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. Author manuscript; available in PMC: 2023 Feb 1.
Published in final edited form as: Patient Educ Couns. 2021 May 16;105(2):466–473. doi: 10.1016/j.pec.2021.05.022

The interaction of sexual orientation and provider-patient communication on sexual and reproductive health in a sample of U.S. women of diverse sexual orientations

Ariella R Tabaac a,b,c, Megan E Sutter d,e, Sebastien Haneuse f, Madina Agénor g,h, S Bryn Austin a,c,i,j, Carly E Guss a,c, Brittany M Charlton a,c,j,k
PMCID: PMC8594287  NIHMSID: NIHMS1705303  PMID: 34023174

Abstract

Objective:

Our goal was to examine associations among provider-patient communication, past-year contraceptive use and lifetime sexually transmitted infection.

Methods:

Data were analyzed cross-sectionally from 22,554 women in the Growing Up Today Study and Nurses’ Health Study 3 between the follow-up period of 1996–2020. We used multivariable Poisson regression models adjusted for race/ethnicity, age in years, study cohort, and region of residence to obtain risk ratio (RR) associations and 95% confidence intervals (CI).

Results:

Provider-patient communication was associated with higher likelihood of using all methods of past-year contraceptive use (RRs ranging from 1.11–1.63) and lifetime STI diagnosis (RRs ranging from 1.18–1.96). Completely heterosexual women with no same-sex partners (referent) were 13% more likely than lesbians and 4% less likely than other groups to report a provider ever discussed their SRH. Significant interactions emerged between sexual minority status and provider-patient communication. Sexual minority women whose providers discussed their SRH were less likely to report contraceptive non-use in the past year (p<.0001).

Conclusion:

Provider-patient communication may benefit sexual minority women’s contraceptive practices and engagement with STI testing.

Practice Implications:

Differences in provider-patient SRH discussion by sexual orientation indicate lesbian women are not receiving the same attention in clinical encounters.

Keywords: sexual and gender minorities, health communication, reproductive health services, sexual health

1. Introduction

A growing body of research has established that, compared to heterosexual women, sexual minority women (e.g., lesbians, bisexual women) experience a number of sexual and reproductive health (SRH) disparities that include less frequent contraceptive use [1,2] and higher rates of sexually transmitted infection (STI) diagnosis [3,4]. These associations can also vary by sexual orientation; for example, compared to completely heterosexual women, bisexual and mostly heterosexual women are more likely to use any type of contraceptive method, while lesbians (including those with cisgender male partners in the past year)[5] tend to be less likely to use any method [6]. Through the lens of the Structural Influence Model [7], health communication inequality that stems from social determinants of health, like sexual orientation, can compound health communication disparities and drive negative health outcomes. Since themes of sexual minority erasure in the context of contraception counseling [8], pregnancy prevention [9], and STI risk [9,10] persist for sexual minority women, provider-patient communication is likely an important determinant of sexual minority women’s SRH.

Better-rated perceptions of provider-patient communication have been associated with increased odds of contraception use [11] and greater adolescent pregnancy prevention self-efficacy [12] in presumed heterosexual samples in the U.S. However, stigma and misinformation from healthcare providers may reduce opportunities for sexual minority women to receive appropriate or accurate counseling about their SRH concerns [8–10,13,14]. These concerns are compounded by sexual orientation-based disparities in provider-patient communication. For instance, compared to heterosexual women, lesbians (including those with past-year male sexual partners) have lower odds of receiving birth control counseling during a pregnancy test, and lesbians without past-year male partners are also less likely to receive information on condoms during an STI consult [15]. In contrast, provider-patient communication may function differently for bisexual women, as prior research on sexual stigma implies bisexual identity could be interpreted as a risk factor by sexual health providers [14,16], which may thereby increase SRH service recommendations. At present, disparities in other indicators of SRH communication as well as their association with SRH outcomes have yet to be determined. In the few studies of young adult sexual minority women, provider recommendation of Pap tests[17,18] and better perceived provider-patient communication and trust [19] were associated with increased likelihood of cervical cancer screening, but it is not clear whether the influence of provider-patient communication on SRH extends beyond cervical cancer screening for sexual minority women.

