HETROSEXISM IN MEDICINE:
LESBIANS’ ACCESS TO AND QUALITY OF HEALTHCARE
Hannah Banfield
Thesis
submitted in partial fulfillment of the requirements
for the Degree of Bachelor of Arts
with Honours in Sociology
Acadia University
April, 2010
© Copyright by Hannah Banfield, 2010
This thesis by Hannah Banfield
is accepted in its present form by the
Department of Sociology
as satisfying the thesis requirements for the degree of
Bachelor of Arts with Honours
Approved by the Thesis Supervisor
______
Dr. Zelda Abramson Date
Approved by the Head of the Department
______
Dr. Jim Sacouman Date
Approved by the Honours Committee
______Dr. Sonja Hewitt Date
ii
I, Hannah Banfield, grant permission to the University Librarian at Acadia University to reproduce, loan, or distribute copies of my thesis in microform, paper or electronic formats on a non-profit basis. I however, retain the copyright in my thesis.
______Signature of Author
______Date
iii ACKNOWLEDGEMENTS
There are several people without whom this work would not have been possible. Foremost, I would like to thank the women who consented to be interviewed, giving their time and sharing their experiences. Their collective efforts are the heart of this project.
I am especially grateful to my supervisor, Dr. Zelda Abramson, who recognized a potential in me of which I was not aware. Zelda, your guidance and support have been invaluable and your passion infectious.
I would like to express my sincere gratitude to Karen Turner, the department‟s administrative assistant. Karen, you go above and beyond in every way. Your insight has been so valuable, but your friendship is priceless.
Ali, I am grateful for your friendship, your intellect, and of course, for the endless laughter we have shared. I cannot imagine my experience over the past year without you.
Dan, you leave me in awe of your never-ending patience, constant faith, pure love, and support. I feel so fortunate to be traveling through this life with you.
Finally, to my Nanny, my Mum, and my sisters, I thank you for showing me what strong, independent women can achieve; your courage is my inspiration.
iv TABLE OF CONTENTS
ACKNOWLEDGEMENTS ...... iv ABSTRACT ...... vi 1. INTRODUCTION ...... 1 2. LITERATURE REVIEW ...... 4 Women and Medicine in History ...... 4 Women and Medicine in the New Millennium...... 10 Heterosexism in Healthcare ...... 13 Lesbians and Gynecological Health ...... 16 Attitudes and Behaviours of Healthcare Professionals ...... 17 Aspects of the Procedure ...... 18 Lesbians and Pregnancy ...... 20
3. THEORETICAL FRAMEWORK ...... 22 4. METHODOLOGY ...... 27 5. FINDINGS AND DISCUSSION ...... 31 Medicine’s Assumption of Heterosexuality ...... 31 Sensitivity of Physician ...... 34 Perception ...... 36 Healthcare Choice and Decision-Making ...... 38
6. CONCLUSION ...... 40 7. BIBLIOGRAPHY ...... 44
Appendix A ...... 49 Appendix B ...... 50 ABSTRACT
In this thesis, I ask whether lesbians have equal access to healthcare and whether the healthcare they receive is in an environment of respect, free from discrimination. I use data gathered from various scholarly texts and journals to explore women and medicine in history, women and medicine in the new millennium, heterosexism in medicine, lesbians and gynecological care, and lesbians and pregnancy. Looking through a lens of feminist standpoint theory, I conduct four semi-structured interviews with lesbian women in Nova Scotia to explore their experiences in healthcare. The interviews dissect a variety of themes, including medicine‟s assumption of heterosexuality, physician sensitivity, the effects of patient perception, and healthcare decision-making.
My key finding shows that with increased age and education, women are more able to exercise agency and challenge the power relations that exist in healthcare, and thus are better equipped to receive quality healthcare. Finally, I address solutions for a more inclusive healthcare system, involving both policy planners and healthcare professionals.
vi 1. INTRODUCTION
The World Health Organization states that health is a fundamental human right
(WHO Constitution 1946), recognizing that all people deserve equal access to healthcare and to quality treatment in an environment of respect, free from discrimination.
However, not all Canadians obtain these basic privileges, perhaps as a consequence of their social class or race, of their intellectual or physical disability, or their self-identity as
LGBTTIQQ2S (lesbian, gay, bisexual, transgender, transsexual, intersex, queer, questioning, and two-spirited). Although all of these groups may face specific and equally trying hurdles to access quality healthcare, this thesis focuses specifically on lesbians in Nova Scotia. I ask whether lesbians have equal access to healthcare, and whether the healthcare they receive is in a respectful environment, free from discrimination. To do this, I explore women and medicine in history, women and medicine in the new millennium, heterosexism in medicine, lesbians and gynecological care, lesbians and pregnancy, as well as the role of physician sensitivity, and the patients‟ perceptions and choices. The method used in my research is a combination of secondary data gathered from various scholarly texts and journals and primary sources.
The review of the pertinent literature (in Chapter 2) reveals that historically, women have been a marginalized group (Ehrenreich and English 1973, Mendelsohn
1981). Women were long excluded from medical knowledge and lacked the power and control held by men in society (Ehrenreich and English 1973). Even after the rise of the
Women‟s Health Movement in the early 1970s, there certainly remains much to learn about women‟s health, especially those women who belong to marginalized groups. The
1 medical establishment, even in the new millennium, does not adequately address women‟s health issues; women are excluded from clinical investigations, provided less funding for studies specific to their gender, are often prescribed unnecessary psychotropic drugs, and receive a higher number of avoidable surgeries than their male counterparts
(The Boston Women‟s Health Book Collective 1998).
For women who belong to marginalized groups, access to quality healthcare is even more difficult; lesbians frequently encounter heterosexist assumptions and attitudes in healthcare (Hudspith 1999). They operate in a healthcare system that is entrenched in heteropolarity and heteronormativity, which negatively affects healthcare delivery to lesbians in a number of ways (Fish 2006). Most commonly, lesbians speak of negative experiences in regard to gynecological and obstetrical care.
Using feminist standpoint theory, in Chapter 3 I examine lesbians‟ access to healthcare. Standpoint feminism states that women‟s lives are very different from those of men. It asserts that women possess a different kind of knowledge; their status as the subordinate group allows them to see and understand the world in a different way.
Dorothy Smith‟s (1987) writings are critical in understanding feminist standpoint theory and how it relates to women‟s experiences in their daily lives. In my study I use standpoint theory to offer a better understanding of lesbians‟ access to healthcare, my aim being to establish whether lesbians are receiving the same quality of healthcare as their heterosexual counterparts. Readers will obtain an understanding of how gendered power relations, more generally, affect women‟s access to quality healthcare, and more specifically, how these power relations relate to the experiences marginalized groups‟ have in healthcare.
2 Primary data are collected through interview sessions with four white, middle- class women from Nova Scotia. The methodology chapter in this thesis focuses on the concepts for choosing my interviewees, the organization of the interview sessions, and the process of interviewing the participants. Participants were asked open-ended questions about their experiences with healthcare providers, and the obstacles they have faced in seeking out quality healthcare in a respectful environment. Examining lesbians‟ experiences of healthcare is a critical step in assessing power relations between marginalized groups and their healthcare providers. The raw data collected through the interviews will be presented, analyzed, and discussed in Chapter 5.
3 2. LITERATURE REVIEW
Understanding lesbian health requires examining the history of women and medicine generally. As a group, women have been treated as sick and weak objects by the mainstream medical system, from the days of Hippocrates through to today in the new millennium. However, lesbians have faced further barriers in accessing healthcare due to their sexual orientation being in the minority, especially in their access to gynecological and obstetric care. Thus, this literature review provides an historical and contemporary overview of women‟s access to healthcare and then demonstrates that lesbian women are doubly marginalized based on both their gender and their sexual identity.
Women and Medicine in History
I begin my review of the literature with a historical overview of women and medicine throughout history. This is an important topic as sexism has been present in medicine as far back as the days of Hippocrates (Mendelsohn 1981). During the fifth and fourth centuries B.C., doctors believed that the female reproductive system was the source of hysteria and even insanity in women (Mendelsohn 1981). For two thousand years, if a woman stepped out of the expected pattern of submissive behavior, her ovaries and uterus were diagnosed as the cause (Mendelsohn 1981). By the nineteenth century, female health had become a prevalent topic in medicine. Affluent women of the time were seen as inherently sick, weak and delicate, and only able to engage in the most delicate of pastimes; thus they were prescribed lives of leisure to ward off illness, and in
4 turn, women saw their roles as weak and delicate (Ehrenreich and English 1973). This was particularly true for women of the leisure class. By the 1850s, a series of popular books on the subject of female‟s ill health written by doctors had a major following.
