Ten percent of the population is lesbian, gay, bisexual or transgender. This group faces health care risks that are often not addressed because of inadequate patient-physician communication or lack of physician knowledge about specific health care issues. Up to two thirds of physicians do not ask about sexual orientation; typically, heterosexuality is assumed. Other physicians choose to avoid the issue. Lee searched literature spanning the past 20 years to identify health care concerns among homosexual patients.

A controversial 1989 report from the U.S. Department of Health and Human Services estimated that gay adolescents and adults are at a greatly increased risk for suicide compared with their heterosexual counterparts. Risk factors for attempted suicide include nonconforming gender roles (e.g., men in a more feminine gender role), self-identification as gay or bisexual at a young age, first homosexual experience at an early age, history of sexual and physical abuse, and rejection from important social supports. Adults also are also at risk because of social isolation, fear of discrimination at work and loss of loved ones.

Substance abuse and violence are also common health risks in this population. The incidence of substance abuse, including alcohol and illicit drug use, is similar between homosexual and heterosexual men. However, lesbians and bisexual women are more likely to report being recovering alcoholics than heterosexual women. Gay men report using a wider variety of drugs and, although causality cannot be determined, increased use of inhalants, amphetamines and cocaine is strongly associated with HIV seroconversion. Cigarette smoking is also more common among gay men and lesbians. Antigay violence, including verbal assaults and threatened or actual physical violence, is reported as being common.

Specific health risks for lesbians include a lower rate of screening for cervical cancer and inadequate knowledge of the risk of sexually transmitted diseases caused by vaginal secretions or objects used during sexual activity. The risks of breast and endometrial cancer are higher among lesbians because of their lower use of oral contraceptives, the increased likelihood of nulliparity and the increased prevalence of smoking.

Specific health risks for gay men include eating disorders, sexually transmitted diseases and anal cancer. Transgender persons, those who maintain a strong and persistent cross-gender identification, are a minority within a minority and have a high risk for depression, suicide, substance abuse and antigay violence.

The author concludes that physicians must acknowledge the importance of knowing a patient's sexuality to prevent morbidity from conditions for which lesbian, gay, bisexual and transgender patients are at higher risk. Physicians should ask about substance misuse and refer patients for additional care when appropriate. The physician's office should be considered a safe and nonjudgmental haven for patients who are victims of violence. Physicians are encouraged to make appropriate inquiries and provide needed education and screening examinations, and to attempt to reduce antigay activities whenever possible.