Culture, Health & Sexuality, 2015 Vol. 17, No. 2, 180–193,

Healthcare experiences of lesbian and bisexual women in Cape Town, South Africa Riley Smith* Gender and Sexuality Studies, Northwestern University, Evanston, USA (Received 13 January 2014; accepted 30 August 2014) Understanding the health needs and experiences of South African lesbian and bisexual women is imperative for implementing effective and inclusive public health strategies. Such understanding, however, is limited due to the exclusion of these women from most existing research on healthcare access in the region. This paper bridges that gap by investigating the healthcare experiences of lesbian and bisexual women in Cape Town. Data were gathered from 22 interviews with self-identified lesbian and bisexual community members and university students in the Cape Town area. Interviews explored obstacles women face in accessing affirming services, different experiences with public and private healthcare, fear of stigma/discrimination, availability of relevant sexual health information and suggestions to improve existing programmes. Findings suggest that South African lesbians and bisexual women may have a range of both positive and negative experiences in public and private health services, that they use protective strategies when ‘coming out’ and that they find that sexual health information pertinent to them is largely unavailable. These discussions contribute to a more inclusive understanding of the experiences of lesbian and bisexual women accessing healthcare and other services and help to inform providers, thereby enabling them to deliver more meaningful care to lesbian, gay, bisexual and transgender persons in South Africa. Keywords: South Africa; healthcare access; lesbian; bisexual women

Introduction South Africa, formally one of the world’s leaders in lesbian, gay, bisexual and transgender equality, was the first African nation to constitutionally outlaw discrimination based on sexual orientation. Despite this progressive legislation, however, non-heterosexual sexualities remain stigmatised across the country. For example, hate crimes against lesbian, gay, bisexual and transgender persons are a growing concern, especially in low-income township areas (Mkhize 2010). The stigma surrounding same-sex relationships and the potential violence that lesbian, gay, bisexual and transgender people face may negatively impact healthcare access for lesbians and bisexual women, especially those who are marginalised on multiple levels (Tallis 2009). South Africa offers a unique context for exploring these issues due to the discrepancy between the nation’s legal framework and the day-to-day experiences of sexual-minority women, the disparities between public and private healthcare facilities and the profound inequalities that marginalised communities still face, two decades after the dismantling of apartheid. Within the two-tiered healthcare system, citizens can receive free primary care at public clinics or purchase private health insurance in order to access private care. However, because private insurance is expensive,

*Email: [email protected] q 2014 Taylor & Francis

Culture, Health & Sexuality


approximately 80% of the population relies on public care in facilities that are often underresourced and over-crowded (McIntyre et al. 2008). Numerous studies have demonstrated that, internationally, lesbians and bisexual women face health disparities and unique challenges in accessing healthcare compared to other populations (Bjorkman and Malterud 2009; McNair, Hegarty, and Taft 2012). Within South Africa, researchers have attributed these women’s unique experiences to their double marginalisation as women and as sexual minorities (Tallis 2009). As women, they may be neglected by health programmes that generally focus on reproduction and motherhood if they are not accessing healthcare for those reasons. Additionally, women are often disregarded in lesbian, gay, bisexual and transgender health research and outreach that typically focuses on gay or other men who have sex with men and HIV/AIDS. While limited research has been conducted on South African sexual minority women’s health, one of the few studies conducted with this population found that over half of the women surveyed had experienced heterosexism from healthcare providers (Tallis 2009). The Tallis study points to discrimination and heteronormativity in the South African healthcare system, but little is known about the actual healthcare experiences of these women. An understanding of these experiences is imperative for the provision of meaningful healthcare and other services for lesbian, gay, bisexual and transgender South Africans. Understanding the health needs of lesbians and bisexual women in South Africa is essential for creating effective and inclusive public health strategies. This study aimed to improve that understanding by considering how such women experience healthcare in the Cape Town area, how and where they access sexual health information and what suggestions they have for ways to make healthcare facilities more inclusive. In doing so, I consider the ways in which cultural capital and intersectionality influence sexual minority women’s experiences with healthcare (Bourdieu 1986; Crenshaw 1991; Makkonen 2002). Theoretical framework Worldwide, lesbian, gay, bisexual and transgender individuals face unique health needs and experiences that researchers, policy makers and service providers have only recently begun to recognise. Studies have shown that lesbian, gay, bisexual and transgender people may face discrimination and homophobia when accessing healthcare, which can lead to negative health outcomes (Pascoe and Smart Richman 2009). The majority of such studies have been conducted in the USA, but lesbian, gay, bisexual and transgender individuals and communities around the world may face similar disparities (World Health Organization 2013). When attempting to understand South African lesbian and bisexualidentified women’s specific healthcare experiences, the concepts of cultural capital and intersectionality provide a useful framework. Pierre Bourdieu’s (1986) notion of cultural capital posits that people possess varying degrees of non-economic, culture-based resources and knowledge acquired through cultural activities such as attending museums and films, as well as through more subtle social and cultural interactions. When applied to healthcare, cultural capital has been defined as, ‘The culture-based resources that are available for maintaining and promoting [people’s] health’ (Abel 2008, 3), and may include familiarity with medical vocabulary, knowledge of and value attributed to healthy behaviours and verbal and nonverbal skills that influence healthcare interactions (Shim 2010). Additionally, the concept has been applied to explore issues such as how patients make healthcare decisions and form strategies for managing chronic illnesses (Grineski 2009). Correlations exist between