We will address these gaps by examining how sexual orientation-based differences in provider’s encouragement for STI testing services and discussion about SRH are associated with past-year contraceptive use and lifetime STI diagnosis. We seek to expand upon our team’s past analysis of sexual orientation-based differences in contraception use [6] and STI diagnosis [3] by examining effect modifiers of these disparities. Given the importance of provider-patient communication in improving SRH outcomes like contraception use [11,20] and adolescent pregnancy prevention [12] in presumed heterosexual samples, identifying its associations with sexual minority women’s health will aid in identifying important pathways for improving their SRH. Further, quantifying the relationships between provider-patient communication and SRH outcomes can better inform SRH intervention research for all women by uncovering unmet needs that can be targeted based on identity as well as behavior.

We hypothesized that reporting provider-patient communication would be associated with a greater likelihood of past-year contraceptive use and lower likelihood of lifetime STI diagnosis. We further expected these associations to vary as a function of sexual orientation. Specifically, sexual minority women would be less likely to report provider-patient communication, and thereby have worse SRH compared to heterosexual referents. Given stigma experienced by bisexual women [9,16,21], we also expected a higher likelihood of provider-patient communication, though this may not translate to better SRH due to stigmatizing or low-quality information.

2. Methods

Female participants in the Growing Up Today Study (GUTS), and participants in the Nurses’ Health Study (NHS) 3 between the follow-up period of 1996–2020 were included for analyses. GUTS began in 1996 when children (aged 9–14 years) of nurses from the Nurses’ Health 2 Study were enrolled. NHS3 is a new cohort of nurses ages 19–54 initially enrolled in 2010. Cohorts were combined for analyses due to similar age ranges of participants. These are prospective cohort studies, with survey questionnaires administered annually. The combined NHS3 and GUTS sample consisted of 30,359 women from both the GUTS cohort and women who reached NHS3 Questionnaire 8. For current analyses, participants were excluded if they were missing (n=2,523, 8.3%) or reported an unsure (n=80, <1%) sexual orientation across all questionnaire years; reported a gender minority identity (n=44, <1%); or were missing all information on provider-patient communication (n=5,237). Missing outcome data was driven by study attrition during GUTS follow-up (n=6,380 prior to other exclusions). The final analytical sample consisted of 22,554 women. This study was approved by the Brigham & Women’s Hospital Institutional Review Board.

Sexual orientation has been collected on every GUTS questionnaire starting in 1999 and NHS3 Questionnaire 5. The item was adapted from the Minnesota Adolescent Health Survey [22], which asks about feelings of attraction and identity with six mutually exclusive response options (ranging from completely heterosexual to completely homosexual). An additional item asks about sex of sexual partners (male, female, both male and female). For current analyses, we used the participant’s report of sexual orientation from the same year (GUTS) or most proximal year (NHS3) to the provider-patient communication outcomes. Sexual orientation groups were categorized as: completely heterosexual without same-sex partners (reference); completely heterosexual with same-sex partners, mostly heterosexual; bisexual; and lesbian/gay (combination of the mostly homosexual and completely homosexual categories). If data were missing from GUTS, the most recent previous response was carried forward.

The GUTS 2016 questionnaire and NHS3 Questionnaire 8 included information on whether a healthcare provider (including a current primary care provider in NHS3) ever encouraged STI testing or discussed SRH (yes; no; don’t know [coded as missing]).

GUTS 2016 and NHS3 Questionnaire 8 assessed participants’ reports of past-year contraceptive use for any reason (check all that apply). Five dichotomous variables were created for “past-year use” with the following groups based on World Health Organization [23] efficacy guidelines: Tier 1—long-acting reversible contraceptives (i.e., intrauterine devices, implants like Nexplanon®) and surgical procedures like vasectomy and tubal ligation; Tier 2—oral contraceptives, injectables, patches, and rings ; Tier 3—external and internal condoms, diaphragm/cervical cap, and natural family planning such as the calendar rhythm method; Tier 4—sponge/spermicide/jelly, and withdrawal; and no contraception method (i.e., during at least one sexual encounter or time period, they did not use a method). Since these categories were not mutually exclusive, a participant may have reported multiple methods (including none) in the past year; for example, a participant could report both condom use and no method, which would indicate that during some encounters in the past year a condom was used, and during other encounters no method was used. For the “no method” category, sensitivity analyses were conducted with a version of the variable that was mutually exclusive with all other contraception categories (e.g., the participant did not report any method in the past year).

