Effects of Gender Identity on Experiences of Healthcare for Sexual Minority Women K. R. Hiestand S. G. Horne H. M. Levitt
ABSTRACT. While research examining healthcare experiences of sexual minority individuals is growing, thus far research has been limited on lesbian gender identity and its relationship to physical and mental health. This study explores access to and experiences of healthcare with a sample of 516 butch and femme identified lesbian and bisexual women. In comparison to femme-identified women, it was found that butch women had routine gynecological examinations significantly less frequently, perceived poorer treatment in healthcare settings, were more likely to be out within healthcare settings, placed more importance on securing LGBT-positive healthcare practitioners, and had more difficulty finding LGBT-positive medical doctors. No differences were found for mental health. The results suggest that butch women may be more at risk for physical health concerns than femme women, in particular those illnesses that can be prevented or treated with regular gynecological care (e.g., uterine or cervical cancer). Implications of the study include greater awareness among healthcare professionals of sexual minority gender identity in addition to sexual identity, and more support for butch-identified women to access vital healthcare services. KEYWORDS. Butch, femme, healthcare, lesbian, bisexual, gender identity, LGBT
The challenges facing sexual minority women in seeking out and receiving quality healthcare has been a growing topic of research within lesbian, gay, bisexual, and transgender (LGBT) literature. However, the intersection between sexual identities (such as lesbian and bisexual) and gender identities (such as butch and femme women) has not been addressed within research on health research. The purpose of this study was to identify health concerns specific to the LGBT population, as well as to examine how well the healthcare system addressed their concerns. Specifically, we explored how these two specified gender identities affect experiences of
sexual minority women in medical and mental healthcare settings. Sexual minority women appear to face more obstacles than heterosexual women when it comes to seeking healthcare (e.g., Fish & Wilkinson, 2003; O’Hanlan, Dibble, Hagan, & Davids, 2004; Saphira & Glover, 2000). These challenges may include discrimination based on their sexual orientation, lack of inclusion on intake forms, as well as presumed heterosexuality on the part of healthcare practitioners and staff. These experiences may lead to lower healthcare utilization among sexual minority women, which can increase the chance of serious medical
K. R. Hiestand, S. G. Horne, and H. M. Levitt are affiliated with The University of Memphis. Address correspondence to: K. R. Hiestand, Ball Hall 100, University of Memphis, Memphis, TN 38152 (E-mail:
[email protected]). Journal of LGBT Health Research, Vol. 3(4) 2007 Available online at http://www.haworthpress.com C 2007 by The Haworth Press. All rights reserved. doi: 10.1080/15574090802263405
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conditions going undetected and may lead to a higher risk of certain cancers (Wilkinson, 2003). In particular, lesbian and bisexual women appear to access services less frequently than heterosexual women. Cochran et al. (2001) found that lesbian and bisexual women were less likely than heterosexual women to have had a recent pelvic examination or mammogram. Powers, Bowen, and White (2001) found that lesbians participated in mammography and Pap testing at significantly lower levels than bisexual and heterosexual women. Additionally, Saphira and Glover (2000) found that lesbians not only delay seeking healthcare but they also encounter barriers to healthcare, including financial obstacles (related to lower income and lack of insurance coverage), difficulty finding a supportive practitioner, and homophobic attitudes in healthcare settings when compared with heterosexual women. Finally, Wells, Bimbi, Tider, Van Ora, and Parsons (2007) differentiated between lesbian and bisexual women in their study, and found that bisexual women reported being less likely than lesbian women to perform self-breast exams. Although less is known about bisexual women and healthcare, the association between lesbian women and an increased risk of particular health conditions is clearer. Fish and Wilkinson (2003) reported that lesbian women are at higher risk for breast cancer than women in general, as fewer lesbian women go through pregnancy and childbirth, and the associated hormonal changes of pregnancy appear to reduce the risk of breast cancer. Also, they are concerned that this risk is compounded by the fact that lesbians are less likely to practice breast self-examinations than heterosexual women. This research does not assess the actual incidence of cancer in lesbians, only the prevalence of risk factors for cancer. Research has shown that lesbian women are at a higher risk than heterosexual women for certain behaviors that can adversely affect their health, such as alcohol use (Cochran, 2001), smoking (Case et al., 2004), and illicit drug use (Hughes & Eliason, 2002). Further, lesbian women have been shown to have a higher body mass index and greater rates of obesity than heterosexual women, which are associated with a number of increased health
risks such as heart disease, strokes, and cancer (Saphira & Glover, 2000). Thus, a combination of increased risk factors and additional barriers to preventative health practices leaves lesbian women especially vulnerable to life-threatening illnesses. Although approximately 3–6% of patients seen by physicians are gay or lesbian (Bonvicini & Perlin, 2003), medical training generally ignores gay and lesbian health issues (Beehler, 2001; McNair, 2003). Neville and Henrickson (2006), in their study on gay men and women, found that significantly more women than men reported that their healthcare provider assumed they were heterosexual, creating an additional barrier to quality healthcare for nonheterosexual women. Discrimination and differential treatment may occur in several ways. For example, Rankow (1995) described how routine exams can become uncomfortable to lesbians who are asked if they are sexually active and then, if so, what birth control they are using. The lesbian client then must decide whether or not to come out, placing her at risk for differential treatment. O’Hanlan et al. (2004) found that lesbians who experience discrimination in healthcare tend to avoid preventative healthcare in the future.
