Abstract

Background

While significant evidence demonstrates disproportionate burden of poor health among sexual minority men and transgender women, there is a dearth of research on the health of sexual minority women (SMW). We conducted a review to examine social stressors, physical and mental health, and health behaviors of SMW in post-communist countries in Europe.

Methods

In September 2023, August 2024, and January 2025, we used the Joanna Briggs Institute guidelines and PRISMA-ScR protocol to conduct a scoping review of empirical quantitative or qualitative studies published in English, Romanian, Czech, and/or Russian that focused on the health of adult SMW living in Albania, Armenia, Azerbaijan, Belarus, Bosnia and Herzegovina, Bulgaria, Croatia, Czechia, Estonia, Georgia, Hungary, Kosovo, Latvia, Lithuania, Moldova, Montenegro, North Macedonia, Poland, Romania, Serbia, Slovakia, Slovenia, and Ukraine. Seven databases were searched.

Results

We found few research articles (N鈥�=鈥�21) that met full inclusion criteria. Existing evidence documented poor mental health, discrimination in the workplace, reproductive health problems, coming out and relationship challenges, and heightened risk of substance use. Most studies were conducted in Poland; the earliest report was published in 2011. Only one quarter of the studies focused exclusively on SMW, and most study samples included few SMW.

Conclusion

This first review of literature on SMW鈥檚 health in post-communist countries in Europe indicates a dearth of research on and under-prioritization of the health and needs of SMW, signaling a pressing need for related health equity research. Longitudinal and interventional studies with large samples are warranted to document SMW鈥檚 health needs as well as intervention studies on the stigma-driven mechanisms and sources that perpetuate SMW鈥檚 marginalization to improve health outcomes of this underrepresented population group.

Background

SMW across the globe

Across the globe and throughout the lifespan, lesbian, gay, bisexual, transgender, intersex, and queer (LGBTIQ+) individuals show substantially higher rates of poor mental and physical health compared with their heterosexual and cisgender counterparts [1,2,3,4,5]. Research has documented a broad range of health risk behaviors and poor health outcomes. Examples include high rates of substance use [1, 6,7,8,9], depression and/or suicidality [5, 10,11,12,13] and cardiovascular disease and asthma [2, 14]. Many early studies used small, nonrepresentative samples and self-report measures of health concerns. However, more recent research, especially in the United Kingdom, the United States, Netherlands, New Zealand, and Sweden, have employed more rigorous research designs and used representative samples to systematically document the state of the health of LGBTIQ鈥�+鈥塱ndividuals in these countries and regions [15,16,17,18]. Many of these studies have capitalized on the diversity of social acceptance of LGBTIQ鈥�+鈥塸eople in various countries to examine the differential impact of stigma, discrimination, and/or affirming practices and attitudes on health outcomes [19,20,21,22]. The most common explanations for sexual and gender minority-related health inequities are experiences of stigma and discrimination based on minority sexual orientation or gender identity that are experienced across settings and contexts [19, 23,24,25,26,27,28,29,30]. While researchers use a variety of terms to describe sexual and gender minority population groups, in this review we use LGBTIQ鈥�+鈥塧s an umbrella term that includes the full spectrum of sexual and gender minority identities.

While significant bodies of evidence demonstrate disproportionately poorer health, especially within the field of HIV and mental health, among sexual minority men (SMM) [31,32,33,34] and transgender women (TGW) [35,36,37], literature reviews highlight the dearth of research on the health of sexual minority women (SMW) [1, 38, 39]. To document this lack of attention and to catalyze more research on SMW鈥檚 health, Hughes and colleagues have conducted a series of scoping reviews focused specifically on SMW鈥檚 health in several regions of the world [3, 8, 40, 41]. For example, in a review of research conducted in Latin America and the Caribbean, Caceres, Jackman (3) found that SMW were at elevated risk for sexually transmitted infections (STIs), which was related to low use of barrier contraceptives during sexual experiences with men. Mental health and substance use were also prominent health concerns among SMW in this sample, as was gender-based violence. Findings also highlighted low levels of help-seeking for health concerns and high levels of distrust of healthcare providers [3]. Further, Muller and Hughes (41) conducted a literature review of health concerns of SMW in Southern Africa and found that most reviewed studies focused on STIs, particularly HIV. Eight of the 15 included studies reported on experiences of sexual violence, a widespread concern for both SMW and heterosexual women in the region. Study findings also highlighted high levels of mental health concerns, as well as SMW鈥檚 reluctance to engage with the healthcare system. Pervasive social exclusion appeared to contribute to limited socio-economic opportunities (e.g., difficulty finding employment) and invisibility in the healthcare system [41].

Hughes, Veldhuis (8) conducted a large-scale literature review of substance use among SMW across the globe. Of the 181 studies, ten studies were conducted in Australia, five in the UK, four in Canada, and one or two studies in other countries (e.g., Argentina, Botswana, Costa Rica, Denmark, France, Puerto Rico, Taiwan, and Vietnam); the majority were conducted in the U.S. Nearly all studies focused on alcohol use; relatively little attention was paid to other substances. Despite the large number of studies included in the review, inclusion of SMW in substance use research remains limited, largely because most substance use research in the LGBTIQ鈥�+鈥塸opulation has focused on the role of substance use on HIV/AIDS risk among SMM. Findings from the review provide strong evidence that SMW are at substantially higher risk for a range of negative alcohol-related outcomes. Notably, the high rates of violence and victimization were significantly associated with substance use.

