THE EXPERIENCES OF CONSENSUALLY NON-MONOGAMOUS PATIENTS ACCESSING HEALTHCARE by Ashley Serl B.Sc.N., British Columbia Institute of Technology, 2016 B.A. (Hons), University of British Columbia, 2009 CAPSTONE SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE IN NURSING – FAMILY NURSE PRACTITIONER UNIVERSITY OF NORTHERN BRITISH COLUMBIA August 2025 © Ashley Serl, 2025 ii Abstract Individuals who practice consensual non-monogamy (CNM) face a variety of challenges in the healthcare system, from administrative barriers to negative comments to overt discrimination to refusal of care. It is estimated that up to 20% of adults in Canada and the United States have engaged in CNM during their lifetime, and public awareness of CNM is increasing (Haupert et al., 2017). However, the provision of pertinent education for healthcare providers (HCPs), as well as research into this type of relationship, remains rudimentary at best and this has resulted in a lack of knowledge, understanding, and general sensitivity to the healthcare needs of these individuals. This lack of awareness, in combination with a general dearth of sexual health training for HCPs, and a societal privileging of monogamy, most often results in negative healthcare experiences for those individuals who practice CNM. This review explores existing research into the healthcare experiences of adults who practice CNM, and it offers suggestions for enabling a better understanding of CNM by HCPs. iii TABLE OF CONTENTS Table of Contents ........................................................................................................................... iii Glossary .......................................................................................................................................... v Acknowledgements ....................................................................................................................... vii Chapter One: Introduction .............................................................................................................. 1 Chapter Two: Background .............................................................................................................. 3 Defining Consensual Non-Monogamy ....................................................................................... 3 Consensual Non-Monogamy’s Prevalence in Society ................................................................ 3 Consensual Non-Monogamy and Stigma ................................................................................... 4 Scope and Purpose ...................................................................................................................... 6 Chapter Three: Methods ................................................................................................................. 7 Search Terms .............................................................................................................................. 8 Databases .................................................................................................................................... 8 Inclusion and Exclusion Criteria ................................................................................................. 9 Search Results ........................................................................................................................... 10 Chapter Four: Findings ................................................................................................................. 11 Section 1: Structural Analysis of Studies.................................................................................. 11 Study Comparison................................................................................................................. 12 Theme 1: Healthcare Experiences of CNM Patients ................................................................ 15 Negative Experiences with Healthcare Providers ................................................................. 15 Factors Contributing to Negative Experiences ..................................................................... 16 Factors Contributing to Positive Healthcare Experiences .................................................... 21 Theme 2: Mononormativity and Gender: The Role of Societal Expectations .......................... 22 Theme 3: Decisions Around Disclosure ................................................................................... 24 Avoiding Questions .............................................................................................................. 25 Obfuscation ........................................................................................................................... 25 Pre-Screening ........................................................................................................................ 26 Theme 4: Recommendations for Improving CNM Patients’ Experiences ............................... 27 Recommendations for HCP Education ................................................................................. 27 Recommendations for Administrative Changes ................................................................... 28 Chapter Five: Discussion .............................................................................................................. 30 Where Do We Locate CNM? .................................................................................................... 30 Unique Challenges Associated with CNM ........................................................................... 31 Viewing CNM as a Family Structure.................................................................................... 31 Beyond a Sexual Practice...................................................................................................... 32 It’s Worse Than We Think ....................................................................................................... 33 iv Expanding Focus ....................................................................................................................... 35 Paths for Future Research ......................................................................................................... 36 Chapter Six: Conclusion ............................................................................................................... 39 References ..................................................................................................................................... 40 Appendix A ................................................................................................................................... 45 Appendix B ................................................................................................................................... 47 Appendix C ................................................................................................................................... 48 Appendix D ................................................................................................................................... 50 v Glossary 2SLGBTQIA+: “2S: at the front, recognizes Two-Spirit people as the first 2SLGBTQI+ communities; L: Lesbian; G: Gay; B: Bisexual; T: Transgender; Q: Queer; I: Intersex, considers sex characteristics beyond sexual orientation, gender identity and gender expression; A: Asexual; +: is inclusive of people who identify as part of sexual and gender diverse communities, who use additional terminologies” (Women and Gender Equality Canada, 2024, para. 1). Cisgender (Cis-): “A person whose gender identity corresponds to their sex assigned at birth” (Women and Gender Equality Canada, 2024, para. 13). Consensual non-monogamy: “any relationship arrangement in which the partners agree to have extradyadic sexual or romantic relationships” (Conley et al., 2013, p. 2). Healthcare provider: A licensed person or organization that provides health care services. For the purposes of this paper, ‘healthcare provider’ refers to individuals rather than organizations. Heterosexual/Heteroromantic (Het-): “A person who is sexually and/or romantically attracted to people of a different gender than themselves” (Women and Gender Equality Canada, 2024, para. 19). Infidelity (Cheating): “Nonconsensual nonmonogamy—a situation in which partners have an agreement to be monogamous but one or both partners are breaking the monogamy agreement” (Conley, 2013, p. 2). Monogamy: “The state or practice of having only one sexual partner at a time” (MerriamWebster, n.d.). Mononormativity: “The assumption that clients are and should be monogamous” (Flicker, 2019, p. E1118). Open relationship: “Both partners can engage in extra-dyadic sex but maintain emotional (i.e. romantic) monogamy” (Séguin, 2019, p. 669). Polyamory: “A form of CNM in which participants have multiple loving and romantic—rather than merely sexual—relationships” (Conley et al., 2013, p. 7). Polygamy: “Marriage to more than one spouse at a time” (“Polygamy,” 2025). Swinging/Swingers: “Swingers tend to be characterised as attending organised events where they have sex with people other than their established partner (if they have one) while generally eschewing the development of romantic emotional bonds (although friendships do often develop)” (Scoats & Campbell, 2022, p. 1). Two-spirit: “A term that describes non heterosexual and/or non-cisgender Indigenous sexual and gender expressions. The term comes from the Northern Algonquin word niizh manitoag, vi meaning two spirits. The term Two-spirit represents the presence of masculine and feminine traits within an individual” (Women and Gender Equality Canada, 2024, para. 32). Woman/women: People who self-identify as women (Women and Gender Equality Canada, 2024). vii Acknowledgements I would like to express my deep gratitude and thanks to my supervisor, Dr Catharine Schiller, for her support, encouragement, and feedback throughout the process of researching and writing this capstone. To my parents Sue and Don, and my brother Graham and his partner Elodie – thank you for being the compassionate, loving, brilliant people you are. I consider myself endlessly fortunate to have you as family. To my partners, Georg and Lytton – I love you so very much. Thank you for pushing me, believing in me, and for helping me see this through. Thank you for your patience and kindness, your companionship and curiosity, and for the endless cups of tea. To their partners, Charlie, Domi, and Em, and to the various other stars in our scattered constellation – I am honoured to share space, people, love, and joy with you. 1 Chapter One: Introduction Consensual non-monogamy (CNM) is an umbrella term for “any relationship arrangement in which the partners agree to have extradyadic sexual or romantic relationships” (Conley et al., 2013, p. 2). CNM has been gaining public, as well as academic attention in recent years (Conley et al., 2013; Séguin, 2019); however, it remains understudied and underacknowledged within healthcare. Healthcare providers (HCPs) include members of licensed professions such as physicians, nurse practitioners, nurses, and others who care for health needs. Gaps in HCP understanding and awareness of CNM, combined with societal norms and expectations of monogamy, result in stigma and discrimination toward CNM practitioners. Negative experiences, or fear of negative experiences, constitute a barrier to care for patients who practice CNM. This integrative review was conducted to answer the research question: What are the experiences of consensually non-monogamous patients accessing healthcare? It aims to evaluate and consolidate existing healthcare-centred research into the experiences of CNM patients, identifying commonalities and factors that may contribute to those experiences, and possible avenues for improving the understanding of, and by extension the care for, patients who practice CNM. The Background chapter discusses what CNM is, how it interacts with society, and what healthcare systems and providers know about it. The Methods chapter discusses the procedure for framing the literature search and selecting studies for inclusion. The Findings chapter compares the methodologies and processes of included studies, then consolidates the information they contain. It is divided into four segments following the primary themes identified from included studies: Healthcare Experiences of CNM Patients, Mononormativity and Gender: The 2 Role of Societal Expectations, Decisions Around Disclosure, and Recommendations for Improving CNM Patients’ Experiences. The Discussion chapter then examines the implications of the Findings section and applies a variety of lenses to the findings to identify potential future research areas. 3 Chapter Two: Background CNM is not well understood and, despite its relative prevalence, is underacknowledged in society generally as well as within healthcare practice. This chapter establishes a shared understanding of CNM and its contexts, including what and how common it is, and how a combination of lack of awareness and stigma affects CNM practitioners both within and outside of healthcare contexts. Defining Consensual Non-Monogamy CNM is an umbrella term that encompasses a range of possible relationship structures. It is broadly defined as a relationship “in which all partners give explicit consent to engage in romantic, intimate, and/or sexual relationships with multiple people” (Moors et al., 2019, p. 1). For the purposes of this paper, the abbreviation ‘CNM’ will be used to denote both the noun form ‘Consensual Non-Monogamy’ and the adjective ‘Consensually Non-Monogamous.’ CNM includes swinging, open relationships, polyamory, and other relationship styles that adhere to the same principles of openness and consent between all partners. Consensual Non-Monogamy’s Prevalence in Society CNM is more common than is generally known or acknowledged. Among people currently in a relationship, 4% of Canadians (Fairbrother et al., 2019) and 5% of Americans (Scoats & Campbell, 2022) report that they are in an open or non-monogamous relationship, while approximately 20% of both Canadians and Americans have been in a CNM relationship or arrangement at some point in their lives (Haupert et al., 2017, as cited in Scoats & Campbell, 2022). CNM accounts for a similar percentage of the population to those who identify gay, lesbian, or bisexual; 4.4% of the adult population in Canada (Government of Canada, 2022) and 7.6% of the adult population in the United States (Gallup Inc., 2024). 