Participant characteristics are described in Table 1. Mean age was 37.2 years. Most respondents identified themselves as lesbian, and more than half reported being in cohabiting relationships. About two thirds of participants lived in urban regions. More than half had university degrees or higher, making the sample highly educated. We interviewed one vision-impaired woman, two hearing-impaired women, two physically challenged women, one black woman, and three Micmac women.
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Importance of being gay positive
We asked participants, “How would you describe your ideal health care provider?” followed by “If you had to identify one category of health care provider who would care for your needs on a regular basis, who would that be?” Almost 70% of participants said that a family physician would be their ideal provider, compared with 49% who told us that their family physician was now their regular provider. Nearly all (94%) described being gay positive as the most important attribute of a family physician. This quality was cited more often than the ideal physician being a woman (71%), lesbian (20%), or a feminist (10%).

* Rural—counties with populations 8000 to 60 ООО; urban—population total 350 ООО.

What is it to be gay positive? A gay-positive physician is open-minded, knowledgeable about lesbian and bisexual health care needs, and able to create and sustain a safe space for disclosure:

My ideal health care provider [would] be knowledgeable about health issues particular to lesbians, for example, breast cancer,… either lesbian, bisexual, or straight but not nar-row…. If she has posters on the wall, they will include posters that depict lesbians. generic albendazole

One important feature about being gay positive is that the physician realizes that disclosure is not restricted to the health care interaction. This acknowledgment is not as simple as having a question about sexual orientation on the health history. Respect from physicians about a patient’s decision to come out requires that providers have some idea what it means in the outside world to be lesbian or bisexual:

[Lesbian women have to deal with things like invisibility, discrimination.... I don't see how keeping a whole part of yourself secret either with everyone or with some people at certain times could not affect your health. [There is] no acknowledgment of what it’s like to live as a lesbian woman. [Physicians are] not concerned with society’s views, how that is affecting my health.

Gay positive means that a provider is sensitive to the realities of being lesbian or bisexual in a fundamentally heterosexist world. buy skelaxin online

Barriers to care
Half the participants reported having forgone seeking health care of one type or another at least once because of their sexual orientation. A third said they had forgone seeking routine physical care, and roughly the same proportion reported they did not go for regular breast screening and Pap smears. But what exactly happens in health care interaction with a family physician that bars women from care? Barriers to adequate care included heterosexist assumptions, physicians’ responses to disclosure, and the implicit responsibility for patients to educate providers.

More than two thirds of the sample reported being always aware of heterosexist assumptions. Three prominent cues were the healthxhistory, restrictive titles or categories on health care forms (“Mrs,” “your spouse,” etc), and the clinic or waiting room environment. The last two will be discussed under the section on strategies.
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Examples of heterosexist assumptions in taking a health history—and subsequent inappropriate advice—were frequently mentioned in the interviews and seemed to follow a certain chain of events when a provider assumed heterosexuality. The prototype health history story in our interviews described family physicians asking such things as, “Do you have a boyfriend?” or “Are you married?” to start the sexual health history. Another variant was asking, “Are you sexually active?” and when the response was yesr assuming that this meant with men:

Next came his [her doctor's] intern who basically went through the same questions and why was I there and what were my symptoms and what was I using for birth control,… and I said, “I don’t,” and he kinda looked at me like “What?” Anyways, I kinda mouthed the words, “I’m gay,”… to him, and… he just couldn’t get it, right?… So then, [I] just took the pen out of his hand and wrote it on the paper…. Once he regained his compo¬sure,. .. he was back and forth a couple of times with a couple of questions and one of them was, “Have you had an AIDS test?”