SMW in Central and Eastern Europe

Despite gains in knowledge about the health of SMW in several regions of the world, SMW in post-communist countries in Europe (Albania, Armenia, Azerbaijan, Belarus, Bosnia and Herzegovina, Bulgaria, Croatia, Czechia, Estonia, Georgia, Hungary, Kosovo, Latvia, Lithuania, Moldova, Montenegro, North Macedonia, Poland, Romania, Serbia, Slovakia, Slovenia, and Ukraine) remain an underprioritized population group whose physical and mental health has yet to be systematically researched. Based on data from other regions (e.g., North America, Australia) it is reasonable to assume that SMW in post-communist countries in Europe likely display similar patterns of risk and distribution of disease. However, the unique post-communist socio-political landscape suggests that SMW in these countries may face different stressors and health challenges. Systematically documenting the health of SMW in post-communist countries in Europe is important from a health equity perspective, including for prioritizing health-related programming, developing affirming care, and allocating resources.

Comprehensive reports on SMW in post-communist countries in Europe are rare, as publications mostly focus on LGBTIQ鈥�+鈥塸eople as a whole. When SMW are included in studies or reports, primary issues include the evolution of LGBTIQ鈥�+鈥塺ights across various post-communist countries in Europe [42, 43], attitudes of health trainees and professionals and the general population towards LGBTIQ鈥�+鈥塸eople, family formation, having children, and parenting [44,45,46], with some intersecting themes across reports. Comparative studies conducted in European countries support a more nuanced approach to understanding interregional differences in social attitudes and related health outcomes among LGBTIQ鈥�+鈥塸eople in Europe that goes beyond the East-West binary. Findings, overall, indicate that post-communist countries continue to demonstrate lower levels of social acceptance compared to other regions of Europe [47].

For example, Wycisk and Kleka (46) found that psychology students in Poland displayed three types of attitudes towards incorporating female partners of biological mothers in interventions for children. The most common attitudes were unconditional acceptance of both women (45.4%) and conditional acceptance with openness to contact with the biological mother鈥檚 female partner if the child was conceived with sperm from a donor (rather than in a past relationship with a cisgender male) (46.4%). Hostility towards and avoidance of the biological mother鈥檚 female partner was endorsed by only 8% of the sample. Those who reported unconditional or conditional acceptance were more likely to support LGBTIQ鈥�+鈥塺ights. In a study conducted in Croatia, more favorable attitudes towards gay parents were found among women (vs. men) who were less religious and more liberal, and among individuals who were co-habiting (vs. being married) [48].

Further, understanding attitudes of health professionals is key given their potential role in reducing widely documented health disparities among LGBTIQ鈥�+鈥塸opulations. One large study of medical students in Hungary found an inverse relationship between religiosity and levels of homophobia and knowledge about homosexuality [49]. Similarly, students who were more advanced in their medical training or who had close LGBTIQ鈥�+鈥塧cquaintances had lower levels of homonegativity. A more recent study conducted in Hungary compared foreign and Hungarian medical and other university students鈥� attitudes towards LGBTIQ鈥�+鈥塸atients. The researchers found that medical students, male students, and those who were more religious and politically conservative, held more negative attitudes and inadequate knowledge about sexual minorities [50]. That medical students held more negative attitudes than other students is concerning given the direct interaction with patients by these future doctors [50]. These findings from Hungary are consistent with those of a study conducted in Croatia, where fewer negative attitudes towards LGBTIQ鈥�+鈥塸eople were held by participants who were female, more advanced in their training, and had more knowledge of homosexuality [51].

It is not surprising, therefore, that researchers have proposed solutions to reducing negative attitudes and structural stigma toward LGBTIQ鈥�+鈥塸eople in post-communist countries, with educational approaches being the most commonly proposed [48]. As such, it has been suggested that strategies to reduce stigma and discrimination toward LGBTIQ鈥�+鈥塱ndividuals ought to include curricula aimed at improving knowledge of LGBTIQ鈥�+鈥塱dentities and health needs [50], including an emphasis on sex education [43]. To date, only two evidence-based trials have been tested across the countries included in this review; both of these took place in Romania. The trials showed evidence of acceptability, feasibility, and impact of trainings aimed at reducing homophobic and transphobic attitudes among mental health clinicians [52, 53]. Specifically, a recent pilot study showed that, after a 2-day training in LGBTIQ+-affirmative clinical practice, participating Romanian psychologists and psychiatrists demonstrated a significant increase in perceived LGBTIQ+-relevant clinical skills and knowledge [43]. LGBTIQ+-affirmative practice attitudes and comfort in addressing the mental health of LGBTIQ鈥�+鈥塱ndividuals also increased significantly, and homo- and trans-negative attitudes decreased significantly [52]. A second trial, which included randomization of Romanian psychologists and psychiatrists to either an in-person or web-based training in LGBTIQ+-affirmative clinical practice, found that regardless of training modality, trainees reported significant decreases from baseline to 15-month follow-up in implicit and explicit bias, and significant increases in LGBTIQ+-affirmative clinical skills, beliefs, and behaviors [53]. Such approaches hold promise in shifting negative attitudes, although impact on LGBTIQ鈥�+鈥塩lients is yet to be measured.

