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Journal of Bioethical Inquiry

, Volume 15, Issue 4, pp 511–524 | Cite as

Vulnerability, Harm, and Compromised Ethics Revealed by the Experiences of Queer Birthing Women in Rural Healthcare

  • Sylvia BurrowEmail author
  • Lisa Goldberg
  • Jennifer Searle
  • Megan Aston
Original Research

Abstract

Phenomenological interviews with queer women in rural Nova Scotia reveal significant forms of trauma experienced during labour and birth. Situating the accounts of participants within both phenomenological and intersectional analyses reveals harms enabled by structurally embedded heteronormative and homophobic healthcare practices and policies. Our account illustrates the breadth and depth of harm experienced and outlines how these violate core ethical principles and values in healthcare.

Keywords

Queer women Reproductive autonomy Feminist phenomenology Birth Vulnerability Trauma-informed care 

Introduction

Recent systematic reviews reveal alarming negative conditions affecting women’s experience of birth worldwide (Vogel et al. 2015; Bohren et al. 2014). These conditions are concerning and are not reserved for women in developing countries or those who may otherwise experience recognized barriers to adequate healthcare. Rather, such conditions form an everyday backdrop against which women in childbirth are situated across a diversity of contexts, such as sexual orientation(s), gender identity, age, (dis)ability, race, geography, socio-economic status, and so forth. Philosophers have begun to acknowledge harms constraining birthing women’s experiences in relation to compromised ethical principles and values, most notably constrained or limited autonomy (see Young 2005; Soliday 2012; Belu 2012; Burrow 2012a, 2012b). Yet addressing queer birthing women in these contexts is just beginning (Goldberg, Ryan, and Sawchyn 2009; Goldberg, Harbin, and Campbell 2011; Harbin, Beagan, and Goldberg 2012; Searle et al. 2017). In this paper we assess queer women’s birthing experiences through a phenomenological methodology and feminist intersectional analysis attending to themes of power and control related to traumatic experiences of participants.

Our project draws on findings from qualitative interviews with queer birthing women to explore how their experiences within rural healthcare institutions in Nova Scotia are connected to routine healthcare practices introducing trauma and vulnerability revealing compromised ethical principles. The aim is to show that queer women experience vulnerabilities to particular harms and losses in light of structurally embedded and intersecting heteronormative and homophobic attitudes, practices, and policies. We suggest that response and recognition must attend to such structurally embedded harms if either is to foster ethical care. While healthcare experiences may differ according to a rural or urban context; according to queer, heterosexual, or cisgendered status; and according to healthcare services required, our aim is not to provide a separate analysis of each component. Intersectional theory is a cornerstone of current feminist analyses precisely because “adding up” separate accounts of prejudice fail to adequately capture the harms at stake—as Spelman’s (1988) critique of the additive analysis shows. Following Crenshaw’s (1991) theory of intersectionality, we maintain that appreciating how different points of privilege, power, and prejudice intersect provides for clearer, more accurate accounts of experiences of marginalization and oppression.

In what follows, we address the everyday occurrences of vulnerability and harm experienced by queer birthing women in rural healthcare institutions (albeit often unknown to their healthcare providers). In refusing an additive analysis in favour of an intersectional approach, we do not break down the experiences of our participants according to each area of marginalization but attend to the intersection of these features as they impact each person’s experiences. We investigate how these experiences are problematic precisely when they are systematically structured by heteronormative and homophobic practices. Informed by qualitative interview data from queer birthing women grounded in feminist phenomenology, the paper aims to do the following: 1) situate the research in a broader body of evidence related to the vulnerability and harms experienced by queer birthing women; 2) provide an overview of our methodology and methods; 3) articulate our findings grounded in the narrative accounts obtained from the women; and 4) indicate compromised ethical principles and values.

Background

Feminist scholars have increasingly recognized the vulnerability of marginalized groups as a result of social, political, and historical position (Mackenzie, Rogers, and Dodds 2014; Gilson 2013; Burghardt 2013; Sullivan 2015). Following Rogers, Mackenzie, and Dodds (2012) we regard vulnerability as susceptibility to serious harm (psychological, physical, and emotional) undermining one’s ability to lead a fulfilling life. Queer birthing women routinely experience vulnerability as part of their embodied queerness as lived within heteronormative and homophobic structures (Searle et al. 2017). Problematically, healthcare structures commonly render invisible the particular rural healthcare needs of queer persons (Whitehead, Shaver, and Stephenson 2016; King and Dabelko-Schoeny 2009; Fish 2008). Queer women as a population are particularly vulnerable to harm and trauma (Valanis et al. 2000; Salamon 2009; Goldberg, Ryan, and Sawchyn 2009; Goldberg, Harbin, and Campbell 2011; Ryan-Flood 2009). We suggest that this vulnerability is amplified by existent experiences of harm during labour and birth. Our previous research provides evidence that harm experienced during labour and birth can invoke previous trauma or amplify experiences of discrimination and marginalization (Searle et al. 2017). Such outcomes bear negative costs to queer women’s health in two main ways. One is that marginalization in healthcare environments magnify the risk of poor health outcomes (Irwin 2007). The second is that negative attitudes toward queer women discourage their access to healthcare (Hayman et al. 2015). Both outcomes undermine possibilities for optimizing health and well-being and may additionally introduce compromised ethical care.

