2015
University of Southern Denmark
Faculty of Business and Social Sciences
Department of Political Science and Public Management
Comparative Public Policy and Welfare Studies
Challenging Heteronormativity Experiences of Lesbian Mothers When Transitioning Into Parenthood in
Finland and Denmark
Thesis submitted in partial fulfilment of the requirements for the degree of Master of
Science in Comparative Public Policy and Welfare Studies
Beatrice Carraro 100891-3516
Saana Sirkkala 060590-3118
Supervisor: Romana Careja
Department of Political Science and Public Management
Number of pages: 131.
Number of keystrokes: 332.268.
Academic Thesis: Declaration of title and Authorship
Name: ​
Beatrice Carraro & Saana Sirkkala
__________________________________________________________________________
Cpr.no.: ​
100891-3516 & 060590-3118
__________________________________________________________________________
Programme: ​
Comparative Public Policy and Welfare Studies
__________________________________________________________________________
We declare that this thesis and the work presented in it is our own and has been carried
out in collaboration.
__________________________________________________________________________
Title: ​
Challenging Heteronormativity - Experiences of Lesbian Mothers When Transitioning
Into Parenthood in Finland and Denmark
__________________________________________________________________________
I confirm that:
1. This work is performed entirely or mainly while I was enrolled for an academic
degree at the University of Southern Denmark.
2. Where any part of this thesis has previously been used in any other written work at
the University of Southern Denmark or any other institution, this has been clearly
stated.
3. Where I have consulted the published work of others, this is always clearly
attributed.
4. Where I have quoted from the work of others, the source is always given, except my
own work.
5. I have specified all major sources in connection with elaboration of this thesis.
Date: _________________ Signature: _________________________________________
To mothers.
Table of Contents
Summary………………………………………………………………………
1
1. Introduction………………………………………………………………...
2
2. Institutional Background…………………………………………………..
7
2.1. Social Policies and LGBT Minorities……………………………………
7
2.2. Legal Development of LGBT Rights in Finland and Denmark…………
9
2.2.1. From Decriminalization to Anti-Discrimination……………………..
10
2.2.2. Registered Partnership……………………………………………….
10
2.2.3. Equal Marriage…………………………………………………………
11
2.3. Healthcare in Finland and in Denmark………………………………
12
2.3.1. Fertility Treatments……………………………………………………
12
2.3.2. Perinatal Care…………………………………………………………..
14
2.4. Parents’ Rights and Second-Parent Adoption for Lesbian Couples…
15
3. Literature Review…………………………………………………………...
19
3.1. Positive and Negative Experiences in ​
Healthcare…………………….
19
3.2. Institutionalized Heterosexuality and Heteronormativity in Healthcare.
23
3.3. Disclosing Sexual Orientation and Invisibility of Lesbian Patients…..
27
3.4. Challenges When Accessing Healthcare……………………………….
30
3.5. Incomplete Institutionalization…………………………………………
33
3.6. Conclusions From the Literature Review………………………………
35
4. Theoretical Framework…………………………………………………....
37
4.1. Social Policy Constituting Sexuality……………………………………..
38
4.2. Sexual Citizenship………………………………………………………...
40
4.3. Sexual Citizenship and Public Space……………………………………
42
4.4. Queer Theory…………………………………………………………..
45
4.5. Incomplete Institutionalization……………………………………….
46
4.6. Our Theoretical Framework and Working Hypotheses……………
48
5. Data and Methods ………………………………………………………
50
5.1. The Sample…………………………………………………………….
50
5.2. Recruitment and Data Collection……………………………………
52
5.3. Interviews……………………………………………………………...
53
5.4. Data Analysis and Method…………………………………………….
54
5.5. Ethical Considerations…………………………………………………
57
5.6. Study Limitations……………………………………………………....
58
6. Analysis …………………………………………………………………..
59
6.1. “Suddenly I was overwhelmed with being a minority”.................
60
6.1.1. Unproblematic Experiences………………………………………..
60
6.1.1.1. Finland……………………………………………………..………
60
6.1.1.2. Denmark……………………………………………………...……
63
6.1.1.3. Comparison………………………………………………...……..
64
6.1.2. Positive Experiences……………………………....………………..
66
6.1.2.1. Finland……………………………………………………………..
66
6.1.2.2. Denmark…………………………………………………………...
68
6.1.2.3. Comparison………………………………………………………..
71
6.1.3. Negative Experiences………………………………………………
72
6.1.3.1. Finland……………………………………………………………..
72
6.1.3.2. Denmark…………………………………………………………...
77
6.1.3.3. Comparison………………………………………………………...
82
6.2. “We weren’t adopting a child, we were having a child”..................
84
7.2.1. Legal and Institutional Challenges…………………………….
84
6.2.1.1. Finland…………………………………………………………….
84
6.2.1.2. Denmark…………………………………………………………..
90
6.2.1.3.Comparison………………………………………………………...
93
6.2.2. Lack of Knowledge.…………………………………………………..
95
6.2.2.1. Finland……………………………………………………………..
95
6.2.2.2. Denmark…………………………………………………………...
97
6.2.2.3. Comparison………………………………………………………..
100
6.2.3. Incomplete Institutionalization……………………………………
101
6.2.3.1. Finland……………………………………………………………..
101
6.2.3.2. Denmark…………………………………………………………...
111
6.2.3.3. Comparison………………………………………………………..
116
7. Discussion………………………………………………………………..
118
7.1. Results………………………………………………………………….
118
7.2. Our Results and Previous Studies……………………………………
122
7.3. Policy Implications……………………………………………………..
128
8. Conclusion………………………………………………………………..
129
References
Annex 1 - Vocabulary
Annex 2 - Participants’ Information
Annex 3 - Gay Men’s Possibilities to Become Parents
Annex 4 - Minimizing Experiences
Annex 5 - Privacy Statement and Interview Structure
Annex 6 - Division of the Written Work
Summary
S. Sirkkala & B.Carraro
In Finnish and Danish healthcare, communication and healthcare routines are based on the
assumption that heterosexual patients are the norm. Heteronormativity is especially rooted
in perinatal care, where the concept of family and parents are strongly gendered and
services are tailored for this type of a family. Thus, the heterosexual assumption and
expectation in healthcare and especially in the delivery rooms make the experiences for
those families who do not conform to the norms especially interesting for research. This
comparative, qualitative study aims to describe lesbian women’s healthcare experiences
when transitioning into parenthood in Finland and in Denmark, and the challenges that
these relatively new types of families face due to heteronormative legislation, social policies
and caring routines.
First, our research aims to uncover whether lesbian couples’ experiences in perinatal care
are atypical from heterosexual couples’ standard experience and if so, what are the possible
reasons for that. Second, we compare the institutional differences between Denmark and
Finland to investigate whether they have an influence on the type of experiences these
lesbian parents have. We adopted a qualitative, explorative and descriptive design and
conducted semi-structured, conversational interviews. We interviewed 20 mothers or
mothers-to-be, ten in each country. We employ Qualitative Content Analysis and Constant
Comparison to analyze the narratives of our respondents.
We interpret our findings with the help of several authors and the theoretical notions they
have provided. We employ Carabine’s (2001) notion of sexuality being regulated by welfare
and social policy, which then exclude those citizens’ who do not conform to the heterosexual
norm. We use the notions of sexual citizenship elaborated by Richardson (1998; 2000a;
2000b) to interpret narratives where the heteronormative foundations of citizenship may
cause exclusion. We use Hubbard’s (2001) notions on the idea that citizenship is linked to
what is considered appropriate within particular spaces. We also use queer theory and
particularly Goldberg et al. (2011) to understand lesbian mothers experiences when
disrupting heteronormativity in public spaces. Lastly, we use Cherlin’s (1978) concept of
incomplete institutionalization in a similar manner to Hequembourg (2004): to better
understand how same-sex families face unique challenges with societal institutions due to
their marginalized status.
1 We found that both Finnish and Danish lesbian couples had a variety of unproblematic,
positive and negative experiences. First, we argue that the experiences of the lesbian
couples in healthcare have indeed proven to be atypical experiences, and positive and
negative experiences demonstrate it. Accounts of positive experiences include a variety of
atypical episodes where the prospective mothers had positive interactions with the medical
staff who made an extra effort especially because they were treating a lesbian couple in
order to adjust heteronormative written material and practices. Accounts of negative
experiences include challenges and discriminatory practices on personal and cultural level,
as the lesbian couples negative interactions with healthcare professionals.
Second, we found that institutional differences between the countries on one hand ​
do
influence and on the other hand, ​
do not​
. moreover, we expected more LGBT-inclusive laws
in Denmark to make the care received by lesbian couples better than in Finland. However,
we found that the influence of institutions, such as new second-parent adoption laws, do
not have an immediate effect on practice. The Danish family laws regulating same-sex
parenthood are very recent, and therein lies the risk that practices, training and material
may not updated. We argue that more inclusive laws have an important role in creating
more inclusive and nondiscriminatory attitudes in the society at large, but this does not
happen without the appropriate training and the necessary time for healthcare centers and
the professionals to adapt old practices and to create new ones. This is based on the findings
that despite inclusive laws are in force in Denmark, forms, documents and healthcare
professional’s practices are still not always LGBT inclusive The key insight of these results, in
the Danish case, is that care practices and professionals’ attitudes toward sexual minorities
do not straightforwardly reflect LGBT-friendly legal provisions.
1. Introduction
B. Carraro & S. Sirkkala
The normative assumption of heterosexuality has been, and to some extent still is, the
premise to welfare policies and practice. L​
aws and social policies have a normalizing,
regulatory role in constituting welfare subjects and provisions, and in distinguishing
appropriate and ​
deserving citizens and welfare recipients from those who are not. T​
he
normative status of heterosexuality in Western societies continues to affect the experiences
of different individuals either through direct oppression of non-heterosexuals or, more
indirectly, through privileging heterosexuals. ​
Institutionalized heterosexuality is manifested
2 through the discriminatory laws and regulations that differentiate between heterosexuals
and homosexuals (i.e. marriage, ​
adoption and assisted reproduction laws). Moreover, the
heterosexual nuclear family unit remains the most prevalent family form, making it also the
societal norm. This is ​
demonstrated also in the way medical professionals expect the
patients entering perinatal care to conform to this norm.
Yet, the legal and cultural definitions of family have been challenged by alternative types of
families which have been increasingly gaining visibility and even acknowledgement through
laws and social policies. In Nordic countries such as Finland and Denmark, the number of
same-sex families is expected to rise, as a result of a change in social attitudes and
introduction of more LGBT inclusive laws. However, some important legal loopholes remain
and LGBT individuals and their families still often face exclusionary response. ​
I​
f having
children is one of the biggest decisions that any couple or individual will have to make, for a
same-sex couple it is even bigger as it involves further processes, choices, stressors and
challenges that are not encountered by heterosexual couples.
The transition into parenthood can be considered as one of the most vulnerable times for
lesbian couples as parents and patients, because their care experiences occur within
heteronormative institutions and spaces such as maternity wards in healthcare centers. In
perinatal care, heteronormativity prevails as the assumption and expectation of a couples
being heterosexual is especially strong, because there the medical staff mostly encounters
heterosexual couples. Heteronormativity is evident in awkward and confused situations
where care and nursing practices are constructed for opposite-sex parents and healthcare
professional stick to their routines and overlook the fact that the family they are treating
does not conform to the norm. Thereby, the presence of lesbian couples can pose a
challenge for the professionals to provide appropriate treatment. Not only can the quality of
care be jeopardized if the healthcare system and structures are not flexible enough to
integrate lesbian mothers as patients into these spaces, but also when and if these patients
face interpersonal challenges with the medical personnel. Thus, lesbian couples can be in an
even more vulnerable situation, should they experience discrimination or homophobic
attitudes. ​
Even though one can not always consider the medical staff as directly responsible
of homophobic or discriminatory practices, ​
there is a more institutionalized form of
oppression that affects LGBT patients , and that is heteronormativity embedded in social
3 policies, family laws and healthcare practices1 . ​
When and if the designed healthcare
practices are designed only for heterosexual couples transitioning into parenthood,
non-heterosexuals risk to stay in the ​
shadow of heteronormativity a​
nd thus, are left socially
invisible.
Although the existing literature provide several useful insights, few of them link attitudes
and behaviors of the professionals, and therefore the LGBT patients’ experiences, to the
local institutional context. Our thesis aims to fill this niche to some extent by highlighting
how different institutions may have an influence and therefore produce different behavioral
and attitudinal outcomes. This thesis brings together three arenas of public policy: social
welfare, family, and civil rights. In fact, when analyzing welfare state institutions such as
healthcare, the way welfare practices have a normalizing and regulatory in constituting
deserving citizens, families, sexuality and appropriate behavior, are rarely taken into
consideration. Our work ​
critiques heterosexuality as taken-for-granted assumption in social
policies and public institutions such as​
the ​
healthcare system.
L​
ittle is known about the real experiences of lesbian-led families in healthcare, or perinatal
care, and also in relation to the welfare state institutions. Yet, ​
w​
hat makes research on
lesbian-headed families so important, is that these families deeply challenge the
heteronormative dominant discourses revolving around the institution of family. ​
Lesbian
health entails some issues that are different than heterosexual women’s standard healthcare
provision, and thus the system cannot provide comprehensive quality care to lesbian women
unless it considers the surrounding social and cultural frames that impact these individuals’
healthcare needs. ​
Moreover, since more prospective lesbian couples are seeking public
healthcare during their transition into parenthood, it is important that the service ​
develops
so that high quality care to lesbian parents is ensured.
In this study we will describe the healthcare experiences of lesbian mothers transitioning
into parenthood, with a specific focus on perinatal care. Our study is comparative by nature,
as we examine these experiences in parallel in both Finland and in Denmark. We focus
mainly on lesbian motherhood, as in case of lesbian mothers the transition to parenthood
involves more regular visits to public healthcare spaces and a wide range of encounters with
​
Morrison, Dinkel 2012; Heck et al. 2006; Foreman & Quinlan 2008; Short 2007; Röndahl et al. 2006; Westerståhl & Bjorkelund 2003 and Saulnier 2002. 1
4 professionals than ​
often in the case of gay fathers. Our research question is: what are the
experiences of lesbian couples in public healthcare when transitioning into parenthood both
in Finland and Denmark? We further divided this question into two sub-questions. First, are
the lesbian couples’ experiences in perinatal care atypical from heterosexual couples’
standard experience and what are the possible reasons that make their experiences
atypical? Second, do institutional differences between these two countries influence the
type of experiences these lesbian parents have in Finland and Denmark?
The reason we also elaborate on institutional structures and the institutional differences
between these two countries in addition to healthcare, or while describing the healthcare
experiences for these couples, is that we argue that these institutions influence the
healthcare experience for the lesbian parents. For example, the link between the
problematique of automatic parental recognition (i.e. adoption) and healthcare is that the
lack of equal and automatic legal entitlements to parenthood for Finnish lesbian parents
demonstrates how non-heterosexual families are incompletely institutionalized. It is an
example showing how this lack of institutional support for their family makes the family
atypical also in public healthcare space, and can consequently lead to atypical healthcare
experience. For instance, the lack of automatic recognition of the co-mother as a parent can
cause legal problems. Same might happen also in healthcare spaces when and if the second
parent is considered as a legal stranger to the child.
Our approach contributes to the understanding of heteronormative mechanisms in
institutions and provides insights into the unique relationships and interactions between
lesbian parents and nurses in the public healthcare spaces that are crucial point of contact
between these new mothers and healthcare structures. ​
By examining the experiences of
lesbian parents in public healthcare, we are able to detect ​
institutionalized heterosexuality
and heteronormative practices and further highlight the relevance of sexuality in analyzing
social welfare practice. Thus, we take part in the discussion of centering sexuality in social
policy analyses. Further, our analysis ​
contributes to existing literature in terms lesbian
experiences when transitioning into parenthood within public spaces such as hospital
environments. This study can provide useful information for further research, medical
professionals, educators, policy makers, hospital management to develop more sensitive
and inclusive policies and practices for LGBT families.
5 This thesis adopts qualitative methods because of the strictly qualitative nature of our
investigation, and because our aim is to give voice to vulnerable, marginal groups and to
raise issues, rather than to generalize our findings. ​
The primary data used for this thesis was
collected through eleven in-depth, semi-structured interviews with twenty women, ten from
Finland and ten from Denmark. All of these women were in a same-sex relationship, or had
been in one when they had children through assisted reproductive technology. The data is
analyzed by using Qualitative Content Analysis, and Constant Comparison is used as a tool
for comparing the two countries.
The body of theory we use has been elaborated several authors. First of all, ​
Carabine’s
(2001) notion of sexuality being regulated by welfare and social policy, which then exclude
those citizens’ who do not conform to the heterosexual norm, guides our analysis unveiling
whether lesbian women and their families are granted the same status as heterosexual
families on the field of legal rights and public healthcare provision. We also use the notions
of sexual citizenship elaborated by Richardson (1998; 2000a; 2000b) to interpret narratives
where the heteronormative foundations of citizenship deny lesbian mothers full citizen
rights and may cause exclusion especially in healthcare. We employ Hubbard’s (2001)
notions on the idea of citizenship linked to what is considered appropriate within particular
spaces. For instance, public perinatal care is located in highly heteronormative space and
thereby only heterosexual citizens are considered appropriate within that space. Thus,
lesbian mothers are not necessarily expected into that space, which can lead to invisibility
and to disrupting/queering the space by their presence.
We aim to discover whether these heterosexual expectations hold true for Finnish and
Danish lesbian mothers and whether they remain invisible and/or whether the way they
queer these public spaces have consequences to the quality of their care. Along these lines,
we also use queer theory in a similar manner as the notions on disrupting public spaces to
understand lesbian mothers experiences confronting heteronormativity, similarly to
Goldberg et al. (2011). Lastly, we use Cherlin’s (1978) concept of incomplete
institutionalization in a similar manner to Hequembourg (2004) as we use it to provide us
with tools for better understanding how same-sex families face unique challenges with
societal institutions due to their marginalized status and how they forge strategies that aid
them to overcome these challenges.
6 We conclude this first part, introduction, with an overview of how this paper is organized.
The second part presents the Institutional Background, consisting of insights of the public
healthcare systems and legislation in Finland and Denmark affecting the LGBT community.
The third part consists of the Literature Review and in the fourth part we present our
Theoretical Framework. The fifth part presents a comprehensive overview of the Data and
Methods we employed in this paper. The main part of this paper, the analysis, is presented
in the sixth part. It is organized by themes and in each of these we present our analysis and
findings first by country and then jointly in a short comparison of the findings between the
two countries. In part seven – the discussion – we discuss our results, also in the light of
previous studies, and present policy implications of our findings. The last and eighth part
consists of the conclusion.
2. Institutional Background
S. Sirkkala
In this part we present a general overview on the social policy issues affecting LGBT
minorities. Following this, we will briefly describe the basic public healthcare system and
maternity care in Finland and in Denmark and present the legal frame of the laws regulating
the lives of the LGBT individuals in these two countries. We consider it necessary to
understand how public policies and laws ​
constitute the national policy context and
institutions, such as the healthcare system, to also ​
understand the experiences of ​
LGBT
patients in public healthcare.
2.1.​
Social Policies and LGBT Minorities
S. Sirkkala
The arena of public policy is under constant changes and development. New laws are
steadily being developed, proposed, discussed and being voted on. Without question, many
of these policies and laws will affect the whole LGBT community. Unquestionably, public
social policy does not have to be specifically targeted to treat sexuality for it to involve
sexuality into the discussion and to regulate sexual relations and behavior. It can actually act
as means by which the appropriate sexuality and sexual relations, family and marriage are
spoken about (Messinger 2006, 427; Carabine 2001, 294, 310).
Based on a historical review of social welfare policy, there are four main stances on how
LGBT individuals have been approached based on conceptions of the LGBT minority as a
7 whole. First, ​
invisibility refers to way the existence of LGBT people have been refused to be
acknowledged publicly. The advocates for this approach argue that because LGBT individuals
are part of a small minority, they are not a significant enough as a group to be represented
or recognized in public policies. Second, ​
illegality covers the way both same-sex sexual
behaviors and blurring the gender lines (e.g. transsexuality, transvestism) have been
criminalized through history based on conception of LGBT individuals as ​
morally ​
distorted
and thus, as posing a risk to the society. Third, ​
separation consists of acts trying to remove
LGBT minorities away from the public sphere in order to protect the “greater good”. Fourth,
rehabilitation comprises of programs seeking to ​
mend ​
broken LGBT citizens. It relies on the
idea that LGBT people are suffering from a mental or physical illness meaning that they can
be somehow cured (Messinger 2006, 428).
The denial of citizen rights to sexual minorities can be traced to a social construction of
institutionalized heterosexuality and to norms and practices, whereby only heterosexuality
has been considered as natural, normal and moral sexual behavior. Thus, institutionalized
heterosexuality ​
has been used as justification for countless discriminatory laws and policies
against LGBT people and their families​
. In essence, the social construction of institutionalized
heterosexuality is being constantly produced through these very policies and laws that
establish hierarchies and power relations in the society (​
Richardson 2000b, 111; ​
Cahill et al.
2002; ​
Lind 2004, 32).
Most social welfare policies such as public assistance, employment, child welfare and health
services have a profound impact on the lives of LGBT individuals and their families even if
they are not explicitly targeted to this minority group. Yet, especially public policies such as
family policies affect LGBT individuals, their own and their families’ security and wellbeing
throughout their lives irrespective of the fact whether these policies have indeed been
designed bearing the LGBT minority group’s needs and rights in mind or not ​
(Messinger
2006, 447; ​
Cahill et al. 2002​
). Both the lack of regulation affecting LGBT citizens and the
existence of regulations and policies excluding them can influence LGBT individuals.Indeed,
Social welfare and public policy decisions will affect the LGBT community either directly or
indirectly. They can be directly discriminatory in case when LGBT people are being treated as
different or even inferior to other citizens. As an example, explicitly promoting the rights of
heterosexual nuclear family leads to ​
ignoring the needs of nonconforming LGBT families.
Discriminatory social policies can also be indirect when the policies ignore the ways in which
8 the individual’s sexual orientation affects his/her life (Messinger 2006, 457). For example
when considering a lesbian-headed family, not granting the co-mother an automatic legal
entitlement to parenthood straight from the birth is an indirect discriminatory policy.
Many civil rights rights and obligations of individual citizens are grounded in sexual relations
and partnerships. Furthermore, the history has proven how the ​
idealized coupledom, due to
institutionalized heterosexuality, is and has been a heterosexual marriage (Richardson
2000b, 123). Indeed, ​
promoting the family unit and giving special priority to the family bond
between family members is a goal onto which a lot of public policy bases on. Therefore,
definition on the family ​
is especially important as the family unit is such a central component
of the policies and laws that dictate and regulate our daily lives. However, many of the
public policies have historically been based on a narrow definition of family encompassing
only the family ideal led by a heterosexual married couple, e​
xcluding sexual minorities by
not granting them the same rights (Richardson 2000b, 123).
LGBT ​
individuals pursue different paths to parenthood than heterosexual couples.2
Evidently, due to more complicated family structures and while laws and policies designed
for married heterosexual families, LGBT families’ situation is significantly complicated by the
lack of many of the protections that others are privileged to have (Cahill et al. 2002, 68).
Nonetheless, the legislative authority should represent all the people equally and that is why
it should adopt policies which reflect the needs and rights of all.
3
In order for the LGBT
individuals to have full citizenship rights, the lesbian and gay rights movements have
demanded public and social recognition of their rights and institutional support to acquire
social legitimacy and to validate their relationships and families (Richardson 2000b,
120–126).
2.2. Legal Development of LGBT Rights in Finland and Denmark
B. Carraro
This section sums up the milestones in the development of LGBT rights and family policies
affecting LGBT people in Denmark and Finland, from recognition of same-sex relationships to
reproductive rights. In the following chapter we will outline the key moments legal
​
For example, some have biological children from heterosexual relationships, through fertility treatments or through
adoption. Some also involve more than one household by creating other co-parenting arrangements.
3
​
As a matter of fact, LGBT activists have been demanding equal rights (not special or ​
partial ​
rights) and equal recognition in
social welfare policies for a long time (Messinger 2006, 428). 2
9 development of the both countries, Finland and Denmark, which have come to force within
the last half century in Denmark and Finland. ​
The reader can find information about
parenthood options for male same-sex couples in Annex 3. In this section we will mainly deal
with assisted reproduction possibilities in Denmark and Finland, given that all couples of our
sample had children by those means, and with laws that regulate co-mothership in both
Finland and Denmark. Other than in this section, some legal aspects for lesbian families are
also discussed in the analysis.
2.2.1. From Decriminalization to Anti-Discrimination
B. Carraro
Medicine’s historical view of homosexuality as a mental disorder and the resulting
heterosexism can be seen to have a role in historically maintaining and justifying
homophobic and heteronormative attitudes in the society (Christensen 2005). In Denmark, a
1683 law stating that homosexuality between men was a crime was in force until 1930. It
took until 1933 for the decriminalization of homosexual acts, and until 1981 for
homosexuality to be deleted from the official national list of diseases (LGBT Denmark 2015)​
.
In Denmark, i​
ncitement to hatred based on sexual orientation was prohibited 1987,
prohibition of discrimination in employment based on sexual orientation has been in force
since 1996 and hate crimes based on sexual orientation have been considered an
aggravating circumstance since 2004 resulting in higher sanction (Ilga 2013b).
In Finland the law criminalizing homosexual acts came into effect 1889 and was in force until
1971, but at the same time encouraging homosexual acts was criminalized. Only after the
year 1981 homosexuality was deleted from the official national classifications of diseases
(SETA 2015). ​
In Finland the decriminalization of homosexuality has led the way to more LGBT
inclusive laws. In 1995 discrimination on the basis of sexual orientation was prohibited, and
in 1999 the Criminal Code was revised and the prohibition of promotion of homosexuality
was removed. In 2015, the newest Non-Discrimination Act was adopted, prohibiting direct
and indirect discrimination and harassment based, among others, on sexual orientation,
gender identity and gender expression (SETA 2015).
2.2.2. Registered Partnership
B. Carraro
10 In 1989 Denmark was the first country in the world to introduce Registered Partnership,
followed by Norway in 1993, Sweden in 1995, Iceland in 1996 and Finland in 2001 (Carbin et
al. 2011).4 T​
he Finnish law on registration of registered partnership adopted in 2001 came
into force in 2002, and has the same legal effects as marriage, but with several exceptions:
registered partners not obtain a common last name automatically, but they have to apply
and pay for it, they have to apply for stepchild adoption and joint adoption is not possible
(Finlex 2015a). ​
Even though registered partnership laws were approved in strive for equality
in both countries, they have only formalized the differences in the treatment received by
hetero- and homosexual couples. This created a de facto ​
second-rate citizen status that did
not include reproduction and parenthood rights for same-sex couples, because they were
deemed as unfit to become parents and their families were classified as unsuitable.
Registered partnerships, parallel to recognizing some rights similar to marriage, reinforces
the heteronormative family model as the norm (Carbin et al. 2011, 60). After this and similar
debates prevailed, long after the approval of civil partnerships in the two countries, equal
marriage laws got approved by the national parliaments.
2.2.3. Equal Marriage
B. Carraro
On 15th of June 2012 Denmark was the eighth country in Europe to pass a law allowing
same-sex marriage and is currently also one of the few countries allowing same-sex couples
to get married in the state church (Rolandsen Agustin 2015; Ilga 2013).5 In Finland, the
citizen’s initiative for equal marriage ​
was passed by the parliament in December 2014 and
the president signed the law on 20th of February 2015 (Tahdon 2013). ​
At the time of writing
this thesis, the equal marriage law is not yet in force, but it is scheduled to become effective
from March 2017.6 ​
The proposition for the equal marriage law in Finland includes provisions
such as: right to apply for joint adoption, right to second-parent adoption to be in effect
straight after birth, automatic right to acquisition of spouse’s surname without having to
apply and pay for it (Tahdon 2013).
​
In Denmark the Registered Partnership Act included the right to stepchild adoption, whereas joint adoption has been
made legal in 2009 for couples in a registered partnership (Carbin et al. 2011). 5
​
Equal Marriage Law overruled the previous law on Registered Partnership, but left those couples that registered under
​
the previous law the freedom to choose whether to convert their partnership into a marriage or not. 6
​
As for Denmark, the new law will allow registered partners to decide whether to change their registered partnership into
marriage or to leave it as it is. 4
11 Striving for marriage equality is an endeavor to achieve equality, public normalization and
privacy at the same time. Being able to marry allows a person in a committed same-sex
relationship to be able to appear in forms or registries as ​
married and not ​
in a registered
partnership​
. This means that, in practice, people will no longer be able to tell if that person is
in an opposite-sex or same-sex relationship. This allows people in a same-sex relationship to
regain the discretional power to decide whether and when to disclose sexual orientation. To
strive for equality at the legal level also means to strive for normalization of same-sex
relationships and their families in public spaces. The legal recognition of same-sex
relationships on the same stand of heterosexual relationships is especially important for
LGBT people to protect their children through the establishment of legal parental rights for
both parents.
2.3. Healthcare in Finland and in Denmark
B. Carraro
In the Finnish healthcare system, it is the responsibility of the municipalities to arrange and
fund healthcare services (through taxes). In general terms, Finland has a wide range of
healthcare organisations, that provide services both free of charge and for a fee. The Finnish
municipalities can provide basic healthcare services alone, or jointly with other
municipalities or purchase them from, for example, private service providers. Moreover, the
health services are divided into primary healthcare, municipally arranged, and specialized
medical care, performed in hospitals. Additionally, private companies provide services
alongside the public sector and they supplement municipal services (Ministry of Social
Affairs and Health 2015). Denmark has an extensive public healthcare system in which all
legal residents are automatically enrolled once they register and get a health insurance card
from the municipality. Danish healthcare system is funded from taxes. Most health services
such as visits to general practitioners, private practice specialists or hospital treatment are
free at point of contact, while the cost of dental treatments and medicines are only partly
state-funded (Lifeindenmark 2015).
2.3.1. Fertility Treatments
B. Carraro
Public healthcare staff, including midwives and nursing staff in maternity care clinics,
encounter increasingly more future lesbian parents today than before and the numbers are
12 expected to rise as new laws facilitating same-sex parenthood for women are being
approved.
ART was introduced for everyone in Denmark in the beginning of the 1980s and are
regulated under the Act on Assisted reproduction (Ingerslev et al. 2005; Sundhed DK 2015).
However, a bill on medically assisted reproduction passed in 1996, forbidding to lesbian and
single women to be treated in public fertility clinics. The ban allowed doctors to treat only
heterosexual couples in a marriage-like relationship (Bryld 2001). Although doctors were
forbidden to provide ART to lesbian and single women, a loophole in the legislation implicitly
allowed midwives to continue to do so (Carbin et al. 2011). As a consequence, a few private
clinics managed by midwives were put up to help lesbian couples and single mothers to
conceive. In 2006, the Danish ban on ART for lesbian and single women was lifted and
women were granted access to publicly financed reproductive treatment irrespective of
their civil status or sexual orientation (Jeppesen de Boer & Kronborg 2011). From 2011, all
childless people had to pay for fertility treatment as a consequence of a spending review bill,
but already in June 2012, free, public fertility treatments were reintroduced with the
government change and the new law on ART (Carbin et al. 2011; Damløv, and Nørregaard
2013; Ilga 2013). Currently, in Denmark, state-subsidized ART (Assisted reproductive
technology) is only offered for one child and only with anonymous donor.
In Finland, the 2006 law on fertility treatments entitles also female couples to receive
assisted reproduction – after psychological assessment and if the donor has chosen to
donate also to same-sex couples. However, ​
the law does not ​
compel fertility clinics to
provide treatment to same sex couples and thus, ​
the final decision whether to treat or not
to treat women in same-sex relationships is left for each clinic to decide for themselves,
depending on their working principles (Aarnipuu 2010, 11; ​
Finlex 2015). Public, free fertility
treatments are provided only in case of diagnosed infertility ​
(which would be ​
rare
occurrence for a female couple) ​
and with the couples’ own gametes, which naturally
excludes same-sex couples ​
(YLE 2012). In conclusion, lesbian couples are compelled to seek
treatments from private clinics and where they can get donor gametes – and pay for the
treatments themselves. That can pose evident economic challenges for the couples and act
as a hurdle keeping them from becoming parents (Miettinen 2011, 7–8). Yet, the ​
Action Plan
of the Finnish National Institute for Health and Welfare for 2014–2020 affirms that the
promotion of sexual and reproductive health should create an equal footing according to the
13 individual needs of the patient regardless of, for example, sexual orientation (THL 2014b,
22).
2.3.2. Perinatal Care
B. Carraro
In Denmark, maternity care is offered only in public hospitals as there are no private
maternity clinics, thus, meetings, counseling and prenatal examinations are provided for
free. It is the GP’s (general practitioner) responsibility to confirm the pregnancy and refer
the pregnant woman to a midwife. The routine prenatal care schedule recommended by the
government includes a minimum of nine checkups for all pregnant women, which include
both visits to their midwife and their GP. After the birth a health visitor or nurse
(​
sundhedsplejersken​
) is responsible for postnatal care. Most of the prenatal consultations
are carried out by a midwife and arranged in individual or in group meetings. Aside from the
standard individual prenatal care, midwives also teach in antenatal classes offered to
prospective parents in public hospitals to learn about pregnancy and birth (Angloinfo 2015).
In Finland, maternity care is also part of free public healthcare including advice on birth
control, maternity and child health clinic services for pregnant women and expectant
families as well as for children under school age and their families (Finlex 2014). The Finnish
Primary Health Care Act regulates maternity care: the municipality needs to arrange one
broad medical examination for the pregnant women and her family and three
comprehensive medical examinations in the child health/welfare clinic (THL 2014a).
Throughout their pregnancy, Finnish women will refer to a maternity clinic where they will
have the necessary appointments and checkups with a midwife, or a public health nurse, and
a physician. More specifically, public maternity care consists of visits from the beginning of
the pregnancy to up to 12 weeks after the birth, although patients can also choose to attend
pregnancy follow-up visits in private clinics. Both Finnish and Danish healthcare centers offer
family coaching to prospective parents. These voluntary coaching classes are designed for
anyone expecting a child, and their aim is to support future parents and to strengthen the
child-related knowledge of the parents.7
7
​
In Finland, family coaching is also organized outside the public healthcare institutions by, among others, ​
The Rainbow
Families​
, a voluntary association supporting LGBT parents and their children (Rainbow Families 2015). 14 Healthcare professionals’ interaction with patients has a major impact on the overall
healthcare experiences and actual well-being of their patients, especially in vulnerable
moments such as pregnancy and childbirth. In fact, according to the general ethical
guidelines in nursing, it is important that the patient is treated with respect and that their
private life, human rights and human dignity are not violated. Inherent to the code of ethics
in nursing is that the nursing care is unrestricted by considerations of, among others, gender
and sexual orientation, in order to ensure high quality and appropriate care for all patients.
This can be ensured, on behalf of the healthcare professional, by for example not deriving
any assumptions based on patient’s appearance or based on social norms, and by not
allowing anything related to individual’s characteristics affect the care. All in all, the nurses
share the responsibility with the society to meet the health and social needs of the public,
but especially those of vulnerable populations, such as sexual minorities (ICN 2012, 1).