Some literature on SMW in post-communist countries has focused on family configurations and reproductive rights and outcomes. One recent examination of reproductive rights and practices among lesbian couples in Poland (part of the larger Families of Choice in Poland study) [45], suggested that female same-sex couples face significant barriers in having children due to normative recognition of only 鈥渙ne mother鈥� figure (e.g., monomaternalism) and high fertility treatment costs, many of which are restricted to heterosexual married couples. As such, 61% of SMW participants in a large survey reported that their children had been born in a past heterosexual relationship, with only 8% being the result of conception within a same-sex relationship [45]. Moreover, the existing discourse of lesbian mothers creating 鈥渋nappropriate鈥� and 鈥渄angerous鈥� environments for children constitutes a harmful backdrop for lesbian couples raising children. This discourse is further influenced by the fact that sexuality is centered around phallocentrism in post-communist countries in Europe (and the rest of the world) and the lives of SMW are therefore considered incomplete and nearly invisibible [44].

Research on LGBTIQ鈥�+鈥塰ealth in post-communist countries in Europe has been conducted in a context of deep-seated homophobia and transphobia that is rooted in religious dogma, the 鈥渢hreat鈥� to the 鈥渘uclear family,鈥� and the rigidity of gender roles and heteronormativity, with some variation across countries [42, 45, 47, 54, 55]. With the exception of Czechoslovakia and Hungary, same sex behavior was criminalized during communism in this region. However, most countries decriminalized homosexuality after the collapse of the Soviet Union [56]. Other post-communist countries retained criminalization until much later. For example, Romania and other countries did not remove a section of the penal code pertaining to the criminalization of public displays of homosexuality until 2001 [56]. This, decriminalization of homosexuality was part of a movement to gain European Union membership [42]. While LGBTIQ鈥�+鈥塺ights initially gained some ground in post-communist countries in the early 1990s, few of these countries currently offer protections and civil rights for LGBTIQ鈥�+鈥塸eople. Discrimination remains rampant across sectors, from marriage, to employment, education, housing, parenting, and healthcare [57].

This context of limited rights, resources, and protections for LGBTIQ鈥�+鈥塱ndividuals is reflected in the annual report of the International Lesbian, Gay, Bisexual, Trans and Intersex Association (ILGA) European region ranked post-communist countries in Europe in the bottom half among EU states and contiguous countries [58]. Although this report does not directly address the health of SMW, given mounting evidence from other regions of the world on topics such as the minority stress [23, 59], it is reasonable to hypothesize that SMW鈥檚 health in post-communist countries in Europe is likely affected by stress-induced mechanisms driven by structural and interpersonal stigma that have been associated with poor mental and behavioral health outcomes [19, 29, 60, 61]. Findings from studies comparing the health of sexual minority individuals to their heterosexual counterparts in post-communist countries in Europe have documented significantly higher levels of psychological distress among sexual minorities, including among SMW specifically [62]. This disparity in psychological distress has significant implications for health outcomes among this population [62].

Given the nascent state of the research on the health of SMW in post-communist countries in Europe, we conducted a scoping review to document what is known about the health (physical health, mental health) and health behaviors (healthcare access, healthcare utilization) of this population and highlight important areas of future research.

Methods

Study protocol and eligibility criteria

We used the Joanna Briggs Institute (JBI) guidelines for conducting scoping reviews [63] and report eligibility for study inclusion using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) protocol (see Fig.听1). This study was considered exempt by the Columbia University Irving Medical Center Institutional Review Board.

Fig. 1

PRISMA-ScR

Articles were included if they: (1) reported empirical quantitative or qualitative data; (2) were published in English, Romanian, Czech, and/or Russian (languages in which authors were proficient); and (3) reported findings related to adult SMW (age 18 and older) living in post-communist countries in Europe (Albania, Armenia, Azerbaijan, Belarus, Bosnia and Herzegovina, Bulgaria, Croatia, Czechia, Estonia, Georgia, Hungary, Kosovo, Latvia, Lithuania, Moldova, Montenegro, North Macedonia, Poland, Romania, Serbia, Slovakia, Slovenia, and Ukraine). Studies including individuals in the broader LGBTIQ鈥�+鈥塩ommunity (e.g., gay, or bisexual men), heterosexual women, or youth were included if the authors conducted analyses and reported results for adult SMW separately, regardless of sample size. We did not limit the searches by year of publication as to conduct an exhaustive search of all that had been published on this topic. We excluded gender minority women because given the nascent state of research on SMW in this region it is important to establish a focused baseline of information about cisgender SMW鈥檚 health and well-being before expanding to include gender diverse women who also identify as a sexual minority. In addition, gender minorities experience different stressors, such as trans-specific discrimination, different healthcare needs, such as barriers to gender-affirming care, and legal recognition challenges. Including transgender women would have increased the risk of obscuring findings for both groups, and a future scoping review of transgender women鈥檚 health in this area is warranted.

Search strategy and study selection

Three separate searches were conducted. The initial search was conducted in September 2023 and a second search, using an identical strategy, was conducted prior to submission (August 2024) to ensure inclusion of studies published after the initial search. A third search was conducted in January 2025, to include all countries in the 鈥淓astern Bloc.鈥� These include Georgia, Armenia, Azerbaijan, Belarus, and Kosovo, countries that were either part of the former Union of Soviet Socialist Republics (USSR) or under its influence. It was deemed important to include these countries given their unique histories under communism that negatively influence(d) views on sexual and gender diversity.

