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.