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Research
People who identify as LGBTIQþcan experience assumptions, discomfort, some
discrimination, and a lack of knowledge while attending physiotherapy: a survey
Megan H Ross, Jenny Setchell
School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Australia
KEY WORDS
Sexual and gender minorities
Health
Communication
Gender identity
Physical therapy
ABSTRACT
Questions: What are the experiences of people who identify as lesbian, gay, bisexual, transgender, intersex,
queer or related identities (LGBTIQþ) and attend physiotherapy? How could those experiences of physio-
therapy be improved? Design: Primarily qualitative design using a purpose-built online survey. Participants:
People aged 18 years or older, who self-identified as LGBTIQþ, and had attended physiotherapy in Australia.
Methods: Open responses were analysed with thematic analysis and quantitative responses with descriptive
statistics. Results: One hundred and fourteen participants responded to the survey, with 108 meeting all
eligibility criteria. Four main themes were identified in the analysis, with almost all participants reporting
experiences during physiotherapy interactions relating to at least one of the following themes: ‘assumptions’
about participants’sexuality or gender identity; ‘proximity/exposure of bodies’, including discomfort about
various aspects of physical proximity and/or touch and undressing and/or observing the body; ‘discrimina-
tion’, including reports of overt and implicit discrimination as well as a fear of discrimination; and ‘lack of
knowledge about transgender-specific health issues’. Positive experiences were also evident across the first,
third and fourth themes. Participants suggested or supported a number of ways to improve LGBTIQþex-
periences with physiotherapy, including: LGBTIQþdiversity training for physiotherapists, education specific
to the LGBTIQþpopulation (particularly transgender health), and open options for gender provided on forms.
Conclusion: People who identify as LGBTIQþcan experience challenges when attending physiotherapy,
including: erroneous assumptions by physiotherapists, discomfort, explicit and implicit discrimination, and a
lack of knowledge specific to their health needs. Positive findings and participant-suggested changes offer
ways to improve physiotherapy for LGBTIQþpeople across educational and clinical settings. [Ross MH,
Setchell J (2019) People who identify as LGBTIQDcan experience assumptions, discomfort, some
discrimination, and a lack of knowledge while attending physiotherapy: a survey. Journal of Physio-
therapy 65:99–105]
© 2019 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under
the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
A significant, and increasing, number of Australians identify as not
being heterosexual (3 to 11%)
1
and/or gender diverse. Lesbian, gay,
bisexual, transgender, intersex, queer and related identities
(LGBTIQþ) civil rights have become a topic of increased social and
political debate in Australia and other countries over recent years.
Although this debate has resulted in reduced discrimination,
including policy changes such as legalisation of same-sex marriage in
some countries, stigma and inequity still exist.
2
Health and access to healthcare remain an important area of
inequity for LGBTIQþpeople.
3
Globally, LGBTIQþpeople experience
significantly poorer health and greater barriers to healthcare.
Research consistently highlights poorer mental health,
4–6
including
much higher suicide rates than in the general population.
7,8
Physical
health is also poorer,
9
with those identifying as LGBTIQþmore likely
to be diagnosed with cardiovascular disease,
10,11
cancer,
12
diabetes,
13
and disability.
11,14
One third of Australians who identify as LGBTIQþdo not disclose
their sexuality or gender identity when accessing healthcare,
15
with
reasons largely unresearched but proposed to be due to fear of
discrimination, including receiving poorer care.
16
Research has
highlighted that LGBTIQþpatients feel judged and receive subopti-
mal care from a variety of health professions, including medicine and
nursing,
17
mental health,
16,18
and peri-natal care.
19
However, there
has been no research investigating how people who identify as
LGBTIQþexperience physiotherapy.
While similarities between physiotherapy and other health
professions exist, and previously identified barriers may apply
to all forms of healthcare, it is likely that there are barriers
unique to physiotherapy.
20
Physiotherapy can be innately inti-
mate, with undressing, critical observation and touch common
during treatment.
21,22
These aspects can be difficult to
negotiate, with some physiotherapy patients feeling uncom-
fortable or judged.
23
There may be similar effects for LGBTIQþ
people.
Journal of Physiotherapy 65 (2019) 99–105
https://doi.org/10.1016/j.jphys.2019.02.002
1836-9553/© 2019 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/
licenses/by-nc-nd/4.0/).
journal homepage: www.elsevier.com/locate/jphys
To address the dearth of literature on the topic, this studyaimed to
identify how people who identify as LGBTIQþexperience physio-
therapy. Understanding any key concerns will provide physiothera-
pists with opportunities to improve (where required) provision of
healthcare to LGBTIQþpeople.
