title: Women's health care: the experiences and behaviors of rural and urban lesbians in the USA.
abstract: Previous research has consistently demonstrated that, in comparison to their cisgender heterosexual counterparts, lesbians face a multitude of women's healthcare-related disparities. However, very little research has been conducted that takes an intersectionality approach to examining the potential influences of rural-urban location on the health-related needs and experiences of lesbians. The purpose of this study was to quantitatively compare rural and urban lesbians' access to women's health care, experiences with women's healthcare providers (WHCPs), and preventive behavior using a large, diverse sample of lesbians from across the USA.
  
  
  
  A total of 895 (31.1% rural and 68.9% urban) lesbian-identified cisgender women (ie not transgender) from the USA participated in the current online study. As part of a larger parent study, participants were recruited from across the USA through email communication to lesbian, gay, bisexual, and transgender (LGBT)-focused organizations and online advertisements. Participants were asked to complete a series of questions related to their women's healthcare-related experiences and behaviors (ie access to care, experiences with WHCPs, and preventive behavior). A series of χ2 analyses were utilized in order to examine rural-urban differences across dependent variables.
  
  
  
  An examination of sexual risks revealed that relatively more rural lesbians reported at least one previous male sexual partner in comparison to the urban sample of lesbians (78.1% vs 69.1%, χ2(1,N=890)=7.56,p=0.006).A similarly low percentage of rural (42.4%) and urban (42.9%) lesbians reported that they have a WHCP that they see on a regular basis for preventive care. In terms of experiences with WHCP providers, relatively fewer rural lesbians indicated that their current WHCP had discussed/recommended the human papillomavirus (HPV) vaccination in comparison to urban lesbians (27.5% vs. 37.2%; χ2 (1, N=796)=7.24,p=0.007). No other rural-urban differences in experiences with WHCPs emerged - few rural and urban lesbians had been asked about their sexual orientation by their WHCP (38.8% and 45.0%, respectively), been provided with appropriate safe-sex education by their WHCP (21.4% and 25.3%), had their last HIV/sexually transmitted infection screening instigated by their WHCP (if applicable; 15.7% and 19.5%), and reported that their WHCP seems knowledgeable about lesbian health concerns (56.5% vs 54.6%). In terms of preventive behavior, significantly fewer rural lesbians aged 40 years or more had received a mammogram in the past 3 years (63.2% vs 83.2%; χ2(1,N=163)=8.36,p=0.004) when compared to their urban counterparts. No other significant rural-urban differences in preventive behaviors emerged. A similarly low percentage of rural and urban lesbians indicated that they have received the HPV vaccination (22.8% and 29.0%, respectively) and/or have had a HIV/STI screening (43.0% and 47.8%), Pap test (62.0% and 64.5%) or breast exam (59.2% and 62.8%), in the past 3 years.
  
  
  
  The current findings highlight that rural lesbians in the USA, in comparison to urban lesbians, may experience elevated health risks related to being more likely to have at least one previous male sexual partner, less likely to be recommended the HPV vaccination by a WHCP, and, for those 40 or older, less likely to receive routine mammogram screenings. Furthermore, rural lesbians appear to engage in similarly low rates of HPV vaccination and regular HIV/STI screenings, Pap tests, and clinical breast exams as their urban counterparts. Given the increased cervical and breast cancer risks associated with rural living, the current findings underscore the dire need for health promotion efforts aimed at increasing rural lesbians' engagement in routine pelvic and breast exams.
authors.affiliation: Rural Health Research Institute, Georgia Southern University, Statesboro, Georgia, USA. kbarefoot@georgiasouthern.edu.
authors.forename: K Nikki
authors.initials: KN
authors.lastname: Barefoot
authors.affiliation: Center for Rural Health and Health Disparities, Mercer University School of Medicine, Macon, Georgia, USA. warren_jc@mercer.edu.
authors.forename: Jacob C
authors.initials: JC
authors.lastname: Warren
authors.affiliation: Rural Health Research Institute, Georgia Southern University, Statesboro, Georgia, USA. bsmalley@georgiasouthern.edu.
authors.forename: K Bryant
authors.initials: KB
authors.lastname: Smalley
mesh_terms: D000328:Adult; D005260:Female; D015438:Health Behavior; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D054625:Healthcare Disparities; D018452:Homosexuality, Female / Q000706:statistics & numerical data*; D006801:Humans; D008875:Middle Aged; D012424:Rural Population / Q000706:statistics & numerical data*; D014481:United States; D014505:Urban Population / Q000706:statistics & numerical data*; D016387:Women's Health; D014932:Women's Health Services / Q000706:statistics & numerical data*; D055815:Young Adult
keywords: General/Family Practice; Gynaecology; Health Promotion; Medical; North America; Nursing; Obstetrics; Primary Health Care; Professional conduct; Public Health; Researcher; Sexual Health; Women's Health