Healthcare News and Research

[*Anya*]

Diet is inextricably linked to conditions such as heart disease, obesity, and diabetes. However, what we consume also seems to have significant implications for the brain: Unhealthy diets may increase risk for psychiatric and neurologic conditions, such as depression and dementia, whereas healthy diets may be protective. Based primarily on recent Medscape News coverage, the following slideshow collects some of the more prominent investigations on nutrition and the brain into a single resource to aid in counseling your patients.

Make for Malta in Depression, Stroke, and Dementia

A 2009 study published in Archives of General Psychiatry found that people who follow Mediterranean dietary patterns -- that is, a diet high in fruits, vegetables, nuts, whole grains, fish, and unsaturated fat (common in olive and other plan oils) -- are up to 30% less likely to develop depression than those who typically consume meatier, dairy-heavy fare.[1]The olive oil-inclined also show a lower risk for ischemic stroke[2,3] and are less likely to develop mild cognitive impairment and Alzheimer disease, particularly when they engage in higher levels of physical activity.[4,5]

Fat: The Good and the Bad

A study conducted in Spain[6,7] reported that consumption of both polyunsaturated fatty acids (found in nuts, seeds, fish, and leafy green vegetables) and monounsaturated fatty acids (found in olive oil, avocados, and nuts) decreases the risk for depression over time. However, there were clear dose-response relationships between dietary intake of trans fats and depression risk, whereas other data support an association between trans fats and ischemic stroke risk.[8] Trans fats are found extensively in processed foods.

Fish Oil to Fend Off Psychosis?

Thanks to their high levels of polyunsaturated fatty acids, namely omega-3 fatty acids, fish can help fend off numerous diseases of the brain. A 2010 study correlated fish consumption with a lower risk for psychotic symptoms,[10] and concurrent work suggested that fish oil may help prevent psychosis in high-risk individuals.[11] Although data are conflicting, new research shows that the omega-3 fatty acids eicosapentaenoic acid and docosahexaenoic acid are beneficial in depression and postpartum depression, respectively, and other research suggests that omega-3 deficiency may be a risk factor for suicide.[12-16] Oily, cold-water fish, such as salmon, herring, and mackerel, have the highest omega-3 levels.

Berries for Oxidative Stress

Polyphenols, namely anthocyanins, found in berries and other darkly pigmented fruits and vegetables may slow cognitive decline through antioxidant and anti-inflammatory properties. A study in rats from 2010 showed that a diet high in strawberry, blueberry, or blackberry extract leads to a "reversal of age-related deficits in nerve function and behavior involving learning and memory."[17] In vitro work by the same group found that strawberry, blueberry, and acai berry extracts -- albeit in very high concentrations -- can induce autophagy, a means by which cells clear debris, such as proteins linked to mental decline and memory loss.[18] Berry anthocyanins may also reduce cardiovascular disease risk by reducing oxidative stress and attenuating inflammatory gene expression.

What Not to Eat?

Saturated fats and refined carbohydrates have highly detrimental effects on the immune system, oxidative stress, and neurotrophins, all factors that are known to play a role in depression. The study by Akbaraly and colleagues cited previously[22] showed that a diet rich in high-fat dairy foods and fried, refined, and sugary foods significantly increases risk for depression. Similar findings were seen in another study from Spain,[7] showing that intake of such foods as pizza and hamburgers increased the risk for depression over time, and in another study, women with a diet higher in processed foods were more likely to have clinical major depression or dysthymia.[17] Research published last year[37] also showed for the first time that quality of adolescents' diets was linked to mental health: Healthier diets were associated with reduced mental health symptoms and unhealthy diets with increased mental health symptoms over time. Excess salt intake has been long known to increase blood pressure and stroke risk[38,39]; however, recent data also correlate high salt intake, as well as diets high in trans or saturated fats, with impaired cognition.[40,41]

PLEASE NOTE:

**Studies and references available if interested. Did not list as there are 41 separate citations!

[*Anya*]

From Pharmacotherapy

Comparison of Prescription Drug Costs in the United States and the United Kingdom: Statins

Hershel Jick, M.D.; Andrew Wilson, M.P.H.; Peter Wiggins, M.B.; Douglas P. Chamberlin, B.A.

Boston Collaborative Drug Surveillance Program, Boston University School of Medicine, Lexington, Massachusetts (Dr. Jick and Mr. Chamberlin); the Tufts Center for the Study of Drug Development, Boston, Massachusetts (Mr. Wilson); and Castlemilk Group Practice, Glasgow, UK (Dr. Wiggins).