SEXUAL MINORITY WOMEN IN MENTAL HEALTHCARE SETTINGS Saulnier and Wheeler (2000) explored the prevalence of heterosexism in mental healthcare settings. They found examples of heterosexism, such as assuming that women would have male partners and limiting relational status options on intake forms, which frequently rendered sexual minority women invisible. These clients found themselves choosing between coming out and risking negative consequences from psychotherapists and their staff, or remaining closeted and not being truthful in therapy. Garnets, Hancock, Cochran, Goodchilds, and Peplau (1991) found that mental health services for gay men and lesbian women were potentially biased or inadequate. Some of the biases or inadequacies they noted were the belief, reported by psychologists surveyed, that homosexuality is a form of psychopathology, automatically attributing a
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client’s problems to their sexual orientation, or assuming that clients are heterosexual. In a study focused on the satisfaction with mental health services among minorities with major mental illness, Avery, Hellman, and Sudderth (2001) found that the LGBT group was significantly less satisfied (17.6%) than the control group (8%). Further, they determined that this difference was exacerbated if the person was also a racial minority, female, or lived alone. Although much of the literature does not differentiate between lesbian and bisexual women, one study compared mental health factors between three groups: heterosexual adults, homosexual adults, and bisexual adults (Jorm, Korten, Rodgers, Jacomb, & Christensen, 2002). Using a community survey of 4,824 adults (aged 20– 24 and 40–44 yrs) in Canberra, Australia, they found that the bisexual group was highest on measures of anxiety, depression, and negative affect, with the homosexual group falling between the bisexual group and the heterosexual group on those factors. Both the homosexual and bisexual groups were higher than the heterosexual group on suicidality, although no significant difference was found between them. The authors concluded that although both homosexual and bisexual individuals appeared to have poorer mental health than heterosexual individuals, the bisexual groups represented the worst overall mental health. There are some indications that mental healthcare for sexual minority women may be improving. Israel, Burnes, Gorcheva, and Walther (2005) examined the variables that influence LGBT clients’ experiences in counseling. They found that the validation of the client’s sexual orientation by the therapist and encouragement to explore and develop a positive identity around sexual orientation was associated with an overall positive counseling experience. On the other hand, a negative experience was associated with encouragement to reject an LGBT orientation, a focus on sexual orientation by the therapist when it was not the issue, or the therapist avoiding the topic of sexual orientation when the client wanted to address it. P. E. Stevens (1996) found that her participants characterized positive encounters with healthcare professionals (both mental and medical healthcare) as solidarity,
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in which the healthcare professional listened to them, worked with them, and talked with them. In opposition to this solidarity was domination, which included the practitioner withholding information or defensively dismissing the client’s input, and a failure by medical practitioners to explore reproductive options with lesbian and bisexual patients and their partners.
