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A guest post by Bianca Palmisano, founder and owner of Intimate Health Consulting.
“The gynecologist assumed that because I’d had male and female partners within the last year, I was irresponsible somehow. And to top it off, she didn’t even know what a dental dam was, when I told her I’d been using protection.”
“Even in trans-inclusive spaces, I’ve had a hard time accessing care that feels comfortable. Because I have not legally changed my name, doctors/practitioners consistently use my birth/legal name, especially when calling my name at the beginning of appointments and addressing me when asking questions.”
“When I went to the doctor in March and asked for more STI tests (I had been tested in January), they told me that it had been too recently since my last test. I blinked at them and sputtered, “But I’ve slept with a lot of people since then! I had to learn the code words that “a condom broke” or a “partner experienced symptoms” to get my insurance to cover more tests.”
These reactions by medical providers to sexual health requests from patients would be embarrassing if they weren’t so appallingly commonplace. The sad truth of the matter is that if you identify as some kind of sexual or gender minority—LGBT, non-binary, asexual, kinky, non-monogamous—you probably have a terrible doctor story of your own.
For most of us, it’s hard to understand the rationale behind these kinds of experiences: why can’t healthcare professionals just reserve judgment, treat everyone like a human being, and ask questions when they aren’t familiar with a certain community or practice?
The answer of course is inexcusably simple—because they don’t have to—but that apathy towards quality sexual healthcare is rooted in some complex medical, public health, and sociological issues.
Most medical professionals have been trained to address the malfunctioning of a specific body part: the broken bone, the fatty liver, the unexplained rash, the sexually transmitted infection. The disconnect between symptom and holistic patient experience is so marked in this profession that it’s spawned a whole offshoot of practice, osteopathic medicine, that shifts the medical gaze from symptomology to patient wellness. But most of us don’t see osteopathic physicians. We see MDs and their nurses, who have been rigorously engaged in this disconnected style of diagnosis for many years.
It’s pretty easy to see where I’m going here: when you see the symptom instead of the patient first, it’s a lot easier to discredit the importance of clinical empathy, compassionate non-judgment, cultural competency, and all those other important “soft skills” that make us more likely to actually LISTEN to our doctors. Doctors see a problem: you have an STI. They know the solution: a course of antibiotics and hearty dose of shaming so that you “never do something so reckless and irresponsible as to exposure yourself again.” The social and emotional implications of that shaming? Not really within a doctor’s scope of practice.
And where does that shaming come from? In part, medical shaming comes from the same toxic, sex-negative, intolerant society that we live in every day. Unfortunately, you can generally ignore or avoid the biphobic rants of your next door neighbor Randolph, but you’re wholly reliant on a doctor (and their attendant prejudices) to access your basic healthcare needs.
Even when doctors aren’t actively shaming their patients, they often simply lack up-to-date information and skills for talking about sexual health. The average MD receives barely 3-10 hours of instructional time covering sexual health topics over the course of a 4 year medical program. None of that is devoted to discussing bedside manner, unpacking prejudices, or confronting stereotypes. So if your doctor came into medical school thinking that queer people are promiscuous and deserve all the STIs they have coming, they’ll most likely leave medical school the same way. This lack of instructional time is compounded in shorter programs for nurses, medical assistants, phlebotomists, nursing home aids, and any number of other care professionals you might encounter.
Many educational programs are starting to incorporate content around LGBT health specifically, which is a good step, but even those efforts ignore so many communities and sexual health issues. Even public health, which has long claimed to be ahead of the larger medical community on minority health, has a limited lens through which to discuss sexual health. The public health model utilizes its own special cocktail of stigma to address groups that the CDC considers “high-risk”—primarily gay and bisexual cis-men, transgender women, Latino and Black cis-men, and Black cis-women. For these “high risk” groups, the prevailing understanding of the disease network is that individuals are sexually non-monogamous with many partners who rarely communicate their status. In the case of transwomen, the primary assumption is that most of their sexual partners are clients from sex work. While there’s some reality to those framing assumptions, the model doesn’t leave a lot of room for people who aren’t monogamously partnered or traditionally “high risk,” to say nothing of folks who fall into high risk categories but counter those expectations with low or no-risk activities.
And regardless of the healthcare domain or the amount of schooling, the vast majority of healthcare professionals will have had no exposure to BDSM, asexuality, polyamory, trans*-competent care, nor an understanding of how those identities and practices relate to risk reduction.