Posted: 02/19/2012; Pharmacotherapy. 2012; 32(1):1-6. © 2012 Pharmacotherapy Publications

Abstract

Study Objective To compare the annual cost of statins in the United States and in the United Kingdom.

Design Matched-cohort cost analysis.

Data Sources U.K. General Practice Research Database (GPRD), and MarketScan Commercial Claims and Encounters Database, a large, U.S. self-insured medical claims database.

Study Population We initially identified 1.6 million people in the GPRD who were younger than 65 years of age in 2005. These people were then matched by year of birth and sex with 1.6 million people in the U.S. database. From this matched pool, we estimated that 280,000 people aged 55–64 years from each country in 2005 were prescribed at least one drug. Of these, 91,474 (33%) in the U.S. were prescribed a statin compared with 68,217 (24%) in the U.K. After excluding those who did not receive statins continuously or who switched statins during the year, there remained 61,470 in the U.S. and 45,788 in the U.K. who were prescribed a single statin preparation continuously during 2005 (annual statin users). We estimated and compared drug costs (presented in 2005 U.S. dollars) separately in the two countries.

Measurements and Main Results Estimated drug costs were determined by random sampling. Estimated annual costs/patient in the U.S. ranged from $313 for generic Lovastatin to $1428 for nongeneric simvastatin. In the U.K., annual costs/patient ranged from $164 for generic simvastatin to $509 for nongeneric Atorvastatin. The total annual cost of the continuous receipt of statins in the U.S. was $64.9 million compared with $15.7 million in the U.K. In June 2006, after our study results were analyzed, the U.S. Food and Drug Administration approved generic simvastatin. We thus derived cost estimates for simvastatin use during 2006 and found that more than 60% of simvastatin users switched to the generic product, which reduced the cost/pill by more than 50%.

Conclusion The cost paid for statins in the U.S. for people younger than 65 years, who were insured by private companies, was approximately 400% higher than comparable costs paid by the government in the U.K. Available generic statins were substantially less expensive than those that were still under patent in both countries.

For reprints, visit http://caesar.sheridan.com/reprints/...0089&acro=PHAR. For questions or comments, contact Hershel Jick, M.D., Boston Collaborative Drug Surveillance Program, Boston University School of Medicine, 11 Muzzey Street, Lexington, MA 02421; e-mail: hjick@bu.edu.

[*Anya*]

New Position Statement from NAMS on Hormone Therapy
Reassuring News for Many Women
JoAnn E. Manson, MD, DrPH

This Dr. JoAnn Manson, Professor of Medicine at Brigham and Women's Hospital and Harvard Medical School. I would like to talk with you today about a new position statement on hormone therapy from the North American Menopause Society (NAMS) that was just published in the journal Menopause.[1] This position statement is freely available on the NAMS Website, and it also is accompanied by a patient education handout that can be downloaded and may be very helpful for patient care. I would like to acknowledge that I served in the writing group for this position statement and also that I am currently serving as president of NAMS.

What is new in this 2012 position statement? First, the statement does reaffirm that hormone therapy is the most effective treatment for vasomotor symptoms and other symptoms of menopause. However, now with a decade of research findings since publication of the first results from the Women's Health Initiative (WHI), it has become clear that there are important distinctions between estrogen plus progestin and estrogen alone in terms of benefits and risks. Furthermore, the benefit/risk profile of hormone therapy can vary by a woman's age, time since menopause and her personal risk-factor profile.

One of the reasons that previous guidelines have recommended avoiding treatment with hormones for more than 5 years is that estrogen plus progestin is linked to an increased risk for breast cancer after 3-5 years. This has been seen in many types of studies. Estrogen therapy alone was associated with no increase in the risk for breast cancer in the WHI Estrogen-Alone Trial, with an average of 7 years of treatment and up to 11 years of follow-up. These findings suggest that there may be more flexibility in terms of the duration of treatment of women with hysterectomy who are taking estrogen alone.

Overall, it is suggested that treatment with hormone therapy should be individualized -- that it will depend on the severity of a woman's symptoms, impairment of quality of life, her personal risk-factor status, and her personal preferences. Women who have early surgical or natural menopause may be treated until the average age of natural menopause, around age 51, in the absence of contraindications, and even longer if necessary for symptoms. This is also highlighted in the position statement.