Therefore, the research questions for this mixed-methods survey
were:
1. What are the experiences of people who identify as LGBTIQþand
attend physiotherapy?
2. How could those experiences be improved?
Method
Design
People who identified as LGBTIQþand had attended physiotherapy
were invited to complete an online survey about their experiences of
physiotherapy. Recruitment was via social media, word of mouth, and
LGBTIQþorganisations in Australia. Snowballing was encouraged.
Data were collected using the online survey.
24
This method was
chosen because data needed to be collected from a large number of
participants to suit the study aim of seeking an overview of the ex-
periences of people identifying as LGBTIQþwith physiotherapy.
Study information was detailed online before providing consent and
entering the survey. Participants remained anonymous throughout
the survey. The survey was purpose-built and comprised questions
related to demographic data, and about participant’s experiences of
physiotherapy relating to their identity as LGBTIQþ(see Box 1 for an
overview of questions). The survey had one quantitative section
where participants identified (using a Likert scale) levels of support
for strategies to improve LGBTIQþexperiences of physiotherapy.
Participants
Inclusion criteria were: aged 18 years, self-identifying as
LGBTIQþ, had attended physiotherapy, and English speaking. Key
recruitment wording was ‘Do you identify as LGBTIQþ?Haveyou
seen a physiotherapist? We want to hear from you.’Participant
numbers were determined by the principle of saturation. Sufficient
saturation was considered to be reached when iterative analyses
during data collection demonstrated sufficient repetition and depth
of concepts in the data related to the study aims.
25
Theoretical underpinnings
This descriptive study was underpinned by the theory of rela-
tivism. That is: people have different experiences and there is no one
knowable version of reality.
26
This theoretical perspective allows the
possibility for no singular experience of people who identify as
LGBTIQþand attend physiotherapy, but rather there may be multiple
experiences. This reasoning is consistent with understandings of
pluralism (ie, many factors influence people’s experiences) and
intersectionality (ie, these many factors affect each other).
27
For this
study, this means that people who identify as one aspect of LGBTIQþ
might have different physiotherapy experiences (eg, someone who
identifies as a lesbian might have different experiences to a trans-
gender man). Further, sexuality and gender might not be the only
factors influencing people’s physiotherapy experiences: other factors
such as race or social class might also have an effect. Consistent with
this theoretical approach, this study was designed to invite and detect
divergent experiences.
Data analysis
Data analysis was principally qualitative, with a small quantitative
component. For qualitative data, a descriptive thematic analysis
outlined by Braun and Clarke was used.
26
Analyses were conducted
by two physiotherapists, both of whom identify as LGBTIQþ:JSisan
experienced qualitative researcher and MHR is trained in qualitative
analysis.
The analysis involved five iterative stages. First, MHR and JS
independently read the entire dataset and made preliminary notes.
They then re-read the dataset and refined analyses into provisional
themes. Next, the authors discussed their independent analyses to
Box 1. Survey questions.
Participants were encouraged to provide as much detail as possible in response to the following questions:
Overall, how did you feel during your [physiotherapy] appointment/s?
Please describe any situations that made you think about your gender and/or sexual preference [during appointments]?
Please describe any conversations about your gender and/or sexual preference and why you did or did not discuss these.
Please describe any physiotherapy experiences where you felt comfortable or uncomfortable about your gender or sexual preferences.
Were any of your negative or positive LGBTIQþand physiotherapy experiences affected by other factors such as your race, ability, age,
religion, etc?
How do you think the physiotherapist themselves felt during your appointment in relation to your gender or sexual preference? Did they
mention their own gender and/or sexuality?
During your physiotherapy appointment/s, has anyone ever assumed anything about your gender and/or sexuality? If so, please describe
the assumptions and any effects on you.
Please indicate if you would have felt comfortable or uncomfortable discussing your gender/sexual preference with your physiotherapists.
Please describe any experiences you had with ‘coming out’about any aspect of your gender and/or sexuality during any of your
appointments with a physiotherapist.
Do you have any suggestions of what could help your/other LGBTIQþpeople’s experience of physiotherapy?
