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BEHAVIOR
ORIGINAL RESEARCH
Healthcare Experiences and Needs of Consensually
Non-Monogamous People: Results From a Focus Group Study
Michelle D. Vaughan, PhD,
1
Peyton Jones, BS,
1
B. Adam Taylor, BS,
2
and Jessica Roush, BS
3
ABSTRACT
Background: Individuals engaged in consensual non-monogamy (CNM) face broad and potentially harmful
experiences of sexual stigma in society, yet no published empirical literature has examined the experiences of this
population within the healthcare system.
Aim: The present investigation sought to explore positive and negative experiences of CNM individuals within
the healthcare system, as well as specific needs of these patients regarding inclusive healthcare practices.
Methods: 20 CNM-identified adults from a non-profit organization serving CNM individuals completed a brief
survey and participated in 1 of 3 focus groups of 70 minutes duration centered on their healthcare needs and
experiences.
Outcomes: CNM patients report challenges in addressing their healthcare needs related to lack of provider
knowledge, inadequate preventative screenings, and stigmatizing behaviors that impact their health and trust in
the healthcare system.
Clinical Implications: Healthcare providers must monitor and work to avoid assumptions and pathologization
of individuals who engage in CNM, creating an open, accepting environment to work collaboratively with CNM
individuals to meet their unique sexual health needs.
Strength & Limitations: Although the present sample is diverse with respect to sexual and gender identity and
socioeconomic status, it may not represent the experiences of CNM individuals outside of the midwestern
United States and those who do not identify as polyamorous.
Conclusion: CNM individuals frequently experience sexual stigma in interactions with the healthcare system
that interferes with receipt of sensitive, medically accurate care relevant to their unique needs and experiences.
Vaughan MD, Jones P, Taylor BA, et al. Healthcare Experiences and Needs of Consensually Non-
Monogamous People: Results From a Focus Group Study. J Sex Med 2019;16:42e51.
Copyright 2018, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.
Key Words: Social Stigma; Multiple Partners; Consensual Non-Monogamy; Qualitative Research; Culturally
Competent Care
INTRODUCTION
Characterized by an agreement to romantic and/or sexual re-
lationships based on explicit consent of all partners involved,
studies conducted by U.S. researchers indicate that between
3.5% and 5.0% of individuals are currently engaged in
consensual non-monogamy (CNM) or identify as being engaged
in CNM relationships,
1
with up to 20% of single individuals
reporting experience with CNM.
2
Incorporating polyamory,
swinging, open relationships, and relationship agreements,
3
sci-
entific literature on CNM has been expanding rapidly in the past
decade.
4
CNM individuals are broadly perceived as emotionally un-
healthy, immoral, and engaged in unhealthy, sexually risky re-
lationships
1,5,6
; however, these assumptions have been widely
refuted by empirical research. Across multiple studies, CNM and
non-CNM individuals score similarly on measures of relationship
quality and psychological well-being.
7
Although CNM in-
dividuals are likely to have more lifetime sexual partners than
their monogamous counterparts,
8
there is no evidence that this
Received May 20, 2018. Accepted November 7, 2018.
1
School of Professional Psychology, Wright State University, Dayton, OH,
USA;
2
Aetna Insurance, New Albany, OH, USA;
3
Wexner Medical Center, The Ohio State University, Columbus, OH, USA
Copyright ª2018, International Society for Sexual Medicine. Published by
Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.jsxm.2018.11.006
42 J Sex Med 2019;16:42e51
population has higher rates of sexually transmitted infections
(STIs).
8,9
In fact, evidence indicates that CNM individuals more
frequently engage in STI testing.
8
They are also more likely to
discuss STI testing and partner history with sexual partners,
9
and
they report more consistent and correct use of barriers compared
with other sexually active adults.
8e10
Individuals who engage in relationships or sexual behaviors
that defy social norms (eg, lesbian, gay, bisexual [LGB]) have
long faced the experience of being stigmatized, devalued, ste-
reotyped, and/or discriminated against for deviating from these
norms.
11
Such experiences may be contextualized as forms of
minority stress and may be a critical factor in health disparities in
LGB populations.
12,13
Evidence of sexual stigma via explicit and
implicit biases by healthcare providers toward lesbian and gay
individuals
14
and those who engage in sexually “kinky”
behavior
15
has been established. Physicians have acknowledged a
reluctance/hesitance to conduct a thorough sexual health history
with patients who may have same-gender attractions.
16
Such
biases may have deleterious effects on judgments/decisions about
patient care, lack of trust, and poor communication with pro-
viders, especially in the context of stigmatized or sensitive
topics,
17
including sexuality.
