For lesbian and bisexual women, a trip to the doctor’s office may be an exercise in anxiety. (Chad Baker/Jason Reed/Ryan McVay/Getty Images)

“Are you sexually active?”

For any patient, that question — often asked when you’re wearing nothing more than a paper gown — is awkward, especially coming from a health-care provider you barely know. But for lesbian and bisexual women, that inquiry can feel particularly threatening.

At an annual exam, Nicole Flemmer, a nurse practitioner in Seattle, Washington, replied that, yes, she was sexually active, which led to her provider’s next question: “Are you trying to get pregnant?” When Flemmer said no, her provider pointed out her wedding ring, and summed up with frustration: “You’re sexually active, you’re not on birth control, you’re not trying to get pregnant — what is going on?” That’s when Flemmer revealed that her spouse is a woman, at which point her practitioner simply frowned and wordlessly jotted down a few notes.

It’s interactions like these that inspired Flemmer to push for change in the way the health-care system treats women who have sex with women. “I have had providers make a lot of assumptions about me,” she tells Yahoo Health. In 2011, for example, she noticed “ego-dystonic homosexuality” — a diagnosis not recognized for decades — was included in her medical records. “It was diagnosed in 2009 by a doctor who I saw for a medication refill, who had never even talked to be me about my sexuality,” Flemmer says.

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To avoid such strained interactions, Flemmer has sometimes tried to “pass as straight” during doctor’s appointments. “I was afraid of what they might say or do,” she says, though as a nurse practitioner, she realizes that her fear could be costing her the quality of care that all patients deserve. “Sexuality is a big part of a whole person. In medicine and nursing, we’re trying to treat whole people,” she says. “If you make an assumption about a big part of that, you’re doing a real disservice to patients. If you have misinformation, you may miss an important factor in determining the [health] risks of a person’s specific circumstance.”

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Nicole Flemmer, a nurse practitioner in Seattle, aims to change the way doctors treat lesbian and bisexual women. (Photo courtesy of NIcole Flemmer)

As Flemmer became increasingly empowered in her personal life — “I realized that perhaps the worldview I grew up with wasn’t the truth” — she wanted to bring that perspective to her work in the medical field.

In a new paper in the Journal of Nurse Practitioners, Flemmer proposes a new model for health care that she calls “empathetic partnership,” designed to create a sense of safety and inclusion for women of sexual minority. “They struggle to feel comfortable because there is so much stigma in society in general,” she says. “And that stigma has crossed over into the medical and nursing field.”

The framework includes six elements that are vital for health-care providers to create “effective and therapeutic partnerships with patients,” according to the study — particularly with women who have sex with women. They are:

Reflection

The first step: having providers examine their beliefs and assumptions about the people they treat. “Reflection basically asks the provider to look at their own culture — their worldview,” says Flemmer, who doesn’t necessarily ask doctors or nurses to alter those beliefs right away. “Just becoming aware is a big part of reflection,” she says.

For practitioners who struggle to identify exactly what they believe, Flemmer suggests this exercise: Write down the words “lesbian,” “gay,” and “queer,” and jot down any associations that come to mind. Often, she says, providers link homosexuality to things like promiscuity or substance abuse — assumptions that could color the care they provide.

Environment

The artwork in a doctor’s office isn’t just meaningless decoration — it’s a message to patients about the views of the practice. Same goes for the magazines in the waiting room. “I’ve been to places where the reading material was all one worldview,” says Flemmer, “where all the photos were of a man and a woman.” If the environment suggests a single perspective — say, that sexual relationships are strictly heterosexual — lesbian or bisexual women may not feel comfortable opening up to their provider for fear of judgment, she says.

Another key environmental cue: whether a nondiscrimination policy is posted. “Often [doctors] don’t even have a nondiscrimination policy, and if they do have one, it doesn’t include sexuality,” Flemmer says. However, some clinicians are starting to post symbols, such as rainbows or pink triangles, in their offices to signal acceptance. “Subtle cues like that can help women be a lot more open, and also help the provider get more accurate health information,” she says.

Language

Closed-ended questions can imply that a certain response is the right one — which may leave women whose answer is “wrong” feeling alienated or even silenced. Instead of asking, “Are you sexually active?” Flemmer suggests health-care providers ask, “Do you have sex with men, women, both, or neither?” or even simply, “Do you have any concerns about your sex life?” “That’s a really open-ended question,” she says. “So patients can feel free to disclose anything they feel like disclosing.” And rather than inquiring whether patients are married, providers might ask, “Who is family to you?” That way, women can comfortably mention same-sex partners, without fear that “husband” will be expected to make the list.

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Knowledge

There’s little research about unique health risks that may be faced by women who have sex with women. And what is out there is often unreliable or contradictory, says Flemmer. Even so, “accessing what research is available is important,” she says, while cautioning that doctors should view lesbian and bisexual women as more than stereotypes and statistics. “Use that statistic to inform your practice, but understand that each individual is unique,” she says.

An area of particular concern: Providers may think women who have sex with women don’t need Pap smears, due to an assumed low risk of cervical cancer. However, these patients may have previously had sex with men and should not be excluded from screenings (regardless of their sexual history).

Partnership

Instead of harping on patients, providers should work with them to set goals for their health — Flemmer envisions doctors walking alongside their patients, rather than directing them. They should be more of an “expert cheerleader, versus someone telling them, ‘This is what health needs to look like for you, this is what you need to do, this is what your problem is,’” she says. Women who have sex with women often enter health-care settings feeling defensive; this approach will help remove that barrier to care, says Flemmer.

Empathy

Empathy is the ability “to look at a person and see their situation through their eyes.” Flemmer explains. And it can be taught. Why is it so essential to quality health care? An empathetic doctor or nurse is non-judgmental and understanding, both of which may encourage patients to be open and honest with their provider.

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