A truly great doctor (and a few of them do exist!) will have taken the initiative to self-educate on some of these issues, and will be proactive in their engagement around sexual health during an appointment. That means the first time you see a new provider, they should be taking your full sexual history, which is more than simply asking if you are sexually active. You should be hearing your doctor ask open ended questions like, “Tell me about any sexual concerns you would like to discuss,” and “How does the problem affect your life and relationship(s)?” or “What are your goals for your sexual health?”
Ideally you should know that your doctor runs an informed and inclusive practice as soon as you step into the waiting room, because the medical paperwork you fill out includes spaces to identity your sexual orientation and gender identity. A separate form might even offer a place for you to note other relevant social information, like whether you have an invisible disability or identify as a survivor of assault, stalking, or intimate partner violence.
But there aren’t a lot of stellar medical practices out there. And those that really do care and invest in a patient’s sexual health might not be good at signaling it to the outside world in their advertising or patient materials. Frequently, finding the right provider is a crapshoot where some get lucky and plenty more get disappointed.
Suffice to say, shit is hard. It’s going to take a huge investment of energy and a large culture shift from within and beyond the medical community to change these realities. My advice to those who are suffering the ignorance and prejudice of systems right now: if you have the means, vote with your voice, your dollars, and your feet. Promote the few really great doctors out there through social media networks, word of mouth, and review sites like RadRemedy, HealthGrades, and Vitals.com. Refuse to stand for ill treatment by those who are less informed and hold your healthcare provider to the highest possible standard. It is your health, after all, and you deserve informed, respectful, affirmative care. Full stop. No qualifications.
I’m in the middle of writing an academic paper on the effect of drug and alcohol use on contraceptive decision-making [edit: I actually originally wrote this post a couple of years ago, and the paper was eventually published here]. For many years, I’ve been a researcher in the public health world. But I’m a long way from being one of the people who actually has much influence over what doctors and public health professionals actually do.
When I started this research years ago, I’d never slept with anyone except my husband. I wasn’t exactly one of the people that public health professionals spend much time worrying about. And while I’ve still never had a drink or smoked a cigarette, I’m continually frustrated by the abysmal failure of the public health world to cope with the real lives of people like me, who live relatively “high-risk” sexual lives.
For starters, there’s the fact that my insurance doesn’t want to cover multiple STI (Sexually Transmitted Infection) tests a year. What the fuck??? When I went to the doctor in March and asked for more STI tests (I had been tested in January), they told me that it had been too recently since my last test. I blinked at them and sputtered, “But I’ve slept with a lot of people since then!”
It’s clearly in the best interest of the public as a whole (not to mention me and my partners) for me to get tested regularly. For Goddess’ sake, I can’t even calculate the extent of my overall potential disease network (I can calculate the very short fluid-bound intercourse network, but not the condoms-and-unprotected-oral-sex network). I would wager large sums of money that within three degrees of separation (my partners’ partners’ partners) that there are well over 100 concurrent people in it. It might very well be a helluva lot more than that. That’s an entire small community worth of people. Can’t my doctor just declare me to be a “high-risk case” and recommend me for more testing? Instead, I had to learn the code words that “a condom broke” or a “partner experienced symptoms” to get my insurance to cover more tests. Good grief. I’m 31-years-old and I don’t enjoy going to the doctor’s. I don’t get tested for kicks.
Then there’s the fact that the public health people really really really don’t get it. My doctor asked me if I had had “any new partners” since the last time I was in for an appointment. I realize that I haven’t explained my life in very great detail to her, but I’ve explained that I’m non-monogamously married, so she should know that me having a new partner only encompasses a relatively small portion of my overall STI risk. Back to that whole disease-network issue: what matters is what me and my partners and my partners’ partners are doing. The public health community really isn’t prepared to grasp the particular STI risks of people who maintain concurrent multiple partners.