Thinking broadly about LGBTIQþpeople attending physiotherapy, would it be helpful if (Likert scale):
physiotherapists use gender-neutral language
there is an option for ‘non-binary’on forms
physiotherapy workplaces displayed a small rainbow flag in the reception area
physiotherapy clinics’images show a range of people of different genders and sexualities
physiotherapists receive LGBTIQþdiversity training
physiotherapists are more aware of health issues specific to LGBTIQþpeople
LGBTIQþ= lesbian, gay, bisexual, transgender, intersex, queer or related identities.
100 Ross and Setchell: LGBTIQ+ people’s experiences of physiotherapy
solidify themes and subthemes. MHR then coded all data into these
categories. The fifth step was for the authors to further refine this
analysis to finalise coding. Any discrepancies were included in the
findings. To enhance rigour, an experienced qualitative researcher
external to the study checked final coding to ensure that results were
grounded in the data. The Consolidated Criteria for Reporting Quali-
tative Data (COREQ)
28
was also used for rigour; all relevant criteria
were satisfied. Quantitative data (Likert scale results) were analysed
using descriptive statistics.
Results
Participants
In total, 114 people responded to the online survey, with 108 of
these meeting all of the eligibility criteria. The participants’ages
ranged from 19 to 75 years. The sample was diverse in terms of living
situation, household income and education level (Table 1).
The participants identified with over 13 genders, including: 67
females (62%), eight transgender males (7%) and four non-binary
people (ie, identifying as neither male nor female, 4%) (Table 2 ).
There was also large variability in sexual orientation, with 41 (38%)
identifying as lesbian, 22 (20%) as gay and 16 (15%) as queer,
amongst 12 other orientations (Table 2). For readers who are un-
familiar with the terminology used in Ta bl e 2, a glossary is pre-
sented in Table 3.
Table 2
Participant gender and sexual orientation.
Characteristic Participants (n = 108)
Gender, n (%)
female 67 (62)
male 18 (17)
transgender male, transmasculine 8 (7)
non-binary 4 (4)
cis-female 3 (3)
gender queer 1 (1)
agender 1 (1)
fluid 1 (1)
transmasculine non-binary guy 1 (1)
trans/non-binary 1 (1)
gender queer male 1 (1)
femme 1 (1)
butch female 1 (1)
Sexual orientation, n (%)
lesbian 41 (38)
gay 22 (20)
queer 16 (15)
bisexual 15 (14)
pansexual 4 (4)
heterosexual 3 (3)
bi/pansexual 2 (2)
bisexual/queer 1 (1)
asexual 1 (1)
panromantic 1 (1)
queer lesbian 1 (1)
homosexual 1 (1)
Participants chose more terms to explain their gender and sexual orientations than
presented here (gender n = 18, sexuality n = 17). Some similar terms are grouped.
Table 3
Glossary of gender and sexual orientation terminology. Adapted from the Anti-
Discrimination Commission Queensland
65
and the Human Rights Campaign.
66
Term Definition
Agender A term used to describe people who identify as being
without gender
Asexual Having a general lack of interest in sex and sexual desire
Binder Tight fabric worn around the chest to obscure the shape of
breasts
Bisexual Having an attraction to both males and females as sexual
partners though not necessarily simultaneously, in the same
way or to the same degree
Butch A word used to describe people who identify as lesbian and
whose appearance and behaviour are seen as traditionally
masculine
Cis-gender A person whose gender identity and biological sex (assigned
at birth) align
Gay A term to describe people who are primarily attracted to
people of the same sex as them
Gender binary A concept or belief that there are only two genders and that
one’s biological or birth-assigned gender will align with
traditional social constructs of masculinity and femininity
Gender identity An inner sense of one’s gender, which could be neither,
either, both, or moving around freely between or outside of
the gender binary
Femme A word to describe people who identify as lesbian and
whose appearance and behaviour are seen as traditionally
feminine
Fluid/Gender fluid A person who does not identify with a sin gle fixed gender or
has a fluid or unfixed gender identity
Heterocentric Having a heterosexual bias
Homosexual Sexual feeling for a person (or persons) of the same sex
Intersex A term used to describe people born with physical,
hormonal or genetic features that do not fit medical norms
for female or male bodies
Lesbian A term used to describe women who are attracted to other
women
Misgendering Referring to a person in a way that does not reflect their
gender identity
Non-binary Not identifying as either male or female
Panromantic Having a romantic attraction to people of all genders
Pansexual A term used to describe someone who has the potential for
attraction to people of any gender though not necessarily
simultaneously, in the same way or to the same degree
Queer An umbrella term used by the LGBTIQþcommunity to
describe a range of sexualities and gender identities that are
outside of heterosexual and gender binary norms
Transgender A term used to describe people who do not identify with the
biological sex they were assigned at birth
Transmasculine/
Transfeminine
A term used to describe people who do not identify with the
biological sex they were assigned at birth –they identify
with masculinity more than femininity or the reverse
Table 1
Characteristics of participants.