Evidence has been increasing that different formulations and routes of delivery (for example, transdermal or low-dose estrogen) may have different benefits and risks. Overall, we need much more research on the role of formulation and route of delivery of estrogen, but we have some evidence that the transdermal route of delivery may have some advantages, especially for women who are at increased risk for thrombosis.

The NAMS statement reaffirms that estrogen therapy (ET) represents the most effective treatment for the dryness and dyspareunia caused by genital atrophy. When the only indication for use of HT is genital atrophy, vaginal ET, including 2 marketed creams, the 2-mg estradiol 3-month ring, and 10-µg estradiol slow-release tablets, represent appropriate therapy and can be used safely as long as needed to relieve symptoms.

Vaginal ET is approved to treat genital atrophy only; however, vaginal ET also helps to prevent recurrent urinary tract infections, and the 2-mg estradiol vaginal ring in particular has been noted to benefit women with overactive bladder. Although use of a progestin to protect the endometrium is, in general, not recommended while vaginal ET is used, any bleeding that occurs during use should be evaluated.

http://www.menopause.org/psht12.pdf

http://www.medscape.com/viewarticle/759409

Menopause: The Journal of The North American Menopause Society
Vol. 19, No. 3, pp. 257/271
DOI: 10.1097/gme.0b013e31824b970a
* 2012 by The North American Menopause Society

[Kobi]

Study Links Cat Litter Box to Increased Suicide Risk

A common parasite that can lurk in the cat litter box may cause undetected brain changes in women that make them more prone to suicide, according to an international study.

Scientists have long known that pregnant women infected with the toxoplasma gondii parasite -- spread through cat feces, undercooked meat or unwashed vegetables -- could risk still birth or brain damage if transmitted to an unborn infant.

But a new study of more than 45,000 women in Denmark shows changes in their own brains after being infected by the common parasite.

The study, authored by University of Maryland School of Medicine psychiatrist and suicide neuroimmunology expert Dr. Teodor T. Postolache, was published online today in the Archives of General Psychiatry.

The study found that women infected with T. gondii were one and a half times more likely to attempt suicide than those who were not infected. As the level of antibodies in the blood rose, so did the suicide risk. The relative risk was even higher for violent suicide attempts.

"We can't say with certainty that T. gondii caused the women to try to kill themselves, but we did find a predictive association between the infection and suicide attempts later in life that warrants additional studies," said Postolache, who is director of the university's Mood and Anxiety Program and is a senior consultant on suicide prevention.

"There is still a lot we don't know," he told ABCNews.com. "We need a larger cohort and need a better understanding of the vulnerabilities that certain people have to the parasite."

Suicide is a global public health problem. An estimated 10 million attempt suicide and 1 million are successful, according to Postlache's work.

More than 60 million men, women, and children in the United States carry the toxoplasma parasite, according to the Centers for Disease Control and Prevention, but very few have symptoms.

Toxoplasmosis is considered one of the "neglected parasitic infections," a group of five parasitic diseases that have been targeted by CDC for public health action.

About one-third of the world is exposed to T. gondii, and most never experience symptoms and therefore don't know they have been infected. When humans ingest the parasite, the organism spreads from the intestine to the muscles and the brain.

Previous research on rodents shows that the parasite can reside in multiple brain structures, including the amygdala and the prefrontal cortex, which are responsible for emotional and behavioral regulation.

Rat Study Showed Parasite Changes the Brain
A 2011 study on rats infected by the parasite showed that their fear of cats disappeared. Instead, the parts of their brains associated with sexual arousal were activated. Researchers theorized that the mind-manipulating T. gondii ensures that the parasite will reach and reproduce in the gut of a cat, which it depends upon for its survival.

"The parasite does actually alter the brain of its host," Stanford University study co-author Patrick House told ABCNews.com last year. "The fact that a parasite can get into an organism, target its brain, stay there without killing the host and alter the circuitry of the brain -- we've seen this is insects and fungi, but it's the first time we've seen it in a mammalian host."

It was this and other research that led Postolache to investigate the relationship between the parasite and biological changes in the brain that might lead to suicide. He was also intrigued by studies on allergies and research that showed a connection between toxoplasmosis and schizophrenia.

"I was interested in the neuron aspects of suicide and intrigued by low-grade activation in patients who attempted suicide, as well as victims," he said. "Other studies had looked at the brain and suicide risk and impulsivity. The next question was, what could be the triggers that perpetuate this level of heightened activation in the brain?"

