Bisexuals Have Worse Health Outcomes; Here’s How Physicians Can Help

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Current estimates state that bisexual people comprise more than half the LGBT population in the United States, making them the largest group within the LGBT community.1Health Disparities Among Bisexual People [Internet]. Human Rights Campaign. 2018 [cited 2018 Dec 12]. Available from: https://www.hrc.org/resources/health-disparities-among-bisexual-people Even so, in my medical education up to this point, when we’re taught to take a sexual history and assess a patient’s health risks we group “bisexual” into the same category as lesbian or gay, without recognizing that people who identify as bisexual have different lived experiences than those groups and that their experiences result in different health outcomes. As a medical student who identifies as bisexual, I feel compelled to try to bridge the gap between the bisexual and medical communities.

First, some statistics about the state of bisexual health right now. Studies have consistently found that bisexual people have higher rates of mental health problems than heterosexual, gay, and lesbian people. The incidence of mood disorders and anxiety among bisexual women is 58.7 percent and 57.8 percent, respectively.2Feinstein B, Dyar C. Bisexuality, Minority Stress, and Health. Current Sexual Health Reports. 2017;9(1):42-49. Comparatively, lesbians experience mood disorders and anxiety at 44.4 percent and 40.8 percent. A 2010 study found that 18.5 percent of bisexual individuals had seriously considered suicide in the past year compared to 5.8 percent of gay men, 2.5 percent of lesbians, and 3.0 percent of heterosexual individuals.3Conron K, Mimiaga M, Landers S. A Population-Based Study of Sexual Orientation Identity and Gender Differences in Adult Health. American Journal of Public Health. 2010;100(10):1953-1960. Bisexual people report higher rates of substance abuse, including heavy alcohol use, marijuana, and other drug use.4McCabe S, Hughes T, Bostwick W, West B, Boyd C. Sexual orientation, substance use behaviors and substance dependence in the United States. Addiction. 2009;104(8):1333-1345. Men who identify as bisexual are less likely to get HIV testing and to use condoms compared with gay men.5Jeffries W. HIV Testing Among Bisexual Men in the United States. AIDS Education and Prevention. 2010;22(4):356-370.,6Dodge B, Schnarrs P, Reece M, Martinez O, Goncalves G, Malebranche D, Van Der Pol B, Nix R, Fortenberry J. Sexual Behaviors and Experiences Among Behaviorally Bisexual Men in the Midwestern United States. Archives of Sexual Behavior. 2011;42(2):247-256. I could go on, but the trend is clear: health outcomes in the bisexual community are substantially worse than among the gay and lesbian communities.

Health outcomes are worse among bisexuals, but why?

Most research suggests that chronic stress related to the stigma and discrimination as a bisexual person, known as minority stress theory, increases health risks. Bisexual individuals experience many of the same types of discrimination within the healthcare system and society at large as gay and lesbian people do, but there are also many factors that are unique to the bisexual community. Perhaps the most important of these is referred to as bi-negativity: the phenomenon of both the heterosexual and gay/lesbian communities holding negative attitudes about bisexuality.7Feinstein B, Dyar C. Bisexuality, Minority Stress, and Health. Current Sexual Health Reports. 2017;9(1):42-49.

Health outcomes in the bisexual community are substantially worse than among the gay and lesbian communities.

It can be difficult for many bisexual people to find a home in either the heterosexual or LGBT community due to misconceptions that bisexuality is not a stable or legitimate identity or that people who are bisexual are too promiscuous and are unable to hold monogamous relationships.8Feinstein B, Dyar C. Bisexuality, Minority Stress, and Health. Current Sexual Health Reports. 2017;9(1):42-49. This “double discrimination,” as it has been called by people who study this topic,9Mereish E, Katz-Wise S, Woulfe J. Bisexual-Specific Minority Stressors, Psychological Distress, and Suicidality in Bisexual Individuals: the Mediating Role of Loneliness. Prevention Science. 2017;18(6):716-725. can lead bisexual people to feel rejected and invisible, without any spaces in which they can be safely out about their sexual orientation.

The challenge of coming out to providers

39 percent of bisexual men and 33 percent of bisexual women report not disclosing their sexual orientation to any of their healthcare providers, compared to 13 percent of gay men and 10 percent of lesbians.10Health Disparities Among Bisexual People [Internet]. Human Rights Campaign. 2018 [cited 2018 Dec 12]. Available from: https://www.hrc.org/resources/health-disparities-among-bisexual-people

I might have found these numbers surprising until I thought about my own encounters with doctors and realized that I have never disclosed my sexuality to them, either. I’ve had plenty of the awkward, halting conversations: Are you sexually active? Yes. Any chance of pregnancy? No. Do you use contraception? No. Then how do you know you aren’t pregnant? Well… my partner is a… um, a female person…

But it always ends there. The doctor nods knowingly, immediately crossing pregnancy and STIs off the list of things they will ever have to worry about with me. In my experience, the way that most doctors carry out this conversation leaves no space to convey that one is bisexual, should one want to. For all they know, I could very well have a female partner at this moment but three male partners next month. I may be at significantly greater risk for pregnancy and STIs than the general population, but they fail to learn enough about me to assess that risk. If I really wanted my doctors to know that I was bisexual so that they could form an accurate clinical assessment of my health needs and risks, I would have to completely derail the conversation.

Interrupting a doctor’s well-practiced stream of questioning is always difficult, but can be especially so for disclosing something as deeply personal as your sexual orientation. If it is difficult for me, someone who is constantly surrounded by doctors and medical jargon and who is also extremely comfortable and open about my sexual orientation, imagine what it must be like for our patients–people who may have experienced a lifetime of discrimination from other healthcare providers or who may live in family situations that require them to hide their sexuality out of fear for their safety.

How physicians can improve bisexual health

There are plenty of ways that individual physicians, medical students, and other care providers can play a role in reducing bisexual health disparities. The easiest way to start is to get comfortable taking a thorough sexual history with all of your patients. This may look different for everyone depending on practice setting and the amount of time available to spend with each patient, but the National LGBT Health Education Center’s sexual history toolkit is a great place to begin.

Ask questions in a way that doesn’t assume someone’s sexual orientation based on the gender of their current partner(s).

Explain to each patient why you’re asking these questions and how they’re relevant to the care that you provide to them. Ask questions in a way that doesn’t assume someone’s sexual orientation based on the gender of their current partner(s). Leave space in the conversation for your patients to come out about their sexual orientation, should they choose to. Be cognizant of your reactions when a patient tells you something about their identity or sexuality that is non-normative. Seeing a look of surprise or confusion on their doctor’s face, as innocent as that expression may be, can make people feel incredibly uncomfortable when they’ve just told you something that is deeply personal to them.

Some patients may not have ever had someone tell them that being bisexual is normal, that it is okay, that it doesn’t mean they are bad or strange in any way. If nothing else, you can be the person who affirms their identity, the first person to tell them, “Your identity is valid.”

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Juliana Madzia

Juliana Madzia is an M.D./Ph.D. student at the University of Cincinnati College of Medicine. She will pursue a Ph.D. in sociology with a focus on environmental health disparities and urban inequality. In her free time, Juliana enjoys listening to wonky policy podcasts, running competitively, and exploring the city of Cincinnati, one coffee shop at a time.

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