As part of their Clinical Prevention Guidance, the Centers for
Disease Control and Prevention (CDC)
18
has called for in-
terviewers to demonstrate respect, compassion, and a non-
judgmental attitude toward patients to obtain a complete and
accurate sexual history. This history should include questions
about the number and gender of the patient’s recent sexual
partners (and any additional sexual partners that their partners
may have), sexual behaviors, as well as STI/HIV and pregnancy
prevention practices. They also explicitly recommend gathering
data about the sexual behavior of the patient’s sexual partners and
providing STI/HIV testing services for all patients with multiple
current sexual partners.
Within the context of CNM, mononormativity is a unique
subtype of sexual stigma that promotes monogamy as the
expectation and the only healthy standard for romantic/sexual
relationships.
19,20
These internally held biases often are expressed
toward CNM individuals, who report judgmental attitudes,
verbal shaming about having multiple partners, and the
assumption by others that they must have or be at elevated risk
for STIs.
21
However, exceptionally little is known within the
scientific literature about the needs and experiences of this
unique population.
22
In an unpublished doctoral dissertation,
Witherspoon,
23
in a sample of more than 1,220 adults currently
engaged in consensual non-monogamy, found that 20.3% re-
ported at least 1 experience of explicit discrimination from a
medical doctor, 19% reported discrimination from a mental
health provider, and 9% reported discrimination from other
providers associated with their CNM status. Within the domain
of mental health services, another study found that 38% of
CNM individuals concealed their status from their provider
owing to fear of being stigmatized, and 10% of those who had
disclosed their status reported a negative response from their
provider.
24
In the sole (unpublished) study of CNM healthcare experi-
ences, McCrosky et al
25
interviewed 9 polyamorous women on
their experiences with providers, barriers to access, and adaptive
strategies they used to meet their needs. The women expressed a
strong desire for open, honest relationships with providers and a
commitment to monitoring their sexual health through frequent,
broad-based STI testing. They reported a lack of provider
knowledge about CNM, and a lack of provider interest in/effort
to assess risk-reduction practices (eg, condom use). Most re-
ported experiences of judgment related to CNM, including un-
professional remarks about their sexual behavior, refusal to
provide treatment, and a request to not return to the provider’s
office. Fear and frustration led many participants to prescreen
potential providers, carefully manage decisions about disclosure,
seek services outside of their primary care provider, or delay/
avoid necessary care.
Based on these studies, evidence exists that CNM individuals
frequently experience sexual stigma in a variety of contexts that
may have important implications for healthcare practice and
sexual health outcomes. However, given the dearth of published
literature on the sexual healthcare experiences of CNM in-
dividuals, little is known about the specific needs and experiences
of this population with respect to accessing and receiving high-
quality sexual health care.
The present investigation sought to address this gap in the
literature through a qualitative/focus group study to provide
initial data on the needs and experiences of CNM individuals
within the context of health care. Given the lack of existing
empirical research on CNM health care, the present study was
exploratory in nature, seeking to compare trust in healthcare
providers between our CNM patient sample and other (pre-
sumably monogamous) patient samples and to explore the nature
of CNM individuals’healthcare needs, relevant experiences
within the healthcare system, and recommendations for health-
care provider training and practice.
METHODS
This study was approved by the Institutional Review Board at
Wright State University. The research team included a female
doctoral-level counseling psychologist and researcher, a male
clinical psychologist-in-training with a bachelor’s degree and
graduate training (both with graduate training in qualitative
methods), and 2 registered nurses (1 male and 1 female) with
bachelor’s degrees. The initial research question for this project
was proposed to the first author by a leader of a regional
polyamory-themed non-profit organization, and feedback from
members of this community was solicited during the develop-
ment and refinement of focus group questions.
After providing informed consent, participants completed a
demographic survey that included several questions about their
J Sex Med 2019;16:42e51
CNM Healthcare Experiences 43
CNM style, current relationships, and trust in and disclosure of
CNM to healthcare providers. Each participant was asked to
provide a pseudonym to allow their responses on the survey to be
matched with their focus group data. No personally identifiable
information was solicited or retained, and participants were free
to not respond to any survey or focus group question or dis-
continue participation at any time. References to names of spe-
cific providers or names of partners were deidentified to protect
participant confidentiality. All focus group sessions were audio-
recorded. All data/devices were physically secured by the re-
searchers during the recording/transcription process and stored in
a locked cabinet. All electronic files were maintained in a secure
(private) storage system that was not accessible to individuals
outside of the research team.
