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Revisiting the Physician’s Approach to Lesbian and Bisexual Patients in Lebanon

Health disparities among sexual minority groups exist worldwide. Lesbian and bisexual women face barriers to healthcare access and provision. Disparities are even more striking in Middle Eastern countries like Lebanon. This paper assesses healthcare resources and practices pertaining to sexual minority women in Lebanon. We found a significant scarcity of research on lesbian or bisexual women coming out of Lebanon or the Middle East. We call for enriching the literature with such research to better understand the needs of women and recommend effective interventions.


Introduction
The lesbian, gay, bisexual, and transgender (LGBT) community experiences unique health disparities worldwide. 1 Yet, health issues vary widely among different subgroups of this population. 2 Both in the United States and in Lebanon, there exists a lack of training and preparation for physicians to provide adequate healthcare to different members of the LGBT community. 3,4 While some efforts have been made in the U.S. to improve this issue, attempts in Lebanon have been marginal. Research done on LGBT health is relatively scarce. 5 A report published in 2011 by the Institute of Medicine confirms this knowledge gap: To advance understanding of the health needs of all LGBT individuals, researchers need more data about the demographics of these populations, improved methods for collecting and analyzing data, and an increased participation of sexual and gender minorities in research. 6 While this applies to all members of the LGBT community, the primary focus of this paper will be addressing the healthcare issues of lesbian and bisexual women, and women who have sex with women (WSW). 7 For the rest of this paper, these groups will be collectively referred to as sexual minority women (SMW). It is necessary to look closer at the medical practices of healthcare professionals caring for this underrepresented population to help identify shortcomings, and strategize how to overcome them. Subsection I: Sexual minority women's health risks As is the case with sexual minority men, SMW have a higher prevalence of certain psychological and medical conditions when compared to heterosexual women. Studies conducted in the U.S. show that lesbian and bisexual women are more likely than their heterosexual counterparts to engage in maladaptive behavior. 1,8 Smoking and alcohol consumption are higher Publication support provided by eScienta (www.escienta.com)

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Al Raida Journal Vol. 43, Issue 1, 2019 pp 56-65 F in lesbian and bisexual women. 5,8,9 Multiple studies have shown an increased rate of the following morbidities in SMW as compared to heterosexual women: heart disease, obesity, breast cancer, depression, post-traumatic stress disorder, and suicidal attempts. 8,9 Contrary to common misconceptions, SMW are at risk of acquiring sexually transmissible infections (STIs) 10 despite this being perceived as low-risk by physicians and patients alike. 8,11 Factors that increase their risk of acquiring STIs include having sex with men, 12 and sharing sex toys. 11 Studies have shown that bacterial vaginosis has been identified in 24 to 52% of women who have sex with women. 13,14 Further, a study conducted in the U.S. in 2010 found that lesbians are 30% less likely than heterosexuals to get a routine physical examination within the span of a year. 5 Physician failure to conduct patient interviews in a "sensitive and nonjudgmental manner" is considered a contributing factor. 1 The American Cancer Society released a booklet stating that fear of discrimination and having negative experiences with healthcare providers are two of the major reasons why SMW avoid seeking proper healthcare. 15 Certain skills can be adopted by healthcare providers to improve patient access to care. Factors that increase the likelihood of "coming out" to one's physician include: being asked about one's sexual orientation, filling out an intake form that allows writing down one's sexual orientation, and trusting the confidentiality of the information provided. 16 In light of the true or perceived homophobia or heterosexism that SMW face within the healthcare system, certain institutions have been established to address such health disparities. For example, GLMA: Health Professionals Advancing LGBT Equality in the U.S., published specific guidelines for physicians to adhere to be regarded as LGBT-friendly. 17 More particularly, they devised a range of interventions from merely displaying a rainbow flag in the physician's office to modifying question formats during patient interviews. 17 In addition, the Human Rights Campaign (HRC) publishes annual Health Equality Indices that rank hospitals based on their commitment to LGBT equality and inclusion. 18 Efforts such as these help bridge the gap between healthcare providers and their patients.