Postolache collaborated with Danish, German and Swedish researchers, using the Danish Cause of Death Register, which logs the causes of all deaths, including suicide. The Danish National Hospital Register was also a source of medical histories on those subjects.

They analyzed data from women who gave birth between 1992 and 1995 and whose babies were screened for T. gondii antibodies. It takes three months for antibodies to develop in babies, so when they were present, it meant their mothers had been infected.

The scientists then cross-checked the death registry to see if these women later killed themselves. They used psychiatric records to rule out women with histories of mental illness.

Postolache said there were limitations to the study and further research is needed, particularly with a larger subject group.

Dr. J. John Mann, a psychiatrist from Columbia University, said Postolache's research mirrors his work in the field of suicidal behavior.

"The relationship of the brain to the immune system is more complex than it may appear," said Mann. "The brain regulates the stress response system, which impacts the immune response."

Scientists already know that steroids like cortisone can affect the immune response. Some antibodies whose goal is to kill off cancer can also affect the brain. Oftentimes the first symptom of pancreatic cancer is depression, he said.

Research also shows that streptococcus bacteria can trigger obsessive-compulsive disorder (OCD) in some children. Sydenham's chorea, the loss of motor control that can occur after acute rheumatic fever, may also be an immune response affecting the brain, according to Mann.

Maryland researcher Postolache suspects that some individuals have a predisposition to these neurological changes.

He speculates that the parasite may disrupt neurological pathways in those who are vulnerable, so that projections of fear and depression from the amygdala are not tempered or controlled by the "braking" function of the prefrontal cortex.

But, Postolache warns that even if a direct cause were found, no antibiotics for T. gondii yet exist and it could be a decade before effective vaccines or other agents that might stop the neurological damage are developed.

Right now, the most effective weapon against T. gondii is education about handwashing, the proper cooking of food, and not using a knife exposed to raw meat on cooked meat.

He also cautions against trendy food production techniques that let animals roam free. "The risk of infection could go up," he said, "and increase the rate of toxoplasmosis."

http://gma.yahoo.com/study-links-cat...ws-health.html

[Kobi]

Brian Kearney was an angry teenager.

"There were lots of holes in my bedroom wall," said 21-year-old Kearney, recalling the "superhuman strength" that sent his VCR clear across the room. "I would say I was a little on edge."

For Kearney, who also struggled with an eating disorder in his teens, anger was a way release the pressure of high school.

"I didn't develop appropriate coping mechanisms," Kearney said.

Nearly two-thirds of American teenagers admit to having "anger attacks" that that involve destroying property, threatening or engaging in violence, a new study found. And one in 12 has intermittent explosive disorder, characterized by chronic, uncontrollable fits of rage.

"It's an enormous problem that mental health professionals have not taken seriously," said Ronald Kessler, a psychiatric epidemiologist at Harvard Medical School in Boston and lead author of the study, published Monday in the journal Archives of General Psychiatry. "I think it's clear from this study that needs to change."

"Without a really good reason, people all of a sudden feel very fearful, or very angry, and do something excessive," he said. "It's either fight or flight."

For Kearney, one wrong look could trigger a "vicious" reaction.

"I can't explain how I felt when I was in one of those fits of rage," he said. "It's almost like I would black out."

Kessler said Kearney's situation is too common to ignore.

"One in 12 kids has this problem. And people very often continue to have this problem into adulthood, affecting their education, jobs and marriages," he said. "Not to mention the criminal implications."

Although IED is listed in the American Psychiatric Association's Diagnostic and Statistical Manual, its cause – and how best to treat it – remain unknown.

"It bears studying, because what we currently know remains speculative," said Dr. Bela Sood, chair of child and adolescent psychiatry at VCU Medical Center in Richmond, Va.

Sood said IED can be hard for patients – and their parents – to handle.

"During an episode, a person goes from zero to 60," she said. "Afterward they often feel remorseful, but the deed is done."

Kearney said he would apologize to his parents after an attack but admitted the anger took a heavy toll.

"It definitely affected our relationship," he said. "But in the end I'm closer to them than I ever was."

Kearney, now a junior at Rowan University in Glassboro, N.J., patched up his relationships – and the holes in his wall – and left his troubled teenage years behind. He credits talk therapy for his victory over anger, as well as Xanax that helps quell his anxiety.

