Royal Women’s Hospital, Victoria. Latrobe University
Introduction
There is increasing interest in lesbian health evidenced by the growing body of international literature and research, which provides important information about the challenges facing lesbians and health professionals regarding lesbian health care. However, compared to other areas of women’s health what research is available is limited and there are few longitudinal studies, this is particularly true in Australia.
In response to a growing interest in lesbian health the Royal Women’s Hospital (RWH) Victoria, undertook a four month ‘Lesbian Health Information Project’ (LHIP) in 2000. The aim of the project was to inform the RWH’s future service direction to improve lesbian access to health information and services. Central to the project was a consultation with consumers and health professional with 225 participants 125 of whom were lesbian consumers, 80 hospital staff and 25 community health professionals. The project culminated in the report ‘More than Lip Service’ with recommendations and service model to improve access for lesbians to the hospital’s services. This paper will draw on the major themes from the consultation particularly the internal hospital consultation. It will be argued that lesbians as a cultural sub-group do have specific health issues and that health practitioners who are culturally sensitive, aware and knowledgeable can improve lesbians’ access to appropriate and timely care.
Lesbian Culture - Are Lesbians Different to Other Women
It should be noted that lesbians are not a homogenous group but there is much diversity of identity, sexual practice, age, ethnicity, socio-economic and educational backgrounds, relationships, families and geographic location Some lesbians have children, some are planning to and others are not; some live in relationships as couples, with friends, in shared households, others live alone; some have disabilities and health problems; some have come out, some have not, others may be having difficulty coming to terms with their sexual preference (Dyson, 2001; Solarz, 1999; White and Levinson, 1995;).
While there is great diversity within the lesbian community, lesbians do share a culture which is rich, diverse and meaningful. Within this culture shared values, beliefs, ideas, language and ways of being provide a context for lesbian lives. Lesbian culture is divergent from the dominant mainstream culture of heterosexuality which has rules, ideals, behaviors and ways of living with which lesbians cannot identify and do not wish to assimilate.
In their writing about queer culture Hostetler and Herdt (1998) describe “sexual lifeways which are culturally constituted developmental pathways, embedded within social and symbolic systems, that provide rich and meaningful contexts for the realization of full personhood in a society. These lifeways are conventionalized in the sense that they provide customary means and ends for individual development according to the locally situated theory of human nature” (Hostetler and Gilbert, 1998:42).
There is increasing acknowledgement that lesbians as a minority group have similar health inequalities to those of other minorities including indigenous, non-English speaking background and rural communities. Similar to other minority and cultural groups, lesbians experience barriers when seeking health care and frequently encounter insensitive and uninformed practitioners, heterosexist and homophobic attitudes, stigmatisation and discrimination. This affects their access to services and compounds their sense of invisibility within the health care system. Thus there is a need to recognise lesbians as a distinct group from heterosexual women and for health care practitioners to become culturally aware when lesbians access their services.
Lesbian Health Concerns
The findings from the RWH consultation support the literature highlighting that while lesbians experience the same health issues as other women, the social and political context of lesbian lives brings additional health concerns specific to this community. While lesbianism is not in itself a health issue, lesbians frequently experience difficultly accessing appropriate health care potentially placing them at higher risk of some illness affecting long-term health outcomes.
125 lesbians participated in the RWH Lesbian Health Information Project, 93 in focus groups and individual interviews with another 32 choosing to complete questionnaires. The following represents a summary of the findings.
Lesbians consistently raised concerns about their experience of homophobia, heterosexism and even discrimination when accessing health services. Assumptions of heterosexuality were common and many feared disclosure of their sexual orientation because of negative reactions by the practitioner; inappropriate comments and some even reported being denied services when their GP found out they were lesbian. Lesbian mothers fear not only will they be discriminated against by health practitioners but so to will their children. This promotes invisibly of their same sex partners and their role as co-parent, who are subsequently excluded from significant health decisions about their child. It was not uncommon for women to report partners being excluded from other decisions about their health care.