R. Smith

cultural and economic capital in that socioeconomic status often provides access to cultural activities through which capital is acquired. However, evidence exists that cultural capital is associated with health status, even within populations of similar socioeconomic standing. For instance, a study in Lebanon found that women with low cultural capital were significantly more likely to report poor general and mental health compared to those with high cultural capital, even when participants were of the same socioeconomic status (Khawaja and Mowafi 2006). Cultural capital may impact the health status and healthcare experiences of South African women who may have less capital due to institutionalised homophobia and heteronormativity, lack of social acceptance for sexual minorities and limited access to lesbian, gay, bisexual and transgender-affirming social spaces (Mkhize 2010). This can limit women’s ability to negotiate the quality of care they receive if they do not have adequate support networks in their communities, knowledge about healthy behaviours and access to the necessary means to enact those behaviours, and/or economic resources to seek healthcare elsewhere. Additionally, lesbians’ and bisexual women’s experiences in different healthcare settings could be impacted upon by the cultural capital of healthcare providers who may have different backgrounds and medical training. In examining women’s experiences with public and private healthcare, it is helpful to consider how healthcare providers’ cultural capital and exposure to diverse sexualities through social and cultural endeavours may impact their ability to provide culturally competent care to sexual minorities. While cultural capital provides a useful framework for this analysis, it is insufficient when considering the combined effects of various forms of oppression that South African lesbians and bisexual women face. Intersectionality considers the overlap of various systems of oppression related to social structures such as gender, race, class and sexuality (Crenshaw 1991). Central to the concept is the understanding that a purely additive approach to analysing multiple modes of oppression is insufficient in capturing the complexity of experiences with marginalisation (Gibson and Macleod 2012). As the women in this study may have unique experiences of marginalisation compared to other women or sexual minorities, intersectional discrimination, which occurs when several grounds of discrimination interact concurrently, is helpful for understanding their experiences (Makkonen 2002). Applying intersectionality to cultural capital is necessary for considering how, for instance, a black lesbian living in a low-income township community may have different cultural, social and economic capital than other persons with various combinations of those identities. While intersectionality often considers numerous identities such as race, gender, class and sexual orientation, this study will primarily focus on class and sexual orientation because the participants did not often discuss race and, while the sample was racially diverse, that diversity did not extend across socioeconomic divisions (see below for breakdown of participant demographics). However, South Africa offers a unique environment for considering the intersectional effects of race, and future studies should explore this issue further. Methods Ethics approval was received from the Institutional Review Board at Northwestern University with the support of Stellenbosch University in Stellenbosch, South Africa. The data were collected via qualitative, semi-structured, in-person interviews conducted between June and August of 2013. Participants were recruited through their involvement with lesbian, gay, bisexual and transgender student groups at two universities in the greater

Culture, Health & Sexuality


Cape Town area and a non-profit organisation that serves lesbian, gay, bisexual and transgender communities in townships surrounding Cape Town. These recruitment sites were chosen because they provided a racially and socioeconomically diverse sample of women who self-identified as lesbian or bisexual that was accessible within the short time frame of this exploratory study. Recruitment of participants occurred using multiple methods: email contact with persons involved with the student groups and non-profit organisation, Facebook posts on group pages and on-site recruitment at lesbian, gay, bisexual and transgender events. The recruitment criteria were that participants were at least 18 years old, able to speak and understand English and self-identified as lesbian or bisexual. Lesbian or bisexual identity, as opposed to a behaviour-based category such as ‘women who have sex with women’, was used for two reasons: (1) because the recruitment sites used the label ‘lesbian, gay, bisexual and transgender’, it was felt that potential participants in those spaces would find the labels ‘lesbian’ and ‘bisexual’ more accessible and relatable than the more academic term ‘women who have sex with women’ and (2) as the interviews focused on concepts other than just sexual health, such as ‘coming out’ and feelings of inclusivity in healthcare spaces, using the identity categories of lesbian and bisexual are more appropriate for considering same-sex attracted individuals from a broader perspective than only sexual behaviour. However, with this one must recognise that the lesbian or bisexual identity does necessarily correlate with same-sex sexual behaviour, and a lesbian or bisexual woman’s sexual history may include sex with men (Roberts et al. 2000). Interviews were conducted at private locations on or near the university campuses or in community centres in various townships near Cape Town. Participants provided verbal consent and each interview lasted between 15 minutes and one hour, with an average interview length of 27 minutes. Interviews were audio-taped, transcribed verbatim and manually coded by the author. A total of 22 interviews were conducted with self-identified lesbian or bisexual women. Each participant was asked to select a pseudonym, which is how she is identified throughout the report. The interview guide included a series of topics related to women’s experiences ‘coming out’ to healthcare providers, their perceptions of how lesbian, gay, bisexual and transgender-friendly different health services are, how and where they access sexual health and/or safer sex information, and what they think can be done to improve the healthcare experiences of sexual-minority women. Data were analysed through open-coding, which allowed findings to be sorted into various themes that had been identified using the interview guide and initial readings of the transcripts (DeCuir-Gunby, Marshall, and McCulloch 2011; Ryan and Bernard 2003). While the thematic analysis was data-driven, once data were sorted into themes, the theoretical frameworks of cultural capital and intersectionality were identified as the most appropriate to illuminate differences in the women’s experiences. Participants The sample was racially and socioeconomically diverse and rather young. Of the 22 women interviewed, 13 were Black, five were mixed/‘coloured’ and four were white. The women ranged in age from 19 to 32 years old, with an average age of 23. Eighteen self-identified as lesbian and four as bisexual. Eight women lived in low-income townships and primarily used public healthcare facilities, nine lived in suburban or urban areas and primarily used private healthcare and five lived in suburban or urban areas and used both private and public healthcare. As noted previously, the racial diversity was not


R. Smith

present across the socioeconomically driven public/private healthcare divide: all but one of the participants using public healthcare were Black and all but one of the white and mixed/‘coloured’ participants exclusively used private healthcare.