Compromised ethical care for queer birthing women is connected to fixed or rigid dominant heteronormative perspectives commonly attached to views privileging biological processes over social and historical contexts. Medical contexts play a significant role in reinforcing historical inhibiting and control of women’s bodies in ways policing female experience (Young 2005). So too, medical contexts reinforce essentialist views of the body as biologically constructed without attending to social, cultural, and political influences, thus complicating the process of separating the body from discourses that define it (Young 2005; Cohen and Weiss 2003). When the body is essentialized, it becomes determinate. Debates about nature versus nurture (and divides between nature and culture) point to an historical challenge in recognizing the body as an indeterminate, narrative horizon that serves as an “integral aspect of each and every one of our experiences” (Cohen and Weiss 2003, 26). Missing such an indeterminate view of persons, theory may overlook experiences of “memories of previous imaginings, our past, present, and future perceptions, our attitudes, and the memories, perceptions, and attitudes of others” (Cohen and Weiss 2003, 27). If attention becomes fixed on biological processes rather than experiences of individuals within healthcare, then narrative understandings are overlooked, dominant perspectives emerge, and opportunities to bring about new narratives are negated (Cohen and Weiss 2003).

In the context of our paper, “queer” is understood as an umbrella term with a politicized aim of critiquing and questioning that which is taken for granted—by, at the very least, not conforming to everyday, unchecked practices reproducing heteronormativity, gendernormativity, and gender binaries (Searle et al. 2017; Harbin et al. 2012). To recognize participants’ experiential accounts, we acknowledge the embodied experiences of birthing as queer as distinct from embodied experiences of birthing as heterosexual. Additionally, we aim to recognize that birthing as queer occurs in a heterosexual space: birthing women are typically assumed by healthcare providers to be heterosexual because they are giving birth. Such assumptions privilege heterosexual attitudes and practices and are echoed within institutional practices and policies. To enter a birthing space with a non-normative partnership; non-normative body; and/or non-normative desires deviating from the status quo queers a space that takes for granted “straightness” as the default positionality. What Ahmed (2017) describes as a privileging of the heterosexual couple as a social gift at once incurs a deviation that is pathologized for queer birthing individuals. By legitimizing the language of “queer” in the birthing context, we aim to capture how and why queer birthing individuals are not simply members of the LGBTQ+ community, but rather, collectively counter the very institutional norms upon which the institution of birthing has been built.

Methodology

Phenomenology explores the ways in which individual lives are influenced by social practices, how structural processes reinstate constructions of difference, and how historically marginalized communities are often disproportionately affected by systems of privilege and oppression (Goldberg, Ryan, and Sawchyn 2009; Goldberg, Harbin, and Campbell 2011). Our analysis renders salient individuals’ experiences of birthing within social and historical contexts of marginalization and critiques heteronormative birthing practices embedded within existing structures of care. The aim of this project is to assess empirical findings through a phenomenological approach guided by feminist and queer theoretical underpinnings. A methodology providing a phenomenological analysis of queer birthing in rural Nova Scotia challenges heteronormative privilege by rendering salient individual experiences that cannot be explained simply through biological processes or through an analysis of women as birthing subjects. Analyses focusing on mere biology fail to capture features relevant to birthing within a particular social, historical, and cultural context; assessing experiences of birthing individuals simply as women fails to recognize intersectional sites of oppression and subordination. A fundamental feminist concern is that oppressive practices alienate women from their experiential understanding of the world, for instance through negating expressions of their bodily experiences (Weiss 1994, Young 2005). We explore how internalized, alienating social barriers contribute to vulnerability for queer birthing individuals.

This paper illuminates connections between personal experiences and susceptibility to harm—not simply psychological or physical harm but also moral harms. Queer birthing seems to further vulnerability within marginalizing social and political climates, and that vulnerability is distinct within rural contexts. Rural healthcare contexts see difficulties in access to healthcare due to place (geographical isolation, lack of transportation options), lack of choice, and isolation or lack of connection to community services—but here queer persons are disproportionately affected by a sense of isolation and lack of informal support (King and Dabelko-Schoeny 2009). These difficulties are further exacerbated by the prevalence of primary healthcare providers who subject queer persons to stigma and discrimination, thereby negatively affecting their use of primary and preventative healthcare resources (Whitehead, Shaver, and Stephenson 2016). Within a homonegative, rural healthcare climate, queer birthing women are susceptible to lack of support, dismissal, and physical or emotional harm precisely when the urgency of accessing healthcare is pressing but support networks are unlikely to already have been established. Tensions between theory and practice both reveal and reinstate the susceptibility of women to experience harms, risking lost opportunities for theory and practice to “expand our visions, challenge our thinking and living, [and] inspire our growth” (Weiss 1994, 472). Such social inhibition threatens social disadvantages for birthing women on the whole but increases vulnerability for those who are oriented as members of queer communities. The larger point is that subordination impedes the social progress of the feminist commitment to challenge patriarchal rule (Weiss 1994). While attention to inequality (rights, opportunities) and injustice are integral to feminist analysis and response, our approach draws attention instead to birthing as a local, personal experience as a starting point of analysis.

