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Healthcare Experiences and Needs of Consensually Non-Monogamous People: Results From a Focus Group Study

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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;16:42-51.
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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 specic needs of these patients regarding inclusive healthcare practices.
Methods: 20 CNM-identied adults from a non-prot 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-
entic 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 patients 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 patients 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
scientic 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 providers
ofce. 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 specic 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 individualshealthcare 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 bachelors degree and
graduate training (both with graduate training in qualitative
methods), and 2 registered nurses (1 male and 1 female) with
bachelors degrees. The initial research question for this project
was proposed to the rst author by a leader of a regional
polyamory-themed non-prot organization, and feedback from
members of this community was solicited during the develop-
ment and renement 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 identiable
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-
cic providers or names of partners were deidentied to protect
participant condentiality. 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 les 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-
identied as CNM individuals or currently practiced any form
of CNM (eg, polyamory, open relationship, swinging) and were
uent 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 rst 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-prot 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 specic pro-
viders or names of partners were anonymized to protect partic-
ipant condentiality. Audio recordings were transcribed verbatim
by the second author (P.J.) and reviewed for accuracy by the rst
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 participantslevel 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.AsampleitemfromthesubscaleisMy
health care provider is usually considerate of my needs and puts
them rst.
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
Genderuid 1 5
Sexual identity*
Lesbian 2 10
Gay 1 5
Bisexual 5 25
Pansexual/omnisexual 5 25
Queer 2 10
Sexually uid 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 signicantly 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 sufcient 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 rst 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 nal 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 conrmation 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 identied 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 signicantly
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; Cohensd¼e1.09].
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 yearand I
wasnt out to her that I was polyand then one year she
was like, Oh youre in a monogamous relationship with
your husband, you know, we dont 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 thats a whole other job. Thatsa
whole other ball of wax. Whats covered? What isnt
covered? They dont always know. Then youre asking and
theyre like, Well if youre monogamous, and thatsnot
going to be covered.”“But Im not [monogamous].”“Well,
I dont 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, genderuid, 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 its like, Well, you had
one last year, why do you need one now?”“Well, because
theres a possibility there could be other people involved.
Oh, if he tested negative 6 months ago, youre ne.”“Uh,
nooooo. Even if he tested negative, no.
Ann (single, white, transgender, lesbian/queer polyamorous
woman): When we do nd someone at that level, we have
to educate them (nods in agreement from other partici-
pants). So well, whats 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 gure
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 its some type of STI than trying to gure 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. Its kind of like they hear risk factorand all medical
knowledge stops until theyre able to factor out the
obviousSTI 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, Ive done this,
and Ive had these experiences,and you just get judged for
it or at least go into this talk about Lets talk about the
dangers of STIsor 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): Theyre saying like, Well thats risky, and you
shouldnt behave in that manner.And so just being like,
Well this is my thing, and heres the things I do to
minimize it,they dont 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
eyebrowsand dirty looksdirected 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].
Providersinaccurate assumptions about CNM individuals
and their relationships were also commonly reported, as was
judgmental language. Unsolicited, unwanted advice regarding
participantsrelationship 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 theyre
like, Well maybe if you came up with a more stableenvi-
ronment, maybe these other symptoms [depression] can go
away.And I was like, No, these dont work like that.-
thank you for your judgment. Lets move on.
Luna (single, African American/black, cisgender, hetero-
sexual polyamorous woman): They [my providers] told me
that if I wasnt so sexually promiscuous, I wouldnt have to
spend so much money to get tested and that maybe I should
just nd 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 condentiality of their healthcare experiences were
reported:
Mischa (married, white, cisgender, pan/omnisexual poly-
amorous woman): I think its especially frustrating when
you come in for your STI test that is part of your safer sex
practice, and you get treated like youve never heard of such
a thing as an STI, or that you dont 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, shes 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/ofce:
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 daddingme, 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? Ill
come to you when I need a specic service, and youll 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 ofces 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): Ive been calling around asking people, Well is
this doctor someone thats cool with someone thats poly-
amorous?”“Well what does that mean?”“Well ask the
doctor and nd out, and call me back before I schedule this
appointment.And theyre like, The doctorsnot
comfortable with seeing you as a patient.”“Okay, thanks,
and then I move on.