Findings The primary themes that emerged from the analysis were the contrast between experiences in public and private healthcare, perceptions of the accessibility of sexual health information and interviewee’s suggestions for how the healthcare system could improve lesbians’ and bisexual women’s experiences. Differing experiences with public and private care The women interviewed had a range of positive and negative experiences when accessing healthcare in various settings. however, the women who exclusively used public care had significantly more negative experiences with and perceptions of the healthcare system than those who exclusively used private care. Almost all of the women interviewed who used public care felt that the government healthcare system was generally unfriendly towards them. Even if they had not directly experienced homophobia in a clinical setting, most feared that if they disclosed their orientation to healthcare providers they would face homophobic and/or insensitive questions or remarks. This was most often discussed in reference to accessing sexual health services such as HIV or STI (sexually transmitted infection) testing: As a lesbian, I would say the system has . . . it’s not working properly for LGBT [lesbian, gay, bisexual and transgender] women . . . . We can go to the clinic, maybe I have STI because I could have STI although I sleep with another women. I’m going to the clinic, I say to the nurse that I have an STI, the nurse could ask me, ‘Why? Why do you have an STI although you sleep with another woman?’ You see, so something like that. If you’re [HIV] positive, the nurses will ask you some questions about your sexuality but not about the thing that you came for. (Mkhulu, age 32, lesbian, public care)

Other interviewees echoed Mkhulu’s concern about the type of questions nurses in the public clinics ask when lesbian or bisexual women access sexual health services: And let’s say I’m going to test for an STI. So, a nurse will come to me and ask ‘Why are you testing for this? You don’t sleep with men? Why go through that?’ . . . She’ll ask about my personal life, ‘Why do you date girls? Why do you do stuff like that?’ So it’s not fair, man, it’s not right. (Ayanda, age 19, lesbian, pubic care)

These statements reflect interviewees’ perceptions that healthcare providers are uneducated on their health needs, are unable to provide testing services in a sensitive manner and are judgmental about women’s same-sex sexual behaviour. Occasionally, it was unclear if interviewees were referring to specific experiences they had or speaking abstractly about what they thought would occur in such a situation. However, whether perceived or directly experienced, the homophobia they described may have negative consequences on disclosure of orientation and/or healthcare seeking behaviour in public healthcare facilities. While women using private healthcare expressed similar concerns about healthcare providers’ knowledge of sexuality and health, most felt that they would be comfortable disclosing their orientation to a healthcare provider if it was ‘medically relevant’. Although many of the women had never actually ‘come out’ to a provider, they thought they would if, for example, they were discussing sexual health. These women explained

Culture, Health & Sexuality


how, because they used private care and were of a higher socioeconomic status, they had the option to ‘go somewhere else’ if they were dissatisfied with the service they receive at one healthcare facility: If I had to say something and it depended on my health then I would definitely say it, that I’m a lesbian. And if they couldn’t deal with that then I’d go somewhere else. (Tweety, age 20, lesbian, private care)

Here, the intersection of sexuality and class is evident in that women using public clinics could typically only attend the clinic in their neighbourhood, as transport to a different clinic would be expensive and time consuming, and they therefore generally did not have the option to go elsewhere if treated negatively. Additionally, interviewees using both private and public facilities discussed perceptions of heteronormativity or homophobia that made them uncomfortable in healthcare settings: I have hidden it from [my private GP] just because I know not all doctors are as open minded, but it’s more of a religious thing. (Sharon, age 22, lesbian, private care) [The healthcare system], it’s mostly made for straight people so it’s not actually, there’s nothing that I can relate to that is there. The nurses, the environment, you know, what you see there. When they talk about HIV they talk about HIV between men and women and how men can catch it. There is nothing that I can relate to when I go to the clinic. (Asherah, age 26, lesbian, public care)

As the above quotations demonstrate, women using private care typically attributed heteronormativity or homophobia to an individual provider – Sharon’s discomfort was due to her physician’s conservative religious beliefs – while those using public care generally felt that such experiences were reflective of the entire healthcare system being simply ‘not for them’. Participants were highly aware of environmental and behavioural cues that indicated the heteronormativity of healthcare spaces. For example, sexual health information being presented with heteronormative language, providers exclusively asking about opposite-sex partners, and a lack of lesbian, gay, bisexual and transgender visibility on brochures and posters were thought of as presenting an image of healthcare facilities as unwelcoming to all women, and these cues were referenced most often by women using public facilities. Although all of the women were perceptive to heteronormativity in certain spaces, many felt that they could still ‘come out’ to providers and, for those who had disclosed their orientation to at least one provider, most had generally positive experiences in doing so. However, all but one of these positive experiences occurred in either private clinics or university settings. For example, Morgan, a 21-year-old lesbian, described an experience in which she ‘came out’ to an HIV tester at a university testing centre: ‘She was very open and she was very calm, she was like “let’s go to a private place and we can chat this out, it shouldn’t feel like I’m interrogating you or anything” and then she made me feel really comfortable.’ Morgan and the other participants’ comfort disclosing their orientation in private healthcare facilities indicates a perception that those providers might be more accepting of sexual minorities or, if not, at least better able to provide culturally competent and non-judgmental care irrespective of their personal attitudes or beliefs. For some women using private healthcare this perception was supported by rights-based arguments, demonstrating the role that cultural capital and knowledge of healthcare structures and rights plays in women’s experiences. As Julia explained: I think right now if a doctor turns you away or shows you any form of discrimination based on your sexual orientation, that is illegal. So most doctors, even if they, they might not be totally