2.4. Parents’ Rights and Second-Parent Adoption for Lesbian Couples
B. Carraro
In Denmark, if a person in a same sex relationship has a biological child, and the partner
wishes to have parent rights and duties, he or she can do so through the so-called ​
stepchild
adoption​
, which is classified by the state under the broader term ​
adoption of relatives
(Statsforvaltningen 2013). ​
Since 1999, ​
under the civil partnership law in Denmark, ​
a person
in a same-sex registered partnership has been able to adopt his or her partner's biological
children through stepchild adoption​
, if the couple was registered, and that used to be the
only option for co-mothers before new laws got approved ​
(Kronborg 2012)​
. Non-biological
mothers could only apply for adoption three months after at the birth. Among all related
concerns is also that the three month wait would not allow co-mothers to have the two
weeks of ​
paternal leave​
, since those weeks have to be use ​
within the first three months after
the birth. In 2009 this legal drawback was fixed and stepchild adoption was made possible
even before the usual minimum of 3 months from the birth of the child, if the registered
partners are cohabitants and if the reproduction has been performed with anonymous
donor (Jeppesen de Boer & Kronborg 2011).8
8
​
In Finland and in Denmark remunerated parental leave systems are part of national family policies and they are
state-subsidized, consisting of three parts: maternity leave, paternity leave and parental leave. The first two parts of the
leave are earmarked respectively for the biological mother and the father, or co-mother. After that, parents can choose
freely how to split the remaining parental leave regardless of their gender, as well as some additional weeks of leave
without economic compensation (Rolandsen Agustin 2015, 15; Salmi & Lammi-Taskula 2015). Since September 2010 in
Finland, co-mothers have been able to receive paternal leave if they have legally adopted the child and live in the same
household as the biological mother (Kela 2015). As for Denmark, in January 2013, the non-governmental organization LGBT
Denmark was appointed to a governmental working group that was assigned the task to reform parental leaves. In the end,
15 In 2013, after equal marriage was approved, ​
second-parent adoption was introduced within
a reform of the Children’s Act. The reform grants both members of the couple, regardless of
their gender, automatic parent status recognition from the birth, when their child is born
through ART (Ilga 2015). Implementation of second-parent adoption is crucial for
co-mothers, as it grants parent status from the birth, unlike stepchild adoption, allowing
co-mothers to benefit from the ​
father’s leave​
(Statsforvaltningen 2015b).
On 1st of December 2013, another amendment was introduced in the Children’s Act, this
time regulating on known donors. The new provision allows a woman, her female partner
and a man can make a binding decision, before conceiving a child, on which will be the
second parent among the non-biological mother and the biological father. Yet, the law still
does not allow for a child to have more than two parents, meaning that the third parent will
still be a legal stranger to the child (Ilga 2014; Statsforvaltningen 2015). ​
The amendment to
the Children's Act in force since 1st of December 2013 applies only to children conceived
through ART after that date. Because some of the Danish couples in our sample conceived a
child before that date, it is important to report the old rules that still apply to them. If the
couple had a known donor, he could claim his paternal rights and be legal parent straight
away or, if he did not, the child would have only one legal parent for two and a half years,
until the co-mother could apply for stepchild adoption.9 If instead the donor was
anonymous, in order for the co-mother to have legal parental rights from the birth of the
child, she would have to fulfill the following requirements: she and the biological mother had
to be living together at the time of the conception, being registered as civil partners or
spouses a certain number of weeks before birth, the birth mother would have to declare
that the father was unknown (even though it was an anonymous donor, this was a
mandatory step) and that she consented to the co-mother's adoption, strictly within three
months after the birth. If one of these requirements was missing, they would have to wait
two and a half years to adopt, and would have to go through the more complicated
procedure of stepchild adoption (​
Statsforvaltningen 2015).
the government decided against modifying parental leave rules, and since then, co-mothers get the same share as fathers
(Ilga 2014).
9
Stepchild adoption could start only ​
after two and a half years of cohabitation with the child.
16 Further amendments to the Children’s Act were introduced in January 2015, to ensure
co-mothers the same legal stand as fathers by becoming legal parents at the birth of their
child, regardless of their marital status (Ilga 2015; Rolandsen Agustin 2015). Whether the
treatment is carried out in public or private clinics, co-maternity can be obtained only if two
women have a child together through ART performed by a healthcare professional or under
a healthcare professional’s responsibility. The future co-mother has to give written consent
to the healthcare staff before the fertility treatment begins, and if the donor is known, he
must also provide written consent in advance (Statsforvaltningen 2015).10
In 2009 in Finland, a law came into force that made internal adoption for registered
same-sex couples possible when one of them gives birth to a child (SETA 2015; Finlex
2015b). This law is especially important for lesbian couples forming a family, when both
partners wish to be recognized as legal parents of their child/ren. The reality, as it is now for
female same-sex couple​
s, is that they are always compelled to pursue internal adoptions
due to the fact that the partner of the biological mother does not automatically have a legal
entitlement to parenthood. Before the adoption, the biological mother has to give her
consent to proceed with the adoption.11 Due to this, internal adoptions are essential in order
to have the children’s rights and security ensured. In order to achieve all this, it is essential
for the parents to have their relationship first legally recognized (Cahill et al. 2002, 78–80).
As a matter of fact, these internal adoptions are possible for only registered same-sex
couples in Finland and in Denmark.
In Finland, a precondition for adoption is that parties undergo adoption counseling
consisting of meetings and interviews, one to three office visits and a home visit after what
officials write an assessment statement to “establish the suitability” of the adoptive parent
(i.e. co-mother). This service is provided either by the social services department of the local
municipality or in the regional office of for example organizations such as ​
Save the Children
Finland (Save The Children 2015). Depending on the municipality, practices can slightly vary
from one or two meetings with an adoption counselor and in case whether home visits are
issued or not. The length of this process is counted in months. It is an easier process than
external adoption. Moreover, starting the internal adoption process is possible before the
10
If the couple wishing to go through fertility treatments is not married, in order for the co-mothership to be effective in
time, the State Administration just recommends that the future mothers submit a consent form from the donor (if known)
and a ​
care and responsibility declaration​
or recognition of co-mothership two or three months before the expected due
date (Statsforvaltningen 2015).
11
In contrast, husband in a similarly-positioned heterosexual married couple would be automatically considered as the legal
parent – even if he would not be the child’s biological parent.
17 birth only if the couple has registered their partnership before the conception of the child.
Unless they have done so, the internal adoption process includes a reflection period of 8
weeks given for the biological mother to reflect upon the decision. In detail, the couple can
sign up for adoption counseling in advance and to go through some of the proceedings
already before the birth of the child to fasten the adoption process. Yet, finalizing the
adoption is ​
only possible after the birth and it is most likely to be extended to several
months. Again, the length of the process varies depending on the municipality (HEL 2015a;
Finlex 2015c).
If the couple conceives a child with a known (possibly involved) donor the adoption process
if further extended in order to hear all the parties involved and to clarify all the legal aspects
related to the adoption. If the couple instead conceives in a clinic with the help of an
unknown donor, the female couples have to sign a document prohibiting public officials to
clarify the paternity of the child – although they could not, even if they wanted. As a matter
of fact, though the mothers are not entitled to know the identity of the donor, his identity is
never completely anonymous.12 Children conceived in fertility clinics with the help of a
donor have the right to obtain information on their donor’s identity when they turn 18, but
this right is not granted to the mothers (HEL 2015a; Finlex 2015c).
In conclusion, though Denmark and Finland implemented laws providing a foundation for
the recognition of family units of same-sex couples, there are still significant disparities
between these two Nordic countries and despite these legal changes, ​
public policies
concerning marriage, family and healthcare are significantly influenced by Western culture’s
concepts of gender, sexuality, and parenthood (Golding 2006, 37). ​
Denmark and Finland can
still be described in some ways, but to different extents, as heteronormative societies that
encourage and support heterosexual parenthood and where heteronormativity is
institutionalized in public spaces (Kulick, 2005; Ryan-Flood, 2009). Overall, ​
the most
important b​
aseline differences between the two countries affecting the couples in our
sample are: the possibility to get married only in Denmark (until 2017), whereas registered
partnership is the only option in Finland, second-parent adoption from birth possible only in
Denmark, while in Finland couples have to bear a waiting time after the birth, couples still
need to be registered in order to have right to stepchild adoption.
​
Although the possibility to use Finnish anonymous donor sperm does not exist in Finland, a loophole in the legislation
allows Finnish fertility clinics to obtain gametes from foreign sperm banks which indeed have anonymous donors. 12
18 3. Literature Review
S. Sirkkala
The following literature review consists of five different subheadings. These are the themes
under what we have grouped relevant studies in the field based on their findings. In the first
section, we present the studies presenting findings of positive and negative experiences in
the healthcare context and studies focusing on what sort of emotions and attitudes are at
stake in the healthcare experiences of individuals that are a part of sexual minorities. In the
second section, we consider studies that linked their findings regarding the healthcare
experiences of lesbian women to institutionalized heterosexuality and heteronormativity.
The theme we introduce in the third section deals with disclosing sexual orientation during
medical checkups, which is strictly linked to the invisibility of LGBT patients. In the fourth
part, we summarize articles explaining what kind of challenges LGBT patients meet when
seeking healthcare. The fifth section deals with the theme incompletely institutionalized
status of same-sex families. In the final part, we shortly summarize the designs and findings
of the previous literature.
All in all, there is a constantly growing body of literature describing the experiences of
lesbian women in healthcare and in maternity care and their encounters with professionals
within sociology, psychology and nursing (e.g. Goldberg et al. 2009; Goldberg 2011; Wilton &
Kaufmann 2001; McManus et al. 2006; Larsson & Dykes, 2009; Lee et al. 2011; Röndahl et al.
2009). This master’s thesis builds on the previous research investigating the experiences of
lesbian women when accessing healthcare and heteronormative communication with
lesbian parents over the transition phase into parenthood (e.g. Röndahl et al. 2009, Wilton &
Kaufmann 2001). In general, our overview of previous research presents a contradictory and
multifaceted picture. On one hand, several studies report exposure to homophobic,
judgemental and condescending attitudes (e.g. Lee et al. 2009; Röndahl et al. 2009), but on
the other hand other studies accounted experiences of respectful care from competent
healthcare providers (e.g. O'Neill et al. 2013; Malmquist & Zetterqvist Nelson 2014).
3.1. Positive and Negative Experiences in healthcare
S. Sirkkala
Goldberg et al. (2011) ascribe lesbians’ experiences within healthcare environments when
giving birth. The authors use an experiential methodology, queer orientations and
19 phenomenological framework to bring complex prejudices into light and show how
non-normative bodies can make others, the healthcare professionals, uncomfortable. The
study focuses on birthing space, because it is often considered a heteronormative and
homophobic scene among various healthcare practices. From their sample of 12
participants, seven were childbearing lesbian couples and five perinatal nurses. They all
participated in phenomenological interviews where the lesbian couples reported their
relationships with perinatal nurses, while the perinatal nurses reported their experiences of
working with these lesbian couples. Through phenomenological analysis, the authors found
that the lesbian couples had generally positive expectations regarding the events and
behavior of the professionals in their future birthing experience. Yet, feelings of gratitude for
good quality treatment the patients received, were not interpreted as positive experiences,
because in this case, it revealed that the patients had originally negative expectations, due
to their vulnerable position as being part of a minority.
The healthcare professionals remarked how the presence of lesbian mothers “interrupted”
them and made them “break their habits” and thereby, made them feel insecure about how
to react and respond to their presence. Goldberg and colleagues argue that explicitly noting
the presence of lesbian patients reveals the default status of the heterosexual couple in the
birthing space. Furthermore, the lesbian mothers raised a concern of how it can be possibly
even dangerous for them to “disrupt spaces”, if it means that their well-being might be
compromised in the case of making the birthing spaces uncomfortable for the healthcare
professionals (Goldberg et al. 2011).
Similarly to Goldberg et al. (2011), the qualitative and exploratory study by Lee et al. (2011)
also adapts phenomenological framework in order to analyze lesbian women’s experiences
through ​
what is said and ​
how things are said. As many articles show both positive and
negative experiences, the authors naturally interpret the findings depending on their chosen
theoretical or methodological angle. In this article the authors analyze the lesbian women’s
experiences with a special focus on interpretations of negative experiences, and on how the
respondents were inclined to interpret those experiences. This small-scale bases its findings
on data from unstructured interviews with eight lesbian women. These interviews were
interpreted with the help of an iterative hermeneutic framework.
20 In this study, the research subjects generally described their experiences of maternity care
as positive, but they also offered examples of negative experiences. These negative
incidents, which the women attributed to their sexual orientation, were analyzed separately
in order to find how the women understood them. Lee and colleagues found that the lesbian
women handled the negative experiences in a way that helped them to retain their overall
experience as positive by rationalizing and reinterpreting them. This was done by reassuring
oneself that the incidents were related to other factors than sexual orientation. The findings
suggest that here were evident aspects of homophobia in the patients’ experiences, but the
participants did not agree to recognize them as such even though they knew, saw, and heard
of homophobic practices (Lee et al. 2011).
Röndahl and colleagues (2009) revealed similar findings in their study, as their interviewees
seemed to be inclined to explain negative experiences with poor personal chemistry rather
than with homophobic or discriminatory attitudes towards lesbian patients. Their
qualitative, small-scale interview study with ten lesbian mothers, concerning perinatal care
in Sweden revealed that the lesbian women had mostly positive experiences in the
healthcare services. For example, the respondents found that the midwives’ overall
response towards them was friendly even though they might have reacted to them with
surprise. The prospective parents considered it important that the midwives communicated
acceptance by acknowledging also the co-mother’s presence and role just as they would do
with a father. However, when encountering negative experiences, the respondents
rationalized them as being more likely to be related to personality clashes rather than to
homophobia or negative attitudes towards sexual minorities. Furthermore, all of the
participants of this study expressed anxiety about coming out to their healthcare provider
(Röndahl et al. 2009).
In psychology, a rhetoric mechanism, minimization involves denial and rationalization. It is a
strategy of downplaying the significance of accountability, events or emotions. Minimization
can be a way to rationalize or sustain an experience in order to see it in a more desirable
way (Scott & Strauss, 2007). Along the lines with the previous studies by Röndahl et al.
(2009) and Lee et al. (2011), Malmquist and Zetterqvist Nelson (2014) found that negatively
framed encounters were usually presented by the respondents in a rhetorical manner
minimizing their impact. This study gives special focus to the ways the interviewees talked
about themselves, including variations and contradictions in the talk, and analyzed the talk
21 through a lens of critical discursive social psychology. Furthermore, the authors employed
interpretative repertoire as their analytical tool.
During the 51 semi-structured parent interviews with 96 lesbian mothers regarding
encounters with healthcare professionals, the participants were encouraged to tell their
family narrative. The authors found two separate and contradictory repertoires: the “just
great” and the “heteronormative issues” repertoire. According to the authors, the
predominating and recurrent “just great” accounts had a normalizing function for lesbian
mothers. Although the interviewees mainly depicted their journey towards parenthood as
positive and uncomplicated, they also depicted meetings with the professionals and
treatment as problematic and as inadequate. This “heteronormative issues” repertoire
consist of accounts when the interviewees reported encountering uninformed professionals
who lacked specific knowledge about lesbian families and of notes about not receiving
treatment equivalent to heterosexuals or treatment adapted to lesbian families’ needs.
In addition to these studies, in order to acquire more comprehensive depiction of these
positive and negative healthcare experiences, and to provide possible reasons that might
explain them, we also include two studies from the point of view of professionals by Röndahl
et al. (2004a & 2004b). These two studies recount valuable information about the emotions
of healthcare professionals towards lesbians and gays in Sweden. The first study (Röndahl et
al. 2004a) analyzes a possible link with cultural background and gender with emotions
towards homosexual patients, and how the nursing staff and nursing students would act if
the option existed to refrain from nursing homosexual patients. The findings of the first
study show that both professional nursing staff and the nursing students, exhibited various
emotions such as homophobic anger, guilt and delight. A staggering 36% of the nursing
professionals (nurses and assistant nurses) stated that if they could, they would avoid
nursing for homosexual patients, while for students, the corresponding number was only
9%. The authors of the study explain the notable difference between the groups by
speculating that the negative attitudes might reflect the lower level of education and
personal experience of the assistant nurses with homosexual people. Furthermore, they
found that cultural background plays a role as homophobia was expressed more in groups of
non-Swedish cultural background.
22 Even though the prominent findings showed a high percentage of homophobic emotions,
Röndahl and colleagues also report positive attitudes in the accounts of the nursing staff
stating that all patients have the right to good care irrespective of their sexual orientation. In
continuation with the exploration of the healthcare staff emotions, the second study
(Röndahl et al. 2004b) focused on the healthcare staff's opinions about the causes of
homosexuality by investigating their beliefs about the causes of homosexuality. They found
that the most positive attitudes were expressed by the nurses, whom believed that
homosexuality was congenital, and the least positive attitudes were expressed by the
assistant nursing students.
Overall, according to the findings from the literature, the encounters between lesbian
women and healthcare professionals have been found to be potentially hindered by the
professionals’ homophobic attitudes. At the same time the response of the lesbian women
was often to minimize those negative behaviors or attitudes in order to maintain the overall
experience as positive. Many lesbian patients expected good quality treatment, but at the
same time they were later on grateful if they actually received the expected treatment. Also
the fact that professionals remarked how they were interrupted and how they were insecure
when treating lesbian patients, highlights the strength of the professionals’ assumption that
all patients are heterosexual.
3.2. Institutionalized Heterosexuality and Heteronormativity in Healthcare
S. Sirkkala
This second section covers studies in the field that found that the presence of
heteronormativity and heterosexism were important elements affecting the lesbian
women’s experiences in healthcare services. First, however, we introduce the conceptual
framework regarding heteronormativity and heterosexism.
Heteronormativity includes the institutions, practices, and norms that support
heterosexuality (especially monogamous and reproductive) and subjugate other forms of
sexuality, especially homosexuality (Martin 2009, 190). Heteronormativity covers the ways
heterosexuality is privileged, superior and considered everyday as the normal and natural
way of life. It can be understood in the light of compulsory and standardized
institutionalization of heterosexuality when heterosexuality is considered as the default for
legitimate and expected social and sexual relations. This normative organization of
23 heterosexuality sets the standards for ​
normal in the social, economic, cultural, and political
fields (Davis et al. 2006b, 14). Heteronormativity occurs when only heterosexual
relationships are considered as possible options as this is the social norm. This social
norming of heterosexuality as normal and natural starts in a young age and is
institutionalized by for example the home setting, school, church, media and state laws
(Martin 2009; Davis et al. 2006b). Thus, the social and legal structures are designed and
maintained to support the predominating, socially, culturally and politically privileged, and
institutionally valorized heterosexual relations (Perlesz et al. 2006; Carabine 2001, 308).
Davis et al. (2006b) argue that elemental to the institutionalized heterosexuality is the belief
system and its ideological framework of heteronormativity, which is the prevailing paradigm
in the whole Western society. When heterosexuality is taken for granted, it is normalized
and established as the legitimate social and sexual behavior. It is then assumed as the
default for all people. When this heterosexual assumption is reinforced by the highest
authorities of our society through heteronormativity, it becomes institutionalized. However,
it is important to notice that this institution of heterosexuality is indeed ​
socially ​
constructed
and it is produced through policies and laws, cultural and religious practices and the
educational system (Lind 2004, 32).
In addition to heteronormativity, the literature also uses the term heterosexism. However,
the difference between these terms is occasionally blurred, which is why we will use the
terms as the original authors used them – sometimes interchangeably. Nevertheless, in our
analysis we will use the term heteronormativity, as we will focus more on the
heteronormativity embedded in the institutions reflecting into heterosexist practices.
Heterosexism is a belief or an assumed norm about heterosexuality, meaning that everyone
is – or should be – heterosexual and that heterosexuality is superior to and preferable to
homosexuality by nature. Following this, alternative sexual orientations are deemed as
unnatural, lesser or somehow wrong. Predecessors to heterosexism are a the binary gender
system that categorizes gender into two categories of male and female, heteronormativity,
homophobia, and the heteronormative political power structure (Martin, 2009). That is to
say that in order for heteronormativity to render into heterosexism, there is a need for the
dominant group to have the political and legal authority and resources. Only then
heteronormativity can turn into heterosexist societal laws and policies – also influencing the
24 healthcare system (Morrison & Dinkel 2012, 128). At the individual level heterosexism is
reinforced by behaviors that include for example social exclusion and discrimination by the
dominant group. Furthermore, these heterosexist norms can also be extended into the
understanding of the preferred family structure of two parents from the opposite sexes
(Brown et al. 2009, 230–1).
In healthcare when only the heterosexual population’s needs are taken into account, the
healthcare services provision can be limited due to heterosexism (Herek et al. 1991).
Examples of heterosexism exist in large amounts in healthcare, but it is important to notice
that discriminatory heterosexual assumptions can be deliberate or unconscious.
Heterosexist discrimination occurs unintentionally when it is caused by a lack of awareness
that LGBT people exist among the patients13 . Thus, LGBT individuals often face the
assumption that they are heterosexual unless they state otherwise and come out. These
heterosexual assumptions and social exclusion can limit the possibility to gather the
necessary and correct medical information and thus, negatively impact the healthcare of
LGBT individuals (Saulnier 2002; Röndahl et al. 2006; Morrison & Dinkel 2012; Trettin et al.
2006).
The themes of heteronormativity, heterosexism and homophobia are constant throughout
the literature. Westerståhl and Björkelund (2003) focused in particular on the relative
invisibility of lesbian women in their qualitative study to further understand the mechanisms
of heteronormativity in medical practices. More specifically, they investigated general
practitioners’ (GP) awareness of having lesbians among their female patients. Ten GPs
volunteered to participate to this study and to loosely structured interviews organized in
focus groups. The findings of this study suggest that some physicians who were making
heterosexual assumptions about their patients were doing so even though they regarded
themselves as open-minded individuals. Only few GPs were aware of any lesbian women
among their patients. Thus, although the physicians generally assumed that their patients
have a traditional heterosexual family arrangement, this study suggests that making
heterosexual assumptions does not necessarily imply that an individual has an openly
homophobic attitude. In addition, the GPs further commented how they believe it is the
13
Fo​
r example, when acquiring demographic information from patients and providing only certain kind of options in the
check box forms, or when the nurses routinely ask sexually active lesbian patients about their chosen method for birth
control.
25 patient’s responsibility to correct the healthcare provider if the heteronormative assumption
is ​
not​
correct (Westerståhl & Björkelund, 2003).
The study by Hayman et al. (2013) bases its findings on qualitative data about experiences of
lesbian mothers. Fifteen self-identified lesbian participated in the study using story-sharing
method, in-depth semi-structured interviews and journaling. From the constant comparative
analysis of the data, the researchers found that participants of the study experienced
differing forms of homophobia within the healthcare services.14 In detail, Hayman and
colleagues found that the co-mothers did not feel acknowledged as legitimate parents,
which even blocked their access to some procedures in the hospital. Also the heterosexual
assumption was frequently evident in the heteronormative language of healthcare forms
and promotion materials, which made participants feel self-conscious (Hayman et al. 2013).
The sometimes exceptional situation of encountering a lesbian couple in maternity
healthcare services quickly highlights, and challenges, the heteronormative care routine to
which the healthcare professionals are easily committed to. The situation can be new to
many professionals and thus, can put the non-biological mother into a possibly problematic
position when there is a heteronormative habit of addressing the information only to a
mother and to a ​
father​
. As Hayman et al. (2013) found, the co-mothers did not always feel
acknowledged as legitimate parents. O'Neill and colleagues (2013) reached similar
conclusions. They found that the healthcare professionals did not seem to value their
patients’ lesbian relationships. When in contact with healthcare professionals, the lesbians
participants experienced institutional heteronormativity and homophobia. As a part of a
larger study O'Neill and colleagues interviewed eight lesbian women about their experiences
of planned parenthood and its impact on their couple relationships. This qualitative study
using a general inductive approach and Queer Theory found that the participants'
experiences of healthcare professionals' ranged from mostly positive to homophobic.
Furthermore, O’Neill and colleagues found that an existing power imbalance lead to a
situation where some participants were unable to communicate concerns about their
treatment and that they lacked personal power when it came to their reproductive
opportunities (O'Neill et al. 2013).
14
​
By homophobia the authors refer to feelings of exclusion, being addressed with improper questions and even blocking
their access to healthcare services due to their sexual orientation. 26 Giving value to the lesbian relationship and recognizing and acknowledging also the
non-biological members of the family are challenges faced by several LGBT individuals in the
healthcare context. These findings can be easily explained by the institutionalized
assumption of heterosexuality. For example, the study by Röndahl et al. (2006) found that
heteronormativity and heterosexual assumptions were evident and promoted in waiting
rooms, in patient registration and admission forms. The 27 participants of the study, men
and women who took part in semi-structured interviews, experienced that the nursing staff
seemed occasionally even puzzled when a patient stood out from the crowd by not being
heterosexual and broke the heteronormative ​
routine​
. Some research subjects even reported
being treated as heterosexuals irrespectively of the fact that they already had disclosed their
orientation. The experiences of the participants revealed that they often met nursing staff
with averse behavior towards them. The authors argued that this can potentially lead to
hindering further communication between staff and patients.
Poor communication can undoubtedly harm the quality of the healthcare services provided.
Saulnier (2002) argues that the consequences of heterosexism can lead to barriers to
healthcare for LGBT patients when, and if, the communication between the professionals
and patients is inefficient. When investigating the experiences of 33 lesbian and bisexual
women in healthcare, this qualitative study using focus groups found that among one of the
most common complaints of the women was related to lesbian invisibility due to
heterosexism. In detail, the women were assumed to be heterosexual unless they openly
stated otherwise and the healthcare service forms and questions lacked an option for them
to state their sexual orientation that was deviant from heterosexual. Consequently, the
lesbian partners felt left outside as they were not acknowledged in the service nor taken into
account in the sharing of information. Several participants also had experiences of
homophobia as the practitioners failed to honor and respect the diverse family forms of the
LGBT patients.
3.3. Disclosing Sexual Orientation and Invisibility of Lesbian patients
B. Carraro
Although this third section also deals with heterosexim to some extent, the focus here is on
studies about how heterosexism can deteriorate the communication between patients and
medical staff. When healthcare professionals communicate homophobia or heterosexism,
patients belonging to sexual minorities can find it harder or even impossible to disclose their
27 sexual orientation. This potential obstacle to honest communication between patients and
doctors may lead to negative health consequences.
Heterosexism affects LGBT people in healthcare in many ways, such as by fostering fear in
LGBT patients about disclosing their sexual orientation. According to the literature, feelings
of fear to come out to the medical staff is related to the LGBT patients’ belief that the quality
and impartiality of the treatment received might then be compromised. Lesbian mothers in
particular are reported to be wary concerning not only about their treatment, but also their
children. The fear of disclosure may ultimately result in lack of quality care for lesbian
parents and their children, because of expected or previously experienced discrimination.
The extent of the problem rises as more and more lesbian couples are addressing fertility
clinics when starting a family, and thereafter coming into contact with public perinatal care
and other types of public healthcare services (Wilton & Kaufmann 2000; Saulnier 2002;
Larsson & Dykes 2009).
There are numerous issues in heteronormative communications in nursing: such as fears of
being mistreated after disclosure, fear of lack of confidentiality and family conflicts,
insecurity, rejection, social isolation and feelings of invisibility (Wilton & Kaufmann 2000;
Saulnier 2002; Larsson & Dykes 2009). Although heterosexism exists, it is homophobia that
can especially be potentially harmful to LGBT patients (Perlesz et al. 2006; Pennington &
Knight 2011, 60). In a way, homophobia indicates a clear negative attitude, and it can reflect
a type of behavior, which can pose more explicit threat to sexual minorities. As a
consequence, homophobia can become a health concern for society, since it can threaten
the right to quality healthcare for a group of people. In fact, many lesbian women choose
not to tell their midwife or other healthcare professionals about their sexual orientation.
Heteronormative and heterosexist assumptions and discriminatory environment in public
healthcare can lead to inappropriate health related screenings and inappropriate
interventions. Making assumptions about heterosexuality in a hospital or medical practice
could in fact be alienating patients, even though unintentionally (Morrison & Dinkel 2012,
127–9). Heterosexism can also have a negative impact on the communication between the
healthcare provider and patient, which may leave the patient feeling embarrassed, invisible,
and lead to a situation where the holistic health needs of the lesbian patients are left unmet
(Heck et al. 2006; Saulnier 2002).
28 Larsson and Dykes (2009) explore the views and experiences of lesbian women during
pregnancy and childbirth in a qualitative study including 18 lesbian women in Sweden. The
data was analyzed through content analysis method. The authors found that the women
experience challenges related to confirmation of both parents and the heteronormative
documentation used in maternity care. The heterosexism was found not only in the birth
medical record forms, but also in other forms within the health-care system in general.
Lesbians reported wishing not to always inform their healthcare providers about their
sexuality. The reasons for this behavior are not only the wishes for privacy, but also feelings
of fear and insecurity. However, most women had positive encounters within the healthcare
system and they attributed their positive experience to their own openness regarding their
sexuality (Larsson & Dykes 2009).
Marques et al. (2014) interviewed 30 self-identified lesbian women on their experiences
during medical encounters with a particular focus on sexual and reproductive health.
Through qualitative thematic analysis of semi-structured interviews, the authors found that
the women experiences difficulties when disclosing their sexuality and that doctors often
expressed themselves in a heteronormative manner. Nevertheless, medical practices were
reported mainly as positive by the interviewees. The authors also showed that doctor have a
tendency to simply assume that women attending medical encounters are heterosexual. This
study confirms that patients tend to avoid revealing their sexual orientation to doctors, at
least in the first few encounters or in occasional check-ups (Marques et al. 2014).
Wilton and Kaufmann (2000) investigated the maternity care experiences of 50 lesbian
women in the United Kingdom and evaluated service delivery to this group in antenatal,
intrapartum and postnatal care. Their descriptive study adopts both qualitative and
quantitative methods, such as self-administered questionnaires. The findings of this study
suggest that the participants were generally thankful of the care they received, but they also
reported high levels of anxiety regarding disclosure of their sexual orientation and its
possible consequences. They further reported professionals’ insensitivity to their needs,
flawed assumptions, marginalization and even moral disapproval or sheer hostility. Thus, the
findings of this study reveal an illustration of discomfort, improper service delivery and even
resentment. The authors argue that when lesbians decide not to disclose their sexual
orientation, the healthcare practitioners can easily overlook their specific health needs being
29 unaware of their presence. This can result in a lack of appropriate or adequate healthcare
for the lesbian patients (Wilton & Kaufmann 2000).
From the point of view of the medical and nursing staff, Chapman and colleagues (2011)
found in their study that most healthcare practitioners were often unprepared when they
encountered patients belonging to a sexual minority. This study investigated a sample of 86
healthcare professionals and their knowledge, attitudes and beliefs regarding LGBT parents
seeking healthcare for their children. The results show that professionals had incomplete or
even inexistent LGBT-specific knowledge. Nurses held more positive attitudes towards LGBT
parenting than doctors. The authors found that these results were significantly associated
with race, religious beliefs and with having a friend who is openly part of LGBT minority.
Furthermore, the healthcare professionals were unlikely to encourage LGBT parents to
disclose their sexual orientation (Chapman et al. 2011).
As studies show, lesbian women are easily regarded as heterosexual, which can be seen as a
sign of their invisibility. This invisibility can disappear only when they decide to disclose their
sexual orientation when necessary. However, disclosure requires that the attitudes and
behavior of the health professional make the patient feel that it is safe to do so (O'Neill et al.
2013, 214). In fact, in order to deliver the best level of care medical professionals should
have the relevant information regarding their patients’ sexuality. Disclosure is an important
pre-condition for an honest relationship between medical practitioners and their patients.
However, a broad number of studies have shown how disclosure is still very much of an issue
from both sides. On one hand, patients are on the less powerful end of an asymmetrical
relationship and fear worse treatment, should their sexual orientation be disclosed. On the
other hand, professionals tend to assume that their patients are heterosexual and may
therefore deliver inadequate treatment.
3.4. Challenges When Accessing Healthcare
S. Sirkkala
In order to understand the difficulties lesbian women face when accessing public health
services, their healthcare experiences and encounters with healthcare professionals in public
healthcare are especially relevant. The research suggests that if the lesbian patients feel that
the healthcare environment is not safe or welcoming for them, some might even stop
seeking for care. Thus, assessing the access of lesbian patients to public healthcare is
30 important in order to locate possible barriers to healthcare that are potentially
compromising the health of the affected individuals. Therefore, this fourth theme of the
literature review summarizes the findings of the chosen literature related to barriers to
healthcare for individuals in a same-sex relationship.
According to previous research, women in same-sex relationships seek healthcare less often
and are less likely to have a regular healthcare provider than heterosexual women. This
disparity is often attributed to discrimination and historical baggage of pathologizing
homosexuality. In connection to this, lesbians are more likely to seek for gay-friendly
healthcare providers or alternative healthcare services that offer more welcoming
environment. If such alternative services are not accessible, some women might ultimately
even stop seeking for preventive healthcare. This can place these women at an increased
risk for developing health related problems (e.g. Fields & Scout, 2001; Heck et al. 2006;
Goldberg et al. 2009).
healthcare access is an integral component of the overall health status for an individual.
Using data from the National Health Interview Survey, Heck and colleagues (2006) compared
the access to healthcare among individuals in same-sex versus heterosexual relationships.
Through descriptive and logistic regression analyses, this study found important differences
in access to healthcare between these groups; between persons in same-sex and in
opposite-sex relationships. Particularly women in same-sex relationships were significantly
more likely to have unmet medical needs. However, healthcare access among men in
same-sex relationships was equivalent to, or greater than, men in opposite-sex relationships.
The authors proposed explanation suggesting that the HIV epidemic had a role in
revolutionizing healthcare among some gay men, leading them to more likely to have a
regular healthcare provider or to seek preventive care (Heck et al. 2006).
Rounds et al. (2013) used focus groups to gather LGBTQ individuals’ perspectives and
descriptions regarding interactions with healthcare providers and information about
behaviors that improve or impede quality of care on behalf of healthcare providers. Their
sample consists of eleven self-identified LGBTQ individuals. According to the findings, the
behaviors of healthcare providers were either supportive or represented barriers to quality
healthcare. The strongest finding of this study further suggests that there is a need for
providers who are comfortable and competent to work with LGBTQ patients. The study also
31 emphasizes the need for improved education and training in order to improve the quality of
care and the health outcomes for LGBTQ people (Rounds et al. 2013).
In healthcare context, the role of the lesbian partner or the co-parent is frequently
questioned. Their role is often even ignored as there is confusion and lack of understanding
over their roles within the family dynamics. For example Wilton and Kaufmann (2000) found
that over 30% of the lesbian women in their study reported that their partner had been
excluded at some point in the healthcare processes. Also the findings of the study by
Cherguit et al. (2013) indicated that the co-mothers have difficulties to have their parental
identity formally recognized due to legal and structural exclusion. Thus, discrimination from
the system leaves co-mothers often invisible and strengthens the prevalence of the
heterosexual assumption and heteronormativity (Wilton & Kaufmann 2000; Cherguit et al.
2013; Larsson & Dykes 2009; Röndahl et al. 2009).
A qualitative study by Cherguit et al. (2013) explored ten co-mothers’ experiences with
maternity healthcare services through semi-structured interviews. Following a qualitative
design and by using an interpretative phenomenological analysis the authors found both
negative and positive experiences: including positive and inclusive interaction with
healthcare staff, but also negative experiences characterized by feelings exclusion and
invisibility. The co-mothers were left questioning the reason behind the negative
experiences: whether they were due to homophobic attitudes or professional
incompetence. According to the analysis these experiences were due to the fact that the
healthcare services promoted heterosexual nuclear family model throughout their maternity
literature and documentation (Cherguit et al. 2013).
The recognition and inclusion of the nonbiological parent can pose a challenge in the
healthcare context, but also in the legal context. The study by Goldberg (2006) found no
evidence of a positive trend towards recognition of the nonbiological parent. This study
examined aspects and experience of the transition to parenthood for 29 lesbian couples with
quantitative and qualitative methods and through in-depth interviews. Goldberg also found
that staggering one fifth of the sample experienced homophobic attitudes from the side of
the healthcare providers during the course of conception, as they encountered doctors who
chose not to treat them because of their sexual orientation. The lesbian couples also
32 encountered healthcare providers who did not know how to deal with the nonbiological
partner (Goldberg 2006).