4 CNM is increasingly in the public view, both because these relationships are more often being acknowledged openly (Flicker, 2019; Scoats & Campbell, 2024) and because CNM has gained public attention in the wake of legalization of same-sex marriage (Conley et al., 2013). Given the similarity in numbers between CNM practitioners and those who engage in same-sex relationships, it is not unrealistic that a comparable social and political movement may occur seeking recognition, protection, and rights for CNM relationships (Conley et al., 2013). Consensual Non-Monogamy and Stigma In 2013, Conley et al. (2013) published a series of studies investigating CNM stigma in the United States. These studies established that monogamy is socially privileged and those who practice monogamy benefit from a halo effect. A halo effect occurs when an individual is evaluated based on one easily identifiable and prized trait, such as intelligence or physical attractiveness; the individual is deemed ‘good’ because of their association with that desirable attribute (Conley et al., 2013). Those who practice monogamy benefit from its halo effect, while those who practice CNM are subject to negative bias and stigma, even by other CNM practitioners: [T]he depth and pervasiveness of the bias and stigma toward monogamy is quite surprising […P]articipants assumed that people in monogamous relationships were happier in their relationships, sexually more satisfied, and simply better citizens than those in CNM relationships. Moreover, the belief that CNM people are lesser than monogamous people on a variety of traits held true among each social and cultural group that we studied, including people who were currently in CNM relationships. (Conley et al., 2013, p. 23) 5 In contrast to the halo effect surrounding monogamy, Scoats and Campbell (2022) offer a summary of the most common misconceptions about CMN: CNM is presumed to: 1) be primarily motivated by a desire for more sex, and thus must lead to an elevated risk of [sexually transmitted infections]; 2) be inherently oppressive to women; 3) means practitioners do not love their partners; 4) is a defective behaviour that does not work well in comparison to monogamy; 5) will result in jealousy which will be relationship destroying; and finally 6) is not natural. (p. 2) The interaction of the halo effect of monogamy and unproven but negative misconceptions of CNM is further complicated by additional co-occurring sources of inequity, such as gender or sexual minority status (Scoats & Campbell, 2022). As an example, which will be discussed in more detail in the Findings chapter, women who practice CNM experience more discrimination than men as CNM women are also subject to stricter social norms around sexual behaviour or risk-taking (McCrosky, 2015; Scoats & Campbell, 2022). Hatzenbuehler et al. (2013) define stigma as “the cooccurrence of labeling, stereotyping, separation, status loss, and discrimination in a context in which power is exercised” (p. 813); they argue that stigma “is in fact a central driver of morbidity and mortality” (p. 813) and that it “meets all of the criteria to be considered a fundamental cause of health inequalities” (p. 819). To address health inequities, HCPs must confront stigma about CNM just as they would stigma about any other minority group. Healthcare Provider Awareness of CNM HCPs receive little, if any, training in discussing the sexuality and sexual health of their patients. For example, Beebe et al. (2021) found that, of a respondent pool of 276 American medical students, residents, and fellows, 20.6% received no training in sexual health during 6 medical school. Unless they work in a subfield in which such discussions are more common, HCPs have been found to be generally unaware of CNM or, if they are aware, then they likely have no direct knowledge of it (Anderson et al., 2025). HCPs are most likely to learn that a patient practices CNM in the context of sexual health, an area which is particularly vulnerable to influence by personal beliefs and social norms (McCrosky, 2015). Mononormativity, combined with: (a) traditional societal beliefs about sexuality and relationship structures; and (b) a lack of accurate information about CNM, can lead to prejudiced, discriminatory, and pathologizing treatment of patients who practice CNM (Flicker, 2019; Scoats & Campbell, 2019; Vaughan et al., 2019). Both anticipatory and responsive fears of such reactions from a HCP constitutes a barrier to safe healthcare for patients who practice CNM, an emotionally and psychologically harmful situation that is comparable to health disparities experienced by members of other sexual minorities (Flicker, 2019; Scoats & Campbell, 2024). Scope and Purpose The primary purpose of this integrative review is to collect, synthesize, and analyse existing research that focuses on CNM patients’ experiences of interacting with HCPs and healthcare systems. The review summarizes the ways that disclosure or discovery of a patient’s CNM status can impact the patient-provider relationship from the patient’s perspective, including an exploration of the systemic and individual factors that can contribute to both negative and positive interactions. The second purpose of this review is to evaluate the current status and trajectory of research into CNM, the implications of what has been explored thus far, and potential areas for future research. 7 Chapter Three: Methods This integrative review was conducted to answer the research question: What are the experiences of consensually non-monogamous patients when they access healthcare? The review followed Whittemore and Knafl’s (2005) methodology, which evaluates and integrates data across multiple types and methodologies of research, and accounts for qualitative, experiential information, to yield generalized results (Whittemore & Knafl, 2005). Since the research question sought experiences of the target population, CNM adults, it was important that the review methodology be able to account for qualitative or anecdotal information. Whittemore and Knafl’s (2005) methodology begins with problem identification, followed by a literature search, and data evaluation and analysis. Problem Identification CNM is not well studied or understood within healthcare and CNM practitioners experience health disparities because of this lack of awareness (Flicker, 2019). It behooves healthcare as a field to become more aware of and informed about CNM. The research question was therefore developed along a PIO (Population, Intervention, Outcome) structure (Gray et al., 2017) to focus on the qualitative, first-hand experiences of CNM practitioners when interacting with healthcare. The population (P) is adults who practice CNM; although the search parameters used to identify studies for this integrative review did not specify adults, no study included anyone under the age of 18. The intervention (I) focuses on healthcare-specific encounters, excluding therapy or counselling. This restriction was imposed for three reasons. First, the author is a healthcare worker and therefore healthcare is their primary area of interest. Second, while there is significantly more research into CNM in fields such as therapy or sexuality, the relative lack of healthcare-specific data constitutes a research gap. Third, therapy and counselling are 8 expensive, optional services with which not every person is able to engage and therefore not all CNM practitioners have access to therapy or counselling. The outcome (O) is the patient experience, and this parameter was left intentionally broad because research into CNM healthcare encounters that focus on patient experience is still an emerging field. Search Terms The research question was divided into two primary concepts: Concept 1 was ‘consensual non-monogamy’. The search string was expanded to include both hyphenated and non-hyphenated spellings and variations thereof, as well as polyamory as this term is often preferentially used when discussing long-term partnerships involving more than two people. The asterisk (*) wildcard was used to broaden potential matches, for example ‘polyamor*’could return ‘polyamory’ and ‘polyamorous.’ The resulting search terms were: nonmonogam*; nonmonogamy*; consensual* non-monogam*; consensual* nonmonogamy*; polyamor*. Concept 2 covered healthcare and terms synonymous with healthcare. Included terms were: healthcare system; health system; health services; medical care; primary care. Each set of concept terms was combined in search strings using the Boolean operator “OR”. The results of each concept search were then combined using “AND” to generate a list of articles containing any combination of terms from the first and second concepts. Databases Searches were conducted in Medline (EBSCO) and the Cumulative Index to Nursing Allied Health Literature (CINAHL), both of which were chosen for their extensive coverage of topics related to nursing, medicine, and health disciplines. The complete search history is included in Appendix A. 9 Inclusion and Exclusion Criteria This literature review focused on two concepts, CNM and healthcare, and considered them only from the perspective of patient experiences. Results were limited to articles published in English, as that is the author’s primary language and translation services were unavailable. The search excluded articles on polygamy and infidelity; infidelity is “nonconsensual nonmonogamy—a situation in which partners have an agreement to be monogamous but one or both partners are breaking the monogamy agreement” (Conley, 2013, p. 2) and, as such, is not comparable to CNM. Polygamy is a subtype of marital structure which excludes the possibility of outside relationships. Also excluded were articles with a focus on sexual health data in which CNM status had been collected as a data point, for example studies on condom use or testing for sexually transmitted infections (STIs). Articles that focused on sociological, political, or legal issues, in which healthcare may have been cited as an example but was not examined directly, were likewise excluded. Finally, articles that focused on counselling or couples’ therapy were excluded because these they are not covered services under universal healthcare and are therefore financially inaccessible to many. Originally, publication year had been considered as a potential inclusion criterion; however, when date restrictions were fully removed from database searches, results showed that all relevant studies had been published in 2019 or later except for one 2015 study and one 2017 study. As a result, there was no need to restrict the findings in this way and all articles returned from database searches were included for further consideration. 10 Search Results The search concepts were combined in Medline and this yielded a total of 39 results. When combined in CINAHL, the searches yielded 43 results. The total number of results was therefore 82 articles. Twenty-six duplicate articles were removed immediately, and one article was removed as it was not in English. The remaining 55 articles were screened by checking titles and abstracts for any clear indications that they met exclusion criteria, and 41 articles were removed at this stage. The remaining 14 articles were retrieved for full text review, and seven articles were removed as a result of this review. A total of seven articles remained. The reference list of each of these articles was scanned for additional articles that were not captured in the database searches, but this did not yield further results. The same search strategy was used in Journal Storage (JSTOR) and Google Scholar, neither of which returned any new articles that met the inclusion and exclusion criteria. One additional article, Anderson et al. (2025), was published after the original searches had been concluded. It was discovered by chance during the integrative review writing process and was included in the review to ensure a thorough end product. Therefore, a total of eight publications were included in this integrative review. See Appendix B for a PRISMA diagram summary of the steps involved in identifying articles for inclusion in this integrative review. 11 Chapter Four: Findings This review synthesizes existing literature to answer the question: What are the experiences of consensually non-monogamous patients accessing healthcare? Studies in this area are limited, and a search of available literature resulted in eight articles. The first section of the Findings chapter summarizes and compares characteristics of the studies, including their recruitment and interview techniques, population of interest, sample size, and demographics. Sections two through five of this chapter summarize the predominant themes among the studies’ findings: Healthcare Experiences of CNM Patients; Mononormativity and Gender: The Role of Societal Expectations; Decisions Around Disclosure; Recommendations for Improving CNM Patients’ Experiences. Section 1: Structural Analysis of Studies This section summarizes and compares the structural components of the included studies. Table 1 (see Appendix C1) summarizes characteristics of each study design: geographic location, recruitment methods, and information gathering technique. Table 2 (see Appendix C2) summarizes characteristics of the study respondents: the population studied, number of respondents, and selected demographic data. The demographic data included in Table 2 has been condensed as the purpose of these tables is not a complete reproduction of the study results but rather a summary of important points of comparison across studies. The tables therefore highlight the commonly collected demographic categories, such as age, sexual orientation, ethnicity, and level of education, and do not include data points that only appear in a minority of studies, such as place of residence and whether each participant was ‘out’ about CNM at work (Campbell et al., 2023). In cases where there were multiple response options, information is sometimes condensed; for example, the Smith (2017) study had 20 participants and seven 12 possible categories for ‘Income.’ This has been condensed to ‘<$60,000: n=14; above $120,000: n=4’, thus efficiently providing this same information. Terminology used in Tables 1 and 2 matches the terminology used in each corresponding article. For example, when an article used ‘race,’ ‘ethnicity,’ or ‘race/ethnicity’ in their demographic data, the same terminology is reflected in the tables. Study Comparison The eight included research articles all used qualitative methodology with some quantitative data gathered in the form of demographics (Anderson et al., 2025; Arseneau et al., 2019; Avanthay Strus & Polomeno, 2021; Campbell et al., 2023; McCrosky, 2015; Scoats & Campbell, 2024; Smith, 2017; Vaughan et al., 2019). Six of the eight studies conducted real-time semi-structured interviews either in person or via a conferencing platform and added follow-up or clarifying questions during their interviews (Anderson et al., 2025; Arseneau et al., 2019; Avanthay Strus & Polomeno, 2021; McCrosky, 2015; Smith, 2017; Vaughan et al., 2019). Of those six, Vaughan et al. (2019) conducted focus group interviews while the other five conducted individual interviews. The remaining two articles, Campbell et al. (2023) and Scoats and Campbell (2024), drew from the same dataset which was gathered via online survey with demographic and qualitative experiential data provided as free text, meaning there was no opportunity to ask clarifying questions (Campbell et al., 2023; Scoats & Campbell, 2024). Campbell et al. (2023) examined the experiences of CNM people accessing sexual healthcare, and Scoats and Campbell (2024) focused on a subset of the data to examine the factors that influence CNM people’s decisions to access certain types of sexual healthcare. Thus, the eight articles that were included in this review have been derived from seven different data sets. 13 There is some variation across the eight students in the population each recruited. Seven of the eight studies recruited respondents who self-identified as CNM, while one, Smith (2017), restricted participation to respondents who had been in at relationship involving three or more people for at least one year. McCrosky’s (2015) study was an outlier in two ways: this was the only study to examine the experiences of sex workers, and was also the only study that restricted its respondent pool to women. Arseneau et al. (2019) and Avanthay Strus and Polomeno (2021) both focused on birthing and the transition to parenthood, so their study populations were CNM people who had given birth or had supported their partner through the journey of pregnancy, birth, and parenting. Several studies indicated that their respondents were not representative of the greater population: Anderson et al.’s (2025) 32 participants were universally nonheterosexual and educated at a tertiary level; 90% of Arsenault et al.’s (2019) respondents were white or European, as were 60 out of 67 respondents in Campbell et al. (2023) and Scoats and Campbell (2024). Recruitment strategies involved a combination of targeted online advertising and snowball sampling, with two exceptions: Anderson et al. (2025) used only targeted online advertising and Vaughan et al. (2019) used only convenience sampling through attending polyamory-themed meetups. The remaining six studies used a combination of social media posting and snowball sampling to recruit participants (Arseneau et al., 2019; Avanthay Strus & Polomeno, 2021; Campbell et al., 2023; McCrosky, 2015; Scoats & Campbell, 2024; Smith, 2017). Snowball sampling is a recruitment method in which initial participants, often members of a researcher’s network, in turn recruit other research participants for that same study (Browne, 2005). Snowball sampling is a non-random recruitment strategy that does not result in a representative sample and therefore it is better suited to gathering qualitative and experiential 14 data rather than quantitative or objective data (Browne, 2005). It is especially effective at accessing hidden populations or those who operate outside of societal norms, especially if the researcher is also a member of that same hidden population and is seen as an ‘insider’ (Browne, 2005). As such, snowball sampling is an ideal sampling method when approaching CNM practitioners, a population which Campbell et al. (2023), McCrosky (2019), and Smith (2017) all described as difficult to reach. All of the studies were conducted in relatively affluent, English-speaking countries: three studies, McCrosky (2015), Smith (2017), and Vaughan et al. (2019), were conducted in the USA and included information about the ways that for-profit aspects of the American healthcare system affect CNM practitioners’ healthcare options and decisions. One study, Anderson et al. (2025), was conducted in Australia, and two studies, Arseneau et al. (2019) and Avanthay Strus and Polomeno (2021), were conducted in Canada. The remaining two studies, Campbell et al. (2023) and Scoats and Campbell (2024), conducted their participant interviews online and, although most respondents were British, there were also respondents from other European countries and from North America. Concerns about representativeness are explicitly listed as study limitations in four out of eight studies, and four studies included a statement that their results would likely not be generalizable to populations in other circumstances (Campbell et al., 2023; McCrosky, 2015; Smith, 2017; Vaughan et al., 2019). The articles in this review overlapped in their recruitment methods and data gathering, as well as their focus on experiential data. Although the exact population of study varied, the study participants in all eight studies had lived experience with CNM and the interaction of CNM with healthcare. Despite some differences in overall study focus, the findings of all studies intersected on several points, which are presented below as common themes. 15 Full data extraction tables are included in Appendix D. Theme 1: Healthcare Experiences of CNM Patients All studies reported both negative and positive interactions with HCPs as a direct result of participants disclosing their CNM status. Interactions were viewed positively when CNM patients were able to express their healthcare wishes and needs without fear of discrimination or rejection. Negative interactions were influenced by systemic or administrative barriers and interpersonal factors such as a lack of HCP awareness of CNM, or the presence of provider discomfort or negative bias. Negative Experiences with Healthcare Providers Negative HCP reactions to the disclosure of CNM manifested in a variety of ways. Study respondents reported the following HCP reactions as reflecting discomfort or disapproval of CNM: (a) changes in facial expression, tone, or overall demeanour (Anderson et al., 2025; Avanthay Strus & Polomeno, 2021; Campbell et al., 2023; McCrosky, 2015; Smith, 2017; Vaughan et al., 2019); (b) the use of prejudicial or derogatory language, either with or about the patient (Anderson et al., 2025; Campbell et al., 2023; McCrosky, 2015; Smith, 2017; Vaughan et al., 2019); (c) lecturing the patient about sexual health in a condescending manner (Anderson et al., 2025; Campbell et al., 2023; McCrosky, 2015; Vaughan et al., 2019); (d) the expression of negative stereotypes and judgemental statements (Anderson et al., 2025; Campbell et al., 2023; McCrosky, 2015; Smith, 2017; Vaughan et al., 2019); (e) invasive and irrelevant questioning that appeared to be out of curiosity rather than medical relevance (Anderson et al., 2025; Campbell et al., 2023; McCrosky, 2015); 16 (f) changes in treatment plan, including refusal of care that had been previously planned or agreed upon (Anderson et al., 2025; Campbell et al., 2023; McCrosky, 2015; Smith, 2017; Vaughan et al., 2019); and (g) redirection away from the provider or clinic (Anderson et al., 2025; McCrosky, 2015; Vaughan et al., 2019). Respondents in all included studies reported feeling uncomfortable or unsafe returning to the same clinic or provider in future, whether for sexual or other health care (Anderson et al., 2025; Arseneau et al., 2019; Avanthay Strus & Polomeno, 2021; Campbell et al., 2023; McCrosky, 2015; Scoats & Campbell, 2024; Smith, 2017; Vaughan et al., 2019). Factors Contributing to Negative Experiences The factors that contributed to CNM patients’ negative experiences with HCPs can be divided into interpersonal and systemic issues. Interpersonal issues stemmed from either lack of provider awareness about CNM or from provider-held misconceptions about CNM. In contrast, systemic issues stemmed from administrative inflexibility and mononormativity. Interpersonal Issues. Most of the negative interactions shared by study participants occurred in the context of sexual health care provision (Anderson et al., 2025; Arseneau et al., 2019; Avanthay Strus & Polomeno, 2021; Campbell et al., 2023; McCrosky, 2015; Scoats & Campbell, 2024; Smith, 2017; Vaughan et al., 2019), although Arseneau et al. (2019) also included interactions in the context of childbearing. CNM practitioners have unique sexual health care needs. Although CNM practitioners generally obtain STI screening more often than their monogamous counterparts, sexual health screening algorithms are constructed on the assumption of monogamy and therefore are not representative of CNM practitioners’ experiences or risk profiles (Anderson et al., 2025; Arseneau et al., 2019; Avanthay Strus & Polomeno, 2021; 17 Campbell et al., 2023; McCrosky, 2015; Scoats & Campbell, 2024; Smith, 2017; Vaughan et al., 2019). As a result, respondents in seven of the eight studies reported arguing with their HCP to receive more STI testing; the final study, Scoats and Campbell (2024), did not discuss denial of care, focusing instead on CNM patient perceptions of provider acceptance or stigma. Lack of HCP knowledge about CNM was reported as leading to incorrect assumptions or judgements about patients and their practices. One such assumption that was identified was that any married patient would be monogamous (Anderson et al., 2025; Arseneau et al., 2019; Avanthay Strus & Polomeno, 2021; Campbell et al., 2023; McCrosky, 2015; Smith, 2017; Vaughan et al., 2019), which in turn led to the conclusion that either the patient or their partner was cheating (Anderson et al., 2025; Avanthay Strus & Polomeno, 2021; Campbell et al., 2023; McCrosky, 2015). Study respondents also reported experiences in which HCPs assumed that they were not taking adequate measures to protect themselves against STIs, or that they by default must have STIs because they are CNM practitioners (Anderson et al., 2025; Avanthay Strus & Polomeno, 2021; Campbell et al., 2023; McCrosky, 2015; Smith, 2017; Vaughan et al., 2019). CNM respondents in several studies reported being lectured extensively and repeatedly on sexual health, as though they would make different decisions if they were given more information (Anderson et al., 2025, Campbell et al., 2023; McCrosky, 2015). In contrast, studies found that CNM patients generally had a very good understanding of safer sex practices, tended to be more proactive and communicative regarding sexual safety than their monogamous counterparts, and often implemented protocols requiring STI testing with a certain frequency or within a certain timeframe prior to having a sexual encounter with a new partner (Arseneau et al., 2019; Campbell et al., 2023; McCrosky, 2015; Smith, 2017; Vaughan et al., 2019). 18 Respondents in six of the eight studies reported that, as a result of their HCP’s lack of familiarity with CNM, they did not feel they could trust their HCP to provide accurate sexual health advice or care that would meet their needs (Anderson et al., 2025; Avanthay Strus & Polomeno, 2021; Campbell et al., 2023; McCrosky, 2015; Smith, 2017; Vaughan et al., 2019). Moreover, respondents in seven of eight studies felt that they knew more about sexual health promotion and safety than their HCPs (Anderson et al., 2025; Avanthay Strus & Polomeno, 2021; Campbell et al., 2023; McCrosky, 2015; Scoats & Campbell, 2024; Smith, 2017; Vaughan et al., 2019). The eighth study, Arseneau et al. (2019), focused primarily on the childbearing experience and, although the authors agreed that HCPs generally lack accurate information about CNM, they did not discuss how that might manifest in sexual health discussions. Sexuality is an area which is particularly prone to bias through a combination of personal belief and discomfort discussing the topic (Anderson et al., 2025; Avanthay Strus & Polomeno, 2021; Campbell et al., 2023; McCrosky, 2015; Smith, 2017; Vaughan et al., 2019). Bias can contribute to a tendency for HCPs to pathologize CNM, as reported by respondents in five of the studies; HCPs either attributed unrelated health concerns like depression to a patient’s CNM status, or linked their CNM status to mental health concerns such as attention deficit disorder or to an unsettled lifestyle (Anderson et al., 2025; Campbell et al., 2023; McCrosky, 2015; Smith, 2017; Vaughan et al., 2019). In consequence, respondents in all but one study described feeling obligated to educate their HCP about CNM (Anderson et al., 2025; Arseneau et al., 2019; Avanthay Strus & Polomeno, 2021; Campbell et al., 2023; McCrosky, 2015; Smith, 2017; Vaughan et al., 2019). The final study, Scoats and Campbell (2024), did not discuss specifics of interactions between HCPs and CNM patients. 19 Even when healthcare providers are well-intentioned and supportive of their patient’s decisions, ignorance often contributed to non-affirming experiences. Several respondents expressed frustration and disappointment that HCPs, particularly those working in the area of sexual health, were not taking the initiative to self-educate on CNM (Anderson et al., 2025; Campbell et al., 2023; McCrosky, 2015; Smith, 2017; Vaughan et al., 2019). These HCPs’ questions were often viewed with exasperation or resignation, as a drain on energy, and as a reminder of marginalization (Anderson et al., 2025; Avanthay Strus & Polomeno, 2021; Campbell et al., 2023; McCrosky, 2015; Smith, 2017; Vaughan et al., 2019). Structural/Administrative Barriers. CNM patients reported routinely facing administrative barriers in addition to interpersonal ones. The systemic inability to integrate and adequately document CNM partnerships not only caused confusion and upset, but also had farreaching legal consequences, affecting things such as next-of-kin designation and access to health insurance benefits. No Space on Forms. Healthcare intake and demographic sheets were reported as not being equipped to address relationships involving multiple partners. Because there is generally no mechanism to list multiple partners, including no free-text space where a patient can include that information, respondents in four out of eight studies described feelings of erasure, invalidation, or guilt towards the partners that could not be listed; they felt that the healthcare system consistently demonstrates that it is incapable of accurately representing their relationships or family structure, which was all the more frustrating when respondents were trying to be open about their CNM status (Anderson et al., 2025; Arseneau et al., 2019; Avanthay Strus & Polomeno, 2021; Smith, 2017). 