December 1, 2025
The Damaging Impacts of Assuming Relationship Norms in Healthcare Communication
By Amanda Weiss
Imagine your doctor avoids eye contact with you after you tell them about a health-relevant behavior. Imagine they keep their distance from you or tell you that an integral part of yourself and your relationships is wrong. Imagine they even refuse to administer an examination or procedure as a result. If these kinds of reactions are surprising to you, then consider that they reflect the reality for some patients whose identities and relationship structures go against societal expectations or predominant family dynamics.
Social norms and implicit biases shape our thoughts, influence our speech and non-verbal cues, and lurk within the social institutions with which we engage. So, perhaps it’s not a surprise that even healthcare providers, whose work is based in data-driven science, can be influenced by the norms of the culture around them. When patients have non-normative traits or behaviors (those that don’t match societal expectations) that affect health, biased messages or reactions from healthcare providers can pose barriers to patient comfort and clinical care. Likewise, if a provider assumes that their patients match all norms, they may preemptively cut off important lines of communication by not asking about relevant factors that impact health.
One area where such assumptions run rampant is relationships. Society at large still considers the standard adult relationship to be a romantic and sexual relationship between one cisgender man and one cisgender woman, often with the end goal of having a nuclear family (although different family and relationship structures have existed across cultures throughout history). But that’s not the case for everyone. When healthcare providers communicate based on assumptions about the “who,” “whether,” and “how many” of partners their patients have—or should have—problems arise for patient-provider relationships and care. While this discussion focuses primarily on the harm from negative experiences and communication, many of the research studies mentioned here also bring up the positive experiences that other patients have had with non-judgmental healthcare providers.
Assumptions about Straightness
Shifts in what is considered the norm do not necessarily keep up with increased public acceptance of diversity. A large majority of Americans support equal rights for LGBTQIA+ people, and in many countries acceptance of homosexuality has increased over time, yet heterosexuality is still largely seen as the norm.[1] Heteronormativity—the assumption of heterosexuality as default—continues to influence healthcare, despite homosexuality being officially de-pathologized over fifty years ago through removal from the Diagnostic and Statistical Manual of Mental Disorders (DSM, the American Psychiatric Association’s reference book for diagnosing mental illnesses).[2] Additionally, many research studies have found health disparities between LGBTQIA+ and non-LGBTQIA+ people, including elements of physical health, mental health, reproductive health, and social factors that impact health.[3]
The reinforcement of heteronormativity in healthcare begins in medical education. A research study of over two hundred undergraduate medical education schools found that although the median amount of time devoted to LGBTQIA+ curricula had increased between 2011 and 2022, some schools still did not spend any time on these topics during particular phases of their programs.[4] Additionally, there’s not a lot of data about the inclusion of LGBTQIA+ curricula at more advanced training stages, although the Accreditation Council for Graduate Medical Education includes a requirement for medical residents to demonstrate “respect and responsiveness to diverse patient populations, including . . . gender . . . and sexual orientation.”[5] Only a few medical residency specialties have even been surveyed for LGBTQIA+ content inclusion, and some medical education professionals have brought attention to the need to require this content in curricula.[6]
So, how does heteronormativity and lack of LGBTQIA+ knowledge and acceptance manifest in clinical settings? A review of many research studies found several common occurrences, including the following: Some providers are unprepared; for example, some providers expressed that they didn’t know as much about queer-relevant health concerns as they felt they should.[7] Both patients and providers may feel uncomfortable talking about sexual orientation, although some providers and patients think it’s the responsibility of the provider to make the setting comfortable, while others think the patient should be upfront to help make the provider comfortable. Additionally, some patients face stigma from providers; for example, some patients recalled providers looking at and talking with them differently after finding out about their orientation, or even refusing to give care, such as a pelvic exam or artificial insemination.
Furthermore, some providers and healthcare infrastructures assume that patients are straight; for instance, patients reported experiences including their same-sex relationship not being treated as a couple relationship, providers directly questioning or challenging the idea of a child having two same-sex parents, and providers giving out condoms but not dental dams (an indirect assumption of male-female penetrative sex).