From the point of view of the midwives, a sample of healthcare professionals described
caring for lesbian couples as unproblematic in a descriptive, qualitative study by Spidsberg
and Sørlie (2011). This study reports midwives’ experiences of caring for lesbian couples. A
sample of eleven midwives were interviewed regarding encountering lesbian women in the
healthcare service. Using a phenomenological-hermeneutical method in the analysis, the
authors found that the midwives experienced ambivalence or anxiety in their encounters
with lesbian women. The midwives further reported that they had noticed that some
couples had had negative experiences within the maternity care. The midwives highlighted
the importance of acknowledging their own attitudes, paying attention to culturally sensitive
non-verbal communication and considering the co-mothers’ needs and role as different
compared with those of fathers’.
3.5. Incomplete Institutionalization
S. Sirkkala
This fifth part of the literature review consists of literature reporting dimensions of
incompletely institutionalized status of LGBT families. First however, we ​
shortly present the
conceptualization of incomplete institutionalization by Cherlin (1978), which is elaborated
more in part 4. Theoretical Framework.
According to Cherlin the institution of family unit is a method of social control of
reproduction and it provides the family members with guidelines for appropriate behavior.
Through this routinization of everyday behavior, also institutional support is acquired for the
family unity. As the family unit has been traditionally defined through a heterosexual lens, it
has excluded the LGBT families. Thus, more complicated or deviant family situations that are
exceptions from opposite-sex family norm often lack institutionalized social regulation and
thus, the statuses of non-heterosexual relationships and families are left incompletely
institutionalized (Cherlin 1978, 634–6, 644). For example, when regarding the institution of
language that shapes people’s behavior, in the academic literature the lesbian partner of the
non-biological mother is called throughout the literature with diverse terms such as the
co-mother, non-biological mother, co-parent, social mother, non-birth mother, step-mother,
other mother, second female parent and even a ​
mather (for ​
mather see, Padavic &
33 Butterfield 2011). This is an example of how lack of appropriate terms for two-mother
families reveals that the institutional support of lesbian-headed families is insufficient.
Using Cherlin’s insight of incomplete institutionalization as a conceptual tool,
Hequembourg’s (2004) study aimed at understanding the parenting stories of forty lesbian
mothers and at examining the hardships they face when interacting with social institutions
while negotiating their roles and relationships within their families. The data and results of
this study suggest that there are similarities between lesbian families and heterosexual
stepfamilies, but that lesbian families face further difficulties due to their incompletely
institutionalized status. The analysis of the open-ended interviews showed that lesbian
families confront situations similar to heterosexual stepfamilies in their interactions with
social institutions. For example, the lesbian birth- and co-mothers disagreed about their
parenting roles, as they lacked certain manuscripts to guide their parenting activities on a
daily basis. Thus, Hequembourg argues that lesbian co-mothers need to negotiate their
positions next to the biological parent and create strategies (e.g. second-parent adoptions)
to surpass barriers due to their incompletely institutionalized status (Hequembourg 2004).
The unconventional LGBT family dynamics and especially the unsettled role for the
second-parent challenge the institutional structures, but also the heteronormative
healthcare routines. The way the situation with the second parent is dealt with in the
healthcare is seen to determine the overall healthcare experience in the study by Chapman
et al. (2012). In this descriptive qualitative study with eleven LGBT parents in Australia, the
authors found that the participants experienced both positive and negative interactions with
healthcare staff. Through semi-structured interviews the participants recounted their
positive and negative experiences in healthcare. Overall, the positive experiences were
connected to the fact that both parents were acknowledged as having an equal stance when
it comes to their child’s healthcare decisions. Conversely, the negative interactions included
situations where the other parent was excluded from the healthcare situations and decision
making, necessity to ​
come out​
, encounters with homo- or transphobia and the obligation to
educate healthcare professionals on LGBT family-specific healthcare issues (Chapman et al.
2012).
Short (2007) found that lesbian mothers face notable heterosexism and that there are still
discriminatory family laws, public policies and discourses that deny certain rights from them,
34 such as fertility services and the recognition of the status of their families. In order to shed
light to issues related to the life of lesbian parents in Australia, Short interviewed sixty-eight
women, service providers and community organizers. Using a grounded theory in the
analysis, Short found that laws and regulations recognizing the co-mother’s parenthood in
same-sex relationships were the most important resource that these women had or wanted
to have. The findings provided evidence on the way many lesbian women have different
successful strategies helping them to deal with discriminatory practices and to proceed
despite their incompletely institutionalized statuses (i.e. supportive networks, and
understanding heterosexism in the legal, political and discursive context) (Short 2007).
Lack of guiding and mentoring role models and fears related to legal issues regarding
second-parent adoption processes were the prominent findings in the study by Brown et al.
(2009). This study investigated adoption and parenting experiences of lesbian and gay
adoptive parents by using qualitative commentary data from a larger cross-sectional survey
study with 183 lesbian and gay adoptive parents. The authors found that the lesbian and gay
parents encountered barriers specific to their sexual orientation in becoming adoptive
parents, including discrimination during the adoption process (Brown et al. 2009, 229).
All these aforementioned studies show that some of the family policies ​
or the lack of ​
these
policies leave LGBT families in precarious situation, legally speaking. The incompletely
institutionalized status of the LGBT families leaves them into a weaker legal stand, due to
lack of institutional support. In fact, the problem is not always that the necessary policies
and institutions do not exist, but it that they exclude groups of people who do not conform
to the norm, such as LGBT families who deviate from the heterosexual nuclear family.
3.6. Conclusions From the Literature Review
B. Carraro
In this last section of the literature review, we summarize what has been done, what study
designs and methods have been used and what were the overall findings in order to have a
succinct, comprehensive picture of the literature.
Nearly all of these studies described that the experiences of LGBT minorities in healthcare
and their encounters with healthcare providers and used qualitative methods, such as
in-depth interviews or focus groups, and had small-scale samples. In general, these studies
35 aim to achieve deep understanding of underlying mechanisms rather than strive for vast
generalizability. Only a few studies have larger samples: Malmquist & Zetterqvist Nelson
(2014) stands out with the largest sample of 96 participants, and some of these studies also
used surveys and questionnaires. All in all the samples include both gay men and lesbian
women (and in some cases, bisexuals), both single and in same-sex relationships.
Nevertheless, especially when dealing with family issues and perinatal care, the authors
heard exclusively women’s experiences. Fewer studies focus on the nurses, doctors,
midwives and the medical staff and tell the story from their viewpoint, including their
attitudes and emotions when treating LGBT patients. In general, all the studies are either
descriptive or interpretative, and geographically they extend from European countries
(Sweden in particular) to USA, to Australia and New Zealand.
Many of the studies we reviewed are atheoretical and studied and analyzed data without
using one specific theory. However, some use theoretical approaches in the interpretation of
the findings such as phenomenology, queer theory, grounded theory, and incomplete
institutionalization. The second and the latter are particularly relevant and we will also use
them to guide our analysis. We will elaborate these theories more broadly in the next
chapter. Methodologically speaking, phenomenology and grounded theory were often used
to analyze the respondents’ answers.
Five main themes arise from the literature: positive and negative experiences and attitudes
in healthcare, institutionalized heterosexuality and heteronormativity in healthcare,
disclosing sexual orientation and invisibility of lesbian patients, challenges when accessing
healthcare and incomplete institutionalization. On one hand, the studies report how
professionals encountered difficulties when they had to break their routine because of LGBT
patients or families, demonstrating their insecurity on how to deal with LGBT minorities. On
the other hand, several studies showed how respondents tried to rationalize and minimize
bad experiences to justify bad behaviour from the medical staff in order not to categorize it
under the term ​
homophobic​
.
Heterosexism (or heteronormativity) was found to pose limits the access to healthcare for
sexual minorities. Even when professionals were being unconsciously heterosexist, the lack
of awareness generated a negative impact on the LGBT patients’ healthcare quality. Some
physicians lacked awareness of having LGBT patients in their practice, and blamed the
36 patients for not correcting their faulty assumptions about their sexuality or family
arrangement, saying it is the responsibility of the patients to correct them. Consequently,
invisibility remains the status quo if the LGBT patients do not disclose their sexual
orientation, and the practitioners’ assumption of heterosexuality (at least until disclosure)
can lead to negative health consequences. Disclosure from the patient might not even ever
occur, because of fear. In a study by Wilton and Kaufmann (2000), 14 out of 50 patients
feared negative reaction and did not disclose to their doctor, fearing that it would
compromise the service they receive.
Professionals’ attitudes can encourage or create a barrier for healthcare for sexual
minorities. According to the literature, when patients faced averse behaviour, it did in fact
hinder communication and compromised their treatment in the short run, but most
importantly, it posed a serious threat to their health in the long run, as bad experiences
dissuaded patients from seeking healthcare in the future due to apprehensive feelings.
Homophobia can pose a serious threat to the right to quality healthcare. Access to
healthcare was found to be different between same-sex and opposite-sex relationships:
lesbian women are more likely to have unmet medical needs. On a more positive note, some
midwives described their caring for lesbian couples as unproblematic, and underlined the
importance of acknowledging the different family formation of the LGBT patient and of
paying attention to their own communication.
Many studies show how co-mothers had been excluded and felt invisible in healthcare, as
their parental identity was not recognized because they were not acknowledged as ​
real
relatives. Forms and modules in hospitals and clinics were also found to be almost
exclusively heteronormative and that was seen to act as a block against the non-biological
mother’s access to procedures. Other studies bring out also positive experiences. Studies
explain how positive experiences were correlated to situations where both parents were
acknowledged, and how in negative experiences they were not. Overall, these studies
provide a great deal of insight on different issues that affect LGBT families in the healthcare
context.
4. Theoretical Framework
S. Sirkkala
37 In addition to some of the theoretical insights introduced earlier in the literature review, this
chapter introduces and elaborates the whole main theoretical framework used to guide the
analysis of this thesis. Some of these theories will intertwine with each other, which is highly
useful in order for us to outline more comprehensive picture of the issues of interest. First,
we explore the way social policy constitutes sexuality. We provide insights about the special
role of policies in constituting sexual norms and thus, deserving and undeserving welfare
subjects. Second, we develop to the notion of sexual rights and the theorisation sexual
citizenship, which is ideologically grounded in hegemonic heterosexuality. Sexual citizenship
is considered important here in order to examine how the citizenship of LGBT individuals ​
is
and whether it is any different from the citizenship of heterosexual individuals. In addition
we consider the issues related to the question of on what grounds certain citizens’ rights are
restricted without any less obligations for those citizens.
Third, we focus on theorization on space and sexuality: the way public space is sexed and
how space can serve to ​
naturalize heterosexuality. In the analysis when dealing with public
space, we will refer to public healthcare centers. As a matter of fact, heteronormative public
space can be challenged by ​
queering​
, thus making diverse sexualities visible in the public
eye. Thus fourth, we elaborate the field of queer theory (or queer thinking) as it provides
tools to challenge common understandings related to, among others, the the state and
widespread social institutions linked to gender, health and justice. Fifth and last, we provide
insights to Cherlin’s notion of incomplete institutionalization, adapted by Hequembourg
(2004), which helps us to gain understanding of why and how LGBT families face problems to
which institutionalized solutions do not exist.
4.1. Social Policy Constituting Sexuality
S. Sirkkala
The paper by Jean Carabine (2001) provides us with tools in understanding the intersection
of sexuality and social policy through two arguments. First, Carabine argues that welfare
policies have a normalizing and regulatory role when it comes to sexuality as policy makers
have the power to impose their own set of moral norms at the same time dismissing moral
rationalities of welfare subjects believing them to be inferior or as lacking moral integrity.
Sexuality is regulated through welfare and social policies and normative assumptions about
sexuality, which have a role in constituting and regulating welfare subjects, discourses,
provisions and practices. As an illustration of this, Carabine uses an example of creation of a
38 social problem, namely the categorization of single pregnant women and unmarried mothers
and their stigmatizing representations as deliberately getting pregnant in order to obtain
benefits. In this example, “social policy is used to override unmarried/lone mothers’
moralities by asserting an alternative moral matrix” (Carabine 2001, 292). ​
Even if single
motherhood is nowadays tolerated, it is not granted the same moral status as to a family led
by a heterosexual married couple as ​
all welfare subjects are subjected to the norm of
heterosexuality.
In fact, heterosexuality has been, and to some extent still is, the premise to welfare policies
and in welfare practice. The normative expectation of universal heterosexuality has lead to
ignoring the relevance of sexuality in theorizing and analysing social welfare policy and
welfare practice (Carabine 2001, 292). In her article, Carabine uses a poststructural approach
to challenge the rationality of traditional policy discourses, practices, logics, conventions and
norms. Thus, and second, Carabine draws upon the work of Foucault, suggesting that social
policy/sexuality relationship can be characterized by four different interrelated aspects:
normalization, invisibility, constitutive and contestation.
Normalization refers to how social policy has a role in defining and reaffirming
heterosexuality as the acceptable and appropriate sexuality. Its function in social policy is
observed for example in the constitution of the ideal gendered and sexual roles for men and
women, the ideal heterosexual married couple comprised of the father and mother, and the
typification of natural and acceptable sexuality: heterosexuality. Social policy and welfare
provision have reflected this normalization of heterosexuality, which has resulted in partial
inclusion and conditional eligibility for welfare benefits and services for groups of people15
for not conforming to the norm (Carabine 2001, 293). As a further effect of normalization,
invisibility is an aspect referring to the ways social policy has a tendency to support,
recognize and defend normative sexualities while other sexualities remain ignored and thus,
marginal or even invisible. Within the aspect of invisibility lies the reason why lesbian and
gay men have frequently been ignored in the development, implementation and provision of
social welfare provided, if they had not been addressed either by conditional or limited
inclusion (e.g. limited entitlement to benefits) (Carabine 2001, 294–5).
15
S​
uch as single mothers and homosexuals, due to acts such as cohabitation and divorce. 39 The constitutive aspect refers to the way existing power-knowledge relation focused on
sexuality also constitutes social policy. Carabine refers to the dominant ideas about what
sexuality is and to ideas about what is considered acceptable or legal sexuality. Carabine
notes how norms entrenched in social policies and welfare practice all contribute to they
way social policy is itself constituted, but remarks that it is not a one-way process. Sexuality
is itself produced through social policy as what we know as sexuality is apprised by the
norms promoted by social policies and welfare practice: for example, the traditional ideal of
heterosexual female homemaker (Carabine 2001, 294).
With the aspect of contestation Carabine refers to how social policy can be a focus for social
and political action. Social policy arena can be a site where the norms and ​
truths of sexuality
are challenged and even changed. For example, since law is the important institution
responsible for enforcing and supporting norms and privileging types of sexualities, law can
also be a mean of reformation and transformation (Carabine 2001, 295). In practice this has
been evident when homosexuality was decriminalized and when, more recently, equal
marriage laws have been approved, one country after the other.
All in all, according to Carabine, welfare and social policy discourses are means by which
appropriate sexuality, gender relations, morality, the family and marriage are spoken about.
Thus, welfare policies have a normalizing and regulatory role when it comes to sexuality.
4.2. Sexual Citizenship
S. Sirkkala
Equal citizenship rights between different social groups have been demanded over the
course of time by different actors. However, there is still a need to critically consider the
limitations of the concept of citizenship as it is now, shaped by heteronormativity (Hubbard,
2001; Richardson, 2000a). Thus, in accordance with Richardson (2000b), we examine how
heteronormative definition of citizenship excludes those who do not conform to the
heterosexual norm. With the help of the concept of sexual citizenship we are able to
investigate the attainment of legal rights and responsibilities, social inclusion and
recognition of sexual minorities against heterosexual norms (Formby 2011; Marques et al.
2014, 3).
40 Among the approaches to understand sexual citizenship, Richardson (2000b) presents three
views: first, with sexual citizenship one can refer to the sexual rights granted or denied to
various social groups. Thus, sexual citizenship can be defined in terms of varying level of
access to a set of rights to sexual expression. Second, sexual citizenship can be
conceptualized by access to rights, but more broadly. The question is, how a form of
citizenship status is reliant upon an individual’s sexuality? Third, sexual citizenship can be
conceptualized as the right to seek public validation within social institutions of various
forms of sexual relations (Richardson 2000b, 107–8). Additionally, Weeks (1998) defines
sexual citizenship as a notion trying to ​
patch limitations of the earlier definitions of
citizenship and thus making it more comprehensive. Thus, the idea of sexual citizenship is
about inclusion, equity and justice, and about rights balanced with responsibilities (Weeks
1998, 39).
The first of the two arguments we apply from Richardson (2000b) encompasses the idea that
from the premise of institutionalized heterosexual norms and practices derives that all other
forms of sexuality are judged, leading to exclusions from the boundaries of sexual
citizenship, and disqualification based on ​
naturality​
. This, in turn, may lead to lack of
recognition of rights for those that are ​
disqualified​
, justified by defending the society against
moral threat​
. In reality, many of the claims for sexual rights involve claims for civil rights:
including removal of discriminatory laws, but also an access to social rights, such as provision
of welfare (Richardson 2000b, 111–2). Examples of such claims can be for example women’s
right to vote and access education (like in the beginning of 20th Century) and currently
same-sex couples’ right to marry and to access reproductive healthcare services16
(Richardson 2000b, 118–9).
The second argument involves the way demands for lesbian and gay rights have been
primarily viewed as private individual rights rather than as ​
public human or citizen rights.
However, to be publicly visible is crucial in claiming citizen rights, when rights are negotiated
in the public arena. Thus, claiming citizenship rights would be seriously restricted if one is
not allowed to that public arena and consequently, if homosexuals are denied their public
homosexual identity and lifestyle. Highly associated with this battle between private and
public are the recent claims for public recognition, social legitimacy and institutional support
16
​
An important argument used for claiming civil, social and sexual rights for lesbian women and gay men, has been that
homosexuality is an inborn characteristic. Indeed, within a liberal democracy it is considered possible to claim that
discrimination on the basis of an unchangeable personality trait beyond one’s control should be regarded as unfair. 41 for diverse sexual relationships (Richardson 2000b, 120–6). In essence, these are claims for
public, universal citizen rights and ​
not​
private, individual rights.
When speaking about rights, one mainly refers to the rights and obligations of the individual
citizen. However, many citizenship rights are grounded in the state of living in a relationship
or as a couple (e.g. situations where partner’s income is taken into account when assessing
entitlements to benefits). With a few exceptions, heterosexual relationships and marriage
are considered to be the norm by which the eligibility of rights granted to couples are
measured. For example, the right to marry and form a family is recognized even in many
respected documents including the United Nations’ Declaration of Human Rights. Yet, in
many countries such rights are still denied to individuals in same-sex relationships even
though they might have, among others, the same immigration, pension and inheritance
rights as those granted to married heterosexual couples. Additionally it should be noted that
even in countries where same-sex relationships are legally recognized, there can still be
disparities with the rights that granted to heterosexual couples than to homosexual ones. In
these cases, the major disparity is usually around the rights of parenthood (Richardson
2000b, 123–7). An example from Finland would be the case of state supported fertility
treatments that are not granted to same-sex couples as they are to heterosexual couples,
and the lack of automatic parental recognition within a registered partnership unlike in a
heterosexual marriage.
4.3. Sexual Citizenship and Public Space
S. Sirkkala
Hubbard (2001) argues that notions of sexual citizenship have moved from the margins to
the center and thus, certain groups and individuals have been now claiming full citizenship
with all the possible rights included. In his article, Hubbard uses the term ​
citizenship in its
widest sense by referring to it as a state of a person being vested with the rights, privileges,
and duties of a citizen, as well as the character of an individual viewed as a member of
society. He uses the concept in a broad sense to explain how the state is able to exercise
control over people without resorting to physical violence (Hubbard 2001, 53). Furthermore,
Hubbard argues that notions of appropriate sexual conduct and behaviour are considered
central for the entitlement to different rights embodied within the citizenship.
42 In his article, Hubbard considered issues of citizenship in relation to geographic ideas and
concepts. The reason to this is that ideas of citizenship deal with what is considered
appropriate within particular spaces of ordinary, civil life. When one of the basic rights of
citizenship consist of rights to access and use certain spaces within a set territory, Hubbard
explores in his article “how ideas of sexual citizenship are institutionalized and contested in a
variety of different spaces.” These spaces include private and public spaces: everything from
home and work to streets, parks and squares (Hubbard 2001, 53–4).
In his paper Hubbard argues that studies have shown that notions focused around
appropriate, heterosexual and procreative sexual behavior construct public spaces, resulting
in exclusion of those who do not conform to the norm. More specifically, heterosexuality is
naturalized when people are encouraged to adopt heterosexual identities and behavior
promoted through images and behaviours in the arenas of work, leisure and consumption.
The spatial exclusion of non-heterosexuals is, in turn, seen to reproduce and reflect notions
of citizenship based on heteronormativity17 . Thus, “space is sexed in a variety of complex
ways” leading to the way homosexuals can be inclined to deny or disguise their sexual
orientation in the fear of intolerance when in public space as only heterosexual displays of
actions such as affection are regarded as acceptable or normal (Hubbard 2001, 51–5).
This first argument of sexed spaces and spatial exclusion of homosexuals, we apply from
Hubbard, is highly applicable also in case of healthcare and lesbian-led families, as it
provides fruitful insights to the way lesbian mothers have to confront and challenge
heteronormative expectations in public spaces, such as in healthcare centers.
In the eyes of the law and the state, all individuals are considered equal. But if it is so,
homosexual men and women should be able to be identified just as they are also in the
public realm without fear or discrimination. However, if civil society is to conceptualized as a
heterosexual construction, entering the public realm can be difficult for those whose sexual
lives can be judged ​
immoral against the idealized heterosexuality. Consequently,
homosexuals might feel free and safe to express their sexuality only in private spaces,
excluding public spaces, such as streets, where heterosexuality is strongly asserted as the
norm (Hubbard 2001, 55–7).
17
​
Hubbard uses a word ​
heteronormality. 43 Thereby, the questions of sexual orientation and identity intertwine with issues related to
citizenship. As notions of sexual morality are prominent in definitions of citizenship and not
all comply to the dominant definitions of heterosexual morality, sexual ​
others have been
denied full citizenship rights when it comes to state benefits and public recognition and
therefore they are only ​
partial citizens​
. Thus, the second argument we apply from Hubbard
is how in the eyes of the state, homosexuals have several obligations, but only limited
entitlements (Hubbard 2001, 53, 57; Richardson 1998). For example, all citizens regardless of
their sexual orientation are compelled to pay taxes to the state. In return, the state usually
compensates the financial loss to its citizens with different services. However, important
point here is that not all citizens are equally entitled to these services due to their sexual
orientation even though they all are obliged to pay taxes. As currently in Finland, same-sex
couples do not have the same rights when it comes to marriage and parenthood as
heterosexual couples do.
In addition, promoting certain ideas and norms excludes the ones not conforming to the
ideal leading to invisibility in terms of their rights. Hubbard argues that “this visibility and
invisibility is apparently mirrored in the presence (or absence) of particular sexual identities
in public space” (Hubbard 2001, 60). As Hubbard investigates in his article how to break
down public and civic spaces to undermine the dominant heteronormative notion of
citizenship and challenge the naturalization of heterosexual norms, he considers “spatial
tactics” in order to seek recognition (Hubbard 2001, 67).
Thus, the third argument we apply from Hubbard includes notions on how sexual minorities
should re-territorialize public space and turn them into sites of sexual diversity. In doing so,
they would succeed in changing their statuses regarding citizen rights from ​
partial to ​
whole
citizens. Hubbard suggests making diverse sexualities visible by “queering” of public space.
Queering public space is about making the needs and wants of sexual minorities visible
through transgressing these needs and wants onto the heteronormative public streets This
would remind people of the existence of diverse sexualities and their claims to citizenship
rights. As a matter of fact, a group stays invisible, unless it exists in the public space, as this
invisibility makes the group and its needs invisible also in the eyes of the law and in the
public debate. This is why public space should be used as a site to fight against
discrimination and homophobia by making minorities visible (Hubbard 2001, 62).
44 In addition to the third argument we apply, regarding making sexual minorities more visible
in the public space, Hubbard also provides a fourth applicable argument, by stating that the
problem of invisible sexual groups is not necessarily a lack of publicity, but a lack of privacy:
“publicity needs to be defined as the power to access whereas privacy needs to be defined
as the power to exclude”(64). Sexual minorities can be argued to have too much publicity
and access to spaces leading them not to have enough privacy as they lack power to control
those spaces and to exclude others. Consequently, if sexual minorities enjoy neither true
publicity nor privacy, they are unable to enjoy full sexual citizenship. Thus, sexual minorities
do not only need the right to publicity, but also the right to privacy (Hubbard 2001, 64–6).
4.4. Queer Theory
S. Sirkkala
Queer is a word that was once commonly understood to refer for example to ​
strange ​
or
abnormal​
. However, nowaday it bears such complex meanings that spelling them out
specifically is thought to limit its full potential. ​
Queer theory was deliberately coined by
Teresa de Lauretis in 1990 as ​
provocation to challenge the dominant discourses, to introduce
a problematique of multiple differences, and to offer a potential escape from traditional and
dominant models of analysis. de Lauretis aimed to “make theory queer” and “to queer
theory” and hoped to challenge the heterosexist assumptions embedded in theory in the
academic field (Halperin 2003, 339–40). Queer theory opens up when one begins to treat
gender as a primary category for understanding problems that do not necessarily look too
gender-specific (Warner 1991, 6). Furthermore, the recognition that people do not naturally
fit into socially constructed categories is highly important for queer theory. Queer theorists
question the constitution of sexual identities, how they are enacted and in what ways they
enable and how much they constrain us. The queer “deconstructive” project or mission is to
“disrupt, to render unnatural and strange texts and practices that are naturalised and
neutralised” (Watson 2005, 74).
In the political terrain, sexuality and its regulation are generally linked to social institutions
and to the most basic norms of our society. Sexual order is profoundly embedded in many
different social institutions and the way we see and understand the world. Thus, every
person is marked with a stigma by, among others, notions of gender, family, the state,
nature, healthcare, and profound cultural norms related to the bearing of the body. To
Warner (1991), being queer is about fighting these notions. A queer struggle is about
45 achieving not only tolerance or equality, but it is about challenging common understandings
related to the role of the state, widespread institutions of the society, accounts on gender,
health and fairness. Warner argues that “the task of queer social theory in this context as in
so many others must be to confront the default heteronormativity of modern culture”
(Warner 1991, 6, 16).
For example, Goldberg et al. (2011) deal with queering in their article on lesbian and queer
embodiment within the context of heteronormative birthing practices. By using feminist
phenomenology as their guide, Goldberg and colleagues aim to understand how gendered
bodies of lesbian parents and perinatal nurses navigate their “locatedness” within
institutional and hierarchical environments: how non-normative bodies can make others
uncomfortable in a heteronormative space. Thus, by “queering the birthing space” lesbian
couples can make medical professionals uncomfortable in birthing environments due to
their heteronormative expectations (see also Goldberg et. al 2009).
Queer theory can serve as a useful framework to understand the constitution of (sexual)
identities and as a method to disturb the taken-for-granted heteronormative assumptions
about sex, gender and sexuality in which LGBT persons are considered as problematical
against the dominant heterosexual norm (Watson 2005, 79). Thus, queer theory is an useful
tool in understanding lesbian mothers experiences confronting heteronormativity in
healthcare and the way lesbian mothers disrupt heteronormative assumptions in public
spaces. More specifically, queer theory is relevant for our analysis when examining issues of
structures and routines within the healthcare context and when deconstructing the
emphasis on biology in healthcare and in birthing environments. It enables us to view the
way the lesbian relationships are seen and valued in the heteronormative healthcare context
from the viewpoint of lesbian patients and facilitates our critical interpretation of the
findings and consideration of the impact of heteronormativity in the patients’ experiences.
4.5. Incomplete Institutionalization
S. Sirkkala
The theoretical focus of this last part is on incomplete institutionalization. This
conceptualization by Cherlin (1978) has a key role in our paper in explaining why lesbian
families and couples can be argued to have incompletely institutionalized status in the
society, and provides a framework to understand the challenges lesbian mothers face with
46 their familial relationships. Cherlin used the concept first to explain difficulties heterosexual
stepfamilies face while attempting to form families in a context that often ignores and even
denies their existence. However, the notion of incomplete institutionalization also applies
for understanding lesbian couples’ experiences, because they face similar hardships as
stepfamilies as they pursuit to start a family together (Hequembourg 2004, 741).
In his paper, when comparing remarriage to first marriage, Cherlin argues that the high level
of institutionalization of the nuclear family becomes instantly evident. Yet, families formed
after remarriage, including children from previous unions, are faced with problems that are
unknown to other families. These problems include proper vocabulary, authority over
children and legal relationships that lack institutionalized solutions. As a matter of fact,
Cherlin argues that two of the biggest institutions in society are the language and the law. As
an example, in a situation where there is a lack of adequate and coherent terms for an
important social role within the family unit, the institutional support for this role is
insufficient. This can, in turn, even lead to questioning the legitimacy of the activity and the
roles’ general acceptance (Cherlin 1978, 636, 643).
Indeed, the definition and concept of family or the family unit is very important in our
society and everyday life. Family is
one of the most fundamental forms of social
organization and a very central component of many of our society’s core institutions, such as
public policies and laws, that regulate our lives18 (including the educational and health
system). Thus, public policies have a particularly important impact on families as they define
many of the rights and responsibilities of parents, and create incentives and disincentives for
families supporting certain types of families over others (Gauthier 2007). In fact, in
sociological theory it is believed that social institutions, from political, economic and legal
institutions to language and family, shape people's behavior in many important ways. For
Cherlin (1978) the defined family unit is a method of social control of reproduction and child
upbringing and it provides the family members with guidelines for appropriate behavior that
also act as unifying and stabilizing forces. In fact, in most societies, family roles and
relationships are well defined and regulated by determined patterns of behavior and
heterosexuality is regarded as the natural basis for the family unit.
It is for example the measure and standard for distribution of many benefits that cover the citizens’ welfare (Cahill et al.
​
2002, VI).
18
47 Yet, defining the family institution through a heterosexual lens excludes LGBT individuals and
results in defining their family forms as “non-family” (Lind 2004, 23).19 According to Cherlin,
this is due to the fact that more complicated family situations that are exceptions from the
norm sometimes lack institutionalized social regulation and thus, the statuses of these
relationships and families are left incompletely institutionalized (Cherlin 1978, 634–6, 644).
Yet, institutional support20 is highly important for all the families because it has a key role in
the process of institutionalization. It is ​
the antidote ​
for the incompletely institutionalized
status.
In sum, Cherlin’s arguments on the incomplete institutionalization provide meaningful
insights also to the incompletely institutionalized status of LGBT families (see Hequembourg
2004). For instance, as our society is characterized by binary categories and ideological
preference for the nuclear heterosexual family model, it is evident that our society is limited
by language when it provides just two options for parental titles: mother or father (Padavic
& Butterfield 2011, 176–7). Thus, within the core institution of our society, the family,
same-sex parents need to negotiate their parental identities and their position in their
families in a society that lacks of institutionalized guidelines for their family.
4.6. Our Theoretical Framework and Working Hypotheses
B. Carraro
This section provides an outline of the way we use the main theoretical ideas in order to
develop working hypotheses driving our analysis. Our working hypotheses are deriving from
our research question and represent the results we expect to find. Our research question is:
how are the experiences of lesbian couples when becoming parents in Denmark and
Finland? More in detail, we aim to find whether the lesbian couples’ experiences of
transitioning to parenthood are different from heterosexual couples’ experiences, what
could be the reasons for that, and whether institutional differences between Finland and
Denmark influence the type of experiences these mothers have.
Carabine (2001) argues that sexuality is regulated through welfare and social policies. Thus,
they constitute and regulate welfare subjects, discourses, provisions and practices. When
When legislation does not recognize lesbian couples as parents due to the presence of heteronormative ideals for
​
parenthood, it creates discomfort as the lesbian parents and they are compelled to create strategies to overcome the
challenges created by the lack of regulation (Malmquist & Zetterqvist Nelson 2014, 70).
19
20
​
Such as formal legal recognition and supporting policies. 48 and if social policies constitute appropriate citizens through normative expectation of
universal heterosexuality, it ignores citizens who do not conform to the norm. Thereby, we
use Carabine’s notions in the analysis to detect whether LGBT families, or specifically
families led by lesbian women, are granted the same status in society as to a family led by a
heterosexual married couple – as all welfare subjects are subjected to the norm of
heterosexuality – by focusing on legal rights and public healthcare provision.
Further, if citizenship is grounded in hegemonic heterosexuality and thus, the full citizen is
considered heterosexual as Richardson (1998; 2005) points out, it leads to denial of multiple
citizenship (social) rights to ​
sexual others​
: namely non-heterosexuals and in our case, lesbian
women. Thus, we use the notions of sexual citizenship to point out narratives where the
heteronormative basis of citizenship becomes clear and we are able to be sensitive to see
clear examples of whether non-heterosexual subjects, lesbian parents, are denied access to
particular social rights especially when it comes to parenthood and, therefore, lack full
citizen rights. Furthermore, we use the notion to further detect points of production of
difference and exclusion especially in the healthcare context.
Hubbard’s (2001) notions on invisibility and disrupting public spaces help us to discover
whether lesbian women enjoy full citizenship rights also by having to access and use public
spaces. As Hubbard argues, ideas of citizenship deal with what is considered appropriate
within particular spaces. Public perinatal care is located in highly heteronormative space as
the expectation of heterosexuality is especially strong. Thereby, heterosexual citizens
become appropriate patients within that space as they are expected. In turn, lesbian
mothers are not necessarily expected, which can lead to their invisibility due to heterosexual
assumptions and language, and to disrupting or queering the space with their presence.
With the help of these notions, we will try to discover whether these heterosexual
expectations hold true in case of Finnish and Danish lesbian mothers accessing healthcare
spaces. Moreover, we will also use queer theory in a similar manner as Hubbard’s notions on
disrupting public spaces, as we also consider it as an useful tool to understand lesbian
mothers experiences confronting heteronormativity in healthcare and the way they disrupt
heteronormative assumptions in public spaces21 . Thus, in light of these notions, we expect
our findings to reveal the atypical nature of the lesbian participants’ healthcare experiences
when and if they disrupt these heteronormative spaces.
21
Similarly to Goldberg et al. (2011).
​
49 Lastly, we will use Cherlin’s (1978) concept of incomplete institutionalization in a similar
manner to Hequembourg (2004) by using it to provide us with tools for better understanding
how same-sex families face unique challenges with societal institutions, due to
institutionalized heterosexuality promoting and supporting the heterosexual family form and
thus, leaving the same-sex couples marginalized and incompletely institutionalized. Thus,
we also expect institutions, and in particular the law, to influence the way professionals act
around the couples, examined from the viewpoint of lesbian parents. We expect that the
experiences of lesbian parents when transitioning into parenthood are, among other things,
affected by civil servants’ behavior, and we argue that these behaviors are shaped
differently by different institutions in the two countries.
Thus, we expect to find higher preparedness of the professionals in matters such as laws and
regulations affecting LGBT families, and consequently better of the couples, in Denmark. This
derives to country’s family laws being more inclusive towards sexual minorities and
therefore determining a more institutionalized status of LGBT families. We expect Finnish
couples to experience discriminatory treatment and challenging bureaucratic procedures
when transitioning into parenthood to a higher degree than Danish couples, because of the
lack of complete institutionalization of LGBT families, or due to more legal drawbacks in
relation to same-sex families in Finland.
5. Data and Methods
B. Carraro
This chapter is organized in four sections: the sample, participants’ characteristics,
recruitment and data collection, interviews and content, ethical considerations, data analysis
and method, and finally, study limitations and restrictions.