We investigate how birthing in rural Nova Scotia places queer women at risk for intersectional vulnerability and harm. We recognize that Atlantic Canada is geographically and demographically distinct from the rest of Canada because it has sections of the province that are rural yet relatively close to small regional centres. These regional centres do not disrupt rurality because they are small, often with few resources (healthcare or otherwise), and are typically medically understaffed and underfunded. Lack of resources vary significantly. Nova Scotia’s healthcare resources considerably differ across rural regions in terms of patients’ access to healthcare services despite a newly created Nova Scotia Health Care Authority. Here Nova Scotia is not an exception but seems to reflect a common rural condition. Uneven distribution of healthcare resources remains a recalcitrant feature of the rural health landscape despite efforts by regional and federal governments over the past three decades (Hart et al. 2002). While the view that “lonely rural landscapes feel laden with menace” (Halberstam, 2005, 22) is not our understanding of rurality, we nevertheless recognize that heath care in rural contexts incurs distinct challenges. Healthcare experiences, particularly those for underrepresented communities including those who are queer, are not well understood. As a case in point, a number of nurses from our study were unaware that queer women were birthing in their healthcare settings; and one nurse manager had no knowledge of the meaning of the acronym LGBTQ. We do not suggest that queer community can only be cultivated in urban settings or that only rural communities reveal queer barriers, thus we do not privilege “metronormativity.” Neither do we aim to show how rurality simpliciter impacts queer experiences as a feminist, geographical analysis. Rather, we point to the rural setting as a site of homonegativity intersectionally impacting queer women’s birthing experiences—a point obscured by those assuming that birthing women are homogeneously heterosexual.

Methods

Dialogical and semi-structured interviews provided a conversational and safe environment for participant stories to emerge related to their birthing experiences in rural Nova Scotia. This methodology is consistent with a feminist phenomenological design promoting an environment of disclosure (Goldberg 2005). Responses included participants’ interpretation of the impact of their queer identity in regard to birthing care, the environment of their birthing spaces, and reflection on their interactions with their perinatal health providers. Research Ethics Boards from the Nova Scotia Health Authority and related research institutions approved the project and measures to preserve confidentiality of participants and data, which were upheld throughout. Participants consented to confidential transcription of audio-digital recordings of interviews, which were transcribed with pseudonyms before distribution to the research team. Recruitment of participants took place at a number of venues, including hospitals, health clinics, community bulletin boards, social media, and through word of mouth. The research team created a website to provide background information to participants, such as the main goals of the project and researchers’ biographies. Interviews lasted 60–90 minutes via telephone or on-site and at a date, time, and location of mutual convenience to participants and the project coordinator. Transcripts were analysed by the research team along the four existential themes of body, time, space, and relation (see van Manen 2016). From this phenomenological analysis, the narratives were situated within the following themes: power and control; embodied safety and supportive care; and vulnerability and harm. These themes were then critically interrogated in connection to core bioethical principles and values.

Participants

Thirteen participants were interviewed and provided narrative data. They were mainly oriented as woman and diverse in terms of their sexual orientation, claiming membership within the lesbian, gay, bisexual, queer, pansexual and two-spirit (LGBQP2S) communities. We refer to persons in these communities as “queer” to allow a range of experience across the spectrum of LGBQP2S, recognizing the constraints of language and that some persons may not fully orient themselves with one term over another within this category.

Sample diversity included intersections of race, socio-economic status, age, education, and queer identity. Racial orientation of ten participants were White, one was First Nations, one was African-Nova Scotian and White, and one was Scottish/Francophone/First Nations. Socio-economic status was mainly working class but also ranged to upper class. Age of participants spanned eighteen to forty-two years. Educational background covered high school completion (GED status) to PhD preparation. The geographical location of all participants at the time of their birthing experience was in rural Nova Scotia. Self-orientation of participant sexuality varied from time of birthing to time of interviewing. At the time of interview, birthing participants had a variety of partners, including woman- and man-oriented partners, no partners, and multiple partners. At the time of the interviews, no participants had a monogamous relationship with a cis-gendered man. The small, purposeful sample of participants proved suitable to phenomenological research methods using experiential accounts designed to gain insight and awareness of the birthing experience (see Goldberg et al. 2011).

Findings: Vulnerability, Harm, Trauma, Compromised Ethics

Current evidence suggests that the treatment of women during birth continues to result in harm and trauma (Bohren et al. 2014). Trauma is significantly more prevalent in queer communities than in the heterosexual population (Brown and Pantalone 2011). Structurally traumatic conditions are created for queer persons by social practices that aim to realign those who deviate from the expectation of heterosexuality (Searle et al. 2017). Queer women are restricted in ability to move safely through spaces in different ways to heterosexually oriented women and this restriction affects how individuals access structural resources, including healthcare services (Young 2005; Searle et al. 2017). Thus, queer women are especially vulnerable to trauma attached to harm in the birthing context. Participants in our study experienced vulnerability in their relationships with their healthcare providers not simply attached to queerness. Some felt vulnerable due to intersections such as age and marital status, as Maggie recognizes:

I was 19. I was just on the cusp of 20 when I had her. So very, very young…. [the physician] treated me as if I was a naughty child doing, you know, things that shouldn't have been done because I wasn’t married. (Maggie)

Below, we indicate physical and verbal harm queer birthing women experience before expanding on harms of compromised ethical values and principles connected to an environment of disrespect and vulnerability.

