Você está na página 1de 10

JAN

JOURNAL OF ADVANCED NURSING

ORIGINAL RESEARCH

Its not me, its them: How lesbian women make sense of negative
experiences of maternity care: a hermeneutic study
Elaine Lee, Julie Taylor & Fiona Raitt
Accepted for publication 13 November 2010

Correspondence to E. Lee:
e-mail: e.c.lee@dundee.ac.uk
Elaine Lee MSc RM LLB (Hons)
Lecturer in Midwifery
School of Nursing and Midwifery, University
of Dundee, UK
Julie Taylor PhD MSc RN
Professor of Family Health
School of Nursing and Midwifery, University
of Dundee, UK
Fiona Raitt LLB PhD
Professor of Evidence and Social Justice
School of Law, University of Dundee, UK

L E E E . , T A Y L O R J . & R A I T T F . ( 2 0 1 1 ) Its not me, its them: How lesbian


women make sense of negative experiences of maternity care: a hermeneutic
study. Journal of Advanced Nursing 67(5), 982990.
doi: 10.1111/j.1365-2648.2010.05548.x

Abstract
Aim. The paper is a report of one aspect of a hermeneutic study of lesbian womens
experiences of maternity care, specifically interpretations of negative experiences.
Background. There is a growing body of literature in relation to lesbian womens
experiences of maternity care. Although most commentators discuss the negative
experiences encountered by lesbian mothers, there has been no contextual analysis
of these expressions of negativity in an increasingly positive environment.
Methods. The study was undertaken using a qualitative approach using an adapted
Gadamerian hermeneutic phenomenology using unstructured interviews with eight
women. The interviews took place between November 2007 and March 2008. All of
the participants had disclosed their sexual orientation in pregnancy. Snowball
sampling was used. The data were then analysed using an iterative hermeneutic
framework.
Findings. The participants not only described their experiences of maternity care as
being positive but also offered examples of negative experiences. These were analysed separately to explore the ways in which the women made sense of them in the
context of an otherwise positive experience. These experiences were expressed in
ways that distanced the negative and that seemed to rationalize behaviour or ascribe
it to the health professional.
Conclusions. Negative encounters with health professionals are processed by
women in a way that protects their overall experience. Health professionals in
maternity care should consider the impact of negative responses to lesbian mothers
and the effect that it has in reducing the overall quality of this significant life event.
Keywords: hermeneutic phenomenology, lesbians, maternity care, midwives, sexual
orientation in pregnancy

Introduction
Lesbian mothers are a growing population in maternity care
as access to fertility treatment has become more widely
982

available, particularly within the United Kingdom (UK),


parts of Europe, Australia and the United States. However,
there is evidence that challenges continue for this group of
women in accessing care that is sensitive to the variation of
 2011 Blackwell Publishing Ltd

JAN: ORIGINAL RESEARCH

needs within this client group (Spidsberg 2007, Rondahl


et al. 2009). Optimizing the maternity care experiences of all
women is a fundamental tenet of midwifery practice (Leap
2009). Woman-centred care is a key concept in midwifery
and underpins professional philosophies and standards
(Nursing & Midwifery Council 2009) while also informing
strategic policy (particularly in the United Kingdom and also
in The United States (US), Australia and New Zealand
among other countries) (Scottish Executive Health Department 2001, Leap 2009). Indeed, it has been the focus of
maternity care since Changing Childbirth (Department of
Health 1993) with its mantra of choice, continuity and
control. Presumptions and generalizations should be avoided
within this model as all women are different. The aim of
midwifery care is to help the woman have the best experience
possible based on the womans own ideas of what is best
(Thorstensen 2000) and it is in this context that the reported
study was undertaken.
Where maternity care uses a woman-centred approach and
where the equality and diversity agenda is supported, the
study findings would be transferable. However, it is acknowledged that the political and legal situation in relation to
sexual orientation varies widely. The research should be
viewed within the context of that wide variation. The
authors own perspective is that of being a heterosexual
midwife espousing woman-centred care.

