those who drink consume at least three drinks per day. Compared to national averages, while a higher percentage of the study group were current drinkers, a lower percentage could be classified as heavy drinkers.

DRUGS: Twelve percent self-identified as using drugs to get high. Of those, 96% use marijuana, 6% use LSD or hallucinogenic drugs, 6% use downers, and 5% use crack or cocaine. Only one respondent reported current heroin use. The average time they have used drugs is 14 years.

DIET AND EXERCISE: Over 60% report they exercise regularly, with three-fourths of those exercising at least three times per week. Almost one-third report they eat a healthy diet, with 5% percent reporting they have no bad eating habits. However, over one-third also report eating too much sugar and sweets, not enough fruits and vegetables, too much fatty food, or too much fast food. Over 25% report eating too much (overeating), with 8% reporting eating too little (undereating).

PREVENTIVE AND SCREENING TESTS: Concerning the standard health screening measures, at least three-fourths of the respondents had the tests for blood pressure, cholesterol, blood sugar, and PAP smears within the last five years. Over one-third of the respondents had never had a digital rectal exam, stool blood test, or a mammogram. The main reasons for not having the screening tests were that the doctor didn't recommend the test (23%), the respondents didn't think they needed the test (21%), and they couldn't afford the tests (16%).

Ninety-two percent of all respondents report they know how to perform a breast self-exam. However, only 28% of those who know how do the exam monthly, with 16% reporting they never do breast self exam. Nine percent report they do breast self-exams weekly. Over 70% report they have had no problems with their breasts, while 7% report they have had a lump in their breast.

HIV/AIDS: Thirty-eight percent of the respondents had been tested for HIV in the prior 12 months, mostly in connection with being a blood donor. There is no indication in the results that any of the respondents were HIV infected.

CANCER: Twenty-five of the respondents reported incidences of cancer in the preceding 12 months, representing 4% of all respondents. Half of the reported cases of cancer were skin cancers and 20% were breast cancer.

MENTAL HEALTH: Almost half of the respondents had sought help for a mental health problem. Of the total 612 respondents, there were reports of moderate to severe problems with the following: depression/sadness/grief (53%); relationships (44%); low self-esteem (40%); repeated trouble sleeping (37%); anxiety/fear (36%); difficulty being lesbian in a homophobic world (29%); and thoughts of suicide (12%). Asked whether they considered themselves happy, only 8% self-reported as unhappy. The rest reported their day-to-day lives as being either happy or average.

STRESS: Over one-third of the respondents reported they had more than an average amount of stress in their life. Only 11% reported less than average amounts of stress. The sources of stress included: work (52%); money (48%); mental/emotional health (26%); family problems (18%); and physical health (18%).

HEALTH CARE PROVIDERS: Almost 80% prefer a female health care provider, almost 60% prefer a lesbian provider, and over three-fourths do not care about the ethnicity of their provider. The most routinely utilized provider is a medical doctor, with over half the respondents reporting that they had been treated by a medical doctor in the previous 12 months. Dentist (43%), eye doctor (29%), and psychotherapist (23%) were also routinely utilized.

UTILIZATION OF HEALTH CARE SERVICES: When the respondents were presented with a hypothetical situation in which they were sick and were asked to decide where they would seek help, 82% responded they would go to a physician's office, 33% to an emergency room, and 18% to a women's clinic. One percent reported they would not seek help for a health problem if they were sick. Responding to a question concerning where they would go to get information about health care issues, 70% report they would go to a doctor or nurse, 39% would go to a feminist or women's publication, 35% would go to a women's health clinic, 26% would go to friends, and 25% would look in a medical textbook.

INSURANCE: Over 80% have health insurance, with most receiving coverage through employment. For the less than 20% who don't have health insurance, almost 90% identified cost as a reason for their lack of coverage. Almost two-thirds of those in committed relationships would like to be added to their partner's insurance policy.

BARRIERS TO SERVICE: Twenty-four percent of the respondents reported incidences in which they had not received medical help in the last twelve months when they needed it. Of those, 57% said it was because they couldn't afford it, 36% because they had no health insurance, 14% because they could not make arrangements (such as time off from work, child care, or transportation), 14% because they feared how they would be treated due to discrimination, and 13% because they feared the results. Over one-fourth of the respondents reported that, in their experiences with health care providers, the providers assumed they were heterosexual. Thirteen percent reported the provider did not take their concerns seriously.

SEXUAL ASSAULT: Forty-two percent of the respondents reported experiences of being forced to have sex against their will. Of those, 37% reported the experience happened when they were children, 36% when they were adults, and 27% experienced forced sex as both children and adults. For those reporting forced sex experiences, the perpetrator was often a family member (55%) or an acquaintance or date (51%). Over one-third reported the event happened more than one time. Twenty percent reported there was more than one person involved in the attack. While the questionnaire did not ask the gender of the person who forced the respondent to have sex, many of the respondents wrote in answers which indicated that the attacker was male.