Women, more than ever, saw their social role to be sick and delicate (Ehrenreich and
English 1973).
Just as women were seen as sickly, sickness was seen as feminine, and the field of medicine defined all women‟s functions as inherently sick. Puberty was seen as a crisis, menstruation as a sickness, pregnancy was a disease, which called for isolation and requiring the strictest of care from a physician, and menopause was the final, incurable illness (Ehrenreich and English 1978). Because female functions were seen as sickly, doctors believed that this sickness must be attributed to women‟s sexual organs. Doctors believed that female‟s all-powerful reproductive organs controlled her mind, body, and soul. According to Dr. F. Hollick‟s article, The Diseases of Women (1849), “The Uterus, it must be remembered, is the controlling organ in the female body, being the most excitable of all, and so intimately connected, by the ramifications of its numerous nerves, with every other part” (205). When prescriptions of isolation or bed rest to cure hysterical women failed, symptoms such as headache, irritability, or indigestion, could provoke an invasive attack of the female sexual organs (Ehrenreich and English 1978), examples being placing leeches on the vulva or inside the cervical cavity, injections of substances such as water, milk, and tea into the uterus, and cauterization of the clitoris or ovaries or often both.
Doctors‟ views of women served as a powerful rationale against allowing women to act in any other way than sick. In fact, medical arguments were used to bar women
5 from higher education and from voting (Ehrenreich and English 1973). According to bio- medical theory at the time, the human body‟s energy was directed only to the organ, which was being used the most at any given time (Ehrenreich and English 1973).
Doctors believed that women should concentrate the totality of their energy internally toward the womb, and not to other organs such as the brain. In this way, women would conserve their energy for childbirth, considered to be a woman‟s grand purpose in life.
Higher education for women was viewed to be impossible, if not physically dangerous.
Too much development of the brain, doctors counseled, would impair the uterus because the brain would drain the much-needed energy required for childbirth. In his work called
“Concerning the Physiological and Intellectual Weakness of Women”, scientist P.
Moebius wrote:
If we wish woman to fulfill the task of motherhood fully she cannot possess a masculine brain. If the feminine abilities were developed to the same degree as those of the male, her material organs would suffer and we should have before us a repulsive and useless hybrid. (1907: 28)
In short, reproduction was seen as completely antagonistic to intellectual development.
The historic beliefs regarding women‟s reproductive organs have shaped gynecology today. In the section titled “Women and Medicine in the New Millennium”,
I will show that the medical system continues to medicalize women‟s health, similarly to that of male-diagnosed hysteria. First, however, I will address issues of women‟s health between 1940 and the 1990s.
The late 1960s and early 1970s saw the rise of the Women‟s Health Movement- a movement in which women of all ages and backgrounds joined together in local communities to fight for better healthcare for women (The Boston Women‟s Health Book
Collective 1998). Though this effort has created significant changes to the ways in which
6 both women and their healthcare providers think about women‟s health and medical care,
40 years later, women continue to confront barriers to their health care. To illustrate my point, I will discuss three examples that illustrate how medicine and science err on the side of Big Pharma over women‟s health.
Diethylstilbestrol, or DES, is a synthetic hormone prescribed to millions of pregnant women between the early 1940s and late 1960s in order to prevent miscarriages
(Direcks and Hoen 1986). According to Fenichell and Charfoos (1981), the U.S. Food and Drug Administration (FDA), played a key role in the launching of DES. Despite evidence that estrogen could cause cancer in mice, and a warning that DES was much more powerful than natural estrogen, the FDA, by the end of 1940, received more than 10 requests from pharmaceutical companies to sell DES (Fenichell and Charfoos 1981). By
1948, despite all the risks, DES was promoted in the pharmaceutical market and appeared in advertisements that claimed that DES was recommended for routine prophylaxis in all pregnancies. The drug played on the women‟s strong desire to do everything possible to maintain their pregnancies.
In 1971, an American gynecologist established a connection between DES and a rare type of vaginal cancer occurring among the daughters of women who had taken the drug during their pregnancy (Direcks and Hoen 1986). Though cancer was the most tragic outcome of the DES saga and there were relatively few cases, many women, who have come to be known as the DES daughters, experienced other serious health effects such as vaginal adenosis, deformations of the uterus, vagina, and fallopian tubes, resulting in a range of reproductive difficulties, including increased rates of spontaneous abortion, ectopic pregnancy, and premature births (Direcks and Hoen 1986). By the
7 1980s, increased rates of breast cancer were seen in women who took DES. The history of DES reveals that the FDA‟s decision to approve DES was driven by the pharmaceutical industry at the expense of women‟s short and long-term health.
The Dalkon Shield is an intrauterine device (IUD) manufactured by the A.H.
Robins Company that was marketed from 1971 to 1975 (The Boston Women‟s Health
Book Collective 1998). Despite disturbing reports from company insiders that the
Shield's rate of effectiveness was misleading, the company marketed the Dalkon Shield with claims that it prevented pregnancy without any effects, and that it was nearly as effective as the birth control pill (Mokhiber 1987). Between 1971 and 1975, A. H.
Robins distributed an estimated 4.5 million Dalkon Shields in at least 80 countries (The
Boston Women‟s Health Book Collective 1998). Promises of safety soon proved false as thousands of women reported serious health effects. Most suffered from pelvic inflammatory disease (PID), which could lead to infertility and in some instances death.
In fact, Dalkon Shield induced PID killed at least 18 women in the United States
(Mokhiber 1987). Of the estimated 110,000 women who became pregnant while using the Shield, 66,000 (60%) miscarried. This figure stands in sharp contrast to the miscarriage rate of 30% for women not using the Shield. For those women using the
Shield who carried their pregnancies to term, hundreds of women gave birth prematurely to stillborn children or to children with birth defects including blindness, cerebral palsy, and physical or intellectual disabilities (Mokhiber 1987).
Women of all ages were targeted by the pharmaceutical industry. In the 1960s,
Ayerst began an aggressive marketing campaign promoting synthetic estrogen as a drug to treat the symptoms associated with menopause, such as hot flashes, night sweats,
8 irritability, loss of libido, dryness of the vagina, feelings of anxiety, and depression
(Boston Women‟s Health Book Collective 1998). The pharmaceutical companies claimed that estrogen replacement therapy, or ERT, could relieve the menopausal symptoms caused by decreased levels of estrogen (Abramson 2002). In the thirty years that followed, many other uses were attributed to the use of estrogen, such as the reduction of risk by up to 50% for developing both osteoporosis and heart disease, the leading cause of death among post-menopausal women, (Abramson 2002). As such, the medical establishment implemented guidelines that recommended all menopausal women be offered hormonal treatment (Abramson 2002). Sales of estrogen remained steadily high until two studies published in the New England Journal of Medicine linked the use of postmenopausal estrogen to increasing rates of endometrial carcinoma (cancer of the lining of the uterus) (Smith et al. 1975). In 1977, the FDA warned women about the causal relationship between ERT and cancer. However, it was not until 1979 that the consensus conference on ERT, organized by the National Institute of Health, alerted women to the risks of ERT and the need for alternative remedies (NIH 1979). By 1980, researchers agreed that the risk of cancer could be increased three to six times by the use of estrogen (Abramson 2002). Then, in order to lower that risk, doctors began to prescribe synthetic progesterone (progestin) together with estrogen (Abramson 2002).
The combination of estrogen and progesterone is referred to as Hormone Replacement
Therapy (HRT).
Recent research on HRT has indicated that, in fact, there are no cardiovascular benefits associated with estrogen use and that synthetic estrogen can actually increase the risk of coronary disease in women with pre-existing heart conditions (Abramson 2002).