BUTCH–FEMME LESBIAN GENDERS The lesbian genders butch and femme arose in the United States in the 1940s and 1950s, in the aftermath of World War II (see Faderman, 1991, and Lapovsky-Kennedy & Davis, 1993, for an extensive history of butch and femme cultures). Although femme women, at that time, adopted an exaggerated feminine appearance (often characterized by bright lipstick and seductive dress), butch women embraced a masculine appearance, typically characterized by men’s clothing and short haircuts. These two lesbian genders “were the key structure for organizing against heterosexual dominance” (Lapovsky-Kennedy & Davis, 1993, p. 6) and allowed for the formation of the first visible lesbian communities in the United States (Faderman, 1991). Although these lesbian genders were distinct from heterosexual gender norms and roles, the relationships between a butch and a femme lesbian entailed all of the complexities of a heterosexual relationship, and maintained a dichotomous lesbian gender system. With the start of the feminist movement in the 1970s, butch–femme dynamics were viewed as mimicking the patriarchal heterosexual marriages that feminists were challenging. Femme lesbians were viewed as encouraging the objectification of women, and butch lesbians were accused of claiming male privilege. During this era, butch and femme women either withdrew or adopted the androgynous aesthetic of the prevailing lesbian culture, as a preferable choice to facing exclusion from the feministlesbian community. In the 1980s, the butch–femme culture began to reemerge in selected communities as women reclaimed these identities (e.g., Faderman, 1991). This resurgence of butch–femme, however, occurred within a feminist lesbian context
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as well as a more progressive mainstream culture. As a result, there was greater flexibility in constructing modern butch and femme identities (e.g., Nestle, 1992). Levitt and her colleagues have developed a body of research focused upon the contemporary experience of butch and femme women. Levitt and Hiestand (2004) found that, when interviewed, butch women reported that from a young age their authenticity as female often was placed under question both by themselves and those around them—leading to childhoods replete with self-doubt and isolation. As a result, they characterized the adoption of a butch identity as resulting from a quest for authenticity. In this process, they had to overcome their own internalized homophobia and genderphobia before their female sex and nontraditional gender expression could be comfortably reconciled (see Hiestand & Levitt, 2005, for a model of butch identity development). In contrast, femme women tended to become aware of their sexual orientations at a later age, and tended to be spared the childhood burdens that butch women had to bear, but often faced challenges within lesbian communities where their sexual orientations may have been suspect due to their gender presentation (Levitt, Gerrish, & Hiestand, 2003). Although butch women had to deal with this earlier sense of difference in relation to gender presentation, a sense of difference tended to emerge for femme women in relation to sexual attraction (Levitt & Hiestand, 2005). Quantitative survey results have supported these findings by demonstrating that butch women were aware of their sexual orientations significantly earlier than femme women (a mean of 21.9 years vs. 14.6 years respectively; Levitt & Horne, 2002). In interviews, butch women more often reported being read as lesbian than femme women, and being obvious targets for homophobic attacks or treatment as adults (e.g., Levitt & Hiestand, 2004). Levitt and Horne (2002) found that butch women in a surveyed sample also reported experiencing marginally more discrimination based upon their sexual orientation than femme women, and significantly more discrimination based upon their gender expression. Although these studies point to differences in discrimination and suggest developmental differences that may influence one’s comfort in
seeking healthcare, none of them were specifically related to healthcare. Within the body of research addressing sexual minority women’s experiences in healthcare settings, the potential influence of butch and femme identities on the differences in receiving and accessing healthcare has not yet been investigated.
STUDY OBJECTIVES The purpose of this study was to explore sexual minority gender identity as it relates to access to and experiences within both medical and mental healthcare facilities. We explored six research questions in this study. 1. Is there a difference in accessing healthcare (specifically, visits to medical doctors for illness or checkups, visits to gynecologists for checkups, and consulting with medical doctors when ill) reported for butchidentified and femme-identified women? It was hypothesized that butch women would report accessing services to a lesser degree than femme women. 2. Is there a difference in the discomfort experienced by butch and femme women when seeking medical and mental healthcare services? It was hypothesized that butchidentified women would report experiencing significantly more discomfort when seeking medical and mental healthcare services than femme-identified women. 3. Is there a difference in the quality of treatment from medical healthcare practitioners, mental healthcare practitioners, and in hospital settings received by butch and femme women? It was hypothesized that butch-identified women would report significantly poorer treatment than femme-identified women from their medical healthcare practitioners, their mental healthcare practitioners, and in hospital settings. 4. Is there a difference in level of outness to medical healthcare practitioners and to gynecologists between butch and femme women? It was hypothesized that butchidentified women would report being out
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to their medical doctor and to their gynecologist significantly more than femmeidentified women. 5. Is there a difference in the level of importance assigned to having a gaypositive healthcare provider between butch and femme women? It was hypothesized that butch-identified women would assign more importance to having a lesbian and bisexual affirming healthcare provider. 6. Is there a difference in the difficulty of finding affirming medical and mental healthcare providers between butch and femme women? It was hypothesized that butchidentified women would encounter more difficulty finding affirming medical and mental healthcare providers that femmeidentified women.