"Everything I've gone through has shaped me into the person I am today," he said. "And I think I'm a pretty good person."

http://abcnews.go.com/Health/MindMoo...ry?id=16694231

[*Anya*]

References

1. Dean L, Meyer I, Robinson K, et al. Lesbian, gay, bisexual, and transgender health: findings and concerns. J Gay Lesbian Med Assoc. 2000;4(3):101–151.
2. Neville S, Henrickson M. Perceptions of lesbian, gay and bisexual people of primary healthcare services. J Adv Nurs. 2006;55(4):407–415.
3. Institute of Medicine. Lesbian Health: Current Assessment and Directions for the Future. Washington, DC: National Academy Press; 1999. http://books.nap.edu/openbook.php?record_id_6109&page_1. Accessed April 3, 2012.
4. Hutchinson M, Thompson A, Cederbaum J. Multisystem factors contributing to disparities in preventive health care among lesbian women. J Obstet Gynecol Neonatal Nurs. 2006;35(3):393–402.
5. Spinks VS, Andrews J, Boyle J. Providing health care for lesbian clients. J Transcult Nurs. 2000;11(2):137–143.
6. Mravcak S. Primary care for lesbians and bisexual women. Am Fam Physician. 2006;74(2):279–286.
7. O'Hanlan KA, Dibble SL, Hagan HJJ, Davids R. Advocacy for women's health should include lesbian health. J Womens Health (Larchmt). 2004;13(2):227–234.
8. Seaver MR, Freund KM, Wright LM, Tjia J, Frayne SM. Healthcare preferences among lesbians: a focus group analysis. J Womens Health (Larchmt). 2008;17(2):215–225.
9. Dibble SL, Roberts SA, Robertson PA, Paul SM. Risk factors for ovarian cancer: lesbian and heterosexual women. Oncol Nurs Forum. 2002;29(1):E1-E7.
10. The Joint Commission. Advancing effective communication, cultural competence, and patient- and family-centered care: a roadmap for hospitals. 2010. http://www.jointcommission.org/Advan..._Communication. Accessed April 3, 2012.
11. Gay and Lesbian Medical Association. Healthy People 2010 Companion Document for Lesbian, Gay, Bisexual and Transgender (LGBT) Health. 2001. http://www.nalgap.org/PDF/Resources/...LGBTHealth.pdf.
12. Gay and Lesbian Medical Association. Lesbian, gay, bisexual, and transgender health: overview. Healthy People 2020 Web site. http://healthypeople.gov/2020/topics...spx?topicid_25. Updated November 18, 2011. Accessed November 21, 2011.
13. Bjorkman M, Malterud K. Lesbian women's experience with health care: a qualitative study. Scand J Prim Health Care. 2009;27(4):238–243.
14. Platzer H, James T. Lesbians' experiences of healthcare. Nurs Times Res. 2000;5(3):194–202.
15. Nursing Council of New Zealand. Guidelines for cultural safety, the treaty of Waitangi, and Maori health in nursing education and practice. 2005. Amended and reprinted March 2009. http://www.nursingcouncil.org.nz/dow...l-safety09.pdf. Accessed February 5, 2011.
16. Roberts SJ. Health care recommendations for lesbian women. J Obstet Gynecol Neonatal Nurs. 2006;35(5):583–591.
17. Boehmer U, Bowen DJ. Examining factors linked to overweight and obesity in women of different sexual orientations. Prev Med. 2009;48(4):357–361.
18. Marrazzo JM, Koutsky LA, Kiviat NB, Kuypers JM, Stine K. Papanicolaou test screening and prevalence of genital human papillomavirus among women who have sex with women. Am J Public Health. 2001;91(6):947–952.
19. Cochran SD, Mays VM. Burden of psychiatric morbidity among lesbian, gay, and bisexual individuals in the California Quality of Life Survey. J Abnorm Psychol. 2009;118(3):647–658.
20. Matthews AK, Hughes TL, Johnson T, Razzano LA, Cassiday R. Prediction of depressive distress in a community sample of women: the role of sexual orientation. Am J Public Health. 2002;92(7):1131–1139.
21. Marshal MP, Dietz LJ, Friedman MS, et al. Suicidality and depression disparities between sexual minority and heterosexual youth: a meta-analytic review. J Adolesc Health. 2011;49(2):115–123.
22. Mustanski BS, Garofalo R, Emerson EM. Mental health disorders, psychological distress, and suicidality in a diverse sample of lesbian, gay, bisexual, and transgender youths. Am J Public Health. 2010;100(12):2426–2432.
23. Haas AP, Eliason M, Mays VM, et al. Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: review and recommendations. J Homosex. 2011;58(1):10–51.
24. Lehavot K, Simoni JM. The impact of minority stress on mental health and substance use among sexual minority women. J Consult Clin Psychol. 2011;79(2):159–170.
25. Blosnich JR, Horn K. Associations of discrimination and violence with smoking among emerging adults: differences by gender and sexual orientation. Nicotine Tob Res. 2011;13(12):1284–1295.
26. Centers for Disease Control and Prevention. HIV/AIDS among women who have sex with women. 2006. http://www.cdc.gov/hiv/topics/women/...sheets/wsw.htm. Accessed March 1, 2011.
27. Marrazzo JM, Coffey P, Bingham A. Sexual practices, risk perception and knowledge of sexually transmitted disease risk among lesbian and bisexual women. Perspect Sex Reprod Health. 2005;37(1):6–12.
28. O'Hanlan KA. Health policy considerations for our sexual minority patients. Obstet Gynecol. 2006;107(3):709–714.
29. Zeidenstein L. Health issues of lesbian and bisexual women. In: Varney's Midwifery. Varney H, Kriebs JM, Gegor CL, eds. 4th ed. Sudbury: Jones and Bartlett Publishers; 2004:299–311.
30. McManus A. Creating an LGBT-friendly practice: practical implications for NPs. Am J Nurse Pract. 2008;12(4):29–38.
31. Anderson T. Nursing profession development: scope and standards of practice (2010). Nebr Nurse. 2011;44(3):8–9.
32. Makadon HJ, Mayer KH, Potter J, Goldhammer H, eds. Fenway Guide to Lesbian, Gay, Bisexual and Transgender Health. Philadelphia: American College of Physicians Press; 2007.