In all searches, seven databases were searched: PubMed (pubmed.gov), PsycInfo (EBSCO), CINAHL (EBSCO), Embase (embase.com), Scopus (scopus.com), Gender Studies Database (EBSCO), and GenderWatch (ProQuest) (see Table听1). Search terms (see Table听2) were entered into the advanced search field of each database. In the first search, a total of 1,336 records were identified and uploaded into Covidence (a management system for systematic and scoping reviews) [64]. A duplicate merge was then conducted, yielding 994 unique articles. Two authors independently reviewed titles and abstracts. Following this initial screening, two authors independently reviewed full text articles to determine eligibility. Any discrepancies were resolved through a consensus-driven discussion with a third author. A total of N鈥�=鈥�21 studies met full inclusion criteria. No new studies met full inclusion criteria during the second search conducted in August 2024 and two additional studies met full inclusion criteria during the third search conducted in February 2025.

Table 1 Sample search terms used in pubmed

Table 2 Sample characteristics of included reports

Data extraction, analysis, and synthesis

Study data (e.g., sample characteristics, design, results) were extracted from each article by three of the authors, after which the first author, who was not involved in the data extraction, completed a quality check of all articles to ensure accuracy. The following categories of data were extracted: study location, design, and dates of data collection, sample size, participant demographics, results, and limitations. All data generated or analysed during this study are included in this published article.

Results

Study characteristics

Of the 21 studies, 14 focused on mental health outcomes [65,66,67,68,69,70,71,72,73,74,75,76] and examined topics such as resilience, coming out, and experiences of discrimination. Five focused on sexual and reproductive health (SRH) [44, 77,78,79,80,81]. We found one study on each of the following topics: substance use/addiction [82], the effects of COVID-19 [83], and aging [66]. Some studies focused on more than one topic [44, 82], such as SRH, mental health, and substance use/addiction [82]. Nine studies used quantitative methods [68, 70, 72, 77, 79,80,81,82,83], and seven studies used qualitative methods [44, 66, 67, 69, 71, 74, 75]. Three studies used ethnographic fieldwork methods [44, 76, 78], and two used mixed methods [84]. Most studies were conducted in Poland (n鈥�=鈥�10); two studies were conducted in Croatia and two in North Macedonia. The remaining studies were conducted in Hungary, Romania, Moldova, Kosovo, Czechia, Estonia, and Slovenia (see Fig.听2). Although our inclusion criteria did not restrict year of publication, the earliest study was conducted in 2011 [67]. Overall, study sample size (including all LGBTIQ鈥�+鈥塱ndividuals, not just SMW) and other inclusion criteria varied widely. For example, sample sizes ranged from six [67] to 5964 [79] and age ranged from 18 [69, 75, 80,81,82,83] to 72 [66] years old. Many studies did not provide other demographic information; five studies did not report ages of the participants [44, 74, 76, 80, 81] and only one study reported information about race or ethnicity [69].

Fig. 2

Map of Europe indicating countries included in search and number of studies included from each

Mental health

Among the 14 studies that focused on mental health, four were conducted in Poland, two in Croatia, two in North Macedonia, and one study each in Slovenia, Kosovo, Estonia, Hungary, Moldova, and Romania. These studies covered a range of topics including resilience, coming out, experiences of discrimination, substance use, aging, and the impact of the COVID-19 pandemic.

Health determinants and minority stress

Koziara, Mijas (72) explored the association between age, health determinants (e.g., resilience, self-esteem, depression), and minority stress exposure among Polish LGBTIQ鈥�+鈥塱ndividuals. SMW showed significantly lower levels of resilience (p鈥�=.001, 95% CI 鈭掆��0.42, 鈭掆��0.12) and self-esteem (p鈥�=.001, 95% CI -3.87, -1.05) compared to sexual minority men (SMM) However, resilience was positively associated with age in SMW, but not in SMM. Although there was no significant relationship between age and exposure to stigma, age was negatively associated with depression and positively associated with self-esteem for SMW.

Llullaku, Selimi (84) investigated differences in depression, anxiety, and stress among LGB individuals in Kosovo. Of the total sample (N鈥�=鈥�103), 22.3% identified as lesbian women and 17.5% as bisexual women. Results indicated that, compared to gay men, bisexual women experience higher levels of depression (mean difference 0.61, p鈥�=.034) and anxiety (mean difference 0.60, p鈥�=.026). No other findings for SMW were reported.