R. Smith

accepting of it, if they are overtly discriminating towards you then they’d get in trouble. (Julia, age 25, lesbian, private care)

In contrast to women using public care who often expressed feeling disempowered from advocating for more inclusive healthcare, Julia’s comments express an understanding of the legal structures and, perhaps more significantly, confidence that those legal structures will protect against discrimination. Accessing sexual health information and HIV testing Regardless of where they accessed care, all of the women interviewed felt that sexual health information pertaining to them was generally unavailable in healthcare or other settings. Women cited examples such as the heteronormativity of brochures and posters in both public and private clinics and the exclusively heterosexual focus of safe sex education in schools. For example: If I look in the clinics now it’s mainly heterosexual sex . . . I look at what literature they have available for patients and, yeah, it’s mainly aimed at heterosexuals. Yeah, in fact I don’t think I’ve ever seen something that’s aimed at non-heterosexuals. (Taylor, age 22, bisexual, private care)

These statements indicate that participants are aware of the safer-sex information available for heterosexuals and feel neglected because they are not provided with similar resources. Multiple interviewees also expressed concern that healthcare professionals are not educated on lesbian, gay, bisexual and transgender health or sexuality. As Asherah described it, ‘sometimes you feel like [healthcare workers] have no clue, you know, they have no clue.’ Interviewee’s perceptions that their healthcare providers are uneducated on lesbian, gay, bisexual and transgender issues negatively affect their healthcare experiences. For example, Kiki described an experience with HIV testing in a public clinic: I went to the clinic, you know, and normally where I go to test for HIV, for my sake to know my status because it’s good to know your status, so this time I went there and obviously they ask you a question, ‘When last did you have sex?’ and then you’re gonna tell them did you use a condom. And then when you tell them that you don’t use a condom because, they’re gonna ask you why, and when you tell them why, ‘Because I’m not intimate with males’ or whatsoever, so now they’re gonna shift on what they’re supposed to do to be specific on your sexuality. They’re gonna ask you ‘How, well when you come here what are your intentions? Why do you think that you can be affected? Because you’re a woman, you’re sleeping with another woman.’ The lack of education, or the lack of knowledge for them, it’s really affecting us. (Kiki, age 22, lesbian, public care)

Kiki’s experience also speaks to the issue of HIV testing for lesbian and bisexual women. Although sex between women is generally considered to be low risk for HIV transmission, over half of interviewees had participated in voluntary testing (it should be noted that the interviewer did not directly ask about this or anything else related to HIV status or testing). While interviews did not include a sexual history and the motivation for testing was not extensively explored, these findings indicate that some lesbian or bisexualidentified women participate in HIV testing and may face challenges in doing so. The interviewees’ experiences with testing varied tremendously, as women tested in public clinics generally felt negatively judged by testers, while women testing at universities felt more accepted. For example, Morgan, a university student, described her experience saying, ‘When I was testing for HIV I spoke to the healthcare person and I said, “this is my sexual orientation” and I asked her questions about statistics and that and she was very helpful,’ (Morgan, age 21, lesbian). In contrast, Alianda described how a woman she knows was denied access to testing in a public clinic due to her sexual orientation:

Culture, Health & Sexuality


She went to a clinic and was like ‘Uh, I’d like to get tested for AIDS and also I’d like information on how to keep myself safe like with my partner.’ And the woman was just like ‘Number 1, you’re a lesbian get out of here, Number 2 why do you think you’ll get AIDS if you’re not sleeping with men? Like why do you think you’ll get sick? Are you secretly sleeping with men and you don’t want to tell these friends of yours?’ And stuff like that and was basically just a tirade. And they were actually denied the information. They were denied any information, I think they were even denied being tested and they were like, ‘It’s a waste of resources, it’s a waste of time, what you need to be doing is becoming straight, that’s what you need to be doing. That’s like the cure you need to be looking for,’ type thing. (Alianda, age 25, bisexual, public and private care)

Additionally, although many interviewees had been tested, some felt that other women were unlikely to test since healthcare professionals have told them it is unnecessary, and one interviewee discussed the added stigma that HIV-positive sexual-minority women face: I think most lesbians don’t know anything about HIV and AIDS and stuff and then they don’t want to be, they don’t want to test and stuff because I think, maybe I go test and then I find out I’m HIV-positive and then I go to the community clinic to like get the pills and stuff and then what the people gonna say about me? So, they end up not going there and then just keeping quiet, just not disclosing their status to anybody. (Shareldin, age 24, lesbian, public care)

