PART I
by Per Larson

reast cancer can demolish our financial lives literally overnight. This is why we should get current on how big the problem is - and what we can do to prevent it. Disease facts are financial liabilities on our personal balance sheets.

Sometimes we can fight our medical injury but eventually succumb to the cumulative financial insults of disease.

The pandemic rate for breast cancer for lesbians is now three times the national average for all women. Yet the unpublished National Lesbian Health Care Survey in 1985 identified that 28% had experienced some breast abnormality. Some experts project that one in three lesbians will get breast cancer in her lifetime. Because of underreporting rates for lesbians need attention urgently.

The more frightening figures occur with delays in detection: over 75% of women with late diagnoses die within four years. Detection is a bottom line issue.

Many factors will have to be corrected before early detection becomes a reality: the prejudice of the medical professions, the extra invisibility of lesbians, a possible hesitancy of lesbians to discuss sex, lack of finances, lack of partner insurance, and an often-merited reluctance to self-identify when face-to-face with medical personnel. This all gets translated into much greater delays. And delays get translated into dollars.

The risk factors for breast and cervical cancer for women include:

* 70% do not have children or have children later in life
* higher alcohol and smoking rates than heterosexual women
* greater body mass
* stress from discrimination
* fewer gynecological exams and breast cancer screenings

Pap smears and lower pelvic exams are often the only effective ways to be sure there is no cancer. Yet lesbians let three times as much time go by between Pap smears as heterosexual women do. The National Cancer Institute notes that 45% of lesbians don't have regular obstetric-gynecological care and another 25% have only sporadic care. As many as 10% of lesbians either have never had a Pap smear or have had just one in the previous 10 years.

Many lesbians incorrectly assume that with fewer or no children they do not have to do breast self-exams. The truth is that because of this they're at higher risk. We insure against the risk of fire or car accidents because we know they happen; likewise we need medical, disability, and life insurance to fight disease. Remember: twice as requests to convert life insurance policies into cash through accelerated benefits are based on cancer as on HIV.

More invisible than gay men, lesbians are reluctant to self-identify. This compounds the secrecy already surrounding gynecological health concerns and its focus on childbearing. Women often encounter shame issues around body issues as it is.

Although lesbians are active in AIDS and often led the women's health movement, little has been done to document lesbian health needs or address them explicitly. Few lesbians have come out about breast cancer; few role models or awareness exists.

Many providers show a lack of interest in cancer and focus instead on birth control. Remember: over half of all doctors report either denial of care or substandard care for gays overall. Three-quartesr of lesbian patients report derogatory remarks or ostracism.

A further problem can occur if lesbians reject traditional medicine as a result and rely instead on more personable practitioners of alternative medicine whose remedies remain unscientifically proven.
Most insurance will not reimburse alter- native treatment - or reimburse it for short periods of time at exceptionally low levels. This added out-of-pocket expense can quickly drain personal reserves. Then financial stress adds itself to all the other stress aggravating the illness.

Medical research reflects the high cost of lesbian invisibility. Only four studies of lesbian health have been published in peer-reviewed obstetric and gynecological journals since 1966.

Thanks due to pressure by gay and lesbian doctors, progress is being made. The AMA issued a policy statement in 1994 urging doctors to be more sensitive to gays. The American College of Obstetricians and Gynecologists updated its brochures to patients and doctors in 1995 to include information on lesbian health. In that year as well, the American Academy of Family Physicians held its second forum for doctors on gay and lesbian health issues.

Two large studies will have major implications for lesbians. The Harvard Nurses Study and the Women's Helath Initiative of the National Institutes of Health are both large scale surveys that include data on lesbian participants to document whether lesbians are at high risk and what preventive measures they can take.