Theme 4: CNM-Inclusive Care
Specic 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 specic 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 dont feel like youre prejudging already.youre
letting me tell you about my life. I think thats really
helpful. That made me feel like, Oh, hes really interested
in me. Hell listen. He wont 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 isnt right,or I
really dont 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 Im poly, and she just stopped and
she was like, Okay, Im 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 Ill want to do this.Its
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
dont really care what yall do as long as youre honest with
me about doing it, because I dont want to treat you for
something and then nd out you have something else.
Because that would totally suck.
Subtheme 5: Meeting Healthcare Needs/Requests
Participants repeatedly voiced the specic need for providers to
work with them to provide frequent, customized STI testing to
fulll agreements made within their sexual networks. Protection of
condentiality as well as easy access to sharing ofcial copies of
testing results for members of participantssexual 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, Im
like, Okay, I need all of this [STI tests] extra.Theyre aware
of my relationship status, and theyre 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 Im gonna make my life choices, help me make my
health choices. So instead of saying, Well, dontbe
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 ndings 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 identied as predictors
of negative health outcomes in individuals with other concealable
stigmatized identities,
30
including LGBT-identied
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 scientic 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 benets 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-specic education in these domains is war-
ranted. Exposure to CNM individuals during professional
training may also be highly benecial to develop a base of
scientically 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 specic 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, speakers 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 afrming
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 patientsexpertise,
acknowledging the power imbalance between provider and pa-
tient, and cultivating a commitment to lifelong self-reection
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 benecial to ensure more accurate
risk assessment.
32
Other CNM-inclusive healthcare practices
may include secure sharing of test results with members of the
patients 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 specic risk factors
and needs.
Limitations
This largely qualitative investigation relied on a small sample
from a single geographic area, with predominantly white,
polyamorous-identied participants. Moreover, because the
sample was drawn from a polyamory-themed social/educational
non-prot 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 outabout their CNM status,
those in rural settings, or those in other areas of the United
States. Signicant caution should be exercised in any attempts to
generalize these results to all CNM individuals.
Future Research
Research on providersattitudes, 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 ofces 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 scientic 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
Conicts 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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CNM Healthcare Experiences 51
... The effectiveness of persuasive messages might greatly vary across different subgroups of non-single MSM, so strategies should be tailored (Covey et al., 2016). For example, social stigma around non-monogamy may lead to fear of judgment (Vaughan et al., 2019) and pressure to disclose the number of sexual partners to the provider, which might prevent MSM in non-monogamous relationships from getting routine STI testing. To address this issue, social norm-based persuasion that communicates STI testing as "prevalent and common" among non-monogamous MSM may be effective. ...
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Thesis
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This study explored the lived experience of polyamorous individuals in a unit (polycule) as a group and as individuals. The literature review investigated the extant research on polyamory and consensual non-monogamy while also highlighting the lack of information when compared with monogamous relationships. As non-monogamy becomes more common, research and scholarship must keep up with trends to help educators, therapists, social workers, and others understand the complexities of these relationships. This work provides an in-depth look at the nuances and issues faced by a polyamorous group and its’ individuals. This narrative inquiry is comprised of one group activity and individual interviews with nine people in one polycule. Conclusions include a discussion of the polycule’s sense of community and positive experience of interdependence.
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Polyamory and consensual non‐monogamy (CNM) refer to partnerships in which individuals have romantic, emotional, and/or sexual relationships with multiple people, with the knowledge and consent of everyone involved. Recent decades have seen a surge in research interest in polyamory and CNM, warranting efforts to pause and take stock of empirical findings. In this scoping review, we evaluate and synthesize 209 research studies about polyamory and CNM, paying particular attention to trends in research design, theoretical application, and substantive findings. Researchers have focused broadly on (a) outcomes of CNM relationships, (b) attitudes and perceptions of CNM, (c) antecedents of CNM, (d) CNM relational processes, (e) CNM identity development, (f) polyamorous family and parenting, and (g) CNM politics and discourse. We synthesize research findings within each domain, identify gaps in the literature, and discuss the challenges and opportunities we see in advancing research on polyamory and CNM.