Characteristic Participants (n = 108)
Age (yr), mean (SD) range 39 (9) 19 to 75
Place of residence, n (%)
metropolitan/urban 83 (77)
regional 16 (15)
rural/remote 8 (7)
not stated 1 (1)
Living situation, n (%)
a
partner/s 41 (38)
housemate/s 27 (25)
alone 18 (17)
partner/s þchild/ren 17 (16)
child/ren 5 (5)
parent/s 3 (3)
co-housing 1 (1)
partner in a co-operative household 1 (1)
‘fly-in, fly-out’worker 1 (1)
foster carers 1 (1)
siblings 1 (1)
Household income (AUD), n (%)
,20 000 6 (6)
20 000 to 49 999 18 (17)
50 000 to 79 999 14 (13)
80 000 to 109 999 18 (17)
110 000 to 139 999 18 (17)
140 000 to 169 999 13 (12)
170 000 15 (14)
not stated 6 (6)
Level of education, n (%)
post-graduate 36 (33)
university 33 (31)
tertiary 20 (19)
high school 18 (17)
,high school 1 (1)
Number of visits to a physiotherapist, n (%)
.10 61 (57)
5 to 10 26 (24)
2 to 4 18 (17)
1 3 (3)
a
Participants were able to select multiple options.
Research 101
Participants’experiences of physiotherapy (qualitative analysis)
Four themes were identified during analysis of the open responses
(see Table 4). Themes were: ‘assumptions’,‘proximity/exposure of
bodies’,‘discrimination’, and ‘lack of knowledge about transgender
health issues’. Participants are distinguished by participant numbers
(eg, ‘P34’).
Theme 1: Assumptions
Many participants mentioned that physiotherapists made as-
sumptions about them. There were two subthemes –assumptions
about sexuality and assumptions about gender identity.
Assumptions about sexuality were that physiotherapists incor-
rectly assumed participants were heterosexual. For example, P32
(female, bisexual) said the physiotherapist had ‘assumed my partner
was male’and another said her physiotherapist ‘assumed I was
straight as I was being treated for a pregnancy-related condition’
(P102, female, lesbian). Reactions to these assumptions were mixed.
Many participants expressed frustration or annoyance - often because
they then felt that they had to either disclose their sexual preference
(and risk discrimination) or lie (and hide aspects of their life). For
example, P81 (male, gay) said: ‘I hate the feeling of having to come
out all the time’and another said she felt awkward having to ‘make a
decision (whether) to come out or not, or if it’s safe to’(P107, female,
lesbian). Other people (fewer) said they were not concerned by these
assumptions: ‘It didn’t bother me, although it is incorrect, it is the
societal norm and people cannot help assuming these things some-
times’(P33, female, bisexual). In contrast, some participants reported
positive experiences when physiotherapists interacted with them in a
way that counteracted assumptions about their sexuality, for
example, P17 (female, queer) said: there was ‘general conversation
about my partner.this helps to normalise things and put me at ease’.
The second subtheme was assumptions about people’s gender
identity. Generally, it was assumed that people fitted into gender
binary categories of male and female. That is, they were assumed to
be ‘cis-gendered’. For example, P38 who identified as ‘non-binary’
and ‘panromantic’experienced assumptions across both subthemes
saying ‘[physiotherapists] assumed I was a cis-gendered heterosexual
girl. Every. Single. Time. That’s the default, until I explain’. In contrast,
assumptions about gender were received positively by transgender
participants when they were assumed to be the gender with which
they identified. For example, one participant said ‘[the
physiotherapist] assumed I was genetic female.as a transgender
female I was pleased by that’(P63, transgender female).
A few participants mentioned assumptions implicit within the
broader physiotherapy environment. For example, P50 (trans/non-
binary, bisexual) said ‘the environment in general wasn’t outwardly
queer- or trans-friendly.there were assumptions that customers
were cis-gender and straight’and P6 (female, queer) she ‘felt like [it
was] an uber heterocentric space’.
