It is well documented that significant barriers exist for lesbian, gay, bisexual, transgender and queer (LGBTQ) identified persons to receiving quality health care. Due to homophobia, heterosexism and social determinants of health, LGBTQ persons’ health care experiences may be difficult, with negative repercussions (Canadian Mental Health Association 2016, Gold et al. 1994, Hinchliff et al. 2005, Polek et al. 2008). This may lead to reluctance to seek out health care when needed, and in the context of health care interactions, a reluctance to disclose one’s identity (Perrin et al. 2004, Polek et al. 2008, Neville & Henrickson 2009). This can result in substandard care.
Changes at a systemic level are crucial. For example, the consideration of this issue should be part of the health professional education curriculum (Chapman et al. 2012). Attention is also needed at a more personal level in order to address barriers that may exist for our LGBTQ clients. As pelvic health physiotherapists, our work requires the development of significant trust and rapport with our clients – this is amplified when working with persons who may have experienced negative outcomes of health care interactions in the past, or who perceive that the opportunity for a negative outcome exists.
The following are some hints that I have found useful in my practice to acknowledge that the LGBTQ population is a welcome part of my practice, and to create an inclusive and safe environment. I invite you to read them and let me know what you think.
- Are your forms and questionnaires inclusive of persons of all genders? If your forms contain the binary classification of “male” and “female”, those who do not identify with either of these categories are excluded. You may wish to consider creating an inclusive form. For example, if clients are asked to identify their gender, consider adding “transgender” and “other” to the list. Including a section where the client may specify their preferred name is also helpful; transgender persons often adopt a name different than the name that was assigned at birth. Rather than sub-sections of a form for men and women, consider captions that do not assume binary gender identification, providing direction such as “complete this section if applicable”.
- Are any of your beliefs or practices unwittingly based in heterosexism? Heterosexism is the belief that heterosexuality should be taken for granted (Morrison & Dinkel, 2012). A common example of heterosexism in a perinatal pelvic health physiotherapy practice is the assumption that the baby’s parents are a man and a woman. Some babies have two moms or two dads. Some families are combined, with three or more parents involved. When working with women in the peripartum stage, you may wish to consider asking about their partner’s involvement rather than the dad’s involvement.
- Do you understand your client’s comfort level with the assessment and treatment modalities that you are proposing? Many lesbians do not engage in intravaginal sexual activity and may have never had intercourse. They may not be comfortable with intravaginal/ intrarectal pelvic health assessments. They may not be comfortable with the idea of using dilators/ accommodators. They may believe that they are exempt from screening for cervical cancer through Pap smears. If a client identifies as lesbian, you may wish to acknowledge these points and seek to determine their comfort level with these aspects of the assessment and treatment process.
- Do you fully understand your client’s physical and medical status? Transgender individuals may be hesitant to disclose their status, and may omit information that is important to your work with them. Has a transgender man had “top surgery”, with removal of the breasts? Hypomobility of post-surgical scars may be a contributing factor to their presenting symptoms. Is a transgender person taking hormones on a long-term basis? This can have many repercussions relevant to your work together, for example compromised tissue integrity.
- What factors specific to your client may be directly contributing to pelvic floor dysfunction? Transgender men who have not had top surgery and instead bind their breasts may be predisposed to pelvic floor dysfunction. Wearing a binder may limit movement of the ribcage with breathing, leading to increased intra-abdominal pressure with inhalation. Compensatory hypertonicity in the pelvic floor may occur as a response to this.
- What social factors may be contributing to pelvic floor dysfunction? If faced with possible discrimination and verbal/ physical abuse when using public washrooms, transgender persons may opt to wait until they find a safe space before relieving themselves. This can lead to pelvic floor hypertonicity, disruption of reflexes helpful to healthy bladder and bowel function, and constipation.
This is a very rich topic and this list is by no means exhaustive. I hope that this post will inspire you towards deeper reflection and discussion of these important issues. I would love to hear what you think! Please free to contact me directly with your thoughts at email@example.com.
Canadian Mental Health Association Ontario (2016)
Chapman, R., Watkins, R., Zappia, T., Nicol, P., Shields, L. (2012) Nursing and medical students’ attitude, knowledge and beliefs regarding lesbian, gay, bisexual and transgender parents seeking health care for their children. Journal of Clinical Nursing 21 (7-8), 938-945
Gold M, Perrin E, Futterman D & Friedman S (1994) Children of gay or lesbian parents. Pediatric Review 15, 354–358.
Hinchliff S, Gott M & Galena E (2005) ‘I daresay I might find it embarrassing’: general practitioners perspectives on discussing sexual health issues with lesbian and gay patients. Health and Social Care in the Community 13, 345– 353.
Morrison, S. & Dinkel, S. (2012) Heterosexism and Health Care: A Concept Analysis. Nursing Forum 47 (2), 123-130,
Neville S & Henrickson M (2009) The constitution of ‘lavender families’: a LGB perspective. Journal of Clinical Nursing 18, 849–856.
Perrin EC, Cohen KM, Gold M, SavinWilliams RC & Schorzman CM (2004) Gay and lesbian issues in pediatric health care. Current Problems in Pediatric and Adolescent Health Care 34, 355–398 doi:10.1016/j.cppeds.2004. 08.001.
Polek C, Hardie T & Crowley E (2008) Lesbians’ disclosure of sexual orientation and satisfaction with care. Journal of Transcultural Nursing 19, 243–249.
Written by: Michelle Fraser