Some women have had positive experiences when they disclosed their sexual orientation but even if practitioners do respond well, few understand lesbian culture or do not have appropriate lesbian health knowledge. Lesbians consistently raised their concerns about the lack of sensitive and informed practitioners and reported they are frustrated by having to continually educate GPs about being lesbian. Lesbians do not necessarily want access to practitioners who are themselves lesbian, but generally prefer women practitioners and expect practitioners to be lesbian sensitive and informed about lesbian health matters.
Lesbians are concerned about their health but do not always identify that they have different health issues to other women. Many are not well informed about particular health risks and have difficulty accessing relevant health information particularly on issues of safe sex, woman-to-woman transmission of sexually transmitted infections, insemination and pap smears. Lesbians generally rely on mainstream services for health care but will most often seek health information from friends, telephone information services and gay and lesbian media.
Coming out is of particular concern to lesbians and they frequently reported significant stress during the transition from a heterosexual to an alternative lifestyle. Lesbians reported that living in a homophobic and heterosexist society often leads to invisibility, isolation, and disconnection from family and the community resulting in lowered self-esteem, depression and social withdrawal. Lesbians generally identify mental and emotional health being of concern and the lack of access to appropriate low-cost counseling services.
In sum lesbians themselves often lack awareness and knowledge of health risks, have difficulty accessing health information, are reluctant to disclose their sexual orientation, access services less often then other women, change practitioners frequently and are less likely to have a regular GP. This potentially places lesbians at a higher risk of some illnesses as they access services later than their heterosexual counterparts, and have reduced opportunity for screening and early intervention (Royal Women’s Hospital, 2000; Saphira and Glover, 2000; Myers and Lavendar, 1997; Horsley and Tremellen, 1996; Rankow, 1995)
Doctors and Other Health Professionals Are Not Culturally Aware
It has been found that health professionals are not culturally aware and have poor understanding of lesbian health issues. The following includes a summary of the internal consultation of the RWH LHIP (2000) in which 80 hospital staff participated in 16 individual interviews and 64 completed questionnaires. The data collected from the questionnaires is included here.
130 questionnaires were distributed to 6 units (birthing unit, reproductive and biology unit, well women’s service, outpatients, maternity, gynaecology/oncology unit) with 64 returned (just under 50% return rate). 62% (40) of respondents were nurses and midwives, less than 6% (4) were doctors, and surprisingly 18% did not nominate a discipline.
Most (44) were aware of lesbians accessing their service but 80% (59) would never ask if a woman was a lesbian. The main reasons given why they wouldn’t ask:- fear of negative reaction, it’s not relevant to care, ‘it’s none of my business’, and it doesn’t matter whether a woman is a lesbian or not. However, most (60) said they would recongise a lesbian's partner as next of kin if a lesbian informed them so. However, 18% (12) said they may consider asking in certain circumstances most commonly in relation to taking a sexual history and childbirth.
45% of respondents thought lesbians had specific health issues. Surprisingly 38% thought they had good to very good knowledge of lesbian health while 57% thought they had a little or no knowledge.
Those recognising there are lesbians specific health concerns identified similar issues to lesbian consumers:- access to reproduction, donor and insemination services; access to information about legal rights, pap smears and sexual health; access to sensitive, non-homophobic and non-judgmental health services and being able to disclose safely; isolation, alienation and discrimination; coming out and need for social support.
While many practitioners did not ask women if they were lesbian and had varying knowledge of lesbian health an overwhelming 85% believed the RWH to be an appropriate location for a lesbian telephone information service and many expressed an interest in learning more about lesbian health.
Other studies have found that health practitioners are often misinformed or uniformed about lesbian health, have difficulty distinguishing between lesbian health and women’s health and even when sympathetic they often lack knowledge about lesbian health (McNair and Dyson 1999; VGLRL, 2000; Murray 1997).