9 Additionally, it has been found that women who used estrogen for five years had a 35% increased risk of developing breast cancer, with the risk further increasing with prolonged use. However, despite these findings, estrogen-prescribing practices, for the most part, remain unchanged, with medical practice guidelines continuing to promote hormone replacement therapy as the treatment of choice to manage menopausal symptoms
(Abramson 2002).
Sales of HRT have dropped, as women are increasing skeptical about its safety The challenge women continue to face is to find ways to de-medicalize women‟s life course events such as pregnancy and menopause, and to challenge government policies that approve drugs that have yet to be proved totally safe.
Women and Medicine in the New Millennium
Even in the new millennium, women‟s health issues are still not adequately addressed. There are many complex questions and debates which go unanswered or unresolved (Varcoe, Colleen, Olena Hankivsky, and Marina Morrow 2007). Although approaches to women‟s health issues have developed significantly over the past several decades, health inequalities in virtually all areas of healthcare still exist for women, particularly those disadvantaged by multiple forms of oppression, such as being a visible minority, disabled, sexual minority, or of low economic status. In this section I will discuss women‟s marginalization in the specific areas of healthcare of clinical investigations, using statins and psychotropic medications as examples.
Historically, women have been excluded from clinical investigations due to scientists‟ false assumptions that the bodies of men and women were the same, of course with the exception of the reproductive organs (Lewis-Alexander, LaRosa and Bader
10 2001). With time, we have come to learn that many conditions and diseases affect men and women differently, recognizing that certain treatments may work better for one sex and worse for the other (Rosenberg and Allard 2007). Despite this knowledge, women are still often omitted from medical research (Rosenberg and Allard 2007). Even today, participants in medical research studies are predominantly men, as it is falsely assumed that men and women will react similarly to treatments (Rosenberg and Allard 2007).
According to medical doctor Marianne Legato, women are still often seen as small men and as being “identical in all respects except for their reproductive physiology” (1998:
21). This can cause a wide array of issues, as diseases often do not manifest in identical fashion in both men and women just as not all drugs function in the same way for men and women (Rosenberg and Allard 2007).
A prime example of this phenomenon is the use of statins to treat certain heart conditions. There are substantial differences in the ways heart disease manifests in women compared to men. Women experience both different and a much wider range of symptoms (Rosenberg and Allard 2007). Statins are a class of prescription drugs designed to lower cholesterol. Even though statins are commonly prescribed to women, the great majority of clinical trials for statins are researched on men (Abramson 2004).
Despite the difficulty of extrapolating benefit from male-centered trials to women, a key primary prevention trial cited by US guideline writers as evidence of statins benefit for treatment of women did not, in fact, include any women (Abramson 2004). Furthermore, those clinical studies on statins which have included women, have repeatedly failed to show that the use of statins lowers cardiovascular risk in women who do not already have coronary heart disease or diabetes, however, they do show that statin use in women can
11 result in nerve damage, chronic pain, chronic fatigue, memory impairments, episodes of depression, joint and muscle problems, kidney and liver damage, immune system depression and infection, birth defects, and cancer (Abramson 2004).
Clinical trials and the prescription of statins are not the only area of medicine in which women are disadvantaged. It is known that women, as compared to their male counterparts, are over-prescribed psychotropic medications for depression and anxiety
(Tannenbaum 2008). For drugs that can incur significant risks, such as adverse effects on memory, heart problems, and an increased risk of falls, hip fractures, and motor vehicle accidents, the overuse of psychotropics in women is a serious issue. With both the short and long term effects of psychotropic drug-use being fairly well known, why are women taking these medications at such an alarming rate? There are three explanations:
1) women are more likely to seek care for perceived mental health problems than men; 2) physicians are more likely to prescribe psychotropic drugs to women than men; and 3) women‟s health issues are more frequently dismissed as psychosomatic than are men‟s
(Mustard, Kaufert, Kozyrskyj, and Mayer 1998).
The most dominant reason for which women are prescribed more psychotropic drugs than are men is the fact that Canadian women are more avid consumers of healthcare resources than are men (Dickson et al. 2009), in part because of well women‟s exams, birth control management, pregnancy, childbirth, menopause and in part because women tend to take their children to the doctor. During their medical visits, they may express anxiety or psychological distress in which results in a psychotropic prescriptions.
However, this is not the only contributing factor to the over-prescription of psychotropics to women. In fact, physicians‟ practice-styles are such that they are more likely to
12 prescribe psychotropics to female patients than male patients. For example, according to
Simoni-Wastila, if male and female patients visited their doctors at equal rates, women are 55% more likely to be offered an anti-anxiety or anti-depressant prescription.
Furthermore, 1.77% of office visits by women result in a diagnosis of anxiety disorder compared to 1.14% of visits by men (1998). Finally, over-prescription of psychotropic drugs for women is the tendency of doctors to more readily dismiss women‟s symptoms as psychosomatic (Simoni-Wastila 1998). Physicians themselves admit that they are more likely to attribute women‟s health symptoms to anxiety, even in the presence of positive test results that indicate a physical disorder. When differences in psychological morbidity among men and women are accounted for, women are still significantly more likely to receive a prescription for psychotropic drugs than are men (Sayer and Britt
1997). Such practice styles perhaps are remnants of hegemonic beliefs that a woman‟s role is to be ill.
While the discrimination against women that exists within healthcare has been well documented in literature, discrimination against lesbian women in healthcare has been less explored. The following section of my literature review will address the main focus of my thesis: heterosexism in medicine.
Heterosexism in Healthcare
The term heterosexism helps to understand this phenomenon and can be defined as, “the institutionalized assumption that everyone is heterosexual, or should be; the belief that heterosexuality is innately right or superior to any other sexual orientation or identity” (Hudspith 1999: 5). In regard to healthcare, heterosexism can be as blatant as refusing to provide service to a gay or lesbian patient, or as subtle as assuming that all
13 patients are heterosexual. Because our healthcare system is entrenched in heteropolarity and heteronormativity, it then follows that heterosexism exists within the healthcare system and negatively affects healthcare delivery to lesbians in a number of ways. The presumption that all women are heterosexual guides the policies and practices of healthcare, rendering lesbians invisible and directly affecting the quality of healthcare they receive. According to Hudspith (1999), in order to ensure that adequate care is provided, lesbians must often make a declaration of their sexual orientation, which in turn may be met with disgust, hostility or misunderstanding. This section will outline the ways in which heterosexism has a negative impact on lesbian health.
Like most people, lesbians seek acceptance, respect, and a hospitable attitude from their healthcare provider. However, many researchers who have focused on lesbian health suggest that lesbian women underutilize the healthcare system for fear of discrimination (Mathieson 1998). In a study on the healthcare utilization of Canadian lesbians, Bergeron and Senn (2003) surveyed 473 lesbians in Canada (with a 54% participation rate) and found the primary reasons reported for the underutilization of the healthcare system included institutionalized homophobia, heterosexist assumptions by healthcare providers, fear of discrimination, and negative repercussion from the disclosure of sexual orientation. These responses may explain why many lesbians avoid using the healthcare system. This underutilization of the system alone causes a threat to lesbian health as it decreases the likelihood of early detection of diseases, which is often the determining factor in successful treatment, leaving lesbians at a higher risk for life- threatening illnesses (Kunkel and Skokan 1998).
14 Lesbians‟ fears of confronting discrimination when accessing healthcare are not without cause. Faria (1997) suggests that the assumption of heterosexuality begins at the reception desk and on forms where the question of sexual orientation is never asked.
Simply put, the healthcare system operates with the heterosexual woman in mind and does not take into account her lesbian counterpart. This omission of consideration for lesbian health within our healthcare system can have serious consequences for lesbian women (Faria 1997). In the following section I outline some of the ways in which lesbian health is often impacted by a heterosexist healthcare system.
Both psychotic and personality disorders are highly over-diagnosed in lesbian patients (Faria 1997). Often this occurrence is due to the failure to take into the account the difficulties of reconciling one‟s lesbian orientation in day-to-day life. Lesbians may suffer rejection from families, friends, and coworkers. They are often the target of hate- crimes, verbal and physical attacks, and may be denied housing, child custody, employment, and even healthcare (Hudspith 1999). A patient who is struggling with coming out may display signs of impulsiveness, intense anger, and instability, all behaviours which physicians may interpret as signs of borderline personality disorder
(Faria 1997). The failure to understand the patient‟s sexual orientation and the struggles they may face in relation to it, can easily lead to misdiagnosis and often unnecessary and harmful treatments.
