Sizing up the provider and the environment
Thirteen of the studies included metaphors to suggest this theme. Lesbian women who anticipate a health care visit frequently employ protective measures to help minimize adverse or uncomfortable situations during a visit. Our health care system and its providers often reinforce the barriers that vulnerable and marginalized people struggle to negotiate.20 Research has shown that a significant number of lesbian women do not seek traditional health care services because of prior negative encounters.9 Some lesbian women preferred to see a provider who was openly gay or lesbian because they believed that a heterosexual provider would demonstrate prejudice toward them.9 To minimize the chance of a negative encounter, some women contacted different providers' offices to determine their receptiveness to treating a lesbian patient.11 For example, one lesbian couple who relocated to another town during their antepartum desired an open-minded provider who was willing to care for them for the remainder of their pregnancy. They referenced a telephone directory and shared the following account, “And then we just listened without making a concrete decision ... because nobody would say in a direct manner that they were against it. But we listened to their voices, and finally, we picked out a medical office.”11 (p480) Women in Barbara et al's9 study shared that they assessed a provider at the beginning of a visit for certain nonverbal behaviors such as maintaining eye contact when obtaining a health history. The following represents a similar situation: “When I was looking for a primary care physician, I would go and hope that there would be an eye to eye interview, and the test would be, when I came out to the doctor, what their reaction was.”9 (p54) Nonverbal communication also included the appearance of the office environment such as posted safe zone signs, pink triangles, or rainbow stickers to indicate an affirming environment.30 Women who used these more proactive approaches strived to mitigate anxiety and fear before meeting a new provider.
Lesbian women had more positive impressions of their visit when asked whether someone would be accompanying them to the appointment and whether they wanted the person present during their examination.23 These practice environments were more patient-centered and affirming. Providers who extended an open-minded and respectful presence during a visit were viewed positively by lesbian women. The following statement illustrated a sense of normalcy for a lesbian family: “I'm [the physician] so glad I met you because I've never known a lesbian family before and I would have had all these terrible ideas ... I can see you really love your child.”5 (p98) In Scherzer's20 study, women expressed that feeling connected with their health care provider was an important aspect of a positive health care encounter. Other women positively perceived providers who were informed about their health condition and who explored the basis for presenting symptoms rather than relating all physical and psychological illness to sexual orientation.10 Participants in Dinkle's19 study identified the following 7 characteristics of an ideal provider: skilled communicator, competent, open to diversity, caring, committed, respectful, and created a safe and trusting environment.
Women perceived the health care encounter negatively when the provider made prejudicial and homophobic remarks. Some women expressed concern when a provider was uninformed about their health needs or seemed disinterested in them as a person.27 This demeanor created communication barriers between the women and their provider during the visit. A dramatic quote by one woman demonstrated one provider's dismissive mannerism when she said, “No matter what I wanted to bring up; migraine, hot flashes, fatigue, anemia; she switched it to saying that being a lesbian had to be very hard ... I changed doctors.”10 (p241) When the woman left the visit feeling uncertain about her care or having unanswered questions, she formed negative impressions about her experience. Another participant in Bjorkman and Malterud's study shared a slightly different perspective of her provider when she described the following encounter:
I was very physically ill without understanding that I was mentally exhausted ... doctor that I came to understood quickly that my physical illness was caused by something other than a virus, and she gave me a close and good follow-up. She was actually the first one to put into words emotions and difficult things linked to identity.10 (p241)
In contrast to this experience, a woman from another study shared a different perspective on a positive experience when she explained the following story:
I went to a pretty good doctor this time, she was really nice ... She actually talked more about some of my emotional things, like are you getting enough rest, and has anything changed ... my menstrual cycle had been a little funky, so she had asked me about my sleeping habits my eating habits, and was anything new in your life, and I told her about all this new stuff, so I got to talk to her, I felt good about that, that was good.20 (p96)
In all 3 of these examples, the women identified either the presence or absence of an attentive provider to their concerns. In the first situation, the woman thought the provider very quickly assumed that her sexual orientation was the cause of all her worries. In the second scenario, the woman was receptive to the idea that her mental exhaustion might be linked to her sexual orientation. In the third circumstance, the provider listened and focused less on the woman's lesbian identity as the basis for her presenting symptoms. This holistic approach made a positive impression on the woman.