DOMESTIC VIOLENCE AND ABUSE: Concerning domestic violence and abuse, 70% of the respondents reported that no battering had occurred in their relationship in the past year, or they did not have a partner in the past year. Of the remaining 30% who reported incidences of violence, 52% were called hurtful names by their partners, 17% were slapped or hit, 14% had partners who withheld sex as a punishment, and 11% were thrown out of the house. For the entire sample, these figures have the following representation: 16% were called hurtful names by their partners, 5% were slapped or hit, 4% had partners who withheld sex as a punishment, and 3% were thrown out of the house. Compared to national studies which define severe family violence between husbands and wives to include hitting, bodily throwing, and incidents involving guns or knives, the 5% of the respondents of this study who were hit by their partners is slightly higher than the national figures.

GAY BASHING: Less than one percent of the respondents reported they had been the victims of gay bashing (defined as physical attacks based on being gay or the perception that one is gay ) in the previous year.

WORKPLACE: Concerning the work environment, 23% reported the place where they live or work to be hostile to lesbians and 10% reported it was hostile to women. Eleven percent reported the places where they live or work to be dangerous due to violence. (The conditions which made the places dangerous were not elicited from the respondents.)

CHANGING THEIR LIVES: Responding to a question concerning what they would like to change in their lives, 75% reported they would like to improve their exercise habits, 68% want to improve their eating habits, 59% want to lose weight and improve their body image, 53% want to learn to manage stress better, 50% want to improve their relationships, 45% want to increase their self-confidence, and 35% want to improve their general health. Responding to a question concerning topics on which they would like more information, 39% reported they would like information on nutrition/exercise, 38% on lesbian relationships, 36% on power of attorney and legal matters, 36% on lesbian community and culture, 34% on lesbian sexuality and intimacy, and 29% on alternative healing.

ACTION NEEDED

CANCER: It seems clear that there is conflicting information on the purpose of breast self-exams (BSE) and the appropriate way to do them. There is also a clear message that many women need assistance in linking their knowledge with their practices, since almost all the respondents indicated they know how to do BSE, but only 28% do BSE monthly.

Improved outreach and education to explain the known risk factors and survival rates for all kinds of cancer, particularly breast and skin cancer, are necessary. According to the National Center for Health Statistics (1993), the 5-year relative cancer survival rates for women of all races for 1983-1990 indicate that melanoma of the skin has the highest survival rate (89%). Non-cervical uterine cancer has the second highest survival rate (83%).

Breast cancer has the third highest survival rate (80%). Breast cancer risk factors are related to many different (and mostly uncontrollable) factors, such as: family history; gender; age; hormonal factors; obesity; diet; child-bearing; and age at menstruation, menopause, and first childbirth (Royak-Schaler and Lieff Benderly, 1992). The only one of these factors which has been associated with sexual identity is child-bearing, based on the assumption that lesbians don't have children (although this study contradicts such an assumption).

Educational information should not focus on sexual identity labels, but rather on the risk factors mentioned above. All other risk factors being equal, lesbians who do not have children have the same rate of risk for breast cancer as do non-gay women who do not have children. Sensational journalism and panic is not needed, just basic information given in a way which will heighten awareness of the health concern.

Since early detection is the key to successful treatment of breast cancer, the two other screening measures for breast cancer should be made more accessible for lesbians. Clinical breast exams and mammograms should be made available in an atmosphere which is perceived as safe by lesbians. A safe atmosphere is one in which (at a minimum) the client is free from fear of discrimination, devaluation, hostility, and abuse.

Given the geographic location of Houston and the successful treatment rates for skin cancer if diagnosed early, an educational awareness and prevention campaign for skin cancer prevention could be beneficial. Skin cancer was the type of cancer most commonly reported by this population, so such a health promotional program could be effective in improving the health of the women in the community.

SAFER SEX: It is apparent from this study that there is no clear definition of safer sex for women who have sex with women. It seems clear that the term "safer sex" is linked primarily to HIV and not to other STD's. This study does cast more light on the issue of risk for HIV transmission for women who have sex with women. The responses clearly indicate that if transmission is possible through female-to-female sexual contact, then the lack of information and the amount of mis-information that is present in this community is a danger to health status.

Further research on the risk of transmission through female-to-female sex is critically important. There needs to be a clear understanding of what "safer sex" is for women who have sex with women. This research would be used in developing educational, health promotional, and prevention methods for lesbian, gay, bisexual, and transgender women who have sex with women.