5.1. The Sample
B. Carraro
There are a number of reasons why we chose to interview lesbian mothers from Finland and
Denmark. On one hand, we chose Finland and Denmark because they are easily comparable
countries on many levels: similar welfare systems, geographical proximity, political affinity
being both Nordic Countries, and high level of human and civil rights (Richardson 2000a;
50 2000b). On the other hand, the two countries differ in remarkable way on the field of laws
affecting LGBT citizens, in particular LGBT parents.
For both countries, the initial inclusion criteria for our sample were the following: first,
participants must be in a committed (living together) same-sex relationship; second, both
must be legal parents of their children; third, participants must be expecting a child or have
at least one child; fourth, in case of lesbian parents, the father or donor, if known, should
not be involved in healthcare check-ups; fifth, participants can comprehend and speak
English. There are a few reasons why we wanted to restrict the sample to couples. We
thought that a couple’s ability to remember past events would be greater than that of a
single person. Moreover, in order to measure the attitudes of the healthcare professionals
we needed to make sure they knew their patients’ sexual orientation, which is easily
detectable when a same-sex couple comes together for a checkup. This would allow us to
establish a connection as clear as possible between the doctors' attitudes and the sexuality
of the patient. However, due to difficulties in recruiting participants, especially in Denmark,
we had to be more flexible with our inclusion criteria. Two of the lesbian couples we
contacted in Denmark had an involved father, and two of the Danish respondents were
interviewed without their partners, for different reasons. Exception to the fifth point was
made for a one couple in Lapland who requested to be interviewed in Finnish.
Although we did not restrict our sample to women at the beginning, leaving space for
transgender people and gay men, we found only female same-sex couples. One advantage of
this new adjustment is that the restriction made our final sample more homogeneous,
reducing sample error and increasing sample reliability (Blaikie 2010). Overall, 20 women
agreed to participate. For a complete list, see Annex 2. To respect the anonymity of our
interviewees, we do not use code names. Ten women were living and had conceived and
delivered their children in Finland, while the other ten were living and had conceived and
delivered their children in Denmark. For reasons of practicality, we will call the two parts of
the sample as ​
Finnish ​
and ​
Danish sample/couples depending on their country of residence,
even though the nationality of the individuals varies. They were all either in a same-sex
relationship, or had been in one when they had chosen to have children through assisted
reproductive technology. The lesbian participants’ age in the study ranged from 23 to 47;
they had one to three own children in the household. Among them, 16 self-identified as
lesbian or ​
gay​
, three as ​
bisexual, one as ​
more homosexual than bi​
, and everyone identified
51 as ​
female​
. The age of the participants' children ranged from four months to three and a half
years, which makes the recall period around maximum four and a half years before the
interview date. In one case in Finland, the child was not yet born, which made the recall
period for events that happened during prenatal checkups even shorter.
The respondents in the Finnish sample range from 23 to 39 years old. The education of the
respondents goes from Ph.D. to vocational schools, and seven out of ten had university
degrees. The couples live in different parts of Finland and reported experience from several
healthcare facilities all over Finland. The sample is geographically spread, with one couple
living in the north, two in the south and two in central Finland, both in urban and rural areas.
All of the non-biological mothers adopted their partner’s children and are therefore their
legal parents as well. Four are non-biological mothers, four are biological mothers, and two
are both a biological and a non-biological mother.
The respondents in the Danish sample range from 33 to 47 years old. The education of the
respondents goes from Ph.D. to vocational schools, and eight out of ten had university
degrees. Most respondents live in the ​
Hovedstaden (Capital Region), with only one couple
living in the region ​
Syddanmark​
. A total of four couples were interviewed together, and all
were married or registered to the other mother. Two women were interviewed alone
because of the impossibility of the other mother to join. Overall, three were non-biological
mothers and seven were biological mothers. All of the non-biological mothers were legal
parents of their partner’s biological children as well, except two cases in which a father was
involved.
5.2. Recruitment and Data Collection
B. Carraro
We faced two main challenges during our sampling: identification and recruitment. The
population of interest for this study is naturally small (being a minority within a minority)
and hard-to-identify, among many reasons, because of the lack of any type of accessible
registry. The struggle to identify is followed by the difficulty to recruit. Recruiting members
of this population is a challenge because of the widespread unwillingness to disclose
personal details about themselves and their family, the unwillingness to cooperate with
people they did not know, and the lack of consistent reward for their time and information.
52 Consequently, our sampling method was snowballing, which consisted in identifying initial
key informants (friends and acquaintances) and then asking them to identify others willing
to participate. Snowball sampling is also known as network or chain referral sampling, and it
is especially appropriate when the population of interest is difficult to identify and contact
(Blaikie 2010). For this study, we designed a poster calling for participants, placed it on the
websites of LGBT organizations, on LGBT and rainbow families Facebook groups, directed to
target people and acquaintances, hung it in the streets and in LGBT meeting points. Overall,
the response to the advertisement was limited. We successfully recruited most our
participants through personal
recommendations
from acquaintances and initial
interviewees. This indicates how getting into contact through personal recommendations
increased participants’ trust, which is an essential element that must be present from the
very beginning of contact with the potential participants.
The interviews were conducted between April and August 2015. Recruitment for both the
Finnish and Danish sample continued until data saturation was achieved. The amount of new
relevant information given during the interviews started declining already after the second
interview, and the data reached saturation after three or four interviews. After that, similar
answers were given and the interviewees were reporting similar events, analogous opinions
and feelings, that continued to be replicated throughout the remaining interviews, not
adding any new important information.
5.3. Interviews
B. Carraro
Participants were able to choose where the interview would take place, and the
arrangements varied from private to public places. We chose not to interview individuals
when possible to facilitate recall of happenings, and we chose to interview couples instead
of doing focus groups in order to minimize the risk of people feeling uncomfortable for the
personal nature of the questions asked (Rounds et al. 2013, 109). Both researchers
participated and asked questions during the interviews, in order to guarantee transparency
in the procedure and accuracy during the interview and the follow-up transcription.
We carried out semi-structured interviews, each consisting of 17 macro-questions. The
interview structure, as well as the privacy statement, are included in Annex 4. The questions
in our script were divided in blocks to facilitate memory paths in the respondents and to
53 make it easier for the researchers to analyze the content afterwards. The questions were
conversational, informal and open-ended to encourage a narrative flow, and sensitive in
view of the potentially emotive nature of the subject (Röndahl et al. 2006, 375). The
interviews lasted from 40 to 60 minutes, were audio-recorded and transcribed including
both the interviewers’ and respondents’ words. Also some non-verbal expressions were
noted in the transcriptions. In the transcriptions, capital letters mark emphasis in the voice,
while cursive represents a Finnish or Danish word or something our respondents wrongly
translated from their mother tongue. When quoting the respondents, omitted parts have
been marked with square brackets and three dots. Clarifications or translations are also
inserted in square brackets.
Some questions were intentionally broad, to encourage participants to start the dialogue in
their own terms and prioritize whichever issue they thought was more important. This way,
the conversation, rather than the specific questions, produced part of the data, and this
helped avoiding researcher assumptions (Lee et al. 2011, 984). By letting participants
establish their own priorities when asked such a broad question, we were able to identify
which issues and themes were on the top of their minds and therefore put forward first. This
allowed us to better understand their opinion on the level of importance and gravity of the
issues we discussed. This narrative approach involves both the participants and the
researchers, and it is particularly productive of content in our case, since not only two but
four people were involved in the conversation.
5.4. Data Analysis and Method
B. Carraro
When having to analyze rich qualitative material, such as the interviews we conducted, the
researcher is standing before a number of choices. For our analysis, we decided to adopt
both Qualitative Content Analysis and Constant Comparison methods.
Qualitative Content Analysis is good for verbal, visual data, for rich data that requires
interpretation, for data collected through interviews and focus groups. The aim of
Qualitative Content Analysis is not to produce theory, but to performing a thematic analysis.
Meanings can be standardized or not, therefore, when they are not, they require some
degree of interpretation, which can be achieved by using for instance Content Analysis. This
method is ideal when analyzing interview transcripts, and it allows the researcher to focus
54 only on the aspects that are relevant for his or her analysis. With Qualitative Content
Analysis, the research question determines the angle from which the data has to be
analyzed, avoiding other, less relevant aspects that would be considered if the researcher
was using another qualitative, more hermeneutic method (Schreier 2012).
There is a debate involving two different opinions on the possible use of this method.
According to some (Früh 2007, Krippendorff 2004 and Merten 1995), Qualitative Content
Analysis can offer some degree of generalization, and conclusions taken from the analysis go
beyond the material under study. Others (Rustemeyer 1994, Lisch and Kriz 1978 and Rössler
2005) claim that this method can only describe the material to which it is applied (Schreier
2012, 2–4). In our study, due to the type of material we are dealing with, we can be on the
same side of the second group of researchers. Our data will give us no further knowledge
than the words of the respondents during the interviews, which we can describe for what
they are. Without having information on the background of the participants, on their
upbringing, on their relationship to healthcare in general, to motherhood, to the state and
the laws, and so on and so forth, there is little space for adding extra meanings to the words
they say, without merely speculating.
We selected Qualitative Content Analysis among other methods for its characteristics are
systematicness, flexibility and usefulness for data reduction. The first characteristic implies
that Qualitative Content Analysis is made of 8 steps: deciding the research question,
selecting material, building a coding frame, dividing the material into units of coding, trying
out the coding frame, evaluating and modifying it, analyzing the relevant data, interpreting
and presenting the findings. The second characteristic of Qualitative Content Analysis,
flexibility, means that the coding frame has to be essentially data-driven and adapt itself to
that particular set of data. This way, both reliability and validity of the coding frame will
raise. A third useful quality of Qualitative Content Analysis is the fact that it narrows down
the aspects analyzed to the ones relevant for the particular research question of the study
and it categorizes the information according to a particular coding frame (Schreier 2012,
5–7).
For comparative purposes, we will also use Constant Comparison as a tool for comparing
two different countries, Denmark and Finland, and finding possible common patterns. The
constant comparative method has been described by Glaser and Strauss (1967) (in Buchholz
55 2000) as using joint coding and analysis to “generate and plausibly suggest many categories,
properties and hypotheses about general problems.” The main analytical commitment that
characterizes the methodological Constant Comparison is the analytical task to
systematically compare elements throughout a research project. These elements can be
data instances, cases, emergent categories and theoretical propositions (Richardson J.T.E.
1996, 78). When having to compare different interviews, like in our study, it is first useful to
classify specific information in higher-order, more abstract themes or categories, following
the Content Analysis procedure. This way, although small details will be sacrificed, it is
possible to then compare and find similarities or dissimilarities between two texts – say, in
our thesis, between a Finnish and a Danish interview – using Constant Comparison.
In more practical terms, the transcription of each interview that was carried out as primary
data for this thesis was read thoroughly and each relevant segment of data from the
interview was coded. We coded the relevant segments of the interviews into categories to
illustrate certain concepts, and these categories into broader, abstract themes. We then
made a macro-division of these themes into two: some were framed as negative
experiences, and some as positive experiences.
In the first macro-group, we included positive and unproblematic experiences. By
unproblematic experiences we mean those experiences where everything went problem-free
but the interviewees did not make positive remarks. ​
Positive experiences included positive
interactions with professionals and positive expectations towards them and the treatment.
The second macro-group includes negative experiences, legal and institutional barriers, lack
of information and incomplete institutionalization. The theme ​
negative experiences consist
of negative interactions, but also negative expectations towards care (e.g. fear of
homophobia) and expressing gratitude or surprise after receiving a good service. The theme
legal and institutional challenges incorporates legal or institutional problems that the
women faced during the whole process of becoming parents, their concerns, their
frustration with laws and procedures and wishes for changes. The theme ​
lack of information
includes both the lack of knowledge and experience from the professionals. The theme
incomplete institutionalization covers all the institutional faults and shortcomings (like lack
of appropriate forms), the occasions where the professionals were reported to behave in a
heteronormative or heterosexist way (e.g. assumptions about the patients’ heterosexuality,
language misuse), and those where the non-heterosexual family redefined the concept of
56 family itself by ​
queering it and adapting it to their family arrangement. Once the themes
from the interviews had been formulated and framed, we made use of the literature to
analyze, explain and interpret our findings. We interpreted our results both singularly,
meaning for each interview, and in a comparative key, between the two countries.
All in all, the analysis was performed in five steps. First, all interviews for both countries
were repeatedly read until we were able to acquire a comprehensive feeling of what the
research subjects communicated. The second step was an examination of how the
informants described their experiences when transitioning into parenthood in Finland and in
Denmark and as patients in public healthcare during this phase. During this step, a variety of
different perspectives emerged after what matching responses were sorted into categories.
Third, after reading the interviews several times, recurrent answers were organized into
different categories, which were revised when needed after each re-reading. During the
third step of the analysis, the categories were grouped under three more abstract themes,
and under four more specific ones. Fourth, each theme was analyzed separately and linked
to the theoretical framework. Yet, it is important to note that even though the categories
were organized and analyzed separately, in each of them, different theoretical concepts
were useful to interpret our findings. Fifth and last step of our analysis, we performed a
comprehensive comparison between the Finnish and Danish analyses.
5.5. Ethical Considerations
B. Carraro
Due to the sensitivity of LGBT people, which are on average a more vulnerable group for
harm, a number of precautions have been taken (James and Platzer 1999). In-depth
interviews can be demanding for the respondents, for the degree of intrusiveness and recall
difficulty. Thus, the respondents must be granted both protection and control, by giving
respondents the option not to answer each question and to stop whenever they wish so.
(Richardson J.T.E. 1996, 177–9). allow the respondents autonomous decisions as for what
and how much to tell.
There is ongoing debate about whether it is necessary for researchers to identify their own
sexual orientation in studies related to sexuality. Self-disclosure by the researchers about
their own position in the LGBT community makes it generally easier for the respondents to
open up with the interlocutor, even though they have not met before. James and Platzer
57 support this view, stating that there are three main advantages of the fact that the
researchers are a part of the LGBT community. First, the researchers are more likely to have
insider knowledge about current debates and of LGBT history. Second, the researchers are
more prone to start the dialogue in good terms with the sample group of people, since they
are supposedly ​
on the same side​
. Third, being interviewed by an insider possibly makes
respondents more trusting and open (James & Platzer 1999). Nevertheless, establishing role
boundaries is important as blurring of roles is a factual risk (James & Platzer 1999, 79). By
performing the interviews always in pairs, we made sure that neither of us was
over-sympathizing or taking sides. All questions were asked without assuming or suggesting
anything that might have interfered with the answers, ​
how and ​
why questions were
preferred in order to encourage the respondents to elaborate their answers further.
Trust is an essential precondition for people to tell personal details of their lives, and can be
achieved by giving something of yourself, appearing trustworthy and by stressing the
confidential nature of the interview (Richardson J.T.E. 1996). In our project, we guaranteed
confidentiality to our respondents by giving out copy of our privacy statement (see Annex 4)
that explained what would be done to their information and how their anonymity would be
guaranteed. We assigned code names to participants (see Annex 2) for confidentiality
purposes and used them in all data collection and transcripts (O'Neill et al. 2013, 215).
5.6. Study Limitations
B. Carraro
The sampling method we used may contain some limitations. For instance, Platzer and
James (1999) state that the weakness of the snowball sampling method is that researchers
tend to receive similar data. This method was chosen, however, as it was the best way of
recruiting participants and as it proved to be most effective in comparable studies (James &
Platzer 1999). A single-stage non-probability type of sampling like snowballing is adequate
when researchers cannot identify members of a population in order to draw a
representative enough sample (e.g. random sampling would be impossible) (Blaikie 2010,
176).
The language was one of the limitations of this study. The couples interviewed (except for
one) had to express themselves in English, which is not their mother tongue, therefore, the
use of certain words or phrases could depend on their vocabulary limitations and not on a
58 conscious choice. Ambient disturbance was inevitably a part of the face-to-face interviews.
These elements might have represented an obstacle for the couple to speak freely and
extensively, or to focus on the interview rather than the disturbance elements.
Limited generalizability of our study is due to the small size of our sample, nevertheless, as
population homogeneity increases, sample error decreases and sample reliability increases
(Blaikie 2010, 185). The 20 participants to our study may not be representative of all gay
patients in hospital care, but they are able to illustrate gay patients and their partners’
experiences of being nursed in a heteronormative communicational and attitudinal context
(Röndahl et al. 2006, 379–380). Although geographical distribution of the couples turned out
to be rather satisfying, the sample contains inevitable geographical limitations, especially in
the case of Danish participants, which mostly came from the Capital Region.
As the retrieval of information gets harder and harder as events are further in time, we often
gave examples to help our interviewees recall past events (Kreuter & Conrad 2014). The
presence of the women’s partner during the interview with us, was seen as a deterrent for
untrue reports, in addition to operating as a memory help. For this and other reasons,
participants who were interviewed jointly with their partner may have told their stories
differently or more accurately than those that were interviewed individually. Clearly,
because we did not measure or observe the actual experiences and we are merely reporting
the stories of these experiences, we trust our respondents to give us a truthful self-report,
although the narratives told by the participants may not portray ​
exactly what happened. The
data collected within this study consist therefore of narrative accounts that are as close as
possible to the reality of the events, but are likely not to be entirely identical to what
happened (Hequembourg 2004, 744).
6. Analysis
S. Sirkkala
In this chapter we report and analyze our findings. The main division of this chapter is based
on the two main research questions we have proposed. The first half of the analysis answers
the questions whether our participants had an atypical healthcare experience in Finland and
in Denmark and what are the factors behind it, in case their experience was indeed atypical.
Thus, the first half consists of our interviewees accounts reporting unproblematic, positive
and negative experiences. The second half of the analysis answers the question whether
59 institutional differences between the two countries have an influence on the experiences
that our respondents reported. It consists of accounts reporting legal and institutional
challenges, lack of knowledge and incomplete institutionalization. Within each of section, we
first present our findings from Finland, then our findings from Denmark, followed by a
descriptive and analytical comparison between the findings from the two countries. We
have also incorporated our theoretical framework into the analysis, when useful for
interpreting the participants’ accounts.
6.1. “Suddenly I was overwhelmed with being a minority”
S. Sirkkala
In this first part of the analysis we consider whether the lesbian parents’ healthcare
experience is atypical compared to the heterosexual couples’ standard experience and what
are the possible reasons that make their experiences atypical.22 We grouped responses
under subheadings: Unproblematic, Positive and Negative Experiences.
6.1.1. Unproblematic Experiences
S. Sirkkala
The first major theme that arose from the data is unproblematic experiences, including
subcategories of neutral experiences and encounters and practices considered appropriate
by the interviewees. Thus, in this section we describe the experiences of the participants
where they could ​
pass through healthcare services without any notable problems and
transition into parenthood without legal, cultural or interpersonal challenges or barriers.
6.1.1. Finland
S. Sirkkala
Concerning legal entitlements connected to parenthood, such as parental leaves, nearly all
biological and non-biological mothers provided answers, which suggested that they did not
faced any problems in sharing or obtaining the leave from their workplaces. For example,
Grace said: “I get the father's money and all that. [...] there was no problem with it. [...] I
was working at that point and there was nothing weird about it, they just gave the leave
and.. Yeah, it was pretty easy.” However, one participant had difficulties getting her
We define a ​
​
typical or standard​
healthcare experience as an experience that does not entail stress, fear or negative
expectations toward treatment due to discrimination based on sexuality or family arrangement. It is an experience is what
heterosexual couples normally have, where the are no surprises or particular reaction to their family constellation, as it
does not matter, because heterosexuality of patients is assumed and expected.
22
60 paternity leave because of her employer, and she had to submit documents demonstrating
her legal right to the leave. Yet, all other couples acknowledged equal legal recognition of
parental rights between the biological and non-biological mothers, but they also noted how
going through a second-parent adoption process was a prerequisite.
As the interviewees described their path to parenthood in ​
general terms, four out of five
Finnish couples simply thought becoming a parent in a same-sex relationship in Finland is
“easy” as they did not face any insurmountable barriers regarding for example conception
processes. They also generally considered that their treatment did not differ notably from
others due to their family constellation. However, the couples highlighted the fact that they
have access to fertility treatments only in private clinics, where the same-sex couples are
welcome as any other paying customers. Several couples felt, generally speaking, as if their
treatment was not any different from ​
the​
ordinary​
​
.
“In many ways I don't think it [becoming a parent] differs from heterosexual
relationships. [...] I expected there to be more differences and more something that
would be very different from others, but I don't think there really has been.” (Lucy)
Especially in the Finnish capital region, the participants described the reactions from the
professionals to their family composition as “nothing out of the ordinary,” and that they
were not “the first lesbian couple” being treated in their chosen hospital. Their general
thoughts about the experience of the healthcare professionals was that the staff seemed
experienced working with patients who are in a same-sex relationship, because there were
numerous “couples like us” and the professionals “are used to it”. The couples further noted
that sometimes it even seemed as if their sexual orientation or family composition was
irrelevant for the nurses, when the focus was on the care procedures and not on the
individual patients and their sexual identities. Amelia commented that ”I don't really see like
we have any different or special treatment. Because I mean as a whole I see they're
prepared and they know what they're talking about [...] They haven't really specifically
talked about “you” as a gay couple.” These couples remarked that a likely consequence of
the presence of numerous LGBT individuals among all patients in bigger hospitals, is an
increased preparedness of the medical staff to treat LGBT individuals, couples and families.
61 Yet, the couples stressed how the situation would be different, should they live somewhere
else. In fact, couples from a smaller towns did not recognize any experience among the
medical staff during their encounters with them in their home towns. Then again, in a much
bigger hospital in a bigger city they found that the situation was different. Ella and her
partner Poppy remarked that “in a Central Hospital level” the treatment they received was
just as it would be for any other (heterosexual) couple. Thus, the participants’ general
experiences differed depending on geographical location and even the size of the hospital.
Despite the general and positive accounts of the staff’s competences, the respondents
contradicted themselves in this regard in the course of the interviews, when more specific
events were recounted (analyzed in section 6.2.2.). This is why we interpret the
“preparedness and experience” of medical staff in this case as generally neutral experience,
instead of positive, as they were mainly reflections on the way their overall treatments
proceeded without major challenges, and the way the entry of the lesbian couple was not
greeted in any particular positive or negative manner.
In relation to legal rights and institutional safeguards for same-sex headed families, all
Finnish couples considered that their families are protected by the state laws and
regulations as any other families. They did not think they were compelled to fight for rights
for their family nor to struggle to receive care and other services. Nevertheless, it has to be
emphasized the situation was found unproblematic after, and only after​
, finalization of the
second-parent adoption. All the Finnish couples made recurrent remarks how the
unproblematic situation ​
regarding legal protections was achieved solely after the adoption
process was finished and the co-mothers’ parental rights were legally recognized. For
example, co-mother Grace was confident that no one would question her parental rights
after the adoption was completed and thought the law states clearly that after adoption her
child has two legal and ​
equal​
parents.
All in all, families led by lesbian women in Finland are nowadays granted somewhat
comprehensive legal safeguards. These safeguards provide these families similar, but not
equal, legal status with heterosexual-led families (against what rights are traditionally
measured). In fact, as Carabine argues, heterosexuality has been, and to some extent still is,
the premise to welfare policies and in welfare practice. Thereby, the obligatory internal
adoption is a clear example of the differentiation made between heterosexual and
62 non-heterosexual headed families, as the default heterosexual families do not have to resort
to additional legal measures in order to acquire formal recognition of their family members.
This is an example of normalization of heterosexuality in social policy resulting in partial
inclusion and conditional eligibility due to not conforming to the norm (Carabine 2001, 293).
6.1.1.2. Denmark
B. Carraro
For the couples interviewed in Denmark, being a lesbian parent has been in general "easy",
"same as everyone else" or even "great". People from the Capital Region expressed their
well-being in the city they live in and linked geographical location of the hospital with
openness of the medical staff and the civil servants working in the area. Despite the fact that
those women thought things would have been worse, had they given birth somewhere else,
we found that the couple coming from the Region of Southern Denmark had a very positive
experience. Tara described maternity as a very common experience among Danish lesbians:
“I think it’s more common as a lesbian couple to get kids now, than not to get them”. Sienna
remarked how becoming a parent in 2013 in Denmark was easier than when she and her
former partner had their child eight years earlier. None of the Danish mothers could think of
differences between how the law would treat their child as opposed to children of
heterosexual couples. The majority of our respondent reported that they are confident
about their rights as parents and as a family.23 Obtaining parental leave from their
workplaces had also been in general problem-free for the couples.24
Getting fertility treatments within public healthcare was reported generally as a
unproblematic experience. None of them had heard any myths or stereotypes about LGBT
families from the medical staff and couples felt mostly acknowledged as parents and called
with the right names.25 However, in some episodes, some of them reported incidents when
the staff did not acknowledge the other mother or called her with a wrong title. All Danish
respondents thought medical staff had professional experience with treating same-sex
couples and they linked the professionals’ experience with LGBT patients to their openness
​
Three-parent families represent an exception, because the third parent (namely, in our sample, the co-mothers) were
not legally the children’s parents and therefore lacked the basic parental rights. 24
Except for three-parent families, where only the biological mother and father had right to parental leave. The two
​
non-legal co-mothers had different treatments: one had her work schedule rearranged and the other could not get any
leave.
25
​
When asked whether the staff in the hospital ever asked about a father, Tara answered without hesitation: “Nooo! I
think they know how it works now. That would be a completely stupid question [...] I’d feel offended I think.” 23
63 towards sexual minorities. Her wife Erin agreed: “I think it felt quite natural for me to be
there and for us to be there together.”
Danish couples that became parents more recently26 , said how being married made
adoption procedures more straightforward, for instance, as no ​
care and responsibility
declaration had to be submitted. Most couples said to be pleased to see how bureaucracy is
evolving and the system is adapting and optimizing its procedures. The adoption process had
been "the worst part" for Freya and Erin in 2012-2013 and they expressed their relief for the
approval of long-wished changes in the second-parent adoption procedures. After Diane's
baby was born, she was positively impressed by the name tag on top of the baby’s hospital
cradle reporting the names and surnames of the two mothers and two female signs next to
it. Aside from these positive remarks, however, only two out of ten women had neutral or
positive feelings about the written information material the hospital had provided before
and after the birth, and almost none of the respondents thought the forms they had to fill
out were appropriately designed to include their family.
Professionalism was a characteristic most mothers attributed to the medical staff. Erin
reported the medical staff being more focused on the project of conceiving and delivering
rather than other aspects. For instance, Kaelyn said she felt treated more like a pregnant
woman than a lesbian, and two couples said they rarely think of themselves as lesbian
parents. We argue this ​
lack of thought​
, the fact that these women identify themselves and
live more as women, mothers and citizens before lesbians, can be attributed to the lack of
presence of discrimination and homophobia in their daily lives.
6.1.1.3. Comparison
B. Carraro
Two main sets of results emerged from the data from the two countries. First, the Finnish
couples found the experience of becoming parents in a same-sex relationship overall easy,
as illustrated by getting fertility treatments in private clinics. Medical staff was also reported
to be more used to same-sex couples, but in bigger cities and hospitals, and therefore,
reacted in a more neutral way to their family arrangement. Second, the couples reported
feeling protected by the law and social security system as parents once the adoption was
through.
26
​
From late 2013 to 2014.
64 In Denmark, the first set of findings revealed how becoming a parent in a same-sex
relationship has been easy and even “great”. Getting fertility treatments in public healthcare
was not a problem, as long as the couples had an anonymous donor. If their wish was to
include a known donor, the law formally does not allow for public healthcare to provide
assistance. The staff Danish mothers met mostly proved to be actively LGBT-friendly and
very used to same-sex couples. The second set of findings for Denmark shows how couples
feel protected by the law and entitled to have the rights they have.
In both countries, the overall judgment that couples gave on becoming a parent in a
same-sex relationship was that it had been rather easy. Half of the Danish women said that
their experience had been so good that they do not think of themselves as belonging to a
minority. All couples in both countries found that getting fertility treatments was easy,
although notable differences affect the experience in the two countries. For the Finnish
couples, private clinics were the only place where they could get fertility treatments, and
therefore their experience as paying customer might affect the comparison to the
experience Danish women attending fertility treatments in public healthcare centers as
patients. In Denmark, all respondents said the professionals seemed very used to same-sex
couples, and in Finland, only in bigger cities and hospitals.
Once the adoption is through, and only ​
then​
, Finnish and Danish couples reckon their family
is protected. The length of the adoption waiting time varies greatly between the two
countries, making the road to parenthood very different.27 We also noticed Danish couples
feeling more entitled to the legal rights they have as a family. Several Danish couples
appreciated the changes that the co-mothership law has undergone and, because of them,
couples who had children in 2014 had an easier time becoming both legal parents.28 Getting
parental leave was easy for four out of five Finnish co-mothers and for all Danish co-mothers
that had legal parent status (four out of six couples). It was not easy or straightforward for
one Finnish co-mother from a small town and for the two Danish non-legal co-mothers.
27
​
This topic will be expanded and explained in the next sections. ​
These findings do not apply to couples who had a child with a known donor, which are not recognized under the law and
therefore face a whole different set of struggles, such as impossibility to get fertility treatments and the lack of parental
rights for one of the three parents involved. 28
65 6.1.2. Positive Experiences
S. Sirkkala
The second theme arising from the data gathers the lesbian couples’ experiences of explicitly
positive interactions with healthcare professionals and positive ​
feedback and observations
regarding the transition phase into parenthood in the healthcare provision as well as in a
broader institutional context.
6.1.2.1. Finland
S. Sirkkala
As the participants recounted their first encounters with the healthcare staff and the
atmosphere in the hospital, nearly all had positive interactions with healthcare
professionals. Most of the couples highlighted how they were treated well ​
irrespective of
their sexual orientation. Olivia recounted a positive interaction with nurses who welcomed
both mothers with easy and light small talk about motherhood and giving birth: “[...] it's
really nice, I mean, these examples where you can talk freely about these things and it's not
like ‘How to address you? What can I say?’ It was really nice.” In general, Olivia and her
partner Emily were left with a really positive impression about the way they were treated
like a family and about the curiosity lesbian motherhood raised in some nurses. Then again
Ella and her partner Poppy, remarked how “everybody knows each other” in their small
hometown and thereby, their first encounters with healthcare staff and their reactions
towards them were “totally normal”. They further described how they were also feeling very
comfortable during their care as one of their nurses welcomed them “amazingly well” and
even addressed the co-mother according to the couple’s wishes. Also Chloe described the
atmosphere at the healthcare center as “warm and nice”, the staff as “professional” and that
she and her partner were “really happy” about the treatment they received. Furthermore,
Chloe described how she and her partner Isla appreciated the fact that a nurse disclosed her
excitement regarding the fact that they were his/her first lesbian patients.
Moreover, incontestably recurrent positive reports throughout the Finnish couple interviews
were experiences recounting how healthcare professionals acknowledged inadequacies in
the healthcare provision. A total 80% of the Finnish interviewees had positive interactions
with healthcare professionals despite challenges with heteronormative bureaucratic
language in official paperwork provided by the healthcare centers, such as forms named only
according to ​
mother and ​
father​
. The nurses were apologizing for the language used and thus,
66 the inadequacies in the official material especially in situations where co-mothers were
required to fill in ​
paternity forms​
. Chloe and her partner Ella narrated how they received
profound apologies from the professionals who considered it “embarrassing” to ask the new
co-mother to write into the father’s form. Thus, according to the couples, the healthcare
professionals were mostly well aware of the inadequacies, and they were undoubtedly
regretful for not being able to provide any LGBT family specific material. Poppy described
how she and her partner Ella had “such a good nurse that she was always apologizing when
she was handing over those papers: ‘these are again those mother and father forms.’”
Carabine (2001) argues that social policy, which healthcare is part of, has a tendency to
support, recognize and defend normative sexualities while other sexualities remain marginal
or even invisible. The heteronormative forms that the Finnish couples mentioned are an
example of how those not conforming to the heterosexual norms are being ignored resulting
in invisibility. Furthermore, within this aspect of invisibility lies the reason why for example
lesbians have been ignored in the development, implementation and provision of social
welfare such as in healthcare in case of governmental standardized forms (Carabine 2001,
294–5).
Among the respondents, the apologies were highly welcomed turning potentially negative
and awkward incidents into considerate and respectful situations. What is more, according
to three couples, nurses also seemed mostly aware of the spoken language and vocabulary
they were using, as the couples noticed the staff trying not to use the word ​
father around
the lesbian headed family and trying to address both of the mothers with the same title:
mother​
. The participants explained how they noticed that the personnel tried to make an
effort in including also the non-pregnant parent in the care and to be careful about not
leaving her to feel like an outsider during treatments. Two couples further commented how
positively they were affected by certain professionals’ expressed desire and even excitement
to learn more about lesbian families and about other LGBT-specific issues that the couples
were able to share with them. These expressions of willingness to learn can be seen as
means of the professionals to explain, apologize and compensate for their lack of experience
and knowledge.
An additional positive experience was described by Isla and her partner Chloe, who were
also wondering whether Chloe, being the co-mother, could also breastfeed the child. Since
67 members of the medical staff could not provide an immediate answer, one particular nurse
decided to do research on her own and later informed the couple by email. This episode left
a strong positive imprint on the healthcare experience of this couple as they were genuinely
delighted by the nurse’s own initiative. In a similar manner, Holly and Amelia recounted how
an individual nurse gained a key role in “saving the situation”, when the couple had
encounters with a doctor who had evident difficulties with providing quality care for the
couple. For their positive surprise, a training nurse, who was involved in the care, made an
additional effort to compensate the doctor’s behavior by trying to be “more sensitive”, in
contrast to improper and inconsiderate behavior of their doctor. The couple explicitly
expressed their gratitude to the way this individual nurse handled the occurrence.
The ​
so very natural experience of having children for many women, can become a deviant
experience when lesbian couples enter the heteronormative space of maternity wards and
delivery rooms. Due to the atypical nature of the lesbian couples in these particular public
spaces, the situation does not only require strategies from the lesbian couple to adapt to the
existing structures, but also the medical personnel must orient themselves in a different way
to make ​
queer spaces possible for the prospective lesbian parents and their families
(Goldberg et al. 2009, 543; Goldberg et al. 2011, 16). In fact, what happened in the case of
the Finnish couples, the personnel became suddenly aware of their heteronormative habits
and the heteronormative care structures disrupted by these deviant couples and thereby,
they had to compensate the lack appropriate care and practices by apologizing and
deploring.29
6.1.2.2. Denmark
B. Carraro
Most Danish couples gave a lot of importance to the way the medical staff interacted with
them. Phoebe was very pleased to notice that “everyone was so good at their job”. When
she and her wife Jane went for a tour at the hospital, they were not initially noticed among
all the other heterosexual couples by the midwife, but the very moment the midwife saw
them, she immediately changed her vocabulary: “She looked at [Jane] and she was like ‘this
is for the dad...no... for the partner’ [laughs]” (Phoebe). Similarly, Rose stressed the
​
Our Finnish data further suggests that positive expectations were mainly related to the recently approved Finnish equal
marriage law (in effect in 2017) regarding three issues: surname, adoption and access to public fertility treatments. These
hopes convey a message of claiming equal access to rights that are already granted to opposite-sex couples, such as a more
equal stance with heterosexual couples with children (via discarding second-parent adoption and automatic right to
common surname). They also commented how changing the law has the capacity to “change the atmosphere.” 29
68 importance of positive interactions with medical personnel as the element having most
impact on the quality of the experience. After ​
coming out as a three-parent family, Rose said
they did not register any prejudice or problematic reactions, and her wife Senna added that
there were “many signs of approval” of their decision to have a family with three parents:
“Then the people […] we met. That is of course the most important thing. They have
always been willing and able to, sort of, figure out how our circumstances were and..