Even after disclosure, then, exploring the needs of patients can be precluded by practitioners’ refusal or inability to engage with the disclosure:

After that, the sexual history stops in many ways. It’s like, “Oh, okay, so you’re not really sexually active. Yeah, but you’re not having sex with men.” “No, but I’m sexually active….” I guess people are thinking that, you know, we kiss a lot and hold hands… sorta like what my mom thinks, right? purchase imitrex

Participants reported receiving inaccurate information after disclosure: for example, being told that lesbians are at low risk for HIV because their relationships are confined to women. However, some women who currently live as lesbians have not always had women-exclusive relationships. Consistent with Rankow’s suggestion, some of the women in our study reported that they were told they did not need pelvic examinations or screening because as lesbians they were not at risk for cervical cancer or sexually transmitted infections. The issues around bisexuality seemed to present special problems for providers. Some bisexual participants thought that the whole concept of bisexuality posed enough difficulty that sexual health information was generally suspect anyway. They implied that their physicians were more comfortable with the notion of patients’ relationships with men than with women:

[W]hen you go for your Pap smear, your regular checkups,… sometimes your doctor will ask you about your sexual relationships,… and when I told her… that I was bisexual, it seemed like she was more concerned about the men I was sleeping with [than] the women.

This restrictive focus could seriously skew a health history.
We heard some striking stories about physicians’ reactions to disclosure. Fifteen women reported being told their sexuality was pathological; some were referred to psychiatric services. Seven women recalled having physically “rough” internal examinations after disclosure, and four women told us they were refused care. The wider context of these stories suggests that the behaviours of providers were important events around which women later made decisions to forgo seeking health care.
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Finally, almost all our participants spontaneously articulated that providers need to take responsibility for educating themselves. The implicit expectation that lesbian and bisexual women will be patients and educators simultaneously in health care interactions is a barrier to adequate care:

I think it’s really important for us to be honest about who we are and the kinds of things we do, because I think there’s a lot of ramifications for our health. It’s been frustrating at times because my doctor… wasn’t homophobic, [but clearly] she doesn’t have any kind of knowledge; it wasn’t even [discom¬fort], but any kind of knowledge about sexual practices, so that’s a huge problem… and I simply couldn’t be responsible for trying to educate her.

Strategies for providing appropriate care
Participants suggested ways family physicians can provide appropriate care. In discussing such strategies, most participants included the notion of safety as a prerequisite for disclosure. For example, when asked whether one should be approached about orientation during a health history, most respondents said yes, but this must be interpreted in terms of the ideal, where safety (eg, lack of discrimination, trust in professional uses of information) is unquestioned. One of the first steps has to be an honest evaluation of physicians’ own biases:

[H]ere I am, you know, this lesbian physician and I’ve been caught making really… obvious assumptions about people… when they’ve said, “Oh well, I sleep with women,” or something like that…. I can’t believe… that I have made this assumption. stratterra

Educating gay-positive providers and re-educating others requires attitude change, the goal of which is the following:

To find a doctor,… or any kind of health practitioner actually,… to be able to say, “And this is my partner,” and not have people do a double take, or [ask] “Excuse me,” or “What do you mean?” or… even when we’ve said it… and it’s not acknowledged, so we know that even though we’ve come out, the person on the other end of that is just not willing to accept our relationship in any kind of way.

Taking patient histories deserves immediate attention if health care providers are serious about addressing heterosexism. Birth control information provided under assumptions of heterosexuality can constrain taking a sexual history and misrepresent women’s needs. Our participants drove home the point that the significance of the health history lies in validating the importance of relationships to health but that it also acts as an indicator of who one’s patients are:

Yeah, I would love it if it were on the form…. I think it would be helpful if [physicians] understand how many lesbian and bisexual women were coming through their door;… they’d say, “Gee, there seems to be a lot of dykes comin’ through the door, maybe we should look for a little literature, maybe we should be checkin’ in to see how we could help these gals a little more.”… If you don’t even know we’re there, if We’re all invisible, then nothing can be done…. I’d love to see forms that were somehow a little more realistic about how relationships are formed.

Several participants suggested that physicians start history taking by asking such questions as, “Are you in a relationship?” and “Who is in that relationship you want to acknowledge?” nifedipine 30mg

Participants described some immediate changes physicians could make in their waiting rooms and clinic areas to signal a gay-positive environment:

[T]hese health care posters… they’re all definitely heterosexual and very oriented toward the nuclear family…. I don’t go into a health care place and see… a thing about lesbians and AIDS, a poster on the wall, or a pamphlet… They must be assuming that everyone coming in is straight or does not need to be acknowledged.