Stojanovski, Zhou (85) used mixed methods to explore mental health outcomes in sexual and gender minority (SGM) young adults in North Macedonia. While, quantitative findings were not disaggregated by gender and sexual identity, reducing our capacity to make inferences about the unique experiences of SMW, data from focus groups revealed the depth of discriminatory experiences experienced by SMW. Both of the two young lesbian participants reported high levels of discrimination and stigma and associated fear and stress. They described a lack of protections from the state and within educational settings that contributed to a sense of pervasiveness of prejudice and discrimination across social settings and institutions. As one participant noted: 鈥渢he psychological violence is much worse than the physical violence鈥� and 鈥渢he violence doesn鈥檛 have to be physical in order to be scary.鈥�

Workplace discrimination

Two studies [70, 74] reported on the experiences of workplace discrimination. In the first study, Butterfield (74) examined experiences of work discrimination and harassment of two lesbian women in Croatia. One woman was able to rely on her reputation as a dedicated worker to prevent colleagues from continuing to engage in discriminatory behaviors, while the second woman quit her job and was able to quickly find another by relying on community support. In the second study, Voina, Pavelea (70) explored experiences of LGBT individuals in the workplace across Romania. Of the total sample (N鈥�=鈥�10), two identified as lesbian women. Findings revealed mixed experiences, with one lesbian woman reporting positive experiences of coming out to coworkers, while the other reported name-calling, jokes, and ridicule. Both women reported discrimination and microaggressions, resulting in shame and paralysis (not knowing what to do/how to respond).

Coming out

Three studies explored coming out experiences. Butterfield (75) used qualitative methods to examine the process of coming out in rural and urban communities in Croatia among LGB women and men. Of the total sample (N鈥�=鈥�16), four identified as SMW. Although rural towns and villages were described as not 鈥渙pen鈥�, 鈥減rogressive鈥�, or welcoming to SGM individuals, interviews with LGB women and men highlighted different ways in which SGM individuals negotiate their sexuality and create their lives outside urban spaces. Findings from the SMW participants revealed how they navigated disclosure and non-disclosure of their identity. For example, one lesbian woman living in a small town reported that although she did not explicitly talk to her mother about her sexuality, she believed they had a mutual understanding of her identity. Two other lesbian women shared that, to avoid unnecessary upset to their family, they did not come out until they had a partner.

In another study conducted in Hungary, B茅res-De谩k (76) explored the process of coming out through the perspectives of individuals who had been in a same-sex relationship (N鈥�=鈥�68) or those who had a family member in a same-sex relationship (N鈥�=鈥�13). The authors did not provide information about the total number of SMW participants, nor did they expand on how the experiences of SMW differed from those of SMM or other individuals in same-sex relationships. Only three female participants were quoted in the article. One lesbian woman reflected on whether to come out to her grandparents as she feared it would make them suffer. One lesbian couple shared that they were unable to be as out in their small hometown as they were in Budapest, the capital city where they lived [76].

Kuhar and 艩vab (65) examined the perceptions of gay men and lesbian women living in rural and urban areas of Slovenia about coming out, intimate partnerships, access to and use of gay-affirming infrastructure, and violence against gay men and lesbian women. Although female participants represented 47% of the study sample, only qualitative data from three female participants were presented. Findings indicated that SMW feared that their minority identity would be discovered and lead to violence, which is why they felt the need to conceal their identity and avoid public displays of a same-sex romantic partnership.

Health needs

Stojanovski, King (69) conducted a needs assessment of SGM people in North Macedonia. The study identified relevant health needs as well as their social, cultural, and political determinants. The researchers also explored issues of inequity to determine how the needs of SGM persons might be better addressed through community-engaged platforms. Several themes emerged, such as health, social/cultural norms, victimization and safety, and education/democratization of knowledge. Some participants highlighted unmet mental health care needs, with SMW reporting experiences of sexual harassment and prejudicial attitudes when seeking mental health services. Others emphasized the ubiquity of homophobia in North Macedonia resulting in constant vigilance and fear. Participants also highlighted that such fears are compounded by the lack of legal protections.

Lasala and Revere (67) conducted interviews with six gay men and lesbian women to examine perceptions of changes in Estonia since the end of the Soviet occupation, and how participants believed these changes affected them, including their perceptions of changes in stigma and coping. Only one participant identified as a SMW. All participants perceived that the end of the communist regime brought greater freedom. While the sole SMW participant indicated that she was able to stop hiding her sexual orientation, the study highlighted that LGBTIQ鈥�+鈥塃stonians had few legal protections and continued to experience violence.

Aging

In the only study that addressed aging among LGBTIQ鈥�+鈥塸eople, Mizieli艅ska, Struzik (66) conducted a qualitative inquiry focused on the ways in which LGBTIQ鈥�+鈥塱ndividuals defined and negotiated kinship over the life course. The sample of 10 participants included five SMW. Data from SMW revealed several themes including feelings of invisibility, isolation, and navigation of concealment and disclosure of sexual identity. SMW highlighted using concealment of sexual identity as means to care about others鈥� feelings. For example, some described introducing a romantic partner simply as a friend to allow themselves to include their same-sex partners while avoiding the risk of rejection from loved ones. Perceived this way, 鈥榥ot coming out鈥� was described as a way of kinning, reaching out to others, caring for their needs. For some SMW, this was sometimes the only way to merge families of origin and families of choice. Others reported using a 鈥榖etwixt strategy,鈥� indicating partial disclosure of identity to certain individuals - some verbal, some implied/non-verbal, to help maintain kinship without risk of experiencing homophobic reactions.

COVID-19

In a mixed-methods study conducted in Moldova, Holliday and Mulear (83) examined the effects of the COVID-19 pandemic on the mental and physical health of LGBTIQ鈥�+鈥塱ndividuals. The quantitative findings were not stratified by sexual identity, reducing the ability to make interpretations about SMW. The only cisgender, bisexual female participant stated that she had established an online LGBTIQ鈥�+鈥塯roup for individuals to connect and check in with each other throughout the pandemic.