And of course help us with the background that we have. […] it is just like ‘okay,
that’s comfortable when you have two children!’. That was the most common. ‘What
a smart solution!’ [...] But the best experiences was when they absolutely did not […]
make a subject out of it. Just notice it and kept on talking about the things that were
going to happen and […] physiological things” (Rose)
In Diane’s case, she was most impressed by the interaction she had with the chief doctor in
the neonatal department where she gave birth. The doctor was giving her some instructions
before entering the delivery room, and because the doctor was clearly in a hurry, she spoke
about the child's father, assuming that there was one, without leaving too much space for
Diane to correct her. Diane said she did not interrupt her and she just mentally replaced
father with ​
other mother​
. Diane described with amusement the situation the next day after
the birth:
“Then the next morning when I went to see my daughter for the first time and met
the doctor, she was walking around with other nurses and then came to me and hit
me in the shoulder and said ‘Oh [Diane], you should just have said it was a girl! That
confused! [...] We have so many lesbian couples, you should have told me!’ ‘oh, well,
I didn’t’ because I could see she was very busy.” (Diane)
We interpret the fact that the doctor reacted strongly giving two main possible explanations.
First, the doctor wanted to emphasize how LGBT-friendly she is, and how there was no
reason why Diane should lie to her or omit that her partner was actually a woman. Second, it
is almost as if the doctor was reproaching Diane for giving her so little credit and thinking
she would discriminate her for her sexual orientation. The doctor also mentioned experience
in connection with acceptance and openness (“we have so many lesbian couples”). Diane
justified the fact that she did not correct the doctor, saying that she thought it did not
69 matter, but as it turned out, it did, because later when the midwife was looking for the
husband, she obviously could not find him.
In general, Danish couples appreciated the fact that, although the forms they had to fill out
were for the most part heteronormative, civil servants and healthcare staff were often
apologizing for that and helping them get past the obstacle. When Jane could not
understand whether she had to write her name on the ​
baby's father section, the midwife
was “​
so sorry” and “thought it was so embarrassing, that it said father and not [second]
parent” (Phoebe). Freya and Erin, for instance, overlooked the fact that the paperwork they
had to deal with was heteronormative, because of the civil servants and hospital staff
apologized for it and instructed them on how to proceed. Freya expressed her gratitude for
the help received from the employees in public administrative offices: “you could feel that
everybody was working to make this work as smooth as possible”. The mandatory interview
Erin had to go to in order to adopt their child was, as she defined it, “really pure pro forma​
”
and was no longer going to be necessary under the upcoming new regulations, later in 2013.
Jane reported being confident that, whenever her and Phoebe will decide to have their
second child, the procedures for adoption will be easier and the civil servants and hospital
personnel will be more prepared. The expectation that forms will be updated is something
three other Danish respondents have said. All except those with an involved father were
confident that their families would also be protected in the future, under circumstances such
as divorce or death.
In a couple of occasions, medical staff and public employees have shown to make an
additional effort, anticipating their needs and assuming correctly before the couples had to
explain. For example, even though Scarlett and Tara normally called each other ​
kæreste
(girlfriend/partner), the hospital staff could see they were married from their personal
records and took the initiative to call them ​
kone (wife), giving them a title that the couple
itself did not use. We interpret this as a positive sign of normalization of the term in
everyday use: applying it also to married same-sex couples means that the professionals
were not only used to, but also comfortable using it in a non-heterosexual context. The use
of this word is a clear sign of mentally and socially institutionalizing same-sex marriage on
equal footing with heterosexual marriage. Tara noticed the professionals making "a little
extra effort" towards them: "sometimes I think they go a little further, to be nicer, they want
to make sure that we feel that we’re welcome". Kaelyn also commented on a situation
70 where authorities ​
free-willingly recognized her family constellation in a situation where
there was no actual legal necessity to do so, and expressed her gratitude by saying:
“Sometimes it works kind of the other way, we don’t always have to fight all the time,
someone is fighting for us.”30
Some of our Danish respondents told about some episodes when the medical staff even
made exceptions to the rules in their favor. For example, although Rose was formally
allowed to bring only one person in the room where ultrasounds were carried out, the staff
granted access to both her wife Sienna and the father, after knowing and understanding
about the family composition. The same rule was also bent for Kaelyn, her wife and for the
father of their children. These two co-mothers also reported that professionals were
understanding of their situation, as well as their employers. Kaelyn was in the same situation
as Sienna when their children were born: as co-mothers they were not entitled to any leave
from work. However, both Kaelyn and Sienna managed to get it, as a favor from their
employers "because they were nice" (Kaelyn), and even though for both of them it was not
very long, "when you are not entitled to anything you are grateful" (Sienna). Sienna
expressed the importance of being treated the same as her colleagues and how after this
favor she has grown very fond of her workplace, for letting her begin her motherhood in a
positive way.
We found that the Danish couples, which did not have an involved father, felt entitled about
their rights and expected to be treated well in public spaces. When asked if the the law
treated their child differently than any other child, Scarlett and Tara firmly stated that it was
not the case, and agreed that “it should not” be the case. This statement indicates that this
couple knows their rights, is used to them from the beginning and feels entitled to have
them. Kaelyn stated that after introducing their family, her and her wife were fully
acknowledged as parents, and she expressed how she would expect that treatment: “I can’t
remember any incidents, because we always start to say, ‘Hello, this is my wife and this is
the father of our child’. […] Then it should be like very provocative if they ignored the third
person” (Kaelyn).
6.1.2.3. Comparison
30
B. Carraro
They granted a second-child discount in their kindergarten even though their two children had different birth mothers.
71 The first set of findings for Finland are the positive interactions with the staff, which
depended mostly on their good interpersonal skills, on their welcoming treatment and on
the attempt to make a situation better. The second set of findings are the occurrences,
reported by striking 80% of the Finnish couples, where the staff was reported to be
competent on the professional level, acknowledging when forms and procedures were
inadequate and non-inclusive. By apologizing for inadequacies the professionals were able to
turn a potentially negative incidents into something more positive. The first set of results for
Denmark is similar to that of Finland: mostly friendly, open professionals, some making an
extra effort were found to have a big impact on the quality of the overall experience. The
second set of results for Denmark showed how professionals were acknowledging
inadequacies and providing assistance to overcome obstacles, making up for
heteronormative forms and heteronormative bureaucratic procedures. In two cases, medical
professionals even bent the rules in favor of these patients, showing understanding for the
situation.
Both Danish and Finnish data suggests that positive interactions were mostly references to
good relational skills of doctors and nurses, which had a positive impact on the level of
satisfaction of the patients regarding the overall healthcare experience. Although couples
from Finland and couples from Denmark described their experiences and interactions with
the staff as positive, the nature and quality of those experiences actually varies a lot when
compared. On one hand, in Finnish sample, the positive interactions mainly encompassed
situations where healthcare staff did not ​
judge the lesbian couples accessing care and when
the staff was generally more focused on the reasons the couples were seeking healthcare
rather than the fact that their family constellation was different. On the other hand, in
Denmark, the professionals that left a good impression and determined a positive
interaction, actively manifested their approval towards the respondents, and made an extra
effort to ensure the wellbeing of the families. The professionals even bent hospital rules in
favor of the couples. Danish civil servants and healthcare professionals were more often
reported to actively help with bureaucratic procedures to allow couples’ experiences to go
as smooth as possible.
6.1.3. Negative Experiences
S. Sirkkala
72 Under negative experiences we have gathered responses that were general accounts of
evidently negative incidents. These are responses that include negative interactions with
professionals and negative expectations related to treatments or legal and bureaucratic
proceedings – even fear of homophobia or discrimination. In addition, in this section we also
included responses where the interviewees expressed gratitude for service.
6.1.3.1. Finland
While straightforwardly negative attitudes toward sexual minorities are nowadays less
widely held, heteronormativity and even homophobia are still often either encountered or
feared – also when it comes to healthcare. In reality, not even the public healthcare is
immune to ideologies, attitudes nor to actions that are responsible for negative experiences
and unequal quality of care based on sexual orientation (Fields & Scout 2001, 182). In fact,
contrary to some of the general accounts of positive interactions with healthcare
professionals in the previous section, the most remarkable negatively biased findings in this
section were also related to the interactions with the staff. Indeed, four out of five couples
from different parts of Finland had at least some negative experiences related to the
atmosphere in the hospital due to negatively biased communication with medical staff. Holly
and Amelia reported two occasions of very negative experience with their doctors. The first
incident was related to Amelia’s first pregnancy.
“[...] the doctor, she was […] I'm not gonna say the word but. She was not very nice,
let's say it that way. Especially if you think about the fact that you had just lost a
baby. You know, you would expect a little more softness or sympathy about it. [...] As
soon as she realized it was the two of us, her face was like… went from somewhat
normal to I don't know, upside down. [...] Rudeness, and if you asked something
then, the answers were like... one word.” (Amelia)
This couple strongly believed that their sexual orientation had an effect on the way their
doctor behaved in their presence. During the second pregnancy, Holly and Amelia had
another, similar negative incident with another doctor. Holly explained how she understands
that people can have “bad days”, but argued that in a profession like that one should still be
able to communicate in a respectful manner. Amelia argued that one could tell that myths
and stereotypes affected their treatment by the way the doctors were acting and from their
73 nonverbal communication, because their behavior seemed to change after they disclosed
that they are a lesbian couple.
Another couple, Poppy and Ella, described how they had a negative experience while going
to an ultrasound in a Central Hospital. They remarked how older midwives they encountered
acted as if they were either “seriously bothered” by the presence of the lesbian couple or
then “just tired” and speculated whether the midwives behavior was because of them or
whether they “had a bad day.” Moreover, they further stressed how they wished that no
other family would receive the kind of treatment they did, because their whole healthcare
experience was left with a negative imprint because of the negative interactions they had
with some of the professionals.
“[...] one could sense from few nurses that they didn’t necessarily accept same-sex
relationships, or at least their behavior was really downbeat, like ‘let’s just get things
done’ and ‘let’s exit quietly from the room.’ [...] Still we got the feeling that these
[nurses] have some problems. Like in relation to [same-sex] couples.” (Ella)
Also Grace and Lucy described experiences of negative nonverbal communication during an
encounter at the end of their pregnancy with a new healthcare staff member. This couple
reported how the professional treated Grace, the co-mother, as if “she did not exist” and
made “weird comments” about the biological mother’s special importance. They also noted
that some staff members “were maybe a bit awkward around us in the hospital.” Similarly,
Olivia and Emily also had a “really awkward” experience while participating in family
coaching provided by their healthcare center.
“They had no idea how to address [us]. Because they talked about me as a ‘support
person’ as opposed to a partner because we didn't we tell them [...] I'm her partner,
not just some support! [...] So it didn't go well and that was the only time we went
there [...] the whole concept is a bit stupid. But they had no idea how to deal with
us.” (Emily)
In two negative episodes, Grace and Lucy described how parenthood of the non-biological
mother was questioned. This was done by highlighting the importance of biology, which
created a potential for tension between the couple and the professionals as biological
74 connection of one parent was being seemingly favoured over the other. On the first occasion
the couple came into an office to handle paperwork related to their adoption, and the office
worker there started making inappropriate comments about the rights of the child’s
biological father.
“Yeah, and the lady there was a bit funny, because she gave me this lecture about
how it's important for children to know their biological roots and fathers and
mothers and everything. [...] She knew why I was there [...]. And I told her that this is
an anonymous donor so [clears throat], there is no father as such. But she said that
‘Well, well, then at least when she's 18 she'll know who it is.’ [...] Sometimes people
[...] refer to me as the ‘real mom’ and she [partner] hates that [laughs] because it is
kind of horrible.” (Lucy)
In this situation, the office worker implies that all children have an innate need for a mother
and a father, and thus, two lesbian mothers can never meet this need. It seems as if the
lesbian relationship and motherhood are considered as a threat to the natural order of
things and to the family ideal. Underlying this is the idea that only heterosexual couples have
a functional set of gender relations that are necessary to promote proper child development
(Hicks 2006, 764). Thus, the emphasis reveals the idea of superiority of the heterosexual
family undermining the capacities of the lesbian-led family to raise children.
Grace and Lucy had also another, similar incident in the hospital when one of the nurses
during her/his visit reinforced the normative idea of how the biological relation to the child
made the birth-giving mother “the real mother”. In this situation the couple faced challenges
in establishing parenthood in the face of others. It was as if motherhood and the capacity for
self-identification were denied from the co-mother by the healthcare professional, and as if
the co-mother does not have the means to identify herself as “a real mother,” it being
against the nurse’s customary comprehension of the family and parenthood (Goldberg 2011,
15–6). In fact, focusing on biological aspects of parenthood reveals important aspects of
gender, biology and heteronormative assumptions about conception within the healthcare
environment. When biology and genetic links are seen to be more important than parenting
relationship with the child, it can result in conveying messages about how the lesbian-led
family is considered to be substandard and even unnatural (O'Neill et al. 2013, 216, 219). In
short, it shows of how these families are considered ​
queer​
in essence.
75 A clearly revealing experience of negative expectations and challenges that the lesbian
parents faced regarding creating a family together, was the way Chloe explained how she
was glad that the healthcare professionals “weren’t even questioning” her and her partner’s
family constellation, and treated the couple “like normal people”. She also mentioned how
starting a family together in a same-sex relationship was easier than what she and her
partner had initially thought. Then again, Grace and Lucy expressed how they thought they
were “lucky” with the nurse assigned to them, because they received such good and
respectful care. This if anything reveals how, in essence, the expectation toward the care
was negative and how the unexpected positive experience was welcomed with gratitude. In
another occasion, similar negative expectation was obvious when Amelia and Holly were
asked how the co-mother Holly was included and addressed in the healthcare center by the
professionals. To this Holly answered how she was not “expecting anything special”, but how
at the same time she was consciously expecting that the co-mother would be addressed
somehow “differently”. She added: “If it's better, then good [laughs]”.
Holly provided another example by commenting how she was prepared for not receiving
information about her partner giving birth and thus, not being considered as family. She
commented how the healthcare staff, knowing their family situation, generally states that
they will consider the co-mother as family, but that they are not compelled to do so. Holly
said: “Depends if they have a good night or bad [laughs].” This remark shows the way the
trust on the medical personnel is compromised due to negative expectations and
uncertainty of the quality of treatment the expectant couple will receive. These negative
expectations demonstrate how heteronormativity and even homophobia are still often
either feared or encountered. These experiences demonstrate the way lesbian couples were
fearful of how they will be welcomed into a potentially exclusionary space often dominated
by heterosexual couples (Hubbard 2001). In fact, expectations direct individuals’ attention
and make them more aware of potential harms and difficulties they might face. By expecting
negative occurrences, the couples prepared themselves to deal with potentially challenging
situations in the future. Yet, in turn, the couples were consequently also more aware and
responsive to notice when those expectations were not met.
76 The Finnish couples expressed gratitude for service and treatment they received in many
ways. For example, when considering adoption, the couples expressed gratitude for good
service and workers’ helpfulness in the social offices. Poppy was relieved by the fact that
their adoption proceedings went ​
finally “very nicely”, without any major problems, and that
a worker in the social office was “nice and helpful.” Similarly, another parent was feeling
stressed about the whole adoption process and its preceding assessment, but was relieved
when the person responsible for it turned out to be “a nice lady”. Also the couples from the
capital region were surprised how well their own adoption processes finally went, “thank
God”, as they had heard how in other municipalities, “like in Lapland somewhere”, it might
take notably longer.
In general, the necessary legal step in the recognition of the parental rights in a family
consisting of two mothers, the adoption, evoked downright negative feelings and frustration
in all couples interviewed.31 The reality is that the combined time lag after the birth until
finalization of the adoption, due to ​
speed bumps such as adoption counseling and
bureaucracy, can make the time after the birth without a doubt precarious and stressful for
the lesbian headed family, as the family remains legally unprotected for a period of time.
The way one respondent phrased it, “Thank God nothing [happened],” gives an example of
the relief the lesbian couples assuredly feel after finalizing the adoption. Expressions of
gratitude for ​
smooth proceedings with the adoption can thus be seen as an expression of
relief the couples felt before, during and after going through the negative and stressful
experience.
6.1.3.2. Denmark
B. Carraro
Despite the fact that all couples in Denmark had positive interactions with the majority of
the medical staff, they all recounted about at least one episode when they felt annoyed,
embarrassed or uncomfortable about an encounter with a professional. For instance, Rose
expressed her discomfort and embarrassment whenever she goes to her gynecologist, due
to the fact that he keeps not getting the fact that she is married to a woman. She described
some recent episodes when she went for a checkup:
31
​
In Finland adoption proceedings vary depending on the municipality regarding adoption counseling and assessment
steps, as well as waiting time and a possible reflection period. 77 “he didn’t really [...] seem open to this gay thing. So actually he kept saying ‘the man’
about my partner and it was so really, really awkward situation. […] he is a very
sweet man but he just doesn’t really open up for [an] honest relation. […] And I get
like caught in that somehow and I feel really uncomfortable trying to.. […] and he
keeps forgetting from time to time, and it comes again and I just stopped correcting
him and it is not good. It is not good for an honest relation.” (Rose)
Rose acknowledged her own part of the fault in the non-completely-honest relationship, and
stresses both the importance of disclosing one’s sexual orientation to one's doctor and the
importance of having a doctor that is open and actively listening to his/her patients. Her
wife, Sienna, defined herself open about her sexuality and also stressed the importance of
coming out to one’s doctor, but at the same time said that once people have that
information, in several contexts (such as healthcare centers and at one's workplace) "it
becomes enormously confidential. [...] It's like you're giving a bit of yourself away". We
interpret these words as a perception of coming out as a double-edged sword: on one hand
it is a liberating act that can make communication easier and more honest, on the other it
tends to label the person and eclipses all the other characteristics of the person coming out,
if the interlocutor is not LGBT-sensitive. Rose pointed out how disclosure for her is especially
thorny when that person is a healthcare professional:
"You’re in a vulnerable [...] asymmetric power relation. [...] You’re sitting there with
an authority [...] and if they don’t show that openness or interest, you feel very small
suddenly. And you cannot get over that. I think it is really hard to fight. It feels like a
very big hurdle sometimes, to correct him or her. [...] You are very dependent on this
person [...] and this person’s ability to help you [...] So if suddenly you get scared that
it’s [...] an uncomfortable situation for him or her [...] it’s not very nice." (Rose)
As it becomes evident in this segment, not only are sexual minorities made invisible by
normative assumptions about heterosexuality and their family, but they even may end up
having to let welfare and legal practitioners believe that they are heterosexual in order to
avoid discrimination or so as to gain certain rights and welfare services (Carabine 2001, 295).
All in all, Rose and her wife Sienna recounted how there was two main episodes when they
felt treated differently than a heterosexual couple. The first circumstance was during the
very crucial moment of Rose's delivery, when one of the midwives was insistently talking
78 about her lesbian sister and asking questions about their family and their sexual orientation.
None of the two women appreciated what was likely said with friendly intentions:
“That was actually pretty irritating because we didn’t want to hear about her sister.
We just wanted to give birth. Focus on what was happening. But that is where they
want to show you that they are welcoming and they all know somebody […] and “I’m
a best friend..” (Sienna)
“It was a bit annoying because she really wanted to talk about our [...] sexuality and
being three parents. In that situation it just wasn’t appropriate I think. […] I was in
labour and it was just not the subject I wanted to talk about. So how has it been to be
in 3 parent relationship, same-sex... Argh! I don’t know! [scoffs]” (Rose)
Rose also recounted her frustration with other professionals that in other cases had shown
interest and wanted to make a conversation out of their sexuality or family arrangements
(“it’s not why you are there”). The second case in which the couple felt treated differently in
the healthcare context was when they met some professionals asking about how Rose got
pregnant and wanting to know which fertility treatment she had gone through: “so many
heterosexual couples receive fertility treatments as well and [...] you never talk about that,
that’s really an issue. But you can always ask a same-sex couple about their fertility
treatment because of course, they can’t do it naturally! [scoffs]” (Rose). Rose had also some
individual experiences that she labeled as negative because of the way the personnel
interacted with her. When Rose went to maternity coaching classes, the teacher kept
referring to the parents in the group as mother and father, and that made her feel very
uncomfortable and prevented her from coming out to the group. Rose also remembered
how once she got her own personal midwife and came out to her, the midwife seemed not
to take it very well, although conveying her hostility merely through nonverbal signs. In
Freya and Erin’s case instead, homophobic verbal remarks were expressly verbalized. Freya
reported the words of a nurse casting a shadow on the first joyful moments as mothers:
“just after birth there was this nurse that was saying a whole bunch of stupid things,
[…] that ‘but ​
your ​
kind of.... [people] when you are with a donor you have a higher
possibility of […] ​
svangerskabsforgiftning [​
preeclampsia​
]’. [...] Just before you give
birth, you can get it. It is not a disease but it is kind of an infection. [...] It is really
79 serious. […] She just assumed that we had a donor, which we had, but she didn’t
know. And it was kind of this ‘and ​
your ​
kind​
... [is] even at higher risk’ She said that, so
that was kind of disturbing.” (Freya)
Tara recounted how a doctor at the fertility department in the public hospital made a few
inappropriate remarks about her sexuality leaving her astonished and embarrassed. She
explained it to herself as a form of misogyny rather than homophobia: “I think that in
principle it was just an old male doctor, he could have made it to any young woman, to be
quite honest. So not so much because of the LGBT part”.
Kaelyn described her frustration with some of the personnel when she explained her
three-parent family arrangement and they expressed their approval of the presence of a
father in the child's life: “I mean this idea that a child needs to have a father is yeah it is kind
of.. what could you say in English. Old-fashioned and kind of sex-fascist, [...] the conception
that you need to have a man, because without a man the world will not stand.” In another
pregnancy experience, Diane was the one to whom the staff was mainly addressing the
information, without considering her wife during check ups. Diane justifies it with the belief
that doctors mainly address the birth mother when delivering information about her
pregnancy. Since Diane was interviewed alone, we cannot report how her partner
experienced being a co-mother, but even so, we will report what Diane remembered about
the treatment her partner received.
“I think my girlfriend sometimes got recognized wrong […] like, ‘Hey, I’m also a part
of this’ just like, ‘you’re not important’. I think if she would have been a man then
they would have thought ‘Ok, this is the father’. [...] Sometimes, she would say
afterwards ‘she [the doctor/midwife/nurse] didn’t even say hello to me’ or ‘she
didn’t even notice me’, ‘who did she think I was?’. [...] I’m sure [name of partner]
may have felt something in it, yeah I think she just feels as fathers do. All the
professionals are talking to the mother all the time.” (Diane)
On one hand, from the transcript emerges how Diane recognizes that some professionals
have not acknowledged her partner as they would have, had she been a man. On the other
hand, she contradicts herself when she said that her wife “felt just as fathers do” since the
professionals are talking to the birth mother. We interpret this, on those professionals’ side,
80 as an attempt to deny the existence of a lesbian couple in the room by focusing on the
pregnant woman without speaking to the other woman present. On Diane’s side too, we
interpret her attempt not to focus on the poor treatment of her wife as a denial. We argue
that she does not label certain treatments as homophobic because she does not expect
them, and she said to believe everyone treats her and her family the same as any other. This
almost full coverage the law assures to her family and her is arguably contributing to
disguise in her mind heterosexism and homophobia as merely misunderstandings or the
staff just having a bad day (Lee et al. 2011).
Several couples expressed their worry that some problem will arise in the future.
“Sometimes I think we’re too lucky” said Phoebe, “that it’s about to happen, one day. […]
Because I know that we are a minority, so [...] it wouldn’t surprise me if something would
happen” (Phoebe). Sienna does not have optimistic expectations on the future recognition
of three-parent families like hers: “I think that would make a difference. But I mean look at
the recent government change. It is not going to happen, not in a million years.” Sienna also
brought up her fear of homophobia when Rose was being examined by a midwife from a
non-Danish background, most likely Muslim, and remembered thinking “oh my God, you are
wearing a scarf, what do you think of us?” and later reflecting that one of the things LGBT
people should be aware of is that “As a minority, you can’t discriminate other minorities.
You have to try not to.” Rose also remembered in that moment being worried to get a
different treatment because of the cultural and religious beliefs of that midwife. She
emphasized the feeling of vulnerability in that context as an aggravating factor: “ It is just
that when you come in that situation and you are [...] so clearly a homosexual couple. You
feel like you are exposed and you think that [...] Islam is against homosexuality, and that is a
prejudice of course.”
Kaelyn was pleased to find that the situation was better than she had previously expected: “I
kind of feared that someone would ask silly questions or not respect us as a three-parent
family.” She also spoke about how she would expect things to be worse if she was a single
mother or a transgender person, and she said she was “glad” that her situation was easier in
comparison.
Erin was very nervous throughout the process of adoption, and was afraid that she would
“get lost in the [bureaucratic] system” and would not be able to adopt, or not to adopt since
81 the birth, because of some missed deadline or some rule interpreted wrong. Some other
co-mothers had the same concern. Diane believes her family has been lucky so far with the
treatment they received in public hospitals and state administrative offices, but did not
exclude possible challenges in the future of her child. All women from the Capital Region
thought that in other areas people are likely to be less familiar towards LGBT people, and
that might reflect on the way they get treated in public spaces.
“I think it would be different if you interviewed a same-sex couple somewhere […]
not in one of the biggest cities in Denmark, but in the countryside, in smaller
societies […] I think if you’d go to the countryside in Denmark, and ask a gay couple,
you will hear something else, maybe. […] But I think [...] it’s easy to be gay here”
(Diane).
After recounting positive experiences, some of the Danish women said to have been “lucky”,
rather than expressing words suggesting that they had what they expected and deserved.
Rose, for example, was surprised of how, at checkups, the father and the co-mother Sienna,
were put on the same level and both were involved. Freya reported surprise when
“everything went well” throughout her pregnancy experience with her wife Erin, and when
the doctors and nurses were prepared and treating them the same as any other couple. In
another case, when asked if she would have liked something to be done differently for her
overall experience to be better, Diane answered "no, I think we have been lucky". This can
be seen as her way of attributing the credit to luck and not to intentional good treatment
performed by the healthcare professionals. Diane also expressed her gratitude for the
Danish public healthcare allowing lesbian couples to become parents for free. Two couples
expressed their gratitude for the fact that the laws are evolving in the right direction, making
it easier for lesbian couples to adopt their children and build a family.
6.1.3.3. Comparison
The first set of results for Finland includes all the negative experiences the couples had.
These include situations where professionals manifested their awkwardness or where the
staff seemed seriously bothered by the presence of the lesbian couple, and when they made
inappropriate remarks showing, heterosexism or homophobia. The second set of results are
the negative expectations the couples expressed, before starting fertility treatments or going
82 to checkups, as well episodes when the couples reported surprise or gratitude for being
treated with respect, for being acknowledged as a family, or for the bureaucratic
proceedings to be going through without major problems. The first set of results from
Denmark are negative interactions that all couples except one faced at least once
throughout the perinatal experience: several inappropriate remarks, three cases of
reluctance to come out, two couples reporting staff not considering the co-mother, and one
episode of biologism. The second set of results are the negative expectations the Danish
couples had. Some of them disappeared when they received good service or did not have
the expected problems with adoption (three co-mothers out of six) and expressed gratitude
for it; some others still persist, like the fear for the lack of rights of non-legal co-mothers.
Almost all Finnish couples experienced negative interactions with the medical staff. In some
cases the staff was reported to be potentially homophobic, for example when they made
out-of-place comments or in one case when a civil servant made remarks about the the
importance of biological ties. In other cases, the behavior of the professionals was less
hostile, but still couples were left wondering whether they bothered the staff with their
presence or if the personnel just had “a bad day”. In Denmark, all couples except one had at
least one negative experience. Among these, the couples reported staff making
inappropriate remarks (one case) or asking intrusive questions (two cases), not
acknowledging the co-mother (two cases). Two women reported being hesitant to come out
and facing circumstances where they tried and were ignored or simply could not; moreover,
one woman reported episodes of staff showing approval of the presence of a father,
devaluing the lesbian couple as parents within that family. These episodes left a negative
imprint on the overall experience.
Negative expectations of Finnish couples consisted often of emotions such as fear or stress
regarding attitudes of healthcare staff and the treatment they would receive: couples were
not expecting co-mothers to be included and them to be recognized as a family and they
were anticipating that the staff would ask inappropriate questions. These couples also
expressed gratitude for receiving good service. Negative expectations towards healthcare
treatment were also found in Denmark, where five couples said to be thankful for being
acknowledged and not encountering homophobic staff. Negative expectations regarding the
adoption process were also reported in both countries. In the Finnish sample, the negative
83 expectations were reflecting reality more than in the Danish sample, where all four
co-mothers who did not have a known donor were able to adopt straight from the birth.
6.2. “We weren’t adopting a child, we were having a child”
S. Sirkkala
This part of the analysis compiles the Finnish and Danish participants’ responses and
narratives indicating legal and institutional challenges they faced when transitioning into
parenthood – manifested also in healthcare – in addition to their frustration with legal and
bureaucratic procedures. The question we address in this part is whether there are
institutional differences between Finland and Denmark that influence the type of healthcare
experiences lesbian parents have in these two countries.
6.2.1. Legal and Institutional Challenges
S. Sirkkala
Lesbian-led families are as dependent on heterosexist institutions as any other families.
However, they face additional barriers as they seek for ways to get pregnant (e.g. fertility
treatments, finding the right donor), as they go through the whole course of perinatal care,
and as they are often compelled to go through additional legal procedures to safeguard their
family, for example in case of co-mother’s parental rights. Thus, in this section we consider
whether these lesbian parents enjoy the same basic legal protections as any other group and
are certain civil rights guaranteed also to these lesbian citizens.
6.2.1.1. Finland
S. Sirkkala
The most preeminent finding under the theme legal and institutional challenges faced by the
Finnish couples was the inevitable internal adoption process that lesbian couples have to go
through to confirm the legal parental status of the non-biological mother. All five couples
felt strongly about the adoption process and raised a noteworthy concern about the whole
proceeding. First of all, the participants explained how they felt frustrated about the
obligation alone that they are compelled to go through the adoption even though they were
all transitioning into planned parenthood together and went also through fertility
treatments together as a couple. One participant characterized the process as “weird,
bureaucratic and stupid”, “frustrating and not needed” but not “difficult”.
84 According to the lesbian mothers, the most remarkable hindrance regarding adoption was
the possible reflection period32 , ​
granted ​
(or ​
issued​
) to the biological mother to give her time
to consider whether to go through the adoption or not, in addition to bureaucratic waiting
time, which is considered as a normal time needed to handle legal paperwork and a
consequence of governmental institutions’ slowness.
“When they are born, they're without the other legal parent for weeks. I think it's a
big thing. [...] When [name of the child] was born I had to wait eight weeks before I
could even consent, because in a normal adoption when the mother gives away the
child, they have to wait that she's not in a hormonal state. [...] Thank God they have
removed that part. It's a big thing that they're born. That they're not protected by
the law, in that case.” (Olivia)
Olivia and Emily expressed their frustration regarding the adoption proceedings and
experienced that the officials responsible for the adoption assessment agreed with the
couple and also thought it was “stupid and ridiculous”, but that everyone just have to “play
along with the rules” – even though the internal adoption is notably easier process in their
city than in other municipalities. Grace and Lucy also though the adoption was “weird” as
the adoption they had to go through is similar in many ways to adoption processes that
would be in place for a couple adopting a child through external adoption, including
adoption counseling and even home visits. During the adoption counseling and assessment,
Grace and Lucy felt as if the officials were questioning the true nature of their relationship.
Certainly, the officials responsible of the adoption counseling and evaluation are in a
powerful position to qualify lesbian couples as prospective parents. The compulsory
counseling that lesbian couples have to undergo can be stressful and feel even insulting for
the couple. What is more, the situation might take even a worse turn if responsible officials
hold negative opinions about lesbian relationships (O'Neill et al. 2013, 219).
Also the length of a waiting list and thus, waiting period vary depending on the municipality
in addition to varying measures concerning adoption counseling visits..33 Undoubtedly, due
to the extensive adoption process, a combined effect of the time scheduled for counseling,
Eight weeks reflection period is currently issued in Finland only if the couple has not registered their partnership before
​
pregnancy. Thereby, this period does not affect all lesbian couples equally (Finlex 2015c).
33
In fact, the​
answers provided by the couples in this regard varied in function of geographical location: the capital region
was regarded as providing the most easy transition to parenthood for the participants and on the contrary, in smaller
municipalities participants encountered more problems.
32
85 bureaucratic waiting period and a possible reflection period, the adoption process can be
seriously decelerated even when lesbian prospective parents, who are registered before the
conception ​
are able to start the adoption process before the birth of the child. This waiting
period might be even further extended in case of unpreparedness or ignorance of civil
servants to deal with the issue (Rainbow Families 2015; YLE 2012; Aarnipuu 2010, 29). In
fact, for Poppy and Ella the whole adoption process was especially demanding and took in
total six months due to bureaucracy, unpreparedness ​
and ignorance of civil servants
managing the adoption as well as lengthy counseling proceedings. That is, their child was
without a second legal parent for half a year. Undoubtedly, the situation was not only
precarious for this second parent, who did not have legal rights for the child during that
period, but also for the child who did not have the legal guarantees of two legal parents
should something happen to the biological mother.
“[...] the adoption was in effect [in July] and [the name of the child] was born in
[February] so what is the delay? Still six months. Six months took the adoption. So
that it will be in effect. So it is pretty long time [...] And in the cities, we have a family
acquaintance in [name of the city]. In [name of the city] and they got [adoption
finalized] in 1,5 months because their social office knew how to handle this issue so it
went through it faster there. So their adoption process was clear faster.” (Ella)
During the period of waiting for the adoption decision after the birth, the legal position of
the child and the rights of the non-biological parent are in highly precarious situation until
the adoption process is completely finished. This is simply because these couples lack an
automatic legal recognition of their family structure. Under unclear or unfinished legal
procedures, there are challenges, such as if the couple should decide to separate or the
other parent should die, which are problematic and which end result is uncertain for the
child, the parents and even for the extended family. This insecure period evidently raises
concerns over the rights of the prospective parents to protect each other, their family and
their children (Cahill et al. 2002, 23; Rainbow Families 2015).
Regarding adoption Holly and Amelia, who were still expecting their first child during their
interview, were expecting at least few home visits and reflection and bureaucratic waiting
period of few months after the birth, before their adoption would be finalized. They
acknowledged that the adoption process will be one of the biggest legal challenge that their
86 family will have to face. For Isla and Chloe, the adoption process was still unfinished after
four months at the time of their interview, because they were not in a registered (civil)
partnership before the pregnancy and consequently, could not start the adoption process
before the child was born. Thereby, they had to wait for the eight weeks’ reflection period
after birth. Moreover, they also had to go through the adoption counseling delaying the
process.
In essence, incomplete institutionalization encompasses the lack of institutionalized
guidelines and even support. This is evident in the case of LGBT families when their family
members face problems to which institutionalized solutions do not exist. An example of this
is the lack of institutionalized and thus, ​
automatic recognition of parental rights of
lesbian-led families. More specifically, the incompletely institutionalized status of the
lesbian-led family become evident when considering their transition into parenthood in
contrast to heterosexuals. Traditionally when the child is born, the child will have two
biological parents: mother and a father, who are also automatically considered as legal
parents (providing that they are married). Yet, when a lesbian couple attempts to conceive a
child there are always three people involved: the lesbian couple and a sperm donor. In this
case even when the lesbian couple is married or registered, only the birth-mother is
automatically recognized as the legal parent. Thus, despite the fact that in reality there are
two social parents, the biological and non-biological mother (providing that the donor is not
actively involved), the co-mother will be legal stranger to the child due to her gender until a
legal solution (internal adoption) is found (Millbank 2003, 547–8; Dalton & Bielby 2000, 39).
Having to carry out the process of internal adoption, places the child and the registered
same-sex couple as parents into an unequal stance contrary to their heterosexual
equivalents in Finland. In fact, for the recognition of parental rights, all our participants were
aware that many rights for their families are not guaranteed until adoption is clear. As
Cherlin (1978) noted about the lack of legal provisions addressing the needs of stepfamilies,
same applies also to these lesbian-led families. In fact, adoption can be seen as legal mean to
institutionalize and protect a same-sex family as it is a route by which same-sex headed
families can establish a status of legal parenthood for the non-biological mother. Adoption is
a way to overcome difficulties lesbian couples face due to their incompletely
institutionalized status. That is to say, adoption processes are the necessary steps by which
87 non-biological mothers can secure their parental identities and their legal relation to child in
the eyes of the law.