20 The two studies concerned with pregnancy and childrearing, Arseneau et al. (2019) and Avanthay Strus and Polomeno (2021), discussed additional administrative barriers specific to parenting. Arseneau et al.’s (2019) study on the pregnancy and birthing experiences of polyamorous parents described a hospital system organized in alignment with mononormative assumptions of family structures, as evidenced by: • insufficient space for additional partners in birthing rooms, meaning that partners had to wait in the hall and were provided updates on labour by staff members; • an apparent inability of the birthing facility to make additional ‘parent’ wristbands, despite being capable of making additional ‘baby’ bands for twins; and • a need for the birthing parent to insist repeatedly that additional partners be listed as parents on the child’s hospital file, and nonetheless having them listing them under other categories of kin such as “aunt” when the child’s demographic sheet only had two spaces for parents (Arseneau et al., 2019, p. E1126). Parents in Avanthay Strus and Polomeno’s study (2021) described similar struggles to list more than two parents on their child’s school file. Next of Kin. Administrative rigidity regarding relationship structures can have additional legal or financial consequences, especially in the USA. In Smith’s (2017) study on experiences of disclosing non-monogamy, several respondents shared instances of their family or chosen partners not being legally recognized by the healthcare system, resulting in potential denial of visitation in an emergency. Two participants shared situations where, because their polyamorous partnerships were not recognized, the legal ‘next of kin’ hierarchy prioritized biological family over their spouses even against the patient’s stated wishes, and one participant reported marrying in part to protect themselves against such a possibility (Smith, 2017). 21 Insurance. In studies conducted in the USA, insurance coverage creates an additional complication. CNM is neither legally recognized nor protected, so insurance companies are not required to extend coverage to all partners (Anderson et al., 2025; McCrosky, 2015; Scoats & Campbell, 2024; Smith, 2017; Vaughan et al., 2019). Respondents in the three American studies, (McCrosky, 2015), Smith (2017), and Vaughan et al. (2019), as well as the Australian study, Anderson et al. (2025), described instances where two members of a polyamorous constellation strategically posed as monogamous to extend insurance coverage to another member who did not have insurance, with the concern that the insurance coverage could be cancelled if they were discovered to be CNM practitioners. Conversely, insurance companies sometimes refused interventions such as STI testing or HPV immunizations for married patients due to presumed monogamy (Anderson et al., 2025; McCrosky, 2015; Scoats & Campbell, 2024; Smith, 2017; Vaughan et al., 2019). Patients then needed to decide whether to pay out of pocket to hide their status from their insurance provider or take the risk of disclosing their non-monogamy (McCrosky, 2015; Smith, 2017). Factors Contributing to Positive Healthcare Experiences Respondents in every study described positive experiences with HCPs that had elicited feelings of relief and reassurance. The factors that contributed to these positive experiences included appropriate and accurate use of language or terminology (Anderson et al., 2025; Arseneau et al., 2019; Avanthay Strus & Polomeno, 2021; Campbell et al., 2023; Scoats & Campbell, 2024; Smith, 2017); a neutral or practical approach to the patient or their needs, even if the HCP was not familiar with CNM (Anderson et al., 2025; Arseneau et al., 2019; Avanthay Strus & Polomeno, 2021; Campbell et al., 2023; Scoats & Campbell, 2024; Smith, 2017; Vaughan et al., 2019); the willingness to engage in patient-lead care rather than adhering to an 22 algorithmic approach (Anderson et al., 2025; Arseneau et al., 2019; Avanthay Strus & Polomeno, 2021; Campbell et al., 2023; Scoats & Campbell, 2024; Smith, 2017; Vaughan et al., 2019); and expressions of support, which included positive statements about CNM itself or compliments about the patient’s partnership dynamics or safer sex practices (Anderson et al., 2025; Avanthay Strus & Polomeno, 2021; Campbell et al., 2023; Scoats & Campbell, 2024; Smith, 2017; Vaughan et al., 2019). Some respondents described interactions in which HCPs did not know what CNM was, but either were unconcerned and asked only what was needed to provide accurate care (Campbell et al., 2023; Scoats & Campbell, 2024; Vaughan et al., 2019), or asked the patient for resource recommendations so they could engage in independent research to familiarize themselves with this relationship structure (Anderson et al., 2025). HCP questions were not considered invasive when the HCP approached questions from a clinical, care-focused perspective rather than out of perceived curiosity. Respondents in Anderson et al. (2025) and Scoats and Campbell (2024) related feelings of solidarity during exchanges with HCPs who were also members of sexual minority groups, and two respondents in Smith’s (2017) study also described their feelings of relief and of acceptance when their HCPs disclosed also being part of a CNM relationship. Theme 2: Mononormativity and Gender: The Role of Societal Expectations Sexual behaviour is highly socially regulated, and elements like an individual’s gender presentation, social standing, and marital status determine what behaviour is socially acceptable and how much resistance they meet in deviating from those behaviours (Flicker, 2019; Weber & Friese, 2025). Respondents in all included studies reflected on how mononormativity, “the assumption that clients are and should be monogamous” (Flicker, 2019, p. E1118), affected their interactions with large societal structures such as healthcare systems, while five of the eight 23 included studies contained references to the impact that gender, specifically being perceived as a woman, has on a CNM practitioner’s experiences both within and outside of healthcare (Anderson et al., 2025; Campbell et al., 2023; McCrosky, 2015; Smith, 2017; Vaughan et al., 2019). Societal expectations of women’s sexual behaviours differ from expectations of men (Conley et al., 2013; McCrosky, 2015; Scoats & Campbell, 2022; Smith, 2017; Weber & Friese, 2025). Women are expected to be monogamous and desire monogamy, more so than men who are more often expected to ‘play the field’ (McCrosky, 2015; Smith, 2017). Women who have more sex partners “are seen as having unhealthy, riskier, and less meaningful sex than their monogamous counterparts” (Conley et al. 2013, as cited in McCrosky, 2015, p. 6). Some woman-presenting respondents described situations where the disclosure of CNM in a social context led to harassment and repeated unwanted advances (Anderson et al., 2025; McCrosky, 2015). Others described situations where, despite repeated insistence that they were happy, they were unable to convince HCPs that they had chosen to engage with CNM, or other nonnormative sexual behaviours like kink, sex work, or pornography, of their own free will (Anderson et al., 2025; Campbell et al., 2023; McCrosky, 2015; Smith, 2017; Vaughan et al., 2019). Responses from HCPs sometimes took on a distinctly patronizing or patriarchal tone; for example, several women were asked what their boyfriends or husbands thought of their lifestyle (Campbell et al., 2023; McCrosky, 2015; Smith, 2017) and one woman’s therapist attributed her sexual assault by her ex-husband to masculine jealousy over her other partner (Smith, 2017). Monogamous relationships are viewed more positively by society at large than CNM relationships, with traditional marriage and parenting serving as the ultimate affirmations of mononormativity (Avanthay Strus & Polomeno, 2021; Conley et al., 2013; McCrosky, 2015). 24 Married patients are assumed to be monogamous, and respondents in multiple studies indicated that there was more resistance to a CNM disclosure if a patient was married than if they were not (Anderson et al., 2025; Arseneau et al., 2019; Avanthay Strus & Polomeno, 2021; Campbell et al., 2023; McCrosky, 2015; Smith, 2017; Vaughan et al., 2019). CNM parents also needed to contend with the additional perceived risk that their ‘deviant’ lifestyle could negatively affect their children, either through schoolyard bullying or through interference from Child and Family Services (Arseneau et al., 2019; Avanthay Strus & Polomeno, 2021). The co-occurrence of mononormative and gendered social scripts was reported as placing additional pressures on CNM women to conform, as exemplified by one respondent’s experience: “ [my providers] told me that if I wasn’t so sexually promiscuous, I wouldn’t have to spend so much money to get tested and that maybe I should just find a man (laughs), and stop ‘sleeping around’” (Vaughan et al., 2019, p. 46). Theme 3: Decisions Around Disclosure When deciding whether to disclose their CNM status, patients reported balancing the potential negative impacts of prejudice, stigma, and intolerance against the necessity of accessing adequate healthcare. Most respondents advised that they would rather be open with their providers but are reluctant to disclose due to prior negative experiences and concern about repercussions (Anderson et al., 2025; Arseneau et al., 2019; Avanthay Strus & Polomeno, 2021; Campbell et al., 2023; McCrosky, 2015; Scoats & Campbell, 2024; Smith, 2017; Vaughan et al., 2019). This left them with three options: avoid raising questions, obfuscate, or seek out providers who were less likely to react negatively. 25 Avoiding Questions Avoidance tactics reported in several studies included rotating through multiple sexual health clinics or having a primary care provider and visiting sexual health clinics ‘on the side’ (Campbell et al., 2023; McCrosky, 2015; Scoats & Campbell, 2024). This often meant paying out of pocket for testing to avoid alerting an insurer, which is a less viable option for those of lower socioeconomic status (McCrosky, 2015; Scoats & Campbell, 2024; Smith, 2017). Where available, mail-in testing allowed patients to avoid seeing a provider altogether, a less-than-ideal solution because such testing generally does not include blood tests and results in an incomplete STI testing panel (Campbell et al., 2023; McCrosky, 2019; Scoats & Campbell, 2024). Especially, although not exclusively, within the American healthcare system, alienating a primary care provider is risky as changing HCPs can be difficult and expensive (McCrosky, 2015). Likewise, informing insurance providers that an individual practices CNM may negate their health insurance, particularly if the person is a dependent on a partner’s plan (Smith, 2017). For CNM patients who had the means to do so, avoiding situations where they might be discovered was often viewed as the preferable solution (Anderson et al., 2025; McCrosky, 2015; Scoats & Campbell, 2024; Smith, 2017). Obfuscation If disclosure is unsafe and avoidance is impractical (for example, if a married patient sought STI screening and could not afford to pay out of pocket for independent testing), then obfuscation was viewed as a second-line option. The most common lies that were told involved a cheating spouse or partner, although some unmarried patients opted to substitute a lesser taboo such as saying they were dating several people casually rather than multiple people continuously (Anderson et al., 2025; Avanthay Strus & Polomeno, 2021; Campbell et al., 2023; McCrosky, 26 2015; Smith, 2017). Ironically, some patients reported that they needed to lie to increase their perceived risk; one respondent, a woman who dates women, reported having to exaggerate her number of partners to obtain full-panel STI testing which would otherwise have been denied because women who exclusively have sex with women are considered lower risk (Campbell et al., 2023). Obfuscation is not always practical nor desirable. Keeping stories straight can be difficult, especially if the patient will be seeing the same HCP again in future (McCrosky, 2015). Sometimes the patient’s CNM status is central to their request for healthcare services, for example when an adult film actor or sex worker seeks frequent STI testing, or when a married person wants HPV immunization (Campbell et al., 2023; McCrosky, 2015; Scoats & Campbell, 2024; Smith, 2017). Some married or partnered patients reported worrying that their providers might neglect to consider STIs among their possible diagnoses on the assumption that they were monogamous (Anderson et al., 2025; Arseneau et al., 2019; Avanthay Strus & Polomeno, 2021; Campbell et al., 2023; McCrosky, 2015; Smith, 2017; Vaughan et al., 2019). Finally, several respondents described being open about CNM, whether to normalize it (Anderson et al., 2025; Arseneau et al., 2019; Campbell et al., 2023; McCrosky, 2015; Smith, 2017; Vaughan et al., 2019) or because disclosure was viewed as preferable to allowing the HCP to make assumptions of infidelity (Anderson et al., 2025; Avanthay Strus & Polomeno, 2021; Campbell et al., 2023; McCrosky, 2015). Pre-Screening In cases where disclosure is desired or necessary, and where patients have options, they may mitigate risk by seeking clinics where CNM is less likely to be either a new concept or one that will be viewed negatively (Campbell et al., 2023; Scoats & Campbell, 2024; McCrosky, 27 2015; Smith, 2017; Vaughan et al., 2019). Examples of preferred clinics reported in the