Negative or dismissive reactions from healthcare providers can also halt important communication in clinical interactions. One woman interviewed for a research study recounted that a practitioner had not provided sexual health information after finding out that she was sexually active with other women and not having penetrative sex, and another woman recalled not wanting to continue talking about sexual health with a practitioner who said that she didn’t “‘look gay.’”[8]
On the flip side of assuming that a patient is straight, if a patient does choose to disclose their orientation, they may be faced with a barrage of questions, even if well-meaning. One participant in a study in rural Canada conveyed to researchers that both homophobic reactions and excessive positive questions can be emotionally tiring, and that coming out to physicians is “‘not worth my energy in case they are not a safe person.’”[9] In contrast, a woman in a Boston study told the interviewer that when a provider respectfully switched the conversation to same-sex relevant health information without a visible facial response upon disclosure, “‘it was very cool.’”[10] These examples highlight how a provider’s response to disclosure of a non-straight orientation can influence the patient’s communication with that provider or others in the future, impacting whether they’ll receive necessary and relevant health information.
Women in same-sex relationships also face unique problems in situations dealing with fertility and pregnancy. Comprehensive and reliable information about reproductive technologies for women without a male partner can be difficult to find, and some common conception advice for fertility issues is not applicable to same-sex couples. For example, cisgender women in same-sex relationships have reported that advice from nurses at fertility clinics included having timed intercourse.[11] Additionally, when women in same-sex relationships become parents, they face a healthcare system that may implicitly communicate that their family structure is incorrect, such as by providers questioning a child having two mothers, the non-birthing mother being disallowed to hold a newborn, or security guards questioning the non-birthing mother when she goes to see her baby in the Neonatal Intensive Care Unit.[12]
Additionally, although it’s not a primary focus of this article, relationships involving non-cisgender individuals are also non-normative, and some of the studies cited also discuss negative experiences that people who are transgender, non-binary, or otherwise non-cisgender have had in clinical settings and when communicating with healthcare practitioners.
Assumptions About Sexual Attraction and Activity
Heteronormativity falls under the umbrella of the less commonly acknowledged assumption that all people experience sexual attraction to others—a norm called allonormativity. In actuality, there are asexual people who experience little to no sexual attraction, and the lack of widespread recognition of this orientation poses challenges, especially in mental and sexual healthcare.[13] In fact, while homosexuality was removed from the DSM in 1973, identifying as asexual wasn’t named as an exception to sexual dysfunctions until 2013. Further, even the framing of that current exception remains contentious for several reasons, including that it requires a person to self-identify as asexual (which they can only do if they’re familiar with the term to begin with).[14]
The lack of common knowledge about asexuality is reflected in academic literature, which is the primary way that researchers communicate their work to others in their field. A recent analysis of articles in sex therapy journals found that over 40 percent of the articles failed to acknowledge that asexuality represents a spectrum of experiences, and several articles failed to differentiate between asexuality and aromanticism (lack of romantic attraction).[15]
When we move outside of reference books and academic journals, we can see how the lack of widespread recognition of asexuality can lead to harms distinct from heteronormativity. Namely, some asexual people report experiences where healthcare practitioners don’t even believe in their orientation or, where applicable, lack of sexual activity. As reported by asexual patients in Germany, some doctors treated asexuality as something that a patient would grow out of or as something that could be changed through therapy, and another provider told a patient with vaginismus to come back for an internal exam after she became sexually active. One person interviewed in this study even talked about how she had resorted to lying to her gynecologist about using protection since the doctor wouldn’t believe that she wasn’t sexually active.[16] A provider disbelieving their patient can harm the patient-provider relationship, leading to a breakdown of further communication and care.
Even more concerningly, practitioners sometimes recommend treatments to “fix” asexuality or tell their patients that their asexuality is due to a mental health problem. For example, for some participants in Stonewall’s “Ace in the UK Report,” mental health providers had attributed their asexuality to trauma and suggested ways to get over it. One participant had a general practitioner who refused to provide a gynecology referral for a physical problem until the patient saw a psychosexual therapist. In such cases, practitioners’ misplaced focus on asexuality as a problem can delay treatment of the actual issues of concern. On a more positive note, one of the participants whose therapist encouraged open sharing about her asexual experience developed a strong relationship with that therapist.[17]
These experiences highlight how even when a patient discloses health-relevant information to providers, some providers, falling back on allonormativity, frame their communications around the idea that the patient will change, rather than engaging in dialogue about how healthcare needs may vary for asexual patients.
