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Alena Papayanis is a Professor of Arts and Humanities at Humber College in Toronto and a writer whose work focuses on queer issues, including coming out later in life.

“What kind of birth control are you taking?” my gynecologist asked me while staring down at my file. “None,” I replied. “Well,” she said, looking a bit confused, “then why aren’t you pregnant?” She looked up at me and, feeling a bit put on the spot, I told her that I am a lesbian.

This wasn’t the first time I had come out to her; I had done so on a previous visit. I had been nervous telling her the first time and was happy to be past that milestone, but then suddenly here I was in front of it again.

It was a moment that made me feel like an “other,” a feeling that is quite common for many people in their interactions with health care, due to any number of differences. Ableism, ageism, fatphobia, racism and sexism can all impact quality of care, but my recent experiences have been predominantly with heterosexism – the implicit assumption that everyone is straight.

LGBTQ2+ patients are more likely to have a negative experience in the health care system than our straight counterparts, although many report positive experiences with individual health care providers. This is largely owing to the fact that heteronormativity and cisnormativity (the assumption that the gender binary is the norm and that all human beings have a gender identity which matches their biological sex) – is institutionalized within health care.

The World Health Organization reports that, worldwide, members of the queer community are more likely to experience human-rights violations, including violence, torture, criminalization, forced sterilization, discrimination and stigma. Furthermore, the sexual rights of transgender and gender-variant people are not respected; they are constantly exposed to stigmatization, discrimination, and legal, economic and social marginalization and exclusion. The recent attempts in Texas to treat gender-confirming care for children as child abuse is evidence that this is an ever-present danger.

Even though LGBTQ2+ legal rights are mostly established in Canada at the moment, health care is still one location where we can witness the difference between the legal reality and the lived experience of queer people.

Sexual and gender minorities often feel invisible: forms that imply that a child has a mother and a father, sexual-health pamphlets and posters targeted at heterosexual people, the treatment of non-birth mothers in lesbian relationships as illegitimate parents, even the refusal of services.

This community has distinct health risks because of stigma and systemic discrimination: a higher prevalence of mental-health disorders, including more depressive symptoms and lower levels of psychological well-being, and an elevated prevalence of substance abuse. It’s not biological – it’s non-medical factors determining our outcomes: the conditions in which we live and work, economic policies that put us at a disadvantage, social norms that alienate us – over all, the systems that shape our daily lives and experience.

Heterosexism and homophobia exacerbate these health disparities, leading queer people to experience poorer health outcomes than their heterosexual and non-transgender counterparts, such as higher morbidity rates in a range of conditions including breast, uterine, colon and ovarian cancers, heart disease, and stroke for lesbians and bisexual women.

Despite needing preventative health care, the queer population is less likely to engage in it not exactly by choice, but in order to avoid negative experiences or the fears and anxieties that can be fundamentally wrapped up in their relationship to the health care system.

In every encounter I have with a new health care professional, I have a choice to make: to come out or not to come out. My decision is based on the assessed safety of the environment and staff there – I’m essentially looking around the space for clues as to how my disclosure will be received: the level of inclusivity in the language being used by staff when speaking to patients, the posters and pamphlets on display, the assumptions inherent in the questions I’m being asked, even the kinds of bathrooms available for patient use. While I’m aware that disclosing my sexual orientation would likely result in better care, I fear the consequence of my disclosure: discomfort, alienation, hate, perhaps even refusal to treat me. It’s hard to predict the depth of homophobia with each new health care encounter.

This even applies to one of my longer-term health care providers, who first met me as a straight woman. I only came out as queer about five years ago, when I was in my late 30s, after being married to a man and having a child. I’ve been seeing my acupuncturist ever since I was first trying to get pregnant and she’s seen me in my worst state, not knowing that she was treating symptoms that reflected my strained emotional state as I was coming out.

I still get anxious in moments when there is an opening for me to bring it up – a comment she’ll make about my (now ex-) husband or my new dog as a nice addition to a nuclear family. These moments are all laden with assumptions of straightness, so the barrier feels that much harder to break through and the impact of my words even more jarring.

I also fear that my confession will change our relationship. I’m almost positive that she’ll be supportive, but I don’t want to risk the small chance that her personal views will fundamentally change the way she sees and treats me.

When we enter public space, heteronormativity functions to make queer people at first invisible until the moment they become transgressive: the men in the waiting room are assumed to be brothers or friends until an intimate kiss between them, at which point other patients might become uncomfortable; a trans person gets outed in front of a full waiting room when the doctor doesn’t call them by their preferred name or pronoun and an unwanted spotlight is suddenly shone on them.

Assumptions are shaping our health care spaces and queer people are suffering because of it.

Queer identities should not be made to fit into heteronormative spaces. Our health care spaces need to be transformed. This goes beyond rainbow flags and stickers, which, although important and necessary, are insufficient. If the desks they are stuck on and the offices you find them in are still inhabited by homophobic and transphobic workers, or well-intentioned workers that are ignorant to, or have unchallenged biases towards, the queer community, then those signs of safety are not only superficial, but they are a ruse, a betrayal.

Here are the changes needed.

Health care staff want and need more equity, diversity and inclusion training, with one Australian study finding that more than 93 per cent of those asked whether they wanted to know more answering “yes.” Training is one very important part of the solution, but there are others.

Representation is important. I want to walk into a doctor’s office and see queer couples on posters and pamphlets on display that are clearly directed at addressing queer people’s health care needs.

We need to disappear the assumptions and potential for experiences that can lead to harm. Even though I am a cisgender woman, I should be offered health care services that a transgender man or non-binary person might need; this would make it immeasurably better for those who walk into the office needing care that’s not obvious from their gender presentation. This takes the onus off of queer people to disclose, to force ourselves into being seen, or to educate and normalize queerness to the staff ourselves.

One single electronic medical record that follows a patient across all health care spaces would also protect queer patients from having to come out over and over again, an experience that might only be annoying for some but can be retraumatizing for others.

Forms should also provide opportunities for self-identification, rather than literally being made to fit into narrowly defined boxes: the terms need to be much more inclusive and go beyond “man” or “woman.” and “husband” and “wife.”

For this to happen, the “family” also needs to be redefined within health care to include less traditional family configurations and to similarly recognize queer parents. When a baby is born to a man and a woman, both names go on the birth certificate without issue; for couples that use a known sperm donor, in some provinces the non-birth parent must later adopt the child through a court proceeding – something no heterosexual couple has to experience.

Every health care facility should have their own set of policies that carefully, clearly, and specifically articulate how these Charter rights can be upheld and protected so that there is no leeway, no confusion, no convenient excuse for ignorance around how anyone should be treated within those walls. It was only in 2011 when anti-discrimination policies came into effect federally in the United States, and although patients in Canada are protected under the Charter of Rights and Freedoms, it’s quite apparent that many people in minority groups in Canada can attest to experiences not in line with the promises that the Charter embodies.

This is very much needed in our long-term care facilities, where queer seniors, many of whom carry with them a history of being pathologized and even criminalized, are forced to live under the assumption of binary gender and heterosexual structures and in the face of homophobia and transphobia, often go back “into the closet.”

Change needs to happen on both personal and systemic levels, by examining the assumptions that underlie our health care system, by exposing harmful myths about queerness that lead to assumptions in the first place, and confronting negative connotations about the queer community with an understanding of our lived realities.

In the same way that the popular saying “love is love” reminds us that love should not be limited by gender identity or sexual orientation, health care can also be seen in this simple yet profound way – “care is care” – everyone is deserving of quality health care, including the ability to be seen, heard and respected in the fullness of our identities.

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