Abstract
Our study of queer women patients and their primary health care providers (HCPs) in Halifax, Nova Scotia, reveals a gap between providers’ theoretical knowledge of “cultural competency” and patients’ experience. Drawing on Patricia Benner’s Dreyfusian model of skill acquisition in nursing, we suggest that the dissonance between the anti-heteronormative principles expressed in interviews and the relative absence of skilled anti-heteronormative clinical practice can be understood as a failure to grasp the field of practice as a whole. Moving from “knowing-that” to “knowing-how” in terms of anti-heteronormative clinical skills is not only a desirable epistemological trajectory, we argue, but also a way of understanding better and worse ethical practice.
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Notes
The larger research study drew on two sites—Halifax and Vancouver—with a roughly equal number of interviews at each. We examine here only the Halifax interviews, and some of our specific examples were clearly influenced by the context of a small, relatively conservative, culturally homogeneous city located in a large area of isolated rural communities (see Bryson 2012 for some initial comparisons between the research sites).
Two other women identified as primarily lesbian with a qualifier (“I see myself as just Arlene” and currently identified as lesbian “but exploring doing the bi thing”), two as trans, two as queer, four as bisexual, and one as “fluid.” Many other terms were introduced during the interviews (“polysexual,” “bent”). In addition to the complexities of their own gender/sexuality as it related to the complexities of their partners’ gender and sexuality, a few participants also construed “queer” (especially in the context of health care) as connected to polyamory or undertaking commercial sex or practicing BDSM (bondage, domination/submission, or sado-masochistic sex). The use of the term “queer women” in the way this research was conceptualized and conducted clearly raises its own methodological and epistemological questions, which are not our focus here (see Bryson 2012).
Some health care providers (HCPs) objected to the term “queer” and early in the project recruitment materials were changed to “LBGT” to avoid discouraging participation or encouraging participation only from those HCPs already comfortable with the term “queer.”
Ethics review and approval for the Halifax interviews were granted by Dalhousie University. All names used are pseudonyms.
Note that the HCP and patient populations did not map—i.e., although all the research participants came from the same small city, the patients were not reporting directly on the HCPs we interviewed (nor vice versa).
The distinction between “knowing how (to)” and “knowing that” has generated a large philosophical literature. In recent years the debate has focused around the work of Timothy Williamson and Jason Stanley (Stanley and Williamson 2001; Stanley 2011), who argue that knowing-how in fact always does turn out to be dependent on knowing-that. Stanley argues against Dreyfus (and Gilbert Ryle before him) on the grounds that both presuppose a false view about what it must mean to act on propositional knowledge. According to Stanley, Dreyfus assumes that because we do not mentally consult our propositional knowledge prior to conducting a skilled action, knowing-how cannot be dependent on knowing-that (2011, esp. 23–24). Stanley then goes on to make a lengthy, complex argument to the conclusion that knowing how to do something is the same as knowing a fact. Although a longer consideration of our position could usefully engage parts of Stanley’s analysis, we bracket it here. Our argument starts from the distinction between propositional knowledge as claims upon which an audience is invited to reflect and the complex everyday encounters practitioners have with their patients. That is, we are concerned with an epistemically and pedagogically implausible emphasis in medical education on abstracted discussion and moral guidelines as remedies for heteronormative practice. One could still, in theory, agree with Stanley and find this distinction unproductive in the situations we describe.
The phrase “epistemic modesty” is also used in a philosophical literature where it has related but more narrowly defined connotations. We are not concerned with that literature here.
Women who have sex only with women are advised to get regular cervical cancer screening, as HPV can be transmitted between female sexual partners (see Henderson 2009 for a recent summary of research). Although HPV can be transmitted between women via oral sex, and HPV does appear to raise the risk of oral cancer, cancer itself is non-transmissible.
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Funding
This study was funded by Canadian Institutes for Health Research [CIHR]. The authors would like to acknowledge and thank all members of the research team, which also includes Brenda Beagan and Lisa Goldberg (co-PIs), Sue Atkinson, Mary Bryson, Megan Dean, Erin Fredericks, Ami Harbin, and Brenda Hattie. CIHR retains no rights over the direction of the research or the publication of results. Neither author received any other financial support for this work, and neither has any conflicts of interest to declare. The authors also would like to thank audiences at the Feminist Approaches to Bioethics and Canadian Association of Bioethics conferences, Alexis Shotwell, and an anonymous reviewer for their helpful comments on earlier drafts.
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Heyes, C.J., Thachuk, A. Queering Know-How: Clinical Skill Acquisition as Ethical Practice. Bioethical Inquiry 12, 331–341 (2015). https://doi.org/10.1007/s11673-014-9566-8
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DOI: https://doi.org/10.1007/s11673-014-9566-8