Need for Cultural Awareness
Homophobic and heterosexist attitudes by health practitioners are significant barriers to lesbians accessing health care. Several studies identify that lesbians often fail to access health services or delay treatment because of their sexual orientatation and have below average breast and cervical screening rates (Mathieson, 1998; Saphira and Glover, 2000; Barbeler 1992). Other studies report that at least 40% of lesbians choose not to reveal their sexual orientation (McNair and Dyson, 1999; Carr et al, 1999; Smith et al, 1985). According to Harrison (1996) most lesbians and gays believe that their health care would be of a higher quality if they could safely disclose their homosexual identity.
Meanwhile two Australian studies report that lesbians experience discrimination by doctors and hospitals because of their sexuality (12% in Barbeler’s 1992 study and 30% in a more recent study by the Victorian Gay and Lesbian Rights Lobby in 2000). Even if practitioners are sensitive to lesbians they frequently are misinformed or uniformed about lesbian health. Lesbians are reluctant to disclose their sexual orientation for fear of discrimination by health professionals and because of their own lack awareness and knowledge of health risks.
International studies (Matthews et al, 1986; Stevens, 1992; Rankow, 1995; Harrison, 1996; Bergman and Zinberg, 1997) confirm that many health practitioners exhibit negative attitudes towards lesbians, are homophobic and heterosexist. Lesbians themselves report reactions by health practitioners ranging from being uncomfortable or anxious, responding in an inappropriate way, rough handling, denying treatment, showing hostility, voyeuristic questioning, and displaying pity and condescension (Royal Women’s Hospital, 2000; Chinnock, 2000; Harrison, 1996; Stevens, 1992). These attitudes continue to promote invisibility of lesbians, reduce access to health care and reduce potential for screening and early intervention.
HCPs Can Make a Difference
Health practitioners can make a difference to lesbians’ experience of health services by becoming culturally competent, through training and education and adopting a lesbian sensitive approach to their practice.
Health practitioners need to become more culturally aware to improve health care for lesbians. Solarz (1999) argues that there is a need for culturally competent health care practitioners. She defines cultural competence as a set of skills that enable practitioners to provide high quality services to persons from different cultural backgrounds and that these skills are relevant to lesbians as a specific cultural group. Cultural competency demonstrates knowledge of “the culture and values of the group, the ability to communicate in the same language, and understanding the impact of group membership on health status, behavior, and attitudes” (Solarz, 1992:42). Culturally competent practitioners would understand the reasons lesbians might be reluctant to seek health care and the impact of homophobia on the provision of care to lesbians; be knowledgeable of lesbian health and potential health risks; have access to relevant health information for lesbians; avoid heterosexual assumptions and use of heterosexist language when gathering health and social information; and be willing to involve partners of lesbians in discussions and decision about their health (Solarz, 1992).
There is a need for training and education in lesbian health at undergraduate and postgraduate level for health practitioners. Using lesbian health scenarios in training programs, inviting lesbians to speak to trainees, inviting lesbians to participate in the development of training programs, service improvement and service development would contribute to better understanding and awareness of lesbian culture among health professionals. Encouraging and promoting lesbian health research would also provide the basis for improving training.
Health professionals can make their services more lesbian friendly by adopting a lesbian-sensitive approach to care by having lesbian health information readily available and visible in waiting rooms; improving registration forms with more inclusive language such as partner instead of spouse; making provision for and incorporating lesbians into service and organisation policies; working closely with the lesbian community; not assuming heterosexuality; using non sexist language when gathering information. Health practitioners should assume lesbians are accessing their services whether they are aware of this or not; be aware that not all same sex attracted women (SSA) or women who have sex with women (WSW) identify as lesbian. Some women may identify as same-sex attracted, gay, bi-sexual, dyke or may not choose to define themselves in any way. Some WSW also have sex with men (adapted from Dyson, 2001)
Conclusion
By becoming culturally aware, improving knowledge and adopting lesbian sensitive practice, health practitioners can make a difference to lesbians’ experience of the health care system. Culturally competent practitioners can improve lesbians’ access to health care, foster more open and trusting relationships with lesbian clients and the lesbian community and ultimately contribute to improved health outcomes for lesbians.