Physical Harm

Birth by its very nature positions one in a profound place of physical vulnerability. Physical harm in the context of birth includes rough handling, forced examination, or other forms of physically aggressive behaviour. Widespread reports of physical harm include healthcare providers “strenuously pushing” on abdomens to try and force babies out, excessive force used against women to pull babies out, unnecessary episiotomies, and post-partum suturing of vaginal tears without use of anaesthesia (Bowser and Hill 2010, 10). Jackson, one of the participants in our study who is oriented as Two-Spirited and uses the gender-neutral pronouns “they/them,” shared a traumatic experience during their interview:

He [the physician] was very forceful with my body and rough as if I was a slab of meat. And not waiting until I was completely numb to cut me open [for a caesarean section] (Jackson).

Perhaps lack of adequate anaesthesia was related to the physical harm this participant experienced, as they repeatedly expressed:

When the doctor … cut through stomach muscles or whatever they do, I could feel him. And he was pushing down with his … this part of your hand, your palm, really hard on my stomach. Like pushing like on either side of my pelvis area, my parts, whatever they were, back into my stomach. And I again expressed that, “You’re hurting me, you’re hurting me.” (Jackson)

Experiences of physical harm can deter decision and action concerning labour and birth because of perceived threat of harm, thus compromising autonomous decision-making. Harms to one’s capacity to act, like harms to one’s physical body, create experiences that can recreate trauma or compound trauma in light of previous violent experiences for queer birthing women (Searle et al. 2017).

Verbal Harm

Our study finds multiple examples of the ways in which participants’ experience verbal harm: discourse that bears negative impacts on vulnerable patient populations (like rigid language or attitudes that reinstate heteronormativity). Verbal harm is demonstrated in our study through use of tone and action more than use of particular linguistic terms. Women such as Estelle experienced a harsh and commanding verbal approach:

I was ready to push long before I started pushing. And he [the physician] had somebody else in another room so he came in and yelled like, “Don’t push. Don’t let her push.” (Estelle)

Sally recalls harshness in both tone and environment. She “felt processed” as if moving through the stages of labour were less about her or her baby and more about her healthcare providers moving her through the system, “like packing meat or something.” Her physician had already been “nasty,” “cold,” and “abrupt” towards her in use of tone. These harsh verbal approaches were further reinstated through a contrast of taking a “nice” tone when turning to talk to Sally’s partner. She experienced harm related to feeling judged by her obstetrician that began during prenatal care, noting that she “felt like trash” around her physician.Estelle’s description of her physician’s verbally harmful tone identifies a disruptive and inhibiting discourse during labour that restricted her ability to birth vaginally:

I think his presence in the room and telling me to stop—“You can’t do this”—and I need to do … you know—“Put your legs up in a different position than they are right now. I have to cut an episiotomy.” So, he just—it was just like interrupting my flow and interrupting my coping. So that was negative. (Estelle)

Maggie’s experience of facing a physician who failed to engage in discourse with her reveals harmful and non-collaborative communication strategies that reinforce the vulnerability of queer birthing women:

… when the doctor came in to break my water, he wasn’t in a very good mood. There was a little bit of foul language used as he was breaking my water. My daughter had made a bowel movement. So, when they broke my water, it was green in colour. I had no idea what that meant at the time. I had to get a nurse to explain it to me because he wouldn’t. It was just bad. Everything about it was bad … the whole process was just scary, terrifying. I had questions that weren’t answered. (Maggie)

Verbal harm includes hostility and threat of harm. Women are commonly threatened with poor outcomes for their babies as a result of their actions during childbirth (Bohren et al. 2014, 10). In our study, Wyn was scared by her physician’s language after revealing during prenatal visits that she preferred a home birth, and this combined with hostile actions towards her midwife:

It was very difficult to find for me, to find a doctor in [Region A] who was taking patients and was supportive. So, the doctor that I ended up finding actually turned out to be a complete bitch and refused to shake my midwife’s hand. I didn’t even tell her I was having a home birth, I just went in to get my check-up … And then when I did … I was like, “I’m going to bring my midwife in next time because I’m actually having a home birth.” And she was like, “What!” and was absolutely shocked and appalled and tried to scare the shit out of me. (Wyn)

Wyn experienced more hostility from her physician toward her desire to have a home birth:

“This is a priority. If there’s anything I can do to make this home birth happen, I will do it.” And she [the physician] was like, “Oh, yeah, but it’s fine if it’s a hospital birth.” And I was like, “I will squat in the corner and have this baby at home by myself if I have to.” And she was like, “I’m going to pretend like I didn’t hear you say that.” (Wyn)

Jackson’s physician threatened “the baby would die” without immediate surgery because the umbilical cord was wrapped around the baby’s neck. Jackson is an Aboriginal person whose first language is not English and who appears in our study as the participant with the most traumatic labour and birth. Without reiterating the many instances of serious harms Jackson experienced, we should understand that their experience of the physician’s claim that the baby would die is compounded by multiple concerns about their experience as traumatic. Jackson’s experience that they were threatened rather than told the truth was later vindicated:

[A]nd this was the kicker, Doctor [participant’s obstetrician] came in to speak to me a day after [son] was born … And said he had took a look at the ultrasound results and there was absolutely no risk on that baby, that there was no umbilical cord wrapped around his neck. And I was so angry, and I was so sad for so long. (Jackson)

Jackson further remarked that nurses disclosed a motive for the physician preferring that Jackson have a caesarean section rather than attend a full labour and vaginal delivery, namely that the physician had a Valentine’s day dinner date arranged:

I found out that evening that the doctor who delivered me … This nurse came in and she goes, “Oh, you had your baby already. Oh, that makes a lot of sense.” And I’m like, “What are you talking about?” She goes, “Well, Doctor [on call] had a dinner engagement with his wife at 8:30 for Valentine’s Day.” (Jackson)

Jackson then relates that the experience of a caesarean seemingly forced upon them was similar to their experience of rape, further troubled by sexual allegations against the physician:

And I just … I went through major depression after that. The same feelings were very similar to rape. I really was affected by that significantly. And then just six months ago maybe, his name showed up in the newspaper for sexually assaulting one of his patients … (Jackson)

Verbal harm resulting in trauma such as those illustrated above bear potential for further harm through constraining opportunities for expressing and acting on autonomous decisions. Experiences of verbal harm, like physical harm, impair reproductive autonomy through discouraging or preventing decisions and actions in light of one’s own judgements concerning reproductive healthcare choices. Constraints such as these are compounded by previous trauma resulting from experienced homophobic stigma and discrimination. When homophobic content becomes internalized, it belies healthy psychological development in ways threatening social and psychological alienation (Crispin 2001). Such alienation is itself harmful. Inhabiting a homophobic social, political, or historical context renders queer birthing women vulnerable to further psychological harms during childbirth because of the possibility of repeated or revisited trauma. Moreover, language and communication issues can interfere with autonomy through distorting or omitting information provided to patients or otherwise preventing comprehension, thereby compromising decision-making concerning reproductive care. The ways in which healthcare providers discuss medical interventions and their benefits or harms is not necessarily connected closely—or at all—to the speaker’s ability to communicate, because a number of factors may reduce one’s ability to comprehend, including ability to communicate and rapport between persons.

Poor Communication and Rapport

Communication is highly correlated with rapport. In twenty-eight studies across twenty-two countries, women in labour and birth commonly report communication issues leaving them feeling “in the dark” about their childbirth and related feelings of dissatisfaction with both information and explanations healthcare providers supply to them; women feel distant from their caregivers, fearful of procedures, and less like active participants in their own labour and birth processes (Bohren et al. 2014, 12). Our participants demonstrated a similar lack of rapport. Estelle reports a distinct lack of communication when she reports that her physician did not speak to her, even when performing vaginal examinations:

… [my physician was] just sort of popping in, not being there for the labour, popping in at random points, and not speaking to me. Like speaking at me or like to my mom even … He wouldn’t really talk either to the nurse about me … Like it was really uncomfortable because he would just come in to do a vaginal exam but then not really talk to me. Even though, you know, you’ve just done something very personal. (Estelle)

Estelle experiences discomfort related to a lack of rapport due to not just poor communication but a failure to communicate concerning an intensely vulnerable and sensitive moment. This lack of communication suggests that the physician is not only evidencing a lack of awareness about her well-being but also a lack of accountability as a healthcare provider, since he apparently does not obtain consent or even provide information about what procedure he would like to do, a procedure requiring that he insert his hand into her vagina. In either case the physician is not respecting Estelle’s autonomy as a person who, as a patient, has a morally defensible option to refuse a cervical check. Absent a medical emergency or other exceptional overriding factors, healthcare providers have a moral imperative to obtain informed consent from competent adults, whether informal (gestures such as nods or rolling up a sleeve) or formal (oral or written consent). In either case, the first step is to communicate proposed medical interventions. In Estelle’s case, an apparent lack of communication belies the possibility of informed consent. (While lack of consent raises patient vulnerability, the particularly sensitive vulnerabilities Estelle experiences when the physician inserts his hand into her vagina are complex and difficult to fully capture along any one moral axis since damage to trust, care, and support are further implicated.)

While Jackson appears to understand all of their physician’s communications with them, they also remarked that they lacked information before and during childbirth:

There was no access to any … person that would go into the labour to talk about anything—spirituality, gender, sexuality, comfort, comfortability [sic] being naked and what the boundaries are for this person who’s about to expose their body and to give life. Like no … And that was very different than my experience at [Hospital D], which was [Hospital E] in [Region G]. A lot more care in terms of the comfort, also the services available. (Jackson)

How issues concerning one’s healthcare are discussed may compromise ethical values or principles, most notably autonomy. When discussion concerns reproductive decisions, reproductive autonomy is at stake. Reproductive autonomy is most clearly compromised by incomplete information or an insufficient quality/amount of information necessary to making reproductive healthcare decisions. Queer women are vulnerable to such negative impacts on autonomy insofar as information that may be relevant to their lives may be rendered invisible by dominant models of care (Goldberg, Harbin, and Campbell 2011). If violating the ethical principle of respect for autonomy or failing to meet the moral requirement to obtain informed consent, physicians introduce connected losses of trust and increased vulnerability. The impact can be particularly traumatic for patients who are oriented as members of historically marginalized communities, such as queer birthing women.