Disability

Wo艂owicz, Kr贸l (71) conducted qualitative interviews with 11 disabled SMW in Poland that focused on everyday experiences of intimacy and care. The participants reported insufficient attention to their unique needs as SMW within caregiving and disability-related policies, institutions, systems, and social movements. The authors described ways in which heteronormativity and ableism interacted to limit the privacy and autonomy of disabled SMW receiving care, both within the home and institutional contexts. Homecare in Poland is usually provided by family members due to cultural norms and policies describe as the 鈥渇amiliarization of care.鈥� Participants described this caregiving arrangement in the context of stereotypes concerning the infantilization and de-sexualization of disabled adults which results in the invalidation of sexual minority identities and barriers to forming intimate relationships and other forms of sexual expression.

Sexual and reproductive health

Two articles reported data from the Families of Choice in Poland study conducted in 2013鈥�2016 that examined the experiences of sexual and reproductive health of non-heterosexual people using qualitative (e.g. focus groups, narrative interviews, ethnography) and quantitative methods [44, 78]. In the first article, Mizieli艅ska and Stasi艅ska (78) examined planned family formation among two lesbian couples in their 30鈥�40听s after conception. Both couples used assistive reproductive technology to conceive and reported that they had anticipated experiences of discrimination from health care providers even before they planned to conceive. Both couples reported that the lack of legal protection for same-sex parenthood influenced their reproductive choices, including the decision to use an anonymous donor, rather than a known donor, out of fear that a court could one day rule in favor of the father鈥檚 right to custody.

In a second study using the same study dataset, Stasi艅ska and Mizieli艅ska (44) analyzed data from interviews with 53 SMM and SMW. SMW integrated religious and social norms, especially regarding gender, into their sexual experience, which the authors interpreted as demonstrating the impacts of local cultural norms and political contexts on the sexuality of the participants. For example, SMW generally linked sexual activity with romance, in contrast to SMM who largely viewed sex and emotional intimacy as being separate.

Stok艂osa, Stok艂osa (79) surveyed students from the 50 largest universities in Poland (N鈥�=鈥�5964) to examine sexual behavior and outcomes. Women in the study primarily identified as heterosexual (89.5%), with 8.5% identifying as bisexual and 2% as homosexual (sic.). Both bisexual and homosexual (sic.) women were more likely to report casual sex with and without alcohol use compared to heterosexual women. There were similar rates of reported STIs among SMW and heterosexual women.

HIV knowledge and testing

Both studies examining HIV and AIDS testing and knowledge were conducted in Poland. Nied藕wiedzka-Stadnik, Nowakowska-Radziwonka (81) examined laboratory results of HIV testing from doctors and testing centers in Poland in 2019 to understand the epidemiology of newly diagnosed HIV infections and AIDS cases. Of the 723 HIV tests administered to women who have sex with women and men (WSWM) (5.6% of all HIV tests), none were positive. Among 295 HIV tests administered to WSW (2.3%), only one was positive. In total, women were administered 35.3% % and SMW 7.9 of all HIV tests. In a similar analysis from 2020 [80], 432 HIV tests were administered to WSWM, representing 7.2% of all HIV tests, and no test came back positive. A total of 166 HIV tests were administered to WSW (2.7% of all HIV tests), and one (0.5%) came back positive. In total, women were administered 33.5%, and SMW 9.9% of all HIV tests.

Kowalczyk and Nowosielski (77) assessed knowledge about sexually transmitted infections (STIs) and sexual health outcomes via a survey-based study with close to equal proportions of WSW and WSWM (N鈥�=鈥�259). Of the full sample, 7.1% reported a previous STI diagnosis, although the type of STI was not recorded. WSWM had significantly higher levels of STI knowledge compared to WSW. Both number of same-sex partners within the last year and the degree to which sex was reported to be personally important were positively associated with STI knowledge. The generalizability of these findings is restricted by the homogeneity of the sample, especially due to the targeted recruitment method via the local pro-LGBTIQ鈥�+鈥塺ights mailing lists.

Multiple outcomes

Stemmler, Hall (82) conducted a survey study of sexual behavior, HIV-testing practices, and substance use among women attending social venues in Prague, using a time-site sampling strategy between July and August 2011. The sample was primarily heterosexual (76%), but of the female participants, 9% identified as cisgender lesbian women, 8% as bisexual women, and 3% as transgender women. Almost all respondents (97%) reported drinking alcohol and/or using other drugs in the past 30 days. Although SMW reported more frequent alcohol use, rates of excessive alcohol use were similar among heterosexual women (55%) and SMW (61%). When comparing female participants based on sexual behavior, rates of reported substance use at last sexual encounter were similar (48% women who have sex with men and 44% women who have sex with women).

Mijas and Koziara (68) tested an adaptation of the Daily Heterosexist Experiences Questionnaire (DHEQ) [85], which measures experiences of prejudice and discrimination among LGBT people, to test its psychometric characteristics with Polish LGBT participants. Of the 197 participants, 19% (N鈥�=鈥�38) described themselves as non-heterosexual women. Compared to transgender and gay male individuals, cisgender non-heterosexual women scored higher on the DHEQ subscale of vigilance and lower on other subscales including HIV/AIDS stigma and gender expression.

