Social Justice Considerations for Lesbian and Bisexual Women's Health Care
Virginia K. Weisz, MS, WHNP, Radford University School of Nursing, University of North Carolina Greensboro, 11558 Bottom Creek Rd., Bent Mountain, VA 24059.
Lesbian and bisexual women share much with heterosexual women such as the desire to parent and the risk for partner violence. However, these women have unique risks associated with heavy alcohol use, smoking, obesity, and nulliparity. As nurses become increasingly aware of the need for social justice advocacy for marginalized groups, they are in a good position to advocate for lesbian and bisexual women and to bring visibility to their poor treatment in the health care setting.
Social justice and advocacy for marginalized groups have a rich tradition in nursing beginning with Nightingale, Sanger, and others (Falk-Rafael, 2005; Nightingale, 1992). In the last century, nurses along with those in other helping professions have tended to focus on the biomedical model and the health of individuals, departing from the activism that once characterized nursing (Falk-Rafael). Since the 1970s, however, nursing has experienced a global reawakening to the need for a return to advocacy for groups that are socially, economically, and politically disadvantaged (Drevahl, Kneipp, Calanes, & Dorcy, 2001;Falk-Rafael).
Lesbian and bisexual women often struggle to obtain quality health care as a result of a complex set of conditions, including fears of disclosure and homophobic and heterosexist attitudes among nurses and other health professionals (Irwin, 2007; Weitz, Freund, & Wright, 2001). Women's health has come to be defined as heterosexual health (McDonald, McIntyre, & Anderson, 2003), resulting in the invisibility of lesbian and bisexual women. Advocacy for these marginalized groups of women is much needed as we return to our social justice roots.
History of Social Justice in Nursing
Florence Nightingale, a British nurse and statistician, identified significant problems with reproductive health care in the mid-19th century and worked tirelessly to reduce death rates for women (Nightingale, 1992). She improved sanitation for the British military and documented decreased morbidity and mortality rates using statistical analysis. She also used her political influence to affect change. Nightingale reformed civilian hospitals and workhouse infirmaries in England and in the British colonies. Her reforms affected social welfare for the sick and impoverished, young children, and inmates in mid-19th century British prisons. As a response to the fact that one in seven infants in England died before their first birthdays, she wrote Notes on Nursing: What it is, and What it is not. Mothers used this reference to care for their children more effectively (Nightingale).
Nightingale was brilliant and driven by an intense commitment to help humanity despite frequently failing personal health (Falk-Rafael, 2005). She wrote extensively on the topics of sanitation, hygiene, nursing, statistics, and philosophy. She believed that the nurse could be an instrument of reform (Falk-Rafael).
Margaret Sanger was a revolutionary American nurse who fought for reproductive rights for 50 years (Steinem, 1998). She was motivated to help poor women after witnessing her own mother's lengthy illness and untimely death after 18 pregnancies and 11 live births (Steinem). While working as a trained nurse and midwife in the poorest neighborhoods of New York City, she saw the health of women depleted by bearing multiple unplanned children and the inability to care for those already born. In addition, many of these women died in childbirth (Sanger, 1971;Steinem).
Although she was repeatedly jailed and once had to leave her family and flee to Europe to escape incarceration, Sanger tirelessly worked for social justice and reform. Information and contraceptives were prohibited by the clergy, medical community, and law enforcement (Adler, 2004; Steinem, 1998). As a result, people who lived in poverty tried dangerous contraceptive methods in desperation that included deliberately falling down stairs and using knitting needles to abort unwanted pregnancies (Sanger, 1971). However, the wealthy and educated had access to contraception in the form of barrier methods and spermicides disguised as feminine hygiene products (Steinem). Sanger dispensed “woman-controlled” forms of birth control (a phrase she coined) through neighborhood clinics despite repeated raids (Adler; Steinem). Finally, in 1927, laws banning contraception as obscene were repealed, and the American Medical Association legitimized the provision of contraception as a medical practice, due in large part to Sanger's efforts (Adler).
