Erin Fredericks & Ami Harbin

1. “People take their lead from what you say and how you are”: The ethics of rapport between queer patients and their physiciansPresented to 18th International Qualitative Heath Research Conference, Montreal, Quebec, Oct 23-25, 2012 Erin Fredericks & Ami Harbin

2. Context • Health care policy increasingly views the patient-physician relationship as a collaborative partnership. • This requires patient and physician to communicate and build rapport. • In the context of ongoing heterosexism, rapport building between physicians and queer patients can be a complicated process.

3. Methods: The Larger Study Qualitative study to explore how routine practices of health care can perpetuate or challenge the marginalization of queers. The larger study included in-depth, face-to-face interviews with 38 queer women, 24 physicians, and 23 nurses from two Canadian cities, Halifax and Vancouver. Transcripts were analyzed inductively. Thematic analysis was done using team-developed codes and Atlas.ti. Simultaneous narrative analysis was completed.

4. Methods and Participants 19 qualitative interviews with women who self-identify as LGBTTQ in Halifax Regional Municipality, a small urban centre in Nova Scotia, Canada. Participants ranged in age from 23-73. Primarily white, middle class. Self-identified as: lesbian (11), bisexual (6), transgender (2), queer (2), polysexual (1), and fluid (1) (Note: some women identified with multiple groups)

5. Approach to Building Rapport: Seeking Comfortable Interactions “One path toward less heteronormative and gender-normative health care interactions might involve experiences of discomfort that come from uncomfortable providers and uncomfortable queer patients interacting with each other.” “Less harmful practitioner–patient relations may come in part from sharing responsibility for resolving discomfort, rather than asymmetrically assigning this responsibility to patients...” Harbin, A., Beagan, B. & Goldberg, L. (2012). Discomfort, judgement & health care for queers. Journal of Bioethical Inquiry, 9(2), 149-160.

6. Patients: The Work of Building Rapport Queer women did a lot of work to manage health care encounters. Much of this work involved taking responsibility for trying to build rapport with physicians: “People take their lead from what you say and how you are.” (lesbian, age 44) In the following slides I discuss some of this work, including: hypervigilance, use of humour, dressing the part, and being matter of fact.

7. Hypervigilance “I make my own estimate of the type of person I’m talking to. Conventional, unconventional is the basic division. . . Like, is she wearing lipstick? And so next question I ask myself is who needs to know [I’m a lesbian]. Who’s need? Just their curiosity or is there some benefit to me, to answer this question? And I go from there.” (lesbian, age 73)

8. Use of Humour To maintain heterosexual space: “I can joke about guys and she can’t judge me. She doesn’t judge, she just jokes along with it, she thinks it’s hilarious.” (lesbian or bisexual, age 34) To lessen discomfort: “When [the doctor] finally got to why was I sure [I wasn’t pregnant] I said well the last time it happened wise men came from the East.” (lesbian, age 73)

9. Dressing the Part Appearing gender normative and/or heterosexual: “I think the more gender variant you look, you can get more issues. I think that’s why I’ve had an easier time, just because I come in and people see a woman and they’re like o.k. well alright, whatever.” (transgender and bisexual, age 41) Appearing queer: “Well I definitely don’t look normal, you know… Well you know tattoos and piercings and different colored hair and my public body language isn’t stereotypically female.” (queer, 36)

10. Being Matter of Fact Participants felt they could control physicians’ reactions by being matter of fact: “Seem confident and sound confident and just matter of fact about it and it’s not an issue. Then they take that lead and it’s not an issue.” (lesbian, age 44)

11. Consequences of this Work The work required was tiring: “It’s not to say that that’s always easy to do, right? Like it might seem that way, but I’m tied up in knots inside. And you know I have a little bit of trouble with that because again it’s me advocating for me, and that’s not always easy and you get tired of it.” (lesbian, age 44) And stressful: “I have white coat syndrome” (polysexual, age 25)

12. Consequences of this Work Some women’s positions as marginalized because of gender, sexuality, and class characteristics meant that they could not meet expected standards of ‘likeability.’ For some of these women, avoiding health care relationships was easier: “Sometimes I just prefer fast food medicine.” (polysexual, age 25)

13. Conclusions Good health care relationships are an important part of providing quality care to queer women. In the context of heterosexism and efforts to be “comfortable”, queer women do a lot of work to build rapport with their physicians. Rapport building was more difficult for marginalized queer women and some would not or could not do the work required. In order to build rapport across difference, both queer women and physicians need to recognize moments of discomfort and take responsibility for resolving discomfort.

14. Acknowledgments This research was supported by the Canadian Institutes of Health Research www.cihr-irsc.gc.ca. This research was conducted at Dalhousie University. Many thanks to the Research Team members and participants! Email: erin.fredericks@dal.ca Please visit our website: http://lgbtqhealth.weebly.com