Discussion

We used a scoping review methodology to examine the physical health, mental health, and health behaviors (substance use, healthcare access, healthcare utilization) of SMW in post-communist countries in Europe. To our knowledge, this is the first attempt to review research literature focused on the health of SMW in post-communist countries in Europe. While it is difficult to provide a cohesive summary of findings given the widely range of topics found in the articles, overall, the studies indicate that SMW in these countries struggle with coming out, acceptance, forming families, depression, anxiety, fear of rejection and loss, discrimination, victimization, but also resourcefulness and resilience. SMW in post-communist countries in Europe are not particularly visible or prioritized, and the research conducted to date cannot be clearly characterized as health-related inquiries about SMW. Below we provide an overview of the multiple findings of this scoping review, as well as areas of future research that emerged from the gaps identified in the extant literature.

A modest number of research articles met inclusion criteria and most of the articles included had exceptionally small samples of SMW. Findings from the review reflect limited attention to this topic and highlight major gaps in knowledge and corresponding future research directions. Compared to studies on SMW鈥檚 health in other regions of the world (e.g., Southern Africa. Latin America and the Caribbean), which revealed challenges surrounding sexual health (e.g., HIV/STIs), substances use, and experienced violence [41], most included studies focused on mental health [65, 67,68,69, 71,72,73, 75, 76], while a quarter of them focused on reproductive health; [77,78,79,80,81] the rest of studies covered a range of topics, such as discrimination [74], substance use [82], COVID [84], and aging [66]. The majority of studies took place in Poland, and the earliest research on SMW in post-communist countries in Europe was published only a little more than a decade ago (e.g., 2011) [67], indicating limited yet potentially growing interest in this population鈥檚 health. Still, only one quarter of the few available studies focused exclusively on SMW, with many of the studies including very few SMW (e.g., one participant) [67]. These findings indicate an under-prioritization of the health and needs of SMW in post-communist countries in Europe. However, the tendency to underrepresent SMW in LGBTIQ鈥�+鈥塰ealth studies is not unique to post-communist countries in Europe. Most reviews of LGBTIQ鈥�+鈥塰ealth (e.g., in Southern Africa [40], the Middle East and North African region [38], and the Netherlands [1]) found few studies of SMW鈥檚, despite documented liberal attitudes towards sexual minorities in the latter country.

Given the small number of studies with small samples of SMW, all of which were cross-sectional,, findings should be interpreted with caution as they cannot capture a comprehensive characterization of the state of SMW鈥檚 health in the post-communist countries in Europe. While there was some evidence of less resilience among SMW than SMM, they reported lower levels of depression symptoms and showed increasingly higher levels of self-esteem with age, perhaps suggesting increasing resilience across the lifespan [72]. Indications of social adversity were also mixed. For example, in the two studies of workplace experiences available, some SMW reported successful navigation of the work environment based on intrinsic (e.g., self-efficacy) and extrinsic (e.g., co-worker support) factors, with others reporting unpleasant encounters [70, 74]. Themes of sexual harassment and malpractice emerged from SMW seeking mental health care [69], as well as anticipated discrimination among SMW couples using assistive reproductive technology [78]. Heteronormativity and ableism negatively impacted disabled SMW, who felt infantilized and desexualized, and thus experienced invalidation of identities and barriers to intimate relationships. SMW reported invisibility, isolation, and various strategies for navigating concealment and selective disclosure of sexual identity, which was done to some degree to protect those close to them from upset and to maintain the status quo [71].

These findings coalesce with literature on SMW in Southern Africa, another region known for its negative attitudes toward LGBTIQ鈥�+鈥塸eople, reflecting difficulties around identity disclosure and social exclusion, as well as poor mental health due to societal stressors driven by heteronormativity and marginalization of sexual minority individuals [23, 24, 41]. Furthermore, findings from this review of SMW鈥檚 health, where negative attitudes continue to dominate these post-communist countries, surprisingly align with findings from a scoping review that explored the experiences of SMW in the Netherlands [1]. Despite the drastically different landscapes of these two contexts in terms of structural protections of SGM, SMW in the Netherlands, who benefit from substantially more legal rights and protections than SMW within post-communist countries in Europe, also report elevated feelings of isolation, depression, and anxiety, as well as hazardous alcohol use. Additionally, SMW in post-communist countries reported discrimination across social contexts (e.g., fertility counseling, relationships, and mental health care) [1]. These findings point to the continued need to support rights and protections of SMW across contexts, regardless of levels of structural stigma [58].

Although SMW in the current review were more likely than their heterosexual counterparts to report casual sex in general and under the influence of alcohol, both groups reported similar rates of STIs, suggesting that that sex with men might also be common among SMW [79]. SMW鈥檚 HIV testing and HIV rates were low, which is likely explained by SMW鈥檚 lower risk compared to sexual minority men [86], or healthcare practices that assume that only SMM engage in sexual risk. STI knowledge was significantly higher among SMW who had sex with both men and women [77], which can play a highly protective role. While SMW in one study reported more frequent alcohol use compared to heterosexual women, excessive alcohol use was similar across these groups, as was substance use at last sexual encounter [82], indicating the need for harm reduction among women, regardless of sexual orientation.