The very fact that same-sex couples do not have equal parenthood rights as heterosexual
couples do, also demonstrates the way dominant notions of sexual citizenship are based on
the normalization and promotion of the idealized heterosexual marriage and nuclear family
consisting of a ​
mother and a ​
father​
. It demonstrates how heterosexuality is assumed as a
natural basis for the definition of the family and the way reproduction is considered as the
ultimate end product of sexual relations. More specifically, how having children is
considered to be the natural end-product of a sexual relation against homosexual relations
that are regarded as just “producing immoral sex acts” and thus, not children ​
(Hubbard
2001, 57; Richardson 1998). Consequently, defining family through mother and father
categories explicitly excludes LGBT individuals and families, implicitly defining them as
non-family as the narrow definition implies the ruling on who is a qualifying family member.
This places LGBT individuals and LGBT families into clearly disadvantaged position in the
legal and social context (Cahill et al. 2002; Lind 2004, 23; Messinger 2006, 451).
These findings clearly show that even in countries such as Finland, that provide legal
recognition of same-sex relationships via civil unions, there are still clear disparities when
comparing the rights granted to same-sex couples with heterosexuals in heterosexual
unions. Major point of disparity being namely the rights of parenthood (Richardson 2000b,
127). As a matter of fact, when the interviewees had a chance to freely comment on what
they would change in Finland for protecting the rights of families like theirs, most answered
they wished for changes regarding the adoption process and especially for it to be finalized
sooner.
Each Finnish couple was also concerned about fertility treatments as they are usually
provided to lesbian couples only by private clinics and they are very expensive. The costs
were seen to pose a potential obstacle in starting a family, and as one couple commented:
“You just have to save money”. Participants also thought fertility treatments should be
provided by public hospitals and to be compensated by the social security institution to both
homo- and heterosexual couples equally, placing all couples “on the same line”.
88 “Well, I guess one of the biggest problems when you're trying to start a family is that
even though I guess the law says that discrimination is wrong and that everyone
should get the same healthcare... They don't, because the public hospitals and so on
they don't provide fertility treatments to us.” (Lucy)
Yet, despite the costs, all except one couple had gone through fertility treatments in private
clinics. But as an alternative to clinics, female couples can also have a known donor and they
can perform the insemination at home – as Isla and Chloe did. In fact, this couple argued
that the biggest reason to perform home insemination was that the treatments were
expensive. In addition to challenges regarding conception and adoption, two lesbian couples
expressed frustration related to signing a paper forbidding the social services to clarify the
paternity of the child – even though the child was conceived through fertility treatments
with a donor.
“So we had to do it [sign paper about not confirming the paternity of the child] too
and it's like... And the social worker is like: ‘This is stupid.’ We are like: ‘This is stupid.’
And the term goes: ‘I forbid you to find out who the father is.’ You have to sign it. I
mean they have limited time, they should be doing something completely different.
[...] We shouldn't have to do this. It's like, anybody's problem.” (Olivia)
Allowing fertility treatments also to female couples means that healthcare services need to
develop accordingly in order to ensure quality care also for same-sex parents. That is to say,
clarifying the paternity of a lesbian couple’s child, conceived in a clinic with gametes of a
donor, should be something to reconsider. Indeed, the possibility to use of artificial
insemination may expose individuals belonging to a sexual minority to heterosexual
assumptions both in healthcare and legal context (i.e. confirming paternity). Yet, at the same
reproductive techniques can also have a role in the development and adaptation of
healthcare services to the needs of diverse families as more same-sex couples make use of
the technology and services provided (Dempsey 2010, 1147).
All in all, when the interviewees were asked to freely narrate what was their impression of
the whole experience of starting a family with their same-sex partner in Finland, the
respondents ​
generally stated the process is without major challenges. Yet, most of the
couples stressed some specific concerns, such as the necessity to register their relationship
89 before having a child if they wish to proceed to adoption and the costs of fertility
treatments. Even though the couples did not comment on any ​
legal ​
barriers ​
per se​
, they
thought the whole adoption process was a hindrance and a cause of extra stress and
paperwork for the prospective parents, as for now the adoption can not be confirmed as
soon as the child is born. As a way to create some sort of safeguards for their family after the
birth, one couple reported resorting to creating written documents on their own as means
to handle with the situation while the adoption was not yet validated and to ensure that the
co-mother would be considered as family and granted information related to the mother
and the child. Indeed, the lag time after birth with the adoption creates a drawback that
forces many lesbian families to rush for creating ways to safeguard their families (Dalton &
Bielby 2000, 54).
6.2.1.2. Denmark
B. Carraro
All couples had ideas and suggestions about things that should be changed or improved, and
all expressed their frustration with some mandatory but, according to them, useless
procedures. Sienna talked about her first experience with parenthood with her former
partner, in 2005, and about the long time they had to wait until the adoption was through,
Sienna said “at that time they considered our family situation as they consider adoptions.
Well, I can see some legal aspect of that. […] But we weren’t adopting a child, we were
having a child.” Phoebe and Jane, in their more recent parenthood experience, started the
adoption process (in 2014) before their child was born in order for the adoption to be
effective from the birth. They had just started the process when the adoption law was
modified. The hospital staff had not yet received the guidelines regarding the new
procedures, and gave them the wrong papers to fill out and submit. This caused a delay in
the adoption process, and it could have implied that Jane would not obtain the parental
rights from the start, leaving the child with only one legal parent. Jane and Phoebe
recounted how other couples, both hetero- and homosexual, that had a child with the help
of a donor had the same problem. If the adoption from birth would have not succeeded,
non-biological fathers and non-biological mothers would have had to wait until the child was
two and a half years old to apply again, and they would not have right to any leave from
work after the birth. Fortunately, Jane and Phoebe were able to resolve the situation and get
all the bureaucratic paperwork done on time, and were both legal parents from the
beginning.
90 Although they agreed that becoming same-sex parents in Denmark was an overall positive
experience, Freya and Erin pointed out how “there has been a lot of bumps on the way,
especially with adoption”. First of all, the couple chose to go to a private clinic for getting
ART because of the impossibility of having an open donor through the public fertility centers.
Erin then told how they had to respect a number of strict deadlines and proceed carefully in
order for her to be able to adopt their child from the birth: they had to be able to document
that they were living together and intending to become parents at the time of the
conception and they had to get married within a certain amount of weeks before the due
date. The law was, once again, being amended while they were going through the adoption
process in 2013. They were one of the last couples that had to go for an interview and
pre-adoption meeting where Freya had to sign in front of a public official that she was
voluntarily sharing the parental rights with her wife and that Erin did not force her to do so,
“And this felt really really crazy” Freya said in disbelief, while expressing her happiness with
the law amendments that made long stepchild adoption proceedings not necessary. Tara
and Scarlett enumerated all the paperwork they had to do to legally be both mothers from
the moment of birth, and also explained that they had to be married for Scarlett to have the
parental rights from the start, which felt illogical to them: “we're married, of course the child
is for the both of us!” (Tara).
Also Diane felt like the documents she had to sign in front of a state official in order to share
her parental rights with her partner were unnecessary. The civil servant assisting the
procedure explained her that it was made in case a man would force or put under pressure
the mother to share the parental rights, but Diane objected “that was really really stupid,
because we’re a lesbian couple.” All the other mothers that had to adopt under the old legal
provisions also thought the procedures and requirements for the second-parent adoption,
namely cohabiting when conceiving, marriage, co-mother interview and the like were, for
saying it with Diane’s words, “quite stupid” and “not necessary”. Most of those
requirements have now been abolished, showing how relatively fast Danish laws affecting
sexual minorities are being amended and tailored to the citizens' needs. Freya and Erin
talked about introducing the possibility of becoming parent by choice, once the baby is born:
“You could change that you didn’t have to marry, but you could just sign that ‘I want this
child’ that could be a big change” (Freya).
91 The problems inevitably rise when the parents in a family are three. The law only recognizes
a maximum number of two parents per child and therefore leaves one of the three without
any formal rights and duties toward their children. In two distinct cases, the co-mothers
Sienna and Kaelyn have both given up the status of second parent to the father of their
children. Sienna’s wife, Rose, wanted a friend of hers to be the father of her child and she
verbalized her frustration with the system, that does not include different family
arrangements. Rose thought it is important to give everyone the right to have children with
the help of public fertility treatments, and called the impossibility to get them with a known
father unless there are medical problems, “the first stopping barrier”. Since “it is in the
society's interest to have children”, she said, “having children shouldn’t be regulated by who
you are or what family constellation you have.” Sienna is worried about the fact that she
cannot be recognized as a parent:
“I think it is a problem that I don’t have any legal rights. Of course, I mean if [Rose]
died, and [the father] [...] he is a really good father and a very nice person, but if he
wasn’t, he could claim the rights of the children and I wouldn’t have any legal rights. I
mean that, that annoys me. And it annoys me more than I thought it would. And also
of course, the situation with divorce […] and also heritage and stuff.” (Sienna)
Currently, Kaelyn and her wife are both biological and non-biological mothers of their two
children, and the father the second legal parent to both, “And that was not what we
planned” she explains, “but that was what we could do, legally. […] we wanted all three of
us to have it [parental status, our note]. Because we are all three parents, equally parents,
but it is not possible. So […] they chose for us, if you can say that.” As a consequence, Kaelyn
is concerned about many issues that will arise during her life and during the life of her
children, given that Kaelyn and her wife have no legal right or duty towards their
non-biological children. Furthermore, their second child was not lawfully entitled to have the
second-child discount on the kindergarten fee (although, as we said, the municipality bent
the rules for them), because technically, the two children are half-siblings. She is not entitled
to the two days off per year if her non-biological child will get sick, and the child will not
have any inheritance rights because of the lack of legal family connection to her. In case of
death of either one of the birth mothers, the other has no rights toward the non-biological
child, and divorce or separation are also a concern: “if me and my wife get divorced. We will
be [...] not having any rights, for the children we haven’t given birth to.”
92 In relation to their family arrangement with the father, she stresses how trust is an essential
element: “[...] it is about trust, because one of us is like ‘I’m nothing’. [...] my wife could run
away with the father and one of our children too. Without me. I can’t do anything.” Kaelyn
and her wife are now thinking of both applying for step-child adoption, which would grant
them both an equal legal connection to their biological and non-biological children, but
would mean that the father will lose his paternity rights. In fact, a three-parent family cannot
have all three parental roles acknowledged under the law: there can only be up to two
parents, and if a stepparent comes legally in the family, a parent has to go.
6.2.1.3. Comparison
B. Carraro
Two main findings emerged from the Finnish data. The first is that the couples considered
the adoption as the biggest challenge for them, leaving children with only one legal parent
for several months. Aside from the stress caused by the long waiting time for adoption, most
procedures were reported as unnecessary and even offensive, such as reflection period for
the birth-mother, adoption counseling, forbidding authorities to look for the father and
assessment of the co-mother. Finnish women thought their family status is at stake until the
adoption is through. The second finding is that fertility treatments were only offered to
lesbian couples in private clinics and were therefore expensive. The first set of Danish
findings regarded the complaints of the couples that had a child in 2012 and 2013, before
adoption procedures were simplified throughout 2013 and 2014. The frustration of these
couples concerned, among other things, the old obligation of cohabiting before the
conception took place, to be registered within a certain time before the birth, to be
assessed. The second set of findings emphasized the impossibility of getting fertility
treatments with a known donor in public healthcare, and the impossibility of having all three
parental roles recognized.
The most important legal challenge for Finnish couples was the adoption process, which
raised numerous concerns about whole procedure and the safety of their children.
Bureaucracy was called “weird”, “stupid” and “insulting”, adoption counseling “stupid” and
“ridiculous”.
Bureaucratic waiting time, assessments, reflection period, and two cases
where biological mothers had to sign a document forbidding authorities to find the father
(even though they were using a donor and transitioning into planned parenthood) were
93 reported, although they varied accord to municipality. However, what all couples were
mostly worried about is the lack of automatic entitlement to parenthood and the fact that
the procedures for adoption last for too long and leave their children unprotected even up
to 6 months. Couples were concerned in case something serious would happen before
adoption is finalized, during that ​
limbo​
when the co-mothers are legal strangers to the child.
All Finnish couples thought the incompletely institutionalized status of co-mothers and, as a
consequence, of lesbian-led families is a huge problem and puts them in a disadvantaged
position when compared to heterosexual couples, which enjoy full citizen rights and whose
family is a solid legal unit from the beginning. The major point of disparity raised between
heterosexual and homosexual couples are the rights related to parenthood. Danish couples,
who had children earlier (2012-2013), had several complaints about useless legal
proceedings they had to go through (cohabiting at the time of conception, being registered
within a certain time before the birth, being assessed) which were mostly eliminated later
on. For instance, the second-parent adoption was simplified and made more automatic, and
the obligation to be married in order for the adoption to be effective from birth was
eliminated on January 2015. All Danish parents started the adoption process at the time the
child was conceived and all co-mothers (those that had a known donor) were legal parents
from the birth.
Moving on to the second set of findings on fertility treatments, all Finnish couples were
affected by the impossibility of getting assisted reproduction in public healthcare and the
total lack of information about less expensive techniques such as home insemination. The
high cost of fertility treatments in private clinics can take years of savings and can be an
obstacle for many, turning parenthood from a right to a privilege. Moreover, in order to
receive IVF treatments, a psychologist interview was required. No information was made
available by healthcare centers about home insemination, and the only couple that used
that method of conception had to do independent research. Danish parents were happy
about public fertility treatments, although they could not get much information on the
donor unless they paid for it and, most importantly, the gametes that public hospitals offer
are always from anonymous donors. Couples that wished to have a known donor would
have had to resort to private clinics, unless the medical staff had bent the rules especially for
them.
94 6.2.2. Lack of Knowledge
S. Sirkkala
This section organizes accounts pinpointing experiences where healthcare staff either lack
competence, preparedness or knowledge regarding caring for patients belonging to LGBT
minority, resulting in inadequate care or even burdening the lesbian patients with a task to
educate the professionals.
6.2.2.1. Finland
S. Sirkkala
Three couples noted that medical staff generally lacked information on different alternatives
lesbian couples have with respect to conception and starting a family. For example, on two
occasions the staff did not know home insemination was even an option for lesbian couples,
instead of fertility treatments in a clinic. In fact, Isla and Chloe found out about home
insemination through friends and by searching the internet for information. Isla remarked
how the professionals did not seem to have any idea how a lesbian couple can conceive and
were asking the couple how did they do it.
“Actually we had like a few different maternity clinic nurses and every time they
asked like: ‘Okay, home insemination?’ They are like: ‘Okay, what is that?’ And then
we had to explain. So they really don’t know anything about how to make baby. They
only know the heterosexual way. And the clinic. But that’s like the only thing.”
(Chloe)
For Poppy and Ella, the process of conception had been especially challenging. Living in a
small town, proceeding with conception required additional effort from the couple as they
were forced to make most of practical and legal clarifications themselves and to deal with
bureaucracy and official procedures related to same-sex headed families alone, as they were
the first same-sex couple in their hometown to have a child. Thus, they could not get
information from any public offices or officials in their municipality of how to proceed or
what to do when starting a family with a same-sex partner. In the end, Ella commented how
in the end they informed and briefed the personnel in the healthcare center about the
procedures they had undergone.
95 Two couples felt ​
especially ​
strongly about how they did not get enough support and
information they were hoping for from professionals in relation to their families’ specific
needs. They remarked that they could not find “anyone” who could give them answers.
While noting that they were not provided with all the much needed information they hoped
for with respect to their new lesbian-led family, Chloe and Isla illustrated their situation
stating that they had to do plenty of research themselves and even provide the healthcare
professionals with relevant information about lesbian-led families.
“Yeah, we told them [medical staff]. [...] They were like: ‘Okay that is so great I didn’t
know that.’ So they can tell and learn. [...] But we didn’t get any information, they
didn’t know anything at all. [...] I think it’s not a part of their education at all.” (Chloe)
Many of the interviewees simply had the impression as if it was their task to provide
information and to educate professionals on LGBT-specific issues. In a similar occasion, when
another couple Olivia and Emily entered family coaching provided by their healthcare center,
they felt a burden to train the professionals on how to include also their type of families in
the activities. These cases demonstrate how the prospective same-sex parents were used as
an educational resource. The reality is that LGBT individuals grow up in a society where
heterosexuality and gender normativity are valued and promoted through social institutions
and consequently, LGBT people are familiar with the rules and norms of heterosexual
culture. However, even though LGBT individuals are in a way ​
powerless in this dynamics due
to being a minority, we found that they were still asked to do the work of educating
professionals in the prevalent culture (Rounds et al. 2013, 108). In fact, Goldberg and
colleagues (2011) noted: “The oppression of various groups is often evident in the special
explanatory burden that signals their deviance from the norms that govern social spaces”
(15).
When asked about healthcare professionals competences, four out of five Finnish couples
noticed healthcare professionals’ lack of actual experience with providing care for same-sex
headed families. Professionals seemed unaware of how the lesbian couples managed to
conceive, how the processes of conception and adoption are administered in their case and
how to include a lesbian-led family in for example family coaching. In general terms the staff
was not familiar with LGBT families. Three couples further mentioned how the professionals
were also confused about how to act around a lesbian family. Poppy and Ella noticed the
96 medical staff having troubles even with some medical examinations related to Ella’s
pregnancy as the professionals had not performed a specific procedure to a lesbian couple
before. Then again, Grace and Lucy mentioned how the staff asked a lot of questions and
seemed overall confused of what to do when encountering the lesbian-led family. To deal
with the awkward situations, Lucy noticed how the professionals resorted to following
routine procedures – that were sometimes lesbian insensitive. These examples show how
the lesbian couples clearly disrupted the medical staff’s habits making the professionals
unsure of what to say or how to react to the presence of the non-heterosexual couples. The
presence of the couples in the heteronormative space was noted as an exception, which
became evident from the confused reactions and lack of knowledge. Thus, not only did the
couples disrupt the routine practices, but also the public space.
Deficient treatment due medical staff who lack knowledge on how to respond and treat
lesbian prospective parents is an example of how heteronormativity, due to institutionalized
heterosexuality, is apparent in healthcare provision. In effect, the way healthcare is
organized and the way professionals are educated – as well as heteronormative routinized
practices – are concerns of social policy. And as Carabine (2001) argues, social and welfare
policies, including public healthcare, embody assumptions about normal and acceptable
sexual relations and carry messages about desirable behavior. Social policy together with
normative assumptions constitute and regulate deserving, and undeserving, welfare
subjects, discourses, provisions and practices. And together with the law, they are
responsible for enforcing and supporting norms and conveying messages privileging some
types of sexualities. Indeed, privileging heterosexuality is evident when healthcare
professions lack LGBT-specific knowledge and competences to treat lesbian couples (and/or
families), and when the professionals are entrenched in their heteronormative care routines.
6.2.2.2. Denmark
B. Carraro
All Danish women interviewed said they disclose her sexual orientation during checkups,
when that is relevant for medical reasons or when they have to introduce their partner.
Diane stresses the educative function of coming out with healthcare professionals, saying it
is as a necessary step to begin an honest relationship and to avoid awkward moments and
misunderstandings afterwards: "It’s a private thing, I don’t have to tell them, but I can see
97 it’s important [...], because they have to realize that it’s all around them, and it’s not weird
or something."
Erin and Freya's general practitioner showed signs of interest when he asked them how did
they feel about the healthcare system and whether they thought the health system was
"prepared to treat gays" (Erin). Freya remarked "It was like passing the border, in a way. But
in a good way." Similarly, Diane remembered how two nurses asked her and her wife about
their experience being a same-sex couple in perinatal care, one out of spontaneous
initiative, the other on behalf of the hospital. Diane did not mind too much answering
questions and educating the professionals about lesbian couples and she said she had “an
important role” also in introducing her partner. She said to be convinced that it is very
important for the professionals to know, also in order not get the idea that it is something
the couple wants to hide. However, she also mentioned how that can compromise one's
right to privacy.
These attentions can be wanted or unwanted depending on the situation and on the couple
receiving them. The fact that these questions would not necessarily be addressed to other,
heterosexual patients, contributes in making the experience of the lesbian couple atypical,
and compromise their right to privacy. Along the lines with Hubbard (2001) and the way he
argues about publicity and privacy, the lesbian patients challenge is not necessarily the right
to publicity or to be in a public space but the lack of privacy and thus, lack of right to have a
stress-free, non-attention-seeking healthcare experience as any other patients. Instead of
that, some are burdened with inquiries and used as a way to receive feedback and
“educate”.
In two cases the co-mothers had troubles being acknowledged by the medical staff, arguably
for the lack of institutionalization and knowledge about LGBT patients and their family
dynamics. In the first case, the misunderstanding was probably due to the fact that the
co-mother, Sienna, represented a deviant third person in the family frame. Reflecting on the
lack of knowledge of different families, Sienna thought “I don’t think they’ve had any formal
training about it at all. I don’t think so. That is not my impression.” The lack of formal
training can be reflecting in their behavior also when Rose talked about her midwife taking
pauses as she spoke, perhaps to think “about her use of vocabulary” (Rose). The second case
98 was Diane’s partner, not being addressed or even greeted during some pregnancy checkups,
but later being fully acknowledged as a second parent in the hospital.
Rose remembered questions being asked by the staff and reflected, “it has been quite of a
point of interest how do we make these babies.” Sienna stressed the importance of
introducing formal training about LGBT minorities and different kinds of family, for
healthcare professionals and civil servants and in general, those employees “dealing with
other persons”. Rose added that she wishes to see changes in the vocabulary they use, both
verbally and in the forms, “otherwise we would be using the system but we won’t be
integrated in it.” Sienna agreed: “I think it would be nice if they didn’t always assume that all
families are alike. Not just for same-sex couples but there are lots of single moms”. Kaelyn,
like many others, reported not getting much guidance throughout the process. “You are
pretty much on your own” she said, mentioning that other, less educated people, could find
the legal information rather difficult to find and interpret correctly.
All couples were generally satisfied with the perinatal care at the hospital and described how
the knowledge of the professionals on medical procedures was high. Some of them reported
how, throughout the pregnancy and mostly after, the staff recommended the birth mothers
not to have coital sex, or to have it with a condom, (e.g. because of the high risk of infections
after birth). Occasionally, the professionals would correct themselves and agreed that those
recommendations were superfluous for the lesbian patients. Nevertheless, none of the
healthcare professionals was reported instructing their patients about safe sexual practices
and potential risks​
within a lesbian r​
elationship.
Most mothers defined themselves as people with initiative, when it came to searching for
information that they were not provided with by civil servants or healthcare employees.
Nevertheless, the lack of knowledge of the healthcare professionals on the new
second-parent adoption procedures almost costed Jane her parental rights from the birth.
Her wife Phoebe told how, probably due to recent amendments in the adoption law, the
staff was unable to instruct them on the procedures and on which documents and
applications they had to fill out. The same observation about the difficulty of the
professionals to keep up with new laws was made by Freya and Erin. Erin said that she had
much more confidence in “[her]strength and [her] rights” after she became more
experienced and aware of all the legal details concerning her parenthood.
99 6.2.2.3. Comparison
B. Carraro
Two main Findings emerged from the Finnish data: the lack of LGBT-knowledge and the lack
of actual experience of nursing sexual minorities. Three couples noted the professionals lack
basic knowledge on how lesbians can start a family and assisted reproduction technologies,
both in hospitals and public offices. Couples had to take initiative in doing individual
research because public authorities could answer their inquiries. Two couples strongly
emphasized the lack of information they needed and three couples stressed the need to
educate professionals about procedures of conception and adoption and how to include
them in activities such as family coaching. The second set of findings for Finland is the range
of occasions when professionals demonstrated to lack actual experience with caring for
LGBT people: four out of five Finnish couples noticed this. These couples explained how
professionals were unaware of how lesbian couples conceive, how the adoption works, and
how to include them in activities organized for heterosexual expecting parents. Three people
said the staff was clearly confused about how to act around them.
Three main findings emerged from the Danish data. First, all Danish couples thought that
disclosure of one’s sexual orientation is important when relevant for medical reasons. In
three cases the couples stressed the importance of disclosure in order to educate the
professionals, to get them used to sexual minorities attending their practices and to learn
how to call them and act around them. In one case a woman thought there is need for
formal training on that subject. Three-parent families were the ones who had give
explanations all the time to avoid mistakes and felt the burden of explanation the most.
Second, the staff showed initiative in three cases, by asking questions about how they felt
after receiving treatments in that practice and in the healthcare in general and whether the
experience had been good enough. Two people perceived questionings and wanting to
discuss about LGBT-issues as intrusive or inappropriate. Third, in four out of six experiences,
couples reported civil servants and medical staff not being able to give them the needed
advice on the bureaucratic procedures, especially with second-parent adoption. All
emphasize that they had to be independent in their search for information and be careful
how to follow procedures on their own.
100 Privileging heterosexuality is evident when healthcare professions lack LGBT-specific
knowledge or competences to treat lesbian couples and their families in healthcare and are
entrenched in heteronormative care routines. The fact that professionals were not familiar
with LGBT families and patients shows on one hand the lack of experience on the field, and
on the other hand the absence of any professional training on sexual minorities, as the
training is focused on heterosexual couples and heterosexual parenthood. Although Danish
couples’ birthing experiences were overall less awkward and atypical, we feel that it is
necessary to remark that even though all couples thought that disclosure of one’s sexual
orientation is important when relevant for medical reasons, the findings show how
professionals do not know what to do with that information. Once they have it, it seems as if
they just omit instructions they would give to a heterosexual couple, without replacing them
with other LGBT-specific information.
6.2.3. Incomplete Institutionalization
S. Sirkkala
This part of the analysis consist of the lesbian mothers’ experiences in the healthcare
context when encountering heteronormativity either via heteronormative language or
heterosexual assumption. Following this, we take a slightly more structural perspective and
see how the incompletely institutionalized status on the lesbian families was evident in the
participants’ answers. Moreover, we also provide insights of what kind of strategies the
couples created to overcome challenges due to their incompletely institutionalized status.
6.2.3.1. Finland
S. Sirkkala
For lesbian couples, heteronormative care routines are likely to be highlighted during
pregnancy, as it is a time stereotypically for a father and a mother. In practice, in
heteronormative-based care system, the term ​
parents is naturally considered to entail a
female mother and a male father and thus, all communications and care routines are based
on treatment provided to heterosexual couples (Röndahl et al. 2009, 2338). In fact, all
Finnish couples experienced heteronormative language in healthcare. According to the
interviewees, language in public healthcare areas reinforced heterosexual ideal with
different official documents, personal information forms used for civil registries, hospital
records and name tags such as “Father’s Room” in maternity wards (space especially
designed for fathers). When asked about whether there were any signs of inclusion for LGBT
101 families in any official informative material, such as magazines, booklets and handouts in
waiting rooms, provided to the prospective parents by the healthcare centers, participants
gave a straightforwardly negative answer. Indeed, noticing signs of inclusion – or exclusion –
was easy for the lesbian couples in the healthcare centers. This can be due to a reason that
public spaces, such as maternity clinics, are places where the heterosexual assumption of
the patients is considerably strong and consequently, they are places where members of
LGBT minority tend to critically observe any welcoming signs and gay affirmation (Fox 2008,
252).
Poppy commented on the fact that lesbian inclusive material was lacking altogether. She
mentioned how the official information and written material she and her partner received
from the professionals always includes only “mom and dad” and never female couples.
Amelia and Holly also confirmed that they did not see any signs of gay affirmation in any
material, books or in answer sheets, as the terms used were always “mother or father” and
never “parent” or “other parent”.
“Yeah like I mean, one of the two books that we got is half of [...] I mean on one side
it says: ‘To the Mom’ and on the other side it says: ‘To the Dad.’ I mean, we still read
the other side [laughs] what are they saying. If something useful comes. But yeah, it's
that way.” (Amelia)
Also in family coaching several couples encountered heteronormative language as the
personnel responsible for the coaching constantly referred to the ​
mother and the ​
father​
,
despite one or several lesbian couples participating in the activities. On one occasion the
lesbian partner of the biological mother was even personally referred to as the “dad” by the
family coaching group leader. One couple further expressed a wish that prospective parents
could choose themselves what kind of informative material to take home and not to be
compelled to receive same heteronormative official material as heterosexual couples. On
the whole, the couples experienced these situations as awkward – both for them and for the
medical staff.
Also the assumption that all patients are heterosexual in healthcare was evident in each
couples’ narratives. All except one couple experienced that at least some point of their
healthcare experience they, or one of the partners alone, were assumed to be heterosexual
102 or in a opposite-sex relationship. One couple who did not have this experience was going to
a healthcare center in their small hometown where everyone knew each other and thereby,
they also knew the couple. In practice, a medical situation becomes instantly
heteronormative when medical personnel commits to their routinized procedures designed
for the default heterosexual patients and by being unaware of the presence of lesbians
among the patients. Lesbian insensitive behavior, treating everyone the same and asking the
“wrong” questions result in heteronormative healthcare provision (such as the form of
contraception used). In another situation, Holly and Amelia were phoned by a member of
medical personnel wondering who the partner of the biological mother was as her name had
come up in the information system. In this situation the personnel got caught up and
confused when they came across with deviant family constellation from the opposite-sex
headed family norm as they were expecting to find a man’s name from the registers.
Also “awkward” situations where the lesbian partner of the biological mother was addressed
as a “friend” and/or when the medical staff asked the co-mother whether she is a “friend” of
the birth-mother, were recounted by two couples. These couples commented how the
professionals “always assume” that the patients are heterosexual – if not corrected by the
patient herself/himself. For example, when Lucy told the staff about her “partner”, the staff
acted according to a heterosexual assumption and talked about ​
her as a ​
man during Lucy’s
visit. This tendency to assume that all patients are heterosexuals and especially
heteronormative questions – whether conscious or not – can act as means to desexualise
and devalue the lesbian relationship. For example, when referring to the non birth giving
partner as a friend, it is as if healthcare professionals regard only how the biological mother
alone is transitioning into parenthood while not only ignoring her lesbian partner, but also
not acknowledging the lesbian status of the couple (O'Neill et al. 2013, 217–8). Furthermore,
the most striking way the healthcare professionals communicated heteronormativity, was
when after the actual birth of Grace and Lucy’s child, their midwife hurriedly asked the
biological mother whether she wants to “call the father.” Indeed, heteronormativity in
healthcare provision manifests itself when homosexuals are addressed and treated like
heterosexuals until they disclose their orientation – if they choose to do so. In fact, Hubbard
(2001) argues that they might not always choose to do so, as they may also choose to
remain invisible staying attentive of their right to privacy.
103 Heteronormative language is not found only in official materials materials provided by
healthcare centers, but also in legal and political texts and regulations. For example in case
of parental leaves, mentioned also by the interviewees, on the website the Finnish Social
Security Institution it is stated: ”Irrespective of their gender, the parties to a registered
partnership are entitled to ​
paternity allowance”, communicate how institutionalized
heterosexuality is reinforced in practice (KELA.fi). Thereby, the co-mothers are compelled to
adapt into the existing father category. As a matter of fact, in sociological theory it is
believed that social institutions shape people's behavior in many important ways, and one of
these institutions is language. Language is not only means for verbal communication, but it is
also used to communicate widespread elements of social life (Röndahl et al. 2006, 374).
Intrinsically, using heteronormative language, communicated through bureaucratic language
in official written material and through verbal language in healthcare, supports and
maintains the heterosexual ideal. Thus, through heteronormative language not only are
lesbians excluded and left with sense of invisibility, but also the incompletely
institutionalized status of their same-sex families becomes evident (Carabine 2001; Cherlin
1978).
In addition to the heteronormativity in the language used in the information material and by
the professionals, each Finnish couple faced further difficulties with bureaucratic paperwork,
such as standardized forms, at the clinics. The participants took notice that in the paperwork
to be filled in after birth there were always only two options provided: ​
mother and ​
father​
.
Among the most prominent heteronormative situation that each couple remembered having
to deal with was when their child was just born and the medical staff collected information
about the parents. This was when the couples were provided with “mother’s” and “father’s”
information sheets to be filled in. While trying to complete those forms lacking option for
the couples, they commented feeling “awkward”, confused and thinking of options of how
handle the situation.
“I think like, in general the family is like a heterosexual family. Like, on the forms you
fill in, you know, there's like no choice. [...] Either you're a husband or a wife. And
that would be so easy to change. But it hasn't been done, maybe Kela [the Finnish
Social Security Institution] has done some of it. But the city of [name of the city] it's
so old fashioned [...] this form stuff. The people we see, like nurses and doctors are
fine, but like the bureaucracy doesn't evolve.” (Emily)
104 Consequently, when the participants were asked what changes are needed for future LGBT
families to have better healthcare experiences, the couples expressed hopes for changes to
the bureaucratic language in the forms. Lucy commented on how “the biggest difference
that could be better is all those forms. So old and so strict somehow, that whenever you
can't put yourself in it, then their whole system seems to go… [out of order, ​
our note​
]”. She
further speculated that if the forms would be different, then also people's attitudes might
change: “so that they wouldn't assume that everybody fits into these forms and there's
different kinds of families so there needs to be different kinds of forms.” As a matter of fact,
bureaucratic attitudes and positions can be read through the rhetoric of forms. The
heteronormative bureaucratic language excludes the lesbian mothers by not providing other
options than mother and father and reproduces unconscious or unacknowledged
discriminatory attitudes toward LGBT families. Indeed, those attitudes will be reinforced
until the language of the bureaucracies becomes inclusive of all the possible family
constellations (Chapman et al. 2012b, 1133).
All in all, the participants all noted how the public healthcare spaces were filled with
heteronormativity, when it came to professionals’ vocabulary, magazines, booklets,
bureaucratic language in information material, papers, governmental forms, and registers
used by healthcare centers. Evidently, their design promoted and naturalized the idealized
nuclear family consisting of a heterosexual couple, and the family consisting of a mother and
a father. Their design also promoted the way a heterosexual couple’s presence within the
particular public spaces of public healthcare was considered to be the norm by default. As
Hubbard argues, producing heterosexual ideal repeatedly in different moral and legal
contexts in fact serves to define the acceptable (heterosexual) practices and sexual identities
in public and private spaces. Moreover, promoting certain ideas and norms not only
excludes the ones not conforming to the ideal, but also leads to invisibility in terms of their
rights (Hubbard 2001, 59, 67). In short, privileging normative heterosexuality in both law and
social policy, and in healthcare spaces, results in invisibility (Carabine 2001, 295).
When everyone is assumed to be heterosexual, homosexuality is made socially invisible. Yet,
the quality of healthcare provision is influenced by healthcare workers’ awareness of the
sexual orientation of their patients, which is why lesbian invisibility can sometimes have
critical consequences (Marques et al. 2014, 1). As a matter of fact, invisibility, the exclusion
105 of lesbian experience, lack of training of the care-takers and their preparedness to treat
LGBT people among patients, and discriminatory forms that limit the possibility to gather the
necessary medical information about the patients, can potentially turn into barriers to
healthcare and can have a negative impact on the quality of healthcare of LGBT individuals
(Fields & Scout 2001, 182; Trettin et al. 2006, 1).
In sum, Finnish lesbian mothers still experience legal, cultural and interpersonal challenges.
There are still drawbacks in the legal system safeguarding lesbian-led families. Resorting to
adoption after the birth has proven not to be enough, because the adoption is not confirmed
immediately after the birth. There are still employers who are not aware of parental rights of
co-mothers and lesbian couples are still required to resort to supernumerary paperwork to
ensure that the lesbian partner of the biological mother is considered as family. Moreover,
lesbian couples still face difficulties having their family constellation recognized in the eyes
of not only other lay persons, but also professionals in clinics and offices in unfortunate
occasions where the parenthood of the non-biological co-mother is questioned. These
examples show how the challenges that are quickly regarded as legal or interpersonal
concerns actually demonstrate how the lesbian headed family is in essence incompletely
institutionalized.