[*Anya*]

Part II

It is difficult to accurately capture the full effect of marginalization, discrimination, and stigmatization on the mental health of an individual or minority group. LGBT persons "are subject to unique social stressors such as prejudice, stigmatization, and antigay violence that may precipitate mental distress, mental disorders, suicidal ideation, and self-harm."[6] Matthews et al[20] studied the role of sexual orientation in predicting depressive distress in a sample of women. Their sample (N 5 829) showed "51% of lesbians and 38% of heterosexual women reported seriously considering suicide at some point in the past."[20] Also, "more than twice as many lesbians as heterosexual women in this age group (15–19) reported suicide attempts."[20]

Although research is limited, LGBT youth may also be at increased risk for suicide attempts compared to their heterosexual counterparts. Marshal et al[21] found that there is a higher rate of suicidality in sexual minority youth compared with heterosexual youth. However, in the study of LGBT youth by Mutanski et al,[22] there were similar rates of suicidality compared with youth of the same geographical areas. They also noted that mental health disorders were higher among the LGBT youth group compared with national data samples but similar when compared with ethnic/minority urban youth samples. Haas et al[23] said, "Over the last 2 decades, an increasing body of empirical research in the US and other countries has pointed to significantly elevated suicide risk among LGBT compared to heterosexual people."

Although there is limited research describing reasons for increased risk in the WSW population, it may be that many mental health issues are associated with the consequences of being a WSW living in a "heterosexual-oriented society."[7] "Heteronormativity denotes how the social life of Western culture is constructed on the assumption that all people are heterosexual, assuming the heterosexual nuclear family
norm to be natural and universal, and thereby making homosexuality socially invisible and second class."[13] It is important to understand that marginality of any kind can be a risk factor for mental health issues. Lehavot and Simoni[24] suggest screening (and referring as needed) for minority stress and the presence/absence of "coping resources" among sexual minority women.

Substance Abuse

Spinks et al[5] said, "Accurate estimates of the prevalence of substance abuse in lesbians are not available due to the marginalization and hidden nature of the population."[5] The rate of alcohol abuse in WSW is unclear and data are conflicting. Dean et al[1] identify that early studies on the gay and lesbian population recruited subjects in bars "which, not surprisingly, showed higher rates of heavy alcohol and drug use than the general population."

Many reports discussed by Roberts[16] indicate that there is more alcohol use in the lesbian community. "Data from the Women's Health Initiative study and other, smaller studies indicate that tobacco use is higher among lesbians than among the general female population."[6] This finding is in contrast with the Dibble study mentioned above. Roberts[16] said, "Reviews have concluded that smoking rates for adolescent and adult lesbians are higher than their national comparison groups, with adolescents being highest for both groups."