Study participants were adults (age 18 years) who self-
identified as CNM individuals or currently practiced any form
of CNM (eg, polyamory, open relationship, swinging) and were
fluent in English. Participants were recruited via convenience
sampling from a midwestern polyamory-themed organization
through in-person announcements regarding the study, its goals,
and the background of the researchers at a monthly educational
meeting of the group. 3 focus groups (each with 3e10 partici-
pants, for a total of 20 participants) were held between April and
May 2017, were facilitated by the either the first or second
author (M.D.V. or P.J.) and were 40e70 minutes in length. 2
focus groups were held in private meeting rooms during a
monthly meeting of the polyamory-themed non-profit organi-
zation. A third focus group was held in a private location at the
request of several members of the organization who were unable
to attend the original focus groups. No other individuals other
than the participants and the interviewers were present during
the focus groups.
The focus groups used a series of 4 semistructured questions
centered on their experiences as a CNM individual relevant to (i)
healthcare needs, (ii) how/where they attempt to get those needs
met, (iii) experiences with healthcare providers, (iv) factors
impacting disclosure of status, and (v) recommendations/needs
from healthcare providers. References to names of specific pro-
viders or names of partners were anonymized to protect partic-
ipant confidentiality. Audio recordings were transcribed verbatim
by the second author (P.J.) and reviewed for accuracy by the first
author (M.D.V.).
Outcome Measures
The Trust in Health Care Providers subscale of the Multi-
dimensional Trust in Health Care Systems Scale
26
was used to
assess participants’level of trust in their providers. The subscale
consisted of 10 Likert-type items ranked on a 5-point scale,
with total scores ranging from 10 to 50. The scale demonstrated
high reliability (a¼0.89) and evidence of convergent and
divergentvalidity.Asampleitemfromthesubscaleis“My
health care provider is usually considerate of my needs and puts
them first.”
Data Analysis
Demographic data and analysis of the Trust in Health
Care Providers scale was summarized and analyzed using SPSS
version 23 (SPSS Corp, Armonk, NY, USA).
27
A 1-sample t-test
Table 1. Demographic characteristics of the study sample
(N ¼20)
Characteristic n Valid %
Age
18e29 y 8 40
30e44 y 9 45
45e64 y 3 15
Gender identity*
Cisgender man 8 40
Cisgender woman 9 45
Transgender woman 2 10
Genderqueer/gender non-conforming 1 5
Genderfluid 1 5
Sexual identity*
Lesbian 2 10
Gay 1 5
Bisexual 5 25
Pansexual/omnisexual 5 25
Queer 2 10
Sexually fluid 1 5
Gray/asexual 2 10
Heterosexual/straight 6 30
Sexual orientation*
Attracted to men 14 70
Attracted to women 15 75
Unsure of attraction 1 5
No attraction 1 5
Attracted to folks outside of binary 10 50
Race/ethnicity
African American/black 1 5
Biracial/multiracial 1 5
Caucasian/white 17 85
Other 1 5
Type of CNM
Polyamorous 17 85
Swinger 1 5
Relationship/sexual agreement 2 10
Socioeconomic status
Poor 3 15.8
Working class 4 21.1
Middle class 8 42.1
Upper middle class 4 21.1
Marital status
Single (never married) 7 35
Married 7 35
Divorced 5 25
Separated 1 5
CNM ¼consensual non-monogamy.
*Percentages may exceed 100% because participants could choose more
than 1 option.
J Sex Med 2019;16:42e51
44 Vaughan et al
(1-tailed) was used to examine whether trust in healthcare pro-
viders differed significantly from those of the standardization
sample for the measure. Power analysis for a 1-sample t-test was
conducted in G*POWER
28
to determine a sufficient sample size
using an avalue of 0.05 and a power of 0.80, assuming a large
effect size (d¼0.8), and 1-tailed hypotheses. Based on the
aforementioned assumptions, the desired sample size was 12.
The researchers used a thematic analysis approach of Braun
and Clarke
29
for the analysis of the qualitative data from the
focus group interviews. Open, inductive coding was conducted
independently by the first 2 authors (M.D.V. and P.J.) in an
iterative process to identify candidate themes and subthemes.
Discrepancies/disagreements were resolved via discussion be-
tween the coders until consensus was reached over the course of 4
coding meetings until data saturation was obtained. Themes and
subthemes were independently applied to participant responses
and discussed in a final coding meeting until consensus was
reached on codes for each individual response. Themes and
subthemes were shared and discussed with 4 focus group
members for additional validation. All provided confirmation of
these themes as consistent with experiences they heard described
in their respective focus groups.
RESULTS
We collected qualitative and demographic data from 20 par-
ticipants (Table 1). No participants dropped out of the study.