To say or not to say: “Paradoxes of disclosure”
The paradoxical nature of self-disclosure or “coming out” has shown that what one woman identifies as a positive reason to disclose her sexual orientation another woman may view as negative. All of the studies in this metasynthesis addressed varying viewpoints of self-disclosure to a health care provider. This range of perspectives suggests that the “coming out” process for women is highly individualized, and based on either previous positive or negative encounters with providers. A woman's decision of what approach to use is influenced by her worldview, knowing herself, and past experiences with health care providers.5 , 11 , 20 , 23 , 24–26 Dinkle19 identified 4 categories of disclosure among the women she interviewed that included no disclosure, only disclosing when asked, allowing the provider to assume without verifying, and disclosing by referencing the partner on the intake form. Many different factors influenced women's decisions to disclose their sexual orientation, including previous homophobic encounters, occupation, physical and psychosocial contexts, partner status, and perceived social and spiritual support.19
McNair et al5 found women used private, proud, or passive strategies when disclosing their sexual orientation to a health care provider. Lesbian women used more private strategies when they did not believe that their sexual orientation was pertinent to the visit. One woman declared, “Straight people don't have to justify their story, and I don't have to justify mine.”5 (p101) Women who used a proud strategy wanted to be honest and authentic to themselves and their children yet realized doing so exposed them to potential discrimination.5 Some women echoed a proud approach in several studies of this metasynthesis.11 , 12 , 19
Often, women who were comfortable disclosing their sexual orientation felt more emancipated and believed that this feeling aided them in having a more positive experience with their health care provider.12 One woman expressed the following sentiment that reflected the view of other participants: “It just stops seeming so bad, and you start seeing the good things. [Coming out] was a really wonderful feeling, I just felt really emancipated ... in control ... independent ... big freedom.”12 (p133) Women in Spidsberg's11 study believed that a positive approach to self-disclosure was to be open but not overly assertive. Those who were comfortable disclosing to a health care provider wanted to live their lives as openly and honestly as possible19 , 23 and to remain free of the incarcerating effects of internalized homophobia. Such conviction is rooted in a strong sense of knowing oneself.
The women in this sample who chose a passive approach to disclosure were less concerned about health care providers knowing their relationship status and sexual orientation compared with women who used private or proud strategies. In fact, some women were so reticent that they did not correct erroneous provider assumptions. As one couple in McNair et al's study candidly shared the following belief:
Jo: No one ever asks. They probably just assume ... and if they assume I'm Mum [Mom] that's fine. I don't feel any great need to say, “Well, actually I'm not his Mum,” but ...
Bridget (birth mother): Because in that situation you are, you know.
Jo: Yeah, I'm his parent.5 (p104)
In this situation, it felt safer for the couple not to correct the assumptions because they understood that the nonbirth mother had no legal right to make health care decisions concerning the child.
Lesbians describe their “coming out” as either positive or negative depending on how their health care provider reacted after learning this information. Women who felt uninhibited when disclosing their sexual orientation felt empowered,24 whereas those who were guarded remained fearful of negative repercussions by their provider.9
A participant in Barbara et al's study expressed her reluctance to disclose when she said, “For a long time I would sort of lie ... when I was asked about sexual activity.” 9 (p53) Another woman from the same study expressed similar sentiments when she said:
I mean, it's just horrible to think that women have to continue going to the doctor and be afraid with the doctor about who they are because I think there's just too many things that impact on us. And having that freedom, that ability to talk about who you are is very important.9 (p53)
One lesbian couple in McNair et al's5 study had chosen intentional silence regarding disclosure and viewed this strategy positively because they believed it protected them and their children. In contrast to this silent approach, another couple observed their life together in a more open manner. This couple described the following health visit they had during the antenatal period:
Ella: I think we have a charmed experience of lesbian parenting.
Sally: Even in the hospital we never had any problems whatsoever.
Ella: It was never a problem.
Sally: We were “bang” out there straight away.
Ella: Before the nurse even sat down in her seat, it was like, “Hi, I'm Ella, and this is Sally. Sally is the one giving birth.”