METHOD This study was conducted using an Internetbased survey that explored a number of issues, including sexual minority women’s gender identity, experiences in medical and mental healthcare settings, and discrimination. Participants were secured from across the United States and Canada through extensive advertising of the survey on related internet Web sites, and through snowball sampling by encouraging individuals to pass the survey on to interested others. The researchers sent a request for participants, including the survey link, to all Web sites and listserves that included lesbian and bisexual women; this list was generated utilizing the Google search engine. No information is available detailing whether the participants first learned of the survey through a Web site or from an acquaintance. The full sample consisted of 955 participants. For this study, only the participants who identified as either butch (42.6%, n = 220) or femme (57.4%, n = 296) were included (n = 516); no significant differences were found between butch- and femme-identified women and those respondents who did not identify as butch or femme across demographic items, indicating that the butch–femme study sample seemed to be similar to the larger sample. This sample was composed primarily of lesbians
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(included in this option was homosexual, gay, or dyke; 65.5%, n = 338) but included participants who identified as bisexual (25.7%, n = 133), woman-loving-woman (2.7%, n = 14), and “other” (6.1%, n = 31). Of those participants who identified as lesbian, homosexual, gay, or dyke, 55.6% (n = 188) identified as butch and 44.4% (n = 150) identified as femme. Of the 133 participants who identified as bisexual, the vast majority (93.7%, n = 125) identified as femme. The sample included 50 individuals (9.8%) who identified as transgender (but not male) in addition to a sexual minority identity; all of these participants identified as butch. The sample was primarily Caucasian (80%, n = 413), with the remainder identifying as African American (4.6%, n = 24), Latina (3.9%, n = 21), Asian/Pacific Islander (1.7%, n = 9), Jewish (3.6%, n = 19), Native American (.5%, n = 3), and Biracial/Multiracial (5.1%, n = 27). The majority of the sample had some college background (76%, n = 392), and the mean age of the sample was 31.8 years (range = 18–73 years). Respondents represented 44 states and 6 Canadian provinces. Further, 35.1% (n = 181) indicated that they lived in a large city (over one million people), 37.6% (n = 194) indicated they lived in a medium or small city, and 27.3% (n = 141) reported that they lived in a town or rural area. Only the gender identity question and the 14 questions related to medical and mental health were utilized in this analyses.
Assessing Sexual Orientation and Gender Expression To participate in the study, women had to indicate that they self-identified as lesbian, bisexual, or as someone having same-sex romantic relationships, and that they were born and raised female. Participants were asked to indicate their gender identity by indicating how they self-identified in terms of gender. The question read: “How would you describe yourself now (check the answer that best applies)?” They were given options to choose from: Butch (soft butch, hard butch, stone butch, boi-butch, etc.), Femme (high femme, stone femme, etc.), Androgynous (kiki), and None of the Above. This question was devised specifically for this study.
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Assessing Health and Mental Health Experiences: The Dependent Variables A series of questions were designed for this survey that focused upon the utilization of, and experiences with, medical and mental healthcare facilities; these questions were not pilot-tested prior to being used in the study but were developed based on prior health research in the area of lesbian health. The survey questions and their Likert ratings are listed in Table 1. The first three questions asked when participants reported that they last visited a doctor for an illness and for a routine checkup, as well as when they last visited a gynecologist. A fourth question explored whether they sought out medical advice from their doctor when ill. In a series of two questions, they reported their level of discomfort in seeking medical and mental healthcare due to their sexual orientation. Additionally, three questions asked whether or not they ever felt they were treated poorly due to their sexual orientation in medical and mental health settings or in a hospital. Two questions were designed to determine whether they were out to their medical doctor or to their gynecologist about their sexual orientations. One item assessed the level of importance participants assigned to having a LGBT positive medical or mental healthcare provider. Finally, they were asked how difficult it was to locate LGBT positive medical and mental health providers.
Preliminary Data Analysis Initial analyses were conducted to determine whether lesbian and bisexual women, the two largest groups of sexual minority women, differed on any of the outcome variables. Contrary to prior research, there were no significant differences found, therefore, the two groups (lesbians and bisexuals) were combined to assess for differences across gender identity with physical and mental health variables. Second, preliminary analyses were run with four groups (butch, femme, androgynous, and none); significant differences were found only between butch and femme, with androgynous and none groups falling midway between butch and femme on all
explored questions. Therefore, the study focused on butch and femme groups for the subsequent analyses. Preliminary analyses indicated no serious problems with kurtosis, nor were there extreme outlying individuals that were influential data points. Although the multivariate test for homogeneity of dispersion matrixes was significant (Box’s M = 185.37; F [105, 707] = 1.71; p = .001), the absence of extreme differences in the sample sizes for the two groups suggested that the Wilk’s test should be robust; therefore, due to the overall robustness of a multivariate analysis of variance (MANOVA) to violations of homogeneity of variance the analyses were considered valid (J. Stevens, 2002).
