Michele Battle-Fisher and Ramona Peel critique the heteronormative, cisnormative healthcare bias inherent in the medical system.
Sexual and gender minority patients often seek care in healthcare systems that use heteronormative or cisnormative health approaches, to the detriment of their unique LGBTQI+ needs. In the latest Gallup poll reported in 2021, 5.6% of Americans self-identify as lesbian, gay, bisexual, or transgender. The Canadian Community Health Survey found that in 2018, 1 million Canadians, 15 and over, self-identify as “LGBTQ2+”. Research has consistently shown that sexual and gender minorities experience a disproportionate number of health disparities.
Members of sexual minority groups identify as something other than straight or heterosexual. This would include gay, lesbian, and bisexual people, as well as men who have sex with men, women who have sex with women, asexual people, same-gender-loving people, and pansexual people.
Intersex people, also known as people with differences in sexual development, do not neatly fit into the binary categories of the male or female sexes, due to their physiology, genetics or phenotype. Intersex people fall at all points of the spectrum of gender identity and sexual orientation.
In contrast with sexual minority groups, people who are in a gender minority group are those whose gender identity is different from the gender identity typically associated with their sex assigned at birth. Examples include transgender, nonbinary, and gender nonconforming people, genderqueer, agender people, gender-fluid people, and two-spirit people.
This list of groups is far from exhaustive.
Healthcare that upholds ethical care must provide culturally humble and appropriate care regardless of sexual orientation or gender identity. The data in the US shows that American health care systems are not providing this care. Compared to their heterosexual peers, LGBTQI+ folk experience poorer health outcomes due to discrimination, stigma, and prejudice in the healthcare system. Other barriers to utilizing care are a lack of health care provider competence, lack of insurance and problems with personal finances, lack of transportation connecting individuals to specific health care services, lack of trust in providers, lower levels of perceived risk, and having to disclose their sexual orientation, sexual identity, or gender identity.
According to Lambda Legal’s 2010 Survey on discrimination in medical settings in the US, 8% of sexual minority patients and 27% of gender minority patients have been refused needed care. Furthermore, 49% of sexual minority patients and 89% of gender minority patients believe not enough medical professionals are trained to work with sexual and gender minority populations.
Bioethics mirrors the current health system in which it operates. Society in general has also failed to center the moral needs of sexual and gender minorities. In 2011, Wahlert and Fiester introduced LGBTQI+ bioethics as a means of correcting heteronormative, cisnormative bioethics. They call for a “broadening of what is worthy of bioethical attention”. According to this model, LGBTQI+ bioethics or queer bioethics:
- centers marginalized communities, and
- challenges injustice and discrimination in health care encounters, systems, and policies.
What is needed to truly queer bioethics is to center queerness in patient care and in our ethical reflection. Failing to center difference in queerness defaults to anti-queerness. For instance, ethical discussions of sexual reproduction are often based on assumptions about biological and socially-constructed definitions of embodiment. LGBTQI+ people may differ from accepted, normative constructions of what a body is and should be. A transgender man may decide to have children, and at first this might seem improbable and unlikely due to gender identity. A lesbian might intend to have children through physical birth. Assumptions about gender and sexual normativity can be taken for granted in the doctor-patient interaction. When the definitions of biological mothering only apply to straight, cis women, bioethics must deviate from this convention.
Many transgender and non-binary patients have had the experience of being addressed with an incorrect name or incorrect pronouns. These mistakes by front-line staff and providers often lack hostile intent, but the negative impact upon patients can be profound, and can include the severing of linkage to care. Thus, it is crucial to break ingrained habits of gendered assumptions about who will seek particular health care services, and to unlearn the assumptions we often make about people’s gender identities based on observable gender-expression cues or visible secondary sex characteristics.
Queerness must be made inherent to the workings of clinical care and bioethics. Bioethics needs to participate in a re-visioning to ensure that sexual and gender minorities are no longer left out. There is a moral requirement to broaden the scope of bioethics to embrace a queercentric morality. LGBTQI+ bioethics requires that differences in sexuality and gender do not lead to disenfranchisement in receiving care. LGBTQI+ patients unlike their heterosexual and cisgender peers often intentionally veil themselves, hide their identities, in order to receive care. As we have noted elsewhere, “If morality is defined by the assurance of ethical, medically appropriate care owed to the patient, that morality must stand no matter the sexual or gender presentation of the patient”.
Michele Battle-Fisher (she/her) is the Associate Director of Research at Equitas Health Institute in the United States. @battle_fisher
Ramona Peel (she/her) is the Lead Trainer at Equitas Health Institute.