Ella: ... That was the spiel, and I think, really, after the third nurse, they all knew we were lesbians ... We had heard similar stories.5 (p103)
Women who felt more negative or anxious disclosing their sexual orientation feared being marginalized and stigmatized by homophobic practitioners.6 , 9 , 19 Others thought they regularly had to balance vulnerability with maintaining their self-esteem when deciding to disclose.27 When a health care provider demonstrates specific impertinent activities during an office visit, women interpreted the actions as rude and thought that the provider was uncomfortable discussing the topic of sexual orientation. Activities that lesbian women found disrespectful included shuffling papers, not maintaining eye contact when talking, moving around the examination room while women were speaking, or quickly changing the subject of discussion when the woman asked a question related to her sexual orientation.27
Some women feared being told that being a lesbian was merely a phase.10 After hearing such a comment women felt dismissed and invalidated and attributed the remark to the provider's lack of understanding about sexual orientation. In other instances, women described feeling abandoned by their provider after they disclosed their lesbian identity. It is unethical for a health care provider to abandon his or her patient when providing care, yet this occurred to one woman during an office visit when she described the following dialogue:
They said, “Do you think you could be pregnant?” I said, “No.” He said “Are you sure?” It got to the point where he was very annoying. I said, “I am a lesbian, ok.” He turned around very upset and left the room. Then, another doctor came back and finished the examination.9 (p52)
The different pathways to disclosure are fluid and do not imply that one approach is better than another. Ultimately, women chose strategies for disclosure they perceived limited their vulnerability and risk of being stigmatized. Lesbian women were more apt to shift between different strategies based on past and present circumstances and their value system. For most lesbian women, the act of “coming out” is individualized rather than scripted and is regulated by temperance.
Reactions to provider's assumptions
In all of the studies, women shared experiences where they had to cope with different provider assumptions during a health visit. Most of the assumptions these women described centered on questions about marital status, use of birth control, sexual history, and habits. The manner in which providers asked questions often conveyed a heteronormative view. When this perspective influences questioning, it leaves few options for lesbian women to respond and frequently results in negative perceptions about the experience. In one situation, a woman felt as though she had been violated during a pelvic examination when she described the following conversation with a physician:
One thing that he did is asked me if I was a virgin at the time ...and I said yes, and he said, um “well I thought so, I could barely get three fingers in.” I'm going what the fuck are you doing and why was that ... I didn't feel safe at all ... I had already been, felt like I had been raped.19 (p61)
When providers assume that a woman is sexually active exclusively with men and asks about birth control,9 , 23 or tells a woman that having a Pap smear is unnecessary when she denies being sexually active with a man,24 it leaves lesbian women feeling they have to disclose their identity when they might not feel ready. Disclosure under these circumstances often results in negative impressions of the visit. One woman had a physician who advised her against having a Pap smear when she shared the following:
I knew a fair amount about the HPV virus and stuff like that. I've never had sex with men so I mean that, when she [doctor] said that [I didn't need a Pap] I just kind of thought well it makes sense but I really didn't think much more about it.24 (p891)
This example raises issues of self-advocacy and the importance of lesbian women to feel empowered to question provider recommendations relevant to their health. When women are forced to disclose their sexual orientation under vulnerable circumstances, they are less likely to return and subject themselves to similar negative encounters.