RESULTS Gender Identity To address the question of whether butch- and femme-identified women differed in terms of their overall experiences in medical and mental healthcare settings, a two-group MANOVA was conducted. The independent variable was butch or femme identity. Experiences in healthcare settings were operationalized by the 14 dependent variables described in the Methods section. The means and standard deviations of these variables for each lesbian gender identity are provided in Table 2. The multivariate test for differences between butch- and femme-identified women was statistically significant (Wilks = .89; F [14, 501] = 4.18; p = .001), indicating that the two groups differed in terms of their overall experiences in medical and mental healthcare settings. The multivariate effect size (D 2 = .47; η2 = .10) suggests that the difference between the groups is moderate. Univariate analyses of variance (ANOVA) were used to determine which of the 14 dependent variables were contributing to differences between the groups. The Bonferroni adjustment for protection of experiment-wise error rate was conducted, therefore an alpha level of .01 was utilized in the study. Results of the univariate tests are provided in Table 2 and described in the following.
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TABLE 1. Survey Questions with Likert-Scale Ratings Survey Questions
1
2
3
4
5
When was the last time you saw a doctor due to illness?
During the last 6 months
Between 1 and 2 years
Between 2 and 4 years
Over 5 years ago
When was the last time you saw a doctor for a general checkup
During the last 6 months
Between 1 and 2 years
Between 2 and 4 years
Over 5 years ago
When was the last time you saw a gynecologist for a checkup?
During the last 6 months
Between 1 and 2 years
Between 2 and 4 years
Over 5 years ago
When you are sick, do you seek out medical advice by visiting your doctor? Are you uncomfortable seeking medical advice or assistance when it is needed because of your GLBT orientation? Are you uncomfortable seeking therapy or mental health assistance when it is needed because of your GLBT orientation? Have you ever felt that you were treated poorly by a doctor or health care practitioner because of your GLBT orientation? Have you ever felt that you were treated poorly by a psychiatrist or mental health care practitioner because of your GLBT orientation? Are you out to your medical doctor—that is, does s/he know your GLBT orientation? Are you out to your gynecologist—that is, does s/he know your GLBT orientation? Have you been hospitalized for medical treatment since you came out to yourself? If yes, did you feel that you were treated differently because of your GLBT orientation? Is it important to you to have GLBT positive medical or mental health providers? Have you found it difficult to find GLBT positive doctors or medical practitioners? Have you found it difficult to find GLBT positive mental health providers?
Always
Between 7 months and 11 months ago Between 7 months and 11 months ago Between 7 months and 11 months ago Usually
Sometimes
Rarely
Never
Always
Usually
Sometimes
Rarely
Never
Always
Usually
Sometimes
Rarely
Never
Always
Usually
Sometimes
Rarely
Never
Always
Usually
Sometimes
Rarely
Never
Yes
No
Yes
No
Yes
No
Always
Usually
Sometimes
Rarely
Never
Very important
Important
Not important
Very difficult
Difficult
Not difficult
Haven’t tried
Very difficult
Difficult
Not difficult
Haven’t tried
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TABLE 2. Means, Standard Deviations, and Univariate Comparisons Between Butch and Femme Participants (N = 516, df = 514) Butch (N = 220) Variables M. D.-Ill M.D. Gyn. Advice-Ill Discom-M.D. Discom-Men. Poor tx.-M.D. Poor tx-Men. Poor tx-Hos. Out-M.D. Out-Gyn. Import.-LGBT Diff.-M.D. Diff.-Men.
Femme (N = 296)
M
SD
M
SD
F
Cohen’s d
2.07 2.45 2.87 3.04 3.91 4.04 4.04 4.34 4.60 .71 .71 1.40 1.09 .92
1.37 1.39 1.45 .91 1.16 1.16 1.02 .98 .89 .45 .46 .61 .95 .86
1.89 2.29 2.45 2.86 4.12 4.07 4.43 4.53 4.73 .57 .59 1.59 .74 .76
1.16 1.24 1.36 .88 1.10 1.23 .85 .85 .69 .50 .49 .73 .84 .78
2.80 2.01 11.63** 6.63* 4.05 .05 22.60** 5.69 3.9 11.4** 7.82* 9.94* 19.88** 5.11
ns ns .30 .23 ns ns .42 ns ns .30 .25 .28 .39 ns
Note. Effect sizes were only reported for significant univariate tests. M.D.-Ill = last time saw doctor for illness; M.D. = last time saw doctor for check-up; Gyn. = last time saw gynecologist for check-up; Advice-Ill = seek out medical advice when ill; Discom-M.D. = discomfort seeking medical advice; Discom.-Men. = discomfort seeking mental health advice; Poor tx.-M.D. = poor treatment by medical health care practitioner; Poor tx.-Men = poor treatment by mental health care practitioner; Poor tx.-Hos. = poor treatment in hospital setting; Out-M.D. = out to medical doctor; Out-Gyn. = out to gynecologist; Import-LGBT = importance of having an LGBT-positive provider; Diff.-M.D. = difficulty finding LGBT-positive medical health care providers; Diff.-Men. = difficulty finding LGBT-positive mental health care providers. *p < .01. **p < .001.