Shareldin’s statement raises difficult questions about perceptions of HIV within lesbian communities. Conversations around HIV/AIDS in South Africa and around the world have almost exclusively focused on transmission among heterosexuals, people who inject drugs and men who have sex with men and, because of that, some of the women interviewed expressed concerns that other lesbians believed that they could not contract HIV: I think the sexual health education in general is whatever [not ideal] but I think it’s a little bit worse within the LGBT [lesbian, gay, bisexual and transgender] community if you’re not a gay man. Because gay men are always told all the time ‘You are on the verge of AIDS’, whereas like, for like bisexual and lesbian women it’s a case of like, ‘cuz that rhetoric isn’t geared at us so it’s a case of ‘Oh, they’re the ones who get ill’. Like, we’re not even doing anything that you can get ill. (Alianda, age 25, bisexual, public and private care)

Because participants felt that sexual health information was generally unavailable in healthcare settings, most accessed information via non-profit organisation and/or the Internet. Participants appreciated the resources available to them at various non-profits, but they also recognised that other women might not be comfortable accessing lesbian, gay, bisexual and transgender-specific services. For example, one participant raised concerns about the availability of sexual health information for lesbian or bisexual women who are ‘closeted’ and fear being ‘outed’ if others discovered that they associate with a lesbian, gay, bisexual and transgender organisation.

Participants’ suggestions for improvements Participants offered numerous suggestions to improve the healthcare experiences of South African women. These included educating healthcare providers on issues related to lesbian, gay, bisexual and transgender health, providing brochures on sexual health for lesbian, gay, bisexual and transgender persons, and having more healthcare providers who openly identify as lesbian, gay, bisexual or transgender. Almost all of the women interviewed felt that their healthcare experiences would improve if providers were educated on sexuality and lesbian, gay, bisexual and transgender health. The value of education was also emphasised in regards to promoting more comprehensive sexual health information in schools, which was thought to be an important step in reducing stigma:


R. Smith

I prefer that we need to educate [nurses]. We need to make them understand. I don’t say we need to make them accept us because that’s an attitude unfortunately; it’s not something that could happen on next morning. It’s gonna take time for them, but at least make them understand. We need to educate them and form them to know that how affecting it is for us not to get safe-sex education in our clinics because it’s our clinics, it’s a community clinic. (Kiki, age 22, lesbian, public care)

Many women interviewed also thought it would be helpful if healthcare facilities had tangible resources and information such as brochures, posters and dental dams. Some felt that these resources would not only benefit women by providing important sexual health information, but they would also indicate to patients that the facility is lesbian, gay, bisexual and transgender-friendly and educate heterosexual community members on lesbian, gay, bisexual and transgender-related issues. For example: They could have a pamphlet, you know, information. If you’re talking about HIV put a man and a man because gay men are HIV-positive, lesbians are HIV-positive. Put those pictures up there so that everyone would know that whatever they say is relevant to them. Because now the message that they’re sending us is that HIV does not affect us, STIs doesn’t affect us. (Ashera, age 26, lesbian, public care)

As this comment makes evident, some of the women interviewed associated the heteronormativity of resources/information as indicative of the invisibility of lesbian, gay, bisexual and transgender persons in such spaces. Therefore, they felt that information on lesbian, gay, bisexual and transgender health is not only important for promoting safer sexual behaviour for non-heterosexuals, but also for increasing visibility in healthcare settings. Discussion Although this study is helpful in understanding women’s healthcare experiences, it is also limited in several ways. The sample was racially and socioeconomically diverse, but that diversity was insufficient for fully analysing the intersections of class, race, sexuality and gender. While race and socioeconomic status continue to be integrally related due to the nation’s history of racial oppression, utilising a wider range of recruitment methods to achieve a larger, more diverse sample would allow women’s intersecting identities and experiences to be explored more fully. Additionally, the sampling methods limited participants to young women with access to lesbian, gay, bisexual and transgender resources and social networks in Cape Town. It is likely that these women have very different experiences than those who live in more rural and/or conservative parts of the country; are not ‘out’ to their family, friends or communities; are not connected to lesbian, gay, bisexual and transgender social networks; and/or are of different ages. In future studies, it would be helpful to utilise a mixed-methods approach and to include a broader range of women so as to better facilitate comparisons within the study population. Finally, although cultural capital and intersectionality offer a useful framework for understanding these women’s experiences, other theoretical lenses such as theories of heteronormativity (Bjorkman and Malterud 2009), identity disclosure (Eliason and Schope 2001; McNair, Hegarty, and Taft 2012) and status characteristics as they relate to power dynamics in patient-physician interactions (Gallagher et al. 2005) could be explored. Despite these limitations, these findings raise important concerns about healthcare access for lesbian and bisexual women in South Africa. The range of positive and negative experiences and the potential that these contrasting experiences can be attributed to whether a patient accesses public or private healthcare highlights the importance of an intersectional approach. Because of their socioeconomic status and the fact that women

