Why and how do administrative identities and categories matter in the doing of sexual health? In this guest post, Kath Albury discusses how presumptions around sex, gender and identity complicate the space of General Practice
In New South Wales, sexual healthcare and health promotion services are resourced on the basis of epidemiological data, which is classified according to standard demographic categories like male, female, gay and heterosexual.
Sexual health centres are explicitly instructed to filter out anyone who doesn’t present as a sexworker or a gay man, unless they make a case upfront for having especially ‘interesting’ sexual practices. Consequently lesbians, heterosexual and bisexual women are referred to their local GP.
Not, as Seinfeld would say, that there’s anything wrong with that, but it leads to awkwardness in the suburban clinic when the ‘sexual history’ questions that go with the Pap test are framed demonstrate a fairly limited understanding of heterosexual practices, and an even more limited framework of queer women’s sexuality.
Women (including queer women who are read by health care providers as heterosexual) are generally presumed to be in need of ‘reproductive healthcare’, rather than sexual healthcare. The Pap test, a test for HPV (a sexually transmitted infection), falls within the jurisdiction of the Family Planning clinic or the family doctor, not the sexual health centre.
This leads to situations where women asked the diagnostic question “do you ever experience bleeding after sex?” need to respond with ‘complicated’ answers, such as: “Yes – but it usually involves a fist, and sometimes it’s pretty rough”. I suspect this kind of answer may be challenging in health care settings that focus on the kinds of family that the term ‘family doctor’ usually describes.
In late 2010, my colleague Estelle Noonan and I ran a survey of non-gay-and-lesbian identified sex partiers, as part of an ARC Linkage project, partnered with Family Planning NSW. The recruitment email specifically asked for participants who identified as ‘heterosexual, bisexual, bi-curious or queer’.
The demographic section of the survey included a scale that invited participants to identify ‘strongly’ ‘somewhat’ or ‘not at all’ with various categories of sexual orientation, including heterosexual, gay/lesbian, bisexual, bi-curious and queer.
One hundred and five people responded, and respondents were fairly evenly divided between male and female identities (including seven transmen and one transwoman). Eighty-five percent of participants identified as either strongly or somewhat heterosexual, and sixty-one percent identified as being either strongly or somewhat bisexual.
Clearly these two groups overlapped, and the scale for sexual identity allowed for multiple answers across different categories. As expected, we had a number of respondents who identified as ‘strongly heterosexual, somewhat bisexual’, or vice versa. This was reflected in the answers survey questions that asked about sexual behaviours, where just over a third of strongly heterosexual men, and nearly half of all strongly heterosexual women reported same-sex play in the past 12 months.
What intrigued me were the participants who identified ‘strongly’ with more than one category. For example, one man and one woman identified as strongly bisexual, strongly heterosexual, and strongly bi-curious. Four women were both strongly bisexual and strongly queer. Overall, sixteen participants out of one hundred and five demonstrated what I’ve termed ‘identity plus’.
I don’t know why these sixteen self-identified the way they did, but I’m guessing it wasn’t based on their understanding of epidemiology, or public health funding. I don’t know what the terms heterosexual, queer and bisexual mean to them -they may have any number of intersecting political, cultural or sexual affiliations that cause them to identify strongly with multiple categories. Or they may have a strong emotional identification with one ‘orientation’ and an equally strong erotic affiliation with another.
The (limited) literature on sexually adventurous heterosexual women suggests that many women get into swinging or sex partying specifically to have sex with women. In the absence of beats, or sex-on-premises venues, sex parties and ‘sex-seeker’ websites provide the safest spaces for same-sex-attracted women to hook up. For these women, ‘identity plus’ might involve a strong commitment to an existing relationship with a male partner, plus a strong commitment to forming new relationships with female partners.
Excluding heterosexual women from sexual health clinics leads to situations where suburban mums have to justify why they want an anal swab, and explain that their last sexual encounter involved multiple partners, and included men and women. GPs outside of the inner city are anecdotally notorious for arguing with their ‘straight’ clients who ask for STI or BBV tests. After all, heterosexuals (particularly heterosexual women) aren’t a ‘risk group’.
It’s clear from my (still work-in-progress) unpacking of the interview and survey data that services that specialise in reproductive health are not currently meeting the sexual health needs of all their female-identified clients. While standard demographic categories might useful for health economists, they don’t get close to describing the nuances of everyday sexual identities and behaviours.
- Kath Albury