Background
There is a growing body of literature in relation to lesbian
womens experiences of pregnancy and maternity care (e.g.
Wilton & Kaufmann 2001, Lee 2007, Rondahl et al. 2009).
There is some evidence that in the UK, and in other politically
similar countries, in the last 10 years, the experiences of
lesbian mothers have improved. However, the problems
experienced at an individual level are still evident. It appears
that the physical and verbal abuse expressed in earlier work
(Wilton & Kaufmann 2001) has been superseded by ignorance and inappropriate information seeking by midwives
(Rondahl et al. 2009).
General healthcare experiences of the lesbian, gay,
bisexual and transgender (LGBT) population have also
been the focus of research and the outcomes of these studies
have tended to demonstrate more adverse experiences than
the experiences in maternity care (Cant 2006, Taylor 1999).
There is some evidence that closeted behaviour can exacerbate disease processes (Cole et al. 1996) and that emotional disclosure can stabilize them (Wetherell et al. 2005).
Such conclusions are largely speculative. For example,
Wetherell et al. (2005) noted a significant positive trend
 2011 Blackwell Publishing Ltd

Lesbian mothers managing negative encounters

in both physical and psychological outcomes for the


disclosure group, but determined that this was due to the
deterioration within the control group rather than improvement in the intervention group. For Cole et al. (1996), the
issue related to negative behaviours of closeted individuals
in not seeking help rather than positive effects of disclosure
per se.
Decisions around disclosing sexual orientation tend to be
made in relation to the expected response (Griffith & Hebl
2002) and so the quality of the consequences of disclosure
may well determine how other individuals make this
decision. Research into the experiences of LGBT people is
aimed at improving outcomes and promoting change in the
attitudes of all health professionals (Spidsberg 2007, Rondahl
et al. 2009). Recommendations are made for improved
education of midwives and also a more inclusive approach
to communication, which offers the possibility of recognizing
alternative family structures. However, if analysis of interview data takes the responses at face value without recognition of contextual issues, then there is the risk that the
recommendations relate only to changes in individual
approaches to care. There is also a failure to explore further
the impact of such. For example, Wilton and Kaufmann
(2001) recommended that the needs of lesbian mothers be
integrated into pre-registration midwifery curricula or professional development for qualified midwives, a recommendation that has been reiterated elsewhere (Rondahl et al.
2009). However, there is no evidence demonstrating if this
has been achieved.
The existing literature exposes problems with communication, exclusion and invisibility, and fear of homophobia.
However, there is a sense of overall positivity that leads to
pragmatic and solution-based conclusions. What is lacking is
a deeper understanding of why lesbian women raise the issues
they do during the pregnancy and also a contextual reading
between the lines to gain a greater understanding of the
issues raised.
Presented in this article is a modified discourse analysis of
the expression of negativity provided by the women, in the
context of their generally positive experiences. This analysis
derives from a wider study exploring lesbian womens
experiences of disclosing sexual orientation in maternity
care contexts (Lee 2010). A series of unstructured interviews
were undertaken with eight women and analysed using an
iterative approach. The interview data related mainly to the
particular reasons that the women disclosed their sexual
orientation and how they felt about those disclosures. These
were: being invisible and becoming visible; being upfront;
being me and being us; being entitled; being safe/being
careful.
983

E. Lee et al.

The study
Aim
The aim of the main study was to describe lesbian womens
experiences of maternity care, specifically interpretations of
negative experiences.

Design
This was a small scale exploratory, qualitative study using a
modified hermeneutic phenomenology by Fleming et al.
(2003). Hermeneutic phenomenology allows for the perspective of the researcher to form part of the development of
meaning, and enables meaning to be contextualized within
the data as a whole. Fleming et al. (2003) describe the four
stages of method which are: gaining understanding through
dialogue with texts; structural analysis; referral of thematic
elements back to the whole in an iterative process called the
hermeneutic circle (Gadamer 2004); and finally, the identification of textual exemplars for the final themes.

Participants
Recruitment was undertaken using snowballing, identifying
initial key informants and then asking them to identify
others willing to participate (Patton 2002). This ensured a
data-rich sample in what was potentially a small and hardto-identify population, although it can lead to recruitment
of similar participants (Platzer & James 1997). This was
the case for the eight women recruited to the study.
Although the study population was small, data saturation
was largely achieved owing to the nature of the sample.
The context of maternity care was comparable which
enabled coherent, rather than disparate findings from the
analysis.

Data collection
Unstructured interviews were chosen to create narrative texts
for analysis (Fleming et al. 2003). The six interviews used a
trigger question: tell me about your experiences of being
lesbian and being pregnant. This enabled the participants to
establish their own priorities in relation to the question which
proved invaluable in identifying the breadth of issues.
This narrative approach is described as a conversation that
involves both the participant and the researcher (Blaxter
et al. 2001). It is the conversation that produces the data
rather than simply responses to questions and has the
potential to avoid researcher assumptions.
984

Interviews were undertaken between November 2007 and


March 2008. All participants came from a single health
board region of Scotland. All women had used NHS
provision. These similarities were coincidental.

