Sharon Kaye O¡¯Connor
This article explores the challenges experienced by lesbian patients in the health care setting. As the arena of women?s health care, particularly the field of obstetrics and gynecology, is focused primarily on the health needs of heterosexual women, lesbian and bisexual women are less likely to obtain the care they need, and are more likely to encounter stigma and negative responses from practitioners when they do seek care. Negative practitioner attitudes as well as a culture of heter©\ onormativity act as deterrents to non©\heterosexual women obtaining quality and comprehensive care specific to their needs. Along with these challenges encountered in the health care environment, barriers created by policy, such as the inability of lesbian women to obtain health insurance through their partners, and the resulting inability to afford quality health care, also factor in to the overall lacking health care experience for the lesbian patient.
Within the realm of the health care field, the experience of the patient is an extremely important factor in the perceived overall quality of the care received. Because the patient?s experience is such a large element of care in general, in a health care situation in which the experience is unpleasant or lacking, it can also be perceived that the care itself is inadequate. Very often in the field of women?s health, practitioners operate with the ongoing presumption that their patients are heterosexual, and structure their treatments and interactions with patients accordingly. In other cases, practitioners may harbor strong biases against non©\ heterosexual patients. As a result of these assumptions and biases, and their resulting practices, the general health care experience queer women encounter as lacking often leads to inadequate or incomplete care, or the avoidance of health care situations entirely (Fields & Scout, 2001).
The health care experience from the patient?s perspective is frequently influenced by several factors, many of which are addressed by the Agency for Healthcare and Research Quality (2008) in its National Healthcare Disparities Report.
The factors contributing to the overall patient experience, as discussed in the AHRQ report, are largely based upon communication between patients and their health care providers. The quality of communication between patient and provider can be assessed by the patient?s perception of the degree to which the provider listens to her, whether or not the provider spends an adequate amount of time with her, respects her questions and concerns, or explains information in a manner that is understandable (AHRQ, 2008). The quality of patient©\provider communication also depends on the level of comfort the patient feels with disclosing personal information to her provider. In order for successful patient©\provider communication to exist, it is necessary for the patient to feel able to be open and honest with the provider regarding major issues. For the patient to feel such comfort, it requires the practitioner to exude an attitude of unconditional positive regard. The level of comfort necessary for such disclosure and discussion very often does not exist for the female patient who identifies as gay, lesbian or bisexual (Klitzman & Greenberg, 2002).
For the purpose of this discussion, the words ¡°gay¡±, ¡°lesbian¡± and ¡°queer¡± will be used interchangeably to refer to woman whose sexual partners include, or have included women, regardless of whether or not their sexual interactions presently include, or have ever included, men. A 2002 study by Klitzman and Greenberg analyzed the potential factors that might have a detrimental effect on communication between lesbian patients and their health care providers. This study addressed the issue that gay women may be less inclined to openly disclose their sexual orientations to their health care providers due to the fear that they will face stigma and the quality of their care will be compromised (Klitzman & Greenberg, 2002). Fields and Scout (2001) recount the story of a young woman who, after telling her gynecologist she was bisexual, was abandoned in the examination room by the doctor, and the exam was then completed by the physician?s assistant. Klitzman and Greenberg (2002) found that these women are afraid of facing stigma not only from their healthcare providers but from their employers as well, due to the increased skepticism patients feel regarding their health insurance companies? confidentiality practices. This fear of stigma, and ultimately of discrimination, from those in a patient¡¯s life who have access to her personal information, could understandably prevent a patient from disclosing said information to her healthcare provider (Klitzman & Greenberg, 2002).
The Klitzman and Greenberg (2002) study also found that among the LGBTQ population, lesbians were less likely than their gay male counterparts to feel comfortable discussing their sexual orientations with their healthcare providers. The study hypothesized that this disparity existed because women were more likely than men to have physicians of the opposite gender of their own, which could lead to a decrease in trust and increase in presumed inability of the physician to understand the patient?s position (Klitzman & Greenberg, 2002).
Although it might be assumed that lesbians would be much more likely to disclose their sexual orientations to providers who were gay themselves, Klitzman and Greenberg (2002) found that this was not necessarily the case. In general, the gay women in their study were less likely than gay men to feel comfortable discuss©\ ing their sexual orientations, or sex in general, with their physicians. Gay women were also less likely to believe they even had the option of finding a physician who was a lesbian, either due to limitations within their insurance net©\ works or sheer lack of availability of LGBTQ©\ identified physicians (Klitzman & Greenberg, 2002).
Because it is often difficult to find physicians who are gay or gay©\friendly, it could be argued that gay women are so acculturated to the environment of heterosexual physicians (and very often, heterosexual male physicians) that on the rare occasion they do encounter a gay or gay©\ friendly healthcare provider, they may still feel quite uncomfortable discussing their sexual orientations as they are largely unaccustomed to health care situations in which they are able to do so. Considering the heterocentrist medical culture to which so many queer women are accustomed, it may be greatly beneficial to the lesbian population for insurance companies to allow clients to search specifically for LGBTQ©\ identified or LGBTQ©\friendly providers in effort to establish a culture in which lesbians are encouraged to feel comfortable discussing their sexuality and sexual orientations (Klitzman & Greenberg, 2002).
Another significant element of the disparity existing in the healthcare experience for the lesbian patient is the fact that the non©\heterosexual patient falls outside of the ¡°norm¡±; the lesbian patient might be quite correct in assuming that medical knowledge and practice has not been designed with her in mind. Rosser (1993) described how the modern medical model was designed primarily with the heterosexual male in mind, giving the example of heart disease and how it is so often mistaken for a male disease by public perception (although this misconception is beginning to change). Heart disease clearly affects both men and women, despite the fact that the majority of funding for heart disease research has gone towards research of heart disease in males rather than females (Rosser, 1993). Lesbian patients are on the outside of the medical paradigm to begin with due to their gender, and are now at risk of further disenfranchisement, due to their sexual orientation.