studies included Planned Parenthood, which has a general reputation for open-mindedness, or clinics that specifically serve 2SLGBTQIA+ populations as CNM is more common non-cis-het communities (Anderson et al., 2025; McCrosky, 2015; Scoats & Campbell, 2024; Vaughan et al., 2019). Patients may check clinic websites for statements about 2SLGBTQIA+ inclusivity while avoiding clinics with, for example, religious affiliations (McCrosky, 2015; Scoats & Campbell, 2024; Smith, 2017). Some respondents called clinics to ask if they were ‘CNM friendly’ before attending (McCrosky, 2015; Vaughan et al., 2019) and others sought clinics that serve lower incomes or other marginalized groups to provide camouflage (Anderson et al., 2025; McCrosky, 2015; Scoats & Campbell, 2024). In the case of pregnancy or childbirth, some respondents chose to use midwives, specifically to avoid dealing with hospital systems (Arseneau et al., 2019). Respondents also sought recommendations from friends, partners, and CNM community members (Anderson et al., 2025; Campbell et al., 2023; McCrosky, 2015; Scoats & Campbell, 2024; Vaughan et al., 2019). Theme 4: Recommendations for Improving CNM Patients’ Experiences All studies included a section of recommendations for improving CNM patient experiences. These fell into two categories: recommendations for HCP education; and recommendations for administrative changes. Recommendations for HCP Education The foremost recommendation for improving CNM patients’ experiences with the healthcare system was increased HPC education about sexual minorities in general, and CNM in particular (Anderson et al., 2025; Arseneau et al., 2019; Avanthay Strus & Polomeno, 2021; Campbell et al., 2023; McCrosky, 2015; Scoats & Campbell, 2024; Smith, 2017; Vaughan et al., 28 2019). Formal education should include information about non-standard family and relationship structures such as CNM (Anderson et al., 2025; Arseneau et al., 2019; Avanthay Strus & Polomeno, 2021; McCrosky, 2015; Scoats & Campbell, 2024; Smith, 2017; Vaughan et al., 2019). It must provide empiric, peer-reviewed data to counter negative myths, stereotypes, and assumptions about CNM (Anderson et al., 2025; Arseneau et al., 2019; Avanthay Strus & Polomeno, 2021; McCrosky, 2015; Scoats & Campbell, 2024; Smith, 2017; Vaughan et al., 2019). Additionally, HCPs need to expand their understanding of the principles of STI testing and prevention rather than relying on protocols; protocols that presume monogamy are unlikely to represent the needs of CNM patients, and the assignation of risk based primarily on either the absence of sexual exclusivity or the patient’s number of partners risks equating CNM with voluntary risk-taking, thus reinforcing stereotypes that CNM patients are less concerned with safety for either themselves or their partners (Anderson et al., 2025; Arseneau et al., 2019; Avanthay Strus & Polomeno, 2021; Campbell et al., 2023; McCrosky, 2015; Scoats & Campbell, 2024; Smith, 2017; Vaughan et al., 2019). In the absence of formal education, some respondents also suggested that providers self-educate, especially if they work in a field related to sexuality or reproductive health (Anderson et al., 2025; Arseneau et al., 2019; Avanthay Strus & Polomeno, 2021; Campbell et al., 2023; Vaughan et al., 2019). Recommendations for Administrative Changes Studies suggested administrative changes on an individual or clinic level, as well as to the healthcare system overall. Clinics should update intake forms to accommodate multiple partners and/or multiple parents, or provide free-text space where a patient can include that information (Anderson et al., 2025; Arseneau et al., 2019; Avanthay Strus & Polomeno, 2021; McCrosky, 2015; Scoats & Campbell, 2024). Providers should ask questions about what types of 29 relationships people are in rather than simply asking if they are in a relationship (Avanthay Strus & Polomeno, 2021). Adding statements about inclusivity and diversity on websites would allow CNM patients to more easily search and screen clinics to determine where they are more likely to feel safe (McCrosky, 2015, Vaughan et al., 2019). Further, anti-discrimination policies should explicitly include CNM (McCrosky, 2015) and healthcare providers should advocate for changes to policy and structures that currently rely upon and reinforce assumptions of mononormativity (Avanthay Strus & Polomeno, 2021). 30 Chapter Five: Discussion This integrative review has thus far summarized current research on the experiences of CNM patients when they access healthcare. It has focused on common themes that contribute to negative healthcare interactions and methods used by CNM practitioners to avoid harm resulting from disclosure. The Discussion chapter will examine implications of this body of information for CNM patients and HCPs, as well as for future research. The Discussion chapter contains four sections. The first section discusses CNM’s frequent inclusion under the 2SLGBTQIA+ umbrella and whether a shift in this alignment may be warranted and useful. The second section applies an intersectional lens to the poor generalizability and lack of representation that are cited as limitations in half of the included studies (Campbell et al., 2023; McCrosky, 2015; Smith, 2017; Vaughan et al., 2019). The third and fourth sections address future research. The third section applies a feminist violenceprevention lens and a lens of systematic oppression to the collective context of the studies included in this review; these studies have proven the existence of a problem, and future research needs to shift focus to examine the system and structures within which this problem exists. The fourth section proposes avenues for future research regarding interventions aimed at HCPs. Where Do We Locate CNM? CNM is generally categorized as a sexual and gender minority under the umbrella of 2SLGBTQIA+. This is a logical approach as the most socially conspicuous point of difference between CNM and non-CNM patients is a difference in sexual relationships, and HCPs are also most likely to encounter CNM the context of sexual health. Yet it is worth examining this categorization, partly because people in CNM relationships face some genuinely unique 31 challenges and partly because the way that CNM is categorized may affect how healthcare as a field, and HCPs as individuals, approach those who practice it. Unique Challenges Associated with CNM CNM challenges a mononormative foundation that has been built into almost every aspect of how our societies are structured, formally and informally; extended health benefits, marriage, immigration, family law, inheritance, parenting, entertainment media, and many other social edifices all operate on the presumption of monogamy (Anderson et al., 2025; Arseneau et al., 2019; Campbell et al., 2023). Unlike for other sexual minorities, there is no legal protection for CNM as is it not explicitly included in anti-discrimination laws (Anderson et al., 2025; Arseneau et al., 2019; Campbell et al., 2023; McCrosky, 2015; Smith, 2017) so situating CNM as a sexuality may afford practitioners some proxy protection. This suggestion by no means implies that, for other sexual minorities, the enactment of anti-discrimination law has solved oppression, inequity, and mistreatment. However, a complete lack of legal protection may contribute to CNM’s invisibility as many practitioners choose to ‘pass’ as monogamous rather than risk discrimination against which they have no legal recourse (Anderson et al., 2025; Arseneau et al., 2019; Campbell et al., 2023; McCrosky, 2015; Smith, 2017). Viewing CNM as a Family Structure An alternative to situating CNM under the 2SLGBTQIA+ umbrella would be to approach CNM as a family or relationship structure, although this may be more applicable to polyamorous people than to swingers. CNM respondents in several studies discussed the support they received from their partners, sharing burdens and successes, cohabitating, and navigating life together (Anderson et al., 2025; Arseneau et al., 2019; Avanthay Strus & Polomeno, 2021; Smith, 2017). Arseneau et al. (2019) refer to ‘poly family’, with one respondent suggesting that HCP education 32 include CNM as part of a class on diverse family structures (p. E1126). HCPs are already familiar with diversity in family structures; it is not unusual for a patient to live with their grandparents, for example, or to have stepparents actively involved in a child’s life. The healthcare and legal systems already differentiate between a birth parent, a parent, and a guardian. A patient’s support network may primarily consist of friends rather than biological family members. Viewing CNM as another version of alternate family structure may provide a point of reference or familiarity, linking CNM to an already known structure and making it easier to accept. In Canada, there is recent legal precedent for this approach: in 2021, the British Columbia Supreme Court granted ‘parent’ status to the third member of a polyamorous trio who were raising a child together, effectively granting the child two mothers and a father (Proctor, 2021; Zakreski, 2021). Beyond a Sexual Practice It is well-documented that sexual health, especially for sexual minorities, is not adequately taught in medical education (Beebe et al., 2021; Gordon, 2021) and respondents in every included study reported instances of HCPs being unaware or under-aware of CNM and therefore less effective in their care. Sexual health screening and care guidelines, which are built on a presumption of monogamy and do not account for the specific needs or knowledge of CNM patients (Anderson et al., 2025; Avanthay Strus & Polomeno, 2021; Campbell et al., 2023; Scoats & Campbell, 2024; Smith, 2017; Vaughan et al., 2019), state that having multiple sexual partners, or a partner who has multiple sexual partners, is a risk factor for STI transmission (Garcia et al., 2024). HCPs are trained to promote health by, amongst other things, supporting their patients in reducing risk-taking behaviours. It is therefore not unreasonable to hypothesize that some HCPs view CNM as a risk-taking practice to be discouraged because of an availability 33 heuristic; having never been taught sexual health that accounts for CNM, HCPs have no other tool with which to approach it. Teaching CNM as a family structure rather than as a solely sexual practice would legitimize ways of viewing, understanding, and approaching CNM other than as a source of risk. It’s Worse Than We Think In addition to describing healthcare interactions, some study respondents also shared stories of the impact that being open about CNM had had in other aspects of their lives. Smith (2017) included a situation in which Child and Family Services had initiated an investigation against polyamorous parents because of their relationship structure. McCrosky (2015) described having to structure recruitment and interview questions such that no participants who were sex workers would incriminate themselves. Anderson et al. (2025) included multiple respondent stories of being cut off by friends and family members, and one respondent gave up a career in politics rather than risk being subjected to public scrutiny for being in a CNM relationship. This range of experiences, and the impact that being out can have on multiple aspects of CNM practitioners’ lives, may explain why researchers attempting to study CNM sometimes describe them as a hidden or hard-to-reach population who are mistrustful of institutions (Campbell et al., 2023; McCrosky, 2015; Smith, 2017). Study populations, in addition to being difficult to recruit, were also not representative of their greater social contexts; half of the included studies explicitly listed poor generalizability among their limitations, as study participants were disproportionately white, English-speaking, with above average income and education, and living in urban settings in affluent countries (Campbell et al., 2023; McCrosky, 2015; Smith, 2017; Vaughan et al., 2019). In their recommendations for future research, these studies called for greater representation of minority 34 voices. But while a lack of diversity may constitute a weakness from a statistical perspective, applying an intersectional lens to these non-representative samples may in fact reinforce study conclusions about the need for equity and protection for CNM practitioners. Intersectionality, a term coined by Kimberlé Crenshaw in 1989, refers to the theory that inequities compound and that it is not possible to separate one aspect of discrimination from another: We tend to talk about race inequality as separate from inequality based on gender, class, sexuality or immigrant status. What’s often missing is how some people are subject to all of these, and the experience is not just the sum of its parts. (Crenshaw, 2018; as cited in Steinmetz, 2020, para. 2) Race and socioeconomic status can impact access to healthcare regardless of sexual orientation or relationship structure (Campbell et al., 2023). The intersecting effect of multiple additional sources of discrimination makes CNM “more accessible to White women who [have] more financial and cultural capital to fall back on in comparison to women of color” (Sheff, 2006, as cited in Gupta et al., 2024, p. 164). This difference in accessibility and capital is likely not exclusive to women and it may explain why several studies found their respondent populations to be non-representative; it is possible that the people who responded to study recruitment efforts are the ones with enough social protection to either already be out, or be willing to risk being outed (Smith, 2017). By extension, an intersectional approach also suggests that less protected CNM practitioners, those subject to additional layers of stigma, may have worse experiences than the people who felt safe participating in studies. Researching and documenting their experiences may create a more complete record, a better understanding of the problem, and hopefully a more nuanced approach to solutions. 