Another example of heterosexism in healthcare is medical professionals‟ frequent failure to recognize a gay or lesbian patient‟s partner as a spouse (Forsten 2005). When a lesbian patient is admitted to the hospital, staff often refuse to treat the patient‟s partner as her spouse, even though the couple would have named each other “next of kin” on
15 their health proxies and assigned each other power of attorney. Mimeault (2009) also found that during surgeries the lesbian patient‟s spouse is often not updated on her partner‟s condition, nor is she consulted regarding serious decision-making in the event that the patient is unable to decide for herself. These are only two examples of the ways in which lesbians are disadvantaged in our healthcare system. In the following sections I will focus on two areas of healthcare in which lesbians face perhaps the greatest disadvantage of all: gynecological health and pregnancy.
Lesbians and Gynecological Health
The relationship between female patients and gynecology has been a popular area of study in medical sociology over the last several decades (Fish 2006). For example,
Sociologists have shown that socially marginalized groups, such as working-class, black, and aboriginal women, have differentiated experiences of healthcare, and are less likely to participate in cervical screening (Fish 2006). Lesbian women, too, are less likely to receive cervical screening, however, they, unlike other marginalized groups, have been continually overlooked in campaigns to encourage their participation in screening programmes (Hudspith 1999). However, this accounts for only a small part of the reason why researchers believe lesbian women underuse cervical screening services. According to Scherzer (2000), lesbians avoid gynecological examinations in large part either due to their own adverse experiences of healthcare, or because they have knowledge of the experiences of others, such as partners and friends.
Gynecological care is believed to cause much distress for lesbians as their health needs are unrecognized and they face moral disapproval from their physicians (Fish
2006), causing both physical and emotional vulnerability. Cervical screening particularly
16 has emerged as a key area as health inequality for lesbians as the results of the Lesbian
Health Care Survey (LHCS) revealed (Fish 2006). The survey, conducted over a 12- month period beginning in 1999, was publicized through local, regional, and national
LGBTTIQQ2S publications, reaching a wide range of groups, including women‟s centres and health groups, and lesbian organizations targeting particular groups such as disabled, older, younger, black and bisexual lesbians. The study examined 1066 lesbians‟ diverse experiences with cervical screenings. Two major themes emerged that may explain lesbians‟ negative experiences with gynecological health: attitudes and behaviours of healthcare professionals, and aspects of the procedure, such as painful experiences.
Attitudes and Behaviours of Healthcare Professionals
The LCHS revealed that many of lesbians‟ negative experiences with pap tests could be attributed to the poor attitudes and inappropriate behaviours of their healthcare professionals (Fish 2006). More than a quarter of the women interviewed reported that physicians‟ attitudes and behaviours were to blame for their adverse experiences with cervical screenings, claiming that their healthcare professionals were abrupt, unsympathetic, impatient, patronizing, rude, uncommunicative and impersonal. In their descriptions of adverse experiences, lesbians said that healthcare professionals also exhibited heterosexist attitudes and behaviour. For example, one respondent shared:
The practice nurse assumed I was heterosexual and started asking what contraception I used. When I said none she once again assumed that I was sexually inactive and rather abruptly told me that „I shouldn‟t be having [a pap smear] then‟. Her attitude was rather grudging that she should be giving me the smear, her tone patronizing, making me feel that I‟d wasted her time. I didn‟t feel able to tell her that I was a lesbian. (Anonymous, as quoted by Fish 2006: 151)
17 Women recounted experiences of intrusive and judgmental questions regarding their birth control needs, despite their assurances that they did not require contraceptives. Other lesbians spoke of being told that due to their sexuality, a pap smear was not necessary:
“As a young lesbian, I was treated by a doctor who was blatantly homophobic saying as I was not what was classed as sexually active this process was a waste of time and money”
(Anonymous, as quoted by Fish 2006: 152). It is not surprising then, that many lesbians feel alienated from the healthcare system and avoid seeking medical care (Fish 2006).
Aspects of the Procedure
There were five aspects of the pap test procedure often cited by the interviewees as reasons which led to an adverse experience: gender of the healthcare worker, procedural problems, the speculum, lack of privacy or dignity, and the physical position for taking the pap test. In some cases the women felt very uncomfortable having a male perform the procedure, explaining that having a man examine and touch them in such a way was difficult for them as lesbians. Furthermore, they found that having a male physician perform the procedure with no female nurse present was simply unacceptable.
In instances where a request was made for a female practitioner to perform the pap, the male physician typically responded with anger.
Procedural problems also accounted for negative experiences. Several lesbians recounted that healthcare professionals did not have a range of different sized specula in their practice rooms. The physicians were either indiscreet and inappropriate, shouting to the nurse to fetch a smaller speculum, as the patient was not sexually active, or they were determined to use the large speculum, even though a smaller size was available. The size of the speculum, although an issue for most women, is more pronounced for lesbians, as
18 their sexual activity may not involve penetration, making the vagina more sensitive to the insertion of a speculum.
The issues of privacy and dignity emerged as common themes in Fish‟s (2006) study. The women felt because of their sexuality, their healthcare providers treated them with less respect than they did heterosexual patients. One woman said that after telling her doctor she was a lesbian, he left the room whilst she was in the stirrups and returned with no less than 15 (mostly male) students; in her view this was presumably to show them a lesbian‟s cervix. Others shared stories the room was not private, with staff walking in and out. Finally, a number of the interviewees reported experiences of discomfort and humility. One respondent said that she “intensely disliked the position I was asked to take, typical legs up and away we go” (Anonymous, as quoted by Fish
2006: 155). Lying naked in a missionary position with a speculum inside them was viewed as a symbol of heterosexual sex.
The themes revealed in the LCHS demonstrate that many lesbians have had negative experiences with cervical screenings. Yet, there are few if any, gynecological healthcare policies that address a need to create anti-heterosexist environments and practice styles to accommodate all groups of women. Julie Fish (2006) concluded that her findings emphasize the need for a pro-active agenda for lesbian health, and that while some development has occurred towards these goals, much remains to be done to address the need for culturally competent healthcare. Fish believes that in order to provide equitable healthcare for lesbians, it is necessary to implement lesbian sensitive procedures, create lesbian-positive environments, and develop anti-heterosexist attitudes and behaviours in healthcare professionals.
19 Lesbians and Pregnancy
Lesbian parents choose to have children for the same reasons as heterosexual women (Chabot and Ames 2004). However, having a child as a lesbian usually involves complicated planning and decision-making. Lesbians must consider a range of possibilities regarding conception: donor options such as self-insemination or clinical donor insemination, having a friend donate sperm, whether the donor should first be tested for disease, and issues surrounding legal arrangements and cost (Day 1990). With the emergence of reproductive technology, lesbians increasingly seek to reproduce, and as such, over the past several decades a lesbian „baby boom‟ has emerged (Agigian
2004).
The medicalization of infertility has legitimized the use of reproductive technology among heterosexuals, however, the question remains whether or to what extent the use of these same technologies by lesbian couples has received the same support as heterosexual couples from society and the healthcare system alike. Although several clinicians have written books based on their experiences working with lesbian women and couples who are considering parenthood (e.g., Martin 1993; Pies 1987), very little empirical research examines lesbian couples‟ transition to becoming parents (Gartrell et al. 2000), and scholars who study family diversity (e.g., Allen, Fine, and Demo 2000) underscore this area as one of growing importance.
There are two studies that examine a lesbian couple‟s experience of getting pregnant, specifically, couples decision-making and barriers regarding donor insemination. Chabot and Aims (2004) interviewed ten lesbian couples and Goldberg
(2006) interviewed 29 lesbian couples with similar findings. For example, Goldberg
20 found that twenty-one percent of the sample, or six couples, experienced homophobia from health care providers during the course of becoming pregnant, or becoming a non- biological parent. In two cases, doctors refused to inseminate because the women were lesbians.
