Introduction

This article reviews the literature relating to healthcare provision for lesbians. The author discusses the attitudes of healthcare providers to this client group and the experiences of these women in a prejudiced healthcare system.

by Doreen Kimura.

The incidence of homosexuality in women has been reported to be from 2 to 12 per cent of the female population (Hall 1978, Olesker and Walsh 1984, Robertson 1992). The true incidence may be underestimated due to the 'invisibility' of lesbians in society: women may be forced to hide their sexuality out of necessity for fear of losing family and friends or employment.

Lesbians face a homophobic reaction from healthcare providers, are anxious about the consequences of revealing their sexual orientation, worried about breaches of confidentiality and concerned that they may face hostility or physical harm. Negative experiences can also lead lesbians to delay seeking health care.

It is, therefore, reasonable to assume that healthcare providers have always taken care of lesbians but usually without the providers' knowledge of the woman's sexuality. This is problematic because in order to provide, for example, appropriate gynaecological diagnosis and treatment, accurate information regarding a woman's sexual activity and orientation is important.

Attitudes of healthcare providers

The healthcare system is one part of a predominantly heterosexual society into which most homosexuals will at some time enter, but ignorance about homosexuality has led to exaggerated stereotyping of them by society.

All healthcare providers come to their profession with pre-formed values and opinions and when a subject as sensitive as homosexuality is involved there is certainly the potential for bias and prejudice (Olesker and Walsh 1984). Nurses are not immune from the prejudices prevalent in mainstream society (Wright 1988), and it is perhaps not surprising that they share negative images of lesbians and gay men.

From the studies that have explored healthcare provider's attitudes towards lesbians, it is clear that fear and prejudice are still present in current practice. Significant numbers of doctors and nurses in the research were uncomfortable providing care for lesbian clients, some even refusing services to women who were lesbians (Bond et al 1990, Harvey et al 1989, Rose 1993, Smith et al 1985).

Many healthcare provider's attitudes are based on assumptions that people are heterosexual. Lack of knowledge about different lifestyles and how these affect health can lead healthcare professionals to ask inappropriate questions and to form incorrect judgements.

One of the predictive factors in positive attitudes is familiarity. In Eliason et al's sample (1992) nursing students who reported knowing a lesbian had more accepting attitudes.

According to Eliason et al (1992), academic research, imbued with the values of the dominant heterosexual culture, has contributed to lesbian invisibility in several ways. Earlier studies on the topic of homosexuality sometimes included lesbian women as though men and women could be compared equally. Research that did address lesbianism specifically often examined questions of psychopathology rather than exploring the reasons why society does not accept lesbians.

Also, science is not objective, but is biased by the same heterosexist values as the non-scientific culture. Thus, any research concerning lesbain issues may be tainted with the same faulty assumptions that patriarchal society holds for women in general and lesbians in particular - the 'double jeopardy' of belonging to two minority groups (Potter and Darty 1981).

In studies, healthcare providers have usually assumed that their female clients were heterosexual, had male sexual partners and performed within normative social roles as wives and mothers in traditional family units (Olesker and Walsh 1984, Rose and Platzer 1993, Zeidenstein 1990). Participants felt that simply rephrasing common questions asked during healthcare interviews, would eliminate inaccurate assumptions, thereby allowing the woman to be more open about her sexual orientation.

For example, questions regarding contraception such as 'What type of contraception are you using?', could be rephrased as 'Do you have a need for contraception?' (Olesker and Walsh 1984).

The majority of respondents in Harvey et al's study (1989) felt that the overall quality of care and the providers' ability to meet the healthcare needs of lesbians were adequate to excellent. Conversely, over half of these women rated healthcare providers as inadequate to poor on their practical knowledge of, and sensitivity to, lesbian health concerns, their awareness of homophobia and their ability to comfort lesbians.

In addition, a majority rated providers as inadequate to poor in their support of lesbian relationships or lesbian parenting. The emotions evoked by healthcare providers interactions with lesbian clients included pity, disgust, unease, embarrassment and fear (Stevens 1992).

Smith et al (1985) categorised the negative reactions from healthcare professionals. The respondents described various reactions, including:

• 'Cool' (12 per cent)
• 'Embarrassed' (30 per cent)
• 'Inappropriate' (25 per cent), such as suggesting a referral to a mental health professional
• 'Overt rejection' (22 per cent) for example: He got up, left the room and had a nurse finish the questioning".