Failure to Support Choice

Communication has an ability to open positive spaces respecting difference through conveying safety to patients—or to cause damage to those who are re-traumatized by the use of rigidly heteronormative discourse. Language and behaviour results in failure to support patient choice when reinstating rigid or otherwise unresponsive forms of language and behaviour marginalizing queer experience. Healthcare providers may be unaware of the implications of using rigid language with historically marginalized communities and the ways in which these harms accumulate over time. Relatedly, the ways in which queer women move through healthcare spaces is often informed by rigid socialization within a heteronormative patriarchy and associated structurally traumatic experiences (Searle et al. 2017). We understand rigid practices to include denial of birth companions, denial of safe traditional practices, limiting birthing positions, and lack of supportive care exemplify failures on the part of healthcare providers to uphold patients’ reproductive autonomy through failing to support choice. Failing to support choice impairs autonomy through impeding the ability to act according to one’s judgements, desires, goals, and so forth. To clarify, one might not always be able to successfully act according to one’s aims or goals, and this need not indicate a lack of autonomy. However, contexts preventing actions flowing from particular motives limit autonomy, particularly if motives are connected to deeply held desires, beliefs, and goals. Such contexts can create hostile conditions for persons who are not in line with the desires, beliefs, and goals of those who occupy positions of power (Goldberg 2005). This is well illustrated by the experiences of queer women in heteronormative rural birthing contexts that face constraints on action or undermined choice. We expand on these ideas in the following discussion of denial of birth companions, denial of specific choices, and failure to provide supportive care.

Denial of birth companions either bar from a woman’s labour and birth any companion, allow only a certain social category of companion (spouse, relative, friend, partner), or limit number of companions (to one or more). Participants in our study were not directly denied the presence of birth companions although one queer participant oriented as polyamorous indicated that she brought only one of her two partners with her to the hospital. She expressed doubt that she could have brought both:

I wonder what would have happened, for example, if they [her second partner] lived nearby. And from the polyamorous aspect, if they lived nearby and we were more, I guess, together family-like, the three of us, the two adults, what would have happened, for example, with the baby being in the NICU? Because my partner here, he was able to go in and he saw the baby right away when he was born. And, you know, got to touch him in the incubator and stuff. But I don’t know how the non-parent partner would have been … if they would have been allowed in at all. (Anne)

Anne wonders if both of her partners would have been allowed to have the same access if present at the same time. For queer women, uncertainty and inhibition is common in social contexts, and such uncertainty is unlikely to be overcome in an environment failing to support queerness, as is reflected, reinforced, and reinstated in rural birthing contexts (Searle et al. 2017). Anne’s doubt expresses concern about restrictions her second partner might be subject to and this, we suggest, reflects uncertainty about Anne’s own possibilities for choice and action. One might imagine a scenario in which Anne’s second partner was not simply limited by distance but in which Anne did not perceive bringing both partners as a birthing support option. Perceiving a lack of options constrains choice through limiting possibility. A healthcare environment that is not overtly supportive of queer patients can easily fail to register the need for divergent options. So, for instance, a policy allowing one birth companion may meet the needs of heterosexual couples by allowing one’s partner present, and an institution might be proud to extend that policy to a partner regardless of gender or sexual orientation. But such a policy will not meet the needs of a polyamorous relationship. In that case, a policy limiting number of birth companions to one can further limit a connected set of choices such as closeting one’s relationship due to uncertainty or fear of compromised care or failing to hold true to one’s sexual identity, and so on.
Denial of specific choices such as denial of safe traditional practices or choice of birth position exemplify poor support for birthing women. Denial of safe traditional practices fails to respect autonomy, through imposing restrictions to upholding and acting on the exercise of choice over goals, projects, or aims important to who one is. In our study, Jackson anticipated performing an important traditional practice of pouring cedar water to cleanse their baby and had prepared a jar of cedar water, brought it to the hospital, and communicated the importance of this tradition to their physician:

I told him [the physician] some ceremonial stuff. All three of my children, their first water traditionally should be water from the cedar tree. And so that’s your first water that you cleanse the baby with. And I had prepared a jar of that. And I also did that with the other two boys. But I told him that it’s really important that I get to be awake enough to be able to do this with the child. And so that didn’t happen. That actually didn’t happen at all. (Jackson)

A failure to support Jackson’s choice impedes autonomy through apparently removing possibility of choice. Jackson does not report any discussion with her physician of how or when she might be able to perform this practice once directed to have a caesarean section, nor was she given options of who else might do so if they were unable to do so following surgery.
Failure to support specific choices such as preferred birth position similarly impacts patient autonomy. Many women wish to move or act according to deep physical or emotional needs but are restricted from doing so during childbirth (Bohren et al. 2014). We see a clear example of this restriction in our study:

Intuitively I wanted to move, and I wanted to like moan, and I wanted … Basically I just wanted to let my body do whatever it needed to do. I wanted to be in different positions. And I wanted to breastfeed her whenever she needed to feed. Like I just sort of wanted to like be with my baby and let me and her figure out like our system. But it was a lot of … Instead of that, it was a lot of you need to feed the baby at this time, and you need to …you know, the baby needs to come out of the room with me from this time, and then we’re going to do a bath at this time, and we’re going to … You know, it was just like there was a system set up, and I didn’t want to fit in it, but I didn’t know how to articulate that. (Estelle)