Blosnich and Horn[25] examined discrimination/violence and associated smoking among young adults and found that sexual minorities were more likely to experience discrimination and violence and are twice as likely to smoke when compared with heterosexuals in the same age group. It appears that there may be increased substance abuse among WSW in comparison to heterosexual women, but this, too, needs further research. Many factors may put WSW at higher risk for substance abuse or mental health issues, including social stigma, societal pressures, internalized homophobia, the "coming out" process, and discrimination.[5,6,16]

STDs and Reproductive Health/Services

Women who describe themselves as having same sex orientation may identify themselves as lesbian. However, sexual behavior is not the same as sexual orientation, and these should not be confused.[4] Obtaining an accurate sexual history is important to identify risk factors for STDs and safe sex practices. Sex practices of WSW vary widely and the most important thing a provider can do is refrain from making assumptions.

The risk for STD transmission in WSW changes based on sexual practices and the STD organism.[4] Little is known about transmission of STDs between 2 women. "Transmission of some STDs between women is known to occur; for other STDs, transmission between women is possible in theory but has not been proven."[6] Mravcak[6] provides a table in her article showing known transmission of STDs between women to include herpes simplex, genital warts associated with HPV, and trichomoniasis. Included in the table is the description of theoretical STD transmission between WSW: chlamydia, gonorrhea, syphilis, hepatitis B, and HIV.[6] Bacterial vaginosis, while not an STD, is commonly found in the WSW and their female partners[6,16] and is believed to be transmitted between women.[16]

As identified earlier in this article, most WSW have a history of male sexual partners. This fact increases STD risk for these women and their partners. However, Mravcak[6] said, "Lesbians are less likely than bisexual or heterosexual women to be tested regularly for STDs."[6] Many WSW may not believe that they are at risk for acquiring STDs and may even delay treatment when symptoms arise.[4] In addition, NPs may have inaccurate information about the risks of STDs for WSW and assume that they are not engaging in heterosexual intercourse.[4] This assumption may result in the provider choosing to omit needed routine screening for these patients.[4]

NPs need to teach safe sex practices for WSW. Some recommendations given by Mravcak[6] are to avoid contact with any visible genital lesions, cover sex toys that penetrate more than one person's vagina or anus with a new condom for each person, use a barrier during oral sex, and use latex or vinyl gloves and lubricant for any manual sex that might cause bleeding. The Centers for Disease Control and Prevention[26] (CDC) determined, "No barrier methods for use during oral sex have been evaluated as effective by the Food and Drug Administration. However, natural rubber latex sheets, dental dams, condoms that have been cut and spread open, or plastic wrap may offer some protection from contact with body fluids during oral sex and thus may reduce the possibility of HIV transmission."

The CDC[26] also suggests the importance of knowing a partner's HIV status since there is a potential for HIV transmission through menstrual blood. For WSW at this time, oral sex does not require barrier methods if performed with a monogamous partner whose HIV status is negative and has no lesions or other risk factors.[26] Jeanne Marrazzo, MD, MPH, is a leader in infectious diseases and STD prevention and epidemiology. She and her colleagues[27] said WSW should be educated about possible STD transmission between women and education should be centered on common sex practices between WSW.

Reproductive health services are important topics to discuss with WSW patients. In the US, approximately 6 to 14 million children have parents who are lesbian or gay.[6] WSW may have children from previous relationships with men or may choose to become pregnant through a sperm bank, known donor, or heterosexual intercourse. Adoption and foster care are also options for WSW in many states. Other than dealing with societal stigma, studies have shown that children of lesbians have comparable development and life skills adjustment to children in heterosexual families.[16] "The American Psychological Association, the American Academy of Pediatricians, and the North American Council on Adoptable Children have each endorsed foster parenting, adoption, and parenting by same-gender couples, with the reassurance that their review of all the research on these children show that they develop normally."[28]

Even so, the process of starting a family can be emotionally, mentally, and financially challenging for WSW because of social stigma, discrimination, legal issues, and isolation. Zeidenstein[29] said the birth mother has unique challenges as she may have to "come out" again after becoming pregnant and once again as a lesbian mother. Zeidenstein[29] also identified that the comother can experience pain when her role as a parent is not recognized by the people in her life. Furthermore, state laws vary greatly. Legal action is required in most states for the nonbiological parent to be granted parental rights.[6] While legal implications are not within the scope of this article, it is important for NPs to encourage WSW to seek assistance from lawyers to ensure their wishes are granted and to ensure the comother has the rights of parenting she deserves. As an NP, referring WSW to agencies that are known to be nondiscriminatory can also be very helpful.[5]

Improving Practice Through Cultural Safety

NPs are responsible for creating a safe and caring atmosphere for each patient. A "safe" environment is defined by the patient. Key factors to a safe and caring context are reflection, environment, language, and knowledge. Context includes all the "in-betweens" of these 4 key factors. Most of context is made up of what is not said with words or language. A truly safe and caring health care context cannot be achieved by omitting any of the 4 elements. For example, a clinician who provides a safe environment but does not use inclusive language is not providing safe care.