Seven of the univariate tests of homogeneity of variance were found to be statistically significant: last time saw a gynecologist for a check up, F (1, 515) = 11.63, p = .001; when sick do you seek out medical advice from your doctor, F (1, 515) = 6.63, p = .01; poor treatment by medical healthcare practitioner, F (1, 515) = 22.6, p =.001; out to medical doctor, F (1, 515) = 11.41, p = .001; out to gynecologist, F (1, 515) = 7.83, p = .005; importance of finding LGBTpositive healthcare providers, F (1, 515) = 9.95, p = .002); and, difficulty finding LGBT-positive medical healthcare practitioners, F (1, 515) = 19.89, p = .001.
Medical Heath Care Utilization Differences between butch- and femmeidentified women were found for two of the four questions examining the utilization of medical healthcare facilities. When asked about last visit to a gynecologist, there was a significant difference between the butch and the femme participants, with butch women visiting less re-
cently (Cohen’s d = .30, indicating a moderate effect size). Additionally, there was a significant difference between butch and femme women regarding whether they seek out medical advice from their doctor when they are sick, with butch women seeking it out less frequently (Cohen’s d = .23, suggesting a low to moderate effect). There was no significant difference between butch and femme participants in terms of frequency for accessing medical healthcare facilities for either illness or regular checkups.
Experiences in Healthcare Settings There was no significant difference between butch and femme women in the degree of discomfort that they experienced when seeking advice from either a medical healthcare practitioner or from a mental healthcare practitioner. There was a significant difference between butch and femme participants in that butch lesbians reported poorer treatment by a medical healthcare practitioner (Cohen’s d = .42, suggesting a
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moderate effect size), but not by a mental healthcare practitioner or in a hospital setting. We found a significant difference between butch and femme women in terms of their level of reported outness to their medical doctors and gynecologists, with butch participants reporting being out more than femme participants to medical healthcare practitioners (Cohen’s d= .30) and to a gynecologist (Cohen’s d = .25). Butch women assigned significantly more importance to having a gay-positive provider than did femme women (Cohen’s d = .28). Finally, butch-identified participants reported significantly more difficulty finding an LGBT-positive medical healthcare provider (Cohen’s d = .39, indicating a moderate effect size) but no significant difference in finding a mental healthcare provider than femme-identified women.
Discriminant Analysis A discriminant analysis examined the differences between butch and femme women on the 14 healthcare variables explored in the study. Discriminant analysis is a useful technique for examining the “differences between two or more groups of objects [variables] with respect to several variables simultaneously” (Klecka, 1980, p. 5), and allows the researcher to predict which variables most accurately distinguish between the groups. The results indicated the function was statistically significant, F1: Wilks = .89, (df = 814), p = .001. The function accounted for 100% of the between-group variance in the set of dependent variables and 9.5% of the total variance. The pattern of correlations between the variables and the function indicated a bipolar dimension with the positive end anchored by the following variables: difficulty finding an LGBTpositive medical healthcare provider (r = .57), last time saw a gynecologist for a check-up (r = .44), and outness to medical doctor (r = .43); the negative end was anchored by: poor treatment by a medical healthcare practitioner (r = –.61) and importance of having an LGBT-positive healthcare provider (r = –.40). The standardized coefficients indicated that these same five variables are the primary contributors to group differentiation along the continuum.
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Pair-wise F -tests indicated that the space defined by the function differentiates between the two groups F (14, 501) = 4.18, p = .001. The results indicated that the butch participants were more out than femme participants, visited with a gynecologist less recently, had more difficulty finding an LGBT-positive medical health practitioner, reported poorer quality of care by a medical doctor, and found it more important to have LGBT-positive healthcare providers.
