Straight talking?
Authors: Jeanelle de Gruchy
Journal: BMJ (2007)

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, heterosexuality “rarely has to attest to its existence . . . while homosexuality is silenced, heterosexuality is silent.” And it 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, focuses on health and social care to show how heterosexism distorts the care that users from the lesbian, gay, bisexual, and transgender (LGBT) community 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 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).

We know that attitudes of health professionals towards patients have a major impact on the care they receive. This dance of disclosure, where LGBT users compute in each interaction—how relevant is knowledge about my sexual identity? how easy is it to pass as heterosexual? if I don't, will I be denied the care I need?—is a major element of the care that they receive. Obliged to negotiate a range of barriers to good care, including ignorance of their needs and moral disapproval, users from this 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.

So who are the LGBT community? Fish details what little information there is, and provides a clear, accessible description of diverse groups within this community: young and old, black and disabled, bisexual and transgendered, those living in rural areas, and those who are working class. The invisibility of the latter group is captured in the book by the remarkable (alleged) claim by local MP Joe Ashton that “there are no lesbians in Barnsley.” Fish discusses these groups' particular positioning within heterosexist society, their social and health care needs, and their access to services.

Of course the other aspect of the in-joke is the implied hierarchical positioning of different oppressed groups—gay or black—and the assumption that they're mutually exclusive: “Black LGB sometimes feel they are required to make an either/or choice to identify with either their race or their sexual identity in order to fit in with black heterosexual or white LGB communities.” Yet “not only is it impossible to distinguish between multiple identities, but when people are obliged to compartmentalise their identities, they often experience alienation.” And of course there are large differences within black and minority ethnic groups—in one UK study, only 27% of Asian respondents had come out to their mother, compared with 61% of African-Caribbeans.

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. In an excellent chapter on conducting research among LGBT communities, 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. The discussion on defining and sampling and recruiting participants has broad application to all research into “rare, hidden, or sensitive populations.”

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.”

Health professionals, researchers, and students will all find different parts of this engaging book thought-provoking and useful—from its theorising of heterosexism and its description of the diverse LGBT communities to its discussion of the complexities of probability sampling and the case studies of the ways in which breast and cervical screening are permeated by heterosexism.

Lesbians' accounts of their experiences of cervical screening and breast cancer provide graphic illustrations of how they have to negotiate disclosure about their sexuality.