Culture, Health & Sexuality


accessing public clinics are not paying ‘clients’, they reported feeling less empowered to demand equal treatment in healthcare settings. These women may have less cultural, economic and social capital due to their intersecting identities and experiences with marginalisation, thus placing them in more vulnerable positions in regards to negotiating health systems. However, while women accessing public clinics might be the most vulnerable to negative treatment, they are also the least empowered to exercise agency in choosing a different healthcare provider if they do not have the economic means to do so. In contrast, women with more cultural capital, as well as related economic and social capital, have the knowledge, resources and support to advocate for themselves in healthcare settings if they feel that they are not being treated properly. Additionally, these findings indicate a perception that healthcare providers in private facilities are more accepting of lesbians and bisexual women or that they at least ‘know better’ than to discriminate in such settings. The difference in the training of healthcare providers is noted throughout the interviews, as interviewees who used private healthcare typically used physician-specific terms such as ‘gynaecologist’ or ‘General Practitioner’, while the women accessing public care typically referred to providers as ‘nurse’, ‘sister’ or ‘tester’. Most studies on healthcare and cultural capital have focused on the cultural capital of patients (Khawaja and Mowafi 2006; Shim 2010). However, in settings such as South Africa, where there is significant disparity between healthcare facilities (McIntyre et al. 2008) and patients have such varying experiences, the cultural capital of healthcare providers is also important to consider. In this study, interviewees generally felt that, compared to other healthcare providers, medical doctors may have more extensive training on interacting with diverse patient populations. Here, the cultural capital of healthcare providers in regards to their knowledge of and exposure to diverse sexualities and their ability to communicate effectively about issues related to sexuality directly impacts the experiences of women accessing care. A comprehensive understanding of medical training on lesbian, gay, bisexual and transgender health issues is beyond the scope of this study, but this issue should be explored further to ensure all healthcare providers have the cultural competency to interact with and treat lesbians and bisexual women and other minority groups. Women’s intersectional identities may also impact the way in which they report on their perceptions of homophobia and heteronormativity. A study of lesbian, gay, bisexual and transgender persons in New York found that race, gender and gender expression influenced how respondents interpreted anti-queer physical violence and verbal attacks. The study makes evident that ‘the ways in which lesbian, gay, bisexual and transgender people evaluate the severity of their violent experiences is not a straightforward process that can simply be measured by examining the type of abuse they have experienced’, and that ‘the overlap of multiple systems of oppression’ must be accounted for (Meyer 2012, 868). In the current study, many of the women interviewed who access public care live in communities where hate crimes against lesbian, gay, bisexual and transgender persons are prevalent (Mkhize 2010), and it may be the case that women who have directly experienced homophobia and violence in their communities, or who know other women who have had such experiences, are more sensitive to homophobia in healthcare settings. In regards to the women’s anxieties about ‘coming out’ to healthcare providers, other studies have found that lesbian, gay, and bisexual persons may carefully control the information they share with healthcare providers until they can determine how the provider will respond (Eliason and Schope 2001; McNair, Hegarty, and Taft 2012). In addition, it has been found that persons who disclose their orientation to providers are more likely feel comfortable during patient-clinician interactions and to seek preventative


R. Smith

care (Bonvicini and Perlin 2003). Even if women have not directly experienced homophobia in healthcare settings, the perception that they might face a homophobic response if they disclose their orientation could cause them to be less likely to access preventative services or other forms of healthcare, as this study further elucidates. While interviewees had a range of experiences across healthcare systems, they all stressed the lack of sexual health information available for sexual-minority women. These findings are consistent with previous research that has found that lesbian-identified women in South Africa have unique experiences with HIV testing and treatment and that, although healthcare providers are sufficiently equipped to handle HIV, many are insensitive when discussing same-sex sexual preference (Matebeni et al. 2013). Despite their low-risk categorisation, one study in South Africa’s Gauteng province found that 9% of Black lesbian-identified women who had tested for HIV were seropositive (Wells and Polders 2012). Although this figure is low compared to the national prevalence rate of nearly 18% (Republic of South Africa Department of Health 2012), it indicates that lesbian-identified women are, in fact, at risk of contracting HIV, and thus health promotion and HIVprevention strategies should be inclusive of their unique health needs. As HIV transmission between women is generally considered unlikely (McNair 2005), explanations for the high rate of HIV among lesbians in the Gauteng study include the possibility that ‘lesbians may have bisexual partners, experience high levels of rape and/or engage in transactional sex with men’ (Wells and Polders 2012, 3). Other studies have also found that, for lesbians, the lack of available sexual health information may ‘contribute to a “culture” of not practicing safer sex within their “community”’ (Formby 2011, 1178). This was noted in a few interviews in which participants expressed concern that other lesbians who were less connected to the lesbian, gay, bisexual and transgender community or who were not ‘out’, may be unfamiliar with or unwilling to practice safer sex if they do not feel that they are engaging in risky behaviour. While my study did not extensively explore the reasons for HIV testing, its findings further support those of past studies, which indicate that HIV is a concern for some South African sexual minority women who desire sexual health resources and information that are not currently provided. Conclusion The study contributes to an understanding of the diversity of South African lesbian and bisexual women’s experiences, which is important for informing public health efforts and providing all women with meaningful healthcare. Participants’ suggestions for improvements indicate that they understand their rights as South African citizens and recognise those rights as not being fulfilled, and that they see a disparity between the standard of care provided to heterosexual patients and desire equal treatment. In order to achieve that equality, they feel that healthcare providers at all levels should be educated on lesbian, gay, bisexual and transgender sexuality and health and that healthcare facilities must provide more inclusive sexual health resources. Various organisations have recognised that the South African healthcare system may be failing some sexual-minority citizens and have taken strides to provide culturally competent healthcare for lesbian, gay, bisexual and transgender persons. However, funding and resources understandably limit these groups, necessitating a more broad-based, comprehensive, nationwide approach. The necessary legal frameworks are in place to establish a government-sponsored push for meaningful and affirming healthcare for lesbian, gay, bisexual and transgender South Africans, and such an effort should be undertaken to assure that the health needs of all South Africans are met without fear of discrimination.