35 Expanding Focus The studies included in this review focused on the perspectives and experiences of CNM patients, how those experiences impact their lives, and what measures they take to avoid the harms associated with being members of a stigmatized minority. To most effectively address health inequities for CNM patients, it is also necessary to expand focus beyond their experiences and onto the systemic, structural, cultural, and institutional factors that contribute to that inequity. This is necessary for two reasons. First, a change in focus is necessary to address the underlying causes of inequity. The lens of systemic oppression differentiates between the impact that violence has on lives, evaluated and quantified at the individual level, and the structures that enable and protect violence, evaluated on a system or societal level. This lens proposes that “systemic oppression and its effects can be undone through recognition of inequitable patterns and intentional action to interrupt inequity” (National Equity Project, 2025, p. 5). Thus, addressing stigma against CNM patients involves identifying the structures and patterns that perpetuate it, which requires shifting the focus of future research away from the group subjected to harm and onto the people and systems in positions of power, as well as the mechanisms that seed and support harmful behaviours. Put another way, the most concerning study finding is not that some HCPs do not know about a niche, hidden lifestyle but that there is a subset of providers who find it acceptable to openly call a patient a “hoe” (Vaughan, 2019, p. 47) because they are part of a CNM relationship, without fear of repercussion. Addressing such individual HCP behaviours is not sufficient for foundational change; the system that allows them to feel safe expressing discriminatory language needs to be addressed, which first requires that it be adequately and comprehensively examined. 36 Second, shifting the focus onto a system, and away from those who have been subjected to harm, would avoid contributing to and reinforcing a culture of victim-blaming. Victimblaming involves holding an individual or group responsible for the violence inflicted on them by focusing on their actions, characteristics, and choices, while underemphasizing systemic or situational factors (The Canadian Resource Centre for Victims of Crime, 2009; Witte & Flechsenhar, 2024). It must be clearly stated that the studies included in this review are not being accused of engaging in victim-blaming. Asking why patients did or did not disclose their CNM status, how they presented themselves to HCPs, or what changes they suggest to reduce the harm inflicted on them in future, is a logical starting point for establishing the existence and impact of a problem. However, the conversation cannot remain fixated on the CNM patients’ perspective lest it put the onus on an already marginalized group to both carry the narrative of a problem and to generate solutions for it. Future research must expand its scope, keeping the experiences of CNM patients in frame while also examining the systemic aspects of stigma, discrimination, and oppression. Paths for Future Research Although no research could be found that indicated numbers, the studies included in this review suggest that, while there is likely a subsection of the provider workforce who hold negative views of CNM, there is also likely a portion of providers who are supportive but do not know how to signal and enact allyship. For this latter group in particular, a discomfort with CNM can be addressed with improved education and the dissolution of some myths or assumptions. A fruitful avenue for future research would be to investigate HCP-focused interventions to better equip them to provide informed, equitable, and relevant care and allyship. 37 Elaut’s (2023) study of CNM and the contact hypothesis found that HCPs who have had contact with CNM people, regardless of whether contact occurred as a provider or in another aspect of their lives, not only have better feelings towards them but also are more likely to subsequently encounter patients who are CNM (Elaut, 2023). Vaughan et al. (2019) makes a similar assertion that “[e]xposure to CNM individuals during professional training may also be highly beneficial to develop a base of scientifically accurate knowledge and reduce implicit bias and stigmatizing reactions, while maintaining the responsibility on providers and their supervisors (as opposed to patients) for enhancing their education” (p. 48). One method of accomplishing this could be to introduce HCP students to CNM practitioners and other members of sexual minorities as a routine part of their education. Reassignment of the burden of education from patient to provider is particularly important given the feelings of frustration expressed by CNM respondents across studies. When HCPs asked questions about CNM, patients often reported feeling both reminded of their marginalization and obligated to educate their provider (Anderson et al., 2025; Arseneau et al., 2019; Avanthay Strus & Polomeno, 2021; Campbell et al., 2023; McCrosky, 2015; Smith, 2017; Vaughan et al., 2019). The dissatisfaction accompanying this obligation is perhaps best expressed by a respondent in McCrosky’s (2015) study: “if they deal with sexuality on a daily basis, like a gynecologist is, you'd think maybe at one point in their entire twenty five years as a doctor they Googled 'non-monogamy' just to see what was out there. […] I shouldn't be the first one exposing them to the concept of sexually safe non-monogamy”. (McCrosky, 2015, p. 57) Interestingly, the response is opposite when HCPs ask CNM practitioners for resource recommendations so they can self-educate; such requests are positively perceived, and rather 38 than feeling marginalized one patient described the feeling of having “lucked out” in finding a provider who wanted to take the initiative to care for diverse patients (Anderson et al., 2025, p. 1491). Education-based, provider-forward approaches such as the one proposed in Vaughan (2019) and supported by Elaut (2023) could address CNM health inequity in numerous ways without further burdening an already stigmatized population. Replacing myths and incorrect assumptions about CNM with accurate information reduces bias and stigma, and allows HCPs to support their CNM patients by providing appropriately tailored care. Education gives HCPs ways of categorizing or understanding CNM other than as a source of risk or as a deviation from the norm. Learning and using appropriate, inclusive language when addressing patients and their partners signals open-mindedness and allyship to minorities in general, not only sexual minorities. Experience encountering new and different lifestyles better prepares HCPs to maintain professionalism and neutrality when they encounter other patient situations with which they were previously unfamiliar. Finally, formalized systemic and institutional acknowledgement and support of CNM may reduce the likelihood that providers feel confident making derogatory remarks, even if they fundamentally disagree with their patient’s lifestyle. 39 Chapter Six: Conclusion This integrative review was undertaken to answer the question: What are the experiences of consensually non-monogamous patients accessing healthcare? It found that people who practice CNM frequently experience stigma and judgement from HCPs and the healthcare system, especially around sexual health care, which results in barriers to care and subsequent health disparities. The studies included in this review focused on CNM patient experiences and perspectives, the factors that determine their decisions around disclosure of their relationship structure, and how prior experiences and fear of discrimination impact patients’ healthcare decisions and options. Stigma against CNM is heavily influenced by gendered expectations of sexual behaviour, social norms privileging monogamy, assumptions about sexual health risks, and a general lack of formal education regarding alternate sexualities and relationship structures. Suggestions for improvement include increasing HCP education and awareness of CNM, as well as broadening HCP approaches to sexual health care. Future research could investigate specific, provider-focused interventions with the goal of reducing incidents of discrimination and better preparing HCPs to care for CNM patients. 40 References Anderson, J. R., Bondarchuk-McLaughlin, A., Rosa, S., Goldschlager, K. D., & Jordan, D. X. H. (2025). A qualitative exploration of the experiences of disclosing non-monogamy. Archives of Sexual Behavior, 54(4), 1481–1495. https://doi.org/10.1007/s10508-025-03119-0 Arseneau, E., Landry, S., & Darling, E. K. (2019). The polyamorous childbearing and birth experiences study (POLYBABES): A qualitative study of the health care experiences of polyamorous families during pregnancy and birth. Canadian Medical Association Journal, 191(41), E1120–E1127. https://doi.org/10.1503/cmaj.190224 Avanthay Strus, J., & Polomeno, V. (2021). Consensual non-monogamous parenting couples’ perceptions of healthcare providers during the transition to parenthood. 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British Columbia Law Institute. https://www.bcli.org/the-family-law-act-does-not-adequately-provide-for-polyamorousfamilies-in-the-context-of-parentage-bc-supreme-court/ 45 Appendix A Search Strategy Search concepts Synonyms and additional free text terms for concepts Database 1: Medline Via EBSCO Concept 1 Consensually nonmonogamous Non-monogamous Polyamorous Concept 2 Healthcare Nonmonogam* Non-monogam* Consensual* nonmonogam* Consensual* nonmonogam* Polyamor* Medical Care Primary Care Primary Healthcare Primary Healthcare System Health System Healthcare System Health Services Medical Care Primary Care Primary Healthcare Primary Healthcare System Health System Healthcare System Health Services Each term for Concept 1 was searched individually then combined with Boolean “OR” to create a full list of articles pertaining to this concept. This was repeated for Concept 2. The results were then combined with “AND”. Totals for each search are shown below. Yield: 39 articles Limit: English Yield: 38 articles No option to explode Database 2: CINAHL Via EBSCO Combined with OR Nonmonogam* Non-monogam* Consensual* nonmonogam* Consensual* nonmonogam* Polyamor* MeSH Heading for non-monogamous relationship+ Combined with OR Medical Care Primary Care Primary Healthcare Primary Healthcare System Health System Healthcare System Health Services Yield: 43 articles MeSH headings for MH Health Services + MH Health Services Accessibility+ After removing duplicates: 55 articles remaining 46 Search concepts Database 3: JSTOR Consensually nonmonogamous Nonmonogam* Non-monogam* Consensual* nonmonogam* Consensual* nonmonogam* Polyamor* Healthcare Medical Care Primary Care Primary Healthcare Primary Healthcare System Health System Healthcare System Health Services No new articles No option to explode Combined with OR Google Scholar search Nonmonogam* Non-monogam* Consensual* nonmonogam* Consensual* nonmonogam* Polyamor* MeSH headings for MH Health Services + MH Health Services Accessibility+ Medical Care Primary Care Primary Healthcare Primary Healthcare System Health System Healthcare System Health Services No new articles Combined with OR Combined with OR Citation Search No new articles 47 Appendix B PRISMA Flow Chart Identification Records identified through: Records removed: Database searching (n = 82) Duplicate records removed (n = 26) CINHAL (EBSCO): 43 Record removed for not English (n = 1) Medline (EBSCO): 39 Google: 13 Citation Searching: 11 Titles/Abstracts screened with inclusion criteria. (n = 55) Articles excluded (n = 41) Focus on sexual health data (n = 13) Focus on therapy/counselling (n = 15) Screening Focus on sociological/legal (n = 10) Wrong population (infidelity) (n = 2) Wrong population (polygamy) (n = 1) Full-text articles sought for retrieval Included (n = 14) Records excluded upon full text review (n = 7) Records included in review (n = 7) Note. PRISMA flow chart was adapted from Page et al., (2021). 48 Appendix C Table C1 Comparison of Study Design Study Anderson et al. (2025) Location Australia Recruitment Targeted virtual advertising on social media Arseneau et al. (2019) Canada Avanthay Strus and Polomeno (2021) Winnipeg, Canada Convenience sampling via social media (Facebook, Twitter and Instagram) and snowball sampling Purposive sampling via social media (Fetlife, local swinger clubs) and snowball sampling Campbell et al. (2023) Mostly British, some other European countries, some North American Snowball sampling via researchers’ personal networks and posting to Twitter, Instagram, and Facebook groups McCrosky (2015) United States of America Scoats and Campbell (2024) Mostly British, some from other European countries, some North American Targeted and snowball sampling via contact with sex worker rights groups, as well as social media and personal contacts Snowball sampling via researchers’ personal networks and posting to Twitter, Instagram, and Facebook groups Smith (2017) Puget Sound area of Washington, USA Vaughan et al. (2019) Midwestern USA Convenience and snowball sampling, online (Facebook) and in-person (3 different CNM meet-up groups) Convenience sampling, inperson announcements at a monthly educational meeting of a midwestern polyamory-themed organization Information-Gathering Technique Qualitative: semi-structured interviews (set questions with followup questions if indicated) conducted in person or online via Zoom. Quantitative: demographics information Qualitative: semi structured interview (in person or via Zoom) Quantitative: online questionnaire demographics questionnaire Quantitative: online questionnaire demographics, relational & parenting characteristics Qualitative: semi structured interview (in person, phone, or skype) Online survey Demographic (quantitative) data Quantitative data via “Trust in Health Care Providers” scale Qualitative questions Demographic and Qualitative left as free text entry Semi-structures interviews conducted in person Quantitative data: minimal demographic info (age, ethnicity, relationship status) Online survey Quantitative demographic data Qualitative questions (free-text questions) Demographic and Qualitative left as free text entry Quantitative: demographic collection form Qualitative: single semi-structured inperson interview Online survey and in-person focus group Quantitative: demographics form Qualitative: participation in one of three focus groups, semi-structured interview 49 Table C2 Comparison of Study Participants Study Anderson et al. (2025) Population Studied Age >18, selfidentified nonmonogamous Arseneau et al. (2019) Self-identified polyamorous, gave birth in past 5 years w/ prenatal care, or partners involved in the birthing journey Self-identified as consensual nonmonogamists during the transition to parenthood Participants who have had, or to currently be in a consensually nonmonogamous relationship. 