Ethical considerations
Ethical approval was obtained from the University Research
Ethics Committee as NHS Local Research Ethics Committee
approval was not required. Participants were given an
information sheet prior to agreeing to be interviewed.
Written consent was obtained from all participants and their
right to withdraw that consent was assured.
The main ethical consideration within this study was the
maintenance of confidentiality which is difficult with very
small, minority populations. For this reason, all participants
were given pseudonyms and the area in which the study took
place is not disclosed.

Data analysis
The interviews were transcribed verbatim and analysed
using the four stage process described by Fleming et al.
(2003). The present study focuses on womens expressions
of negative experiences and how they tended to interpret
these experiences. Data analysis of the wider study
suggested that the participants expressed negative findings
in a way that distanced their sexual orientation from the
experience. To explore this further, a modified discourse
analysis of these data was performed. This process involved
identifying phrases that related to negative experiences and
then analysing them in the wider context in which they
were framed.

Rigour
A number of approaches were used to ensure rigour.
Reference to existing literature before data collection and
following analysis ensured consistency with existing research
findings (Polit & Beck 2010). Rigour was also enhanced
through third party analysis with the project supervisors
reading all interview transcripts and agreeing the emerging
themes. An audit trail was created through the use of
thematic coding frames and these were included in the final
report.

Results
There were a total of eight participants and six interviews.
Two couples requested to be interviewed together. All but
 2011 Blackwell Publishing Ltd

JAN: ORIGINAL RESEARCH

one of the women were birth mothers. The social mothers


interview data were included as it was impossible to extricate
it from the overall interview. Maternity care experiences had
taken place from 6 months to 10 years previously.
Following the main process of data analysis, it became
evident that the women expressed and interpreted negative
experiences differently from other parts of their experience.
A modified discourse analysis of this data was performed
and was reported separately from the main research findings
in the final report. It is this analysis that is presented here.
When the women described negative incidents they did so
in the context of it being potentially related to their sexual
orientation. They made speculative references to this possibility, but were quick to reinterpret, or rationalize, this as
something else. Most of the women ascribed the meaning of
the incident to being related to the other person or to the
organizational culture of the hospital where they gave birth.
Aspects of homophobia were evident, but this homophobia
was not seen to exist for the women. Although they knew it
was there and they saw it, or had heard of it, for others, they
did not recognize it in their own experiences. The following
section describes the findings in more detail.

Health professional attitudes


The participants all cited examples of sensitive care provided
by midwives, particularly where those midwives had previous
experience of lesbian mothers. However, a number of
participants suggested that negative experiences were the
result of personalities of health professional providing care.
One participant described the experience of her 13-week scan
where she encountered a radiographer whom she described as
rude and unpleasant. She explains the radiographers attitude
by saying
I think she was like that with everyone. I think thats just how she

Lesbian mothers managing negative encounters

The fact that she suggested that health professionals will hide
their attitudes was an early reference to equality and diversity
legislation and its impact on treatment of LGBT individuals
accessing services in the NHS. This formed part of the theme
of being entitled.
Another participant, Anne, described a similar incident
with an unpleasant health professional.
When I went to theatre, all of the staff were female apart from the
theatre technicianand we had the music we wanted and the CD
was finished because it took so longand he [the technician] was
really rough[Stewart] should have been born to mellow Icelandic
music and he was born to Guns and Roses.

Anne implied that the individual involved was physically


rough. Anne was aware that it could have been the
personality of the technician but also that it could have been
deliberate. She went on to say:
And thats the only time Ive thought, is that because were a lesbian
couple or is that just him? But I cant answer that.

The fact that Anne says that she cannot be sure why the
technician was unpleasant means that it is hard to assess
the issues. It could have been sexism, homophobia, poor
interpersonal skills or a misinterpretation on Annes part.
The covert nature of homophobia and the increased professional awareness of the equality agenda make this a
potentially interesting debate. All of the participants made
reference to equality and diversity legislation and the
protection this affords. However, the potential that this legal
protection has led to the hiding of homophobic attitudes
might mean that it works to protect, but not to change
attitudes.

Organizational pressures

She identified a negative encounter and then ascribed this to


the personality of the radiographer herself. Helen distanced
herself from the other womans attitude. Indeed, there was
nothing in the exchange to indicate that the radiographer was
expressing any kind of personal attitude at all. However,
Helen provides a clue that she thinks this could have been
related to sexual orientation because she goes on to make a
comment about inclusive policies.