DISCUSSION Education on Gender Identity Within the Health Professions Gender identity and sexual orientation both may contribute to the difficulties that sexual minority women face when seeking medical and mental healthcare. Within this study, it appeared that butch-identified women faced the greatest health risks, especially related to poor treatment and access to healthcare. Butch women appear to face two sets of challenges—poorer treatment based upon their sexual orientation, as well as their gender identity. Similarly, Herek (1995) found that gay men who were gender-atypical faced the greatest discrimination within the gay male population. This study adds to the research on the impact of gender atypicality and stresses the need to better address responses to gender within medical training programs. Barbara, Quandt, and Anderson (2001) also identified the need for formal training on lesbian health, and methods for making medical professionals more comfortable with diverse sexual orientations. Their suggestions included not assuming their patients are heterosexual, educating themselves and their staff on issues related to sexual orientation, not tolerating a discriminatory environment in the healthcare setting, incorporating positive inclusion of homosexuality on office paperwork (such as offering choices on registration forms relevant to LGBT concerns, such as significant other or domestic partner as marital status), and inviting female partners of the patient to participate in healthcare decisions. From these results, we found that five of our six hypotheses were supported to some
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degree, and that gender identity also contributes to healthcare experiences and healthcare seeking behaviors for sexual minority women. Although there was no significant difference between butch and femme women in terms of frequency visiting a doctor for either illness or regular health check-ups, as our first hypothesis suggested, butch women visited a gynecologist significantly less frequently than femme women. Given the increased risks of reproductive cancers in the lesbian population (Fish & Wilkinson, 2003), these findings suggest that butch women are at particularly high risk for these diseases due to their lesser use of preventative gynecological healthcare. Our results supported the hypothesis that butch-identified lesbians thought that they received poorer treatment by medical healthcare practitioners than did femme-identified lesbians. Thus, the higher rates of discrimination faced by butch women (Levitt & Horne, 2002) may extend into medical healthcare facilities. The same was not found for mental healthcare facilities; no significant difference was found between butch- and femme-identified women in perceived treatment or in hospital settings. Although the group’s means indicated that they experienced poor treatment by medical practitioners rarely (butch) or rarely to never (femme), the range of scores suggested that the group of butch women contained individuals who may have perceived very poor treatment, which may have resulted in a tendency to not seek regular medical care. Among the butch women, 11.5% reported not having seen a medical doctor in over 5 years. Nearly 20% (19.8%) of the sample participants reported not having visited a gynecologist in over five years. These study findings appear congruent with P. E. Stevens (1995), who demonstrated that lesbian and bisexual women found heterosexist healthcare to be obstructive to their seeking necessary care and knowledge, as heterosexist assumptions interfered in their interactions with healthcare providers. Amato and Morton (2002) conducted a study to assess the status of lesbian health education in obstetrics and gynecology training programs in North America. They found that the mean number of hours devoted to lesbian health education over the 4-
year training period was 1.86 hrs; more than half of the programs offered no instruction at all. Given the specific concerns of sexual minority women related to gynecological services, ensuring that training is in place to increase competency skills for LGBT health-related concerns within obstetrics schools is important. Additionally, because sexual minority women with a butch gender identity appeared to be most at risk for poorer treatment within medical settings and least likely to utilize preventative healthcare such as gynecological services, this intervention should include a component of training focused on gender identity. Training should incorporate research on unconscious bias and stereotyping as they relate to sexual orientation and gender identity. Butch women were significantly more likely to be out to both their medical doctors and gynecologists than femme women. It is not known why butch women tended to be more out, whether it was because they explicitly made their orientation known, or whether, given visual markers of butch appearance (e.g., short haircuts, more masculine dress), they believed that they were out to their doctors. Further, it is unknown, for those individuals who were not out, whether they intentionally remained closeted or just did not feel that disclosure was necessary. Further research should examine whether differences are present between individuals who are out to healthcare providers and those who are not. In any case, butch women coming out more frequently might cause physicians to confront any biases they might have related to both sexual orientation and gender expression at once. It is unknown whether these physicians were aware of any differences in their treatment of butch women or if they consciously registered differences in gender expression as a sign of a minority sexual orientation. Further research on physicians’ reactions to atypical gender expressions is in order to determine the best methods for providing education on these topics. The discriminant analysis identified those variables that most distinguished the two groups. Of the seven variables in which a significant difference was found, five of them can accurately predict an individual’s group membership based
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on their responses on these items. Based on the standardized canonical coefficients, the single most useful variable for distinguishing between the two groups was the last time they saw a gynecologist for a checkup. This finding suggests that education on gender expression and sexual education may be particularly important for this group of healthcare professionals. This training should include the development of sensitivity on how vulnerable it can be for butch women to submit to a gynecological exam, as well as skills on how to empower butch women throughout exams or treatments. As their sex may have been the site of lifelong questioning, harassment, and discrimination for these women, the act of a simple exam might provoke great discomfort— especially if mismanaged. Gender identity, as well as sexual orientation, both impact sexual minority women’s experiences in healthcare settings, and both must be addressed in efforts to improve the quality of healthcare for sexual minority women. Overall findings indicate that there is still a great need for improvement in the access to and quality of care provided to sexual minority women. Wilkinson (2002) found that research aimed at non-heterosexual women’s needs and concerns is still necessary in order to challenge the prevailing heterosexist assumptions within health services and support facilities. Healthcare practitioners should be trained to be comfortably open in discussing sexual orientation with their lesbian and bisexual patients, focusing intentionally on the concerns of this group (Saulnier, 1999; Rankow, 1995). The Gay and Lesbian Medical Association (www.glma.org) provides a number of resources that practitioners can utilize to help create a safer environment for their sexual minority patients.