Sanger founded the American Birth Control League, which later became the Planned Parenthood Federation of America. Her work became a global initiative as she organized the first international population conference (Steinem, 1998). Sanger clearly demonstrated the power of one committed nurse to effect significant change.
Social Justice Today
As nurses, we celebrate the talent, pragmatism, intellect, hard work, and commitment of our foremothers, and they provide us with excellent models of service and social activism. However, we are currently experiencing a period of relative inactivity as models of market justice have superceded models of social justice. Market justice is characterized by inequities of income, and lack of access to health care that have been viewed as tolerable although regrettable by policy makers (Drevahl et al., 2001; Kneipp & Snider, 2001). Nursing and other helping professions are beginning to acknowledge inequalities in health that have been exacerbated in recent years. Our social environment and resources determine our ability to participate fully in society. Socioeconomic position (SEP), defined as economic and social factors that affect the position that groups and individuals have within society, has a tremendous effect on health (Welch & Kneipp, 2005). Although economic disparities related to SEP are being recognized (Healthy People 2010, 2001), much work remains in the identification of disparities resulting from sexual orientation and practices (Gay & Lesbian Medical Association [GLMA], 2008).
Without access to appropriate resources, disparities in health, longevity, and quality of life will persist and widen (Russell, 2002). Lesbian and bisexual clients comprise some of the silent voices who face frequent obstacles and discrimination in their search for health care (Russell). The invisibility of these clients and their health care needs remains a dangerous facilitator of predictably poor health outcomes.
Lesbian and Bisexual Women's Access to Health Care
The varied definitions associated with sexual identity, desire, and behaviors can be difficult to comprehend for health care providers and so can be potential barriers to understanding the needs of lesbian and bisexual women. Women who self-identify as lesbian have affectional and sexual preference for other women. However, sexual behavior may be exclusively homosexual, bisexual, or heterosexual depending on multiple sociocultural and economic factors (Healthy People 2010, 2001: Rankow, 1995). Lesbians and bisexual women are found in every socioeconomic category, and all racial and ethnic groups (Healthy People 2010). They are known to underutilize health care services, and to present for care later than heterosexual women (Carroll, 1999; Hutchinson, Thompson, & Cederbaum, 2006; Rankow; Weitz et al., 2001). Although the health needs of these women are much the same as for heterosexual women, some are specific to this group. However, the unique health concerns of lesbian and bisexual women are often not understood or addressed. Lack of insurance coverage and a history of negative interactions with health care providers are frequently cited as reasons for lack of access to health care (Hutchinson et al.; Irwin, 2007; Rankow; United States Department of Health & Human Services [DHHS], 2000). Many lesbians do not disclose their sexual identity to health care providers after previous negative experiences that led to substandard health care (Carroll; Rankow). Inappropriate and negative exchanges with health care providers have included episodes of hostility, sexist and demeaning comments, withholding information, inappropriate jokes, less physical contact with clients, and inappropriate mental health referrals (Hutchinson et al.).
Health care providers who reflect a segment of the general public have a broad range of views regarding lesbian and bisexual activity. Avery et al. (2007) noted that although the American public has become generally more tolerant toward gay men and lesbians, it continues to oppose rights for this group. In a study of the use of complementary medicine practices (CAM), lesbian women reported more use of CAM compared with heterosexual women when they perceived discrimination in the conventional health care setting (Matthew, Hughes, Osterman, & Kodl, 2005). This may reflect a tendency to find self-care measures for health when conventional avenues appear limited.
The shift to viewing homosexual people as a normal segment of the population has been slow. As recently as 1973, homosexuality was removed from the Diagnostic and Statistical Manual of Mental Disorders (Irwin, 2007). Homophobia has been defined as hatred and fear of the sexual desires and practices of lesbian and gay persons, which may result in abuse (Irwin). Heterosexism refers to belief and practices that reinforce the belief that the world is and should be heterosexual, and other sexual orientations and practices are unhealthy and threatening to society (Irwin). “Women's health” seen through the heterosexist lens is understood to be “reproductive” and “heterosexual health.” Treatment of women as if their biology is their sole reality denies the truth of the social, economic, relational, and contextual experience that defines the life of each woman (McDonald et al., 2003).