GUTS and NHS3 Questionnaire 5 included items about whether a healthcare provider ever diagnosed an STI. If a participant reported an STI diagnosis in any data collection year, they were considered to have ever had an STI diagnosis.

Demographic characteristics of the study participants were summarized using frequencies, percentages, means, and inter-quartile ranges (as appropriate). We then used generalized estimating equations to fit multivariable Poisson regression models and obtained risk ratio (RR) associations and 95% confidence intervals (CI). To account for clustering of siblings among GUTS participants, a robust sandwich estimator was used based on a compound symmetry correlation structure [24,25].

Covariates included for adjustment in the model were: study cohort (NHS3 [reference], GUTS1, GUTS2); current age (continuous); race/ethnicity (White [reference], Non-White Race/Ethnicity); and region (Northeast [reference], West, Midwest, South). Due to minimal missing covariate data for region (n=1,317, 5.8) and race/ethnicity (n=173, <1%), listwise deletion was used to account for missing data.

For the assessment of effect modification of sexual orientation on the association between provider-patient communication and SRH, we additionally included a provider ever discussing SRH and a provider ever encouraging STI testing (as appropriate) interaction terms in separate models. If the joint effect for the interaction term was significant, predicted probabilities (with 95% CIs) were calculated to facilitate communication of the effect modification (Figures 1–3). Due to small sub-sample sizes resulting in large standard errors and wide CIs, sexual minority subgroups were combined. A full table of RRs and CIs for all interaction models can be found in Supplementary Table A. Analyses were conducted using SAS 9.4 (SAS Institute, Cary, NC).

Figure 1.

Figure 1.

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Predicted probability of a provider ever encouraging STI testing by sexual minority status on not using contraception in the past year. Note. STI is “sexually transmitted infection.” Sexual minority includes the completely heterosexual with same-sex partners, mostly heterosexual, bisexual, and lesbian groups. The joint effect of a provider encouraging SRH services use and sexual orientation was significant at p=.002.

Figure 3.

Figure 3.

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Predicted probability of a provider ever encouraging STI testing by sexual minority status on lifetime STI diagnosis in a sample of US women. Note. STI is “sexually transmitted infection.” Sexual minority includes the completely heterosexual with same-sex partners, mostly heterosexual, bisexual, and lesbian groups. The joint effect of a provider encouraging SRH services use and sexual orientation was significant at p=.03.

3. Results

Full demographics of the analytic sample are provided in Table 1. The mean sample age was 35 years (SD=7.71), and the sample was predominately White (n=21,219, 94.8%). Participants from all sexual orientation groups commonly reported that providers had ever encouraged STI testing (47.9%) and discussed SRH (85.3%). Tier 1 contraceptive use was most frequently reported by mostly heterosexual (30.4%) and bisexual (29.5%) women, Tier 2 (33.1%) and 3 (34.2%) by mostly heterosexual women, and Tier 4 by completely heterosexual women with same-sex partners (19.5%) and mostly heterosexual women (20.4%). Lesbians frequently endorsed not using contraception (77.3%). Lifetime STI diagnosis was reported most frequently by sexual minority women (36.2–48.4%) except lesbians (23.6%).

Table 1.

Distribution of demographics and provider-patient communication by sexual orientation in three cohorts of U.S. women (N=22,554).

