One in ten people you meet or patients you treat identify as LGBTQIA+. So, why are these individuals feeling invisible when it comes to health care? And even more concerning, why do they delay or avoid care that’s crucial to their health and wellbeing?

Inclusivity and diversity consultant Bree Gorman, who is also gender diverse, says awareness is a crucial first step, but the real work is in proactivity seeking to include all patients.

“For many LGBTQIA+ people, walking into a new health organisation is daunting. And in many health organisations, gender diverse or non-binary people still aren’t seen to exist.

“As soon as we get to the premises and are asked to fill out our details, we’re asked whether we’re male or female. It’s still rare for there to be other choices, and commonly if there is, it says, ‘not specified.’ It doesn’t feel good to select ‘unspecified’ or ‘other’ – no one wants to be an ‘other’.

“Of course, in some health settings understanding sex is important. But in those cases, the forms should ask for sex separately or both gender and sex, recognising that these are two different things.”

The absence of assumptions in health care is key to creating inclusion and will avoid what Gorman describes as microaggressions.

“I am almost always assumed to be a woman, particularly if I have my children with me. That means the health professional or reception staff will misgender me.

“For many non-binary or trans people, being misgendered is incredibly hurtful. We know you won’t always get it right but seeing someone is trying is a great start!

“Best practice is to collect pronouns from the beginning on intake forms, but health professionals and receptionists can be trained to introduce themselves with their preferred pronoun.

“If you introduce yourself with your pronoun, then you send a strong signal to me that you recognise gender diversity and that you’re an ally – it makes me feel safe and supported.

“Then, if comfortable, I can respond with my pronouns – but I also don’t have to – and we can have a respectful and inclusive conversation.”

It’s okay to get it wrong, explains Gorman, but don’t make a big deal of it.

“If you do misgender someone, just quickly correct yourself without fuss or explanation and move on with the conversation.”

Visible signs of inclusion also matter, explains Gorman.

“We are constantly on the lookout for signs of inclusion or exclusion, particularly as we meet the receptionist and sit in a waiting room.

“Rainbow stickers, flags, lanyards, gender-neutral bathrooms, brochures or flyers from LGBTQIA+ inclusive organisations can all create a greater sense of safety.”

Gorman says, while the outward appearance of inclusiveness is vital, the follow-through is where the real difference is made.

“Many of us have attended facilities where these visible signs exist only to then be treated inconsiderately or even experience outright homophobia or transphobia from a receptionist, health professional or fellow patient. 

“If you are going to claim to be an inclusive organisation and display the rainbow flag, it is only fair that you back that up with true inclusion from your staff,” says Gorman.

Claire Allen, National Program Manager, Pride in Health and Wellbeing ACON Pride Inclusion Programs, says many LGBTQIA+ people fear discrimination to the extent that they avoid or delay care that’s vital for their health and wellbeing.

“Our research shows that 20 per cent of LGBTQIA+ people avoid or delay care due to fear of discrimination, and this jumps to 50 per cent for those with a trans experience.

“These fears are due to past experiences of discrimination and health systems that are set up for the majority and do not support LGBTQIA+ people,” says Allen.

About one in ten people identify as LGBTQIA+ across all cultures, religions, and geographic areas, so it’s crucial the health care profession gets inclusivity right, explains Allen.

“While you might not see the community – as they don’t feel comfortable attending that service or they don’t disclose – LGBTQIA+ people are there.

“All people and services need to demonstrate they are inclusive without the community having to ask. This eliminates the need for LGBTQIA+individuals to guess how staff will respond to their identity.”

The whole patient interaction needs to be inclusive, says Allen, from the visual signs of inclusivity to paperwork and clinical conversations.

“Services and health professionals need to be inclusive to the whole patient interaction, from before they walk in the door, so websites and brochures, to waiting rooms and intake forms. This then extends to clinical conversations and referrals to other providers.

“Display the rainbow, progress and trans flags, instruct on pronouns, update forms, so they don’t conflate sex, gender and legal documentation and avoid assumptions about a person’s gender, relationships and body.

“It needs to be a continuous improvement process to current and best practice to avoid tokenism,” says Allen. 

Kellie Wilton, Principal Midwifery Officer, Australian College of Midwives, says traditional social constructs of gender no longer exist, so health professionals must remain vigilant on inclusivity.

“We live in a very fast-moving environment where more and more people are discovering and giving voice to their true self.

“We must always remain current and up to date with what is happening in our communities. 

“Gender diverse and LGBTQIA+ communities have specific health and wellbeing needs that research shows that health disparities are emerging for this community. 

“With ongoing training for health care professionals, these disparities can be addressed by breaking down stigma and removing barriers to accessing healthcare services,” says Wilton.

When it comes to choosing a training program on inclusivity and diversity, Wilton says it should be bespoke, accredited and outline any barriers to accessing care.

“Training programs need to be tailor-made to meet the unique needs of gender diverse people and the LGBTQIA+ community and ideally have some form of accreditation such as the ‘Rainbow Tick’ or similar. 

“Training should always clarify the difference in sex, gender, expression and sexuality.

“It should articulate barriers to care that the LGBTQIA+ community face as well as the health disparities that result from these barriers.

“This ensures that the program goes beyond just cultural awareness and sensitivity but also builds the capacity, knowledge, and confidence of health professionals to act in ways that demonstrate cultural competency and proficiency. 

“Training programs should also reflect the requirements of the NMBA Code of Conduct with regards to cultural safety and provide staff with strategies to embed cultural safety into their everyday practice,” says Wilton.

The Australian College of Midwives Codes of Conduct set out by the NMBA provides a framework regarding inclusivity etiquette:

• Understand that only the person receiving care and/or her family can determine whether or not care is culturally safe and respectful
• Respect diverse cultures, beliefs, gender identities, sexualities and experiences of women and other birthing people, including among team members
• Acknowledge the social, economic, cultural, historic and behavioural factors influencing health, both at the individual, community and population levels
• Adopt practices that respect diversity, avoid bias, discrimination and racism, and challenge belief based upon assumption (for example, based on gender, disability, race, ethnicity, religion, sexuality, age or political beliefs)
• Support an inclusive environment for the safety and security of individual people and their families and/or significant others, and
• Create a positive, culturally safe work environment through role modelling, and supporting the rights, dignity and safety of others, including women, other birthing people and colleagues.

Delivering safe, supportive and inclusive health care

Creating an environment that is affirming and inclusive of people who identify as gender diverse/ LGBTQIA+ is integral to creating a safe space. 

• Display artwork and posters that depict gender diverse/LGBTQIA+ people receiving respectful healthcare. 
• Staff can also demonstrate inclusivity in small ways by wearing a Rainbow Flag pin or lanyard that identifies them as an ally.
• Encourage staff to use gender-neutral and inclusive language in all conversations and offer ongoing training and reflection.
• Educate yourself on LGBTQA+ related health – don’t expect your patient to teach you or best practice to remain static.
• Healthcare settings can offer gender-neutral toilets and change rooms.
• Train all your staff on inclusion as part of their role – and get training from LGBTQA+ community organisations.
• Review your whole patient lifecycle for inclusion – not just your clinical conversations and break down the assumptions we are making about sex, gender, bodies, and relationships.
• Measure your inclusion for best practice and continuous improvement.
• Identify how to make changes in workplace culture and raise visibility and promote leadership and accountability amongst staff.