Our Bodies, Ourselves (146 page)

Lower income and lack of health insurance:
According to the Lesbian Health & Research Center, lesbians generally have lower incomes than women who partner with men and are less likely to have health insurance coverage from a partner or themselves. Trans people often have a difficult time finding work and so have little income despite many expenses, especially if they are using sex hormones. Lower income and lack of health insurance make paying for screening and preventive health services (and treatment when it is necessary) more difficult. (
“Transsexual Health Issues”
for a discussion of the health insurance tangle for gender-variant people.)

Homophobic attitudes and inadequate training among health care providers:
Some health care providers exhibit homophobic attitudes or have inadequate training for cultural competency in treating lesbians and bisexual women. Markers that can make us feel excluded include the intake forms, the pamphlets lining the wall, and the language used by the provider and intake staff.

Many health care providers (except for my local Planned Parenthood) have intake forms that ask marital status. I always change it to relationship status and handwrite whatever is true for me at the time. I hope they get it
.

Providers may assume we have sex with men and make health care recommendations based on that assumption.

Last time a doctor asked me what birth control I was using (which, she admitted, was completely irrelevant to the reason for my visit), I said that I didn't need to use any at the moment. She wrote “not sexually active” on my form, and I left the room furious, not only at her but at myself for not challenging her
.

On the flip side, some health care providers do not ask lesbians about safer sex practices, because providers assume wrongly that women who have sex with women aren't at risk for sexually transmitted infections.

Attitudes and training have improved significantly, especially in larger cities, but many health care settings continue practices that make LGBT people either less likely to seek care or less likely to be open with providers about sexual orientation, sexual practices, and health care needs. All this can affect long-term health.

I bounced around from one provider to another, looking for someone I could feel comfortable disclosing to about being sexually active with women and men, as well as being a sex worker. The reactions I encountered were very negative and judgmental. Eventually I stopped disclosing. I am happy to say that I finally found a good place to go here in New York. It is a health clinic especially for LGBTQ people. The doctors there are nonjudgmental. I have a provider now who knows all about me, and I always feel comfortable talking to her
.
*

The ability to be out to a health care provider can improve the quality of the care we receive. When we can be fully honest about our lives, our concerns, and our health risks and behaviors, our providers are in a better position to care for us, in part because we are more comfortable asking questions, discussing sensitive information that may be critical for diagnosis of a problem, and seeking help when we need it.

For many of us, coming out to a new provider is the first order of business, so we can determine right away if she or he is a good fit for us.

Even if we are not ready to come out to a provider, it is essential that providers know our risk behaviors, so they can consider all of the information in order to properly care for us:

I practice in advance how to maintain my privacy and still get the care I need—ways of refusing to answer offensive or unnecessary inquiries and of asking direct, specific questions about what I need to know
.

How can you increase your chances of finding a provider who is sensitive to your concerns? The Human Rights Campaign offers these tips.
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Ask for referrals:
Ask friends or local LGBT centers for the names of LGBT-friendly health care providers. You can find the centers closest to you by searching the Community of LGBT Centers (lgbtcenters.org.) Also check out the Gay and Lesbian Medical Association's health care provider directory (“Find a Provider”) (glma.org.)
Inquire by phone:
When you call to make an appointment, ask if the practice has any LGBT patients. If you're nervous about asking, remember you don't have to give your name during that initial call.

Bring a friend:
If you're uneasy about being open with your health care provider, consider asking a trusted friend to come with you.

Bring it up when you feel most comfortable:
Ask your doctor for a few minutes to chat while you're still fully clothed—maybe even before you're in the exam room.

Know what to ask:
Learn about the specific health care issues facing LGBT people.

You have the right to be spoken to in the way that you identify your gender, sexual orientation, and/or relationship status. Some staff members or health care providers who do not regularly work with LGBT communities may default to a heterosexual or gender-normative script (meaning they assume all women are attracted to men and, if you have a vagina, then you identify as a woman). If that happens, remind them of who you are and what issues are relevant to and appropriate for you.

Health history forms may include a space to identify a nickname or other name you prefer to be called. For those of us who are transgender, this is a good place to write in your gender and preferred pronoun. You can reiterate this as you complete questions asking about gender (which you may need to adapt/expand) and also verbally remind the receptionist that you would like the staff to address you by your identified gender and pronoun.

Gender identity is protected under privacy guidelines, so disclosing it in the process of receiving health care does not mean it will be released or shared elsewhere. Intake forms don't often have a line for sexual orientation, but you can go ahead and write it in to help keep assumptions from being made.

You also have the option not to disclose your orientation or gender identity during your exam. It is difficult for the health care staff to do their best job without all pertinent information. But do what feels right for you at the time. Remember, it's your right to get the care that you need.

For more information about particular health issues for LGBT people, see
Chapter 4
, “Gender Identity and Sexual Orientation.”

Women who are incarcerated face particularly difficult barriers navigating the health care system and accessing appropriate medical services. Incarcerated women typically are in poorer health than other women, even before they enter prison, and they are more likely to have experienced sexual abuse and other violence; to live with mental health challenges and with addictions; and to suffer from a variety of physical ailments including hepatitis C, arthritis, asthma, STIs, and post-traumatic stress disorder (PTSD). The complexities of PTSD, mental illness, and addiction, plus physical illnesses, make it difficult to arrange and coordinate proper care in an underfunded system.