The participants made reference to the impact of organizational pressure on the quality of care. This was particularly
evident in an exchange between Bernadette and Daryl, where
Daryl was not a birth mother. The couple had been through
two pregnancies 7 years apart. They agreed that much had
changed, for the better, within that time; however, Daryl
related negative experiences from the first pregnancy and
both women disagreed about the reasons. Daryl felt that the
attitudes were personal, while Bernadette saw it from a
purely organizational perspective.

I think it was justbeing in a major city, that makes a difference

D: it was a pretty awful experience really, for lots of different reasons.

was. (Helen)

maybeThey know theyve got to be more inclusive and if theyve


got a problem with it theyll just skirt around the issueTheyll just
ignore it.

 2011 Blackwell Publishing Ltd

B: But I think that it was down to resources as wellI dont think it


was attitude.

985

E. Lee et al.
D: But some of it was attitude. I didnt know I could go anytime to
visit you. Nobody ever said. Nobody explained. Nobody treated us
like a couple really.

Bernadette was unwilling to agree that negative aspects of


their experience were related to individual attitudes. She was
keen to view these in the context of a challenging cultural
environment and she was not alone in making that comment.
The hospital was due to relocate and there was great tension
among the staff. However, Daryl perhaps did not believe that
this was sufficient to explain the way they were treated.
Indeed, when Bernadette described her postnatal care she
alluded to quality issues:

Sexual orientation and physical care


Alison experienced a number of negative events and was the
only participant who did not believe that she had the same
right as any other woman to have a child. This is not to say
that she was passive in her experience, but that she was very
sensitive to the reactions of others and this enabled her to
make astute observations about her experience.
In the postnatal ward Alison acquired an infection, which
was not treated until after she was discharged. Alison
considered this experience at length.
I should have been demanding that they take a proper look and
take a swab and get antibiotics [the midwife said] you probably

I felt I didnt get any sort of aftercare. Whether its because of my

havent but I actually demanded that she take a swab and I did have

sexual orientation or anything, I dont know what it was all about

an infectionBut Ive got straight friends and whove said exactly the

but nobody came, nobody spoke to me, nobody looked at the

same so its notShe had a similar experience to me and she felt that

stitches I had no idea what to do. I had a catheter in and I was just

it was a horrible environment for everyone.

left to get on with it.

Organizational factors were important here. The context


was unit closures and centralizing of services, which,
Bernadette believed, had led to significant stress. She was
more inclined to blame this than the attitudes of the staff
towards lesbian couples. The increasingly speculative nature
of the motives behind the outcomes was evident across all of
the interviews.
Karrie and Karoline were the only couple where both
partners were birth mothers. While they were generally
happy with their care, they experienced a different consequence of organizational pressure. The midwives seemed
unable to differentiate between the women and had a
tendency to treat Karoline as parous although Karrie had
been birth mother to their first child. Karoline was clearly
alarmed by this and felt that the staff were unable to deal
with the couple appropriately, appearing misinformed.
I went over my medical notes with my midwife because I wasnt

Alison gave up breastfeeding because she felt she was given


no help. The fact that the midwives would not help with
breastfeeding or examine Alisons perineum does suggest
the possibility that the midwives were unwilling to engage
with intimate areas of Alisons body because of her sexual
orientation. Sexual orientation is often viewed in terms of
sexual acts. The persons sexual orientation becomes
embodied in the act of care, which then takes on associations that the care giver finds unacceptable even though
they do not stem from the woman. Eliason (1996) found
that healthcare providers so closely associated sexual
orientation with sexual activity that they were uncomfortable providing care for fear of being approached sexually
by the individual for whom they were caring. This seems to
be less of an issue when caring for heterosexual individuals
of the opposite sex.

Discussion

happyand she was explaining well we dont really worry about the
head being that loose if its a second pregnancybut if its a first one
then its more of a concern. I just wonder for a minute if they fogged out
a bit on that one.

Although it is hard to imagine that the various professionals could all have forgotten how to provide appropriate
care because they are confused by the circumstances,
Karrie and Karoline see this as the only likely explanation.
The implication of this for midwifery practice is that
women and their families will interpret their care in the
context of their own understanding, which can in turn
lead to a reduction in trust in relation to the care
provided.