Indeed, Cherlin (1978) argues that incompletely institutionalized status of different families
becomes evident when they face situations to which institutionalized solutions do not exist.
This is evident, for example, when comparing the situation where the automatic right to
common surname is granted only to heterosexual married couples, but not to homosexual
registered couples and their families. Nearly all interviewees saw this as an important
interference for them, because it means that they and their family members will not
automatically have a joint or common surname. As a matter of fact, the two children of
Olivia and Emily were first given different surnames due to the fact that they had different
birth mothers. They considered the necessity to apply for the name change as “insulting”,
because they were not given the simple right to choose a surname for their family. Holly
commented how it is a “small thing, but it’s important, once [...] there is another person in
the family it becomes important.” In reality, if a same-sex couple wants a common surname
for themselves and for their children, they have a possibility to apply for it. Yet, our
participants considered that “the whole process is ridiculous” as it includes an obligatory
reasoning letter for the application, a waiting time, and a fee to be paid of approximately
106 one hundred euros. The process of applying for the name change was generally seen to be a
heavy mission with a potentially long waiting period. Even though the common last name is
not denied from same-sex couples and their children altogether, it is an unique and
additional difficulty and an example of the extra layer of problems these families face in
their interactions with social institutions (Hequembourg 2004, 742).34
According to Hequembourg (2004), incompletely institutionalized status of lesbian families
signifies that there are institutional blind spots that impact their family relationships and
drive them to create innovative strategies to address those institutional insufficiencies. In
fact, because Finnish lesbian co-mothers lack an automatic legal entitlement to parenthood,
in a system that is also constrained by language offering only two options for parental titles
(mother and father), they might also struggle to forge a parental identity. Thereby, the
whole lesbian-led family is sometimes compelled to create strategies to make room for their
family in a society that privileges some groups (heterosexuals) over others leaving their
status incompletely institutionalized (Padavic & Butterfield 2011, 177). Because they lack
institutional support, also their process of creating a family becomes more ​
deliberate and
less socially scripted process (Dalton & Bielby 2000, 59). Thus, the following different
experiences illustrate strategies the Finnish lesbian-headed families used to forge their own
scripts in situations where the institutionalized structures were inadequate.
Without an exception, all five Finnish couples, and new same-sex parents, had to employ
coarse strategies to deal with official paperwork when the heteronormative and
conservative bureaucratic language provided inadequate answer options, or ​
boxes​
, for them
after birth of their children. In practice, after each birth each child is registered and at this
moment also information of the mother and the father is collected. At that very moment,
each couple had difficulties with paper and/or electronic forms as these forms were named
according to ​
father and ​
mother and the nurses either asked this information or provided the
participants with forms to be filled out that had only slots or boxes for the father and the
mother. In this situations, all Finnish couples were compelled to fill in the standardized forms
one way or another and thus, find a way to adapt to the heteronormative structures. Thus,
Further short examples of incompletely institutionalized status of lesbian-led families were revealed by two Finnish
​
couples when Poppy had difficulties with getting admitted her share of parental leave by her employer. Furthemore, Poppy
and Ella, as well as Holly and Amelia, had to sign a paper in the hospital giving the hospital the right to provide information
about the birth-giving mother to the co-mother. Holly reported that the document was created to ensure that “if she's
[biological mother] not capable to make the decision in the hospital, [...] then I can make on my own the decisions related
to the child, or get information even, of the child.“
34
107 they scratched or crossed over the ​
Father's name and rewrote “the other parent's name” or
wrote on top of it “spouse”. One couple also received help from their nurses to scratch the
father option from the papers, while another couple, Grace and Lucy, further tried to mix up
the mother and father forms on purpose in order to create confusion among the medical
staff and officials about who is the “real” mother. Grace commented how they were “a bit
mean” and crossed ​
mother and ​
mother options, and did not explain this, if they could avoid
it. They did not “specify the biological mother” if it was not necessary. Lucy continued by
saying: “or sometimes if there was just like a form where there was the mother's
information and the father's information, we would just cross out father and write ‘mother’
on top of it. [...] And usually put me [biological mother] so then they're confused about
who's the ‘real mother’ [laughs].”
The lack of option for answers in the governmental standardized forms represents the
incompletely institutionalized status of lesbian-led families. It is an example of the unique
difficulties lesbian couples face in their interactions with social institutions, such as the
governmental paperwork (Hequembourg 2004, 742). Then again, the way the interviewees
managed those heteronormative situations depicts how the couples created strategies to
redefine the predefined family construction and adapted heteronormative structures trying
to make also their family composition ​
fit​
. Moreover, the incompletely institutionalized status
of lesbian-headed families is also evident in the way these families lack consistent and
especially self-explanatory guidelines when it comes to for example vocabulary. More
specifically, the way the participants introduced and called each other in front of authorities,
how they wished professionals to address them and what parental titles they gave to each
other and wished others to use, varied notably. In reality, lesbian mothers are compelled to
negotiate their roles and relationships within their families and in the face of others as they
lack predefined patterns of behavior (Hequembourg 2004).
Three Finnish couples narrated the way they defined their family constellation in front of the
healthcare professionals to avoid any possible confusion. Grace reported using a
self-explanatory word ​
wife to be more explicit “so that they [medical staff] can be surprised
instantly and then forget it.” Olivia and Emily used the word “partner” and emphasized a
wish to have the co-mother called as “child's other parent.” This was their way of making her
role explicit and making sure there would be no misunderstandings in the verbal
communication with the medical staff. Also Isla and Chloe explicitly introduced each other to
108 the professionals in order to make it clear what their family constellation was about.
Furthermore, Lucy expressed her frustration about having to constantly come out to
different professionals, which is why she and her partner Grace decided to resort to an
ungendered word “partner.” They hoped that would help them to be considered just as any
other patient and not to receive different or special treatment.
“Well we've sometimes discussed this because I guess we prefer not to [disclose
sexual orientation] every single time, then it gets a bit tiring, every single time, to say:
‘And, by the way I'm married to another woman, and please remember this in the
future’ [laughs]. But usually I often speak of you as ‘puoliso’, which is like [...] doesn't
really reveal your gender. Kind of like ‘partner’ I guess.” (Lucy)
In addition to titles in a partnership, atypical family constellation from the heterosexual
family norm lacks consistent and definite parental titles for the two mothers. Thus, part of
the strategies in redefining the family due to lack of institutionalize guidelines for parental
titles, one couple even created their own word to use as a title for the second mother in
order to make a distinction between the two mothers. Then again one couple wished their
children with different birth mothers to call the only their biological mother as ​
mother and
the other mother by the name. In effect, the inadequacies related to the institution of
language provides an excellent example of incomplete institutionalization of LGBT families.
More specifically, in sociological theory it is believed that social institutions, such as
language, shape people's behavior in many important ways. Thus, the sometimes inventive
and innovative ways the lesbian partner of the biological mother is called throughout the
interviews by the interviewees themselves or by professionals provides an example how
these families (and even the whole society) lack institutionalized guidelines for language
routinizing their behavior​
. The lack of appropriate terms and even institutionalized
guidelines for parental roles reveal that the institutional support for their roles is insufficient
as the LGBT families lack ​
social regulation ​
(Cherlin 1978).
The interviewees resorted also to other measures when institutionalizing their family. Put
differently, they utilized also other strategies while trying to define themselves as a family in
the eyes of professionals in the healthcare context. Holly and Amelia believed that going to
see the hospital and birthing environment together as a couple in advance was a good
initiative. Especially in the case of lesbian couples, this practice can be seen as a way to make
109 room for them in that particular space ahead of time and to prepare the staff to welcome
and meet them as a lesbian couple. Similarly, Lucy explained how she would also sometimes
express clearly in advance at the hospital that “My wife is coming” to the professionals. Both
of these examples show the participants’ strategies to create space for them as lesbian
couples in the heteronormative public space to avoid heterosexual assumption and other
type of questioning regarding the missing father figure and the deviant and ​
additional
female character. As Lucy phrased it: “so that they don't wonder who's that woman standing
there.”
These examples show how the participants themselves were aware of how their presence
disrupts – or ​
queers –
highly heterosexist public space and the heteronormative
expectations that particular space entails. Yet, the couples tried to prevent the disruption by
letting the staff know in advance they are a lesbian-led family. The need to announce the
entrance of the lesbian partner in fact demonstrates how lesbians are in a shadow of
heteronormativity – especially in public spaces such as birthing environment where the
heterosexual assumption is notable. As Hubbard (2001) notes, the promoting certain ideas
and norms in certain space excludes the ones not conforming to the ideal – leading to
invisibility. If Lucy would be comfortable as a lesbian mother to enter the public space with
her partner, the presence of neither one of them would ​
not need an explanation, because
they would be expected (Goldberg et al. 2011, 15). However due to invisibility and
heteronormativity, they are not only unexpected, but they also disrupt the ​
natural order the
space. In other words, the lesbian couple queers the birthing space.
In addition, Isla and Chloe decided not to take part in the family coaching provided by the
hospital, but instead participated the Rainbow Families Organization’s own coaching
targeted specifically to LGBT families for guaranteed specific information and welcoming
environment. Grace and Lucy also contacted the same organization asking for help with their
own adoption process as they were frustrated about the obligatory assessment steps and
were unwilling to participate to them. They received advice from the organization not to
answer to any questions they did not want, or even to refuse to participate. Their adoption
process went through despite these disruptions. Thus, it was acknowledged that they had a
certain ​
unwritten possibility to refuse to accept some of the visits and proceedings, because
the whole evaluation procedures had put the lesbian couple into a difficult situation.
Resorting to the help of a non-governmental organization was their strategy to disrupt the
110 standardized procedures they considered weird and insulting, and to be considered as an
fitting or appropriate​
family nonetheless.
In sum, the lack of appropriate terms, institutionalized guidelines and support for the roles
of the two mothers reveal that the institutional support for their roles is insufficient, as
Cherlin (1978) has noted. In the case of Finnish lesbian-headed families, their incompletely
institutionalized status shows in the way they lack institutionalized structures to assist them
to solve everyday family issues and to access many of the rights afforded heterosexual
families such as (automatic) legal recognition of the family members in case of the
non-biological mother, terminology to address family members, and overall straightforward
support from the state and its organizations in the recognition of their family constellation
(Hequembourg 2004, 741).
6.2.3.2. Denmark
B. Carraro
Because historically lesbian families were a new, non institutionalized form of families, the
Danish state applied step-child adoption laws to same-sex couples in order to start providing
them with some kind of safeguard. Later in time, these have been adapted and
reformulated, in order to respond better to the needs of the LGBT community. Nonetheless,
the procedures allowing lesbian women to become mothers are not yet completely
straightforward. When she became a parent in 2014, Tara thought it was “silly” that they
had to do so much paperwork for the second-parent adoption, even though she was married
to Scarlett and they had a child with an anonymous donor, and argued that they would not
have had to go through all that if the non-biological parent would have been a man. Another
mother reflected “I can see some legal aspect of that [adoption]. […] but we weren’t
adopting a child, we were having a child” (Sienna).
Without exception, the written material the Danish women received lacked any signs of
inclusiveness towards other types of families than the traditional heterosexual nuclear
family. Only one of the women thought she had seen the option ​
father​
/​
other mother in a
booklet, but could not tell for sure. Tara mentioned that the experience of becoming a father
is unlike the experience co-mothers have, and it would be nice to have different kinds of
booklets for different kinds of parents. All couples received forms and modules to fill out
that had only the options for ​
mother and ​
father. ​
Erin and Jane, lacking a space for their role
111 as co-mothers, remembered being registered as the child's father in the papers. Erin also
reflected on the future bureaucratic forms that their child will have to fill out, and all the
times he will have to find alternative solutions to fit his two mothers. Yet, Freya, on the
other hand, remembered some of the documents had been updated and the ​
father form
had become the ​
partner form. Whenever the two-mother families had to fill out forms that
did not conform to their family model, they crossed over the father and wrote mother, or
simply put the co-mother's data in the file created to fathers.
Phoebe was negatively surprised about encountering the forms and templates that only
included ​
mother and ​
father options, and about other old-fashioned or inadequate names
such as ​
step-child adoption​
: “the name is ​
stepparent adoption [...] that bothers me as well,
because you [Jane] are not the step-parent, you are the parent.” All the other mothers also
expressed their wish for forms to change and become more inclusive, both towards
same-sex couples and three-parent families. Another common wish all couples expressed is
for hospitals to be expressly gay-friendly, for example through more inclusive written
material having some information about same-sex couples and pictures of different types of
families, as they already exist with ethnic minorities. Erin thought the state is pushing
same-sex couples to conform to the heteronormative, married, nuclear family even more
than heterosexual couples: “I think it does feel strange [...] that there’s only one way of
doing it, only one [...] same-sex family construction that they can kind of have in their mind
[chuckles] and this is that it has to look like a heterosexual marriage”. Yet, being just two
mothers is relatively “easy to put into the system”, according to Erin, when compared to
three-parent families. All respondents with an involved father confirmed what Erin
expected: “we have our own little constellation here and then there is the system. Because
we don’t fit into that system, so we just have to [...] make our own laws and rules and
agreements” (Rose).
Kaelyn and her wife deal with the lack of the third slot ​
by just adding either one of their
names below or even by “making a post-it”. Kaelyn phrased well their status of three-parent
family under the law: “what happens sometimes is that we kind of “fall between two chairs”
so there is no rule we can “fit into” [...] It not because it is directly against us, it is just not
fitting most times [...]”. This is the case, for example, if Kaelyn and her wife will end up
applying for the step-child adoption: if they did, the father agreed and they got it approved,
the father of their children would lose his paternity rights. Having a known father and two
112 mothers makes the family unsuitable for entering any legal document or form. Rose
explained “when you have a known father, then it complicates it because it [the system] is
just not made for that somehow. […] There are no categories to include three parents.” The
lack of space for three parents was also experienced by them during the birth: “We could
only put one person to the room with [Rose] and it was me so [the father] was left outside. I
think that was a bit hard on him [...]” (Sienna). The birthing room itself is the reflection of the
institutionalized concept of the family as a nuclear unit with two parents. However, Kaelyn
learned that if she and her three-parent family were “acting like [they] had [the] right to be
there with [their] family and how [they] are”, professionals acknowledged and respected
them. Diane also stated the importance of normalizing, institutionalizing her relationship
and her family: “We have to show it’s normal”.
One of the first times Rose went for a checkup with both Sienna and the father during the
pregnancy, the doctor at the fertility center assumed that Rose and the man were a couple
and gave them instructions accordingly. The misunderstanding was due to the fact that they
had not introduced all members of the family, and between assuming that Rose was married
to the man or the woman in the room, the doctor unconsciously chose to assume that Rose's
partner was the man. Sienna’s invisibility is clearly due to the norm privileging
heterosexuality in law, social policy, and consequently healthcare spaces (Carabine 2001).
Sienna was rather annoyed by that assumption, so after that episode, they tried avoiding
misunderstandings by always introducing the three of them to the healthcare professionals,
had they gone to a check up together. Rose explained:
“You have to be really clear about it and help them in how to grasp this thing and
direct them, instruct them in some ways. [...] it is hard for them to [know] […] what
kind of role you [Sienna] should have and what kind of role the father should have
[…]. They were very in need of instructions from our side.” (Rose)
Sienna recounted how, even after introducing, Rose was still the main person they were
addressing the information to. We argue that, because of the lack of institutionalized
guidelines about how to manage a three-parent family, professionals resorted to speaking to
the figure that they were most familiar with: the birth mother. Rose and Sienna also said
how explanations can be time-consuming and feel like a burden sometimes: “It is also a
113 question of how much do you want to explain all the time. You also want to get the things
done and it doesn’t matter” (Rose).
Something that emerged during some interviews, is that some couples preferred to use the
word ​
kæreste (gender-neutral term for ​
girlfriend/partner) instead of ​
kone (​
wife​
) to introduce
each other to professionals. There are several possible reasons that, in a purely speculative
manner, could explain the use of the word ​
partner instead of ​
wife​
. First, the couples did not
give importance to the institution of marriage, and therefore calling their partner wife or
girlfriend has the same meaning and value to them.35 Second, it just does not "sound good"
to them, it is just a linguistic preference, because ​
kæreste conveys the image of a younger
partner than ​
kone36 . Third, they may have gotten used to using ​
partner or ​
kæreste because
of the incompletely institutionalized status they used to have as registered partners: in the
past they either had to call each other ​
girlfriend or ​
wife​
, and either one would be inaccurate,
since they were ​
civil partners​
. These couples could have just kept calling each other the
same way as they used to, even though their partnership changed into marriage. Fourth,
they may not feel comfortable with using a term that has been for centuries a word charged
with heteronormativity, a word describing a privileged status of a heterosexual, married
woman. Refusing the term is coherent with their annoyance when having to conform to
marriage in order to have children jointly. Fifth, since the term ​
partner​
,​
kæreste​
, (or ​
puoliso​
,
in the Finnish sample) is a gender-neutral word, it does not reveal the gender of the partner
and the sexual orientation of the person speaking. This could be interpreted as a way to
protect their privacy and avoid to have to come out to the staff every time they speak about
their partner.
Episodes of heteronormativity and heterosexism were encountered in almost all Danish
women’s experiences. Rose's gynecologist did not seem to understand or to acknowledge
that she has a wife, and kept referring to her partner as a man, even though she had
previously corrected him. Tara and her wife Scarlett participated to a research project
carried out by a university in collaboration with the hospital, and told how “they had
forgotten to think that maybe some of the couples would be gay couples” (Tara) and when
they separated mothers and fathers in two different groups, Scarlett was sent to the fathers
e​
.g. Scarlett: “We didn’t make a lot of fuzz about our marriage”
e.g. in Tara and Scarlett’s case. Tara: "Or kaereste. Even though we’re married. In principle ​
​
kæreste​
means not married,
but, yeah… I don’t know why. Maybe because the Danish word sounds like an old person". Scarlett: "​
Kone​
...doesn’t sound
very romantic"
35
36
114 group. Similarly, the lack of historical institutionalization of lesbian families could have
brought the midwife in charge of writing Phoebe’s birth journal to name her wife Jane
kæreste (girlfriend) and not ​
kone (wife), although she could see from their records that they
were married. Diane recounted how the chief doctor in the neonatal department went
ahead and gave her information before an operation assuming her partner was a man:
“the doctor just before the operation, [...] she was in this operation suit and she was
very busy and gave me a lot of information about what will happen. ‘your child will
go to this department and they’ll take care of her and […] your husband’ she said ‘he
will go to this department’ and I didn’t interrupt her […] She assumed it was a man.
And I should have corrected her, because just after came a midwife and asked ‘is it
[name], right, who is your girlfriend?’ ‘yeah’ ‘oh but the doctor said…’.” (Diane)
In postnatal classes where Freya and Erin went, there was two other lesbian couples
participating other than them, and yet the teacher still kept talking about ​
fathers​
. Similarly,
Phoebe and Jane's hospital tour leader was using heteronormative language, until she
realized the couple was part of the group and changed vocabulary. Coming out in individual
visits and in group contexts, where all Danish teachers ​
always assumed the mothers had a
male partner, was reported to be more problematic. When Rose's maternity coaching
teacher made heterosexual assumptions, Rose did not find the courage to come out and left
feeling uncomfortable and annoyed. In a different case, Kaelyn remembered a physically
painful situation at a point during her pregnancy, when she was alone with a nurse caring for
her. The nurse, was talking about the father of the baby as her husband, and since Kaelyn
was suffering very much, she said she did not feel like starting an argument. Assumptions
that healthcare professionals make can be as harmless or as harmful as the situation and the
person's mental and physical status changes. There are several degrees of discomfort and
harm created, from Sienna's experience of being ignored during Rose's check up and just
feeling offended, to Rose's maternity coaching leaving her feeling uncomfortable, to Kaelyn's
experience of loneliness when she needed most support.
Kaelyn talked about how after the birth, the nurse responsible for the postnatal counseling
was telling the whole group about birth control and safe sex after birth, and Kaelyn as usual
listened although that information did not apply to her personally. What irritated her was
her GP starting to tell her the same standard recommendations (although she knew she had
115 a wife) during her first postnatal visit. Kaelyn noted: “you know she was in this auto [pilot]
[...] It was not a bad intention or something, she just didn’t think.” In all probability, all
women in our sample went through some counseling after the birth, although not all of
them reported episodes of heterosexism. The lack of historical institutionalization of
same-sex families, affects the type of knowledge hospitals distribute, through books and
handouts, recommendations from healthcare professionals, and information in family
coaching classes. The small number of lesbian patients becoming parents adds up to that,
making it harder to build ad hoc classes and to find a space where co-mothers would fit well.
Their position is the weakest, institutionally speaking, and has been up until recently
disregarded in the law.
6.2.3. Comparison
B. Carraro
From the Finnish data, four main findings emerged: heteronormative language,
heteronormative assumptions, heteronormative forms deriving from the incomplete
institutionalization of LGBT families and various strategies employed by the couples to
overcome challenges and redefining the family. Firstly, all couples experiences
heteronormative language in healthcare and found no signs of inclusion or gay affirmation.
Family coaching and forms were reported to be the most heteronormative: the other parent
was always referred to as ​
father​
. Secondly, all except one couple were assumed to be in a
heterosexual relationship or to be heterosexual. As a consequence, co-mothers were
assumed to be friends, which created awkward situations. Thirdly, incomplete
institutionalization was evident in all forms and other bureaucratic documents, which
represented a problems for all Finnish couples. Standardized language and documents were
heteronormative and included only the options ​
mother-father, making the situations
awkward. Fourthly, the strategies used to overcome heteronormative situations included
scratching the word father and writing instead ​
mother​
,​
other mother or ​
co-mother. ​
Three
couples coped with heteronormative expectations by making their sexuality and family
construction explicit: they announced their sexual orientation, introduced their wife, or
warned that she would be coming to the clinic. These were all strategies used in order to
avoid heterosexual assumptions and have the staff wondering who is the woman figure
accompanying the birth mother. Three couples reported their ways of redefining the family:
creating own parental titles and own words for them were among the strategies for
compensating in some way to the lack of proper institutionalization of their family structure.
116 The lack of institutionalization was clear also in all occasions when they disrupted and
queered​
the hetero-dominated birthing space.
The same four main findings also arose from the Danish interviews. Firstly, written material
including books, magazines, brochures still include only mom-dad roles. This lack of inclusion
toward other types of families was found in all cases except one where the term other
mother ​
was included, although the woman was not sure to remember correctly. One woman
stressed how being a co-mother is intrinsically different than the experience of becoming
father and how the fathers’ material was useless to them. Secondly, all couples encountered
heteronormative forms lacking options for their type of family, although two out of ten
women reported noticing some papers with the word ​
partner instead of ​
father​
. Thirdly,
women reported hearing heterosexual assumptions by professionals in two cases when they
were at the practice without their partners; two more cases of heterosexual assumptions
were reported when given instructions after the birth about safe sexual practices. All women
attending group classes, family coaching, both pre- and postnatal, recounted about
heteronormative language in family coaching in all cases. In one case only the teacher
corrected herself after noticing the lesbian couple. However, most GPs are aware and
remember their patients’ sexual orientation and do not ask about birth control anymore.
Fourthly, respondents from Denmark said that forms were always heteronormative. Two
co-mothers having to be registered as child’s father, other co-mothers scratched the option
father and wrote ​
mother​
. Three women reported cases where they remembered reading
partner instead of ​
father​
, or ​
parent one and ​
parent two​
. Forms have never space for more
than two parents, causing total lack of institutionalized role of the third parent.
Wrong assumptions about patients’ sexuality created awkward moments, especially in
Finland. In one case a woman referred to her partner with the gender-neutral term ​
puoliso​
,
and the staff assumed it was a man. In another episode, a midwife even asked to the new
mothers, after the birth, if they want to call the father, showing how institutionalized
heterosexuality can make professionals blind in front of otherwise clear family formations.
The heteronormative, standardized documents and procedures are forms of institutionalized
heterosexuality and thus disclose the incompletely institutionalized status of other types of
families. The strategies the couples used to overcome challenges and the way they adjusted
the structures and practices to adapt them to their family was similar in the two countries,
and were means for the couples to re-defined the concept of family and making space for
117 their own by first disrupting heteronormative expectations. The lack of institutionalization
for three-parent families implied the inadequacy of forms and material, as well as scanning
and delivery rooms, where there was no space for three parents unless the staff made some
exceptions. Two respondents underlined the importance of acting like their family was
“normal” to encourage the professionals to perceive it as “normal” too.
7. Discussion
B. Carraro & S. Sirkkala
In accordance with the purpose of this qualitative and comparative study, we described the
experiences of lesbian couples in public healthcare when transitioning into parenthood both
in Finland and Denmark. We aimed to uncover whether the lesbian couples’ experience in
perinatal care is atypical from heterosexual couples’ standard experience and what are the
possible reasons that make their experiences atypical. Furthermore, we pursued to
understand whether institutional differences between these two countries influence the
type of experiences these lesbian parents have. In this part we will answer to our research
questions, discuss our findings, interpret them and connect them with the existing literature.
7.1. Results
B. Carraro & S. Sirkkala
We found that when transitioning into parenthood, both Finnish and Danish lesbian couples
had a variety of unproblematic, positive and negative experiences, which include more
specific institutional and legal concerns, problems they encountered due to lack of
knowledge and preparedness of professionals, and troubles related to their incompletely
institutionalized status. To begin with, we found that the experience of transition into
parenthood for lesbian couples includes a variety of standard experiences and neutral
encounters with healthcare professionals, as for any other couple. In fact, in both Finland
and Denmark, we found that the staff is somewhat accustomed to meet also lesbian
couples, making the first encounters largely unproblematic. This finding shows how even
though the road to parenthood in a same-sex relationship is different and includes a variety
of proceedings unlike for the heterosexual couple, there are viable, legally enforced and
supported ways to start a family in these two countries. Indeed, the lesbian parents in both
countries felt that the state laws and social security system protects their family as any other
family, but ​
only​
after finalizing second-parent adoption.
118 At this point we answer our first sub-question on whether lesbian couples’ experiences of
transitioning into parenthood is different from heterosexual couples’ standard experiences
and what are the possible reasons for it. We argue that the experiences of the lesbian
couples in our sample have indeed proven to be atypical experiences either in a positive or
in a negative manner. The positive experiences include a variety of atypical episodes where
the prospective mothers had positive interactions with professionals who made an extra
effort ​
especially ​
because they were treating a lesbian couple. We found that in both
countries, the staff members had the ability to change unpleasant encounters into
something more positive by making an extra effort. A striking positive finding was that
medical staff was aware of the inadequacies due to institutionalized heterosexuality in the
healthcare system. This can be due to the fact that medical staff is increasingly encountering
more and more same-sex parents.
When it comes to negative experiences37 , our sample faced challenges and discriminatory
practices when starting a family on two levels: first, on the personal and cultural level and
second, on the institutional and structural level. Regarding the personal and cultural level
challenges, we found that the negative experiences all the lesbian couples had were due to
negative interactions with professionals. The professionals manifested their awkwardness in
the presence of the lesbian couple, made inappropriate remarks about their sexuality, about
the importance of biological ties with the child and by not acknowledging the co-mother.
The couples expressed fear of discrimination, hesitance to come out and other feelings
connected to position of the couples at the weaker end of an asymmetric power relation
with a heterosexual authority. We argue that these emotions affected the transition to
parenthood of the lesbian couples by making it even more dissimilar to the standard
experience of heterosexual couples. These negative experiences demonstrate how lesbian
parents are still deviant in heteronormative public spaces such as maternity wards. We
argue that behind the negative experiences lays the idea of superiority of the heterosexual
family and the queer nature of the lesbian-led family.
Because heterosexual and homosexual couples go through very different routes to parenthood, their accounts of
​
negative​
experiences ​
as such​
can also be very different. The intrinsic differences between these paths consist of a dissimilar
set of legal and practical formalities. Therefore, having a negative experience as a heterosexual can be very different from
the experience of a homosexual, because heterosexuals do not normally encounter discrimination due to their sexual
orientation or type of family.
37
119 Furthermore, we also found negative expectations regarding future treatment and legal
issues in both countries. We argue that the negative expectations toward laws and
bureaucratic proceedings are likely to be a realistic expression of the women’s awareness of
non-inclusive, heteronormative laws, whereas the negative expectations toward treatment
in public hospitals represents a more serious problem. This findings shows how, although
laws are in force to grant minorities reproductive rights, these have not yet affected the way
these women have internalized their rights to use public spaces, such as maternity wards. It
can also be that these expectations reflect old fears toward more discriminatory treatment,
legitimate back in time when lesbian motherhood was not framed as socially acceptable, or
as supported by the state through public policies, as it is nowadays.
The atypical experience of lesbian women in healthcare can be explained through
institutionalized heterosexuality and the queer nature of the lesbian couples in healthcare
spaces. Due to institutionalized heterosexuality, the family is generally expected to consist of
a mother and a father. In fact, we found that healthcare is still essentially designed and
tailored for opposite-sex parents (e.g. promoted through heteronormative written material
and forms). Thereby, families led by lesbian women constitute a deviance from this norm.
Lesbian mothers bring an element of disruption into the space where the heterosexual
assumption is very strong, such as maternity wards. By disrupting, or by queering, the birth
space, lesbian women need to confront the likelihood of facing an atypical experiences due
to possible negative reactions to the disturbance they cause.38
As mentioned, we also found negative experiences on the institutional and structural level
for both countries. These include legal and institutional challenges, lack of knowledge and
incomplete institutionalization. The responses compiled under these themes provide an
answer to our second sub-question whether institutional differences between Finland and
Denmark influence the type of experience these lesbian parents face in these two countries.
The institutional differences we refer to are mainly laws and public policies that are under
constant changes and development and among the institutional differences there are
LGBT-inclusive laws in Denmark, which have not been developed or adapted at the same
​
Moreover, Hubbard notes that queering is a way to re-territorialize public spaces and turn them into sites of sexual
diversity (Hubbard 2001). Thus, by queering the lesbian couples can also normalize the presence of same-sex couples within
those spaces.
38
120 pace in Finland. We found that institutional differences between these countries on one
hand ​
do​
influence and, on the other hand ​
do not​
.
We expected more LGBT-inclusive laws in Denmark to reflect to the healthcare practice and
thus, to make the quality care received by Danish lesbian couples better, but we found that
healthcare practices and professionals’ attitudes toward sexual minorities do not
straightforwardly reflect legal provisions. Behind this is the fact that Danish family laws
regulating same-sex parenthood are very recent, and therein lies the risk that practices,
training and material may not updated at the same pace. On one hand more inclusive laws
have an important role in creating more inclusive and nondiscriminatory attitudes in the
society at large, but on the other hand, changes do not happen overnight and not without
the appropriate training and the necessary time for healthcare centers and the professionals
to adapt and to adjust old practices, and for new practices to be created. This is based on the
findings that despite inclusive laws are in force in Denmark, forms, documents and
healthcare professional’s practices are still not always LGBT sensitive and as up to date as
the laws.
When comparing the data from the two countries, the lesbian mothers in Finland experience
a variety of legal, cultural and interpersonal challenges when transitioning into parenthood.
39
In fact, challenges that are at first regarded as merely bureaucratic or interpersonal
actually demonstrate how in Finland, the lesbian headed family is in essence incompletely
institutionalized. In Denmark, even though the Danish participants reported encountering
more updated
governmental
forms​
, the process of ​
completely ​
changing the
heteronormative bureaucratic language is expected to take long time. Yet, the difference
between these countries is that the Danish participants and healthcare professionals were
aware of and expecting upcoming changes, unlike in Finland, demonstrating the way
same-sex families are being institutionalized in Denmark with a faster pace.
Historically, before same-sex families became publicly acknowledged, the publicity they
were granted was not more than minor political discourses in national parliaments, which
mostly LGBT citizens were following. Otherwise, same-sex families were invisible in other
​
Resorting to adoption after birth has proven not to be enough, because the adoption is not confirmed immediately after
the birth. Lesbian couples are still required to resort to extraordinary paperwork, they still face difficulties having their
family constellation recognized in the eyes of not only other lay persons, but also professionals in clinics and offices. They
still encounter heterosexual assumptions and heteronormative practices as the bureaucratic language is still highly
heteronormative promoting the family unit.
39
121 public spaces and absent from most citizens’ everyday lives. Yet, only after legal changes
made same-sex parenthood more possible and more common, the dominant heterosexual
citizens, that most healthcare workers are also part of, have had the chance to become more
familiar with ​
queer couples and families, and therefore to think of lesbians and gays as
potential parents. While lesbian couples were increasingly transitioning into parenthood
after they finally obtained the right to use assisted reproduction services, the rest of the
society was not necessarily ready to lesbian motherhood. The fact that lesbians were ready
to be mothers for a long time before they could, does imply that others, such as medical
professionals, were suddenly as ready to welcome these couples into healthcare spaces with
the appropriate vocabulary and tailored practices.40 We argue that only after same-sex
couples became lawful parents and started occupying spaces in heteronormative realities,
such as perinatal care and maternity wards, also allowing professionals to finally meet them,
the staff can become more aware of those laws and rights that lesbians had interiorized long
before.
7.2. Our Results and Previous Studies
B. Carraro & S. Sirkkala
Lesbian women’s experiences in healthcare services compile a constantly growing literature
(e.g. Goldberg et al. 2009 & 2011; Wilton & Kaufmann 2001; McManus et al. 2006; Larsson &
Dykes, 2009; Lee et al. 2011; Röndahl et al. 2006; Röndahl et al. 2009). Although the overall
experiences of our participants varied, all Finnish and Danish participants reported a at least
some positive interactions and experiences of respectful care from healthcare providers. The
experiences were mostly references to good relational skills of doctors and nurses having a
positive impact on the level of satisfaction in the overall healthcare experience similarly to
what Marques et al. (2014), Röndahl et al. (2009) and Malmquist and Zetterqvist Nelson
(2014) found. Furthermore, several of our participants reported positive feelings about the
way they were treated and acknowledged as a family and that atmosphere at the healthcare
centers was warm. Thus, these findings are in accordance with studies by O’Neill et al.
(2013), Röndahl et al. (2009), Marques et al. (2014) and Chapman et al. (2012) reporting how
couples made positive remarks on the incidents where they felt an acceptance of their
lesbian relationship and were not judged against the healthcare professionals'
heteronormative assumptions. In addition, we found several experiences that we defined as
Although especially our Danish respondents have internalized their right to become mothers in a same-sex relationship,
​
some of their narratives show how some of them still expect some negative treatment and interactions, and tend to call
themselves ​
lucky​
if they do not encounter them.
40
122 unproblematic. These were occasions where the professionals focused generally more on
the reason why the couples were seeking healthcare than the fact that the family
constellation was different, similarly to what Chapman et al. (2012) found.
Thus, we do not confirm the finding regarding serious concerns related to possibly
dangerous events for lesbian couples when they ​
disrupt spaces as in the study by Goldberg
et al. (2011) when accessing healthcare. In fact, we did not encounter narratives where our
participants would have raised worries of how disrupting heteronormative spaces, such as
maternity wards, could compromise their well-being by making these public spaces
uncomfortable for the professionals.
We found that the lesbian couples in our sample faced challenges and discriminatory
practices when starting a family across two levels. First, on the personal and cultural level
the lesbian couples reported negative experiences due to negative interactions with some
healthcare professionals and second, on the institutional and structural level the couples
reported institutional and legal challenges. The personal and cultural level challenges
consists of negatively biased interactions. Similarly to the study by Chapman et al. (2012),
our participants experienced both positive and negative interactions with healthcare
professionals. On one hand, both parents were acknowledged and treated respectfully but,
on the other hand, participants also reported more negative situations where they were
encountered heterosexual assumptions and a burden to educate healthcare professionals on
LGBT family-specific issues. Negative experiences in the Finnish sample also included
negative non-verbal communication. This finding is in accordance with the study by Röndahl
et al. (2006), as some of the couples sometimes felt ​
undesired due to their sexual orientation
and were excluded and neglected by nursing staff. In addition, similarly to Wilton and
Kaufmann (2000) and Röndahl et al. (2006), some lesbian women in our Finnish sample,
reported that the co-mother had been excluded during the healthcare processes.