When women are sent to prison they lose the care they may have been receiving. This means that if they were in therapy, it is interrupted, treatment protocols are stopped, diagnoses are not followed up, and relationships with health care providers are disrupted. Within the prison system, requests to see a health care provider or therapist are first made to prison guards, who function as gatekeepers to medical care.

The medical care offered in prison is limited in scope and often privatized. Because of the need to limit expenses, prison health care administrators may be reluctant to send women to see a specialist outside the prison. Pregnant women often encounter inadequate prenatal health care and a lack of nutritious food. They are often forced to give birth in front of guards or in shackles. (Only nine states explicitly prohibit the shackling of women during labor and birth and even in these states, there have been reports of shackling.) Often their babies are taken from them immediately after the birth while they themselves receive no or little postpartum care.

Upon leaving prison women need to reapply
for Medicaid and must wait for an appointment to see a health care provider. Treatment protocols that they may have received in prison are disrupted. Criminalized women both in prison and outside often find that their health complaints are not taken seriously but rather are assumed to be “drug seeking” behavior. They are labeled as “manipulative” when they try to advocate for themselves.

While there are no immediate systemic solutions to these problems, there are a number of steps women prisoners can take to try to minimize the negative impact of incarceration on health care. If you are a woman prisoner, try to:

• Keep copies of your prescriptions so that you can show them to your various medical providers inside and outside prison. While prison health care providers often will not take your word for your medication needs, they may be more willing to honor a written prescription.

• Ask for and hold on to copies of your medical records so that whoever is treating you will know about your other health issues. This is particularly important in order to avoid being given medications that have negative interactions with other conditions or medications.

• When you are approximately one month from your prison discharge date, ask to meet with a nurse, social worker, or chaplain to help you contact a health care provider on the outside so that your care will be disrupted as little as possible.

• Ask the prison health care provider if you can be given one month's supply of your medications when you are discharged from prison. This is particularly important for psychiatric medications, some of which are associated with severe withdrawal symptoms if you stop taking them.

• Remember that as a prisoner you have a right to receive medical attention. Practice being your own advocate by calmly and persistently asking to see a medical professional. There may be a prisoners' advocacy organization in your area that can help you. For more information, see “Women's Anti-prison Activism” on the Our Bodies Ourselves website, our bodiesourselves.org.

Our rights as patients mean little if they cannot be enforced effectively. The method of enforcement we use will depend on state laws and the rights involved. Some of the most common ways to exercise and enforce our rights are listed below. You can obtain further information and possible assistance by contacting women's health groups, consumer groups, or legal services organizations (see Recommended Resources).

When we are sick or in pain, we may be reluctant to complain about our treatment out of fear of alienating our health care providers. However, many of us find that giving voice to our concerns not only improves the care we receive, but also contributes to our own sense of well-being.

It is sometimes useful to discuss your intentions with your practitioner before actually lodging any complaints against her or him, since this may provide the incentive necessary to improve the situation. This can sometimes be the basis for positive and lasting relationships between a woman and her care provider, as conscientious providers want to be told if there is a problem and want a chance to remedy or address it.

Complaints are important because they alert
health care providers to potential problems that, if corrected, can improve care for everyone. If you are unhappy with the results of a medical encounter or experience any inappropriate behavior on the part of the provider, do not hesitate to report the problem. Write down the events as soon as they occur and draft a letter that clearly states what happened and when. If friends or family members have firsthand knowledge of what happened, ask them to record their thoughts and observations right away. Make certain that all your medical records and supporting materials are together before you lodge a complaint, as your care provider may become defensive or try to manipulate the information included in your record after that point. To arrange to obtain your records or have them transferred to another provider you do not need to speak to the previous provider or justify your decision; you can simply ask the office staff to send your records. You will be asked to sign a release and sometimes there may be a small fee for copying papers.

Assess how serious your complaint is. For example, if the doctor consistently runs late and you're spending too much time in the waiting room, that's a complaint that needs to be discussed with the doctor or practice manager first. If the doctor is disrespecting you, then you do much better to politely (at first) call attention to that, ask that he or she show the proper respect, and try to improve the relationship. If you can't—find a new doctor!

On the other hand, if a health care provider is physically, emotionally, or sexually abusive or violates your privacy or safety, then a more formal complaint process should be undertaken. To make a formal complaint, you will need to know where to send it.

• If your complaint is lodged against a licensed health professional, send it to the appropriate licensing board and send a copy to the relevant county and state professional societies. You can also contact a local women's health group for assistance and encouragement. Especially in the case of sexually inappropriate behavior, consider discussing your experience with a reliable lawyer or women's law group.

• To file a complaint against a state-licensed facility (hospital, nursing home, clinic, etc.), contact the appropriate licensing agency as well as the consumer protection division of the state attorney general's office.

Consider sending a copy of your complaint letter to the following people or organizations, depending on their relevance to your care: the individual provider involved; the provider who referred you; the administrator or director of the clinic, hospital, or managed care organization; the hospital's patient affairs or other patient satisfaction office; the organization that will pay for your visit or treatment, if different from the organization providing care (such as your union, insurance plan, or Medicare); the local health department; your neighborhood health council or community board; community agencies; local women's groups and women's centers.