986

Study limitations
There are two primary limitations: sample size and disclosure
status. The study included only eight participants, but was a
smallscale exploratory study where identification of the
broad issues relating to disclosure of sexual orientation was
the purpose. It was hoped that identifying these issues would
enable the development of a focus for future research.
The second limitation was disclosure status. Although the
aim of the main study was to be inclusive, the reality was that
women who had not disclosed their sexual orientation to
midwives did not agree to participate. However, the resulting
participants were a coherent group with similar maternity

 2011 Blackwell Publishing Ltd

JAN: ORIGINAL RESEARCH

care contexts, which helped to increase the consistency of the


findings.

Interpretation of negative experiences


There are several possible reasons for the way that the
women interpreted negative experience. These are: denial and
a rationalization (or accommodation) of these experiences; a
real belief that the events were unrelated to sexual orientation; increasing invisibility of negative attitudes and a
possible move to covert homophobia.
The birth experience: quality and integrity
Since Changing Childbirth (Department of Health 1993),
there has been recognition at policy level in the UK that
women and their families value the experience of pregnancy
and birth. The social importance of pregnancy and childbirth
has been understood for much longer and there is a wealth of
literature exploring the deeper and more personal aspects of
this life event (Kitzinger 1978, Oakley 1980, Kent 2000,
Kitzinger 2000, Gaskin 2002). These authors also seek to
humanize care in pregnancy to protect women from the
lasting effects of care that neglects the wider impact of birth.
It is possible that the women here were protecting
themselves from negativity by distancing the reasons from
the personal; that is, sexual orientation. Maintaining the
integrity of the birth experience in this way enabled them to
attribute the less desirable aspects to other people.
The rationalization of certain aspects of care has been
shown to be used elsewhere in healthcare. Rationalization as
a protective mechanism has been shown to be a strategy used
by patients to maintain dignity and personal identity (Baillie
2009, Parizot et al. 2005). Baillie (2009) suggests that
patients use both rationalization and humour to maintain
their dignity in hospital settings, with a definition of dignity
that moves beyond the physical by including psychosocial
factors such as self-esteem, feeling comfortable and being in
control. The use of rationalization and humour is important
because they are steps that the individual patients can take for
themselves rather than relying on nursing techniques to
protect dignity. Baillie (2009) suggests that nursing staff
generally do not recognize patient attitudes as being relevant
to maintaining dignity because they focus on the physical.
This lack of understanding of the breadth of the concept of
dignity means that it is left to the patients to take back
control in its protection.
Parizot et al. (2005) discuss the role of rationalization in
the maintenance of self-image and identity in circumstances
that challenge the individuals understanding of self. Where
self-esteem and personal identity come under threat from
 2011 Blackwell Publishing Ltd

Lesbian mothers managing negative encounters

external circumstances, then rationalization becomes a way


of altering identity to accommodate the threat. Control by
the woman is a fundamental tenet of midwifery care and is
seen as something that women value. Using rationalization
here mirrors its use in more traditional patient settings where
loss of control often results from the presence of illness and
self-care is less possible.
White and Johnson (2000) also discuss the importance of
self concept and identity and how this is affected by
interactions with healthcare services. In their case, rationalizing the pain experienced by men during a heart attack
distances the individual from the threat rather than facilitating adaptation. The refusal by the participants to see
themselves as their illness was trying to present them meant
that they did not react to the symptoms they felt. Denial is
also an important aspect of this process of protection.
Rationalizing the situation as normal and denying negative
possibilities because of the threat to self-concept protect the
individuals identity, but not their reality (White & Johnson
2000, Miller 2005). In the current study, it is possible to view
the womens interpretations of negativity that they narrated
in these terms. However, the importance of the experience of
pregnancy and the transition to motherhood or family life,
and a very positive self-concept and lesbian identity are
threatened by the negative or inappropriate responses of
others. Rationalizing these can be seen as an important
strategy for self-protection.
Dissonance theory also offers a possible explanation for the
responses. This postulates that people strive to maintain
consistency within individual cognitive processes such as
beliefs and attitudes (Starzyck et al. 2009): when this
consistency is disrupted, cognitive dissonance or discomfort
is experienced. Dissonance is experienced as negative so
individuals take steps to restore consistency by adjusting their
beliefs, values and behaviours. The more important the
elements of dissonance, the harder the individual will work to
restore equilibrium. However, they will do so by changing
those elements, which are most easily changed. For example,
Alison experienced dissonance when her beliefs about her
sexual orientation, her relationship and her much wanted
pregnancy were disrupted by the attitudes of midwives or
other healthcare professionals. This could be resolved only by
changing the meaning of the negative encounter.
Miller (2005) discusses the tension between lay and
professional epidemiology and the way that lay people
rationalize their behaviours or circumstances as a way to
neutralize risk or impact. The need to distance the individual
from the impact of the risk results from the absence of
alternatives. Risk denial theory is generally associated with
deviant behaviours (Becker 1963), but that is not what makes
987

E. Lee et al.

What is already known about this topic


Lesbian mothers are an increasingly visible group of
maternity service users.
Lesbian womens experiences of maternity care are both
positive and negative.
Research often presents experiences findings at face
value, rather than exploring the way the experience is
expressed.

