Feature image via independent
It’s 2013, and I’m about to receive my first ever smear test. I’m talking with the nurse before the whole “cold things going in intimate places” business starts. She asks about my sexual history, and I tell her what I’ve carefully rehearsed: I’ve never had sexual intercourse involving a penis. She looks confused for a minute, then leaves the room. She brings someone else in, and they ask the same question. When I give the same reply, they talk for a minute or two like I’m not there. Then they both leave. I wait until I get bored enough to pull my phone out, then wait some more. The nurse returns. She doesn’t think I need a test, but they’ll do me anyway, since I’m here. And she’ll use the small speculum, so I’m more comfortable. “Oh, there’s no need for that! I’ll be absolutely fine with the large ones,” I laugh. She realises what I’ve implied at the same time I do. The awkward silence lasts a long time.
Uncomfortable encounters like mine are hardly unfamiliar to those of us who don’t fit the standard model of cishet womanhood that healthcare providers are used to treating. At least in the UK, we’re generally not paying to be uncomfortable, as the National Health Service (NHS) has provided healthcare free of charge to all UK residents since 1948.
However, things are changing are changing for the NHS. The Conservatives have been in power for seven years now, and the brutal austerity measures they’ve pushed through while in office have included funding cuts and restructuring that have left the NHS “at breaking point”. Staff are striking, non-citizens are increasingly being stripped of their right to free and equal treatment and services are being axed around the country. As a group reliant on specialist training and services, the LGBTQ community is among those that are especially bearing the brunt of this crisis. And as is so often the case, it’s queer women, both cis and trans, and non-binary folk that are suffering the most.
The National LGB&T Partnership recently held the first annual National Lesbian and Bisexual Women’s Health Week, intended to raise awareness about health inequalities for lesbian, bisexual and other women who have sex with women. The statistics they released over the week are unlikely to be a surprise for most of us: queer woman, and bisexual women in particular, are more likely than heterosexual women to experience long-term mental health issues, to have taken drugs, to drink at a rate damaging to their health and to smoke regularly. Women who identified as lesbian or bisexual were also more likely than both heterosexual women and gay and bisexual men to have experienced discrimination in the health sector, with 50% reporting negative experiences in both Stonewall’s research in 2008 and the National LGB&T Partnership’s own survey last year. Despite it being unlawful to discriminate against patients on the grounds of sexual orientation since 2007, a number of respondents to the LGB&T Partnership’s survey reported being given incorrect information or poor treatment due to their sexuality as recently as the last six months.
For both cis queer women and many DFAB (designated female at birth) non-binary folk, smear tests (aka cervical screening or cervical cancer checks) are a particular source of frustration with the NHS. While every owner of a cervix is susceptible to cervical cancer and thus entitled to a free, regular test for abnormalities, a lot of healthcare professionals are wrongly convinced that those who don’t engage in penis-in-vagina intercourse don’t need to be screened. My own awkward experience was just the tip of the iceberg, with many ending up being refused a test or even taken off the register of those eligible entirely in spite of the General Medical Council (the organisation that regulates doctors in the UK) classing such refusal of treatment as direct and illegal discrimination. As a result, over half of cis lesbian and bisexual women of eligible age have either never had a smear test, or not had one within the recommended time frame of every 3 or 5 years.
For the most part, poor treatment of of LGBTQ patients in the NHS comes down to a lack of knowledge among healthcare practitioners. In 2015, Stonewall found that only one in four patient-facing staff had received training on LGBT health needs and inclusive practices, with trans-specific issues often remaining unaddressed. As a result, 10% of health and social care practitioners in the UK weren’t confident in their ability to understand and meet the needs of LGB service users; this jumped to 24% when it came to trans service users. Understanding of non-binary identities is particularly lacking; as one friend told me: “Most people don’t even know we exist, and even the computers sometimes struggle to deal with us. I’ve actually only found one NHS employee who was written my full referral with correct pronouns, and has consistently been 100% respectful about it”. While they were pleased that “there are more people in the NHS who are learning and understanding about previously invisible identities”, NHS training budgets have been repeatedly cut over the last ten years, standing in the way of attempts to spread knowledge to those who need it the most.
