Published: 04 Sep 2024
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By Dr Kit Tigwell, Dr Ciara Greer, Raphael Kohn
Each year, Pride provides an opportunity for the LGBTQ+ community and allies alike to celebrate, protest and reflect on life for LGBTQ+ people. As glitter is swept from the streets and companies remove rainbow colours from their logos you could be forgiven for thinking it another successful year for the advancement of equality and civil rights. Unfortunately this is not the case, particularly in medicine and healthcare. At GLADD - The Association of LGBTQ+ Doctors and Dentists - we have had plenty to consider over the past year regarding the state of LGBTQ+ healthcare provision and what it is and has been like to be a LGBTQ+ student or practitioner in the NHS.
The health service continues to be mired in the effects of the pandemic, underfunding and staff shortages. All clinical areas are stretched, but it is in this climate that populations experiencing health inequity are most vulnerable. LGBTQ+ people experience poorer health than the general population, driven by pervasive and systematic health inequalities. Access to care for transgender and gender diverse people has been restricted in ways not seen since the 1960s. Legislation to ban conversion therapy has been repeatedly delayed, allowing damaging practices to be promoted by a small minority of healthcare professionals. Funding for the NHS Rainbow Badge Project was abandoned by the previous government, despite it making great strides in workplace equality and patient inclusion.
Despite the urgency and widespread impact of these issues, little has been done to understand them - although this is slowly changing. Much of the data we have is for medicine, with the experiences of LGBTQ+ dentists and patients receiving dental care largely unknown. We suspect the situation is similar for the pharmacological and pharmaceutical professions. It is heartening, however, to see efforts to develop inclusive research in the field.
The best information we currently have comes from a 2022 report from GLADD and the British Medical Association (BMA), which reveals that, beneath the corporate inclusivity of NHS bodies, discrimination is rife. To understand why this is still the case today it is important to appreciate the historical context. The first LGBTQ+ medical group was formed in London in 1975 at a time when the majority of the population still considered homosexuality a mental illness. (In fact, homosexuality was not declassified as a medical disorder by the World Health Organisation until 1990.) Membership was confidential, with many fearing their careers would be limited if their sexuality was discovered. This atmosphere was perpetuated by the actions of the General Medical Council (GMC), which took regulatory action against doctors because of their sexuality. Some did indeed lose their careers, while the prevalent culture of homophobia led to others taking their own lives. This year the GMC formally apologised for its actions, but the marks left were deep and long for many. Following the apology some of our members shared their experiences, which were often difficult to relive and difficult to read. You can find them on the GLADD website.
"During my time in that job I found that, as an outsider, every move I made was scrutinised and I was pulled up over every minor incident. If you did not fit in, your life was hell."
"A surgeon declared in front of the full operating theatre that in his country, “we would be put up against a wall and shot.” When it was reported to management the reply came back that we had misunderstood the comment.”
Given this context, the findings of the BMA GLADD survey are perhaps less surprising. Although respondents broadly felt that things have improved for LGB medics compared to the previous survey in 2016, the situation is regressing for trans and non-binary colleagues. This reflects the vitriolic debate in wider society, including a
186% rise in transphobic hate crime in the past 5 years. Two thirds of trans colleagues are not out at work, with 50% experiencing workplace discrimination. This compares to half of and 43% of LGB colleagues respectively. Although there were instances of serious abuse and harassment, the majority was ‘low level’ banter. 94% of LGBTQ+ people witnessed this, indicating an insidious problem with workplace culture. The impact is by no means low level, with between 20-40% feeling their career had been negatively impacted and some leaving their jobs altogether. Fewer than half of people felt there were visible, positive LGBTQ+ role models in their workplace, and efforts to increase inclusion were often tokenistic.
What we found most disturbing was the number of respondents who felt that a professional survey was an appropriate place to voice anti-LGBTQ+ rhetoric. A number, sadly even some from the LGBTQ+ community, felt that sexuality has no relevance to the workplace. One said:
“Sexual orientation is creeping into the workplace in an undesirable and unwelcome way: it should not be encouraged for people to be ‘out’ at work, as whether they are one or another, their sexual preferences should normally have no relevance to their work, unless they do something immoral or take advantage of vulnerable people.”
It would take a whole other blog to discuss everything worrying about this statement. However a key point, which even members of the LGBTQ+ community sometimes miss, is that sexuality is relevant to the workplace. Who somebody loves or forms romantic or sexual relationships with is often a fundamental part of who they are. To hide this at work is to restrict ourselves for a large part of our lives. When colleagues are discussing their weekend plans are we expected to lie? When everyone builds connections through anecdotes of their personal lives are we to sit silently? To pretend we are that which we are not, to be constantly on guard and ‘othered’ in a way that our heterosexual cisgender colleagues are not, is exhausting, demoralising and unsustainable.
Unhelpfully, heterosexual cisgender colleagues are often unaware of the problem. 70% of LGBTQ+ respondents felt homophobia and biphobia were an issue in the profession, compared to 26% of heterosexual respondents. For transphobia, 84% of trans respondents felt it was an issue and 42% a significant issue. Only 34% of cisgender respondents recognised this, dropping to 6% who saw it as significant. This, along with commonplace ‘low level’ discrimination, goes some way to explain why most incidents go unreported.
Almost 80% of LGBTQ+ respondents and over 80% of witnesses did not report discrimination, usually because they did not know how, had no confidence it would be addressed, did not think it was serious enough, or were worried about being perceived as a ‘troublemaker’.
“I don’t feel I can say I’m having a hard time as I’m a bit of an ambassadress”
“Often the progress that there has been seems quite superficial – I am frequently misgendered by colleagues with rainbow lanyards and pronouns in their email signatures.”
We are concerned that our multidisciplinary team suffers similar problems. It is easy for many doctors to overlook the presence of pharmacy colleagues who quietly and tirelessly work to ensure patient safety. In an environment where so much discrimination occurs we know nothing of their experiences. What mechanisms are in place for their wellbeing? Is adequate training provided on how to deal with inappropriate comments from patients? Are they supported to raise concerns about colleagues?
What too of patients who will have witnessed and been victims of discrimination? In a
2018 Stonewall report, two thirds of LGBTQ+ women who came out to staff felt inappropriate comments were made, and 40% of trans patients had avoided treatment for fear of discrimination. This is disastrous for those to whom we have a duty of care.
What happens after Pride month, often unnoticed, is often what counts. Efforts to understand the needs and improve the working lives of LGBTQ+ people must continue all year. Better education on LGBTQ+ issues at all stages of professional training is needed, along with quality research and evaluation that guides effective intervention. This requires space for dialogue and learning, individual action and meaningful cultural change. If you don’t know of LGBTQ+ people in your workplace it is probably because they haven’t felt able to be themselves yet. What can you do in your teams, organisations, networks and profession to extend a hand?
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