The participants ranged in age from 19 to 60 years (mean age
36.15 ±10.68 years). Most were white (85%), cisgender (90%),
and had at least some college education (85%). The majority of
the sample identified as polyamorous (85%), with a sample
average of 4.47 ±3.08 sexual partners (range 1e12 partners) in
the past 12 months.
90% of the sample reported currently having health insurance.
90% had disclosed their CNM status at least once to a healthcare
provider, with most reporting they had disclosed their CNM
status once or twice (n ¼6; 30%) or several times (n ¼9; 45%).
Participants reported an average level of trust in healthcare pro-
viders of 33.90 ±6.10. Compared with the standardization
sample for this subscale, CNM participants had significantly
lower trust in healthcare providers [t(17) ¼e4.645; standard
error of the mean 1.405; P<.0001, 1-tailed; 95% CI, e9.493 to
e3.563; Cohen’sd¼e1.09].
Analysis of the qualitative data yielded 4 major themes and 5
subthemes (Table 2).
Theme 1: Ignorance of CNM
A common negative experience among individuals in the
sample centered on healthcare providers demonstrating a lack of
awareness regarding the existence of non-monogamous re-
lationships and explicit assumptions that the participants were
monogamous. These participants reported never being asked
about their relationship style or number of partners. This was
reported primarily by cisgender men and women who were le-
gally married to a partner of a different gender:
Mara (married, white, cisgender, bisexual polyamorous
woman): My gynecologist and, you know, she offered up all
the type of tests for everything and then one year—and I
wasn’t out to her that I was poly—and then one year she
was like, “Oh you’re in a monogamous relationship with
your husband, you know, we don’t really need to give you
this, this, and this.”And I was like, “Oh, you just assumed
that.”
Lack of awareness or knowledge of relevant medical standards
and insurance coverage for preventative care related to the sexual
health of individuals with more than 1 recent sexual partner was
also noted:
Jo (married, white, cisgender, bisexual polyamorous
woman): And I think that’s a whole other job. That’sa
whole other ball of wax. What’s covered? What isn’t
covered? They don’t always know. Then you’re asking and
they’re like, “Well if you’re monogamous, and that’snot
going to be covered.”“But I’m not [monogamous].”“Well,
I don’t know.”
Subtheme: Pressure to Educate Providers
Another experience inherently linked to the ignorance of
providers regarding types of non-monogamy was the broad
perception that providers appeared to lack formal education
regarding diverse relationship structures and concepts/terms/ex-
periences related to CNM. This lack of accurate knowledge often
led these patients to feel pressured to/need to take on the role of
educator with their provider:
Tess (married, white, pansexual, genderfluid, polyamorous
person): I have pretty much the same thing as Jo said. Um,
Table 2. Thematic analysis results: Healthcare needs/experiences
Theme Subtheme
Ignorance of CNM
Pressure to
educate providers
Inadequate screening
Sexual stigma
Stigma reactions
Stigma-avoidance
efforts/seeking CNM-inclusive
providers
Experiences of CNM-inclusive care
Open-mindedness
and acceptance
Meeting healthcare
needs/requests
CNM ¼consensual non-monogamy.
J Sex Med 2019;16:42e51
CNM Healthcare Experiences 45
just asking for HIV/STD testing it’s like, “Well, you had
one last year, why do you need one now?”“Well, because
there’s a possibility there could be other people involved.”
“Oh, if he tested negative 6 months ago, you’re fine.”“Uh,
nooooo. Even if he tested negative, no.”
Ann (single, white, transgender, lesbian/queer polyamorous
woman): When we do find someone at that level, we have
to educate them (nods in agreement from other partici-
pants). “So well, what’s that mean?”or “Are you active with
everyone? At the same time or different times?”A lot of
times when I disclose that to medical professionals and
others, I end up being an educator.
Subtheme: Inadequate Screening
This lack of knowledge about the existence of multiple sexual
relationships, and CNM relationships in particular, often led to
experiences with providers making inaccurate assumptions
regarding health risks that directly impacted the screening pro-
cess. These included the assumptions that all CNM individuals
always have multiple sexual partners, engage in high-risk sexual
behaviors, and will invariably contract STIs and have other sexual
health problems. These assumptions all directly impacted the
ability to receive a thorough, accurate preventative health
screening, with participants repeatedly noting that their providers
failed to ask them about their safer sex practices (eg, use of
barriers, testing schedule) or the practices of their sexual partners,
even when they disclosed their CNM status:
Luna (single, African American/black, cisgender, hetero-
sexual polyamorous woman): One of my partners, she kept
on having medical issues. None of the doctors could figure
out what it was. So the doctor.assumed it was an STI. We
all got tested. We all came out clean. They were so focused
on saying that it’s some type of STI than trying to figure out
what the actual reason was. It seemed like they were focused
on that because she told them she was in a poly relation-
ship. It’s kind of like they hear “risk factor”and all medical
knowledge stops until they’re able to factor out the
“obvious”STI that actually never existed.they focused so
much energy on proving that it was an STI.
