JOGNN
PRINCIPLES & PRACTICE
Social Justice Considerations for
Lesbian and Bisexual Women’s Health
Care
Virginia K. Weisz
Correspondence
Virginia K. Weisz, MS,
WHNP, Radford University
School of Nursing,
University of North Carolina
Greensboro, 11558 Bottom
Creek Rd., Bent Mountain,
VA 24059.
[email protected]
ABSTRACT
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.
JOGNN, 38, 81-87; 2009. DOI: 10.1111/j.1552-6909.2008.00306.x
Accepted September 2008
Keywords
social justice
lesbian
bisexual
nursing history
reproductive rights
nursing theory
Virginia K. Weisz, MS,
WHNP, is an assistant
professor of Nursing in the
Radford University School
of Nursing and a doctoral
student at the University of
North Carolina,
Greensboro.
ocial justice and advocacy for marginalized
groups have a rich tradition in nursing beginning with Nightingale, Sanger, and others (FalkRafael, 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 (FalkRafael). 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).
S
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 de¢ned 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.
http://jognn.awhonn.org
History of Social Justice in Nursing
Florence Nightingale
Florence Nightingale, a British nurse and statistician,
identi¢ed signi¢cant 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 in£uence to a¡ect change. Nightingale reformed civilian hospitals and workhouse
in¢rmaries in England and in the British colonies.
Her reforms a¡ected social welfare for the sick and
impoverished, young children, and inmates in mid19th century British prisons. As a response to the fact
that one in seven infants in England died before their
¢rst birthdays, she wrote Notes on Nursing: What it
is, and What it is not. Mothers used this reference to
care for their children more e¡ectively (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
& 2009 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses
81
PRINCIPLES & PRACTICE
Advocacy for marginalized groups of women is needed as
these groups are often invisible.
believed that the nurse could be an instrument of
reform (Falk-Rafael).
Margaret Sanger
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 £ee 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 ‘‘womancontrolled’’ 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 e¡orts (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 ¢rst international
population conference (Steinem, 1998). Sanger
clearly demonstrated the power of one committed
nurse to e¡ect signi¢cant 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 cur-
82
Social Justice for Lesbian and Bisexual Health Care
rently 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), de¢ned as economic and social factors that a¡ect the position that
groups and individuals have within society, has a tremendous e¡ect on health (Welch & Kneipp, 2005).
Although economic disparities related to SEP are
being recognized (Healthy People 2010, 2001), much
work remains in the identi¢cation 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 de¢nitions associated with sexual identity, desire, and behaviors can be di⁄cult to
comprehend for health care providers and so can
be potential barriers to understanding the needs
of lesbian and bisexual women. Women who selfidentify as lesbian have a¡ectional 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 speci¢c 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 inter-
JOGNN, 38, 81-87; 2009. DOI: 10.1111/j.1552-6909.2008.00306.x
http://jognn.awhonn.org
Weisz, V. K.
actions 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 re£ect 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 re£ect a tendency to ¢nd 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 de¢ned 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 de¢nes the life of
each woman (McDonald et al., 2003).
Health Risks and Care
Considerations in Lesbian and
Bisexual Women
Health Risks
The majority of lesbians report having had intercourse with a male partner. Thus there may be
JOGNN 2009; Vol. 38, Issue 1
PRINCIPLES & PRACTICE
Lesbians and bisexual women are known to underutilize
health care services and to present for care later than
heterosexual women.
increased risk for sexually transmitted infections
(STIs) for some women, either from male or female
partners (Hutchinson et al., 2006; Trettin, MosesKolko, & 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
¢ve 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).
83
PRINCIPLES & PRACTICE
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.’’
Parenting Considerations
Many homosexual people desire to become parents, and options including arti¢cial insemination,
surrogacy, and adoption can facilitate this desire.
Reasons for wanting children include ful¢llment, 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).
84
Social Justice for Lesbian and Bisexual Health Care
A summary of research of lesbian and gay parenting reported by Patterson (2006) showed that
parental sexual orientation did not have a detrimental e¡ect on either child or adolescent development. No signi¢cant di¡erences 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 in£uential 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 identi¢ed priority areas for reproductive health service
need (Fajans, Simmons, & Ghiron, 2006).The ¢rst
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
JOGNN, 38, 81-87; 2009. DOI: 10.1111/j.1552-6909.2008.00306.x
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Weisz, V. K.
Chicago began as a clinic for testing and treatment
of sexually transmitted diseases and now o¡ers
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).
PRINCIPLES & PRACTICE
Nurses are uniquely positioned to advocate for lesbian and
bisexual women.
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 de¢ned women
solely by their biological and reproductive functioning. More recently, Cohen proposed a broader
de¢nition 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.
Nurses as Agents for Social Justice
Emerging Frameworks for Nursing
Nursing Interventions for Social Justice
Although some progress has been made in nursing
to identify the in£uence 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 in£uences of race, politics, and
social mores. She called for a closer look at power
issues and di¡erentials between nurse and client
and the inclusion of these issues in developing
nursing theory.
Nurses, by virtue of the intimate nature of the contact they have with persons, families, and
communities who su¡er discrimination and stigma,
are in a unique position to e¡ect positive change
(Bekemeier & Butter¢eld, 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.
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,
JOGNN 2009; Vol. 38, Issue 1
I experienced two instances where my complacence in all was well with my lesbian and bisexual
clients was challenged. The ¢rst occurred when a
woman came to my o⁄ce 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
o⁄ce in which a lesbian couple had been poorly
treated by sta¡ as they attempted to seek health
care for a planned pregnancy. Gupta (2006) stated
85
PRINCIPLES & PRACTICE
that transformation happens when an individual
critically re£ects on preconceived assumptions, allows insights to emerge, and acts on these critically
re£ective insights. These critical experiences and
others motivated me to seek ways to facilitate improved health care for marginalized clients. My ¢rst
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 of¢ce setting often look for signs that it is safe to share
their identities and concerns. Some suggestions
for making a medical o⁄ce LGBT friendly include
posters showing same sex couples, unisex bathroom signs, a rainbow £ag or pink triangle,
information about LGBT health concerns, and journals or newsletters that are LGBT speci¢c. Genderneutral language such as ‘‘partner’’ or ‘‘signi¢cant
other,’’ both on the intake form and while taking history can promote trust and encourage openness
(GLMA, 2008). Speci¢c questions regarding sexual
practices and types of partners can make the discussion regarding sexuality easier, while assuring
con¢dentiality can improve comfort with the provider (GLMA).
Social Justice for Lesbian and Bisexual Health Care
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 o¡ our social justice
lenses, and taking up the mission of our predecessors with vigor and purpose.
Acknowledgment
The author wishes to thank Colleen Weisz, MS,
James Werth Jr., Ph.D., and Lynn Lewallen, Ph.D.,
RN, for editorial assistance.
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