Health Risks and Care Considerations in Lesbian and Bisexual Women
The majority of lesbians report having had intercourse with a male partner. Thus there may be increased risk for sexually transmitted infections (STIs) for some women, either from male or female partners (Hutchinson et al., 2006; Trettin, Moses-Kolko, & Wisner, 2006). However, women who have had sexual activity exclusively with other women may have less risk of STIs (Mathieson, Bailey, & Gurevich, 2002). Sexually active women may be at risk for other STIs depending on their sexual activity. Human papilloma virus transmission resulting in genital warts is possible through woman to woman contact. The herpes virus and hepatitis B can also be contracted with woman to woman contact (DHHS, 2000). Thus, recommendations for testing for these conditions could provide early detection and appropriate treatment.
Lesbian women report greater use of alcohol, illicit drugs, and cigarettes than heterosexual women (Bernhard & Applegate, 1999; Corliss, Grella, Mays, & Cochran, 2006; DHHS, 2000), and higher levels of drug use have been found to be associated with emotional and behavioral problems (Corliss et al.). Higher levels of psychological distress especially in minority populations have also been found to be a major factor in poorer health (Cochran & Mays, 2007). Lesbian and bisexual women were found five times more likely to report marijuana use when compared with the general U.S. female population (Corliss et al.). Nurses who care for these women are in a good position to identify and recommend early treatment for those experiencing distress and using dangerous levels of drugs and alcohol.
Approximately twice as many lesbians as heterosexual women report heavy smoking (DHHS, 2000). This places these women at greater risk for cardiovascular disease, lung cancer, and cervical cancer (DHHS). The increased substance use among lesbian and bisexual women has been viewed as a coping strategy for the psychological distress associated with stigma and discrimination, and possibly that substance use being a social norm in the lesbian and bisexual community (Corliss et al.; Trettin et al., 2006). Risk for breast cancer may be greater in lesbian women because of increased incidence of alcohol use, obesity, cigarette smoking, and null parity (Case et al., 2004; DHHS).
Additionally, lesbian women have fewer clinical breast examinations, pap smears, and mammograms than do heterosexual women (DHHS, 2000; Hutchinson et al., 2006). Cochran and Mays (2007) found that bisexual women reported higher rates of back problems, digestive disorders, and chronic fatigue compared with heterosexual women. These women also reported more functional health limitations. Nurses can advocate for improved access to services such as pap smears and mammograms and provide critical early detection and treatment for their patients. Additionally, nurses can provide a comfortable health care climate so that life-limiting conditions can be treated and quality of life restored.
Violence and Abuse Considerations
The experience of violence is the same with both homosexual and heterosexual women. However, intimate partner violence may be reported less by homosexual victims because of feelings of shame. Abuse is a predictor of attempted suicide in women (Bernhard & Applegate, 1999), and recent studies have reported increased depression and the potential for suicide in lesbian women. This may be a result of the suppression of sexual identity, discrimination in the workplace and elsewhere, and rejection by family members (Trettin et al., 2006). Statistical data for death by suicide are unreliable, because sexual orientation is not included in the mortality data collected (McAndrew & Warne, 2004). The protective factor of openness to therapy and counseling has been shown in lesbian women (Bernhard & Applegate; Corliss et al., 2006). Recent research supports the preference of the majority of lesbian women for a female health care provider and a lesbian or gay counselor (Saulnier, 2002), or one who is “gay-friendly.”
Many homosexual people desire to become parents, and options including artificial insemination, surrogacy, and adoption can facilitate this desire. Reasons for wanting children include fulfillment, biological drive, desire to make a family, and others (Purewal & van den Akker, 2007). Additionally, parents who were previously in heterosexual unions may bring children into same-sex partnerships (Lewallen, 2006). However, parenting by lesbian and gay couples is not universally accepted by health care providers or by the public at large, due mainly to concerns for the welfare of children raised in same-sex households. It is a common fear that heterosexual children will become gay (Lewallen).