Participants also experienced a lack of provider interest in
gathering relevant sexual health information critical to making
an accurate, informed assessment of their sexual health risks
and related healthcare needs. Several participants noted that
they appeared to have greater knowledge of effective risk
reduction practices regarding STIs than their healthcare pro-
viders (eg, testing, barrier use/agreements, human papilloma-
virus [HPV] vaccines, communication about safer sex practices
among partners and their partners). They were frequently
disappointed that providers failed to ask about or acknowledge
their efforts to maximize their own health and safety and that of
their partners:
Tina (single, white, cisgender, pansexual polyamorous
man): My experience in general is to say, “I’ve done this,
and I’ve had these experiences,”and you just get judged for
it or at least go into this talk about “Let’s talk about the
dangers of STIs”or stuff like that, having full knowledge of
the dangers of STIs, and having long conversations with
partners before I do anything with them. So at a certain
point, it would be nice if I could just get tested and not
have to go through these conversations. I feel like I should
go to the doctor and not have to feel like I have to defend
my lifestyle. But oh well.
Kinsey (single, white, cisgender, heterosexual polyamorous
man): They’re saying like, ‘Well that’s risky, and you
shouldn’t behave in that manner.”And so just being like,
“Well this is my thing, and here’s the things I do to
minimize it,”they don’t care that I was using protection or
any of the other kind of stuff.
Theme 2: Sexual Stigma
Explicit and implicit experiences of judgment and shock from
healthcare staff were widely reported by participants and char-
acterized as highly stressful. Several participants described “raised
eyebrows”and “dirty looks”directed at them and their partners,
avoidance of eye contact, and a condescending tone after the
provider/staff became aware of their CNM status:
Kinsey (single, white, cisgender, heterosexual polyamorous
man): I walked out of that room feeling horribly embar-
rassed, very shamed, very judged, and to be frank, I felt
dirty from it [the visit].
Providers’inaccurate assumptions about CNM individuals
and their relationships were also commonly reported, as was
judgmental language. Unsolicited, unwanted advice regarding
participants’relationship choices and partners were also repeat-
edly discussed:
Gree (single, white, cisgender, heterosexual, grey/asexual
polyamorous man): I go to see my regular doctor, and they’re
like, “Well maybe if you came up with a more ‘stable’envi-
ronment, maybe these other symptoms [depression] can go
away.”And I was like, “No, these don’t work like that.-
thank you for your judgment. Let’s move on.”
Luna (single, African American/black, cisgender, hetero-
sexual polyamorous woman): They [my providers] told me
that if I wasn’t so sexually promiscuous, I wouldn’t have to
spend so much money to get tested and that maybe I should
just find a man (laughs), and stop “sleeping around.”
Subtheme: Stigma Reactions
In the context of these experiences of judgment, immediate
reactions of anger/frustration toward providers and fear about the
J Sex Med 2019;16:42e51
46 Vaughan et al
quality and/or confidentiality of their healthcare experiences were
reported:
Mischa (married, white, cisgender, pan/omnisexual poly-
amorous woman): I think it’s especially frustrating when
you come in for your STI test that is part of your safer sex
practice, and you get treated like you’ve never heard of such
a thing as an STI, or that you don’t know that there are
risks to having sex with multiple partners. Of course I know
that, like, we talk about that all the fucking time.
Duchess (married, white, cisgender, heterosexual poly-
amorous man): One of my partners who was taking care of
a patient, she’s a healthcare provider. The cardiothoracic
surgeon, the guy that operates on your heart, walked out of
the room and said “What a hoe.”(Gasps from other par-
ticipants). Because the patient was in there with her hus-
band and her boyfriend.
Such experiences of judgment were frequently followed by
decisions to withhold sexual health information (eg, number of
current partners, status as a CNM individual) from staff in future
visits or reluctance to return to a particular provider/office:
Luna (single, African American/black, cisgender, hetero-
sexual polyamorous woman): He [my provider] thought he
was doing me a favor [by telling me to become monoga-
mous]. I guess he thought he was “dadding”me, but after
that I stopped telling my healthcare providers about my
sexual habits.
