Reaching the In(Invisible): Addressing Barriers to Sexual Reproductive Healthcare of Lesbians, Bisexual Women and Sex Workers in Rivers State, Nigeria

Sexual and reproductive healthcare needs of sexual minority women (lesbians, bi-women, and sex workers) are often overlooked and underserved due to many barriers. These barriers can be both structural and social, leading to a lack of access to healthcare services and a lack of understanding of the specific needs of these populations. One of the most significant structural barriers to sexual and reproductive healthcare for lesbians, bi-women, and sex workers is the lack of legal recognition of their identities. In many countries, the sexual minority population of women lacks recognition, which can inhibit access to sexual reproductive healthcare services and understanding of the specific needs of these populations.

This hindrance to access to essential sexual reproductive healthcare services can also lead to discrimination and stigma, resulting in adverse health outcomes. Furthermore, in many countries, sexual reproductive healthcare services are not readily available and affordable. Finally, there is a lack of research and data on the specific needs of lesbians, bi-women, and sex workers in Rivers State to understand these populations’ specific needs. Therefore, to ensure that these populations have access to the healthcare services they need, it is essential to highlight and address these barriers to engender solutions that can generate the necessary resources and support for their health, rights, and well-being.

Sexual and reproductive healthcare (SRH) services are a fundamental human right and critical to attaining overall health and well-being. However, in Nigeria, sexual minority women may face numerous barriers to accessing sexual reproductive healthcare services. This study explored literature highlighting barriers to lesbians, bisexual women, and sex workers’ needs for essential SRH. The first barrier to the SRH needs of lesbians, bi-women, and sex workers in Nigeria is the lack of legal protection. Nigeria has several laws that criminalise same-sex relationships, which creates an environment of fear and stigma for sexual minority women. This fear and stigma can lead to reluctance to seek sexual and reproductive healthcare services, which may result in fear of discrimination, prejudice, and arrest.

Everett et al reported that heterosexual women had increased access to SRH services (such as birth control counselling during pregnancy/pap tests, condom consults, and sexually transmitted diseases (STD) screening). Whereas sexually minority women were less likely to receive SRH than heterosexual women. Furthermore, some women and providers adjust health care-seeking behaviours and information provided to women based on recent sexual behaviour histories. These adjusted healthcare-seeking behaviour can result in disparities in sexual and reproductive healthcare services among sexual minority women.

Additionally, the lack of legal protection and political will can lead to limited access to services. Providers may be unwilling to offer services to sexual minority women due to the legal risks. Moreover, healthcare providers’ insufficient education on sexual and reproductive healthcare of lesbians, bi-women, and sex can hinder access. At the same time, sexual minority women lack access to accurate and comprehensive information about sexual reproductive health, which can also lead to a lack of understanding of their needs and how to access services. Furthermore, other barriers include scarcity of resources, inability to spend out-of-pocket, transportation, and access to healthcare facilities. Also, limited knowledge of available services and how to access them can contribute to barriers to sexual reproductive healthcare services.

Finally, a lack of acceptance and understanding of the sexual expression of lesbians, bi-women and sex workers often results in discrimination and stigma from healthcare providers and the public toward sexual minority women, which can lead to a reluctance to seek sexual reproductive healthcare services as noted by Paschen-Wolff, Greene & Hughes. In addition, stigma and discrimination induced reluctance to seek care.   In conclusion, lesbians, bi-women, and sex workers in Nigeria face numerous barriers to accessing sexual and reproductive healthcare services.

Common mental health issues experienced by sexual minority women include depression can include internalised homophobia, medical mistrust, and individual choice of affirmative provider. These mental health problems can be attributed to the chronic experiences of discrimination and prejudice in society. Therefore, recognising the mental health needs of sexual minority women is significant to providing respectful sexual and reproductive healthcare services with limited barriers. This study, therefore, fills out the geographical gap that generated new insights on addressing the barriers to sexual and reproductive healthcare needs of lesbians, bi-women and sex workers in Rivers State, Nigeria.