The first [obstetrician] we went to–she elected not to inseminate. It was a Catholic run clinic . . . they might have been concerned that they would have to go through legal stuff in order to approve us. (Anonymous in Goldberg 2006: 28)
Other women encountered healthcare providers that treated their non-biological partner with disrespect, which in essence is indirect homophobia. The women reported their care providers, including their childbirth class instructor, seemed unwilling to adopt the term partner, and consistently referred to the pregnant women‟s partners as husband (Goldberg
2006: 28).
In summary, the literature that addresses the health needs of lesbian women is scant. That literature which I have reviewed demonstrates that lesbians experience discrimination in all areas of healthcare, whether they are having a pap test or trying to become a parent. However, while the literature recognizes that lesbians, as a group, are disadvantaged in regard to accessing quality healthcare, the literature fails to explore and discuss the difference that may exist between individual women‟s experiences of healthcare. My thesis serves to address a gap in the limited existing literature in that it provides a detailed exploration of lesbians‟ experiences of healthcare while addressing the variations between experiences. In the following chapter, I will present the theoretical framework which shapes this thesis.
21 3. THEORETICAL FRAMEWORK
Feminist standpoint theory provides the theoretical framework of my research. It places women, and therefore lesbian women and their experiences at the focus of the research and offers a better understanding of lesbians‟ experiences with healthcare.
Standpoint feminism states that women‟s lives are very different from those of men.
Women possess a different kind of knowledge; their status as the subordinate group allows them to see and understand the world in a different way. In my study I use standpoint theory to offer a better understanding of lesbians‟ access to healthcare.
Dorothy Smith‟s (1987) writings are critical in understanding feminist standpoint theory and how it relates to women‟s experiences in their daily lives. Prior to discussing feminist standpoint theory I will examine women‟s relation to medicine in regard to three different, yet intimately connected themes: medicalization, patriarchy, and control.
Medicalization is the process whereby an activity or a condition becomes defined by society at large as an illness (either physical or psychological) and is thereby moved into the sphere of control of the medical profession (Zola 1972). Berenson, Miller, and
Findlay (2009) offer a thorough analysis of the effect of medicalization on women‟s lives over time. They explain that as medicine in the early twentieth century began to emerge as a profession in its own right, both the lives and health of women were steadily encompassed within the sphere of medical observation and control (Berenson et al.
2009). Rather than working to improve the skills and training of traditional female healers, such as midwives, the overwhelmingly male medical profession moved to take over the role of the management of women‟s health. Eventually, doctors succeeded in
22 discrediting women‟s traditional expertise as ignorance, superstition, and incompetence, and by the early 20th century, in driving them from the medical field (Berensen et al.
2009). As a result, male physicians have become society‟s widely accepted experts on the topic of women, and as such have the power to define what is counted as health and illness. Furthermore, twentieth-century science went on to take the male body as the norm for research on women, with the immediate result that many of women‟s basic functions were misunderstood and viewed as problems, and as such, have become subject to medical intervention (Berensen et al. 2009).
Medicalization has a secondary function as a powerful mechanism of social control because it claims jurisdiction in the ordinary lives of individuals and groups in a given culture (Morgan 1998). Both patriarchy and power relations have a long and complex relationship with the medical establishment and have played a leading role in the medicalization of women‟s lives (Morgan 1998). To give some examples, recall in the literature review, women are more frequently prescribed psychotropic drugs , and are more likely to receive a diagnosis of anxiety disorder than are men (Simoni-Wastila
1998). Additionally, recall the discussion of the medicalization of women‟s lives in relation to menopause. In the 1960s, an aggressive marketing campaign was introduced to promote synthetic estrogen as a drug to treat the dreaded symptoms associated with menopause, such as hot flashes, night sweats, irritability, loss of libido, dryness of the vagina, feelings of anxiety and depression, and the death of womanhood (Boston
Women‟s Health Book Collective 1998). Menopause came to be defined as an unnatural stage of life that requires the expertise of medical establishment to solve. In so doing medicine took control over this phase of a woman‟s life. In her both powerful and
23 insightful book, The Menopause Industry, Sandra Coney (1994) addresses some of the effects of medicalization on women:
It is no longer possible for an individual to simply regard herself as a healthy woman in the prime of her life. This can only be stated with authority if medicine has confirmed it by „screening‟ various parts of her body. She should submit to „monitoring‟ by periodic testing. For her breasts, there should be a „baseline mammogram‟, against which any changes in her tissues will be measured. She will develop a surrogate identity or alter ego– femina medica– in which she is defined by a series of computer printouts and x-ray films… The woman who eschews protecting herself in this way is seen as inexplicably reckless and careless of herself. (Coney 1994: 26)
As such, women‟s relationship to medicine is situated in a complex relationship between patriarchy, power, and social control.
Patriarchal assumptions about women‟s nature, women‟s bodies, and women‟s health have served and continue to serve as a mechanism of social control in that all women have been pathologized (Morgan 1998). Rather than seeing women‟s problems as a product of social inequalities or social roles, the male dominated field of medicine has defined these problems as medical, thus giving medicine the power to control increasing areas of women‟s lives (Berenson et al. 2009). This phenomenon has served to render women both weak and non-confrontational, as they have been taught that their problems are essentially out of their hands, and can be addressed only by the educated minds and skillful hands of medical professionals. Consequently, the full extent of women‟s health experiences and knowledge are not fully understood. For this reason my research will be conducted from the standpoint of women.
Dorothy Smith‟s (1987) feminist standpoint theory emphasizes the importance of understanding women‟s experiences from the dailiness of women‟s lives. She explains that women have been excluded from the making of ideology, knowledge, and culture
24 and as such, women‟s experiences, interests, and ways of knowing the world are not represented in systematically developed knowledge. As a result, the forms of thought that women use do not arise directly or spontaneously out of people‟s everyday lived relationships, but instead are the product of the work of specialists occupying influential positions in the ideological apparatus (Smith 1987). As Dorothy Smith argues in The
Everyday World as Problematic: A Feminist Sociology, we live in a culture that is manufactured. The way we think about ourselves and our society is part of the power ruling relations that originate in positions of power, which are held almost exclusively by men. This results in a worldview that has been created from positions that women do not occupy (Smith 1987). By applying a feminist standpoint theory to the medicalization of women‟s lives, more generally, I seek to understand women‟s experiences of medicine from their own perspective as opposed to from the perspective of those who are part of the patriarchal positions of power, such as those in the medical establishment. Because the women I am interviewing identify as lesbians, I also draw on Sandra Harding‟s
(1991) theoretical work.
Building upon Smith‟s standpoint theory, Sandra Harding (1991) addresses the diversity of standpoint. She asserts that while feminist standpoint speaks to the importance of examining the experiences of women in general, it is equally necessary to recognize that women are not a homogenous group and differ, for example, by socio- economic status, race, ethnicity, physical and intellectual ability, and sexuality, (Harding
1991). Harding goes on to discuss the role of sexuality on standpoint, and offers a lesbian standpoint theory. She explains that lesbian standpoint is necessary as “lesbian lives have been devalued and neglected as origin points for scientific research and as the
25 generators of evidence for or against knowledge claims” (Harding 1991: 264).
Furthermore, if heterosexual women‟s exclusion from the design of social relations provides what can be considered a valuable perspective of the stranger or outsider, lesbian exclusion can likewise be seen as a source of new understandings of the institution of compulsory heterosexuality that those involved in the power ruling positions have adopted (Harding 1991). Harding then asserts, “that the perspective from lesbian lives will generate new important questions about, for example, how heterosexist control of society supports capitalism, racism, and male supremacy” (Harding 1991:
265).
By using feminist standpoint theory (Smith 1987, Harding 1991) I will offer insight into lesbians‟ experiences within the healthcare system. I will capture the diversity of experiences based on age and education, which will provide insight into lesbians‟ experiences with healthcare. In the following chapter I will describe the methods used in carrying out my research.
26 4. METHODOLOGY
This qualitative research on lesbian healthcare examines the experience and perspectives of lesbian women and healthcare across four consecutive generations. My research uses feminist standpoint theory (Smith 1987) to focus on the experiences of lesbian women and healthcare. My interest lay primarily in uncovering whether a group of lesbians living in Nova Scotia believe they have equal access to healthcare, whether they are treated with respect in an environment free from discrimination, and whether they feel their needs and health issues are treated with the same importance than those of heterosexual women.