And then there’s the way that the places that do offer cheap or nearly free testing tend to treat people when they go in. So far, I’ve been fortunate and never once been condescended to by a doctor when I went in for STI testing, but I’m guessing have a Ph.D. helps a lot with that. My husband complains that every time he goes in for testing, the doctors just look at him skeptically and seem to be assuming that he’s cheating on me (we got around this tidily one time by simply going in together, but that isn’t always practical). Other partners of mine have complained that doctors were extremely patronizing to them when they went in for testing. Medical condescension is not helpful. If you’re smart enough to be at the testing clinic, you’re smart enough to know that what you’re doing is risky. Doctors don’t need to lecture the people who are there getting responsibly tested. The people they need to lecture are the people who aren’t there. Lecturing people who’ve had the good sense to calculate their level of risk and realize that it’s not low just makes those people not want to come back and do the right thing. It’s like when teachers yell at the beginning of class about how “many students are late to this class”: it’s an understandable frustration directed at the wrong people. When people show up for preemptive testing (that is, symptom-free testing), say, “I’m so glad you’re here. Do you have any questions? Have some condoms! Please come back soon!”
It doesn’t apply to me personally, but I’m also frustrated by the total failure of the public health community to deal with the fact that the vast majority of “high-risk” sexual encounters (that is, casual sex with someone a person doesn’t know well) typically occur under the influence of drugs and alcohol. I haven’t figured out yet how to deal with that fact better, but I know that just assuming that telling people over and over again to use condoms will solve the problem is probably insufficient. In general, one of the great paradoxes of the public health world (that the medical community is totally blind to) is that the kinds of people who are most likely to have casual sex are the kinds of people who are most likely to be lousy contraceptors (hence my paper linked to above). Currently, The Condom Message has mostly penetrated the ears and brains of the people who are actually at very low risk (obviously, me and many of my friends would be an exception here…). I don’t know what to do about this problem other than to try to teach people to put condoms on bananas while intoxicated (or encourage them to put in female condoms while they’re still sober, but Goddess help a drunk person trying to use one of those things). What I do know is that a lot more smart people need to be putting their brains into solving this problem.
In conclusion, doctors and public health professionals need to start figuring out how to politely and successfully help people manage their changing sexual health risks in a world where traditional monogamy is becoming less popular overall, and where the average age of marriage just keeps going up and up (while the average age of virginity loss stays about the same). Current estimates say that 25% of young American adults will never marry, and our best-guess data suggest that various forms of consensual non-monogamy are becoming more popular. However, I can report that a growing body of research suggests that ethically non-monogamous people are, somewhat ironically, probably a lower STI risk to one other than “monogamous” people. Here’s the most recent study to say so. Go figure.
I love and hate the way poly people use condoms.
Before I go any further, I suppose I should explain that I spent years theorizing and researching the way men and women around the world make decisions about and negotiate contraceptive use; it’s what my dissertation was on, and I have written several academic papers on the topic. Amusingly, my academic background makes me at best only slightly better at actually negotiating contraceptive (condom) use with real people than your average monogamous person, and I’m definitely less skilled at it than your average poly slut. I manage it, but without much finesse. Instead of being helpful, my academic background just makes me very conscious of how profoundly mediocre I am at it, and leaves a voice in the back of my head continually affirming a theoretical paper that I wrote in graduate school arguing that contraceptive negotiations are all about power, trust, and pleasure.
When my husband and I finally set out to become practicing (as opposed to merely theoretical) polyamorists nearly six years ago, we did so outside the context of the BDSM scene and its strictures about condoms. Neither of us had ever slept with anyone else, and we weren’t sleeping with people who were particularly slutty. Since he cared a lot about the idea of me getting pregnant by someone who wasn’t him, I got an IUD right before we embarked on this poly excursion. And after that, for years, we were relatively carefree about condom use with our partners. We weren’t hooking up, we weren’t dating casually, we were only having sex with people we really liked and were forming relationships with. I keenly remember the first time he had sex with another woman–who was my girlfriend at the time, in a threesome. He was having condom issues, and she said, “Oh just don’t worry about it.” And he didn’t. And I didn’t. And she didn’t. Because she and I had been in a relationship for months, she knew he’d never had sex with anyone else, and we all knew she was using birth control.
And even though I think that decision was completely reasonable (I certainly did at the time, and I still do in hindsight), I hesitate to write it here. Because I’m afraid of the judgments that might rain down.
But eventually, he and I got immersed into the BDSM scene, and became more accomplished sluts. For better or worse, at that point, we started absorbing the sense that Condoms Are Very Very Very Important. And they are. Please don’t think that I’m suggesting otherwise here. Condoms save lots of lives, no question. But in the process of saving lives, they’ve accumulated an irrational symbolic value in our subculture that I kind of hate.