22 total (11 birthing parents, 13 partners) McCrosky (2015) Age >18, CNM women who self-identify as either polyamorous or sex workers (or both) 23 (14 current sex workers, 9 current polyamorous) Scoats and Campbell (2024) Participants who consider themselves to have had, or to currently be in a consensually nonmonogamous relationship. Age >18, had been involved in at least one relationship involving 3 or more people for 1 year or longer, able to speak English Age >18 years, selfidentified CNM, fluent in English 67 (32 polyamorous, 28 solo poly, 4 swinger, 3 uncategorized) Avanthay Strus and Polomeno (2021) Campbell et al. (2023) Smith (2017) Vaughan et al. (2019) Participants 32 6 (4 swingers, 1 open relationship, 1 polyamorous) 67 (32 polyamorous, 28 solo poly, 4 swinger, 3 uncategorized) 20 20 (17 polyamorous, 1 swinger, 2 relationship/sexual agreement) Select Demographics Information Sexual orientation: All identified as other than heterosexual Education: All tertiary educated, 41% postgraduate Age: range 23-48 (mean 34) Ethnicity: 18 white/European Primary language: 18 English Education: college/uni:10; graduate level: 3 Sexual orientation: straight: 7; bisexual: 6; Gender: woman: 4; man: 2 Orientation: 5 bisexual, 1 heterosexual Marital status: 4 married, 1 common law, 1 separated All Canadian-born Gender: cis woman: 36; cis man:18; nonbinary: 12; transman: 1 Orientation: bi/pansexual: 45; heterosexual: 12 Race: White: 60; Other: 7 Education: Postgrad: 31; Undergrad: 28 Age: 22 to 55 (mean 34) Race/Ethnicity: 21 white Marital status: 8 married, 8 single, 3 divorced Children: 12 yes, 4 no, 7 no info Education: 22 completed some level of postsecondary Gender: cis woman: 36; cis man:18; nonbinary: 12; transman: 1 Orientation: bi/pansexual: 45; heterosexual: 12 Race: White: 60; Other: 7 Education: Postgrad: 31; Undergrad: 28 Age: 28 to 50 (19 of 20 <46) Sex/Gender: woman: 9; man: 7 Sexual orientation: bisexual or pansexual: 10 Race/Ethnicity: White 18 Education: bachelor’s or higher: 13 Income: <$60,000: 14; above $120,000: 4 Age: 18 to 64 (17 of 20 <45 years) Gender identity: cis woman: 9; cis man: 8 Sexual orientation: bisexual or pansexual: 10; heterosexual: 6 Socioeconomic status: poor: 3; working class: 4; middle class: 8; upper middle class: 4 Marital status: single: 7; married: 7 50 Appendix D Data Extraction Tables Table D1 Data Extraction from Anderson et al. (2025) Article Anderson, J. R., Bondarchuk-McLaughlin, A., Rosa, S., Goldschlager, K. D., & Jordan, D. X. H. (2025). A qualitative exploration of the experiences of disclosing non-monogamy. Archives of Sexual Behavior, 54(4), 1481–1495. https://doi.org/10.1007/s10508-025-03119-0 Purpose and Context Explore the factors around deciding to disclose CNM, and the effect of that disclosure, in a variety of contexts including healthcare. Type of Study and Design Qualitative study semi-structured interviews, face-to-face and via Zoom. Short quantitative demographics section. Inclusion criteria: self-identification as polyamorous, living in Australia, over 18 years old. Recruited via targeted social media advertising. Strengths and Limitations Strengths Two-step coding, using grounded theory. Coding done by two researchers – initial independent coding and cross checking. Sample size 32 Glossary of terms available online. Limitations Over representation of higher education (46.9% had post graduate level education). Minimal diversity. Participants self-identify as polyamorous/relationship anarchists, not including full range of CNM. Sample unlikely representative: social media targeted advertising relies on people searching/interacting with related material. Themes/Subthemes – no statement about frequency of occurrence Findings 4 primary themes: - Decisions around disclosure are complex - Responses to disclosure are typically negative - Structural barriers typically prevent disclosure - Unless specifically trained, healthcare providers are uninformed about CNM Conclusions and Recommendations Given CNM people often choose not to disclose their relationships to avoid rejection, stigma. Healthcare providers are not trained in dealing with CNM, and are unable to provide effective care. Relevance to Research Question Consensual Non-Monogamy 51 a range of relationship structures, practices, and identities that involve having (or being open to having) concurrent relationships with more than one other consenting adult, with the explicit awareness of all parties Health Care Interactions Generally around STI testing, sometimes also discusses counselling/therapy. 52 Table D2 Data Extraction from Arseneau et al. (2019) Article Arseneau, E., Landry, S., & Darling, E. K. (2019). The polyamorous childbearing and birth experiences study (POLYBABES): A qualitative study of the health care experiences of polyamorous families during pregnancy and birth. Canadian Medical Association Journal, 191(41), E1120–E1127. https://doi.org/10.1503/cmaj.190224 Purpose and Context Understand the experiences of polyamorous families during pregnancy and birth and provide HCP recommendations for improvement. Establish areas for further research. First/only study to investigate experiences of CNM patients and their partners while giving birth. Type of Study and Design Qualitative descriptive study using short demographic questionnaire and semi-structured interview. Inclusion criteria: self-identification as polyamorous during pregnancy, had given birth within past 5 years, had received prenatal care in some form. Recruited via social media, snowball sampling. Strengths and Limitations Strengths Screening using a piloted questionnaire, coding done independently and then checked for consistency, generation of themes through axial coding. Additional team member who did not conduct interviews also coded independently to reduce observer bias. Data/coding/questionnaires provided either within the article or as appendices. Glossary of terms available online. Limitations Small sample size (24 people, 11 who had given birth and 13 partners) through convenience/snowball sampling on social media, therefore unlikely to be representative sample. Potential for recall bias (5 year period). Potential bias towards recruiting patients who used midwives d/t midwifery logos on recruitment poster. Findings 4 primary themes: - Deliberately planning families (e.g. planning biological parentage, choosing midwifery to avoid hospitals) - More is more (increased financial, emotional, logistical support from having more partners) - Presenting poly (decisions and navigation around disclosure and non-disclosure and in what contexts) - Living in a mono-normative world (current systems do not account for polyamorous family structures) Suggestions for healthcare providers and health care institutions: - Acknowledge (show openness, remain non-judgemental, and self-educate) - Accommodate (space for multiple partners e.g. for intake forms/parent ID bracelets) 53 - Ally (avoid assumptions, support patient-led care) Conclusions and Recommendations Given “Polyamorous families face marginalization when accessing pregnancy and birth care. Care experiences for polyamorous families can be improved by nonjudgmental, open attitudes of health care providers, and modifications to hospital policies to support multiparent families.” (Arseneau et al., 2019) Relevance to Research Question Consensual Non-Monogamy Simultaneous romantic relationships with the knowledge of all involved Health Care Interactions Prenatal care, birthing, and immediate postnatal period, including a variety of care situations: midwifery care only, obstetric care only, and both. 54 Table D3 Data Extraction from Avanthay Strus and Polomeno (2021) Article Avanthay Strus, J., & Polomeno, V. (2021). Consensual non-monogamous parenting couples’ perceptions of healthcare providers during the transition to parenthood. Aporia, 13(1), 36–45. https://doi.org/10.18192/aporia.v13i1.5276 Purpose and Context Situates CNM within the realm of sexual minority, with associated discussion of minority stress and the subsequent potential for health disparity. Identification of themes from experiences of CNM patients seeking (especially sexual) healthcare, with the additional stressor of pregnancy/transitioning to parenthood. Discussion of ways that HCPs have previously shown support and suggestions for how especially frontline nurses can support CNM patients. NOTE: “This article reports partial findings from a larger study that investigated consensual non-monogamous parenting couples’ (CNMPCs) conciliation of their parenting role and their sexual lifestyle during the transition to parenthood” (Avanthay Strus & Polomeno, 2021). The findings presented in this article pertain to one section of the study questionnaire which related to healthcare experiences. Type of Study and Design Original study was mixed methods, collecting both quantitative data. Quantitative data was collected via online questionnaire which was then analyzed using descriptive statistics. Qualitative data was collected via semi-structured interview (32 questions divided into 4 sections, the 4th of which addressed experiences with healthcare). Purposive sampling via informants and snowball sampling, through social media and invitations sent to swinger groups and hangouts. Strengths and Limitations Strengths Extensive references with good discussion of background/context of CNM, socially and within healthcare. Specificity to nursing and frontline workers. Qualitative data analysis using Schrier approach. Expanding the Movement for Empowerment lens; Reproductive Justice lens Limitations Small geographic area, limited to Manitoba, Canada. Small sample size of 6 (8 participants recruited, 6 completed both questionnaire and interview). Of these, 4 participants identified as swingers, one in an open relationship, and one as polyamorous. Snowball sampling risks bias. Findings Four categories, each with several subcategories (listed below as Category: Subcat 1; Subcat 2) - Fear of Judgement: Heteronormative Assumptions; Perceived Judgement; Fear of Repercussions 55 - Health Risk Awareness: Informed Consumer; Pregnancy and STI Prevention HCP’s Lack of Training: Lack of Sexual Education in Schools; Providers’ Lack of Training during the Prenatal Period - Factors Facilitating and Hindering this Relationship Conclusions and Recommendations Given CNM patients experience a fear of stigmatization from HCPs, which is based on minority stress as well as specific instances of discrimination. When transitioning to parenthood, there is an additional fear of discrimination/stigmatization of the child based on the parents’ sexual practices/lifestyle/relationship structures. HCPs can alleviate part of this fear through (self) education, non-judgemental approach, acknowledgement and inclusion of all members of a family, and building positive interactions by demonstrating respectful support of the patient’s needs. However, this open/supportive approach is not the norm, whether from lack of formal education, lack of awareness of sexual minorities in general, discomfort discussing sexuality, or entrenched mono-/hetero-normative assumptions and beliefs. Relevance to Research Question Consensual Non-Monogamy Partners who made a conscious decision to have more than one sexual partner, identify as swingers, polyamorous or in open relationships Health Care Interactions Interactions around sexual health and around family/parenting/childrearing. 56 Table D4 Data Extraction from Campbell et al. (2023) Article Campbell, C., Scoats, R., & Wignall, L. (2024). “Oh! How modern! And... are you ok with that?”: Consensually non-monogamous people’s experiences when accessing sexual health care. The Journal of Sex Research, 61(9), 1377-1388. https://doi.org/10.1080/00224499.2023.2246464 Purpose and Context Explore the factors around deciding to disclose CNM, and the effect of that disclosure, in a variety of contexts including healthcare. Type of Study and Design Qualitative study semi-structured interviews, face-to-face and via Zoom. Short quantitative demographics section. Inclusion criteria: self-identification as polyamorous, living in Australia, over 18 years old. Recruited via targeted social media advertising. Strengths and Limitations Strengths Two-step coding, using grounded theory. Coding done by two researchers – initial independent coding and cross checking. Sample size 32 Limitations Over representation of higher education (46.9% had post graduate level education). Participants self-identify as polyamorous/relationship anarchists, not including full range of CNM. Sample unlikely representative: social media targeted advertising relies on people searching/interacting with related material. Themes/Subthemes – no statement about frequency of occurrence Findings 4 primary themes: - Decisions around disclosure are complex - Responses to disclosure are typically negative - Structural barriers typically prevent disclosure - Unless specifically trained, healthcare providers are uninformed about CNM Conclusions and Recommendations Given CNM people often choose not to disclose their relationships to avoid rejection, stigma. Healthcare providers are not trained in dealing with CNM, and are unable to provide effective care. Relevance to Research Question Consensual Non-Monogamy A range of relationship structures, practices, and identities that involve having (or being open to having) concurrent relationships with more than one other consenting adult, with the explicit awareness of all parties. Health Care Interactions Generally around STI testing, sometimes also discusses counselling/therapy. 