What this paper adds


Lesbian women appear to use a range of strategies to
make sense of and manage negative experiences in ways
that distance this negativity or rationalize the attitudes
of others.

Implications for practice and/or policy


To improve maternity care experiences for lesbian
mothers, it is important that midwives and those
conducting research with lesbian women take time to
look for the subtext behind disclosures.
Health professionals should recognize the impact their
responses to disclosure of sexual orientation have on
lesbian mothers taking care to ensure that behaviours
and attitudes are consistent with inclusive policies and
women-centred care.
Improvements in attitudes to same sex relationships do
not necessarily indicate the absence of homophobia.
it relevant here. Risk denial can be applied because it stems
from the lack of options open to the individual to change
their situation or to be someone else. The participants
displayed a kind of lay epidemiology in their experiences of
negative encounters, but instead of the argument that illness
happens to those who eat well and exercise, their argument is
that negative experiences happen to straight women.
The absence of homophobia
It is an important possibility that the responses described
were not related to homophobia or otherwise to the womens
sexual orientation. There has been a significant shift in social
attitudes to sexual orientation in the last decade in the UK
and other politically similar countries. This has resulted in
protective legislation both in equality and diversity, including
the workplace and provision of goods and services [Equality
Act (Sexual Orientation Regulations) 2007], and also in the
personal sphere of relationships enabling civil partnerships
and same sex adoption (Civil Partnership Act 2004).
988

The increasing visibility of the LGBT community in many


countries has led to positive change and an attitudinal
improvement. There have been high-profile appointments of
openly gay clergy for example and this has helped to open up
the debate about widening definitions of inclusion. Openly
gay celebrities have introduced an element of popular
acceptability to an extent that was previously unknown. The
extent of this reduction in homophobia was recognized by the
participants in the study.
It is also evident from the interviews that the fertility
services in the particular Health Board area were used to
supporting same sex couples. This willingness to support
lesbian couples prior to changes in the law in relation to
access to fertility services indicates a more open attitude
towards lesbian mothers. Overall, the women were well cared
for and staff engaged with them at a good interpersonal level.
They felt that staff engaged with them emotionally. There
was a sense that the situation was somehow normalized
through the process of intervention and fertility treatment.
The women became clients accessing a service like any other
client. There is some evidence that increased contact with
lesbians and gay men has a positive effect on attitudes
(Anderssen 2002) and it might well be that this was an
outcome here.
However, it would be nave to conclude that homophobia
no longer exists regardless of the improvements in attitudes
towards the LGBT community. It is possible, however, that it
did not exist for these women.
The invisibility of homophobia
The final issue concerns the speculative nature of the negative
experiences. The fact that the participants were so consistently vague about the existence of negative attitudes and
then the reasons for them meant that it was very unclear
whether homophobia, or even just discomfort with the
womens sexual orientation, was a reality. Previous research
suggests that in the past, homophobia was overt (Wilton &
Kaufmann 2001). Women experienced verbal abuse or
inappropriate questioning, which was explicitly related to
their sexual orientation. Care givers felt that they had a right
to express strongly held views in relation to homosexuality
and the right of lesbian women to have children.
None of the women in this study experienced any overt
homophobia and virtually no explicitly negative comments in
relation to sexual orientation. However, it could not be said
that they felt there was an absence of discomfort. There was
an almost ever-present suspicion that all was not as inclusive
and accepting as it seemed. The reason given for this absence
of overt negativity, for all participants, was the belief that
they were protected by legislation.
 2011 Blackwell Publishing Ltd

JAN: ORIGINAL RESEARCH

This was obviously important for the women who felt


protected and felt they had recourse to support mechanisms if
they experienced homophobia. Nonetheless, it does not in
itself demonstrate a change in attitudes and the women were
aware of this. This begs the question, does the presence of
protective legislation and equality driven policies simply
suppress and hide homophobia rather than deal with it at an
attitudinal level? This is a very difficult question and one that
needs to be considered in the discussion of the womens
narratives in the overall study.