Male and female healthcare providers were found to respond equally in a negative manner.

These negative attitudes are thought to be deeply rooted in religious, legal, political and psychological institutions of Western civilisation (Zeidenstein 1990). Thirteen per cent of the study participants in Eliason et al's study (1992) objected to lesbianism on moral, ethical or religious grounds.

Lesbian stereotypes

Damaging stereotypes that are widespread in the general public are also apparent in the way that doctors and nurses think about, and thus interact with, lesbians. Stereotypes are, for the most part, demeaning and offensive and deny the recognition of individual differences among members of a group. Eliason et al (1992) identified the common stereotypes held by female nursing students.

The most prevalent theme was that lesbians aim to seduce heterosexual women, with 38% of the sample suggesting that heterosexual women should be wary of sexual advances made by lesbians. They recommended 'keeping a distance' from all lesbians to 'protect' themselves from those 'overly friendly' lesbians who will 'make eyes at you'.

Other common stereotypical reactions include that 'lesbians hate men', 'lesbians are anti-family' and 'lesbians hate children' (Olesker and Walsh 1984). Brossart (1979) said female nurses were particularly threatened by a lesbian because 'they'd be afraid of what others might suspect if they appeared to be accepting of her'.

In response to the question asked by Eliason et al (1992) – 'How would you know if a co-worker was a lesbian?' – 26% said lesbians were identifiable only through self-disclosure. However, 31% suggested that lesbians may be picked out of a crowd based on their 'aura of masculinity'.

In a heterosexist society, sexuality is a dichotomous variable; there is male sexuality and there is female sexuality. If a lesbian is not perceived as fitting within female sexuality as defined by the culture, then, according to the sexual dichotomy, she must be considered as representing male sexuality.

Sexual health and lesbians

Some healthcare providers inappropriately associate high rates of HIV infection and transmission with lesbian clients (Gentry 1992, Lucas 1992, Olesker and Walsh 1984) presumably because the heterosexual society tends to consider gay men and lesbians as a homogenous group. AIDS has been stereotyped as a 'gay disease', which has led to lesbians being labelled as a high-risk group. In some countries, for example, lesbians have been refused as blood donors on the grounds of their homosexuality (Richardson 1994).

Lesbians are largely absent from the literature on AIDS, health education usually ignores them and lesbian sexual behaviour has never been studied as a separate and distinct group in terms of incidence, rate and modes of transmission of HIV (Richardson 1994, Zeidenstein 1990). Thus, lesbians are both implicated in popular conceptions of AIDS which link homosexuality and disease and neglected in the healthcare system's response to AIDS.

The implications of this lack of information are twofold. By thinking AIDS is an issue which does not affect them, some lesbians may be putting themselves at risk of HIV infection. Equally, some lesbians who are ill-informed may be worrying unnecessarily about HIV infection or AIDS.

Lesbians are less likely to engage in unsafe sexual practices than gay men or heterosexual couples. Risk of HIV infection is created by certain kinds of behaviour, not by social group or sexual identity and Elaison et al (1992) argued that HIV and AIDS education needs to focus on high-risk behaviours and not on groups of people. As this goal is accomplished, perceptions of risk groups may change.

More generally, AIDS has stimulated public debate on sexuality, sexual practice and sexual values which has prompted and encouraged attempts to impose new forms of social control over sexuality. These affect lesbians as well as other groups.

An example of this in the UK was Section 28 of the Local Government Act 1988, which makes it illegal for a local authority to intentionally 'promote' homosexuality and forbids the teaching of the 'acceptability of homosexuality as a pretended family relationship' (Rose 1993).

Richardson (1994) stated that policies like these reinforce negative meanings of lesbianism. Differences in legislation between the age of consent for heterosexuals and homosexual men has also reinforced homophobic attitudes (Rose 1993, Taylor and Robinson 1994).

Studies have shown however, that lesbians have one of the lowest rates of sexually transmitted diseases, such as gonorrhoea, chlamydia and syphilis, but are still at risk from other sexually transmitted diseases such as bacterial vaginosis and herpes (Zeidenstein 1990).

