The country closet

To the Editor: The closet is a common lesbian response to prejudice, discrimination and stigma. Many rural lesbians choose to “pass” as heterosexual and keep their sexuality secret.1,2 Research shows that this secrecy is fuelled by the fear of violence, including harassment, ostracism and rejection,2 and it is unlikely that a lesbian will disclose her sexuality to a doctor unless she feels safe. Without full disclosure, health care planning and delivery may be inadequate or inappropriate. This adds to the disadvantages already faced by rural doctors and their patients in a rural environment with demonstrated shortcomings in the form of fewer resources, greater distances and poorer health outcomes relative to urban areas.3

Because of stigma, societal prejudice and ignorance, many rural lesbians keep their sexuality invisible. This invisibility in a tight-knit small rural community keeps the women safe but isolated. McNair and Hughes state that discrimination and homophobia make a significant contribution to many health disparities for people with marginalised sexualities, and these disparities are now recognised as a public health issue.4

The desire and need for invisibility means that lesbians may choose not to be treated locally. Travelling long distances to the nearest city to access services may be inconvenient, but large populations and long distances offer anonymity and privacy. Disadvantages are mediated by the support of wider networks of lesbians, increased opportunities to meet like-minded women and the increased likelihood of access to sensitive and safe health care. It reduces isolation.

Other researchers suggest that rural health service provision focuses on the medical model approach to rural health disadvantage.3 Discrimination, prejudice and stigma clearly lie outside this model. A social model of health framework, using social determinants of health, is more likely to identify the health disparities experienced by lesbians. McNair and Hughes suggest advocacy as a positive means of changing attitudes and increasing safe spaces for patients.4

Coming out of the closet is risky and stressful. So is remaining there.