Thursday, 14 June 2007

Straight talking?

There’s an in-joke that goes: “Which is it better to be, black or gay?” with the answer “black, as you don’t have to tell your mother.”

For those who are gay, the invis­ibility of their sexuality and the need to
take a position on whether you’re in—or out—of the closet is a con­stant. Conversely, being heterosexual is also invisible. As Julie Fish eloquently writes [in her new book “Heterosexism in Health and Social Care”], heterosexuality “rarely has to attest to its existence . . . while homosexuality is silenced, heterosexuality is silent.” And it is this routine presumption of heterosexuality and its oppressive privi­leging over an “inferior” homosexuality that she terms heterosexism.

Fish, a research fellow at De Montfort University [a university in the city of Leicester, England], shows how heterosexism distorts the health and social care that lesbian, gay, bisexual, and transgender (LGBT) users receive. Take, for instance, the account of one woman’s attendance for a cervical smear: “I was asked when I last had sex—I said my last experience of pen­etrative sex with a man was nine years ago—she said never mind, I’m sure you’ll find someone soon. With an instrument in place and my legs at 10 to 2 I didn’t feel comfortable telling her I was a lesbian!” Or then there’s the woman who “mentioned my girlfriend to the nurse and she bolted—and got a male nurse to come and do [the cervical smear].” Lesbians’ accounts of their experi­ences of cervical screening and breast cancer provide graphic illustrations of how they have to negotiate dis­closure and non-disclosure about their sexuality.

In each interaction with a health professional, the closet is in the room, and they [LGBT patients] have four choices to make — active non-disclosure (pretending to be heterosexual); passive non-disclosure (not actually claiming to be heterosexual); passive disclosure (dropping hints); and active disclosure (a verbal assertion of sexual identity).

Obliged to negotiate a range of barriers to good care, including ignorance of their needs and moral disap­proval, users from the LGBT community are more likely to report adverse rather than positive experi­ences of health care. Currently LGBT issues receive little attention in clinical training—and when they do, they are predictably confined to issues sexual and psy­chiatric. It is perhaps unsurprising, therefore, that the health sector is also uncomfortable for LGBT health professionals—in a recent survey, only 1% were “out” to their superiors.

[and here the reference is to a country (UK) which made significant progress in promoting equality and gay rights, a country in relation to which BBC recently raised the question: "Coming after a series of landmark reforms, is the job now done for gay rights campaigners?" (!)]

Given this diversity, how do we know who is a lesbian or a gay man? This question is fundamental to measur­ing and studying their needs, and whether these are being met equitably. Fish raises many of the inherent difficulties, such as what’s an accepted definition of this community, is it acceptable to the funders, or to those you’re studying—and if they haven’t disclosed to their mother, will they to you? In an infamous example, the US Center for Disease Control researching HIV/AIDS accepted as lesbian only those women who had had sex exclusively with women in the previous 13 years—and unsurprisingly found a low risk of transmission.

Fish quite rightly situates heterosexism within the broader diversity agenda, with its starting point the acknowledgement that inequity and discrimination exist in public services, and the imperative that we change policy and practice to ensure equity. This book chal­lenges us all to examine how our skin colour, nationality, religion, class, abilities, and sexuality may be a privilege, “an invisible package of unearned assets which can be cashed in daily.”

Source: Review of the week by Jeanelle de Gruchy (abridged version), British Medical Journal (BMJ), 2 June 2007
comments in [] are mine

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