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It doesn't help that some clinicians assume that patients don't want to be asked about sexual orientation because it would be uncomfortable or inappropriate. In fact, HHS has only recently required electronic health records (EHRs) to contain a modifiable field for including a patient's SOGI data in the EHR, which was first suggested by the Centers for Medicare and Medicaid Services in 2015. Data collection about sexual orientation and gender identity (SOGI) is relatively new in federally funded health research and even newer in clinical documentation. Oppression incurred by binary monosexism is exacerbated by sexuality being a culturally taboo subject, even when it is clinically relevant. Puritanical roots run deep in the United States and still manifest in clinical encounters. 9 Such hope, rooted in the discomfort of those who view the notion of bisexuality as too liminal, too disruptive of culturally dominant definitions of sexual desire, 10 is harmful to patients whose health depends on more inclusive acceptance of sexual and gender diversity and plurality. 8 Grouping bisexual women with lesbian women seems to express hope that eventually this group will become more homogeneous (ie, when some bisexual women begin identifying as lesbian and others “return” to heterosexuality), reproducing a neat and tidy monosexual, straight vs gay binary. For example, a National LGBT Cancer Network report indicating that lesbian and bisexual women are at increased risk for some cancers implicitly compares these women to heterosexual women. Quiz Ref ID Despite being common, grouping bisexual and lesbian women together makes little sense and needs correction in health equity research because it reproduces monosexism (ie, the view that sexual attraction is only to one gender) and thereby categories that are reductionist-but familiar-to researchers generating the evidence base that clinicians use to care for patients. 6 Yet the CDC's report of sexual contacts among high school students represents sexual minority students monolithically, folding bisexual contacts into the category “same sex only or both sexes” and treating “gay, lesbian, and bisexual” as a single category of sexual identity. 5 A national 2019 Centers for Disease Control and Prevention (CDC) survey of high school students documented that a median of 9% of students identified as bisexual compared to a median of 3% identifying as gay or lesbian. 4 Quiz Ref ID Setting aside implications for gender equity, these numbers are troubling for another reason: bisexual women are the largest subgroup within lesbian, gay, bisexual, and transgender (LGBT) sexual minority communities, a fact that tends to surprise many, including bisexual women. Although these efforts promised departure from “gay vs straight” binary definitions of sexuality, a follow-up NIH report explained that, among 279 studies focused on SGM health that it funded in 2012, only one focused solely on bisexual women roughly 20 grouped bisexual women with other sexual minority women. Starting in 2011, the US Department of Health and Human Services (HHS), 2 the Institute of Medicine (IOM), 3 and the National Institutes of Health (NIH) 4 recognized the health inequity suffered by sexual and gender minorities (SGMs) and recommended prioritizing these minorities' health interests. Making access to health services equitable will require paradigm-shifting confrontation with cultural biases and dismantling of persistent myths that have generated and sustained bisexual women's invisibility in health care.
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1 Continued invisibility of bisexual women in medicine, we argue, demonstrates this dynamic and too often blocks bisexual women's access to resources, including care. Philosopher of science Thomas Kuhn argued that entities or phenomena incompatible with a current paradigm in a scientific field are not recognized for what they are, or possibly not seen at all, since paradigms discourage unexpected discoveries.