References
1. Barbeler V, 1992. The Young Lesbian Report: A study of attitudes and behaviours of adolescent lesbians today. Twenty Ten Association, Sydney.
2. Berkman, C. and Zingberg, G. 1997. Homophobia and heterosexism in social workers. Social Work, 42 (4) 319-326.
3. Carr, S. Scoular, A. Elliot, L. Ilett, R. Meager, M. 1999. A community-based lesbian sexual health service – clinically justified or politically correct? The British Journal of Family Planning, 25:93-95.
4. Chinnock, M. (2000) Barriers to Cervical Cancer Screening Amongst Lesbian Women. Paper presented at the Australian Lesbian Medical Association, 2nd Annual Conference, Sydney.
5. Harrison, A. 1996. Primary care of lesbian and gay patients: educating ourselves and our students. Family Medicine; 28 (1): 10-23.
6. Horsley, P. and Tremellen, S. 1996. Legitimising lesbian health – challenging the lack of demonstrated need argument. Healthsharing Women Newsletter 6 (4) 8-11 Presented at the Third National Women’s Health Conference, Canberra, November.
7. Hostetler, A.J. and Herdt, G.H. 1998. Culture, sexual lifeways, and developmental subjectivities: rethinking sexual taxonomies. Social Research, Summer, 65 (2) 242- 249.
8. Mathews, Booth, Turner and Kessler, 1986. Physician’s attitudes toward homosexuality: a survey of a Californian medical society. Western Journal of Medicine, 144: 106-10.
9. Mathieson, C. 1998. Lesbian and bi-sexual health care. Canadian Family Physician August 44:1634-1640.
10. McNair, R. and Dyson, S. 1999. Lesbian Consumer Visibility within Primary Health Care- A Study. Paper presented at the Health in Difference Conference, Adelaide, November.
11. Moran N, 1996. Lesbian Health Care Needs. Canadian Family Physician, 42: 879-884.
12. Murray L, 1997. Lesbians and Cancer Screening Programs-access barriers and proposed strategies. Cancer screening and Prevention Unit: Lesbian Health Project, Department of Health and Community Services, Tasmania.
13. Myers, H. and Lavender, 1997. An overview of Lesbian Health Issues. Prepared for the Coalition of Activist Lesbians (COAL).
14. Rankow, E. 1995. Lesbian health issues for the primary care providers. Journal of Family Practice, 40 (5): 486-493.
15. Rose, L. 1994. Homophobia among doctors. British Medical Journal; 308: 586-587.
16. Royal Women’s Hospital, Victoria. 2000. More than Lip Service: The report of the Lesbian Health Information Project, Royal Women’s Hospital, Melbourne.
17. Saphira M and Glover M, 2000. New Zealand national lesbian health survey. Journal of the Gay and Lesbian Medical Association, 4 (2) 49-56.
18. Solarz, A. (ed), 1999. Lesbian Health: Current Assessment and Directions for the Future. Committee on Lesbian Health Research Priorities, the Institute of Medicine. Washington, DC: National Academy Press.
19. Smith, E. Johnson S. Guenther, S. M. (1985). Health care attitudes and experiences during gynaecological care among lesbians and bisexuals. American Journal of Public Health, 75: 1085-87.
20. Stevens, P. 1992. Lesbian health care research: A review of the literature from 1970 – 1990. Health Care for Women International, 13 (2): 91-120.
21. Dyson, S. (Ed) 2001. Towards Lesbian Diversity in Health Care Services: Information and Issues Kit. Women’s Health in the South East, Melbourne.
22. Victorian Gay and Lesbian Rights Lobby (VGLRL), 2000. Enough is Enough: A Report on Discrimination and Abuse Experienced by Lesbians, Gay Men, Bisexuals and Transgender People in Victoria. Victorian Gay and Lesbian Rights Lobby, Melbourne.
23. White, J. and Levinson, W. 1995. Lesbian health care what a primary care physician needs to know. Western Journal of Medicine, 162:463-466.