To provide a more in-depth analysis, which captures the experiences of lesbian women, after receiving ethics approval from the Department of Sociology at Acadia
University, I used primary data collected through four in-depth, semi-structured interviews with lesbians in the Wolfville area of Nova Scotia. The goal of this type of interview is to explore a topic more openly and to allow the participants freedom to express their opinions in their own words. This allows the interviewer to seek both clarification and elaboration on the answers given. This method of interviewing also permits the interviewer to have more opportunity to probe beyond the answers and thus enter into a dialogue with the interviewee (May 2001). Valerie Janesick (1998) classifies an interview as “a meeting of two persons to exchange information and ideas through questions and responses, resulting in communication and joint construction of meaning about a particular topic” (1998: 30). I kept this in mind as I approached each interview session.
27 For this thesis, I limited my interviews to four participants. Although increasing the sample size of the female participants would increase the accuracy of the data gathered, due to time constraints this was not feasible. I chose to use a convenience sample for my interviews in order to maximize accessibility and comply with time constraints. Two participants were introduced to me for the purpose of my study, and in order to find additional participants I placed signs throughout the town of Wolfville.
Two women contacted me and these women were interviewed as well. All of the women
I interviewed were enthusiastic about the research.
The criteria for selecting the interviewees included being a self-identifying lesbian, being a member of the middle-class, and being white. Being both white and a member of the middle class are important criteria as this group is seen as being advantaged, thus having the highest accessibility to healthcare. These factors also serve to ensure that all factors such as opportunity to education and social status in relation to healthcare are similar. The women I chose to interview were drawn from different, but consecutive generations. By selecting participants from different generations, I was able to trace the common trends in lesbian healthcare, as well as highlight any changes.
Figure 1 presents the sample. The youngest interviewee is 22, and the eldest 64. All of the women are partnered and reside in Nova Scotia. Levels of education for the interviewees range from some college and some university, to a completed undergraduate and graduate degree.
28 Figure 1 Sample Description of Women Interviewed
Pseudonym Age Relationship Education status Alicia 22 Partnered Some university
27 Partnered College Tara
Yvette Undergraduate 35 Partnered degree 64 Partnered Graduate degree Elizabeth
Prior to the interview sessions, I prepared an interview guide that was divided into four sections composed of open-ended questions to help focus the interview (see
Appendix A). The first section of the interview guide focused on the participant‟s family physician. Participants were asked to discuss their relationship to their doctor, whether he or she is aware of the participant‟s sexual orientation, and how the this knowledge may affect her care. In the second section, I had intended to ask the participants questions in relation to visits with specialists, particularly whether their doctor had informed the specialist of the patient‟s sexual orientation, whether the participant disclosed their sexuality to the specialist, and in turn, whether they feel this had an affect on their care. The third and fourth sections of the interview guide focused on gynecological care and pregnancy, respectively. However, after the first interview I realized that many of the questions I had intended to ask were not relevant and a new set of questions emerged from the interviews with the women, one of the benefits of doing semi-structured interviews.
29 At the start of each interview session, I explained the focus of my study and answered any questions or worries the participant might have. Each interviewee was required to sign a consent form (see Appendix B), indicating they understood the goal of the study and that the data gathered during the sessions was confidential. With the participants‟ permission, all interviews were recorded using digital audio software. There were no problems encountered during the interview sessions. The interviews lasted between 30 and 45 minutes. At the end of each interview session, interviewees were again encouraged to ask any questions they may have had.
After the interviews were completed, the interviews were transcribed, read, and coded. Each line of a passage was coded and sorted into broader themes, which emerged from the shared experiences of the interviewees. May (2005) asserts that the goal of coding is to focus on the potential meanings of the data. The following chapter discusses and interprets the coded themes, giving voice to the women whom I interviewed.
30 5. FINDINGS AND DISCUSSION
For my thesis, I interviewed four women who self-identify as lesbians and who are between the ages of 22 and 64. Each woman has been in, or is currently in a partnered relationship with a woman (see Figure 1, Chapter 4). The four interviews focused primarily on the views, opinions, and experiences of the women within the healthcare system, with each woman bringing her own unique perspectives and insights to the study. The process of coding allowed me to uncover the common themes that appeared throughout the interviews. The main themes that I will discuss in this chapter are medicine‟s assumption of heterosexuality, physician sensitivity, the effects of patient perception, and healthcare decision-making.
Medicine’s Assumption of Heterosexuality
A physician or caregiver‟s assumption of their patient‟s heterosexuality was a common experience shared by all four women in this study. For Yvette, the assumption of heterosexuality begins at the reception desk:
They always assume that you want to be referred to as Mrs. something… in healthcare I definitely deal with situations like that. Like not necessarily with my doctors, because both of my doctors know that I‟m a lesbian, but that happens at desks, yeah, where they assume that your spouse is a male or even my partner‟s name is [Alex] so that‟s a gender-neutral name and so even if I avoid pronouns where I am saying [Alex] instead of she, they always, like they always defer to oh is he a blah, blah, blah… they always think that my partner is a dude, it‟s frustrating.
In other cases, the healthcare professional‟s heterosexual assumptions did not become obvious right away. For example, similar to the experiences of lesbians in Fish‟s
(2006) study, three of the four women I interviewed have been offered birth control on
31 more than one occasion by their physician, even though their doctors knew that they are lesbians. Yvette, who works with LGBTQQTS youth, shared her own experience in relation to doctors and birth control:
[The doctor] made huge assumptions around my sexuality, assuming I was straight, of course… I was seeing him about a skin condition and he was asking about it affecting my sex life and asking whether I was on the pill, and saying that I should be and all that kind of stuff.
As well, she shared some of the experiences the youth with whom she works have discussed with her:
I work in a world where heterosexuality is not the norm and a few people were complaining the other day about [healthcare professional‟s assumption of heterosexuality] and about how it‟s just constantly like your doctor almost can‟t hear that you‟re a lesbian. Their doctors are always like you should be on the pill, or you should be using birth control, do you need condoms, like all of this stuff about safe sex and birth control when every single time the person is like I‟m a lesbian… It just feels like their doctor can‟t hear or won‟t hear that they are lesbians. It‟s like the doctor erases it every single time.
In Tara‟s case the assumption of heterosexuality was more explicit. During
Tara‟s annual Well Women‟s visit, before the nurse practitioner began the pap smear, the nurse asked Tara several questions: was she on birth control, to which Tara responded
“no”; she followed by asking if Tara was using condoms. When Tara responded with
“no”, again, the nurse made a comment assuming that Tara was heterosexual:
She looked me in the eye and said, so you‟re just playing Russian roulette are you then? I said well, I don‟t think my girlfriend is going to get me pregnant. And she was just like oh my gosh I am so sorry, I can‟t believe I just said that. And I just thought, even if I wasn‟t gay, what a rude thing to say to anyone, just playing Russian roulette. Then other times, even when it wasn‟t obvious homophobia, there have been so many times that doctors or nurses have assumed that I am heterosexual and that if I am sexually active, it must be with a male.
32 Tara explained that such experiences made her feel belittled disrespected and as if something is wrong with her. The sense of being viewed as “other” can lead to an eventual avoidance of the healthcare system, as it instills a belief that receiving respectful healthcare, and therefore quality healthcare free from heterosexism and homophobia is an impossibility for her. Research has shown that many lesbians underutilize the healthcare system for fear of discrimination (Mathieson 1998) and the primary reasons reported for the underutilization of the healthcare system by lesbian women include institutionalized homophobia, heterosexist assumptions by healthcare providers, fear of discrimination, and negative repercussion from the disclosure of sexual orientation (Bergeron et al.
2003).
For Elizabeth, the assumption of heterosexuality by the healthcare system manifested into blatant homophobic behaviour towards her and her partner by the staff at a hospital emergency room. Her partner at the time had a herniated disk and when they arrived the hospital emergency room, Elizabeth tried to go into her partner‟s room to see her, the staff told her she was not allowed in:
They said I couldn‟t go because it was only for family and I said well I am her partner and they said yes, but you‟re not “family”. And I said well you know, that is beside the point, I am her partner, and I am her power of attorney, and her health guardian, and all these things, legally. But they still said no, so then in the end I just, you know, I just ended up, I noticed these other couples, heterosexual couples, and the wife or the partner or the girlfriend, whatever they were, was going in and I just went in as well and said you know, forget it. So that wasn‟t a good experience.