Completely Heterosexual with no same-sex partners Completely Heterosexual with same-sex partners Mostly Heterosexual Bisexual Lesbian
(n=17,229, 76%) (n=696, 3%) (n=3,582, 16%) (n=580, 3%) (n=467, 2%)
Current Age (range: 22–55), Mean (SD) 36 (8) 35 (7) 33 (7) 33 (7) 36 (8)
White Race/Ethnicity, N (%) 16,217 (95) 643 (94) 3,368 (95) 559 (97) 432 (93)
Region, N (%)
   Midwest 5,040 (31) 151 (23) 871 (26) 125 (23) 95 (22)
   Northeast 4,401 (27) 180 (27) 1,041 (31) 151 (28) 140 (32)
   South 3,609 (22) 169 (26) 606 (18) 98 (18) 92 (21)
   West 3,154 (19) 155 (24) 883 (26) 164 (30) 113 (26)
Provider-Patient Communication, N (%)
   Provider Ever Encouraged STI Testing 7,534 (45) 423 (63) 2,278 (66) 365 (67) 222 (49)
   Provider Ever Discussed SRH 14,552 (87) 618 (91) 3,214 (92) 501 (90) 342 (76)
Past-Year Contraception Use5, N (%)
   Tier 1 3,208 (19) 180 (26) 1,090 (30) 171 (30) 29 (6)
   Tier 2 5,592 (33) 212 (31) 1,184 (33) 164 (28) 77 (17)
   Tier 3 4,390 (26) 185 (27) 1,225 (34) 181 (31) 28 (6)
   Tier 4 2,193 (13) 136 (20) 731 (20) 100 (17) 7 (2)
   No Method Used 7,317 (43) 242 (35) 1,027 (29) 199 (34) 361 (77)
Lifetime STI Diagnosis, N (%) 4,638 (27) 337 (48) 1,296 (36) 222 (38) 110 (24)
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Note. GUTS1 participants were born 1982–1987, GUTS2 1987–1994, NHS3 in or after 1965. SD is “standard deviation.” STI is “sexually transmitted infection.” SRH is “sexual and reproductive health.” Tier 1 includes hormonal/non-hormonal intrauterine device (IUD), implant, tubal ligation, vasectomy; Tier 2 includes oral contraceptives, shots, ring, patch; Tier 3 includes internal/external condom, diaphragm/cervical cap, natural family planning, rhythm; Tier 4 includes foam/jelly/spermicide/sponge, and withdrawal. “No method used” indicates no method used for at least one sexual encounter within a participant’s lifetime. Frequencies may exceed 100% since participants could select all that apply. If a participant ever reported “no method used,” then they were coded as “yes” for no method used even if other methods were selected since this item was “check all that apply.”

First, we examined the association between provider-patient communication and SRH (i.e., past-year contraception use, lifetime STI diagnosis), adjusting for covariates (Table 2). Broadly, having a provider encourage STI testing or discuss SRH was associated with a higher likelihood of reporting any tier of effectiveness of past-year contraceptive use and a lifetime STI diagnosis (RR estimates ranging from 1.11 to 1.63). In addition, reporting either type of provider-patient communication was associated with roughly a 20% lower likelihood of not using a contraception method at some point in the past year.

Table 2.

Adjusted risk ratios for health communication differences in sexual and reproductive health in three cohorts of U.S. women (N=22,554).

Model Exposure Variables
Provider Encouraged STI Testing (Ref: No) Provider Discussed SRH (Ref: No)
RR (95% CI) RR (95% CI)
Past-Year Contraception Use (n=20,571)
  Model 1: Tier 1 1.41 (1.33, 1.49) 1.63 (1.45, 1.83)
  Model 2: Tier 2 1.17 (1.12, 1.22) 1.31 (1.20, 1.42)
  Model 3: Tier 3 1.11 (1.06, 1.17) 1.28 (1.17, 1.40)
  Model 4: Tier 4 1.23 (1.14, 1.33) 1.29 (1.12, 1.48)
  Model 5: No contraception use 0.79 (0.76, 0.83) 0.81 (0.78, 0.84)
Model 6: Lifetime STI Diagnosis (n=20,571) 1.96 (1.87, 2.05) 1.18 (1.09, 1.27)
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Note. Models adjusted for race/ethnicity (reference: White), age in years, region (reference: Northeast), and longitudinal study cohort (Reference: NHS3). Provider-patient communication variables simultaneously entered into each regression model. Bolded values indicate adjusted relative risk ratios with 95% confidence intervals that do not cross 1.00. Tier 1 includes hormonal/non-hormonal intrauterine device (IUD), implant, tubal ligation, vasectomy; Tier 2 includes oral contraceptives, shots, ring, patch; Tier 3 includes internal/external condom, diaphragm/cervical cap, natural family planning, rhythm; Tier 4 includes foam/jelly/spermicide/sponge, and withdrawal. “No method used” indicates no method used for at least one sexual encounter within a participant’s lifetime. Frequencies may exceed 100% since participants could select all that apply. If a participant ever reported “no method used,” then they were coded as “yes” for no method used even if other methods were selected since this item was “check all that apply.