Women described positive experiences when they encountered practitioners who made no assumptions and created a safe environment for them to disclose. Examples included asking questions on the intake forms that were more neutral and nonassuming. One woman shared how joyful she was in the following experience:
I mean, from the very beginning with the forms, they asked, “Do you live with someone?” “Who is this person to you?” They just didn't make any assumptions. They asked some really basic questions. Every one of them surprised me ... And it was such a joy to think that they had really taken the time to think that I wasn't widowed or divorced, or that I did have a partner.9 (p56)
Other women also perceived the health care experience positively if the practitioner refrained from making negative comments when the women shared personal events in their lives. A woman in Bjorkman and Malterud's study expressed how appreciative she was after visiting her general practitioner:
I saw my GP during a difficult period in my private life, among other things the breakdown of a relationship with a male partner, and starting a relationship with a girl. I wanted to praise the GP for an open attitude and understanding. It was important for me to feel accepted and he was open about the issue.10 (p241)
Acknowledging my partner
Seven of the studies discussed including the woman's partner during a health visit. Women positively perceived acknowledgment of their female partner when communicated in a professional manner. For example, calling a partner by her name9 , 11 and offering the patient the option to invite her partner into the examination,5 , 9 , 23 and validating the role of the birth mother11 were seen as affirming measures that some providers used to create safe environments for their patients. Women in Spidsberg's11 study described being in caring hands as they described positive experiences throughout their pregnancy. Simple gestures as shaking hands with both partners, and congratulating them on a healthy pregnancy conveyed support and validation for both women.11 One couple was pleased when the nurses in the intensive care unit placed a heart-shaped sign on their infant son's cot labeled with both their names as the mother.11 In another situation, a nonbirth mother recanted the following conversation she had with the pediatrician about breastfeeding the baby:
Looking into my eyes he says, “are you going to breastfeed?” Just like that, like it was the easiest thing in the world, that both of us nursed the baby. And then he continued, “Men can breastfeed too, ... it's just not that common.” I must say, it came as a shock to me, I wasn't quite there. He was so incredibly engaged in the thought of me breastfeeding too.11 (p482)
Negative experiences resulted when providers ignored the woman's partner,11 denied a request to have the partner present,9 , 23 discriminated against the partner when she was present,19 and invalidated the role of the nonbirth mother.5 One woman described a frustrating and deplorable experience when the hospital staff denied her request to have her partner with her in the hospital emergency department:
But they refused to let her go back while I was being treated. And, I complained, but I was also very sick at the time too. It was much harder for me to be pushy about it. After the episode was over, I received a questionnaire from the ER asking about my care. I let them have it about how deplorable I thought that was ... We have each other's health care power of attorney. But in emergency situations, you don't always carry the paperwork with you everywhere. I felt like we had to go above and beyond what would normally be required of people in order for me to have the support of her being by my side.9 (p57)
Other women in this sample described similar circumstances like this that left the partner feeling insignificant and invisible. One participant in Duffy's study shared how isolated and terrified she felt during a hospitalization knowing that she had no immediate relatives who could visit or stay with her:
... I was absolutely terrified and very, very ill... and I had told them that Finnesech was my partner and put her on my form as next of kin. I was told that she couldn't come in with me ... it was a very frightening experience to be stuck on my own, ... just having nurses not really wanting to treat me ... let alone touch me.23 (p340)
Not having her partner present during this frightening hospitalization marred any opportunity for the health care provider to make a positive impression. Although this study was conducted in Ireland,23 similar events occurred in the United States prior to the federal legislation in January 2011 allowing same-sex couples to decide who they wish to have visited them and to make health care decisions on their behalf. Prior to this legislation, same-sex couples could be refused the right to visit their partner during hospitalized in the United States.
The 4 themes to emerge from this metasynthesis of 14 qualitative studies offer a more comprehensive understanding of the health care experiences of lesbian women and provide direction for clinical practice and further research. The themes of sizing up the provider and the environment, to say or not to say: “paradoxes of disclosure,” reactions to provider's assumptions, and acknowledging my partner identify important periods during a health care encounter when lesbian women are likely to form positive or negative impressions of the experience after interacting with their provider. With a broader understanding of factors that influence these women's health care experiences, practitioners can use more culturally affirming communication techniques to mitigate negative perceptions. Providers are encouraged to reflect on each of the themes in this metasynthesis, and question whether they exhibit behaviors that contribute to negative or positive health care experiences by lesbian women.
Many studies have identified factors that influence lesbian women's health care experiences and include issues regarding disclosing sexual identify, navigating heteronormative assumptions, and encountering providers who are not well informed about lesbian women's health care needs.1 , 2 , 18 , 31–33 Results from this metasynthesis support these findings and identify circumstances when these factors hinder or facilitate positive perceptions of provider interactions and the care provided. Based on the overarching themes from this metasynthesis, recommendations are offered to help promote affirming and respectful communication between health care providers and lesbian women.