Healthcare professionals’ status as gatekeepers to treatment makes this lack of understanding particularly damaging when it comes to trans healthcare. Hormone therapy, gender confirmation surgery and laser hair removal treatment are all available for free on the NHS, but accessing them typically requires a diagnosis of gender dysphoria and referral to one of the UK’s 14 gender identity clinics, where waiting lists are frequently months or even years long due to lack of funding. A referral and treatment can be denied at the clinician’s discretion, with non-binary trans people and those with disabilities and/or mental health issues (it’s common for GPs to refuse to offer a referral to anyone who’s undergoing treatment for depression, for instance) at particular risk of being denied transition related healthcare. Many end up resorting to private treatment, if they can afford it, or self-medicating.
It’s not all bad, particularly in comparison to the current situation in the US. Even among the right wing, the right to universal free healthcare (for British citizens, at least) is largely considered sacred – a 2013 poll found that 72 percent of people believed the NHS to be “a symbol of what is great about Britain and [that] we must do everything we can to maintain it”. In theory, every LGBTQ person in the UK is entitled to have that healthcare respect them and their identity, and there are many practitioners in the NHS who work to ensure that’s the case. However, that work is becoming harder every day. The NHS is being deprived of the resources and funding it needs to provide adequate services not just to the LGBT community, but to everybody. And until its administrators no longer have to choose between funding hospital beds or equality training, it’s going to keep getting worse.
I don’t know if other people have had this experience, but there seems to be a bit of a gap regarding which healthcare professionals are good with (and presumably have been trained on) lesbian/bi/queer patients and which aren’t. Specifically, I have always had good experiences with staff at sexual health clinics – though I realise that’s not true for everyone – and have come in for baffled looks from GPs and nurses.
My instinct is that this comes down to the old prejudice that LGBT+ people and issues are always inherently sexual, so only the sexual health people need to know anything specific about us.
I enjoy watching the facial expressions of a new gynecologist when they ask me what do I do for pregnancy prevention and I answer “being a lesbian”
This was exactly my experience with getting a pap smear. Made more ironic by the surgery being covered in those leaflets and posters about how queer women did need to have them.
The transitioning people who are being treated for depression are exactly the ones who need to get gender identity confirmation care pronto (with the usual disclaimer, “transitioning can’t fix every problem”).
I <3 the NHS 4evs.
But I do wish it was better at knowing that lgbtq people exist and they have just as many complicated health needs as all those cis straight people.
On my first ever smear test the nurse was much more nervous than me about taking my sample, bless her! I had to ask her to relax and tell her it will be over in a minute. I’ve no idea if me being gay made her uncomfortable or what, I couldn’t tell. It’s a shame what’s happening with the NHS but I think, if they’re being obviously ignorant, it helps if you tell them on the spot they’re making you uncomfortable, or when you give your feedback.
The treatment of Trans* folks by the NHS is atrocious– through no fault of the clinicians and specialists themselves. Like all departments at present, they are being made to do far too much with far to little.
I had to wait a year first– from 15 to 16 to “meet the requirements to go to the adult clinic, since I’d only be referred again if I went to Tavistock”, a year again, from 16 to 17 to be seen at the Charing Cross GIC for an initial appointment, a year further to recieve my first hormonal treatment and FOUR YEARS to get in to theatre for surgery… all things that I had expressed a desire for since I was 15. I should mention that post-surgery, I still am travelling (long distance) to London for complications on a monthly basis.
The Trans* community is typically British; in that in the majority it suffers in silence but we are at such high risk for suicide and I don’t think it’s hard to understand why. The state of the UK is dire and I despair for the future…
I have so many feelings about this. Have been a healthcare assistant since 2008 and now a medical student. And also a regular patient because *fun disabilities*. Seeing (often well-intended) people being spread so thinly they can’t help but give sub standard (to abysmal) care kills me. So for anyone reading who has been denied what they need or is trying to heal from being treated with ignorance or bigotry, you are seen. You are incredibly valuable. And I’m so sorry.
Also. Are there other NHS folk running around here? I try hard to make services suck less for queer folk and advocate for more vulnerable friends… but I feel like maybe we could talk/ hang out/ try to level up?
Hi Amy, I have a friend who’s training to be a mental health nurse and she’s an amazing activist, pm me if you’d like me to put you two in touch.