Theme 2: Proximity/exposure of bodies
The second theme was proximity/exposure of bodies, which
included subthemes of physical proximity and/or touch, and undressing
and/or observing the body. When physical proximity and/or touch were
part of physiotherapy sessions, some participants expressed a fear of
making therapists of the same gender as them uncomfortable. For
example, P80 (female, lesbian) said ‘massages made me feel hyper
aware about my sexuality. They were strictly professional on her
behalf but I was still anxious that my sexuality might make her un-
comfortable’. Male-identified participants highlighted similar
discomfort, for example, P71 (gender queer male, gay) said ‘It wasn’t
until there was body contact did I become aware/think about my
gender and sexuality.[W]ould this be more comfortable if I was a
straight male?’. Some female-identified participants also mentioned
that they feared sexualisation from male physiotherapists for being
lesbians/women. For example, one participant said she didn’t want to
be ‘.seen as buying into any ‘male lesbian fantasies’’ (P17, female,
queer).
When their body was exposed or observed, participants discussed
perceptions or fears of judgement for not fitting into normative
gender conventions. For example, P30 (fluid) said they ‘presented
female but with unshaven legs [and] when the physio was so distant
and cold in her manner, [they] started to wonder whether she was
homophobic or transphobic’. Some participants reported choosing to
hide their gender identity, for example, ‘when my back was the issue I
would often have to take my shirt off and I’d wear a bra instead of a
binder to avoid questions’(P27, agender). Participants also expressed
concern that their biological sex may be exposed while undressed or
being observed. For example, P20 (transgender male) said he ‘was
worried they would know/discover I wasn’t biologically male [and]
would realise that I have female hips, etc. I didn’t really want to tell
them I was trans.’
Theme 3: Discrimination
The third identified theme was discrimination. There were two
subthemes: reports of discrimination by physiotherapists or other
staff, and the fear of discrimination.Reports of discrimination included
both explicit and implicit discrimination. Explicit discrimination was
reported infrequently, but included overt homophobic remarks, or
repeated misgendering. P39 (male transgender) said ‘despite
repeatedly stating my gender and having my gender legally recog-
nised as male/listed as male in their systems, I was referred to as
‘female’and ‘she/her’by the therapist’and another transgender
participant stated that they told the physiotherapist ‘my pronouns are
not optional. She kept ‘forgetting’despite my beard’(P40). Partici-
pants also experienced implicit discrimination, that is, the frequently
assumed heterosexuality and/or gender discussed in Theme 1 above.
Fear of discrimination was also commonly reported, and related to
both gender and sexuality. For example: ‘I was unsure of whether
they would have an awkward or uncomfortable reaction and didn’t
want to create an uncomfortable situation while I was in a vulnerable
or physically compromised position: flat on my face with my clothes
off, or with the therapist manipulating a painful area’(P50,
transgender/non-binary, bisexual).
Importantly this fear of discrimination resulted in some partici-
pants saying they did not disclose their gender or sexuality, even
when relevant. For example: ‘My gender affirmation surgery causes
many problems in movement and posture, I wanted to tell the
practitioner why, but wasn’t brave enough.[disclosure] would have
explained a great deal about my condition and very likely have
improved the quality of my care’(P32, female).
Table 4
Themes and subthemes identified in the qualitative analysis.
Themes
Subthemes
Description of theme
Assumptions This theme encompasses
participant descriptions of
the assumptions that were
made about their sexuality
and/or gender identity.
Assumptions of sexuality
Assumptions of gender
Proximity/exposure of bodies This theme relates to the
issues that participants
expressed when physiotherapy
included aspects of physical
proximity, touch, undress
and/or observation.
Physical proximity and/or touch
Undressing and/or observing the body
Discrimination This theme encompasses
participant reports of
discrimination, or fear of
discrimination, for being
LGBTIQþ.
Reports of discrimination
Fear of discrimination
Lack of knowledge of transgender health issues This theme encompasses
a lack of knowledge,
understanding or an
over-interest in
transgender-specific
health issues.
no subthemes
LGBTIQþ= lesbian, gay, bisexual, transgender, intersex, queer or related identities.
102 Ross and Setchell: LGBTIQ+ people’s experiences of physiotherapy
Other participants similarly suggested they would have liked to
disclose, but felt it would risk the therapeutic relationship ‘if [the
physiotherapist] wasn’t supportive I would never be able to go back
to him and because his skills are so specialised I have limited options’
(P44, female, bisexual/pansexual).