Many sought supplementary testing services at community
STI/sexual health clinics after a negative experience with another
provider. Others discussed how they created emotional distance
between themselves and providers after experiencing a stigmatizing
interaction and chose to stay with that provider for other reasons:
Jo (married, white, cisgender, bisexual polyamorous
woman): Can I kind of look at you as a medical ATM? I’ll
come to you when I need a specific service, and you’ll spit
that out for me, and it will really be a consumable
transaction.
Theme 3: Stigma-Avoidance Efforts/Seeking CNM-
Inclusive Providers
Participants discussed a variety of strategies to identify pro-
viders that might accept their CNM status and relationships,
including asking other CNM individuals for recommendations.
Others sought out public health clinics or local Planned
Parenthood offices to satisfy their agreements within their sexual
network for frequent, broad-based testing. Prescreening of pro-
viders was also a common strategy, including searching provider/
practice websites for information that indicated open-
mindedness/comfort with sexuality, LGBTQþpeople, same-
gender relationships, and/or lack of explicitly religious
language. Others conducted prescreenings to evaluate whether a
provider and their staff was worth the risk:
Darla (single, white, cisgender, grey/asexual polyamorous
woman): I’ve been calling around asking people, “Well is
this doctor someone that’s cool with someone that’s poly-
amorous?”“Well what does that mean?”“Well ask the
doctor and find out, and call me back before I schedule this
appointment.”And they’re like, “The doctor’snot
comfortable with seeing you as a patient.”“Okay, thanks,”
and then I move on.
Theme 4: CNM-Inclusive Care
Specific wants and needs from healthcare providers and staff
were highly consistent across participants in all groups, centering
on the overall interpersonal approach to working with members
of the sexual minority group and the specific services/practical
needs that would allow them to effectively monitor and optimize
their own sexual health as well as the health of members of their
sexual network.
Subtheme: Open-Mindedness and Acceptance
As an overarching theme across nearly all CNM participants in
the sample was a strong desire for accepting, non-judgmental
interactions from healthcare providers and staff to establish a
trusting, collaborative relationship with their providers:
Jo (married, white, cisgender, bisexual polyamorous
woman): [If you are] asking me an open-ended question,
then I don’t feel like you’re prejudging already.you’re
letting me tell you about my life. I think that’s really
helpful. That made me feel like, “Oh, he’s really interested
in me. He’ll listen. He won’t judge.”
How staff reacted to disclosures of CNM was also seen as an
indicator of open-mindedness and respect, incorporating tone
and non-verbal cues around discussion of partners/relationship
status, sexual behaviors, and related healthcare needs as well as
thoughtful choice of language:
Abigail (divorced, white, cisgender, heterosexual poly-
amorous woman): I think just an open mind [is critical].
And even if you have judgment, you have those thoughts
of, like, “I could never do that,”or “That isn’t right,”or “I
really don’t agree with this,”not letting that come out in
your actions, not letting that come out in your tone of
voice, or even the look that you give, because people pick
up on things like that. You can really shut a conversation
down, like a conversation that needs to happen.
When these needs were met, participants described experi-
ences of genuine interest, curiosity, and commitment to
expanding their own knowledge/skills about CNM relationships
from providers, even when the terms and concepts were unfa-
miliar to them:
J Sex Med 2019;16:42e51
CNM Healthcare Experiences 47
Ann (single, white, lesbian/queer transgender polyamorous
woman): I disclosed that I’m poly, and she just stopped and
she was like, “Okay, I’m not quite sure what that means.
Can you explain it to me?”And I discussed on how it went,
and she was like, “Okay, alright, so I’ll want to do this.”It’s
the fact that she paused and asked.
Darla (single, white, cisgender, asexual polyamorous
woman): The old OBGYN that I used to see, she stopped
seeing patients and started doing premi [premium] health-
care, which is great for her and her practice. She was like, “I
don’t really care what y’all do as long as you’re honest with
me about doing it, because I don’t want to treat you for
something and then find out you have something else.”
Because that would totally suck.
Subtheme 5: Meeting Healthcare Needs/Requests
Participants repeatedly voiced the specific need for providers to
work with them to provide frequent, customized STI testing to
fulfill agreements made within their sexual networks. Protection of
confidentiality as well as easy access to sharing official copies of
testing results for members of participants’sexual networks was also
repeatedly mentioned as part of this inclusive approach to care:
Red (single, white, transgender pansexual woman): Actually,
I think I have a little bit different side of that. So every 6
months, I get bloodwork for other issues, but the nice part
about it is.[that] when my doctor sends my bloodwork, I’m
like, “Okay, I need all of this [STI tests] extra.”They’re aware
of my relationship status, and they’re like, “Okay! Whatever.”