Earlier LGBT literature refers often to episodes of disclosing sexual orientation as stressful,
evoking emotions of anxiety and concern about the professionals’ prejudices, or that lesbian
patients tend to avoid disclosing their orientation (e.g. Larsson & Dykes 2009; Wilton &
Kaufmann 2000; O'Neill et al. 2013; Marques et al. 2014; Saulnier 2002). We did not confirm
this as it was frustrating or irritating at most to all Finnish and Danish couples. In fact, the
Finnish couples used disclosure as a mean to avoid heterosexual assumptions, confusion and
123 to ​
create space for their entrance. Disclosure was also justified with the relevance for
medical purposes. Danish couples, in most cases, were not always even compelled to
disclose their sexuality, as the professionals were more used to lesbian couples and were
assuming correctly when encountering them. We also do not confirm the finding of Fields &
Scout (2001), Heck et al. (2006) and Goldberg et al. (2009) that lesbian women seek for
alternative or gay-friendly healthcare providers. The Finnish and Danish couples reported
accessing public healthcare services as being natural and easy for them. Thus, our findings
do not suggest these women might be at an increased risk for developing health related
problems due to avoidance of care because of fears of discrimination.
The lesbian couples faced challenges and discriminatory practices when starting a family also
at the institutional and structural level: mainly as a result of existing laws and public policies.
This reflects to the conservative and stereotyped nature of the official and standardized
material that our couples had to deal with, confirming what Trettin et al. (2006), Larsson and
Dykes (2009), Marques et al. (2014), Chapman et al. (2012) and Röndahl et al. (2006 & 2009)
also found. Indeed, the questions the medical staff asked the patients (e.g. to fill in to the
standardized forms) were a possible source of frustration or embarrassment for both the
professionals and the prospective parents. Trettin and colleagues (2006) further argue that
these forms are expressions of discrimination as they limit the possibility to gather the
necessary and correct medical information. However, our Danish and Finnish participants
mostly reported how professionals, after becoming aware of inadequacies in the
information material and in the forms were acknowledging them, apologizing for them,
and/or helping the patients to find solutions.
Our analysis suggests that despite increased visibility and social acceptance of lesbian
parenthood, supported by increasingly inclusive legislation, heteronormativity and
discrimination continue to affect healthcare provision. Similarly to what Röndahl and
colleagues (2009) found, our Finnish participants described how their visits to the healthcare
centers were performed in heteronormative routinized manner by the medical staff and how
the personnel showed not to always be aware of having lesbians among their patients.
Heteronormative language and assumptions are evident in our findings, especially among
the accounts by Finnish couples. Indeed, we found that, in both countries, LGBT individuals,
especially when often face the assumption that they are heterosexual, unless they state
124 otherwise as found also in studies by Saulnier (2002), Röndahl et al. (2006), Morrison &
Dinkel (2012), Marques et al. (2014), Trettin et al. (2006) and Heck et al. (2006).
Indeed, this can leave the patients feeling embarrassed and even invisible, leading to a
situation where the health needs of the lesbian patients are left unmet, as studies by Heck et
al. (2006) and Saulnier (2002) show. For example, in line with findings by Marques et al.
(2014), our participants reported professionals asking them questions related to sexual
health, such as birth control and sexually transmitted diseases. Thus, the personnel did not
consider the possibility that they are dealing with a lesbian woman. This reveals how
heteronormativity due to institutionalized heterosexuality works in practice, like in Chapman
et al. (2012). In sum, one of our most remarkable finding is heteronormative communication
in perinatal care, which in practice can lead to feelings of invisibility and isolation (Wilton &
Kaufmann 2000; Saulnier 2002; Larsson & Dykes 2009). We argue, along the lines of
Goldberg and colleagues (2009), that health professionals should orientate themselves to
resist the taken-for-granted heteronormative worldview and adjust their standard practice
to create inclusive spaces for queer patients.
Similarly to Hequembourg (2004), especially our Finnish sample of lesbian mothers
employed a variety of strategies to negotiate their incompletely institutionalized statuses.
We found how our sample of lesbian couples had to resort to strategies to ​
fit into
heterosexual structures and redefine families by queering the birth space. This is the case
especially for the Finnish couples as their status is more incompletely institutionalized than
the for the Danish couples.
In relation to legal aspects, we found that rights granted to mother and father in a
heterosexual union are not equivalent to the rights granted to mother and mother in
same-sex union in Finland. This is why lesbian-led families indeed face challenges including
legal fears and struggles during their transition to parenthood, such as the lack of public
fertility treatments and lack of automatic entitlements to parenthood. Also the findings of
the study by Cherguit et al. (2013) indicated that the co-mothers have difficulties to have
their parental identity formally recognized. Thus, legal and structural exclusion and
discrimination pose challenges for the lesbian-led family and compels them to create
strategies to overcome them (i.e. internal adoption) despite their incompletely
institutionalized statuses. This finding is identical to the findings in Short (2007). In reality,
125 the discrimination from the institutions leaves co-mothers often invisible and strengthens
the prevalence of the heterosexual assumption and heteronormativity, also confirmed by
Wilton and Kaufmann (2000), Brown et al. (2009), Cherguit et al. (2013), Larsson and Dykes
(2009) and Röndahl et al. (2009).
In the case of both interpersonal and institutional challenges our participants faced, we
found that minimization was striking feature found in several interviews with Danish
mothers. Our findings and our interpretation of these findings are in agreement with those
of Lee and colleagues (2011) as we, on one hand, suggest that there were evident aspects of
homophobia in the patients’ experiences but, on the other hand, the participants did not
agree to recognize them as such even though they witnessed homophobic practices.
Regarding knowledge and competences of healthcare professionals, necessary to care for
lesbian parents, several Finnish and Danish participants felt the burden to educate the
professionals about same-sex relationships and parenthood. Röndahl et al. (2009) and
Rounds et. al. (2013) also had analogous findings. Descriptions of incidents regarding
uninformed professionals who lacked knowledge about lesbian families or LGBT-specific
information are common in our interviews, confirming what Malmquist & Nelson (2014)
found. As a matter of fact, by knowing about different associations and organizations,
healthcare professionals are in a key position to provide patients with information and
additional support. It has been found that lack of knowledge and information can have a
deteriorating effect on the quality of treatment, which is why it is essential that nurses and
other medical staff are endowed also with LGBT-specific knowledge (Härkönen et al. 2011,
28–9).
The lesbian mothers in our sample expressed a wish for increasing LGBT-specific education
for the healthcare staff. On one hand most couples in our sample expressed feelings of
disapproval of how they, as prospective lesbian parents, were used as an educational
resource. This finding is identical with the study by Röndahl et al (2009). On the other hand,
similarly to Hayman et al. (2013), our participants, especially in Denmark, commented how
they sometimes regarded themselves as sort of ​
reformers and considered educating
healthcare professionals, and normalizing their sexual orientation and same-sex relationship,
as an important role.
126 Although sexuality and sexual health is unavoidably referred to in many areas of healthcare
and thereby, public health nurses should have the preparedness and knowledge, we found
through our participants’ experiences that the professionals’ knowledge on these subjects is
often deficient. In reality, in the basic training of a medical doctor in Finland, the central
issues of sexual and reproductive health are only being dealt with amidst other studies and
questions related to sexuality and sexual diversity fall short or are missing altogether from
the basic training as actual, concrete guidelines for encountering and supporting these
minorities and their families are not given (Sannisto 2011; Härkonen et al. 2011).
Our study, in line with what Rounds and colleagues (2013) argue, shows the need for
providers who are comfortable, knowledgeable, and competent to work with LGBTQ
patients. The study by Rounds and colleagues (2013) emphasizes the need for improved
education and for more LGBT-specific training in order to improve the quality of care and the
health outcomes for LGBT people. Adjusting health assessments, material, practices and
family coaching courses to include LGBT-inclusive language should be part of this reform, to
eliminate all residues of heteronormative communication affecting the quality of the
lesbians’ experience transitioning to parenthood (which were found, among others, by
Röndahl et al. 2009, Wilton & Kaufmann 2001). In addition to education, as Hayman and
colleagues argue (2013), it is evident that the healthcare environment could be improved by
inclusive policy development for these new families including health promotional materials
and health assessment forms focused on the unique needs of same-sex families.
Indeed, an expectation regarding new, LGBT inclusive official forms and materials to the
public healthcare centers, was mentioned in several occasions among the Finnish
participants suggesting their desire for institutional changes that would integrate them into
the existing social structures as in Hequembourg (2004). In accordance with this study, we
confirm its finding that strategies such internal adoptions, wishes for common surname,
equal marriage and what is entails clearly demonstrate a the lesbian couples’ valuation of
their rights and formal inclusion into existing institutional structures (Hequembourg 2004).
All in all, despite a variety of same-sex inclusive laws and policies, equality is not always
attained in Finland nor in Denmark in the case of marginal groups like the sexual minorities.
In public healthcare there is still room for improvement with the encounters of public
healthcare professionals and same-sex families. Sometimes the presence same-sex families
127 or couples is still not acknowledged, which can have a negative effect on the way these
individuals belonging to a sexual minority group perceive the healthcare service. In practice,
the missing consideration of sexual minorities among the patients can be seen from the
official materials and paperwork provided by the public healthcare that are promoting the
ideal of opposite-sex nuclear family, implicitly excluding same-sex families.
7.3. Policy Implications
B. Carraro & S. Sirkkala
The main idea behind all policy implications of our study is that the current, narrow
definition of family in public discourses and public policy should be readjusted. Family
policies should reflect the needs of all families and not only families constructed according to
the dominant heterosexual, nuclear structure. Healthcare in particular is a place that citizens
resort to in vulnerable moments, which is one more reason to emphasize the need for
inclusiveness and attentive care. Professionals should take into consideration that not all
patients are heterosexual nor are their family composition always consisting of a mother and
a father. Healthcare should not be a stage for promoting only one type of a family, but
instead should include them all. This implies that healthcare policies and practices should be
developed to become more sensitive towards patients belonging to sexual minorities, just as
they already increasingly do with ethnic and religious minorities.
First of all, our findings unveiled inadequacies in the language and options in official forms,
showing the need for bureaucracy to be adapted to evolving models of family that do not
necessarily include two parents of the opposite sex. Second, our results stress the need to
update information material, because not all parents are in a heterosexual monogamous
relationship and thus, public offices and healthcare centers should not assume so. Among
these new parents there are lesbian women, gay men, single mothers, and families with
more than two parents. These families need support like any other family and more,
because they have different needs than standard heterosexual families, which have to be
answered through appropriate and tailored strategies, such as inclusive information. Third,
education of healthcare professionals should include also LGBT specific knowledge in order
to meet the needs of these patients belonging to a minority. Fourth, the incompletely
institutionalized status of lesbian-led families in Finland include legal drawbacks and
amending these should be a priority. It is potentially dangerous that children that have been
128 wanted and conceived by two people are entitled to have only one of them as a legal parent
as soon as their child is born.
Legal recognition of parents from birth is not only an argument in favor of lesbian mothers,
but it is first of all an argument in favor of these children’s best interest. The lack of parental
rights as a negative fact from an LGBT perspective becomes a lack of rights from the
children’s perspective. It is indeed a discourse and matter of children’s rights to have as
many parents as there are involved from the start.
8. Conclusion
B. Carraro & S. Sirkkala
The normative status of heterosexuality in Western society continues to shape the
experiences of different groups of individuals either through direct oppression of
non-heterosexuals or indirectly through privileging heterosexuals. This is why we examined
the experiences of twenty lesbian women in public healthcare in Finland and in Denmark in
this qualitative, comparative study to see whether their experiences are atypical from those
of heterosexuals and what are the possible reasons for it. Furthermore, we also investigated
whether institutional differences between these two countries have an effect on the
experiences of the lesbian mothers. We focused in particular in perinatal care, as it is one of
the sectors of public healthcare where heteronormativity is rooted most deeply.
In the analysis, we reported the experiences of the twenty women when transitioning into
parenthood in healthcare and institutional context. Aside from neutral and positive
experiences, we found negative encounters and discriminatory practices on two levels:
interpersonal and institutional. We found that institutionalized heteronormativity
embedded in social policies, family laws and healthcare practices continues to affects lesbian
patients and their families. Both Finnish and Danish lesbian couples had a variety of
unproblematic, positive and negative experiences, which include more specific institutional
and legal concerns. To answer the first part of our research question, we argue that the
experiences of the lesbian couples in healthcare have indeed proven to be atypical
experiences. To explain this, we separated the accounts of our respondents into two
categories: positive and negative. Accounts of positive experiences include a variety of
atypical episodes where the prospective mothers had positive interaction with the medical
staff making an extra effort ​
especially because they were a lesbian couple to adjust
129 heteronormative written material and practices. Then again, accounts of negative
experiences include challenges and discriminatory practices on personal and cultural level,
when the lesbian couples reported negative experiences due to negative interactions with
healthcare professionals.
The atypical experience of lesbian women in healthcare can be explained through
institutionalized heterosexuality and the queer nature of lesbian couples. Our findings show
how lesbian parents are still deviant in heteronormative public spaces such as maternity
wards. We argue that behind negative experiences is the traditional idea that only
heterosexual couples have a functional set of the appropriate gender relations, which serves
as a precondition for a family. Due to institutionalized heterosexuality, heterosexual couples
are the norm, also in healthcare. Thereby, families led by lesbian women continue to
constitute a deviance from the norm.
Negative experiences were reported also on the institutional and structural level. These
include
legal
and institutional challenges, lack of knowledge and incomplete
institutionalization. These experiences provide an answer to the second part of our research
question. In essence, we found that institutional differences between the countries on one
hand ​
do influence and on the other hand, ​
do not​
. Among the differences are especially the
recent institutional changes regarding LGBT-inclusive laws in Denmark. In Finland, similar
laws have not been developed or adapted at the same pace. We expected more inclusive
laws in Denmark to reflect to healthcare practice making the care received by lesbian
couples better. However, we found that the institutions, such as new laws, do not have an
immediate effect on practice. Thus, we found that LGBT-inclusive laws do not always have
an evident and immediate effect on the quality of healthcare. Indeed, especially in the
Danish case, healthcare practices and professionals’ attitudes toward sexual minorities do
not straightforwardly reflect legal provisions.
We argue that behind this is because Danish family laws regulating same-sex parenthood are
very recent, and therein lies the risk that practices, training and material may not updated.
We argue that more inclusive laws have an important role in creating more inclusive and
nondiscriminatory attitudes in the society at large, but this does not happen without the
appropriate training and the necessary time for healthcare centers and the professionals to
130 adapt old practices and to create new ones.41 Thus, there is a need for additional and further
training to bring awareness and competences in addition to legal changes, so quality care is
assured also for LGBT families.
Our study design has few limitations. The generalizability is compromised due to small
sample. Nevertheless, as the population homogeneity in our study is rather high, sample
error decreases and sample reliability increases. The participants of our study may not be
representative of all LGBT patients in healthcare, but they are able to provide meaningful
qualitative descriptions of the experiences lesbian patients have in healthcare practice.
Furthermore, our chosen snowball sampling method contains some limitations as well, its
weakness being that researchers tend to receive similar data. Yet, it proved to be the only
viable option in our study.
With our findings we contribute to knowledge about LGBT families and the unique
challenges they face when transitioning into parenthood, and to the understanding of
heteronormative mechanisms in social and political institutions. This study provides insights
into the unique relationships and interactions between lesbian parents and nurses in the
public healthcare spaces. Because our sample was restricted to only lesbian mothers, we
excluded other types of LGBT families. Thus, we suggest that research in this field should
continue in two important directions: both examining the transition into parenthood, also in
relation to healthcare and to public institutions, in case of, first, families led by a male
couples, and second, families with more than two parents.
This is based on the findings that despite inclusive laws are in force in Denmark, forms, documents and healthcare
​
professional’s practices are still not always LGBT sensitive and as up to date as the laws.
41
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B. Carraro We consider important to insert a small vocabulary here on some LGBT-­‐specific terms and other relevant terms we use throughout the main body of our work. First of all, we use the terms lesbian, gay, bisexual when referring to these groups in particular, whereas we use the acronym LGBT when referring to the whole community of non-­‐heterosexual or gender nonconforming individuals, although in our study we will mostly talk about LGB (lesbian, gay, bisexual) individuals. Another reason to use the acronym ​LGBT is because it is the most widely used term to refer to sexual minorities. This is mainly why we preferred it among other possible options such as ​LGB or LGBTQI. ​With ​LGBT family we refer to non-­‐heterosexual families: mainly families with two parents of the same sex, irrespective of whether the family has two mothers, two fathers, two mothers and one father or something else. Second, we refer to our participants as lesbian mothers or lesbian couples, even though not all of them identify as lesbian. This (perhaps simplistic) way of calling them is due to the fact that they were in a lesbian relationship during the period of time under analysis. Third, we use ART as an acronym for ​assisted reproductive technology​, which comprises procedures such as artificial insemination and in vitro fertilization (IVF). We also refer to ART as ​fertility treatments​. Fourth, we use the verbs ​to come out and to ​disclose​, and the nouns ​coming out and ​disclosure​, they all refer to the act of intentionally revealing one’s sexual orientation. Fifth, by ​healthcare center we mean hospitals, clinics, and all practices where medical treatments and check-­‐ups are being performed. We reminded the participants that we will be dealing with public healthcare giving less attention to their private clinic experiences (e.g. some of the couples’ fertility treatments). Thus, in the course of the analysis we will always deal with public healthcare, unless we state otherwise. Annex 2​ -­‐ ​Participants Information NAME COUNTRY REGION and PARENTAL STATUS NO. CHILDREN CHILDREN’S BIRTH YEAR FERTILITY CENTER 1. Olivia FI -­‐ Capital Region Biological 2 mother and co-­‐mother 2011 & 2013 Private 1. Emily FI -­‐ Capital Region Biological 2 mother and co-­‐mother 2011 & 2013 Private 2. Amelia FI -­‐ Western Finland Biological mother 1 2015 Private 2. Holly FI -­‐ Western Finland Co-­‐mother 1 2015 Private 3. Isla FI -­‐ Capital Region Biological mother 1 2014 Home Insemination 3. Chloe FI -­‐ Capital Region Co-­‐mother 1 2014 Home Insemination 4. Ella FI -­‐ Lapland Biological mother 1 2014 Private 4. Poppy FI -­‐ Lapland Co-­‐mother 1 2014 Private 5. Lucy FI -­‐Eastern Finland Biological mother 1 2012 Private 5. Grace FI -­‐Eastern Finland Co-­‐mother 1 2012 Private 6. Phoebe DK -­‐ Southern Biological Denmark mother 1 2014 Public 6. Jane DK -­‐ Southern Co-­‐mother Denmark 1 2014 Public 7. Sienna DK -­‐ Capital Region Biological 3 mother and (not legal) co-­‐mother Child A: 2005, Children B and C: 2014 Child A: not stated, Children B and C: public 7. Rose DK -­‐ Capital Region Biological 3 mother and Child 2005, A: Child A: not stated, step-­‐mother Children B Children B and and C: 2014 C: public 8. Erin DK -­‐ Capital Region Co-­‐mother 1 2013 private 8. Freya DK -­‐ Capital Region Biological mother 1 2013 private 9. Diane DK -­‐ Capital Region Biological mother 1 2012 not stated 10. Kaelyn DK -­‐ Capital Region Biological 2 mother and (not legal) co-­‐mother Child A:2012 not stated Child B: 2014 11. Scarlett DK -­‐ Capital Region Co-­‐mother 1 2014 public 11. Tara Biological mother 1 2014 public DK -­‐ Capital Region NOTES -­‐ if not stated otherwise, all are legal parents -­‐ people indicated with the same number are married/registered with each other -­‐ all women are or were married or registered at the time they had children Annex 3 -­‐ Gay Men’s Possibilities to Become Parents For men in a same-­‐sex relationship, the chances to become parents in Finland and Denmark are very limited. For female same-­‐sex couples, parenthood is much easier, not only due to their biological sex, but also due to laws supporting lesbian motherhood. For instance, surrogacy, which is a solution for male couples in other countries, is not a viable option in Denmark and Finland. Surrogacy is in fact illegal in Denmark unless it is altruistic, meaning that the surrogate mother must not be compensated for carrying the child for someone else. If the surrogate mother is not paid, it is evidently less likely that any woman will do it for free (Tuazon & McCheyne 2010, 315). An alternative to altruistic surrogacy in Denmark is to have children through commercial surrogacy abroad where national laws (and the couple’s finances) allow it. However, commercial ​surrogacy became illegal in Finland in 2006, filling the previously existing gap in legislation (Finlex 2015). In Finland, external adoption can be an option for same-­‐sex couples, but only when either one of them adopts alone. Thus, external adoption is only a possibility to a couple, if they are in a heterosexual marriage, but not to a same-­‐sex couple in a registered partnership (Aarnipuu 2010, 5). Joint adoption is legal in Denmark for male and female same-­‐sex couples since 2010 (Karlund 2014). ​The ​general requirements for a couple to adopt are: the age difference between child and applicant must be under 43 years; the adoptive parents should have lived together for a minimum of two and a half years and they must be married at the time of approval; their physical and mental health must not be such that it could have a negative influence on the child’s situation; they must have adequate housing conditions, adequate financial situation, and must not have been convicted (Statsforvaltningen 2013). Although joint adoption for same-­‐sex couples has been legal in Denmark since 2010, there has been only two joint adoptions by same-­‐sex couples by the start of 2014, both of Danish children, and the first ever gay couple who was able to adopt a child from outside Denmark completed the adoption process only in June 2014 (Ilga 2014; Klarlund 2014). Although Danish law allows for same-­‐sex couples to adopt, the ​donor country makes the final decision of whether to actually permit it or not, and their restrictions for adoptive parents often deny adoption to same-­‐sex couples. Some countries allow same-­‐sex couples to adopt only children with special needs, because these children are more ​difficult to place for adoption to straight couples (Adoption & Samfund 2015). Another obstacle for same-­‐sex couples to adopt is the cost of an adoption. ​Applicants wishing to adopt must attend a pre-­‐adoption counseling course, costing DKK 2.500 in 2013. (Statsforvaltningen 2013). After the counseling course, international adoptions can cost from 159.000 DKK (roughly 21.308 €) up to 350.000 DKK (roughly 46.907 €) (DIA 2015; Kjær 2015). All families are eligible for an adoption subsidy from the state of 50.871 DKK (6.818 € ca.). However, the couple adopting must be able to pay the whole adoption sum upfront and will be able to apply for the state subsidy only after the children have been taken home (DIA 2015). Annex 4 -­‐ Minimizing Experiences
B. Carraro One last theme was found during our Analysis, without being added to either the positive or the negative experience group is ​minimizing experiences. It includes those cases where the respondents were minimizing what happened, defending attitudes, justifying behaviors, reporting some treatments they had received as normal, even though they were not. In some occasions, especially in Denmark, the participants interpreted negative experience in ways that downplayed their significance by disassociating negative interactions from their sexual orientation, or by attributing negative experiences to coincidence. In Finland, one couple said they did not even expect to get LGBT inclusive material from the hospital nor to read about “two moms” from the books and material provided, because “that's not reality”. Chloe (FI) commented the fact that her leave was called the “paternity leave” by stating that “I’m not taking that so seriously, but of course [..] it’s unfair of course. But I’m like joking to my co-­‐workers [about it]”. In Denmark, after explaining all the legal challenges they faced, four couples (all those that did not have an involved father) tried to minimize the procedures they had to go through. Phoebe and Jane (DK) minimized the troubles they went through during the adoption process. “There were a lot of couples that went through the same [...] also heterosexuals[...] Maybe it wasn’t their fault [of the hospital]. We knew then later because they didn’t have the right information, from the government, so it wasn’t their fault” said Phoebe, making clear that in the end “it was ok”, although the stakes were high, and added, “It won’t happen again for other couples.” Tara (DK) commented the bureaucracy related to adoption by saying: “I mean, it’s not a barrier, it just seems a bit silly. [...] I mean, now we are down at a level where it’s just a little extra paperwork, at least we can [have children together – our note].” (Tara). Tara and her partner also made excuses for the fertility clinic, that did not inform them about the lengthy bureaucratic waiting time when applying for co-­‐mothership. Freya (DK) minimized what she first called “bumps” in the adoption: “Not really obstructions, but something that you think ‘oh this is strange’ or ‘why do we have to do this?’.” Erin (DK) continued, talking about the adoption bureaucracy and the old requirement of marriage: “It’s understandable in a way that, because there is [...] a third party involved. […] But the way that society is kind of forcing you to [look– our note] like a heterosexual more than the heterosexuals have to! It’s kind of funny, I mean, but it wasn’t unpleasant.” She also did not seem to give too much importance to the interview she had to go to in order to adopt: “it was just ​pro forma​” she downplayed. We interpret these narratives as acts of downplaying, because in the end these couples were all able to be legal parents from the birth, and the vital importance of that made them see all previous obstacles as of less of an importance. Although most couples thought official modules and forms should be updated, a few respondents did not agree that is the most important thing. Tara (DK), for example, first mentioned changing heteronormative books and forms as a way to make the perinatal experience better, but then said: “But then you’re really searching for something to complain about.” Diane (DK) also thought changing heteronormative forms is not a priority: “they have so much to take care of, so that doesn’t matter.” After she talks about the lack of institutionalized procedures for her family, Sienna (DK) tried to explain it to us (or to herself) “it is also because this is a quite new constellation”. Three couples minimized assumptions on heterosexuality: Scarlett (DK) commented “That’s also the normal assumption, why would you assume otherwise?”, Sienna (DK) called heterosexist assumptions a “very common reaction”, Jane and Phoebe (DK) justified them with “We are such a minority, that’s why” (Jane, DK) and “it didn’t irritate us at all, we know how it is […] we don’t expect that people are always on their toes, trying to say the right thing” (Phoebe, DK). Moreover, Diane (DK) thought that the fact that her partner did not get acknowledged in some checkups was not important, “because it didn’t matter, who’s this person with you.” We can not tell whether it actually mattered to the non-­‐biological mother. Although Sienna and Rose (DK) did not appreciate at all the special attention and questions from the nurse during Rose’s birth, Sienna somehow later tries to defend her by saying “ those are usually the people who are making this world a bit better.” When Diane (DK) remembered the hospital contacting her to ask about the treatment they received as a lesbian couple, she reflected, “I think also it must be difficult for them to make sure that they are talking [correctly]… I remember some very crucial serious moments at the hospital [...] they have to be professional, I don’t think… it doesn’t matter, is it a father or [someone else]…” Scarlett (DK) also minimized the episode when her wife Tara (DK) received an inappropriate comment on her sexuality from the fertility doctor saying: “But that’s just very ​doctory​.” However, after hearing Tara’s words, we can argue that the fact that the doctor felt entitled to cross the line was perceived by her as inappropriate and intrusive, leaving her with the feeling that their privacy had been somehow violated and the overall interaction has been negative. Tara later tried to downplay the event by saying that that doctor could have made the same comment to any other woman. Contrastingly, we argue that the doctor would have not made comments like that if he had been in the presence of a husband in the room, and in front of a heterosexual woman. We argue his attitude was heterosexist because it showed his opinion of inferiority of the homosexual couple as less deserving for privacy (Hubbard 2001). Similarly, in Rose and Sienna’s (DK) case, professionals were so curious about whose gametes and which type of ART they used (having a known donor) that they did not hesitate to ask questions they would not normally ask to a heterosexual couple going through fertility treatments. Coherently, Hubbard (2001) argues that, at times, homosexuals do not always lack right to publicity, but rather, to privacy. Minimizing can be particularly dangerous as it contributes to increasing invisibility of negative attitudes and can be a possible move to covert homophobia (Lee et al. 2011, 987). Annex 5 -­‐ Privacy Statement and Interview Structure / / 2015 Privacy Statement and Informed Consent
This research project focuses on the experiences of same-­‐sex couples with public healthcare when having a child, and on how they experience the interaction between healthcare professionals with diverse, non-­‐heterosexual families. The research is part of the Master Thesis project conducted at the University of Southern Denmark, at the Department of Political Science and Public Management, within the Master of Social Sciences in Comparative Public Policy and Welfare Studies (http://www.sdu.dk/en/information_til/studerende_ved_sdu/din_uddannelse/kandidat/comppp
welfare). During all the phases of this research, the investigators are bound by the written and unwritten ethical rules for scientific research. The first and foremost concern is that the anonymity of the participants if fully ensured. The researchers are responsible that the information collected or placed at the disposal of research does not become available to external persons in a form that enables an identification of persons who are the subject of, or who have contributed information to the research work. The protection of the identity of those being investigated will be ensured by not reporting the names of the participants and using code names instead. It is the responsibility of the researchers to ensure that security measures are in place to prevent any intentional or unintentional breach of anonymity. It is on the responsibility of the researchers to present their results in accordance with general academic principles and to avoid misreporting or misinterpretation.
Participation is voluntary, and you can decline to participate in specific parts of the investigation. For accuracy, the interviews will be voice recorded. As a general rule, the researcher will make use of all the information provided. However, if certain statements are "off the record" the participants are encouraged to explicitly signal them to the investigators. By agreeing to participate in this interview you give your consent to use the information collected during the interview, for the sole purpose of this Master Thesis. Thank you very much for your time and cooperation. Saana Sirkkala & Beatrice Carraro. Couple n…….. / / 2015 Information Age: Education: Profession: Nationality: City of residence: Gender identity: Sexual orientation: Civil Status: Duration of current relationship: Interview Structure Couple n...... / / 2015 1) PERSONAL INFORMATION We would like you to fill this form with your information and to read our privacy policy. (hand out the Questionnaire and the Privacy Statement). We will use our real names during this interview, but in the Thesis you will be given code names so that your identity will not be revealed. Let’s introduce ourselves for the purpose of voice identification. (Each one speaks on the recorder and register their names: “hi, my name is....”) During this interview, if there is something you don't understand or something you don't know how to say in English, you can say it in Finnish/ Danish and we can help you translate. 2) CHILDREN AND CONCEPTION First we would like you to tell us few things about your family and about your children. (How did you form your family, when did you decide to have children, how did it happen...) -­‐ age of children -­‐ conceived through -­‐ carried by -­‐ legal parent(s) -­‐ parental leave division 3) OPINIONS ON PARENTING How has it been to become a parent in same -­‐sex relationship in Finland? (Think about the techniques, the assistance and the support you needed before and after your children were born.) 4) LAWS AND REGULATIONS Now we would like to hear your experience and your opinion about the legal aspects of becoming a parent in Finland. Legal challenges: a. Parent's rights Q1. In your opinion, are there legal barriers/challenges in starting a family with your partner? Can you describe your experience? Q2. To what extent do you and your children feel protected by the state law and social security system as a parent in same sex relationship? Q3. What about other parental rights? Do you think that the rights of same-­‐ sex parents are recognised and guaranteed in case of events such as divorce or death of the birth mother? Q4. (FI) Do you know about the recent approval of Equal Marriage in Finland? Do you know about its content and do have an opinion about it? How do you think the Equal Marriage law might affect your family? Or Q4. (DK) Do you have an opinion on the equal marriage law in Denmark? Do you think the law affected your family? If so, why and how? Q5. What are the possible things you would change in Finland in relation to protecting the rights of diverse families and families like yours? b. Children's rights ​In your opinion, are there differences between how the law treats children of same sex couples as opposed to children of heterosexual couples? Are there formal or informal differences? (Think about their rights, state benefits and other kinds of economic support) 5) HEALTHCARE EXPERIENCES We would now like to hear about your experiences as lesbian mothers with healthcare around the birth of your child. For example, think about your midwife check ups during the pregnancy, (the experience of childbirth including midwives, nurses and doctors), the gynecologist’s and doctor’s appointments related to your pregnancy, (the pediatrician’s appointments). Try to remember the times when you both were present. We will focus especially on those. 5.1 The patient In the next part, we would like to talk about your experiences at the hospital/ clinic. Q1. How were the first encounters, the atmosphere with the healthcare professionals in the hospital when you went to a check up with your partner? (Before, during, after pregnancy. e.g. Did they assume that you are heterosexual, for example by asking about the father?) Q2. Was your sexual orientation a topic of discussion? If so, how was their reaction and how did the discussion(s) go? (Any questions that made you feel uncomfortable? How was the verbal and nonverbal communication after you disclosed your sexual orientation? (e.g. Signs of approval or disapproval toward homosexual orientation or same-­‐sex parenthood) Q3. How did you introduce your partner? With what names did they later on addressed you and your partner? Did they acknowledge her and treat you both as a couple and equal parents? Q4. Were they addressing info and talking to both or only to the biological mother? How did you feel about that? Q5. In general terms, how important do you think it is to disclose your sexual orientation to your doctor (gp, gynecologist)? What about in your specific case? 5.2. The hospital and the professionals In the last part we would like to focus on your interactions with the medical personnel. Q1. How would you describe their knowledge/preparedness/experience in treating LGBT people? How was your experience? (did you get all the necessary information from the professionals? Did you have to educate healthcare servants about your family?) Q2. Do you remember reading some official written material(brochures, handouts, books, newsletter, magazines...) available in the healthcare centre (e.g. waiting room), was there any signs of inclusion/openness to same sex couples? Q3. Did you have to fill out any forms? If so, how were they? Have you encountered situations where there was a lack of options for the type of family you have (e.g. were the forms sensitive to same-­‐ sex couples and/or rainbow families? / was there only space for mother/father? Was there a box for you?) Q4​. To what extent do you think myths and stereotypes about your sexuality or about same sex parenthood -­‐if you heard any-­‐ affected the treatment you received or the quality of the service? (e.g. parental roles mother -­‐father) Q5. Would you have liked to have something done differently by the hospital/ doctor/ midwife to make your experience better at the healthcare center? What would you expect from them that they did not do? What would you have not wanted them to do? Thank you very much for your time. We will get back to you in September when our thesis will be done and published. Annex 6 -­‐ Division of the Written Work This thesis was collaborative in essence. In other words, the thesis was produced and conducted by us working together, but with individual parts. During the writing process, we, Saana Sirkkala and Beatrice Carraro, have referred to ourselves as “we” even though we had our separate parts. As these separately written parts form a uniform and coherent entity, they do not stand alone. Thus, by referring to ourselves as “we” in our individual parts, we aim to convey a message of the wholeness of the final and complete product. The way we divided the parts is based on random selection. In sum, ​Beatrice Carraro​ was responsible for: ● 2.2, 2.3, 2.4 Institutional Background ● 3.3, 3.6 Literature Review ● 4.6. Theoretical Framework ● 5. Data and Methods ● 6. Analysis: parts on Denmark + comparisons between Finland and Denmark ● Annex 1. Vocabulary, Annex 3. ​Gay Men’s Possibilities to Become Parents​, Annex 4. Minimizing Experiences In sum, ​Saana Sirkkala ​was responsible for: ● 2, 2.1.​ Institutional Background ● 3, 3.1, 3.2, 3.4, 3.5. Literature Review ● 4, 4.1, 4.2,Theoretical Framework ● 6. Analysis: parts on Finland + and general introductions within each section in the analysis We were equally responsible for writing the parts: Summary, 1. Introduction, 7. Discussion, 8. Conclusion, Annex 2. Participants Information, Annex 5. ​Privacy Statement and Interview Structure.​Naturally, the work seen in the written form is only part of the process. We have equally shared the work consisting of creating the interview scheme, recruiting and contacting interviewees, scheduling the interviews, carrying them out and transcribing them. However, we analyzed the country specific data individually both using same qualitative method.