Culture, Health & Sexuality


Acknowledgements I would like to thank the women who participated in this study; the Triangle Project for their support and assistance in recruiting participants; the Office of International Program Development at Northwestern University for their generous financial support; and Noelle Sullivan and He´ctor Carrillo of Northwestern University.

Funding This work was supported by the John & Martha Mabie Fellowship for Public Health Research through the Office of International Program Development at Northwestern University.

References McNair, R. P., K. Hegarty, and A. Taft. 2012. “From Silence to Sensitivity: A New Identity Disclosure Model to Facilitate Disclosure for Same-sex Attracted Women in General Practice Consultations.” Social Science & Medicine 75 (1): 208– 216. Abel, T. 2008. “Cultural Capital and Social Inequality in Health.” Journal of Epidemiology and Community Health 62 (13): 1 – 5. Bjorkman, M., and K. Malterud. 2009. “Lesbian Women’s Experiences with Health Care: A Qualitative Study.” Scandinavian Journal of Primary Health Care 27 (4): 238– 243. Bonvicini, K., and M. Perlin. 2003. “The Same but Different: Clinician-patient Communication with Gay and Lesbian Patients.” Patient Education and Counseling 51 (2): 115– 122. Bourdieu, P. 1986. “The Forms of Capital.” In Handbook of Theory and Research for the Sociology of Education, edited by J. Richardson, 241– 258. Westport, CT: Greenwood Press. Crenshaw, K. 1991. “Mapping the Margins: Intersectionality, Identity Politics, and Violence against Women of Color.” Stanford Law Review 43 (6): 1241 –1299. DeCuir-Gunby, J., P. Marshall, and A. McCulloch. 2011. “Developing and Using a Codebook for the Analysis of Interview Data: An Example from a Professional Development Research Project.” Field Methods 23 (2): 136– 155. Eliason, M., and R. Schope. 2001. “Does ‘Don’t Ask Don’t Tell’ Apply to Health Care? Lesbian, Gay, and Bisexual People’s Disclosure to Health Care Providers.” Journal of the Gay and Lesbian Medical Association 5 (4): 125– 134. Formby, E. 2011. “Lesbian and Bisexual Women’s Human Rights, Sexual Rights and Sexual Citizenship: Negotiating Sexual Health in England.” Culture, Health & Sexuality 13 (10): 1165– 1179. Gallagher, T., S. Gregory, A. Bianchi, P. Hartung, and S. Harkness. 2005. “Examining Medical Interview Asymmetry Using the Expectation States Approach.” Social Psychology Quarterly 68 (3): 187– 203. Gibson, A., and C. Macleod. 2012. “(Dis)allowances of Lesbians’ Sexual Identities: Lesbian Identity Construction in Racialised, Classed, Familial, and Institutional Spaces.” Feminism & Psychology 22 (4): 462– 481. Grineski, S. 2009. “Parental Accounts of Children’s Asthma Care: The Role of Cultural and Social Capital in Health Disparities.” Sociological Focus 42 (2): 107– 132. Khawaja, M., and M. Mowafi. 2006. “Cultural Capital and Self-rated Health in Low Income Women: Evidence from the Urban Health Study, Beirut, Lebanon.” Journal of Urban Health 83 (3): 444– 458. Makkonen, T. 2002. Multiple, Compound and Intersectional Discrimination: Bringing the Experiences of the Most Marginalized to the Fore. Abo Akademi University: Institute for Human Rights. Matebeni, Z., V. Reddy, T. Sandfort, and I. Southey-Swartz. 2013. “‘I Thought We Are Safe’: Southern African Lesbians’ Experiences of Living with HIV.” Culture, Health & Sexuality 15 (sup1): S34– S47. McIntyre, D., B. Garshong, G. Mtei, F. Meheus, M. Thiede, J. Akazili, M. Ally, M. Aikins, J. Mulligan, and J. Goudgei. 2008. “Beyond Fragmentation and Towards Universal Coverage: Insights from Ghana, South Africa and the United Republic of Tanzania.” Bulletin of the World Health Organization 86 (11): 871– 876. McNair, R. 2005. “Risks and Prevention of Sexually Transmissible Infections among Women Who Have Sex with Women.” Sexual Health 2 (4): 209– 217.