57 Table D5 Data Extraction from McCrosky (2015) Article McCrosky, R. (2015). Experiences of stigma during sexual healthcare visits: A qualitative study of non-monogamous women [Master’s thesis, University of Central Florida]. https://stars.library.ucf.edu/etd/1150 Purpose and Context “To examine non-monogamous women’s perceptions of their sexual health care interactions […] and what impact class has on those experiences.” (p.3) Type of Study and Design Qualitative study using in-depth interviews Analyzed through grounded theory, with awareness of feminist theory Inclusion criteria: self-identified polyamorous women and sex workers, 18 years or older, living in the US Strengths and Limitations Strengths Semi-structured interview with flexibility to adapt. Feminist approach of summarizing and discussing themes with participants to ensure accurate representation. Extended, thorough academic foundation in the literature review section showing the history of this topic. Frequent excerpts from interviews demonstrating and supporting views/experiences. In depth discussion of the themes identified, situating them within larger social contexts. Limitations Small sample size (23) with targeted snowball sampling, and author-acknowledged difficulty accessing this community means unlikely to be representative sample - this is acknowledged in sample discussion and areas for further research as researcher suggests focusing on groups that were not well represented in their work (people of colour, different socio-economic status). States ‘numerous themes identified’ but only discusses three. No presentation of total overall data (no table, no list of themes outside of the major themes that the researcher focused on) and does not provide full transcripts of interviews, so unclear whether there is contradictory data. Findings Polyamorous women and sex workers are stigmatized, for the same reasons (including gendered expectations of sexual behaviour), resulting in comparable negative experiences with healthcare from subtle changes in attitude to slurs/derogatory comments to refusal of care. Sexual healthcare in particular causes frustration, as women were often asked to justify their requests for STI testing or contraception resulting in either reluctant disclosure (and often subsequent stigma) or lying/fabrication. Those who have positive relationships with their providers, or who go to clinics that are centered around sexual healthcare, are more likely to disclose their CNM status. More prefer to disclose as it is understood that disclosure (with positive reception) results in better healthcare so CNM women face the a dilemma of risking stigma and possibly losing access to care, receiving incomplete care (especially for sexual health), or using various strategies (such as visiting multiple clinics and paying out of pocket) to avoid being ‘outed’ to their provider. 58 There is no education about CNM in healthcare and participants describe frequently having to educate healthcare providers and handle invasive questioning (sometimes out of curiosity) leading to frustration and stress. Participants suggest three primary strategies for improvement: more resources for CNM people from their own community (e.g. list of ‘friendly’ healthcare providers in their area); changes to the current system including e.g. sensitivity training and modification to structures such as intake questionnaires to be more inclusive and sex positive; development/promotion of healthcare options explicitly for CNM people, sex workers, those in alternative lifestyles. Relevance to Research Question Consensual Non-Monogamy/Polyamory “Polyamory emphasizes a focus on multiple concurrent romantic and sexual relationships with fully informed and consenting relationship partners, in comparison to other forms of consensual non-monogamy, such as swinging or hooking up, which have a focus on primarily sexual, non-romantic relationships (Young 2014).” (McCrosky, 2015, p. 16) Health Care Interactions Primarily focusing on interactions around reproductive and sexual health, usually in GP offices, walk-in clinics, sexual health clinics, and sometimes with specialists. 59 Table D6 Data Extraction from Scoats and Campbell (2024) Article Scoats, R., & Campbell, C. (2024). Understanding service preferences among consensually non-monogamous individuals seeking sexual healthcare. Culture, Health & Sexuality, 27(1), 32-45. https://doi.org/10.1080/13691058.2024.2350434 Purpose and Context “Explore the motivations behind CNM individuals’ choices of sexual healthcare service options” (Scoats & Campbell, 2024). Type of Study and Design Qualitative survey. Snowball sampling via personal networks, social media. Online survey (demographic, qualitative, quantitative questions). Reflexive thematic analysis, coded independently then collaboratively by both authors. Inclusion Criteria Self-described CNM (incl swingers, polyamorous, relationship anarchists, etc.) no need to currently be in such a relationship. Strengths and Limitations Strengths Incorporates info from Canada, USA, UK, Netherlands. Larger sample size: 67 participants. Online survey response and broad inclusion criteria allows breadth of responses. Limitations Lack of diversity: participants were predominantly British, white, living in UK. Snowball sampling may decrease diversity; was conducted via social media, sharing with relevant communities, and via the researchers’ social networks. Unclear if included people known to researchers. Single written survey, two free-text questions, unable to clarify responses. Several of the issues described (e.g. lack of clinics in an area, booking complaints) are not specific to CNM. Findings Two core themes: 1. Perception/Experiences of inclusive healthcare venues/practitioners increases likelihood of choosing those services. Some services/staff/clinics (e.g. LGBTQ+ focus, sexual health clinics) more open to diversity, less judgemental (though not always judgement free), more knowledgeable, more anonymous, than GP. Prior good/bad experiences with providers impacts desire to return, regardless of clinic ethos. Patients often seek out LGBTQ+-specific services, also via recommendations from friends/partners. 2. (In)convenience of services influences care choices, and lack of options/choice means lack of meaningful selection. Factors of note include the ability to make appointments; availability of (full range) STI testing; time commitment; proximity. At home/postal STI testing kits are convenient but cannot blood test therefore are not a complete replacement for in person testing. 60 Conclusions and Recommendations Given Clear preferences for some services/staff/clinics (e.g. LGBTQ+ focus) as ‘safer’ choices, though options are limited in many areas. Clinician positive attitudes improve trust/care, as demonstrated through inclusive language, avoiding assumptions, familiarity with terms, and admin adaptations e.g. on intake forms. Relevance to Research Question Consensual Non-Monogamy “romantic and/or sexual relationships in which people have more than one sexual partner with the informed agreement of everyone else in those relationships […including] polyamory, swinging and open relationships” Health Care Interactions “sexual health services” is not specifically defined, but patients discuss GPs, walk in clinics, drop-in clinics (unclear if these are the same thing), sexual health clinics, take-home/postal testing, specialists/gynecologists, and hospitals. 61 Table D7 Data Extraction from Smith (2017) Article Smith, L. J. (2017). A qualitative study of the healthcare experiences of consensually nonmonogamous adults [Master’s thesis, University of Washington]. http://hdl.handle.net/1773/40595 Purpose and Context Investigate and document experiences CNM adults have when accessing healthcare. Establish themes/commonalities within experiences. Investigation of reasons for disclosing or not disclosing CNM status, factors that influence the decision, and how disclosure changes the patient-provider relationship. First study of CNM experience to focus on healthcare (previous focused on psych, social work, etc.). Type of Study and Design Exploratory Phenomenological Study. Qualitative Analysis. Basic thematic analysis. Participant Selection: Snowball sampling, started via Facebook, Puget Sound area of Washington State Inclusion Criteria: Involved in a CNM relationship at least once since age 18 during which interacted with healthcare; speaks conversational English; over 18 (age of consent for most of USA) Exclusion Criteria: No one known to researcher, their friends/partners; only one member of family group. Information Gathering: Single, semi-structured interviews, audio recorded and then transcribed, transcripts coded and analyzed by thematic elements Strengths and Limitations Strengths Effort made to produce range of experiences rather than case studies. Researcher is member of CNM community, has access to this sometimes hard-to-reach population. Limitations Poor representation and generalizability: small sample size, predominantly Caucasian, ages 18-50, conversational English required, snowball sampling (started online) risks bias, exclusion of people researcher knows/their partner knows can skew representation from within a small community. Author states: Washington Puget Sound is generally liberal, diverse, with laws against discrimination, therefore results not generalizable to less liberal and diverse areas. Findings Themes: Disclosure Vs Nondisclosure and Effects of Disclosure: - Disclosure: out of necessity, desire to be honest - Non-Disclosure: not relevant to current issue, fear of stigma/judgement/impact on care/relationship - Disclosure often had profound effect on experiences and care; bias, judgement, refusal of care - Perceived gender changes reaction: man = ‘guy behaviour’; woman = ‘slut,’ ‘cry for help’. 62 Mental Healthcare: - Inappropriately attribute all difficulties to CNM; conflation of CNM and other conditions (e.g. ADD) Sexual Health: - Conflate CNM with sexual promiscuity and expression of bias against promiscuity (esp. for women); label of ‘risk taking’ behaviour; insurance/clinic refusal to ‘waste’ tests or immunizations for HPV. Institutions: - Institutions are rigid, algorithms do not account for CNM (e.g. emergency contact, next of kin, decision maker status prioritizes blood family) - Insurance: lack of legal status for CNM means no requirement to cover partners, or requirement to lie about exclusivity of relationship for coverage. Difficult to change providers if negative relationship. - CNM not legally protected, no laws against discrimination. Sex workers especially vulnerable. Conclusions and Recommendations Given Similarity between the experiences of CNM adults and members of other sexual minority groups (2SLGBTQIA+) including deciding whether to disclose, experiences of bias, and resultant impact on care. Profit-based insurance causes additional systemic barriers and a lack of legal protection/recognition makes self-advocacy difficult, especially for sex workers. Gendered societal expectations of sexual behaviour create additional barriers for women. Importance of decreasing barriers to sexual healthcare and mental healthcare as the primary areas where CNM is relevant to specifically sought healthcare More research needed, both to represent a broader study population, and to suggest interventions to improve healthcare experiences for CNM patients. Relevance to Research Question Consensual Non-Monogamy Long-term, committed relationships involving three or more people lasting a year or longer. Refers to these CNM relationships as ‘family groups.’ Health Care Interactions Any interaction with the healthcare system related to the patient’s health. 63 Table D8 Data Extraction from Vaughan et al. (2019) Article Vaughan, M. D., Jones, P., Taylor, B. A., & Roush, J. (2019). Healthcare experiences and needs of consensually non-monogamous people: Results from a focus group study. The Journal of Sexual Medicine, 16(1), 42–51. https://doi.org/10.1016/j.jsxm.2018.11.006 Purpose and Context Explore positive and negative experiences of CNM individuals within the healthcare system, Compare trust in healthcare providers between CNM and monogamous patients Outline specific needs of CNM patients, especially sexual health care including STI testing and prevention. Give recommendations for healthcare provider training and practice Type of Study and Design Qualitative. Exploratory. Brief survey then focus group using semi-structured question. Audio recorded. Open, inductive coding conducted independently then shared to determine themes and subthemes – iterative process. Themes reviewed with 4 participants for additional validation. Inclusion criteria: Adults (age 18 years) who self-identified as CNM individuals or currently practiced any form of CNM (e.g., polyamory, open relationship, swinging) and were fluent in English. No exclusion criteria noted. Strengths and Limitations Strengths Full retention of participants, diversity of gender/sexual identity, socioeconomic status. Limitations Poor generalizability: Urban USA, small sample size (20) and geographic area, mostly white, overrepresentation of polyamory d/t recruiting from a non-profit serving CNM individuals. Findings Format: Themes: Subtheme; Subtheme Ignorance of CNM: Pressure to Educate Providers; Inadequate Screening Providers lack education about CNM, sexual health (+ relevant insurance). Mononormativity. Conflation of CNM with high-risk sexual behaviour, inevitable STIs. Assuming health/psych issues are d/t CNM. Sexual Stigma: Stigma Reactions Condescension, judgement, inaccurate assumptions, pejorative language. Provider refusal to see patient. Stigma-Avoidance Efforts/Seeking CNM-Inclusive Providers Pre-screening providers, calling ahead, checking websites. Using other clinics for sexual health needs. CNM-Inclusive Care: Open-Mindedness and Acceptance; Meeting Healthcare Needs/Requests Providers asking open-ended questions and giving thoughtful (rather than knee-jerk) reactions. Providing access to immunizations, risk reduction, thorough STI testing and ability to share results. Conclusions and Recommendations Given 64 CNM patients have unique healthcare needs and are subject to minority stress, even more if they are members of multiple minority groups. Lack of knowledge and biased assumptions compromise CNM individuals’ access to sexual health care. Providers’ education must include CNM and variants, and address/refute myths using scientific research. Responsibility for education lies with providers/their supervisors/trainers, not patients. Relevance to Research Question Consensual Non-Monogamy: Agreement to pursue/have multiple romantic and/or sexual relationships, with explicit consent of all partners.