Sizing up the provider and the environment
Creating affirming and trusting milieus in which to provide care is essential for lesbian women to form a favorable impression of their health care experiences. Providers should assess the places in which they practice and critically reflect on the following questions. How welcoming is the environment for lesbian women? To what extent do the reception staff and providers demonstrate affirming and culturally appropriate care when interacting with lesbian patients? Are there safe zone signs, posters, and literature in the waiting rooms to convey support for patients of diverse sexual orientation and gender identities? These actions will help lesbian women perceive a safe and supportive environment when they enter the practice environment.
To say or not to say: “Paradoxes of disclosure”
Not all health care providers ask about their patient's sexual orientation; instead, women convey this personal characteristic themselves.9 Some women have had negative experiences when disclosing their sexual orientation to a provider and may be more reluctant to share this information with a new provider. Health care providers should ask all patients about sexual orientation on intake forms and in the context of conversations about sexual health,34 while remaining attentive to a discussion about confidentiality and privacy.35 Providers who use inclusive language on all intake forms and ask rather than make assumptions about their patients are more likely to encounter lesbian women who are more comfortable sharing information about their sexual orientation.2 , 9 , 10 , 36 Practitioners who develop caring and trusting relationships with their lesbian patients, and explain why knowing sexual orientation is relevant to providing care, help create more affirming and less threatening environments in which to disclose this information.10 When a woman discloses her sexual orientation to the health care provider, the practitioner's immediate nonverbal and verbal response to this information is critical. If the woman perceives the provider's response as negative or disrespectful, she is less likely to return or to disclose this information to future providers.11 , 27 In fact, some may delay future care because of such adverse reactions.
Reactions to provider's assumptions
Heteronormative assumptions continue to dominate most health care environments; however, providers are asked to consider the implications of these assumptions during a health care visit.9 , 11 , 27 Lesbian women are aware of assumptions made in the context of their care; therefore, the onus of responsibility to not assume does fall to the health care provider. For example, it is preferred to ask a woman in what way she is related to whoever accompanies her to a visit and allow her to decide how to respond. Acknowledging a woman's partner is an empowering and affirming act for lesbian women. Health care providers are encouraged to critically reflect on how their heteronormative perspectives can negatively influence a lesbian woman's health care experience.
Health care providers should understand the power shifts that occur during interactions can result in perceived prejudice and lead some lesbian women to delay or avoid seeking health care. Avoiding or delaying health care contributes to health disparities. Providers must also realize that some women have had previously traumatic experiences with providers. These experiences include hearing unprofessional comments during a pelvic examination and feeling as though they were sexually violated during a pap smear. A lesbian woman who feels respected and is asked to share her health concerns before being questioned about her sexual activity and the need for birth control is more likely to trust her provider. Creating affirming and trusting milieus in which to provide care is essential for lesbian women to believe their provider and form a positive impression of their experiences. These actions will also help decrease vulnerability and stigma.
Acknowledging my partner
It is important for some lesbian women to bring their partner or spouse to a health care visit. If she identifies the woman as a “friend,” “partner,” or spouse as in, “she is my wife” and requests her presence during the health care visit, allow her. Reception staff should also be respectful of this request. Acknowledging a woman's partner is an empowering and affirming act for lesbian women. Modifying the health care environment to convey a more welcoming milieu for these women will help decrease their vulnerability and fear of being stigmatized and marginalized.
The point at which the patient's and provider's perceptions merge creates a common ground for shared understanding, meaning there is an opportunity to engage in an affirming and respectful dialogue between them. Lesbian women face many barriers when they enter the health care system. They learn to adapt by cautiously navigating a health care system that is conditioned by heteronormative perspectives. These women are more likely to seek health care services when they encounter practitioners and environments that affirm their sexual orientation, cultural beliefs, and family structures. Practitioners who are proactive and incorporate culturally appropriate practices when providing care to lesbian women help create nurturing, patient-centered environments in which supportive relationships can flourish. Noblit and Hare remind us that “a meta-ethnography is complete when we understand the meaning of the synthesis to our life and the lives of others.”7 (p81)
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Keywords:Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
family health care; focus groups; gay; grounded theory; homosexual women; lesbian health; lesbian health care; narrative analysis; phenomenology; primary care experience; qualitative research; self-disclosure; women health care