Next, we examined sexual orientation-based differences in whether a provider ever encouraged STI testing or discussed SRH (adjusted for covariates). As identified in our prior work with this sample [26], completely heterosexual women with same-sex partners (RR=1.31; 95% CI: 1.23, 1.39), mostly heterosexual women (RR=1.28, 95% CI: 1.24, 1.32), and bisexual women (RR=1.29, 95% CI: 1.21, 1.38) were more likely than completely heterosexual women with no same-sex partners to report a provider ever encouraging STI testing; lesbian women did not significantly differ from completely heterosexual women without same-sex partners. Similarly, completely heterosexual women with same-sex partners (RR=1.04, 95% CI: 1.01, 1.06) and mostly heterosexual women (RR=1.04, 95% CI: 1.03, 1.05) were more likely than completely heterosexual women with no same-sex partners to report a provider ever discussing their SRH. Meanwhile, lesbian women were less likely than completely heterosexual referents to report providers discussing their SRH (RR=0.87, 95% CI: 0.82, 0.91); bisexual women did not significantly differ from referents.

The interaction between sexual minority status × lifetime provider STI testing encouragement (p=.002; Figure 1) and between sexual minority status × lifetime provider-patient SRH discussion (p<.0001; Figure 2) were significant for not using a contraception method in the past year. Women who never had a provider encourage STI testing were more likely than those with this encouragement to report not using a contraceptive method in the past year (Figure 1); however, sexual minority women who did not report STI testing encouragement, versus those who did, were 1.7 times as likely to report not using a contraceptive method in the past year. A similar pattern was seen among sexual minority women whose provider ever discussed their SRH (Figure 2). A sensitivity analysis was conducted with a “no method” variable that was mutually exclusive with all other contraception outcomes. The only meaningful change to findings was that the sexual minority status × lifetime provider STI testing encouragement interaction was no longer significant in predicting contraception non-use.

Figure 2.

Figure 2.

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Predicted probability of a provider ever discussing SRH by sexual minority status on not using contraception in the past year. Note. SRH is “sexual and reproductive health.” Sexual minority includes the completely heterosexual with same-sex partners, mostly heterosexual, bisexual, and lesbian groups. The joint effect of a provider encouraging SRH services use and sexual orientation was significant at p<.0001.

Additionally, sexual minority women whose providers either encouraged STI testing or discussed their SRH were least likely to report not using a contraceptive method at some point in the past year. The interaction between sexual minority status × lifetime provider STI testing encouragement was significant for lifetime STI diagnosis (p=.03; Figure 3). Sexual minority women were up to 1.3 times more likely than completely heterosexual women with no same-sex partners to report a lifetime STI diagnosis among those reporting no provider encouragement for STI testing and 1.2 times more likely when provider STI testing encouragement was reported. Full interaction model statistics are reported in Supplementary Table A.

4. Discussion and Conclusion

4.1. Discussion

Compared to completely heterosexual women, sexual minority women are 40% more likely to receive an STI diagnosis in their lifetime [3] and up to 4 times as likely to report an adolescent pregnancy [27]. Research on adolescents has found that lesbian girls (including those with lifetime past male partners) are also much less likely than heterosexual women to use condoms at their last sexual encounter [28], while bisexual and mostly heterosexual women were more likely to use more effective (i.e., Tier 1–2) methods [6]. Per Structural Influence Model, inequalities in provider-patient communication may contribute to SRH inequities [7]. In context with key findings, implications are mixed and largely dependent on sexual minority subgroup. For instance, all sexual minority women except for lesbians were more likely than completely heterosexual women with no same-sex partners to report a provider ever discussing their SRH; whereas, lesbian women were less likely to report provider SRH discussions compared to completely heterosexual referents. This is consistent with previous GUTS research that found provider encouragement of STI testing, Pap testing, or HPV vaccination services tends to be higher among mostly heterosexual and bisexual women than completely heterosexual women [26]. Similarly, in a study using a random national sample of U.S. adults [29], lesbians were less likely than heterosexual women to receive birth control or condom counseling when accessing SRH services, even when adjusting for past sex with male partners.