STRESS: Stress is a major factor in most of the respondents' lives. From a health perspective, stress is often linked not only to over-all health status, but specifically to certain diseases such as cancer, coronary heart disease, and stroke. It is also a quality of life issue. On an individual level, there should be a focus on skills-building for coping with stress. Stress reduction which includes such interventions as exercise plans, meditation methods, financial planning advice, improvement of communication and assertiveness skills, and relationship counseling could be beneficial for this group of women. On an individual and institutional level, there should be a focus on combating both homophobia and misogyny which increase stress for lesbian, gay, bisexual, and transgender women.

SEXUAL ASSAULT: The numbers of respondents reporting experiences of sexual assault (which correspond to results in the other studies throughout the country) indicate that services to sexual assault survivors and prevention programs for the lesbian, gay, bisexual, and transgender women's community as a whole is needed.

BARRIERS TO SERVICE: It seems clear, and is consistent with common knowledge, that low economic status and absence of health insurance coverage affect access to health care. This study also implicates the factors of homophobia, the status of women, fear of results, and body image as factors which inhibit access as well.

A project which is indicated by this study would include education and sensitization of health care providers to the needs and concerns of the community of lesbian, gay, bisexual, and transgender women. These issues should be addressed both in current professional settings, as well as in the training/educational programs for those professionals. There should be pressure by consumers to encourage and/or force these changes.

Such pressure could come in the form of a directory of providers who are sensitive to the needs of the community, who are interested in serving the community, and who are willing to address the problem of homophobia. Those women who are "out" to their providers would give those providers feedback (both positive and negative) about quality of service. Information should be made available to consumers to allow them to make informed, assertive and empowered choices, just as information should be made available to providers to allow them to make changes in their behavior.

Pressure should also be put on medical teaching institutions to encourage them to make lesbian, gay, bisexual, and transgender sensitivity training a part of their curriculum.

FURTHER RESEARCH

This study indicates that more research is needed to further investigate the risk for lesbian, gay, bisexual, and transgender women for cancer. In particular, further research is indicated for this community of women in the Houston area to determine if the 1 in 25 (4%) incidence rate of cancer in the 12 month period studied is reproducible in subsequent studies. If so, is the rate related to sexual orientation, diet, family history, environmental toxins, or a combination of any or all of these factors? Or is it some other factor?

The risk for female-to-female HIV transmission must be further investigated. To do this, a clearer picture of the sexual behaviors of women who have sex with women is needed.

More investigation is indicated to determine why lesbian, gay, and bisexual women have higher reported incidences of sexual assault than do heterosexual women. Issues to explore include the gender of the perpetrator of the forced sex experiences, the conditions surrounding the attacks, the effect of homophobia in the institutions that handle sexual assaults (i.e., police force, emergency rooms, women's centers and crisis hotlines), and attitudes and perceptions of the survivors about the definition of forced sex. Further research should also focus on whether sexual assault is a form of gay bashing focusing on lesbians.

Research is also indicated which would further investigate the ways homophobia by providers reduces access to and utilization of health care services, and how this reduction affects the health of lesbian, gay, bisexual, and transgender women.

For a copy of the full report, send $10 (to cover postage and printing) to:
Montrose Counseling Center, 701 Richmond, Houston, TX 77006-5511

REFERENCES
SIMILAR STUDIES AND NATIONAL STATISTICS Bradford, Judith and Ryan, Caitlin. The National Lesbian Health Care Survey: Final Report. 1984.

EMT Associates, Inc. San Francisco Lesbian, Gay, and Bisexual Substance Abuse Needs Assessment. 1990.

The Michigan Lesbian Health Survey Special Report. Michigan Organization for Human Rights. August, 1991.

Warshafsky, Lynn. Los Angeles Lesbian Health Needs Assessment Executive Summary. April, 1992.

National Center for Health Statistics. Health, United States, 1993. Hyattsville, MD: Public Health Service, 1994.

Gelles, R.J. and Straus, M.A. Intimate Violence: Causes and Consequences of Abuse in the American Family. New York: Simon and Schuster, 1988.

OTHER REFERENCES
Lesbian Health Care: Information, Research, and Reports. Compiled by Lyon-Martin Women's Health Services. San Francisco, CA, 1993.

Kemeny, M. Margaret and Dranov, Paula. Breast Cancer and Ovarian Cancer: Beating the Odds. Addison-Wesley Assoc., 1992.

Roberts, Laura. "The Lesbian/Bi/Gay Women's Health Survey." August, 1994.

Royak-Schaler, Renee and Lieff Benderly, Beryl. Challenging the Breast Cancer Legacy. Harper-Collins, New York. 1992. 15