R. Smith

Meyer, D. 2012. “An Intersectional Analysis of Lesbian, Gay, Bisexual, and Transgender (LGBT) People’s Evaluations of Anti-queer Violence.” Gender & Society 26 (6): 849– 873. Mkhize, N. 2010. The Country We Want to Live In: Hate Crimes and Homophobia in the Lives of Black Lesbian South Africans. Cape Town: HSRC Press. Pascoe, E., and L. Smart Richman. 2009. “Perceived Discrimination and Health: A Meta-analytic Review.” Psychological Bulletin 135 (4): 531– 554. Republic of South Africa Department of Health. 2012. “National Strategic Plan on HIV, STIs and TB 2012– 2016.” Roberts, S. J., L. Sorensen, C. A. Patsdaughter, and C. Grindel. 2000. “Sexual Behaviors and Sexually Transmitted Diseases of Lesbians.” Journal of Lesbian Studies 4 (3): 49 – 70. Ryan, G., and H. Bernard. 2003. “Techniques to Identify Themes.” Field Methods 15 (1): 85 –109. Shim, J. 2010. “Cultural Health Capital: A Theoretical Approach to Understanding Health Care Interactions and the Dynamics of Unequal Treatment.” Journal of Health and Social Behavior 51 (1): 1 – 15. Tallis, V. 2009. “Health for All? Health Needs and Issues for Women Who Have Sex with Women.” In From Social Silence to Social Science: Same-sex Sexuality, HIV and AIDS and Gender in South Africa: Conference Proceedings, 216– 225. Cape Town: HSRC Press. Wells, H., and L. Polders. 2012. HIV and Sexually Transmitted Infections (STIs) among Gay and Lesbian people in Gauteng: Prevalence and Testing Practices. Pretoria: OUT LGBTI Well-Being. World Health Organization. 2013. Addressing the Causes of Disparities in Health Service Access and Utilization for Lesbian, Gay, Bisexual, and Transgender Persons. Washington, DC: WHO.

Re´sume´ En Afrique du Sud, la mise en œuvre de strate´gies de sante´ publique, efficaces et inclusives, exige une compre´hension des besoins de sante´ des femmes lesbiennes et bisexuelles. Cette compre´hension est toutefois limite´e en raison de l’exclusion de ces femmes de la plupart des programmes de recherche et d’acce`s aux soins se de´roulant dans la re´gion. Le pre´sent article re´duit cet e´cart en explorant l’expe´rience des soins chez les femmes lesbiennes et bisexuelles dans la ville du Cap. Les donne´es ont e´te´ collecte´es au cours de 22 entretiens avec des femmes s’auto-identifiant comme membres de la communaute´ lesbienne et bisexuelle, dont certaines e´taient inscrites dans deux universite´s de la re´gion du Cap. Les entretiens ont permis d’explorer les obstacles rencontre´s par ces femmes dans l’acce`s a` des services inclusifs, les diffe´rentes expe´riences ve´cues par elles dans les soins de sante´ publics et prive´s, leur crainte de la stigmatisation/discrimination, la disponibilite´ d’une information sur la sante´ sexuelle qui leur soit pertinente et leurs suggestions pour l’ame´lioration des programmes existants. Les re´sultats sugge`rent que les femmes lesbiennes et bisexuelles sudafricaines peuvent avoir ve´cu une diversite´ d’expe´riences positives ou ne´gatives dans les services de soins publics et prive´s, qu’elles ont recours a` des strate´gies de protection lorsqu’elles font leur !coming-out @ et qu’elles conside`rent que l’information sur la sante´ sexuelle qui re´pond a` leurs attentes est tre`s peu disponible. Ces discussions contribuent a` une compre´hension plus inclusive de l’expe´rience ve´cue par les femmes lesbiennes et bisexuelles en matie`re d’acce`s aux services de sante´ et aux autres services; et a` fournir des informations aux professionnels, ce qui devrait renforcer leur capacite´ a` prodiguer des soins plus approprie´s aux personnes LGBT en Afrique du Sud.

Resumen Para poder poner en pra´ctica programas de salud pu´blica eficaces que incluyan a mujeres lesbianas y bisexuales sudafricanas, es sumamente importante conocer cua´les son sus necesidades y experiencias sanitarias. Sin embargo, estos conocimientos esta´n limitados porque en la mayorı´a de los estudios actuales sobre el acceso al cuidado sanitario en la regio´n se excluye a este grupo de mujeres. Este artı´culo sirve de puente al investigar las experiencias sobre el cuidado de la salud de mujeres lesbianas y bisexuales de Ciudad del Cabo. Se recabaron datos de 22 entrevistas con miembros de una comunidad y estudiantes universitarias que se autoidentificaron como lesbianas y bisexuales en la regio´n de Ciudad del Cabo. En las entrevistas se analizaron las dificultades que afrontan las mujeres al acceder a los servicios que las apoyen, sus diferentes experiencias con instituciones de salud pu´blicas y privadas, el temor al estigma o la discriminacio´n, la disponibilidad de informacio´n relevante sobre salud sexual y sugerencias para mejorar los programas existentes.

Culture, Health & Sexuality


Los resultados indican que las mujeres lesbianas y bisexuales en Suda´frica han tenido tanto experiencias positivas como negativas en los servicios sanitarios pu´blicos y privados, que utilizan estrategias protectoras cuando “salen del armario” y que en su opinio´n la informacio´n sobre salud sexual que les concierne es sumamente limitada. Estos debates contribuyen a entender mejor las experiencias de las mujeres lesbianas y bisexuales que acceden a la sanidad y otros servicios y permiten informar a los proveedores para que puedan proporcionar cuidados me´dicos ma´s amplios teniendo en cuenta las necesidades de las personas lesbianas, gays, bisexuales y transexuales (LGBT) en Suda´frica.

Copyright of Culture, Health & Sexuality is the property of Routledge and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.

Healthcare experiences of lesbian and bisexual women in Cape Town, South Africa.

Understanding the health needs and experiences of South African lesbian and bisexual women is imperative for implementing effective and inclusive publ...
110KB Sizes 0 Downloads 5 Views