Assumptions About Monogamy
Similarly, people with multiple partners face their own difficulties in healthcare settings due to mononormativity (the assumption that a two-person pairing is the correct relationship structure).
As with other populations discussed in this article, people who practice consensual non-monogamy (CNM), in which all participants in the relationship are on board with individuals having other romantic and/or sexual relationships (whether they describe their relationship model as polyamory, swinging, open, or another term), encounter negative experiences in sexual and reproductive healthcare as well as mental healthcare.
In a study conducted using focus groups, some non-monogamous participants reported that their healthcare providers didn’t ask about their number of partners, especially if they had an opposite-gender spouse. A participant also described that healthcare providers aren’t always aware of poly-specific insurance coverage concerns. For example, some procedures aren’t covered for someone with only one sexual partner, but providers may not know whether this is different for someone with different risk due to having multiple partners. Additionally, participants spoke about judgmental non-verbal communication cues from healthcare providers, including raised eyebrows, avoiding eye contact, etc. Even further, one participant described how a doctor didn’t want her as a patient when she called ahead to find out about their comfort around non-monogamy.[18]
In addition to judgment, assumptions about monogamy also instill structural barriers for non-monogamous people in the process of pregnancy and childbirth. For example, physical room space for prenatal care and policies for birthing often don’t accommodate more than one partner present. Additionally, hospital infrastructure may only allow for two parental identification bracelets for a newborn, and systems may only allow two parents to be listed, meaning that an additional parent may instead be recorded as a more distant relation. Some pregnant people in poly relationships prefer to have home births to avoid dealing with potential barriers they may face at hospitals.[19] Even if the hospital workers using the system are understanding about poly relationships, the fact that the system itself essentially “downgrades” additional parents implicitly tells the family that only the two listed are the “real” parents.
Previous research studies had identified problems with some therapists being judgmental or lacking knowledge regarding CNM and found that relationship research often idealizes monogamous pairings, despite overall relationship satisfaction not being significantly different between monogamous people and CNM-participants.[20] Additionally, a case study with a patient who practiced non-monogamy highlighted how a therapist who misattributed symptoms of depression to polyamory led to the patient not feeling comfortable discussing her relations and stopping mental health treatment, whereas subsequent non-judgmental therapy and re-engagement with the polyamory community helped the patient improve.[21]
Alternative Relationship Frameworks
Given all this evidence that providers displaying normative assumptions in their interactions can damage patient-provider relationships and negatively impact care, what steps can be taken to mitigate the problems? After all, no individual provider can reverse thoroughly ingrained social norms. However, even relatively small things like using different phrasing to ask about health-relevant information can help. For instance, in the German study mentioned earlier, one participant brought up how gynecologic care providers sometimes ask whether a patient has a boyfriend, instead of asking the actual question relevant for care—whether the patient is having particular types of sex. The participant pointed out that asking about a boyfriend in lieu of asking whether the patient is having penetrative sex assumes the gender of potential partners, that both are cisgender, and the idea that sex always happens in a partner relationship.[22]It also assumes a single partner.
Even if a patient has a boyfriend, the relationship could be sexless or could include only particular types of sex (that is, “sexually active” could mean different things to different people), which could change the patient’s risk for STIs or pregnancy compared to a relationship with “traditional” penetrative sex. The patient could have a boyfriend and also have other partners, whether platonic, romantic, sexual, or a combination of the above. Each of these different scenarios may entail different healthcare needs or concerns. If the practitioner’s goal is to provide the patient with relevant information and care, asking the questions whose answers most directly affect testing and care choices is more effective than relying on the societal ideal of what a particular type of relationship should be. Additionally, providers can educate themselves about some of the relationship frameworks discussed and used by the people who don’t match society’s expectations.