The study is cross-sectional research conducted through a qualitative approach. This study provided a snapshot of addressing barriers to sexual reproductive healthcare service for sexual minority women. The design provided understanding and description of the SRH barriers experienced by sexual minority women accessing healthcare services. The study was carried out in Rivers State among 15 participants delimited to lesbians, bisexual women and sex workers who are 15-35 years old. Data was collected through key informants’ interviews (KIIs) and analysed by narrative analysis.

Barriers that prevent sexual minority women from accessing sexual and reproductive healthcare services include limited sexual and reproductive health information on available services, stigma, discrimination, prejudice from healthcare providers and lack of social acceptance. Furthermore, common mental health issues experienced are self-doubt over sexual orientation, trauma from threats, and parental pressure over marriage.

The study found that sexual minority women in Rivers State have information on sexual reproductive healthcare services, mainly from friends. However, they lack access to accurate and comprehensive information about sexual reproductive health, which can also lead to a poor understanding of their needs and how to access services. This finding agrees with (Paschen-Wolff, Greene & Hughes, regardless that most participants answered that they understand sexual reproductive health and rights. Their poor knowledge of sexual reproductive healthcare is reflected in misinformation on sexual and reproductive healthcare. For example, one of the participants stated that the only sexual reproductive healthcare she seeks is “vaginal cleansing”. Frequently sought sexual reproductive healthcare services are sexually transmitted infection (STIs, HIV) testing and treatment and a few contraceptives like emergency pills which, agrees with Everett, Higgins, Haider, & Carpenter. However, these services are primarily accessed in pharmacies, medical doctor friends and Non-Governmental Organisations instead of Primary Health Centres due to fear of prejudice from healthcare providers.

“I believe they should make this thing accessible to everybody, regardless of your sexuality. You know, I don’t see reasons why. Okay, you are these, you are that when I come because I am this, you now want to give me the cold shoulder because I am this, you get? No, it should be accessible to everybody,”—a participant’s comment.

This study shows that “freedom” is critical to sexual minority women. Freedom to be who they are without prejudice, especially by healthcare providers when they visit a health centre to seek services. “I have people I go to; I go to NGOs to receive these services. I prefer private to avoid “that look”. “I prefer NGOs; I have only visited a health centre once and did not like it”. These findings validate on lack of acceptance and understanding of the sexual expression of lesbians, bi-women, and sex workers results in stigma and discrimination from healthcare providers and the public toward sexual minority women. This discriminatory behaviour causes reluctance to seek sexual reproductive healthcare services, which makes heterosexual women have more access to sexual reproductive healthcare services than sexual minority women.

Self-doubt, questioning and worry about societal acceptance of sexual minority women’s sexuality support Owens, Riggle & Rostosky identified mental health problems attributed to the chronic experiences of discrimination and prejudice in society.

“I have been depressed when I found someone that I like and would want to settle down with (marry), but because of the “clause” and culture and societal laws that limit me from actually living my full potential”, —a participant’s comment. Threats to life also contribute significantly to sexual minority women’s mental health primarily because of dressing and sexual orientation attributable to societal prejudice. In addition, the effect of these experiences hampers lesbians, bisexual women and sex workers’ access to sexual and reproductive healthcare, which supports.

Several factors magnify barriers experienced by sexual minority women when seeking effective sexual reproductive healthcare services in Rivers State, Nigeria. These factors include poor knowledge and information about sexual and reproductive healthcare among sexual minority women, especially lesbians. And healthcare providers limited understanding of lesbians, bisexual women, and sex workers’ needs. Trauma from unmet needs can significantly affect lesbians, bisexual women and sex workers’ sexual reproductive healthcare-seeking behaviour which ultimately impact their mental health. From these findings, the following intervention strategies can make adequate shift to improving sexual minority women’s access to sexual and reproductive healthcare services in Rivers State.

1.Training of healthcare providers on inclusive and intersectional sexual and reproductive healthcare services.

2.Awareness creation on accurate and available sexual and reproductive healthcare services among sexual minority women are needed to eliminate stigma and discrimination to improve access.

3.Improved laws to support the autonomy and agency of sexual minority women to minimize negative mental health experiences.

4.Creation of a social support group for sexual minority women to share experiences, support each other and learn about their sexual and reproductive healthcare services.

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