Disclosure of lesbian identity

Some lesbians believe that disclosure of sexual orientation can affect negatively the quality of care they receive. Upon disclosure, some experienced mistreatment, ranging from refusal to treat, demeaning jokes, avoidance of physical contact, insults to them and to their lesbian partners and friends, rough physical handling and breaches of confidentiality (Harvey et al 1989, McGhee and Owen 1980, Rose 1993, Smith et al 1985).

Due to these negative reactions, many women did not feel free to disclose that they were lesbians in healthcare contexts, even when they would have preferred to do so. One study participant (Zeidenstein 1990) stated: 'Once I was fitted for a diaphragm which I didn't need rather than having to come out'. Due to non-disclosure, they were subjected to health providers' heterosexual assumptions. Many of the women in Zeidenstein's study (1990) who chose to come out did so to dispute the healthcare provider's heterosexual assumptions.

Lesbian clients tended to be vigilant for behavioural and verbal clues from healthcare providers that conveyed their openness toward or discomfort with lesbians. Deevy (1990) summarised this: 'Because lesbians…….negotiate their daily lives in environments that range from hostile to friendly, they are acutely aware of subtleties in language and manner that suggest danger or safety'.

The assumption of heterosexuality is so pervasive within health care that most lesbians report never being asked their sexual preference. The finding by Smith et al (1985) that only 9% of their total sample had ever been asked about sexual preference confirms the fact that healthcare providers rarely ask for such information.

One area in which the assumption of heterosexuality occurs is birth control. This assumption was a dominant theme throughout the interviews carried out by Robertson (1992). Not surprisingly, the most common area in regard to this was contraceptive needs and sexual activity.

Lesbian and gay men who are healthcare providers are rarely mentioned in the literature and the very existence of lesbian nurses is largely hidden. Rose (1993) conducted a research project to examine lesbian nurses' experiences of homophobic attitudes, discrimination and oppression. Silence dominated the subject of lesbians in nursing. One nurse commented: 'Anti-lesbianism I experienced came in the form of complete silence on the subject, as if the other nurses felt okay about me as an individual but not about my lesbianism.' The study suggested that while some lesbian nurses experienced discrimination, others felt that they must live a lie to avoid it.

There are many risks to homosexuals disclosing their sexuality in society as well (Gentry, 1992). By disclosing their homosexuality, lesbians may experience rejection, shame and humiliation from family members and friends who do not understand the homosexual lifestyle.

For some lesbians who believe they can conceal their lesbian identity, comprehensive management of that information involves not only keeping silent about being lesbian, but also being vigilant about the intimate details of who they are, how they act, how they look, what they say, who they are with and where they go. Such a task is extremely complex and is not paralleled in the experiences of non-lesbian women (Stevens, 1992).

Delays in seeking health care

Studies have demonstrated that lesbians avoid or delay seeking care because of the insensitivity of healthcare personnel and poor healthcare experiences (Deevy 1990, Smith et al 1985, Zeidenstein 1990). In Reagan's study (1981), 24 per cent of the sample had at one time delayed care because of concerns regarding negative responses to their sexual preference. In some cases they were more likely to seek help from lesbian friends rather than healthcare providers.

Trippet and Bain (1992) highlighted gaps in care provision which deterred lesbians from seeking healthcare from traditional sources: lack of holistic care; little preventive care and education; lack of communication and respect; and few women-managed clinics. Negative healthcare experiences have also contributed to lesbians choosing Eastern and ancient healthcare practices rather than Western practices (Buenting 1992).

Fear and the unpleasantness associated with coming out influenced the majority of respondents in Zeidenstein's study (1990) to postpone gynaecological care or to seek lesbian-sensitive providers. Study findings have shown that lesbian clients have an overwhelming preference for female healthcare providers (Olesker and Walsh 1984, Robertson 1992, Smith et al 1985, Trippet and Bain 1992).

Although some lesbians would prefer a lesbian healthcare provider, the gender of the provider was more important than the sexual orientation. Lesbians felt more comfortable, perceived more kindness and openness, and believed that they were less vulnerable to harm with a female practitioner, as do many women regardless of sexual orientation. If healthcare providers who were gay felt more comfortable to come out then lesbian women would seek out their care.

Discussion

This review of the literature suggests that lesbians have a range of concerns in relation to their healthcare needs. They fear homophobia from healthcare providers; the consequences of being open about their sexuality and that if they are not, they may not receive relevant care; physical harm; and breach of confidentiality leading to negative consequences for family and friends, as well as for their own employment, housing and future health care. Consequently, they may delay seeking care or avoid healthcare professionals entirely, adversely affecting their health.