Also, this Trans Health Advocacy training is coming up on the first of April, if folks are interested
https://www.facebook.com/events/231960380606635/?ti=cl
Thanks for this Heather.
Really appreciate the increased UK political coverage lately. Hope it will continue!
F*cking Tories. Thanks Heather for the great article as usual.
For people on the trans* spectrum, I highly recommend CliniQ https://cliniq.org.uk/
The services they provide:
Free, confidential sexual health screening (including HIV & Hepatitis C)
Liver function tests (important for monitoring the impact of hormone therapy)
Hepatitis B testing and vaccination
Cervical smear testing (for anyone over 25 with a cervix)
PEP – Post-Exposure Prophylaxis (Emergency HIV Medication)
Hormone injections (with ID and proof of prescription)
Gender identity counseling
Drug & alcohol counseling/support
Housing Advice (1st Wednesday of the month – Stonewall Housing Drop-in Service)
Sexual assault & hate crime support and on-going case work (Via Galop)
Health Adviser support & non-statutory social work
Social support & community drop-ins
Acupuncture
Yoga (1st, 2nd, 3rd Wednesday of each month)
Intersections – A group for queer & trans Muslims, held at cliniQ
cliniQ is a queer inclusive, trans* space. We don’t decide who is ‘trans enough’ to use our service – if you feel marginalised by gendered spaces, mainstream sexual health clinics, or by only being offered the ‘M’ box, or the ‘F’ box, cliniQ might just be the service for you. All of our services (including counselling and advice) are also available to partners, friends and family of trans* people too.
CliniQ is so good, I wish everyone in the country could have access to such a great service.
I’m not sure this article is entirely fair… the smear advice was wrong, – lack of education on their part and it was in the news and they’re obviously not doing that anymore. However crap the NHS is, having worked in the NHS I feel it’s equally crap to everyone gay or not. Also half of the NHS is made of gay people, there are so so many gay nurses and doctors and health care assistants. I don’t think the NHS is any better or worse at treating LBGT considerately than any other body or organisation. It is dreadful but equally so to all. Example: the other week on my friends shift they put a patient in a staff room because they ran out of space. It’s nothing personal they’re just rubbish.
The NHS is under severe pressure, mainly because the governments in recent years have not been planning a way to adapt the NHS from when it was first born to how it (and the growing and larger older population) is now. It has a job in trying to prioritize care for everyone, and it has long been a blessing which some forget is such and are taking clear advantage of. Despite all these various pressure points, the NHS has tried to do its job, and just like anywhere else, there are sometimes workers/services in it that aren’t always up to scratch.
For every bad experience you’ll get a good one and vice versa. Even with a government change, which I’d welcome, the NHS funding/staffing issues (and the rest) won’t be solved overnight. It’s in need of a huge overhaul that’s right up to date with the demands of today (and future ones), and suffering being stuck in the stretching period from when our grandparents were starting to use it. Most don’t want it to become completely private as then potentially so many will miss out, but egos and party politics need to be left aside so that proper unbiased adult conversation can be had about it and action applied now to secure future generations will be cared for sufficently.
My NHS history (GP or other services) have been fine and well dealt with overall. My sexuality has never figured in any health check (to memory) and presumably most people I’ve seen over the years will have just presumed me straight having not corrected them otherwise. None of what I’ve had checked is sexuality specific, but more gender specific if specific. And any injury cases, not sexuality or gender specific. My experience of GPs, A&E and other service within have been as good as they’ve been able to give at the time, and I’m fine so it’s obv been enough.
The Tories are not helping progress the NHS, but that doesn’t mean those struggling in it aren’t trying to do what they can with the high demand. No doubt there are varying and sometimes bad tales for some of us, but I think it’s pretty amazing what the NHS can provide us now (care and info) given how little they’re running on (and we should remind ourselves what they should be running on). I can’t say whether LGBT ppl are treated less well, stats would seem to suggest there is something of evidence there, but of course not all LGBT people (like me) are part of that stat gathering. I’ve used the NHS like most now and then and I’ve had family and friends that would not be here (lives departed) if it weren’t for it and the info/care they got. So, yes, it’s not perfect for everyone, let alone specific groups needs within it, but the negative reasons are broad for lots of us and not letting up soon. Unless you can move job or can afford private, these woes are something plenty of us will be sharing pain of (working inside it, needing from outside).