The Need to Conduct Outreach to Butch Women About Prevention In addition, we found that butch women reported seeking out medical advice when sick significantly less frequently than femme women, which may increase risk for preventable illnesses and may delay treatments. It is notable that, although there was not a significant difference between butch and femme participants in terms of
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when they last visited their medical doctor due to illness, there was a significant difference in terms of how likely they would be to seek medical advice when ill. These findings may suggest that both butch and femme women seek help when facing illnesses, but that the butch participants may experience more difficulty in this respect. There was no significant difference between the discomfort experienced by butchand femme-identified women in seeking care in either medical or mental health settings. LGBT people appear to seek out mental healthcare disproportionately to a greater degree than heterosexual individuals (Balsam, Beauchaine, Mickey, & Rothblum, 2005); it may be that mental healthcare is considered more supportive generally, and this finding is not surprising. Our results suggest that butch women assign more importance to finding LGBT-positive providers and it may be that they take greater precautions to identify LGBT-positive providers before seeking a consultation. However, it appears that both groups experience some discomfort when seeking out healthcare; the reported means for both groups were located between 3 (sometimes experience discomfort) and 4 (rarely). Several strategies may be used to help butch women overcome their reluctance to seek out medical care. Butch women also assigned more importance to finding LGBT-positive practitioners than did femme women, but reported greater difficulty finding LGBT-positive medical healthcare practitioners—although there was no difference in finding mental healthcare practitioners. LGBT community centers may wish to keep lists of LGBT-positive physicians and publicize the availability of these lists. Also, medical clinics, LGBT groups, or LGBT community centers may wish to develop health campaigns in which they emphasize the need for preventative healthcare and check-ups among this population and the hazards that can arise when it is forsaken.
Strengths and Limitations Within this study, there were several limitations that should be noted. Although the sample
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was diverse in a number of ways (age, level of education, income, geographical location, and gender identity), there was limited racial representation other than Caucasian participants. Because the data were gathered via Internet survey, respondents had to have access to a computer. In addition, the results are based on a series of one-item self-report questions. Future research should explore contextual differences in seeking medical and mental healthcare, and better instruments measuring gender identity and expression should be developed to explore these issues among butch and femme women. An additional limitation of this study that warrants future research is that transgender issues were not addressed. The sample included 50 individuals (9.8%) who identified as transgender (but not male), all of whom identified as butch. These individuals may have healthcare needs associated with their transgender identity that may also affect their experiences in healthcare settings differently from butch-identified lesbians who do not identify as transgender. Although some butch-identified individuals identify as transgender without any plans to transition, it is impossible to know how the respondents in our study experience their transgender identity. Future research should examine the differences between butch-identified nontransgender and butch-identified transgender individuals. There is certainly support for the need for formal training on LGBT health issues and the creation of safer, more affirming healthcare environments for LGBT individuals. Such LGBTaffirmative training and care is necessary, as well, for individuals with gender identities outside of the traditional gender binary. The results of our research demonstrated that gender identity affects experiences in healthcare settings beyond the effects of sexual orientation alone, contributing to the literature that has previously compared sexual-minority women to heterosexual women by adding the dimension gender identity. In particular, butch women appear to be most at risk. It is imperative that gender identity, as well as sexual orientation, be addressed within the healthcare field to ensure adequate services for all individuals, regardless of sexual orientation or gender identity.
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