Conclusion
Although the research reported here took place within the
UK, there was consistency with the findings of research
within Europe and the US. The findings could be applied to
other international contexts, particularly politically similar
countries.
Women-centred care is the focus of midwifery practice and
part of that woman-centredness is recognizing the increasing
diversity of women who access maternity services. Explicit
acknowledgement of individual womens needs generated
from the disclosures they make can promote trust and an
effective therapeutic relationship. Failure to do so can result
in speculation on the part of women and a reduction in
professional trust. Being with woman is still the philosophical
stance espoused by the midwifery profession and is still the
most useful way of working with women at an individual
level.
In this study, and others, it is apparent that lesbian women
desire to experience pregnancy as positive and in the main
they do experience it that way. Attributing negative encounters to the culture of maternity care or to the professional
providing it is one way for lesbian women to experience
pregnancy as life affirming and as life changing in the same
way that we hope all women will ideally experience it. If
lesbian women develop strategies for protecting the experience, this can be seen as both positive and empowering for
the individual. Unfortunately, it is unlikely to effect change in
others.
Increasing the visibility of lesbian mothers is an important step in having their needs met. This study was
undertaken with an aim to achieve that. Further research is
required to explore the attitudes of midwives and other
maternity care professionals in relation to the care of
lesbian mothers. The equality agenda limits (and rightly so)
the opportunities for health professionals to reflect on their
own attitudes to minority groups. However, this also
potentially limits the opportunities to effect real attitudinal
change.
 2011 Blackwell Publishing Ltd

Lesbian mothers managing negative encounters

Funding
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.

Conflict of interest
No conflict of interest has been declared by the authors.

Author contributions
EL was responsible for the study conception and design,
performed the data collection, and performed the data
analysis. EL and JT were responsible for the drafting of
the manuscript. JT and FR made critical revisions to the
paper for important intellectual content, and supervised the
study.

References
Anderssen N. (2002) Does contact with lesbians and gays lead to
friendlier attitudes? A two year longitudinal study. Journal of
Community and Applied Social Psychology 12, 124136.
Baillie L. (2009) Patient dignity in an acute hospital setting. International Journal of Nursing Studies 46, 2337.
Becker H.S. (1963) Outsiders; Studies in the Sociology of Deviance.
Free Press, New York.
Blaxter L., Hughes C. & Tight M. (2001) How to Research. Open
University Press, Buckingham.
Cant B. (2006) Exploring the implications for health professionals of
men coming out as gay in healthcare settings. Health and Social
Care in the Community 14, 916.
Civil Partnership Act (2004). HMSO, London.
Cole S., Kemeny M.E., Taylor S.E. & Visscher B.R. (1996) Elevated
physical health risk among gay men who conceal their homosexual
identity. Health Psychology 15, 243251.
Department of Health (1993) Changing Childbirth: Report of the
Expert Maternity Group. HMSO, London.
Eliason M.J. (1996) Caring for lesbian, gay or bisexual patients:
issues for critical care nurses. Critical Care Nursing Quarterly 19,
6572.
Fleming V., Gaidys U. & Robb Y. (2003) Hermeneutic research
in nursing: developing a Gadamerian-based research method.
Nursing Inquiry 10, 113120.
Gadamer H. (2004) Truth and Method. Continuum, London.
Gaskin I.M. (2002) Spiritual Midwifery, 4th edn. Book Publishing
Company, Summertown, TN.
Griffith K.H. & Hebl M.R. (2002) The disclosure dilemma for gay
men and lesbians: Coming out at work. Journal of Applied
Psychology 87, 11911199.
Kent J. (2000) Social Perspectives on Pregnancy and Childbirth for
Midwives, Nurses and the Caring Professions. Open University
Press, Buckingham.
Kitzinger S. (1978) The Experience of Childbirth. Penguin,
Harmondsworth.