Chapter
Embedded within the sociocultural context of romantic relationships are features such as race, culture, neighborhoods, the legal system, and governmental policy. Due to the inherent difficulties with studying large structures and systems, little work has been done at the macro level in relationship science. This volume spotlights the complex interplay between romantic relationships and these structural systems, including varied insights from experts in the field. In turn, more diverse and generalizable research programs on the social ecology of relationships can be developed, helping to facilitate advances in theory. Scholars and students of relationship science in psychology, sociology, communication, and family studies will benefit from these discussions. This title is part of the Flip it Open programme and may also be available Open Access. Check our website Cambridge Core for details.
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Polyamory is a type of consensual non-monogamy (CNM) in which participants engage in multiple simultaneous romantic and often sexual relationships with the knowledge and consent of all involved. CNM practitioners in general, and polyamorous people in specific, appear to be highly stigmatized due to their relational practices, and to frequently encounter CNM-related discrimination, harassment, and violence (DHV). Conceptualizing this dynamic via minority stress theory predicts that this stigma and DHV will lead to negative mental health outcomes for polyamorous individuals. However, recent research has begun to identify possible sources of resilience and strength within polyamorous populations, which may ameliorate these negative effects, as well as enhance satisfaction with CNM and quality of life. This study investigated these hypotheses in a sample of 1,176 polyamorous American adults utilizing structural equation modeling (SEM). Two structural models were proposed and tested, one for polyamorous resilience and one for polyamorous strengths. Four constructs were assessed as potential resilience and strength factors: mindfulness, cognitive flexibility, a positive CNM identity, and connection to a supportive CNM community. Results indicate that CNM-related minority stress was positively related to increased psychological distress, such as higher self-reported depression and anxiety symptoms. Mindfulness was found to have both direct and moderating effects on the relationship between minority stress and psychological distress, such that higher mindfulness attenuated the negative impact of minority stress. Cognitive flexibility also displayed direct and moderating effects, but in the opposite than predicted direction. Regarding polyamorous strengths, mindfulness was found to positively impact overall satisfaction with CNM as well as life satisfaction. In addition, greater connection to a supportive CNM community correlated with having a more positive sense of CNM identity, which in turn was related to higher satisfaction with CNM. Overall satisfaction with CNM was related to greater life satisfaction. Clinical and research implications of these findings are discussed, with an emphasis on improving cultural competence for clinicians working with this unique and under-served population.
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The purpose of this study was to explore prevalent health issues, perceived barriers to seeking healthcare, and utilization of healthcare among lesbian, gay, bisexual and transgender (LGBT) populations in New Jersey. A cross-sectional online survey was administered to 438 self-identified LGBT people. Results identified health needs which included management of chronic diseases, preventive care for risky behaviors, mental health issues and issues related to interpersonal violence. Barriers to seeking healthcare included scarceness of health professionals competent in LGBT health, inadequate health insurance coverage and lack of personal finances, and widely dispersed LGBT inclusive practices making transportation difficult. There is a need for better preparation of healthcare professionals who care for LGBT patients, to strengthen social services to improve access and for better integration of medical and social services.
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This study provides a content analysis of peer-reviewed journal articles about consensual nonmonogamy (CNM) from a social scientific lens published from 1926 through 2016, excluding articles specific to polygamy or other faith-based relational practices. The content analysis yielded 116 articles, with most of the articles being nonempirical research (n = 74) rather than empirical studies (n = 42). Although the number of published articles about CNM has increased significantly in recent decades (n = 26 from 1926 to 2000 compared with n = 90 from 2001 to 2016), the topics discussed in CNM literature were narrow in scope and focused on (a) relationship styles, (b) CNM stigma, and/or (c) LGBTQ issues. Content analysis data showed that the vast majority of articles were published in journals about sexuality, suggesting that CNM remains an underexamined topic in psychological science. Additionally, only a handful of the total articles centered on topics related to family concerns (n = 5) or training and counseling (n = 2). Findings from this content analysis suggest that individuals and families who practice CNM are an underserved and understudied group that would benefit from advancements in psychological scholarship specific to their experiences.