One explanation for the low number of studies and small samples of SMW in this region is the fact that the focus of research among LGBTIQ鈥�+鈥塸eople in post-communist countries in Europe is driven by gender power norms, where men are prioritized in healthcare and funding [87,88,89,90], leaving significant gaps in our understanding of SMW鈥檚 health needs and wellbeing. Funding has also prioritized the HIV epidemic, which, in this region, primarily affects gay, bisexual, and other men who have sex with men [87,88,89,90], as well as transgender women, leaving SMW on the periphery of public health priorities. Nevertheless, SMW who also have sex with men are at increased risk for HIV and STIs [91]. Efforts to reduce stigma towards SMW, alongside efforts to reduce stigma towards LGBTIQ鈥�+鈥塸eople in general, are warranted to promote equitable access to prevention and care across co-morbid conditions that are beginning to be documented for this population in this region of the world (e.g., STIs, substance use, and poor mental health).

The most commonly used theoretical model used in the studies reviewed was the minority stress model [23]. Minority stress theory posits that gender minority- and sexual minority-related health disparities are largely the result of the overburden of unique stressors (e.g., stigma, bullying) in addition to universal stressors experienced by the general population. Although the minority stress model is a useful theoretical framework for guiding LGBTIQ鈥�+鈥塰ealth research, employing alternative theoretical perspectives can potentially deepen understanding of SMW鈥檚 health outcomes in post-communist countries. For instance, researchers can further investigate how structural factors (e.g., socioeconomic status, healthcare experience, institutional practices, economic policies) impact SMW鈥檚 health outcomes. Although two studies included in this review examined the process of coming out in rural and urban spaces, more research is needed to better understand this process, particularly in contexts characterized by high stigma. Considering the low rates of acceptance of SGM individuals in post-communist countries [58, 92], understanding how structural factors impact SMW health disparities is key to advancing the scientific field and improving the lives of SMW living in this region. Research on older SMW in post-communist countries is particularly sparse; we found only one study that examined the experience of aging among SMW. More research is needed to explore whether the health disparities among SMW in these contexts persist as they age, and whether this population group faces unique stressors.

Limitations of included studies

Overall, the quality of studies included in this review was low. Study samples were homogenous, and intersectional identities were rarely reported. Only one study reported data related to race/ethnicity [69], and five studies failed to report ages of the participants [44, 74, 76, 80, 81]. Intersectional identities (e.g., race/ethnicity, socioeconomic status) have been shown to play a key role in understanding mental and physical health disparities across SMW populations in other countries [93,94,95].

Almost half of included studies (N鈥�=鈥�9) recruited participants using either convenience sampling or snowball sampling procedures [65,66,67, 70, 71, 75, 77, 83, 96]. These sampling methods have higher potential for research bias, since participant samples are not chosen through random selection. These studies mostly relied on LGBTIQ鈥�+鈥塋GBT listservs or social groups related to LGBTIQ鈥�+鈥塰ealth and rights to identify potentially participants. Thus, while it may be possible to generalize findings from these studies to other similar contexts, caution should be used given the identified sampling weaknesses. Data collected in quantitative studies were cross-sectional and observational, pointing to the need for longitudinal and intervention studies. For example, it is not possible to establish causality in the absence of prospective studies. Even among studies with larger sample sizes, most study samples included very few women (as low as one SMW [67]).

The 21 studies included in this review were conducted in only in t10 countries, with almost half conducted in Poland. Finally, included studies used inconsistent definitions of sexual minority status, such as those based on sexual attraction or past year sexual behavior. Because mental health varies based on which dimension of sexual orientation (i.e., attraction, behavior) is assessed [97], it is important not to assume dimensions of sexual orientation are equivalent [97]. Taken together, these limitations make it challenging to compare post-communist countries and may contribute to both under- and over-estimation of mental health disparities. Larger, longitudinal studies and randomized controlled trials are needed to get a better understanding of the health outcomes of SMW in post-communist countries.

Limitations of the present study

The inclusion criteria for this scoping review included only peer reviewed studies and dissertations available in the languages spoken by the research team (i.e., English, Romanian, Czech, and/or Russian). There may be additional grey literature sources or articles in other languages that were not included in this review that focus on the health of SMW in post-communist countries. Additionally, consistent with our inclusion criteria, we only included studies with a focus on cisgender SMW. We did not formally evaluate the limitations or quality of individual studies or discuss their risk for bias as is standard with scoping review methodology (as the focus of scoping reviews is to provide a broad overview of research, rather than appraise existing literature).

Conclusion

Concerted efforts are needed across disciplines (e.g., health professions, social sciences, public health, and policy) to systematically document SMW鈥檚 health issues, needs, and wellbeing across post-communist countries. Models of such efforts may be found and followed from other areas of the world, such as the United States or Canada. Although post-communist countries present a unique historical context that is not supportive of LGBTIQ鈥�+鈥塸eople, main themes that emerged from this review align with findings on SMW in other regions of the world and in contexts with both low and high structural protections for LGBTIQ鈥�+鈥塸opulations. Specifically, across studies, SMW demonstrate significant mental, behavioral, and sexual health challenges, alongside discrimination, isolation, violence, and need for identity concealment for protection. These findings signal a significant continued need for health equity research and activism for SMW across various regions of the world, including in the post-communist countries.