Reflection of one's own feelings and possible biases about the WSW population is the first step in establishing a caring and safe patient-provider relationship. Acknowledging these feelings and examining personal biases is a necessary part of providing a safe and caring environment. McManus[30] said, "Awareness of how one's own attitudes affect clinical judgment and the development of a non-homophobic attitude are important steps in providing culturally competent care."[30] Reflection is an ongoing assessment of one's own feelings, reactions, and motivations. It cannot be done once as a single exercise; it is always evolving based on new experiences and interactions. The process of self-reflection is a personal mission of growth and development that requires continual self-evaluation.

Environment is the first factor that a WSW patient will experience. The waiting room can be a significant indicator of the level of acceptance a WSW patient can expect. The presence/absence of a posted nondiscriminatory policy, the art/pictures displayed, and the kinds of reading material available are all examples of environmental factors that a WSW patient will notice immediately. An example of a nondiscriminatory statement is: "This office appreciates the diversity of women [and men] and does not discriminate based on race, age, religion, ability, marital status, sexual orientation, gender, or perceived gender."[7]

The environment will likely affect the WSW patient's openness about her sexuality. "If the environment is perceived as completely unsafe, questioning by the provider will elicit an inaccurate history."[29] Many waiting rooms and clinics have brochures, posters, and educational materials that "reflect heterosexual experience."[29] Including posters or pictures depicting same-sex couples, brochures available that include same-sex experiences, a visible nondiscriminatory policy, and a visible symbol that the WSW population will recognize as a sign of safety are all ways to make an environment more welcoming to them.[4-6,16,30]

McManus[30] gives examples of symbols that health care providers can display to demonstrate a safe environment for the LGBT population:

**pink triangle (symbol of homosexuality in the concentration camps of Nazi Germany)
**A rainbow flag (an icon for the LGBT community since 1978, when it was first used in the San Francisco Gay Pride Parade)
**The Human Rights Campaign's equality symbol (a blue square with a yellow equal sign [5], which is well known to LGBT persons as a sign of acceptance)

Language used by the provider, staff, and in brochures and history/intake forms is also a strong indicator of safety for the WSW patient. Using inclusive, nonjudgmental, and open-ended questions are important to convey caring and safety. This provides a space for each patient to be as open as she chooses to be. A few examples of open-ended and nonjudgmental language include, "Do you have a partner or a spouse?" instead of "Do you have a husband?" or "Are you married?" Also asking, "Do you, or have you had, sexual relations with men, women, both, or none?"[4–6,16,30] This question is more likely to end with an honest response in comparison to simply asking the patient if she is sexually active.[30] "By taking a little time and asking a few sensitive questions, health care providers can create an environment of trust and inclusion."[5]

Knowledge and competency are associated with caring practice.[31] Understanding the health risks for WSW that are different than heterosexual women is valuable and necessary to provide quality care. The ability to refer patients to other providers who are known to be open and nondiscriminatory is helpful[6] and will enable patients to further trust their provider. The availability of information and resources ( Table 1 ) on WSW-specific health considerations is essential when providing care to this population.

Implications for NPS

In a qualitative study by Bjorkman and Malterud[13] on lesbian experiences with health care, 3 essential qualities were described as necessary for the health care provider: awareness, attitudes, and medical knowledge. This study reinforces the importance of personal attributes that play a role in developing a safe and caring patient-provider relationship.

Some suggestions given in the literature for providing a safe and caring health care context for the WSW population include health questionnaires that are inclusive of same-sex relationships or sexual practices, educational materials or brochures that are inclusive of same-sex relationships and sexual practices, open-ended questions from providers, a nonjudgmental approach to questions, images or posters with same-sex couples, and a nondiscriminatory statement.[6,16,30] While it is important to understand the common health disparities found in the WSW population, the population itself is full of unique individuals from every walk of life. Each individual will present a unique set of health issues and needs. Understanding the uniqueness and diversity of each woman allows the opportunity to provide individually tailored health care and best practices for this population.

In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest.