Recently, we were asked by a reporter, "How does heterosexism impact health care? What does your sexuality have to do with the quality of care you receive...& what does it have to do with health in general?". For those of you who are lesbian, the connection between heterosexism & poor health care is probably obvious. However, since health care institutions & agencies generally operate according to heterosexist policies & procedures, the information may be new, as well as startling, to heterosexuals.
According to our government, good health, as well as quality health care, is available to most Canadians. Health is defined as "a complete state of physical, mental, & social well being", including "the ability to realize hopes & satisfy needs & to change or cope with the environment". (Report on the Health of Canadians, 1996). A close examination of how health is measured, however, reveals that although determinants of health have been expanded to include "psychological well being, self-esteem, & the sense of control over our lives", the implications of heterosexism for the health status of LGBT have not been considered -- despite evidence suggesting that it's a health hazard. (Muzychka,1992, Simkin, 1998, O'Hanlon, 1995) Heterosexism impacts our well-being, & thus our overall health, and heterosexist policies & procedures impact the quality of health care we receive. Since the 1980's, a small but growing body of research has documented the numerous & diverse effects of heterosexism on our health & health care. This article represents a preliminary review of some of this research.
When lesbians, gay, & bisexuals enter the health care system, they are heterosexual by default. Because of this invisibility within the medical profession, they often receive inappropriate health care. The level of inappropriateness ranges from unnecessary, invasive physical examinations to intrusive questioning. (Simkin, 1998)
"When I arrived at the hospital, the paramedics informed the nursing staff & doctor of my illness & that it was the probable cause of the bleeding. Although I was almost unconscious, I overheard the medical staff making bets about my condition -- they were predicting a miscarriage while the paramedics were arguing (on my behalf) that it was the result of an existing disease. The next thing I know, a nurse is standing over me, telling me that they were going to do an internal, vaginal exam with a speculum to rule out miscarriage. I insisted that pregnancy was an impossibility, that I had not had intercourse in about 10 years. They seemed to be ignoring me, so I swore rather loudly...they told me to stop using profanity & proceeded with the unneeded, unwanted examination. Because they had totally disregarded me & ignored the information that I had provided them (which was the answer as to why I was bleeding), I felt as if I had been raped". (The Heterosexism Enquirer, 2000)
"I was asked by the nurse in the x-ray department when I had my last period. Because I'm lesbian, & there's no chance of pregnancy, I don't keep track of these dates - so I told her I didn't know. She became concerned & advised me that they couldn't do the x-ray if there was a chance of pregnancy. I explained that there was no chance of pregnancy. She insisted that without knowing the date of my last period, that pregnancy was a possibility. Finally, it occurred to me to tell her that I had never had intercourse. I didn't feel safe enough to come out. It was just a matter of asking the right question..." (The Heterosexism Enquirer, 2000)
Neither of these women disclosed to their health care providers that they were lesbian. It was already assumed that they were heterosexual & questions about their health were framed according to this assumption. Their fear of disclosure was one that had already been validated by blatant heterosexism. In their experience, the presence of heterosexism implied the possibility of homophobia. So, they answered carefully - in the first instance, despite the trauma, & in the second, despite the awkwardness. Disclosure, or coming out, does not always lead to acceptance -- & they knew this. Hate crimes against lesbians are increasing -- they endure "verbal abuse, threats, physical & sexual violence, property damage, & murder. Violence is usually more severe if the woman is identified as being a lesbian...Lesbians in universities are assaulted twice as often as heterosexual women...& 25% of lesbians reported being a victim of a hate crime committed by a family member." (Simkin, 1998) Most significantly, "studies of nurses, physicians, & medical students confirm that prejudice towards homosexuals among health care providers is substantial." (O'Hanlon, 1995)
Yet another consequence of invisibility is that in hospital settings, LGBT are perceived as having no support systems. Same-sex partners & families of choice are often not validated by the policies of health care institutions. (Muzychka, 1992, Simkin, 1998)
"While in the intensive care unit at a hospital in Newfoundland, my lover pretended to be my aunt so that she could visit me. The nurses said that only family was permitted..." (The Heterosexism Enquirer, 2000)
"I was a patient at [a hospital] here in St. John's. Sometimes my lover would visit me. If a nurse entered my room, more than likely she'd say, 'oh! Is this your sister/ mother/ friend?'. The possibility that I was anyone other than a heterosexual was never considered". (The Heterosexism Enquirer, 2000)
When emotional health has such a strong impact on our physical health, and family relationships are not validated, or allowable, in 'healing' centres such as hospitals, then a patient's well-being is placed at risk. Imagine the stress endured by a lesbian who worries whether her partner will be permitted to visit her after surgery, and the energy that she expends in inventing justifications for the presence of a "non-family" member. Since many lesbians, gays, & bisexuals fear that they will be treated poorly or rejected if they come out, it is the responsibility of physicians to "ensure that the emergency departments & ICU's of hospitals where they have admitting privileges is accepting of self-identified family members...People are family if they say they are." (Simkin, 1998).