A summary of research of lesbian and gay parenting reported by Patterson (2006) showed that parental sexual orientation did not have a detrimental effect on either child or adolescent development. No significant differences were noticed between children of lesbian parents and those of heterosexual parents on measures of social competence, behavior problems, self-concept, and interactions with adults and other children. The majority of children parented by same-sex couples also reported heterosexual orientation with same-sex orientation no greater than the general population (about 10%) (Patterson, 2005). The quality of family relationships was shown to be more influential than parental sexual orientation. Nurses can facilitate parenting for prospective lesbian and bisexual parents. Extending options for parenting to all women can also help them avoid risky behaviors such as use of unscreened donor semen.
Current Initiatives to Improve Health Care Access for Lesbian, Gay, Bisexual, and Transgender (LGBT) Individuals
Since the 1980s, there has been an expanded interest in public health research on sexuality. The feminist and women's health movements have called attention to the need for human rights, sexual rights, and social justice, and mainstream biomedical and public health groups have been slow to acknowledge alternatives to traditional views of sexuality and health (Parker, 2007). Several positive initiatives resulting from grassroots coalitions have worked to improve the abysmal state of health care access for LGBT people.
The World Health Organization (WHO) has identified priority areas for reproductive health service need (Fajans, Simmons, & Ghiron, 2006).The first feature of the WHO Strategic Approach to Strengthen Reproductive Health Policies and Programs is a philosophy of social justice, gender equity, and reproductive rights. This includes a participatory joint decision making process between community residents and agencies (Fajans et al.). Two programs that have used the participatory process are the Fenway Community Model and the Howard Brown Health Center. The Fenway Model is an interdisciplinary health care center in Boston that was founded as a grassroots neighborhood clinic in 1971. The model encompasses provision of medical care and CAM, improving cultural competence, and leadership in LGBT health care coalitions (Mayer et al., 2001). The Howard Brown Health Center in Chicago began as a clinic for testing and treatment of sexually transmitted diseases and now offers a broad range of medical services to the LGBT community (Healthy People 2010, 2001). These two programs and others that employ participatory action serve as models for excellent LGBT health care.
Coalitions working with state and federal agencies have recently taken action to address the special needs of the LGBT population. Recognizing the high rates of substance abuse with correspondingly low rates of treatment in the LGBT population, the Substance Abuse and Mental Health Services Administration, working with the LGBT communities, developed a document in 2001: A Provider's Introduction to Substance Abuse Treatment for Lesbian, Gay, Bisexual, and Transgender Individuals. The document was disseminated to thousands of treatment providers. It presented a model of culturally competent care as experts in the LGBT community partnered with federal agencies (Craft & Mulvey, 2001). The LGBT Health Access Project is a partnership between the Massachusetts Department of Public Health and the Fenway Community Health Project. This collaboration developed a training curriculum for health care providers and assists agencies in developing community outreach, LGBT appropriate forms, policies, and standards that serve to facilitate health care access for the LGBT community (Clark, Landers, Linde, & Sperber, 2001).
Nurses as Agents for Social Justice
Emerging Frameworks for Nursing
Although some progress has been made in nursing to identify the influence of culture, there is much work to be done. Much nursing theory has emerged from the White, middle-class perspective and has been based on generalities, thus larger societal and institutional issues have remained unchallenged (Drevahl, 1999). Drevahl argued that the ideas and theories of nursing cannot be completely divorced from the influences of race, politics, and social mores. She called for a closer look at power issues and differentials between nurse and client and the inclusion of these issues in developing nursing theory.
An awareness of the need for social justice as a central concept in nursing theory is beginning to surface in the nursing (Schim, Benkert, Bell, Walker, & Danford, 2006), and the interdisciplinary literature (Gupta, 2006). Cohen (1998) introduced a framework for women's health care that included social, political, and economic factors as well as physical, cultural, emotional, social, and spiritual aspects. She noted that traditional medical practice has been slow to evolve, even into the 20th century. Traditional medical practice was based on concepts such as “hysteria,” which defined women solely by their biological and reproductive functioning. More recently, Cohen proposed a broader definition of women's health that included the individual woman's experiences and beliefs.