Our study significantly expands upon past literature by examining the interaction of sexual orientation and provider-patient communication on SRH outcomes using cross-sectional analysis of both recent (e.g., contraceptive use) and lifetime retrospective (e.g., provider-patient communication) self-report measures. To date, one study using a national random sample of U.S. adults found that past-year contraceptive and STI services use was associated with higher odds of Pap testing among heterosexual and bisexual women [30], which implies SRH services use can be an indicator for SRH services encouragement/referral. Our findings are also consistent with those from another study with a presumed heterosexual sample, which found that having a past SRH care visit was associated with lower odds of contraceptive non-use [11].

Of note, in our study sexual minority women whose provider ever encouraged STI testing or discussed their SRH were the least likely to report “no method” of contraception in the past year (at some point in time). It is important to qualify that this outcome is not mutually exclusive with other contraceptive methods, and thus may indicate lower SRH risk at some sexual encounters (if applicable), but not all. Further, since frequency/type of past-year sexual activity and partner anatomy were not assessed, the “no method” category may not necessarily represent increased risk for certain STIs or pregnancy. However, given that either type of provider-patient communication was associated with greater likelihood of any tier of contraceptive use for all women, even in sensitivity analyses that used a version of the “no method” variable that was mutually exclusive with all other contraception outcomes, it appears that provider-patient communication may influence contraceptive use and SRH risks for sexual minority women. However, such communication may not be sufficient if care is not taken by clinicians to avoid: assumptions about sexuality, sexual behavior, or partner anatomy [31]; prioritizing pregnancy prevention over other needs; providing misinformation about risks associated with certain sexual behavior or identities; and minimizing SRH concerns when presented [8,10,14,31,32]. In particular, patient-centered communication (including shared decision-making) can aid in improving relationships with sexual minority patients [33,34].

In contrast to our contraception findings, women whose provider ever encouraged STI testing were nearly twice as likely to have a lifetime STI diagnosis, with sexual minority women who reported STI test encouragement being the group most likely to report an STI diagnosis. It is likely this outcome is capturing probability of screening (and not diagnosis) due to clinical guidelines [35] for STI testing among sexually active young adult women, thus rates of STIs may be underestimated among those who did not receive encouragement. However, this finding may also point to poor provider-patient communication quality among sexual minority women. Provider-patient interactions at the point of STI testing may not provide accurate, inclusive, or identity-affirming information for future STI prevention for sexual minority women [32]. For instance, lack of competent care is evidenced by lower odds of lesbians receiving barrier-based contraceptive information during STI consults relative to heterosexual women [29].

There are several limitations in the present study. The sample was primarily white and consists of nurses or children of nurses; thus, findings will not be generalizable to all U.S. women, particularly those from minoritized racial/ethnic backgrounds. Further, given the item wording of the lifetime provider-patient communication and SRH outcomes, temporal precedence cannot be determined. Additionally, due to limitations with sub-sample sizes resulting in large standard errors and unstable CIs, sexual minority subgroups could not be disambiguated from one another for interaction analyses. Provider-patient communication indicators were not comprehensive, and more nuanced measures like perceived discrimination in medical settings [19], provider-patient communication quality [19,36], and trust in physicians [19,37], may reveal different patterns of association and mediational effects [19]. We were also unable to stratify by developmental phase due to limited sample size and since most participants fell in the same age and generational cohorts. Future research should examine variations in SRH communication outcomes by generational cohort and developmental phase, as needs and experiences will vary by age (e.g., older adults and early adolescents will differ in their SRH information needs and exposures), sociocultural environment (e.g., political climate toward sexual minorities), and developmental considerations (e.g., readiness for sex). As outcomes could not be validated using medical records, lifetime STI diagnosis estimates may be underestimated due to recall bias.