Estelle experienced compromised options because she views herself as directed by healthcare staff according to “a system set up, and I didn’t want to fit in it.” Her rejection of this system and the directives issued to her indicates that she is not an active participant autonomously choosing how her labour and birth progresses but is a passive recipient of others’ commands.
Attention to autonomy provides an opportunity for healthcare providers to collaborate with their patients and deliver patient-centring care (Searle et al. 2017). Conversely, a lack of supportive care expresses a general lack of concern for autonomy since choices often require the support of others. Autonomy does not necessitate wholly separate, individual decision-making but often calls on our relations with others. Many philosophers regard autonomy as relational, connected or contingent on the involvement of other persons (MacKenzie and Stoljar 2000). If that is correct, then a lack of support and failure to collaborate undermines autonomy through failing to promote or enable others’ decisions. Many of our study participants indicated lack of support.

I left at the end with just an overwhelming sense of disempowerment. And it’s not that anybody was outright rude or that anybody was, you know, mean or … I mean the obstetrician was at a certain point. But there were lots of supportive people and lots of nice comments, but it was just like an overarching sense of disempowerment. (Estelle)

Similarly, Maggie states that she did not feel a sense of support from nursing staff dedicated to her for the duration of her birthing care:

I don’t remember anybody saying like, “I’m nurse so and so and I’m going to be here for the next eight hours.” I don’t remember that at all. (Maggie)

The above illustrations of lack of respect for autonomy can also be associated with negative attitudes towards queer women. Not taking others seriously is a form of lacking respect for persons through not listening or giving uptake, discounting views and opinions, and so forth.
An intersectional analysis of age and sexual orientation reveal further negative attitudes impeding support for birthing women. We see such negative attitudes in Victoria’s account as a young queer woman when she gave birth:

You know, I mean this is kind of my own opinion, but I honestly think that younger females who choose to be with females are not taken seriously at all. I mean that’s in the [Region B] community. But one hundred per cent not taken seriously. And I mean I’ve heard this from many people. People think that it’s a phase. They really just aren’t taken like the way they want to be seen. It’s an awful standard but it’s true, definitely. (Victoria)

Recognizing such attitudes toward herself as both young and queer, Wyn anticipates lack of support and its impact on her ability to make and follow through her choices:

… if I walk into that, you know, hospital environment as an eighteen-year-old, nineteen-year-old girl who at the time was pretty visibly queer, whether she knew it or not … [laughs], who was pretty visibly queer, I felt strongly that, you know, I was going to be at risk. And I was going to be … Based on all the adults in my life who weren’t taking me seriously, who knew me, I knew that doctors and nurses weren’t going to take me seriously and weren’t going to necessarily adhere to my birth plan or to my ideas around how I wanted this [birth] experience to go. (Wyn)

Breaches of Confidentiality

Queer persons are vulnerable to “outing” and may desire to keep their queer orientation from certain persons or groups of persons due to anticipated negative harms and attitudes. In this sense, the significance of confidentiality is paramount and non-transposable to heterosexuals. Within the context of institutionalized heteronormativity, heterosexuality is expected and does not typically risk deep fractures within families or communities in the way that “coming out” as queer does. Thus, queer persons are vulnerable to breaches of confidentiality bearing impacts not encountered by heterosexuals. Moreover, fallout from breaches in confidentiality may be more difficult to repair for queer persons, whose lives are influenced by structurally marginalizing social practices attached to deficits such as receiving less family support than heterosexuals (Valanis et al. 2000). What may appear to be an isolated act of a breach of confidentiality may bear far-reaching, traumatic repercussions for queer women.

To illustrate how sexual orientation and rurality intersect to create conditions of vulnerability to moral harm, consider the following account: Sally reveals a loss of confidentiality by her family physician following her pre- and post-pregnancy care. During prenatal office visits she had revealed both her status as a queer woman and disclosed a previous sexual assault that had fractured relations between her and most of her family. Her physician breached confidentiality by discussing the sexual assault with Sally’s mother, outside of the parameters of providing healthcare and without the expressed or written consent of the patient. Breaches of confidentiality occur when any information patients reveal to healthcare providers is revealed to anyone else without (a) medical necessity, or (b) express consent of the patient to reveal the information. Thus, breaches of confidentiality occur when any information a patient has discussed with a physician is revealed in any context whatsoever that is not related to the healthcare of the patient. For the purposes of recognizing breaches of privacy neither the intention of the physician nor knowledge of who is the recipient of the breached information are relevant. In our case of Sally, the violation of confidentiality is remarkable. Not only is Sally a competent adult and thus deserving the protection of confidentiality, but also the material discussed is particularly sensitive in nature. To appreciate the extent of this breach it is important to recognize the wider implications of the violation for Sally:

I’ve been, you know, excommunicated. I’ve been cut out of the family by everyone but my mom [following her discussion of the violation with her mother]. But he [her physician] spoke to my mom about it. And according to my mom, held her accountable for some of it. Which I won’t ever mention to him because I feel like talking about it is more … I don’t want to talk about it. You know, I don’t want to get into my mom saying he said this to her and then my family doctor saying I said this to her. You know, no one should have said anything to anybody. And that’s the whole point, right? And his daughter is my Facebook friend. I don’t think that he would talk to her about things like that. But absolutely, confidentiality in rural [Region B] is a big thing. (Sally)