One such framework is called relationship anarchy. This concept, defined by Andie Nordgren in 2006, arises out of the idea that “love does not need a specific set of rules,” and encourages people to “customize your commitments.”[23]Notably, relationship anarchy opposes the idea that one can set limits on their partner’s (or partners’) relationships with others, so it’s incompatible with requiring monogamy from a partner or setting rules for others in a polycule (a relationship involving more than two people).[24] As such, not every type of non-normative relationship works with relationship anarchy principles. Nevertheless, the core ideas of rejecting expectations about relationships and communicating clearly with partners to self-define the nature of a relationship can be useful more broadly. Furthermore, if a healthcare provider considers that their patients may not adhere to social rules about relationships, they may better understand the need to ask about specific health-relevant factors.
Other useful frameworks (although not relationship-specific) are split or differentiated attraction models, which describe how an individual can experience different types of attraction to different types of people. For example, an individual may be romantically attracted to people of one gender, not sexually attracted to people of any gender, but platonically attracted to (e.g., drawn towards friendship with) people of all genders, etc. These models are common within the asexual community (although not universally used or even liked), and can help make sense of identity for asexual people who are romantically interested in others.[25] However, split attraction does not occur only for asexual or aromantic people. A research study of more than four hundred American adults found that over 10 percent reported differential sexual and romantic attraction, and most of them were not asexual.[26]
This finding highlights the importance for healthcare providers to not ask roundabout or vague questions about relationships if the information they truly need deals specifically with sexual partners. Furthermore, as discussed in Bogaert’s 2015 review article about asexuality, a lack of sexual attraction doesn’t necessarily mean that someone hasn’t engaged in sexual activity or that they lack physiological sexual arousal responses—again emphasizing the need for physicians to avoid making assumptions about health risks from a patient’s sexual orientation alone.[27]
In considering frameworks like relationship anarchy and split attraction models, providers can challenge themselves to think about how their conversations might assume that patients’ relationships “play by the rules,” and instead be intentional about asking questions. For example, if a patient mentions having a sexual partner, a provider could ask about specific activities or behaviors, and also whether the patient has other partners. Alternatively, a provider can ask their patients more open-ended questions—for example, asking a patient to describe any romantic or sexual relationships they have had. Additionally, providers can ensure that intake forms and paperwork concerning partners or sexual activity have options for “other” and an open space to describe relevant information. If a patient describes having non-normative relationships, providers can be intentional about asking that patient what care they would like to receive and discuss any relationship structure- or identity-specific implications for health or health risks.
Towards a Future Without Relationship Assumptions
Due to the pervasive power of relationship norms, universal acknowledgement of the harm in letting unwarranted assumptions influence healthcare communication would be a meaningful step forward. It’s up to providers to make effortful changes in how they react to patient disclosures and approach plans for care when patients don’t quite fit the mold they expect. By keeping up open dialogue and avoiding pre-judgments in speech, non-verbal body language, infrastructure (for example, medical intake forms, clinical accommodations, etc.), and recommendations for care, providers can foster positive relationships with patients and increase their likelihood of helping without causing inadvertent harm.
—
Amanda N. Weiss (B.S) is is a PhD candidate in Cell and Molecular Biology at the University of Pennsylvania and an aspiring career science communicator. She currently studies RNA biology.
Notes
[1] GLAAD, Accelerating Acceptance (GLAAD Media Institute, 2024), accessed January 17, 2025, https://assets.glaad.org/m/50f6cbd6cb222811/original/Accelerating-Acceptance-2024.pdf. Most survey questions and the report used the acronym “LGBTQ.”; See also: Jacob Poushter and Nicholas Kent, “The Global Divide on Homosexuality Persists,” Pew Research Center, accessed January 17, 2025, https://www.pewresearch.org/global/wp-content/uploads/sites/2/2020/06/PG_2020.06.25_Global-Views-Homosexuality_FINAL.pdf.
[2] Jack Drescher, “Out of DSM: Depathologizing Homosexuality,” Behavioral Sciences (Basel) 5, no. 4 (2015): 565–75, https://doi.org/10.3390/bs5040565.