Kinsey (single, white, cisgender, heterosexual polyamorous
man): Sexual health tends to be of a premium concern of
making sure, not just for myself, but for all of my partners,
not just that I am.but being able to verify and provide
that type of information and security that everything is
good with my sexual health.
Incorporating a strong desire for an open and collaborative
relationship with providers about their sexual health, participants
repeatedly requested that providers conduct a comprehensive
assessment of their actual STI risk (eg, type/frequency of sexual
behaviors, barrier use, STI status of partners) and work with
them to access affordable coverage of frequent testing and/or
relevant vaccines (eg, HPV):
Kinsey (single, white, cisgender, heterosexual polyamorous
man): Become a better advocate for me, to help assist me in
terms of I’m gonna make my life choices, help me make my
health choices. So instead of saying, “Well, don’tbe
involved with a particular behavior,”say “How can we
make healthier choices within those behaviors?”Since this is
going to be my lifestyle, how can we do that [prevent
transmission of infections]?
DISCUSSION
The present empirical study provides critical insight into the
impact of mononormativity and sexual stigma on the healthcare
experiences of CNM patients. Consistent with findings from
other sexually stigmatized populations,
15
our CNM participants
were committed to promoting the health of their sexual health
network through a collaborative relationship with providers who
demonstrated respect and open-mindedness for their relation-
ships and sexual choices. Experiences of mononormativity and
sexual stigma from providers and staff served as major obstacles
to these goals. These experiences of minority stress produced
negative emotional and behavioral reactions in the CNM par-
ticipants that compromised their relationships with providers and
their access to sexual health services. These instances of antici-
pated and experienced stigma have been identified as predictors
of negative health outcomes in individuals with other concealable
stigmatized identities,
30
including LGBT-identified
31
and kink-
oriented patients.
15
These results demonstrate a critical need for training and
recommendations about CNM-inclusive practices/skills for
healthcare providers and staff. Foundational training on human
sexuality/relationships within healthcare curricula must include
CNM and relevant subgroups (eg, polyamory, open relation-
ships, swingers, relationship agreements, relationship anarchy)
and explicitly address CNM myths and other mononormative
assumptions regarding STIs, sexual behavior, safer sex practices,
and relationship dynamics. Incorporation of scientific research
refuting these myths and addressing widespread implicit bias
against CNM people/relationships is critical,
10,32e34
as is work
that highlights the potential strengths and benefits of CNM
relevant to health and well-being.
6
Given that higher levels of provider knowledge and more
positive attitudes toward sexual minorities predict the likelihood
of conducting comprehensive sexual health histories in LGBT
patients,
35
CNM-specific education in these domains is war-
ranted. Exposure to CNM individuals during professional
training may also be highly beneficial to develop a base of
scientifically accurate knowledge and reduce implicit bias and
stigmatizing reactions,
17
while maintaining the responsibility on
providers and their supervisors (as opposed to patients) for
enhancing their education.
Promoting sexual health is a shared responsibility between
providers and patients. According to Kitts,
16
physicians should
routinely obtain a comprehensive sexual history from patients to
help those who identify as a sexual minority feel more
comfortable disclosing certain identities and behaviors. Recom-
mendations from both Sabin et al
15
and Zestcott et al
18
include
more education on sexual minorities and their specific health
concerns in clinical training programs to reduce the likelihood of
implicit biases. Physicians also should gain greater familiarity
with members of marginalized groups through community
outreach (eg, local CNM organizations, speaker’s panels),
J Sex Med 2019;16:42e51
48 Vaughan et al
because personal contact has been found to foster accepting at-
titudes and diminish prejudice.
17
Consistent with the descriptions of inclusive and affirming
provider behaviors among those with little CNM training or
experiences, training rooted in development of cultural humility
may be particularly valuable for healthcare providers serving this
population.
36
Built on mutual respect and collaboration, this
framework focuses explicitly on valuing the patients’expertise,
acknowledging the power imbalance between provider and pa-
tient, and cultivating a commitment to lifelong self-reflection
and self-critique on behalf of the provider.
36
Cultural humility
training has been successfully incorporated into training for
medical residents, with evidence of increased provider atten-
tiveness to patient experience and patient involvement in care.
37
Given that numerous studies have found a positive relationship
between collaborative, patient-centered communication (eg,
empathic physician responses, providerepatient agreement,
shared decision making), patient satisfaction with care,
38
and
health outcomes (eg, symptoms, functioning, physiological
measures),
39
approaches centered in cultural humility may be
particularly useful in building trust between CNM patients and
their providers and promoting relevant health outcomes.
Provider and staff commitment to inclusive language and
respect for diverse relationship structures is also essential, as is
sexual history-taking practices that promote open, honest
communication.