Within rural contexts, compromised ethical principles can lead to further harms such as loss of ability to repair harms and lack of trust. Sally’s reflections show that she recognizes that confidentiality is important and that issues concerning confidentiality in her rural community are common. Yet she is constrained in discussing the issue of confidentiality with the physician who breached that requirement because the rural context generates close quarters. In Sally’s case, the physician is also her mother’s primary physician. Since the physician already violated confidentiality, we can expect that Sally’s trust in her physician is undermined. In particular, it seems that Sally does not trust her physician to address confidential issues only with her. For queer persons in rural contexts, the risk of revealing sexual orientation creates a sort of vulnerability less common to the urban context. In the rural context, close connections are often difficult to avoid. So, persons wishing to keep their queer orientation private face extra challenges. If a physician breached confidentiality of sexual orientation, then any number of catastrophic harms might follow (perhaps like the “excommunication” Sally discusses). In such cases, opportunities to decide with whom and when to reveal one’s sexuality would be taken away, thus undermining autonomy.

Future Directions

A significant issue for queer communities concerns how to avoid or access healthcare services while protecting safety and increased vulnerability of experiencing a re-traumatizing event (Searle et al. 2017). Health disparities that are disproportionately experienced by queer communities are arguably evidence of this fear and avoidance behaviour (Beagan, Fredericks, and Goldberg 2012). Fear and avoidance each undermine autonomy through compromising ability to form and act on one’s own choices. Vulnerability for queer birthing women is a susceptibility to a multitude of harms, ranging from physical and verbal harms to violation of ethical principles and values. We consider such vulnerability to raise moral concerns connected to autonomy (confidentiality, privacy, trust, support) that are relevant for queer persons and not necessarily encountered by heterosexuals. In this environment, how might healthcare providers respond to queer women’s vulnerability in the birthing context? Participants shared various suggestions around how to better provide more responsive care to queer birthing women, mainly through pointing to what is missing. Jackson offered the following:

There was nothing comforting gender or sexuality-wise in the hospital. And I had been out publicly before that. So, it’s something that I’m attuned to. And when I see a slight … even if it’s a little pride flag or whatever, you know, it’s like, oh, great, there’s one person here that’s, you know, okay with this. But there was nothing at all.

Jackson experiences no representations of self, nothing to suggest a safe space in which to birth as queer: no sign, no flag, no poster or pamphlet. While such symbols alone may be insufficient evidence of allies, they offer a step of recognition toward redressing the sort of institutional heteronormativity and gender binary of which Jackson is so keenly aware. Not dissimilar to Jackson, Estelle indicates:

I think it would have been made a different experience if I would have been given a certain level of respect. And I’m just trying to think of some tangible things that would have allowed me to feel that way. Perhaps it was like if I felt like I was being spoken to the same as lots of other clients were being spoken to or given the same information as other clients were given. I didn’t feel either of those things. Or if I was asked … You know, like I could have been asked do you want to do this, would you like to try this, would you like to be on the chair as opposed to be the bed, or would you like to try … here are your options. And there was a certain degree of that, but there was a sort of overarching level of not gaining consent in a way. I mean I just think that sounds too harsh, but just not consulting me, of me not being the expert in my care. (Estelle)

Conclusion

Queer birthing women are more than ordinarily vulnerable to harm compromising morally acceptable treatment, particularly when queerness intersects with other marginalized categories such as rurality. We have not expanded on each sort of intersecting feature nor each form of intersection that might introduce harms since such an analysis runs beyond the scope of this project. We have aimed to show that broadening how harm is understood in healthcare can point to vulnerability through recognizing how persons are marginalized differently according to disparate intersections of marginalization. We have illustrated harms that queer women have experienced during labour and birth for the purpose of furthering recognition and response promoting safe, competent, and ethical care. Situating the experiences of participants within categories of harm discussed above provides guideposts for healthcare providers—guideposts to regard harmful issues not in isolation from one another but to see them as embedded and connected within systems of care. Revising policies and procedures to become more inclusive can foster an institutional environment more responsive to queerness, but doing so needs to respond to vulnerability to better anticipate how harm might be further connected to breaches of ethical principles and values for queer birthing women.

Suggestions for promoting inclusivity aiming to reduce institutionally embedded harmful practices can look to those experiencing harm to redress moral harms or repair lost opportunities for morally positive birthing experiences. Responsiveness to the vulnerability of queer birthing women that actively promotes respect for autonomy, trust, communication, rapport, confidentiality, and privacy can better meet individuals’ healthcare needs in an inclusive, positive, and morally respectful environment. Such responsiveness must actively counter institutional homophobia and heteronormative beliefs and values implicit to common policies and practices guiding healthcare delivery and which inhibit ethical treatment of queer birthing women. The risk is that without such responsiveness, harms birthing queer women experience may deter pursuit of birthing care in the institutionalized setting through seeking or recommending home birth alternatives or reducing pregnancies.

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Copyright information

© Journal of Bioethical Inquiry Pty Ltd. 2018

Authors and Affiliations

  1. 1.Cape Breton UniversitySydneyCanada
  2. 2.Dalhousie UniversityHalifaxCanada

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