989

E. Lee et al.
Kitzinger S. (2000) Rediscovering Birth. Little Brown Publishing,
Boston.
Leap N. (2009) Woman-centred or women-centred care: does it
matter? British Journal of Midwifery 17, 1216.
Lee E. (2007). Lesbian users of maternity services: challenges in
midwifery care. In Challenges for Midwives: Vol. 2 (Richens Y.,
ed.), Quarry Books, London, pp. 6978.
Lee E. (2010). Disclosure in Maternity Care Contexts: The Paradiagm Case of Sexual Orientation. Unpublished doctoral thesis,
University of Dundee, Dundee.
Miller P.G. (2005) Scapegoating, self-confidence and risk comparisons: the functionality of risk neutralization and lay epidemiology
by injecting drug users. The International Journal of Drug Policy
16, 246253.
Nursing and Midwifery Council (2009) Standards for Pre-Registration
Midwifery Education. Nursing and Midwifery Council, London.
Oakley A. (1980) Women Confined: Towards a Sociology of Childbirth. Schocken Books, New York.
Parizot I., Chauvin P. & Paugmam S. (2005) The moral character of
poor patients in free clinics. Social Science and Medicine 61, 1369
1380.
Patton M.Q. (2002) Qualitative Research and Evaluation Methods.
Sage Publications, Thousand Oaks.
Platzer H. & James H. (1997) Ethical considerations in qualitative
research with vulnerable groups: exploring lesbian and gay mens
experiences of health care a personal perspective. Nursing Ethics
6, 7380.
Polit D.F. & Beck C.T. (2010) Essentials of Nursing Research:
Appraising Evidence for Nursing Practice. Wolters Kluwer Health/
Lippincott Williams and Wilkins, Philadelphia.

Rondahl G., Bruhner E. & Lindhe J. (2009) Heteronormative communication with lesbian families in antenatal care, childbirth and
postnatal care. Journal of Advanced Nursing 65, 23372344.
Scottish Executive Health Department (2001) A Framework for
Maternity Services in Scotland. Scottish Executive, Edinburgh.
Spidsberg B.D. (2007) Vulnerable and strong lesbian women
encountering maternity care. Journal of Advanced Nursing 60,
478486.
Starzyck K.B., Fabrigar L.R., Soryal A.S. & Fanning J.J. (2009)
A painful reminder: the role of level and salience of attitude
importance in congnitive dissonance. Personality and Social
Psychology Bulletin 35, 126137.
Taylor B. (1999) Coming out as a life transition: homosexual
identity formation and its implications for health care practice.
Journal of Advanced Nursing 30, 520525.
The Equality Act (Sexual Orientation) Regulations (2007) HMSO,
London.
Thorstensen K.A. (2000) Trusting women: essential to midwifery.
Journal of Midwifery and Womens Health 45, 405407.
Wetherell M.A.L., Byrne-Davies L., Dieppe P., Donovan J., Brookes
S., Byron M., Vedhara K., Horne R., Weinman J. & Miles J.
(2005) Effects of emotional disclosure on psychological and
physiological outcomes in patients with rheumatoid arthritis: an
exploratory home-based study. Journal of Health Psychology 10,
277285.
White A.K. & Johnson M. (2000) Men making sense of the chest
pain niggles, doubts and denials. Journal of Clinical Nursing 9,
534541.
Wilton T. & Kaufmann T. (2001) Lesbian mothers experiences of
maternity care in the UK. Midwifery 17, 203211.

The Journal of Advanced Nursing (JAN) is an international, peer-reviewed, scientific journal. JAN contributes to the advancement of
evidence-based nursing, midwifery and health care by disseminating high quality research and scholarship of contemporary relevance
and with potential to advance knowledge for practice, education, management or policy. JAN publishes research reviews, original
research reports and methodological and theoretical papers.
For further information, please visit JAN on the Wiley Online Library website: http://onlinelibrary.wiley.com
Reasons to publish your work in JAN:
High-impact forum: the worlds most cited nursing journal and with an Impact Factor of 1518 ranked 9th of 70 in the 2010
Thomson Reuters Journal Citation Report (Social Science Nursing). JAN has been in the top ten every year for a decade.
Most read nursing journal in the world: over 3 million articles downloaded online per year and accessible in over 7,000 libraries
worldwide (including over 4,000 in developing countries with free or low cost access).
Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jan.
Positive publishing experience: rapid double-blind peer review with constructive feedback.
Early View: rapid online publication (with doi for referencing) for accepted articles in final form, and fully citable.
Faster print publication than most competitor journals: as quickly as four months after acceptance, rarely longer than seven months.
Online Open: the option to pay to make your article freely and openly accessible to non-subscribers upon publication on Wiley
Online Library, as well as the option to deposit the article in your own or your funding agencys preferred archive (e.g. PubMed).

990

 2011 Blackwell Publishing Ltd

This document is a scanned copy of a printed document. No warranty is given about the accuracy of the copy.
Users should refer to the original published version of the material.