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Introduction: The term kink describes sexual behaviors and identities encompassing bondage, discipline, domination and submission, and sadism and masochism (collectively known as BDSM) and sexual fetishism. Individuals who engage in kink could be at risk for health complications because of their sexual behaviors, and they could be vulnerable to stigma in the health care setting. However, although previous research has addressed experiences in mental health care, very little research has detailed the medical care experiences of kink-oriented patients. Aim: To broadly explore the health care experiences of kink-oriented patients using a community-engaged research approach. Methods: As part of the Kink Health Project, we gathered qualitative data from 115 kink-oriented San Francisco area residents using focus groups and interviews. Interview questions were generated in collaboration with a community advisory board. Data were analyzed using a thematic analysis approach. Main outcome measures: Themes relating to kink-oriented patients' experience with health and healthcare. Results: Major themes included (i) kink and physical health, (ii) sociocultural aspects of kink orientation, (iii) the role of stigma in shaping health care interactions, (iv) coming out to health care providers, and (v) working toward a vision of kink-aware medical care. The study found that kink-oriented patients have genuine health care needs relating to their kink behaviors and social context. Most patients would prefer to be out to their health care providers so they can receive individualized care. However, fewer than half were out to their current provider, with anticipated stigma being the most common reason for avoiding disclosure. Patients are often concerned that clinicians will confuse their behaviors with intimate partner violence and they emphasized the consensual nature of their kink interactions. Conclusion: Like other sexual minorities, kink-oriented patients have a desire to engage with their health care providers in meaningful discussions about their health risks, their identities, and their communities without fear of being judged. Additional research is needed to explore the experiences of kink-oriented patients in other areas of the country and internationally.
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Recent evidence suggests that one possible cause of disparities in health outcomes for stigmatized groups is the implicit biases held by health care providers. In response, several health care organizations have called for, and developed, new training in implicit bias for their providers. This review examines current evidence on the role that provider implicit bias may play in health disparities, and whether training in implicit bias can effectively reduce the biases that providers exhibit. Directions for future research on the presence and consequences of provider implicit bias, and best practices for training to reduce such bias, will be discussed.
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In this article the author reviews research evidence on the prevalence of mental disorders in lesbians, gay men, and bisexuals (LGBs) and shows, using meta-analyses, that LGBs have a higher prevalence of mental disorders than heterosexuals. The author offers a conceptual framework for understanding this excess in prevalence of disorder in terms of minority stress— explaining that stigma, prejudice, and discrimination create a hostile and stressful social environment that causes mental health problems. The model describes stress processes, including the experience of prejudice events, expectations of rejection, hiding and concealing, internalized homophobia, and ameliorative coping processes. This conceptual framework is the basis for the review of research evidence, suggestions for future research directions, and exploration of public policy implications.
Article
We proposed that the premise that monogamy is the exemplary form of romantic partnership underlies much theory and research on relationship quality, and we addressed how this bias has prompted methodological issues that make it difficult to effectively address the quality of nonmonogamous relationships. Because the idea that consensually nonmonogamous (CNM) relationships are functional (i.e., satisfying and of high quality) is controversial, we included a basic study to assess, in a variety of ways, the quality of these relationships. In that study, we found few differences in relationship functioning between individuals engaged in monogamy and those in CNM relationships. We then considered how existing theories could help researchers to understand CNM relationships and how CNM relationships could shed light on relationship processes, and we proposed a model of how CNM and monogamous relationships differ. Finally, in a second study, we determined that even researchers who present data about CNM are affected by the stigma surrounding such relationships. That is, researchers presenting findings favoring polyamory were perceived as more biased than researchers presenting findings favoring monogamy.
Article
Although academic and popular interest in consensual non-monogamy (CNM) is increasing, little is known about the prevalence of CNM. Using two separate nationally representative samples of single adults in the U.S. (Study 1: n = 3905; Study 2: n = 4813), the present studies find that more than one in five (21.9% in Study 1; 21.2% in Study 2) participants report engaging in CNM at some point in their lifetime. This proportion remained constant across age, education level, income, religion, region, political affiliation, and race, but varied with gender and sexual orientation. Specifically, men (compared to women) and people who identify as gay, lesbian, or bisexual (compared to those who identify as heterosexual) were more likely to report previous engagement in CNM. These findings suggest that a sizable and diverse proportion of U.S. adults have experienced CNM, highlighting the need to incorporate CNM into theoretical and empirical therapy and family science work.