Elizabeth explained that the treatment she and her partner received felt unfair and undeserved. In a time in which both Elizabeth and her partner were feeling vulnerable, the actions of the hospital staff had the effect of adding unneeded additional stress to an already stressful and trying situation. This stands in opposition to good healthcare as
33 illness is often directly related to stress (Sayer 1997). Intuitively, one would think that healthcare providers would promote an environment that encourages a supportive environment.
Sensitivity of Physician
As a consequence of the heterosexism they found entrenched in their medical care, almost all of the interviewees expressed their need to see a doctor who showed sensitivity to their sexuality. The women felt that having a doctor who is respectful and accepting of their sexuality is of fundamental importance for receiving good healthcare.
Two of the women I interviewed preferred sensitivity as a physician characteristic over gender. Elizabeth, for example, initially had a female physician. When she discovered she had a breast lump, she brought this to the attention of her physician, who told
Elizabeth not to worry and to return for a check-up in six months time. Elizabeth, however, was not comforted by this response. Shortly after her original visit, through her professional capacity, Elizabeth met a male physician. Still concerned, she not only shared with him that she had found a breast lump but also her doctor‟s response. He asked Elizabeth if she would like a second opinion to which she answered, “yes”.
Elizabeth realized that “he is much more sensitive to me as a woman than my woman doctor was, so I switched to him.
Alicia‟s experience reflects much the same sentiment. Alicia had the same female physician for almost fifteen years when her doctor told her that she was giving up her practice and that it was being taken over by a male physician. Her initial reaction was one of being unhappy:
I didn‟t want a male doing my pap smear. Then I stopped and said, no, if I got to know him and was comfortable with him, then it wouldn‟t matter if he was male
34 of female. But now that I have been seeing him for a while, I know that I am not comfortable enough because he is just, he doesn‟t, he‟s cold, he‟s not warm and friendly and comforting, so I just don‟t want him- I‟m not comfortable.
Alicia‟s decision to ultimately change physicians was based on practice style, rather than because the physician is male.
While Yvette did not mention the role of gender in the quality of healthcare, she did discuss the importance of having a doctor who is sensitive to his or her patient.
Yvette shared there was a time when she experienced numerous and complicated health issues. She found her doctor to be rather unhelpful in diagnosing what was wrong with her. As a result, she decided to go to a health clinic for queers. Here, too, she did not receive the quality healthcare she was looking for. The female physician she saw, instead of addressing her health concerns, decided to focus on her body size, which Yvette did not consider to be a problem:
The doctor would always make assumptions around “oh you‟re fat, you‟re overweight so you must have all of these health complications”. Of course I don‟t because I have a very balanced life-style, and [the doctor] was simply chalking up all of these things that were happening to me to the fact that I was overweight. So that was pretty much what directed me to a naturopath- the fact that my doctor was just not good for me, because these health issues I was having were not panning out to be anything in terms of her diagnosis, right? And it is important to notice and to know that kind of stuff.
Thus, having a female physician does not necessarily translate into a physician who is more sensitive to a lesbian‟s health needs nor does it eliminate doctor-patient power relations. Physicians in general have become society‟s widely accepted experts on the topic of women‟s health, and as such, have the power to define what comprises good health (Berensen et al. 2009).
35 Yvette was able to realize that her doctor was failing to meet her needs as a patient. Her choice was to challenge the hegemonic medical model and pursue alternative healthcare. Yvette was able to challenge the power relations between doctor and patient and was able to exercise agency by questioning her doctor‟s authority. However, Yvette is an example of how “choice” gets socially constructed. She is confident with her sexuality; she has a very supportive partner and is educated. This is not the case for many women, especially those who belong to marginalized groups, such as lesbians.
Perception
A theme that arose from issues around sensitivity was that of perception. Several of the interviewees expressed their recognition that their own perception of an event may have affected their experience within healthcare. Experience and perceptions of healthcare are complex and multi-faceted. They may be rooted in past experiences, which then can shape one‟s perception of future events. Perception is an important theme in the interviews as several of the interviewees felt that their perception plays a role in how they feel about an experience. According to Elizabeth:
It is all about perception. So if you have low self esteem, I mean if you have internalized homophobia, then you‟re going to read a lot of other people‟s behaviour towards you as homophobic, so it‟s a difficult one to separate how was the care provided, when the physician or the nurse truly being homophobic towards you, and when was it your perception of that event. And of course the bottom line is that it doesn‟t matter whether its “real” or not, its your perception that makes it real … The whole issue of homophobia is problematic in that there is my perception of you saying something to me and my perception that it is homophobia and it actually being homophobic. Sometimes it is easier to ignore it.
At this point, I asked Elizabeth whether having good self-esteem enabled her to more easily ignore homophobia encountered both in the medical system and in her daily life:
36
I don‟t know, um, I think it‟s more about that it doesn‟t bother me. I mean I don‟t think it is my problem if you‟re homophobic, right? If you said something about my kids, or in my hearing then I would call you on it. If you don‟t do it to my face I mean you know its like, they could be saying it because I‟m short, because I had glasses, because I had white hair, I mean, you know, you would all the time be walking on eggshells.
In her response, Elizabeth portrays an „I don‟t give a damn what anyone thinks‟ attitude, that may be a factor of who she is or more likely a combination of factors including her age and high level of education.
Similar to previous research findings (Mathieson 1998; Sherry Bergeron and
Charlene Senn 2003), Alicia believes her doctor is homophobic and discriminates against her. That said, Alicia‟s perception is that she has been “pretty fortunate with healthcare”.
Although she recognizes that her doctor is “cold and impersonal”, Alicia considers herself fortunate because she has a physician to provide doctor‟s notes and prescription refills. Yet, these are fundamental services of the Canadian healthcare system, and ones that all patients are entitled to.
There appears to be a disconnect between Alicia‟s perception of the quality of her healthcare and the actual quality of healthcare she receives. I believe that Alicia may be hesitant to be critical of her doctor not only because of the power relations doctors hold over female patients, but also because she is a lesbian: “I could assume he treats me that way because I‟m a lesbian, but why bother going there”. Her refusal to “going there” may be a coping strategy to settle for an inadequate physician over no physician Alicia‟s story is an example of how lesbians perceive they do not have the same choices in access to and quality of healthcare as heterosexuals have, and thus are willing to settle for less. In this way lesbians are doubly marginalized by their gender and sexuality.
37 The interviewed women‟s voices tell that perceptions and expectations play a large role in the interpretation of women‟s experiences of healthcare. Elizabeth does admit to homophobia in medicine, however, it is one‟s perception of their experiences that make it “real” or “not real”. Alicia readily admits that her current doctor is “cold and impersonal”, yet her perception of her experience with healthcare is positive. Others would likely disagree because they have different expectations, an outcome of their heterosexist privilege.
Healthcare Choice and Decision-Making
Emerging from and related to the theme of perception is the issue of choice
(introduced above) and making good decisions about the quality of healthcare one receives.
The women expressed the importance of decision-making in receiving quality healthcare.
Recall Tara made the decision to travel some distance in order to get medical care at a clinic with staff she felt would be more accepting of her sexuality. Yvette attributes her more recent good experiences with healthcare to her own decisions. In her experience with healthcare, Yvette found that heteronormativity is entrenched in western medicine and therefore made the decision to seek an alternative form of care through naturopathy.
While these women made the decision to seek healthcare in an atmosphere they felt would be more accepting of them, many researchers of lesbian health found that instead of deciding to travel to access quality care or seek alternative forms of healthcare, many lesbian women underutilize the healthcare system (Mathieson 1998) because of past negative experiences such as institutionalized heterosexism and homophobia
(Peterkin et al. 2003), heterosexist assumptions by healthcare providers (Bergeron et al.
38 2003), fear of discrimination (Mathieson 1998), or adverse effects of disclosure (Mule et al. 2009). Although the interviewees in my study could relate to and shared similar experiences to those reported in the literature, their solutions were different. The difference between lesbians seeking out appropriate or alternative care and those deciding to underutilize healthcare is probably due to such factors as age, education, partner support, and income. Given that my sample possessed many of these attributes, these women were able to exercise agency in ways women lesbians with fewer resources are able. While privileged heterosexual people, too, often seek alternative care such as naturopathy, it is often a luxury as opposed to a necessary step for receiving quality healthcare.