[3] Nik M. Lampe et al., “Health Disparities Among Lesbian, Gay, Bisexual, Transgender, and Queer Older Adults: A Structural Competency Approach,” The International Journal of Aging and Human Development 98, no. 1 (2023): 39–55, https://doi.org/10.1177/00914150231171838. This review uses “LGBTQ+” as an umbrella acronym.
[4] Carl G. Streed Jr. et al., “Sexual and Gender Minority Content in Undergraduate Medical Education in the United States and Canada: Current State and Changes Since 2011,” BMC Medical Education 24, no. 482 (2024), https://doi.org/10.1186/s12909-024-05469-0. This study assessed “LGBTQI+” content.
[5] Accreditation Council for Graduate Medical Education, Guide to the Common Program Requirements (Residency) Version 4.1,updated March 2024, https://www.acgme.org/globalassets/pdfs/guide-to-the-common-program-requirements-residency.pdf.
[6] Andrew M. Pregnall, André L. Churchwell, and Jesse M. Ehrenfeld, “A Call for LGBTQ Content in Graduate Medical Education Program Requirements,” Academic Medicine 96, no. 6 (2021): 828–35, https://doi.org/10.1097/ACM.0000000000003581. This paper called for “LGBTQ” care content.
[7] Sarah G. McNeill, John McAteer, and Ruth Jepson, “Interactions Between Health Professionals and Lesbian, Gay and Bisexual Patients in Healthcare Settings: A Systematic Review,” Journal of Homosexuality 70, no. 2 (2021): 250–76, https://doi.org/10.1080/00918369.2021.1945338.
[8] Allison M. Baker et al., “Sexual Health Information Sources, Needs, and Preferences of Young Adult Sexual Minority Cisgender Women and Non-binary Individuals Assigned Female at Birth,” Sexuality Research and Social Policy 18, no. 3 (2021): 775–87, https://doi.org/10.1007/s13178-020-00501-6.
[9] Nadine R. Henriquez and Nora Ahmad, “‘The Message Is You Don’t Exist’: Exploring Lived Experiences of Rural Lesbian, Gay, Bisexual, Transgender, Queer/Questioning (LGBTQ) People Utilizing Health Care Services,” SAGE Open Nursing 7 (2021), https://doi.org/10.1177/23779608211051174.
[10] Baker et al., “Sexual Health Information Sources, Needs, and Preferences,” 779.
[11] Patrina Sexton Topper, José A. Bauermeister, and Jesse Golinkoff, “Fertility Health Information Seeking Among Sexual Minority Women,” Fertility and Sterility 117, no. 2 (2022): 399–407, https://doi.org/10.1016/j.fertnstert.2021.09.023.
[12] Nicole Hudak, “‘Who’s the Mom?’: Heterosexism in Patient-Provider Interactions of Queer Pregnant Couples,” Health Communication 38, no. 1 (2021): 114–23, https://doi.org/10.1080/10410236.2021.1936752.
[13] “Overview,” The Asexual Visibility & Education Network, accessed January 27, 2025, https://www.asexuality.org/?q=overview.html; Allison Parshall, “Asexuality Is Finally Breaking Free from Medical Stigma,” Scientific American, January 1, 2024, https://www.scientificamerican.com/article/asexuality-is-finally-breaking-free-from-medical-stigma/.
[14] Leslie Margolin, “Why Is Absent/Low Sexual Desire a Mental Disorder (Except When Patients Identify as Asexual)?,” Psychology & Sexuality 14, no. 4 (2023): 720–33, https://doi.org/10.1080/19419899.2023.2193575; F. Murray, “Asexuality was Considered a Disorder?!,” Aceweek, October 29, 2020, https://aceweek.org/stories/asexuality-in-the-dsm.
[15] Gwendolyn Brown, Andreea Cheva, Megan Fraser, and Robert J. Zeglin, “Asexuality: A Content Analysis of Sex Therapy Journals,” Psychology & Sexuality 14, no. 1 (2023): 17–30, https://doi.org/10.1080/19419899.2022.2052943.