4.2. Practice Implications

Provider-patient communication has the potential to reduce contraception non-use and increase STI screening rates, though lesbian women may not see equal benefit due to sexual orientation-related communication disparities. Extant research [8] points to the need for providers to engage with sexual minority women using cultural humility approaches [38] that acknowledge how structural norms that perpetuate violence and trauma also serve to exclude and minimize sexual minority women in contexts of SRH care. Familiarization with historical conceptualizations of sex, gender, and sexual orientation in healthcare can inform providers about structural biases that are ingrained in current models of care [39]. Heteronormative risk discourse around SRH should be de-centered in provider-patient interactions; providers can acknowledge how patients’ past healthcare interactions may have erased sexual minority identities and experiences, framed “heterosexual” sexual activities as primarily risky due to pregnancy concerns, stigmatized bisexual women as being an elevated risk group, and how most SRH discourse is focused on pregnancy [40]. Addressing these social barriers to care within clinical interactions can help create more trustworthy and comfortable spaces for patients to share their SRH concerns and identities [41]. Additionally, care should be taken to not stereotype sexual minority women, including sexual minority women of color, and make certain assumptions about their sexual behaviors or risks due to their sexual orientation or other identities [41]. Both assumptions about lesbian women’s decreased SRH risk or interest in SRH care [32,40] and the perception of increased SRH risk among bisexual women and sexual minority women of color [40,42] can push sexual minority women away from seeking SRH care or motivate them to conceal stigmatized SRH concerns. Acknowledging patients may have previously had disaffirming SRH care encounters can open dialogue with patients about their past experiences and current expectations, fears, and needs. In other words, meeting patients where they are during SRH encounters is important in shaping open and trustworthy provider-patient relationships that can effectively address sexual minority women’s current and future SRH needs.

Providing general, sexual minority-inclusive information about benefits of certain contraception methods beyond pregnancy prevention [15] as well as STD risks based on sexual anatomy or practice (e.g., oral sex risks, safe toy sharing) can also be opportunities to open dialogue with sexual minority patients about SRH needs. Affirming that sexual inventory procedures are standard across patients of all sexual orientations can help destigmatize topics of sexual orientation and SRH [43]. Recommendations for taking patient-centered and affirming sexual inventories also include asking permission to discuss SRH, limiting inquiry to the patient’s presenting SRH concerns, providing suggestions and SRH counseling relevant to the presenting concern, and identifying and referring further expertise if necessary [44]. To this end, optimizing shared decision-making practices with patients may serve to improve provider-patient interactions in the context of contraception counselling [45]. Affirming confidentiality of medical records and asking patients’ permission to document their identities in their medical records can also serve to boost trust among sexual minority women with concerns over documentation and subsequent stigmatization, involuntary sexual orientation disclosure, or healthcare denial [46].

4.3. Conclusion

Overall, our findings indicate that lesbians and other sexual minority women have different experiences with provider-patient communication compared to heterosexual women. For example, aside from lesbians, sexual minority women were more likely than completely heterosexual referents to report a provider ever discussing their SRH; whereas, lesbian women were less likely to report provider SRH discussions. These differences in provider-patient SRH discussion by sexual orientation indicate lesbian women are not receiving the same attention to their SRH needs in clinical encounters, and efforts should be taken to improve provider-initiated communication with women. Such communication practices would benefit from cultural humility approaches [38] to acknowledging structural stigma and access disparities in sexual minority women’s SRH experiences, as extant studies describe negative, misinforming, and disaffirming interactions with providers during SRH discussions [8–10,13,14]. Improving SRH communication practices may contribute to reducing contraception non-use in this population.

Supplementary Material

1

Highlights.

  • Provider-patient communication may improve contraceptive use for sexual minority women

  • Referral can improve sexually transmitted infection testing among all women

  • Lesbians need to receive more communication about sexual and reproductive health

Acknowledgments

This work was supported by U01 HL145386 from the National Heart, Lung, and Blood Institute, National Institutes of Health, and grant F32HD100081 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health. Dr. Tabaac was supported by the grant F32HD100081 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health. Dr. Charlton was supported by the American Cancer Society [MRSG CPHPS 130006]. Dr. Austin was supported by grants R01HD057368 and R01HD066963 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, and by grants T71MC00009 and T76MC00001 from the Maternal and Child Health Bureau, Health Resources and Services Administration, U.S. Department of Health and Human Services. Dr. Sutter is supported by the Agency for Healthcare Research and Quality (T32HS026120). Dr. Agénor is supported by grant K01CA234226 from the National Cancer Institute at the National Institutes of Health. Dr. Guss is supported in part by T71MC00009 from the Maternal and Child Health Bureau. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Footnotes

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Declaration of interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

The association between sexual orientation and a provider ever encouraging STI testing was first presented in Solazzo et al., 2019. For consistency, this finding was presented in our paper since all other main effects models were reported. However, there is no other crossover between these two projects beyond this single association.

I confirm all patient/personal identifiers have been removed or disguised so the patient/person(s) described are not identifiable and cannot be identified through the details of the story.

Declaration of Interest Statement

No competing financial interests exist.

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