Discrimination in the doctor’s office: how it hurts LBT women’s health

Ayesha* was 16 when she visited her GP for stomach pain. It hurt when she bent over and when she tried to lift things, with a particular tenderness in the middle of her belly. Her doctor was looking through her medical records as she was relaying her symptoms. When she finished, he looked up and asked her: “Do you really like girls in that way?”

Ayesha is a bisexual, Muslim woman and this was noted on her record.

Without examining her or asking any questions about the pain, he continued: “Does it feel different with men? Are you sure [you are bisexual]? Maybe you just need the right experience!”

Ayesha was stunned. “I didn’t know I could walk out of appointments or start yelling about my rights,” she explains. “I just did what I knew and sank into rude teenager mode. When I was cold, answered his questions monosyllabically, and straight-up refused to answer inappropriate questions, he got all weird and standoffish. He insinuated that maybe the problem was due to ‘my spiritual unrest’ because ‘clearly my faith didn’t condone my sexuality.’”

It turns out that Ayesha had a hernia, which was diagnosed promptly in another appointment with a different doctor.

While often invisible to those who don’t experience it, discrimination has very real and significant impacts on lesbian, bisexual, and trans women’s (LBT) health.

Public Health England names discrimination as a core condition for creating risks to LBT women’s health, both directly and indirectly.¹ Directly, discrimination may be felt through actions, including abuse; indirectly, discrimination informs systems and beliefs, which may see LBT women overlooked by certain processes or enable negative assumptions about them.

“These are barriers. They are completely mindless barriers, because none of this matters for the referral: the clinic needs to see that person [whether they have] this information or not”

These factors may then trigger psycho-social risks such as isolation and a lack of social support, which in turn can introduce behavioural risks — including smoking, alcohol, and substance abuse — and physiological risks, including impacts on mental and physical health.²

When seeking care, discrimination may manifest in anything from staff being inadequately trained to patients being excluded by entire systems.

For trans women, this is especially felt in the years-long waiting list to access a gender identity clinic (GIC).

“Once you’re on a waiting list, it can take up to five years,” says GP Dr Philippa James, who works in an LGBT-friendly practice. While the referral itself can be done by a GP quite quickly, having that referral accepted is often challenging and bureaucratic.

Dr James and her team may send a “good referral” to a gender identity clinic — a thorough referral where a proper patient history has been taken — only to receive, by return post, a list of new requirements that aren’t always possible to meet.

For example, someone transitioning from male to female may come to see Dr James who hasn’t changed their name or gender on their health records, because they are in the process of being referred to a GIC. “I will do a referral and will probably include some blood test results, and then they will send me a letter back saying, ‘Well, you’ve not done a test for oestrogen,’ which I can’t, because the system won’t let me, because the system still shows them as male,” she explains.

“These are barriers. They are completely mindless barriers, because none of this matters for the referral: the clinic needs to see that person [whether they have] this information or not.”

“I tried to go through the NHS but they said, ‘There’s no money in the NHS for people like you’”

Tara Fraser is a trans woman and trainee psychotherapeutic counsellor who has experienced these, and other barriers when seeking care first-hand. She tried to pursue a transition through the NHS in 2012, but ended up going through private practice — something she points out is not an option available to everyone.

“I tried to go through the NHS but they said, ‘There’s no money in the NHS for people like you’,” she says. “When you’re at the lowest point in your life and you don’t know what you need to do [to transition], it can be quite destroying.”

As a therapist, she has seen the impacts of waiting years to be able to access a GIC clinic, and so, being prevented from physically transitioning. “There are a lot of people who try to kill themselves and self-harm, and pursue coping mechanisms that aren’t very helpful,” she says. “They aren’t good things to do, but what is the alternative when the NHS has turned its back on you? Are [these coping mechanisms] not better than killing yourself?”

Tara is soon to launch Talk to the Rainbow, a talking therapies service in Bristol for LGBT people. Creating safe and inclusive spaces is essential in not only encouraging someone to seek care in the first place, but in ensuring they receive the correct services and support once they do.

For Donna Black, a lesbian woman, a previous experience of discrimination in the doctor’s office caused her to avoid going for a smear test.

Donna went to the doctor as she’d been having periods for over a month, and was asked whether she was sexually active. “I said yes, but I’m gay. For the rest of the appointment, the doctor just kept saying, ‘Well since you’re not sexually active…’, as if lesbian sex wasn’t sex,” she says. “They could have said, ‘Since you don’t have straight sex…’ rather than acting as if heterosexual sex is the only type of sex.”

“It is so easy to say, ‘Do you have sex with men, women, or both?’”

Since this appointment, Donna has felt nervous talking to other doctors about her sexual health and has avoided going for a smear test — something it is important that all women, including women who don’t have sex with men, do regularly.

Ending discrimination against LBT women will take a wider social effort, but there are steps clinics and healthcare professionals can take to make their services more inclusive.

For one, not making any assumptions about their patients which might lead to assumptions about their needs. Inclusive language and signposting can help here, says Dr James: “It is so easy to say, ‘Do you have sex with men, women, or both?’”

Giving practitioners and staff the correct training can make all the difference in implementing these changes. “Training is crucial, so that clinicians can develop a non-judgemental and open attitude without making default assumptions about patients’ gender and sexuality, making them feel supported and welcome,” says Dr Kate Yarrow, spokesperson for the Faculty of Sexual and Reproductive Healthcare (FSRH).

Even something as simple as a poster in a clinic waiting room, making it clear that all patients are welcome, can make a difference.

Ultimately, it is about being seen and understood. “We still live in a society where people presume that everyone is heterosexual,” says Tara. “There is a concept that trans people are a waste of space — but if you ask someone to be their genuine self, they can be a productive part of society.”

*This name has been changed

This article has been written in support of LBT women’s health week, which aims to to raise awareness about lesbian, gay, bisexual, trans and queer women’s health inequalities.

The NHS was contacted for comment for this piece.

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Page last updated March 2020