What I love about the condom culture of the (poly) Scene
There don’t have to be any condom negotiations. That’s what I love. Outside of this beautiful bubble, an astounding amount of heterosexual casual sex (I suspect the majority, based on my research) happens without condoms. Inside of the bubble, if a person with a penis says they want to fuck me, I really don’t worry much about whether they’re going to put something in between their dick and my pussy. I just take it for granted that they will. I think most people in the Scene would actually be a little insulted by any condom negotiation other than, “so which kind should we use?” I can just imagine the look on some guy’s face if he said he wanted to fuck me, and I said gravely, “well, you have to use a condom.” I think their response would be, “um, duh.”
I love that condom use for PIV/PIA is the norm in the scene, in public or in private. I love that it’s expected, and I love that it’s followed. I even, to a more limited degree, love the way that there’s some social pressure to enforce these norms. Responsible condom use feels like part of someone’s overall good reputation.
What I hate about the condom culture of the (poly) Scene
The default norm of condom use has some serious costs in the Scene, the highest being an anomic situation with regards to fluid-bonding. Anomieis just a fancy French sociological term for saying that we lack clear social norms to guide us in a particular situation, and that that lack of norms creates anxiety and uncertainty, often with a dollop of guilt and shame as well. Since I happen to have an extensive collection of fluid-bound kinks, I find it pretty annoying that my subculture of sexual deviance has so little social support for my kinks–kinks which aren’t even all that kinky, and are in fact shared by a lot of people.
People often create fluid-bound poly groups, but the social norms in favor of condom use are so restrictive that people almost never discuss those fluid-bound groups publicly. Indeed, people are often embarrassed to admit that they’re fluid-bound to multiple partners, even if they’ve been with those partners for years. As a result, there’s no sense of what’s “normal” in a fluid-bound poly group: how long/well do you have to know each other for it to be reasonable to become fluid-bound? How intimate should the relationship be? What rules should guide the behavior of people in a fluid-bound poly group? Without more open and honest discussion about poly fluid-bonding, I think we cause people a lot of undue stress as they end up constantly trying to anxiously reinvent the wheel. I posted my own poly contract long ago on fetlife in an effort to try to get more discussion going in the community, and I regularly get emails from strangers thanking me for providing them with something to go on.
I also hate the way that condoms become symbols of power and status in polyamorous dynamics (mainly through their non-use). The thing is, once you’re fluid-bound with someone, it’s reasonable to give them at least a little control over who you sleep with (in reality, they should probably have some say about your exposure to whatever pathogens you might transmit to them sexually, but people tend to lose sight of that fact). In hierarchical polyamorous dynamics, the norm is that primaries are fluid-bound (which is sometimes very ironic, since many poly people have more sex with people who aren’t their primaries). Consequently, a lot of fluid-bonding negotiations in poly life end up with husbands and wives trying to obtain the privilege of fucking their girlfriend or boyfriend without a condom. I’ve been privy to a lot of these conversations, and most of them are almost comically far removed from concerns about physical safety. Really, the real concern often seems to come down to primaries wanting to preserve their status as primary by ensuring that their partner doesn’t get to have unprotected sex with anyone else. Which is their prerogative, but I personally find it obnoxious.
The amusing corollary of this hierarchical power/status principle is that in anarchical polyamorous dynamics, people tend to assume that fluid-bound partners must be primaries–even if, in reality, you just happen to be fluid-bound to the person that was using birth control, or the person who hates condoms the most, or the person you have the most sex with. Anarchical polys often end up not being fluid-bound with anyone because they don’t want to give up or negotiate the kind of control that happens when you have to worry about someone else’s safety instead of just your own.
I hate the particular way that condoms are symbols of emotional intimacy (again, primarily through their non-use). Really, it’s the converse of this fact that I hate: if non-use of condoms is a sign of emotional intimacy, it means that using condoms is a symbol of emotional distance. Public health campaigns can tell us all they want that loving partners use protection, but we all know that not using condoms is a sign of trust… which inevitably seems to mean that using them is a sign that you don’t fully trust the other person. Or that your fluid-bound partner doesn’t (see above).