SUBSECTION II: Sexual minority women health care in Lebanon
Publication support provided by eScienta (www.escienta.com) 59 Al Raida Journal Vol. 43, Issue 1, 2019 pp 56- 65 F In contrast to the U.S., the meager body of research pertaining to SMW in Lebanon does not shed light on the local community's health needs. Among the available articles addressing Lebanese LGBT individuals, very few seem to address the health needs of SMW. Consequently, one has to rely on international data and then extrapolate to Lebanon. However, from the little that exists in the local literature, it is suggested that sexual health is affected by sociocultural context therefore U.S. findings might not entirely mirror the local population. A study by Gereige and colleagues (2018) comparing the sexual health of SMW and heterosexual women living in Lebanon found that contrary to studies in the U.S., the rates of cervical cancer screening with a PAP smear among SMW and their heterosexual counterparts were similar (42%). 19 This number however, is drastically lower than the number of PAP smears done on SMW and heterosexual women in the U.S. 19,20 The study also showed that significantly more SMW had heard of PAP smears than heterosexual women. SMW asking their physician for a PAP smear directly might explain the similarity in numbers among the two groups of women. 19 SMW are more likely to be tested for sexually transmitted infections, and about half of the SMW in the study reported being comfortable in sharing their sexual orientation with their physician. 19 These findings suggest that SMW are better health advocates for themselves than one would expect given the structural obstacles they face when seeking out medical help. An alarming finding was that 18% of SMW reported not having access to health care when they needed it as opposed to their heterosexual counterparts who never experienced this issue. 19 Despite the differences noted, the study did find some similarities between SMW in Lebanon and the U.S. SMW were found to have more sexual partners, 21 earlier first sexual experiences, 21 and more unwanted sexual contact 22 than their heterosexual counterparts. 19 When it comes to physicians, a study by El-Kak (2004) showed that only one-third of obstetricians and gynecologists in Lebanon take the time to specifically ask their patients about sexual health. 23 In fact, one study (not published in a peer-reviewed journal) showed that among Lebanese physicians in internal medicine, family medicine, and obstetrics and gynecology (OBGYN), only 50% counsel their patients about sexual health practices, and only onethird of them ask about the patient's sexual preference. 4 It also showed that 85.7% of obstetricians and gynecologists in Lebanon rely on "reading scientific publications" to improve their knowledge This knowledge gap is exacerbated by prevailing sociocultural norms in Lebanon which can be particularly conservative in regard to sexuality. Fear of public opinion and a backlash regarding sexuality could be a factor influencing disclosure rates of sexual behavior among women to their providers. When it comes to SMW, it is important to note that they live in an environment where the majority consider homosexuality "immoral as well as sinful," and think that homosexuals should try to overcome their "feelings." 24, 25 A report by the United Nations Human Rights Counsel considers Article 534 from the Lebanese Penal Code--which criminalizes non-heterosexual sex, specifically sodomy--a major factor preventing the Lebanese LGBT population from having easy access to clinical services. 26 In 2009, however, a judge in Batroun, located in northern Lebanon, refused to apply Article 534 in regards to people engaging in same-sex relations citing it was not against the "rules of nature". 27 In the following years, several judges followed suit and ruled in favor of people belonging to sexual minority groups. 27 On the legal front, these events are considered victories, albeit small, in favor Lebanese sexual minority groups.
As for LGBT healthcare in Lebanon, the situation is far from ideal. In their paper, Abdessamad and Fattal explain how political turmoil, religious influences, unqualified healthcare professionals, outdated laws and lack of educational resources in Arabic, among others, all contribute to the lack of proper healthcare for the LGBT community in Lebanon. 26 Another contributing factor is the lack of a governing medical body that can draft official guidelines for healthcare providers with patients from the LGBT community, similar to those published by GLMA in the U.S. As a result, physicians are left without a reference to guide their approach to this community. Furthermore, the attitudes of Lebanese physicians regarding the LGBT community vary greatly, with approximately 50% stating that they would not tend to the needs of a A report published by Outright Action International, an organization that aims to advance human rights for LGBT people everywhere, examines the situation of sexual minority groups in Lebanon, Jordan, Tunisia and Morocco. 27 The report shows that despite individual differences, these countries share overarching similarities. All four countries have witnessed a wave of coalition-building and intersectional work among local LGBT organization which have increased visibility and security for sexual minority groups. 27 Despite more government resistance in Jordan and Morocco, informal networks which bring together professionals from different backgrounds, including healthcare, have managed to advance LGBT issues. 27 The report also highlights that activists in Lebanon, Morocco, and Tunisia recognize that the LGBT movement is mainly Change may already be well underway. A study by Naal et al. in  As for practicing physicians, a reevaluation of the way they communicate with their patients, including word choice and language modification, could go a long way in terms of building better physician-patient trust and openness. In addition to having to tread carefully while addressing these stigmatized issues with their patients, physicians in Lebanon have the added challenge of having to translate and adapt to Arabic the proper medical sexual terms they learn in English or French. In a country where public discourse centering around sexuality is often derogatory, creating an environment that is conducive to such topics can ease the whole patient encounter. Given that patients appear to be comfortable talking about their sexual health to their obstetricians and gynecologists, 4,23 these physicians should take that opportunity and be prepared to explore that aspect of the woman's medical history. If SMW are offered a healthcare system conducive of trust they will feel more comfortable seeking medical and preventative care as well as having more honest conversations with their providers. Without establishing trust and rapport between a patient and physician, the patient's personal health and wellbeing are at stake.

Conclusion
In conclusion, many large-scale obstacles in Lebanon stand in the way of giving SMW fair access to proper healthcare. These impediments, in turn, require large-scale interventions navigating barriers on the political, religious, educational, financial, and social front, to achieve the considerable progress needed in this field. It is, however, the healthcare provider's responsibility to play an active role in breaking down barriers faced by any minority group. We call on healthcare providers in Lebanon to use the few local educational activities offered by NGOs. We call on academics in Lebanon to add a question about sexual orientation within demographic surveys in their studies to enrich the literature with needed local statistics. Change can also start in the confines of a physician's own clinic. By revising the approach to patient interviews and becoming more sensitive to patients' sexual practices, physicians have the potential to provide more holistic care to all patients across varying sexual identities. All these efforts on an individual basis we hope