Invisibility is not the only issue that impacts the quality of health care received by lesbians. Acting & learning according to the assumption that all of their patients will be straight, many physicians, when faced with lesbian patients, will treat them according to stereotypes. Failing to recognize that lesbian women are as diverse as heterosexual women, physicians often treat lesbians according to assumptions about their identities rather than assessing the actual behaviors that impact their health. (Simkin, 1998) For example, it is often assumed that lesbians are sexually inactive, specifically with regards to intercourse. This leads many physicians to assume that because their lesbian patients are supposedly not having intercourse, that they are at low risk for dysplasia, cervical cancer, etc. Based on this assumption, many physicians advise their lesbian patients that Pap smears are unnecessary."Most studies reveal, however, that between 77 & 91% of lesbians have had at least one prior experience with men". (O'Hanlon, 1995) Since studies reveal that rates of dysplasia among lesbian & bisexual women are no different than rates among heterosexual women, the assumption that lesbians are at low risk is a dangerous one. When compared to heterosexual women, lesbians receive fewer Pap smears and the intervals between screening is 3 times longer. (O'Hanlon, 1995).
When obtaining sexual histories from their patients, physicians need to focus on behavior (what people are actually doing), not the labels (hetero/ homo/or bi). Many individuals engage in same-sex behaviors who do not identity themselves as gay or lesbian while others engage in opposite-sex behaviors who do. The solution is simple. "Physicians can routinely ask whether each patient is sexual with men, women, both or neither...& all patients can benefit from the non-biased demonstration of the [physician's] positive attitude..." (O'Hanlon, 1995).
Heterosexism interacts with ageism in the care of older women who may not identify themselves as lesbian but who are in long-term relationships with women. This is simply due to the time period in which these women were raised - words like "homosexual" or "lesbian" were not spoken. Although their relationships may have spanned a life time, our society does not recognize them as valid. "When these women lose their partners...society does not recognize them as 'widows' and they must mourn alone...in silence". (Simkin, 1998) In terms of health care, this lack of validation & acknowledgement could lead to improper or inadequate treatment & counseling. The following anecdote from Simkin's "Not all your patients are straight", illustrates the negative consequences of the heterosexist approach as well as the simplicity of an inclusive treatment style & its positive result:
"A 72-year-old woman has been losing weight & not sleeping. She is tired all the time.
During the course of a physical examination, the physician asks, "Do you live alone?"
"Yes," she sobs.
"What about your husband?"
"I've been divorced for over 40 years, " she replies.
The physician does a complete examination, decides the woman is suffering from depression and prescribes antidepressants.
The woman does not return.
She does, however, go to another physician, who asks, "Do you live alone?"
"Yes, I do," she sobs.
"Have you always lived alone?"
"No. My roommate lived with me for 37 years. She died a few months ago."
"Were you very close to her?"
"Yes."
"You must miss her very much."
"Yes. I can't bear to live without her."
And so the physician sends the woman for the bereavement counseling she so desperately needs." (Simkin, 1998)
As discussed In the Forum, violence in same-sex relationships can exist. There is, however, a gender stereotype that issues of power & control cannot be components of relationships between women. Research indicates that many health care providers subscribe to this stereotype. Thus, when lesbians in abusive relationships do reach out for help, "the violence is often minimized & framed by care providers as mutual aggression". (British Columbia Ministry of Health, 1999). As a result, lesbians who are abused are less likely to seek medical help or to contact a shelter. The abuse thus continues, as well as the fear & shame.
This article represents only a fraction of the research and just begins to address the problems created by the assumption of heterosexuality. Yet, it should now be evident how heterosexism can impact health & health care. In future editions of THE-zine, we will continue to address this issue so that the coverage is inclusive of all whose health is impacted by heterosexism.
Making care safe for lesbians means:
from, "Caring for Lesbian Health: a resource for health care providers, policy makers, & planners", British Columbia Ministry of Health, 1999.