9
Consistent with the aforementioned published
recommendations from the CDC,
18,40
the National Coalition
for Sexual Health,
41
and others,
42
explicit, open-ended questions
regarding sexual behaviors, number and gender(s) of sexual
partners, and the use of risk-reduction/safer sex strategies should
be included. Because having multiple sex partners or having a
partner with multiple other partners is considered a de facto risk
factor for STIs by the CDC,
40
providers should work with CNM
individuals to support their commitment to frequent, broad-
based STI testing to maximize sexual health. Explicit, non-
judgmental questions regarding the sexual behaviors, safer sex
practices, and testing practices of other members of the sexual
health network may also be beneficial to ensure more accurate
risk assessment.
32
Other CNM-inclusive healthcare practices
may include secure sharing of test results with members of the
patient’s sexual health network, identifying multiple emergency
contacts, and exploring needs for long-term highly effective birth
control, preexposure prophylaxis, and/or HPV vaccines
depending on the gender of their partners and specific risk factors
and needs.
Limitations
This largely qualitative investigation relied on a small sample
from a single geographic area, with predominantly white,
polyamorous-identified participants. Moreover, because the
sample was drawn from a polyamory-themed social/educational
non-profit in a larger Midwestern city, these participants’
experiences might not be representative of individuals practicing
types of all types of CNM (eg, swingers, those in open re-
lationships), those who are less “out”about their CNM status,
those in rural settings, or those in other areas of the United
States. Significant caution should be exercised in any attempts to
generalize these results to all CNM individuals.
Future Research
Research on providers’attitudes, knowledge, training, and
experience with CNM patients and their behaviors will be
essential for documenting their ability to provide inclusive/
competent care. Foundational literature identifying possible
health disparities that may exist in CNM individuals is needed to
provide a wider context to the healthcare needs of this popula-
tion. Quasi-experimental work may be particularly useful in
investigating the degree to which providers can accurately
perceive/assess the sexual health risks of mock CNM patients
31
and identify predictors of CNM-inclusive providers/behaviors.
Work in this area should seek to explore healthcare experi-
ences engaged in other geographic areas, those practicing other
forms of CNM (eg, open relationships, swinging), and CNM
individuals who are members of other stigmatized groups. In
particular, it may be highly valuable to conduct qualitative in-
vestigations of the needs/experiences of CNM individuals who
are people of color, transgender, and/or of lower socioeconomic
status to understand how intersecting factors impact their
healthcare needs and experiences. Explicit use of the minority
stress model
12,13
and literature on sexual stigma and mono-
normativity may be particularly useful in this context.
CONCLUSION
CNM patients have unique healthcare needs that can be
addressed through a commitment to an open, collaborative
relationship rooted in a foundational understanding of CNM
individuals and relationships while incorporating existing
evidence-based recommendations for inclusive sexual health
assessments and services. Healthcare offices will enhance the
education of their providers and staff by providing training that
includes information about CNM and exposure to CNM in-
dividuals. Healthcare providers and staff should commit to
using respectful, non-judgmental language while discussing
sexual behaviors, number and gender of sexual partners, and
safer sex strategies with patients.Additionally,askingopen-
ended questions provides patients with opportunities to
advocate for themselves and fosters a collaborative, open
providerepatient relationship. As scientific research on CNM
continues to rapidly expand, more patients may disclose
CNM relationships or behaviors to their healthcare providers.
Providers have a duty to educate themselvesonthispopulation
and implement evidence-based practices to better serve CNM
individuals.
J Sex Med 2019;16:42e51
CNM Healthcare Experiences 49
Corresponding Author: Michelle D. Vaughan, PhD, School of
Professional Psychology, Ellis Human Development Institute,
Wright State University, 9 N Edwin C. Moses Blvd, Dayton,
OH 45402-8470. Tel: 937-775-4300; Fax: 937-775-4323;
E-mail: michelle.vaughan@wright.edu
Conflicts of Interest: None to report.
Funding: None.
STATEMENT OF AUTHORSHIP
Category 1
(a) Conception and Design
Michelle Vaughan; Peyton Jones
(b) Acquisition of Data
Michelle Vaughan; Peyton Jones
(c) Analysis and Interpretation of Data
Michelle Vaughan; Peyton Jones
Category 2
(a) Drafting the Article
Michelle Vaughan; Peyton Jones; Adam Taylor; Jess Roush
(b) Revising It for Intellectual Content
Michelle Vaughan; Peyton Jones
Category 3
(a) Final Approval of the Completed Article
Michelle Vaughan; Peyton Jones
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