[16] Ann Kristin Augst and Annika Spahn, “‘Doctors Don’t Listen to Us or the Things
We Need’: Experiences of Heteronormative Healthcare and Its Aftermath for LGBATIQ Patients in Germany,” in Equal Access to Healthcare in Socially Diverse Societies, ed. Florian Steger, Mojca Ramšak, Pawel Łuków, and Amir Muzur (Karl Alber, 2023), 120–23, https://doi.org/10.5771/9783495997895-111.
[17] Yasmin Benoit and Robbie de Santos, “Ace in the UK Report,” Stonewall (2023), accessed January 28, 2025, https://files.stonewall.org.uk/production/files/ace_in_the_uk_report_2023.pdf?dm=1725385212.
[18] Michelle D. Vaughan, Peyton Jones, B. Adam Taylor, and Jessica Roush, “Healthcare Experiences and Needs of Consensually Non-Monogamous People: Results from a Focus Group Study,” The Journal of Sexual Medicine 16, no. 1 (2019): 42–51, https://doi.org/10.1016/j.jsxm.2018.11.006.
[19] Erika Arseneau, Samantha Landry, and Elizabeth K Darling, “The Polyamorous Childbearing and Birth Experiences Study (POLYBABES): A Qualitative Study of the Health Care Experiences of Polyamorous Families During Pregnancy and Birth,” CMAJ191, no. 41 (2019): E1120–E1127, https://doi.org/10.1503/cmaj.190224.
[20] Cara Herbitter, Michelle D. Vaughan, and David W. Pantalone, “Mental Health Provider Bias and Clinical Competence in Addressing Asexuality, Consensual Non-monogamy, and BDSM: A Narrative Review,” Sexual and Relationship Therapy 39, no. 1 (2024): 131–54, https://doi.org/10.1080/14681994.2021.1969547; Heath A. Schechinger, John Kitchener Sakaluk, and Amy C. Moors, “Harmful and Helpful Therapy Practices With Consensually Non-Monogamous Clients: Toward an Inclusive Framework,” Journal of Consulting and Clinical Psychology 86, no. 11 (2018): 879–91, https://doi.org/10.1037/ccp0000349; Terri D. Conley, Jes L. Matsick, Amy C. Moors, and Ali Ziegler, “Investigation of Consensually Nonmonogamous Relationships: Theories, Methods, and New Directions,” Perspectives on Psychological Science 12, no. 2 (2017): 205–32, https://doi.org/10.1177/1745691616667925.
[21] Nicole Graham, “Polyamory: A Call for Increased Mental Health Professional Awareness,” Archives of Sexual Behavior 43, no. 6 (2014): 1031–34, https://doi.org/10.1007/s10508-014-0321-3.
[22] Augst and Spahn, “Doctors Don’t Listen,” 121.
[23] Andie Nordgren, “The Road to Relationship Anarchy,” The Anarchist Library, published 2018, https://theanarchistlibrary.org/library/andie-nordgren-the-road-to-relationship-anarchy; Andie Nordgren, “The Short Instructional Manifesto for Relationship Anarchy,” The Anarchist Library, published in 2006, adapted to English in 2012, https://theanarchistlibrary.org/library/andie-nordgren-the-short-instructional-manifesto-for-relationship-anarchy.
[24] Ole Martin Moen and Aleksander Sørlie, “The Ethics of Relationship Anarchy,” in The Routledge Handbook of Philosophy of Sex and Sexuality, ed. Brian D. Earp, Clare Chambers, and Lori Watson (Routledge, 2022), 341–56.
[25] Canton Winer, “Splitting Attraction: Differentiating Romantic and Sexual Orientations Among Asexual Individuals,” Social Currents (2024): 1–16, https://doi.org/10.1177/23294965241305170.
[26] Emily M. Lund, Katie B. Thomas, Christina M. Sias, and April R. Bradley, “Examining Concordant and Discordant Sexual and Romantic Attraction in American Adults: Implications for Counselors,” Journal of LGBT Issues in Counseling 10, no. 4 (2016): 211–26, https://doi.org/10.1080/15538605.2016.1233840.
[27] Anthony F. Bogaert, “Asexuality: What It Is and Why It Matters,” Journal of Sex Research 52, no. 4 (2015): 362–79, https://doi.org/10.1080/00224499.2015.1015713.