Community health nurses have historically addressed the issue of social justice. However, a new metaparadigm with social justice at the core emphasizes this concept for community health nurses. Schim et al. (2006) added social justice to the traditional four metaparadigm concepts of person, environment, nursing, and health (Fawcett, 2005). Urban health nursing, a subspecialty in nursing that encompasses community health nursing in urban areas, places social justice issues at the forefront. Falk-Rafael proposed the midrange “critical caring” theory (2005) to include elements of sustainable political, social, and economic environments and describe political action as a caring expression. The theory of critical caring synthesizes Watson's caring science and feminist critical theories (Falk-Rafael). Political action on behalf of LGBT clients would constitute critical caring.
Nursing Interventions for Social Justice
Nurses, by virtue of the intimate nature of the contact they have with persons, families, and communities who suffer discrimination and stigma, are in a unique position to effect positive change (Bekemeier & Butterfield, 2005). Nurses have the potential to advocate for lesbian and bisexual clients who feel “unsafe” and to work to end discrimination and poor treatment in the health care setting.
I experienced two instances where my complacence in all was well with my lesbian and bisexual clients was challenged. The first occurred when a woman came to my office and greeted me with the words, “I heard this was a safe place to come.” I began to contemplate what constituted lack of safety. The other instance occurred when one of my nurse practitioner students returned distraught from an office in which a lesbian couple had been poorly treated by staff as they attempted to seek health care for a planned pregnancy. Gupta (2006) stated that transformation happens when an individual critically reflects on preconceived assumptions, allows insights to emerge, and acts on these critically reflective insights. These critical experiences and others motivated me to seek ways to facilitate improved health care for marginalized clients. My first action was to incorporate a section devoted to care of the lesbian and bisexual client in the women's health NP class at my university. Research has demonstrated that the addition of even one seminar regarding LGBT considerations for quality health care to a training curriculum for health care providers has improved the comfort level of those caring for LGBT patients (McGarry, Clarke, Cyr, & Landau, 2002). I also joined the GLMA to stay abreast of current information for health care providers. Finally, I wrote this manuscript to disseminate information useful in caring for lesbian and bisexual women in the health care setting.
Lesbian and bisexual women who are new to an office setting often look for signs that it is safe to share their identities and concerns. Some suggestions for making a medical office LGBT friendly include posters showing same sex couples, unisex bathroom signs, a rainbow flag or pink triangle, information about LGBT health concerns, and journals or newsletters that are LGBT specific. Gender-neutral language such as “partner” or “significant other,” both on the intake form and while taking history can promote trust and encourage openness (GLMA, 2008). Specific questions regarding sexual practices and types of partners can make the discussion regarding sexuality easier, while assuring confidentiality can improve comfort with the provider (GLMA).
Performing a brief mental health screening for depression, anxiety, and social support can be useful to open a discussion regarding perceived stress and coping (GLMA, 2008). Conversations regarding safe sexual practices that show respect for the lesbian and bisexual client, and do not assume promiscuous or dangerous behavior can engender trust and assist in the provision of excellent care. Screening for violence either by a partner or stranger is also useful, because the patient may fear retaliation by the batterer and be reticent to share episodes of violence and abuse with anyone (GLMA).
Historically, nurses have served as the voice for those not heard in our society (Lucey, 2007), and our predecessors lived lives dedicated to service. Sorrell (2003) stated that ethical practice in nursing involves “intimate listening” to those who may be marginalized and unheard because of “unacceptable” diversity. Cowling, Chinn, and Hagedorn (2000) challenged nurses to reawaken “those precious and powerful ideals that are rooted in nursing's worldwide historical traditions” (p. 4). The needs of women who fall outside the narrow, biomedical view of women's health, do not choose to have children, or prefer a female partner are often invisible or unheard (McDonald et al., 2003). Ensuring access to quality health care for all will best be accomplished by dusting off our social justice lenses, and taking up the mission of our predecessors with vigor and purpose.
The author wishes to thank Colleen Weisz, MS, James Werth Jr., Ph.D., and Lynn Lewallen, Ph.D., RN, for editorial assistance.