The silence about lesbian issues in healthcare training, whether due to lack of knowledge or to homophobia, perpetuates the invisibility of lesbians. It may also contribute to lesbians receiving poorer quality care by neglecting to inform healthcare providers of their unique needs.

Social conditioning regarding sexuality can be countered by appropriate educational preparation, helping to dismantle the traditional views on the subject and improve both health care and the personal development of healthcare providers. Values regarding sexuality develop over years and it takes time, experience and the opportunity for pen discussion to learn to handle the subject sensitively. The RCN (1994) suggested the designing of pre- and post-registration training and education strategies to ensure the profession is better informed.

The healthcare concerns of lesbians differ from those of heterosexual women and health professionals must recognise this. Although lesbians are no more nor less likely to require health care for general medical reasons than heterosexuals, gynaecological concerns or the desire for children focus attention on sexuality. In Zeidenstein's study (1990) 70% of participants wanted to have children.

Healthcare providers, especially midwives, are being faced with several moral, ethical and legal issues in regard to this, including the benefits and risks of using known or unknown donor insemination or coitus, along with male parental involvement and possible custody battles.

One health visitor described how a lesbian mother had hidden the existence of her partner from two previous health visitors because of fears that child protection proceedings might have been started (Rose and Platzer 1993).

There are signs that the concerns of lesbians are beginning to be addressed. The launch of the Sandra Bernhard Clinic at Charing Cross Hospital in 1992 was a recognition of the special health needs of lesbians. The RCN also announced it's commitment to developing and promoting good nursing practice to this group of clients by supporting the Lesbian and Gay Nursing Needs Working Party (RCN 1994). Health professionals are also beginning to conduct research on the health needs of lesbians but studies are few.

The problem with lesbian studies is that they sample only those women who are accessible, those who have come out, and who are white, middle-class and well educated. The majority of respondents were also identified in gay-sensitive areas such as women's cultural events. A lack of women from ethnic backgrounds was also evident.

Trippet and Bain (1992) argued that as long as homophobia exists or is perceived, methodological problems in lesbian healthcare research will continue to exist.

A more fundamental analysis of the relationship between gender and health care and research that focuses specifically on the concerns of lesbians is urgently needed. Major knowledge deficits remain regarding lesbian experiences with healthcare providers across a full range of contexts, such as hospital nursing staff, mental health professionals and alternative medical practitioners, and how healthcare providers' attitudes correspond with their actual behaviour toward lesbian clients (Stevens 1992). New studies also need to include lesbians representative of minority socio-economic groups.

Evidence based care

If healthcare providers and educators are to have a positive impact on the health status of the lesbian population, they need to incorporate information from research into their practice and teaching. It is relevant that all participants in one study stated that characteristics such as insensitivity and ability to approach clients in a non-judgemental manner were important (Olesker and Walsh 1984).

However, they also stated that these characteristics were lacking in much of the traditional medical system and for this reason recommended evaluation and improvement of health services to women in general. Perhaps health professionals need to open themselves to the concept that they can learn from their clients.

Conclusion

The World Health Organization outlined the fundamental rights of the individual, including the right to sexual health (WHO 1975). This right includes freedom from fear, shame guilt, false beliefs and other factors inhibiting sexual response and impairing sexual relationships. Lesbians are an overlooked and underserved population and have historically been excluded from research. Until healthcare providers looking after women and healthcare educators examine their own views and values about homosexuality among the female population, they will be unable to provide the humanistic, non-judgemental, non-heterosexist and sensitive care lesbian women want and have the right to expect.

© Maeveen Brogan BSc(Hons) Nursing (1997) Nursing Standard 11; 45; 39-42.

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Further reading

• Doyle T (1967) Homosexuality and its treatment. Nursing Outlook. 15, 8, 38-40.
• Jones R (1988) With respect to lesbians. Nursing Times. 84, 20, 48-49.
• Kenny J, Tash D (1992) Lesbian childbearing couples' dilemmas and decisions. Health Care for Women International. 13, 2, 209-219.
• Wolff C (1973) Love Between Women. 2nd edition. London, Gerald Duckworth.