Rosser (1993) also points out that the field of women?s reproductive health care, particularly obstetrics and gynecology, was built upon the framework of heterosexual sexual activity as the norm. The elements of this ¡°norm¡± include procreation and women?s sexual relations with men. While funding for research surrounding female©\ specific issues such as menstrual and post©\ menopausal difficulties has been extremely limited, the technologies relating to women?s health that directly involve procreation (particularly in-vitro fertilization and amniocentesis, as well as other technologies to assist reproduction) are much more apt to receive adequate attention and funding. This disparity suggests that women?s health care issues are generally perceived as more ¡°valid¡± or worthy of research when the resulting data and treatment ensure women?s ability to procreate and thus be ¡°useful¡± to men (Rosser, 1993).
Because the health care needs of lesbian women do not necessarily (although they may) revolve around procreation, research in areas of lesbian©\specific health issues has been lacking. Although lesbians are typically at a much lesser risk for certain diseases that are generally transmitted to women by means of heterosexual sex (such as chlamydia, human papilloma virus, and HIV), gay women are at an increased risk for other diseases less likely to strike their heterosexual counterparts. Campbell (1992), in her work, 1 in 3 Lesbians May Get Breast Cancer, Expert Theorizes, quotes Dr. Suzanne Hayes of the National Cancer Institute, who estimates that one in three lesbians may develop breast cancer in their lifetimes because they are more likely than other women to fall into high©\risk categories for the disease (as cited in Rosser, 1993, p. 187). It is thought that the risk for breast cancer is higher for lesbians for several reasons. One reason is that gay women are less likely than heterosexual women to have children, and it is thought that women who have not had children are at an increased risk for breast cancer by 80% (Rosser, 1993, p.187). It is also thought that lesbians are at a greater risk of developing breast cancer due to a higher incidence of obesity. Finally, lesbians statistically visit their gynecologists for exams less than half as often as heterosexual women (Rosser, 1993).
Aside from the potential discomfort with gynecological visits due to the heteronormative mentality among much of the medical community, this difference in frequency of obtaining care can also be accounted for by the increased regularity with which heterosexual women visit their gynecologists. These visits are often for the ostensible purpose of birth control prescriptions as well as pap smears and screenings for various conditions typically transmitted or caused by engaging in heterosexual sex. During these routine gynecological visits, breast exams and/or mammograms are performed. The frequent employment of these screening tools provide heterosexual women with a greater chance of finding breast cancer (or another potentially serious condition) in its earlier and more treatable stages (Rosser, 1993).
Perhaps the largest and most pressing issue facing lesbian health care is the lack of access to health care due to lack of access to health insurance. Because lesbian and gay couples are perpetually denied marriage rights in most geographic areas, many gay women are left uninsured when they are refused coverage under their partners? policies. As quoted by the 2007 AHRQ Report (2008), ¡°Health insurance facilitates entry into the health care system. The uninsured are more likely to die early and have poor health status…are diagnosed at later disease stages…are sicker when hospitalized and more likely to die during their stay¡± (p. 114). Even if the culture of health care existed without its current biases and heterosexist practices, a major disparity would remain present as many lesbians would still lack access to health care in the first place.
The disparities which are present in the lesbian patient?s experience of health care are both pervasive and persistent. From the inherent heterocentrist practices quietly passed off as ¡°standard¡± or ¡°normal¡± in the medical arena, to the biases which are held in secret or expressed blatantly by practitioners, to the inability to gain insurance coverage through their partners due to the bigotry that insists their unions are invalid, the lesbian patient?s experience of health care is vastly different from that of her heterosexual counterpart. Moving forward, it would require nothing short of a shift in cultural consciousness to eliminate these disparities, but there is hope that with effective leadership, education and visibility, the playing field that is the health care experience may be leveled for patients at all points on the sexual orientation spectrum.
Agency for Healthcare Research and Quality, AHRQ (2008). 2007 National healthcare disparities report. (AHRQ Publication No. 08©\0041). Rockville, MD: United States Department of Health and Human Services. Retrieved February 26, 2009, from http://www.ahrq.gov/qual/nhdr07/nhdr07.pdf
Campbell, K. (1992, October 2). 1 in 3 Lesbians may get breast cancer, expert theorizes. Washington Blade. 1,23.
Fields, C., & Scout, S. (2001, September). Addressing the needs of lesbian patients. Journal of Sex Education & Therapy, 26(3), 182. Retrieved February 26, 2009, from Academic Search Premier database.
Klitzman, R., & Greenberg, J. (2002, February). Patterns of communication between gay and lesbian patients and their health care providers. Journal of Homosexuality, 42(4), 65. Retrieved February 26, 2009, from Academic Search Premier database.
Rosser, S. (1993). Ignored, overlooked or subsumed: research on lesbian health and health care. NWSA Journal, 5(2), 183©\203. Retrieved February 26, 2009, from America: History & Life database.
About the Author
Sharon Kaye O?Connor is a graduate of New Jersey City University, where she majored in Music and minored in Psychology. For her first year placement, she worked with homebound elderly clients in Brooklyn at Mapleton Midwood Geriatric Services. For her second year placement, she worked with adult community college students of varying ages and backgrounds in the ASAP Program at LaGuardia Community College. Her major method at HCSSW is Clinical Practice with Individuals and Families. Ms. Kaye O¡¯Connor can be reached at firstname.lastname@example.org.