Culturally Sensitive Care: Caring for a Pregnant Woman who is a Lesbian
I may have helped care for a number of pregnant lesbians, because I have certainly cared for unmarried mothers, but may not have been aware of that they were bisexual or lesbians. What the literature has revealed is that many lesbians remain concerned about divulging sexual orientation to their healthcare professionals, including their gynecologists, so that sexual orientation may not been known for many patients. However, I know that I have been involved in the care of at least one pregnant lesbian. The patient, who I will call Leslie, was a 37-year-old woman who was pregnant for the second time. Her first pregnancy was when she was 15 and she placed that child for adoption. Leslie was in a committed relationship with her "wife" (our state did not recognize homosexual marriage, so they were not legally married) a 34-year-old woman named Debbie. They were financially stable and seemed to have a functional relationship, but there were indications of excessive alcohol use by Leslie prior to conception. Because of her age, the pregnancy was considered high risk and they had been involved with a fertility clinic. The baby was conceived through the use of donor sperm. The donor was an anonymous donor. For a high-risk pregnancy, her prenatal care and treatment during the birth and hospitalization seemed to be very routine. There were some issues with Debbie being excluded initially at different parts of the process, but once people understood that they were family members, those issues were resolved quickly.
My perception of the treatment is almost certainly different than Debbie's perception of Leslie's care. Debbie was somewhat confrontational with healthcare workers, and she seemed to perceive any slights as being directed at her because she was a lesbian. For example, the staff would not release information to her without Leslie's explicit approval, a protocol the office follows for all relationships because pregnancy is oftentimes when domestic violence issues surface and the status of a relationship at the prior visit may no longer be the status at the next visit. For us, it was an issue of patient privacy. Likewise, when Leslie needed an emergency C-Section and Debbie was asked to leave the room for prep, she seemed to think that she would not be permitted in the room for the actual delivery. However, once it was explained that she would be allowed back into the room after prep was complete, she calmed down immediately.
Some of the post-natal care was interesting because a routine part of post-natal care focuses on birth control, issues that seemed inapplicable to a lesbian. However, Leslie was the one to ask about low-dose hormonal birth control at her six-week post-natal checkup because of concerns about heavy periods returning when she resumed menstruating. She also discussed her age and the desire to have multiple children, wanting to know if there was an optimal time to wait before trying to conceive.
I did not feel like there were any particular issues treating this patient because of her sexual orientation. However, I do believe that my perception of the patient does not match the patient's perception of care. For example, unlike the vast majority of the heterosexual patients of the same age that were in our care, Leslie's history of gynecological care was unreliable. She did not have yearly exams, but she did have some history of gynecological checkups. Lesbians do tend to be at lower risk of sexually transmitted diseases than the general population, but they are not in a no-risk population, and many lesbians ignore their reproductive health because of a false sense of security.
I actually found my emotional response to Debbie to be much greater than my emotional response to Leslie, because of her fears that, as a person with no legal relationship to the child, she might somehow be excluded from parts of the prenatal process or even the birth. This did not reflect problems in their relationship; they seemed committed to and supportive of one another. Furthermore, there is a trend in obstetrics to communicate with the patient primarily and not with the father, even if the mother has released information to the father. Despite this, Debbie seemed convinced that any information that we would not share without Leslie's permission would have been given to a father. As a result, she was not always pleasant with our office staff. While her attitude was no more aggressive than the attitudes of some fathers, I do feel like perhaps we could have taken greater steps to ensure that she felt more included in the process. On the other hand, when she would express concerns about not having a legal relationship with the child, those concerns were extremely well-founded, and it made me wonder about how difficult it would be to enter into a relationship with a child and parent with a full and open heart knowing there was no legal relationship. In some ways, I felt like maybe we were doing the child a disservice, not because the parents were lesbians, but because the child might not have an opportunity to have relationship with one parent in the event of a break-up.
Good and Bad
Every single obstetric experience is unique, and each brings with it challenges and opportunities. In this case, there were several things that were good and there are several things that were bad. Most of the negative things were much more highly correlated with maternal age than with any other factor. For example, Leslie's screening test results indicated a possible trisomy and they had to make a decision about amniocentesis, aware that the procedure increased the risk of miscarriage. They ultimately decided against the amniocentesis, but it was a difficulty. Leslie also experienced high blood pressure towards the end of her pregnancy, which was, of course, a potential health issue, but it was controlled and did not result in a premature delivery or in any adverse consequences for maternal health. Therefore, all of the negatives that I perceived were not really linked to sexual orientation.
Interestingly enough, some of the more positive experiences were linked to sexual orientation or maybe to the fact that their sexual orientation did not seem to mean a whole lot to the people around them. For example, both Leslie and Debbie had the full support of both families. All four grandparents, several aunts and uncles, and young cousins, all awaited the birth of the newest family member while Leslie was in labor. One of Debbie's sisters accompanied Leslie to an ultrasound when Debbie could not. There was a tremendous amount of family support; in fact, a much higher level of family support than one sees in most heterosexual relationships. I found this to be very compelling, but the fact that I found it compelling may have been condescending on my part, because I was entering into the relationship with my perceptions that lesbians are going to experience family problems and lack family support. While this may be true for many members of the lesbian population, this experience showed me that I cannot make those blanket assumptions about people based on sexual orientation.
One thing I do believe is that Leslie's sexual orientation was linked to her advanced age at maternity. Because lesbians do not just fall pregnant like women in heterosexual relationships, they have to make more deliberate decisions about pregnancy and childbirth. I believe that for many women, this delays the onset of conception. However, as Leslie's teen pregnancy demonstrates, I also believe that lesbian sexual orientation may lead to early and irresponsible sexual activity in young lesbians out of an attempt to make themselves straight or otherwise prove heterosexuality to themselves or others.
One of the things that I discovered when looking through the literature is that lesbian populations have some special concerns when seeking obstetric and gynecological care, and that traditional medical practitioners have failed to address these issues. There appears to be a perception that gynecologists are heterocentric, perhaps because reproductive issues discussed by gynecologists assume the presence of male/female couples. For example, gynecologists focus on birth control, which with women who have sex exclusively with women, is not going to be the same issue as it is with women who sleep with men. However, because women who have sex exclusively with women do report instances of sexually transmitted diseases and cervical cell atypia, they clearly should be attending the same type of screening as heterosexual women. (Moegelin et al., 2010).
Another interesting factor is that lesbians and bisexual women actually engage in some higher risk behaviors than heterosexual women, and that these health behaviors are not as linked to age as they may be in heterosexual demographics. For example, lesbian and bisexual women engage in lower rates of recommended screening services than heterosexual women (Valanis et al., 2000). However, even if one assumes that those screening services are linked to service seeking for reproductive health…