The idea that condoms symbolize trust is definitely prevalent in monogamous world as well, but in a very different way. It’s fairly common for monogamous couples to have sex about three times with condoms and then stop using them. But in poly world, that seems shockingly cavalier, since the relationship isn’t “serious enough” at that stage to warrant fluid-bonding. It rarely seems to occur to poly people that because condoms are symbols of emotional intimacy, not using them actually meaningfully contributes to the process of BUILDING intimacy and trust (whether we like that fact or not). Because of the way we treat condoms, we end up insisting that people try to establish relationships and then stop using condoms once they’ve trusted one another for a long time (with no norms about how long is long enough)… and we ask them to ignore the cognitive dissonance that emerges from trusting and loving someone and insisting that for some unclear reason, they still need to use this thing that not using would show that they trusted and loved the person. In short, I hate the way that we use condoms as symbols of emotional intimacy and trust and then try to ignore the implications of doing so, or just pretend that we don’t.
To summarize, what I hate about poly condom culture in the Scene is the barriers that it creates to normal sexual relationship building.
What happened to safety?
I’m constantly amused when I listen to people go on at length about the importance of having safe sex, and then go outside to smoke. Or ride a motorcycle. Statistically speaking, if you’re not in a gay anonymous anal hook-up, smoking and motorcycle riding are much more dangerous. But I realize that in poly life, unlike smoking or motorcycle riding, the safety associated with fluid-bound decisions isn’t just about you. You end up having to make risk calculations for yourself and other people that you love. And that can be really intimidating and frightening.
Let me be very clear: I’m not suggesting some radical shift in how we as a subculture deal with condom use. Not at all. I just want us to be able to have honest and sensible conversations about the non-use of condoms in long-term relationships without so much baggage. I want us to be able to take power and status and nervous shame and bullshit emotional feelings out of decisions about fluid-bonding. I realize that’s a tall order, but when you come right down to it, fluid-bonding is about two things: better sex and trust. You need to want to have better sex with someone, and you need to trust that they’ll follow whatever rules you agree on for having safer sex with other people. That’s it. There are lots of other things that are optional (I personally have no desire to be directly fluid-bound with someone that I’m not romantically involved with, for example), but those are the only things that are necessary.
And when my partners come to me wanting to be fluid-bound with someone else (thus resulting in me being indirectly fluid-bound with someone), my only calculations are these: do I trust that person to follow our safer sex agreements? And if I don’t see that person much, do I trust that my partner is in a position to ensure that person will follow our safer sex agreements? Can I still easily calculate my web of risk if I include this person? And if the answer to those questions is yes, then I say yes.
Because I don’t think we should use condoms as barriers to intimacy, or security blankets of relationship status. I think we should use them to keep everyone as safe as possible from sexually transmitted infections (and pregnancy). And at some point, we should be able to agree that we’re safe enough.
The trick is learning what “safe enough” looks like. We just need more subcultural support to figure that out.
People often wonder how the hell poly people manage that sticky business of fluids. A couple of years ago, my partners and I decided to create an official contract so that we could be comfortable being “fluid-bound” with one another–meaning that we were going to stop using condoms with each other. Since I figured a lot of other people could use a model for creating those sorts of contracts for themselves, I decided to post ours here.
- The “polycule” defined here consists of a fluid-bound group of [partners list].
- For the purposes described here, “fluid-bonding” includes functionally all bodily fluids, both sexual and non-sexual.
- All anal and vaginal intercourse outside the polycule should be protected with barriers.
- All members of the polycule should keep an updated list of people outside of the polycule that they define as “current partners” in a shared google document.
- All members of the polycule should email the shared google group whenever they have anything that could reasonably be defined as sex with someone who is not on their list of “current partners” or in the polycule.
- Any sexual partners of anyone outside the polycule should be aware that anyone within it might ask them about their current testing status and their current partners. And they should be happy about this because it means we value each others’ safety!
- If a condom breaks or goes amiss during intercourse with anyone outside the polycule, it should be immediately reported to all members of the polycule, as should the outside partner’s current testing status, so that subsequent fluid-bonding can be re-evaluated.
- If an unintentional blood-based fluid-exchange occurs (mainly from needles), it should be immediately reported to all members of the polycule for subsequent fluid-bonding re-evaluation.
- The polycule will try to schedule a once-a-month group processing session. If there is nothing to discuss, then we will try to watch a movie together. All processing sessions are to conclude in sex.
- This polycule is not defined as “polyfidelitous”; however, there is an expectation that members will be limiting intercourse with people outside the polycule.
- Members are expected to get screened for STI’s at least once every six months and to check on the testing statuses of any partners outside the polycule.
- This agreement will be re-evaluated and re-negotiated after [date], pending the preferences of all involved, with the default assumption that it will dissolve at that time.