In the following chapter, I will further discuss the interviews and offer policy recommendation to improve access and quality for healthcare for lesbians.
39 6. CONCLUSION
In this thesis I have explored lesbians‟ experiences within healthcare, asking whether lesbians have equal access to healthcare, and whether the healthcare they receive is in an environment of respect and free from discrimination. My literature review gave context to my study, providing more generally, an understanding of women‟s access to healthcare both historically and in the new millennium, and more specifically, discussed the healthcare system in relation to lesbian women: how it can be seen as being inherently heterosexist and in turn how that affects lesbian health, specifically in the areas of gynecological health and pregnancy. The review of the literature covered the key themes of women and medicine in history, women and medicine in the new millennium, heterosexism in healthcare, lesbians and gynecological health, and lesbians and pregnancy.
I relied on feminist standpoint theory to shape the theoretical framework of my research as it places women, and therefore lesbian women and their experiences at the focus of the research and thus offers a better understanding of lesbians‟ experiences with healthcare. Standpoint feminism states that women‟s lives are very different from those of men and asserts that women possess a different kind of knowledge; their status as the subordinate group allows them to see and understand the world in a different way. For this reason, I used standpoint theory to offer a better understanding of lesbians‟ access to healthcare while also examining women‟s relation to medicine in regard to three different, yet intimately connected themes: medicalization, patriarchy, and control.
40 I conducted four semi-structured interviews with lesbian women from Nova
Scotia. The primary themes that emerged from the interviews were medicine‟s assumption of heterosexuality, physician sensitivity, the effects of patient perception, and healthcare choice and decision-making. While the overarching themes applied to each woman, each theme cannot be narrowly applied to each woman due to the diversity of their individual experiences. Each woman‟s experiences within healthcare can be affected by a number of variables. In my analysis of the interviews, I found that age and education may play a role in how a woman experiences healthcare.
For example, I found a striking difference between the ways in which Alicia, the youngest of the interviewees, and Elizabeth, the eldest and with the highest level of education, interpreted power relations with their physicians. Alicia seemed very willing to accept that her doctor was cold and impersonal in his dealings with her, and while she suspected he may be homophobic, she considered herself to be lucky to be getting medical care from him. In contrast, Elizabeth expressed her unwillingness to accept medical care that she felt was substandard to her expectations by changing physicians when she felt she was receiving inadequate care. Elizabeth exercised agency by challenging medical hegemony and the power relations within it while Alicia did not. I believe that Elizabeth may have developed skills to challenge medical power relations as a result of her age and education, as people with more education have access to resources that younger and less educated women do not. Alicia‟s unwillingness or more likely, inability to exercise agency and challenge the power relations in healthcare demonstrates the integral need for the implementation of policies to protect all women like Alicia who
41 do not have the skills to challenge medical authority or the resources to pursue alternative health care.
The experiences of the lesbians I interviewed as well as the review of the literature in Chapter 2 reveal that lesbians regularly encounter both systemic barriers and interpersonal expressions of homophobia within society and that within the realm of healthcare, there is no exception (Hudspith 1999). In order to design and implement effective policies, we must first understand the specific situation of lesbians in the healthcare system by conducting more in-depth research that addresses the diversity of lesbians‟ experiences within the healthcare system.
Fundamentally, I believe the healthcare system needs to be more responsive to and inclusive of all types of people. Improving access to care and working toward recognition and equality may remedy many of lesbians‟ health issues in the healthcare system. Health planners and policy makers need to review and revise all policies, forms, and patient literature to eliminate heterosexist and non-inclusive language. This means changing forms from “single, married, divorced, or widowed” to include “same sex partnership” or provide the space for the patient to fill in their relationship status. In addition, policy planners must allow space for the patient to define who they want involved in their care, that is to say, forms must include a blank line for patients to identify an emergency contact or next of kin wherein the patient can identify their partner if they wish, where “spouse” means a person who is married to another person, or is living with another person in a partnered relationship, including same sex partnered relationships.
42 However, health planners and policy makers are not solely responsible for the improvement of the healthcare system. Physicians and healthcare practitioners, too, must address the issue of lesbians‟ access to and quality of healthcare. First, healthcare professionals must be educated and informed about lesbian health through the inclusion of lesbian health issues in technical and professional training programs in the field of health. Doctors must be patient centered and avoid making assumptions about gender or sexual identity, allowing the patient the space to speak openly and freely. Physicians must also take thorough histories, using inclusive language. Questions should be asked about sexual behaviour, not sexual identity. For example, rather than asking “Are you sexually active?” instead ask, “Are you currently sexually active? If so, are you active with men, women, or both?” This opens the door for all patients to talk about their sexual histories and behaviours without fear of negative repercussions.
Fundamentally, an environment must be created in which from the moment a patient walks into a healthcare office they are treated with respect and without any form of discrimination. Such policies would not only address the healthcare issues of lesbians, but of all marginalized people. In this way, we are building a healthcare policy, which supports one of the underlying principles of Canada‟s healthcare system – accessible healthcare to all Canadians
43
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48
Appendix A
Interview Guide
This is a semi-structured interview guide containing open-ended questions I will ask during interview sessions. My questions are divided into four themes that I will focus on during the interview. The questions are subject to changes and alterations before or during the interview.
Family doctor - Do you have a family doctor? - Is your doctor a male or a female? - Is your family doctor aware of your sexual orientation? - Were you asked for this information in a conversation or through paperwork? - Did you feel comfortable divulging this information? - Do you feel your relationship with your doctor has changed since you disclosed your sexuality?
Specialist - Has your doctor ever referred you to a specialist? - Was the specialist made aware of your sexual orientation by your doctor previous to your appointment? - Did you divulge your sexual orientation to the specialist? - How did you feel about your visit with the specialist?
Gynecological care - Does your doctor encourage you to have an annual Well Woman‟s visit? - Does your doctor perform an annual pap smear and/or breast exam? - Does your doctor ask questions concerning your sex-life? - Does your doctor talk to you about birth control? - Does your doctor talk to you about risk of STIs?
Pregnancy - Have you discussed pregnancy with your doctor? - Was your doctor encouraging regarding your desire to conceive? - Did your doctor discuss a variety of options available to you? - Did you see any specialists during your pregnancy? - How were you treated by your doctor/other specialists throughout your pregnancy? - Did you attend hospital pre-natal classes? How were you treated? - How were you treated by hospital staff while giving birth? - Did you attend a neo-natal clinic? How were you treated?
49 Appendix B
ACADIA UNIVERSITY RESEARCH CONSENT FORM
Thank you for participating in my study, A Sociological Study of Lesbian Women‟s Access to and Quality of Healthcare in Canada. This study has been approved by the Departmental Ethics Committee. The purpose of this research is to achieve an understanding of lesbians‟ access to and quality of healthcare in Canada through in-depth interviews. There are no known harms or risks involved in participating in this research project. Participation in this study is voluntary; if you choose to participate and change your mind, you may withdraw from the research at anytime up until the end of the interview without consequences. Should you consent to participate, confidentiality will be respected. No information that discloses your identity will be released or published and pseudonyms will be used for all participants. To obtain a full and accurate record of our conversation, I will make a digital recording of the interviews. Only I will have access to the digital recording. The interviews will be stored on a separate storage device held under lock and key in an office space at Acadia University and will be destroyed at the end of the study. A copy of the thesis will be deposited in the Vaughn Memorial Library and the Sociology office at Acadia University. A copy of this form will be made available to you; however, you may pose questions about the research at any time to my academic supervisor, Dr. Zelda Abramson or myself, Hannah Banfield.
Hannah Banfield Dr. Zelda Abramson Acadia University Acadia University Department of Sociology Department Sociology [email protected] [email protected]
50 A Sociological Study of Lesbian Women’s Access to and Quality of Healthcare in Canada
In signing this form you state that you understand the above information, that your questions have been answered satisfactorily, and that you agree to participate in my research.
I give consent to be interviewed and recorded.
______Name of research participant (please print)
______Signature of research participant Date
______Signature of researcher Date
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