In contrast, a few participants said they had no fear of discrimi-
nation, for example, ‘I have always felt completely comfortable with
my sexual preferences and gender when seeing my physiotherapist. I
have never been given any reason not to feel this way’(P33, female,
bisexual). One participant clearly articulated the benefits of feeling
safe to discuss their LGBTIQþstatus with their physiotherapist, for
example: ‘We talk about our lives together.physios can be incredibly
healing and inspiring guides to reconnecting with those essential
parts of life’(P16, cis-gender woman, bisexual).
Theme 4: Lack of knowledge about transgender health issues
The final theme was a lack of knowledge or misunderstanding of
transgender-specific health concerns (eg, about hormone therapy,
surgeries, etc). For example, P40 (transmasculine, non-binary guy)
said he believed that he ‘had to educate them and that they were
incorrectly blaming health issues on being trans’. Some participants
expressed significant distress about physiotherapists’over-curiosity,
for example, ‘[it] felt like it had nothing to do with anything and [I]
felt they were being invasive about my personal life’(P34, trans-
masculine, asexual). This was not always the case. One participant
reported a positive experience: ‘my physio took my trans status in his
stride, and otherwise continued to work with me exactly as he had
previously’(P21, female).
Participant’s level of support for strategies to improve care (Likert
scale results)
Participants supported a number of proposed ways to improve
LGBTIQþexperiences with physiotherapy. The degree of support for six
proposed recommendations is presentedin Figure 1. (For the numerical
data used to generate this figure, see Appendix 1 on the eAddenda). The
proposed improvements that the participants particularly supported
were: physiotherapists become more aware of health issues specificto
LGBTIQþpeople (94% ‘like’or ‘really like’idea), physiotherapists un-
dertake LGBTIQþdiversity training (93% ‘like’or ‘really like’idea), and
clinics display images with a range of people of different genders and
sexualities (93% ‘like’or ‘really like’idea). The idea of displaying a
rainbow flag (75% ‘like’or ‘really like’idea) and use of gender-neutral
language (72% ‘like’or ‘really like’idea) were comparatively less well
supported. Some participants expressed ambivalence about displaying
rainbow flags, stating the importance of physiotherapists having ‘a
good understanding of LGBTIQþpeople. I would hate for it to be a token
gesture in place of actual support’(P44, female, bisexual/pansexual).
They also highlighted the complexity of using gender-neutrallanguage,
suggesting that some prefer correct use of their gendered pronouns:
‘some transgender people really like it when they are addressed as the
pronoun that they identify with. This can boost their confidence and
make them feel really good about themselves since it’s something
they’ve been wanting and fighting for, for so long.’(P25, transgender
male).
Discussion
The key finding of this study is that physiotherapy interactions
and environments may lack inclusivity of LGBTIQþpeople. This lack
is inconsistent with national and global policies that advocate for
inclusive and respectful physiotherapy treatment of all people.
29
The
findings highlight that almost all participants reported experiences
relating to at least one of the following themes: ‘assumptions’about
sexuality and gender identity, ‘proximity/exposure of bodies’,
‘discrimination’, and a ‘lack of knowledge of trans health issues’.
Positive experiences were also reported. However, as with any survey
of healthcare experiences, it is possible that people experiencing
challenges were more likely to respond. The findings also suggest a
number of potential ways to improve experiences of physiotherapy
for people identifying as LGBTIQþ.
This study found physiotherapists often made erroneous as-
sumptions about LGBTIQþpeople’s gender and sexuality. These as-
sumptions were aligned with the underlying heteronormativity of
physiotherapy that some participants mentioned, including as-
sumptions that people are heterosexual and conform to a binary
gender. This study shows that, like elsewhere in society,
30,31
hetero-
sexuality and gender normativity are woven into physiotherapy as an
expected and general norm. Assumptions of gender and/or sexuality
are also pervasive elsewhere in healthcare,
32,33
manifesting in a va-
riety of ways as ingrained assumptions within healthcare systems,
including presumptuous use of pronouns, patient forms with male/
female checkboxes only, and assumptions about the need for
contraception.
34–36
Unconscious heteronormative assumptions like
those seen in this study unintentionally result in feelings of invisi-
bility for LGBTIQþpeople,
37,38
and incorrect use of gender pronouns
can be distressing for transgender people and other people with non-
binary gender. Similar to other research findings, participants in this
study supported mechanisms to address these issues, including the
use of inclusive intake forms
16,38–40
(eg, ‘non-binary’being an option)
and a willingness to use gender-neutral pronouns (eg, ‘they’instead
of ‘he’or ‘she’) when appropriate.
Another key finding is perhaps more specific to the physical ther-
apies. The proximity and exposure of bodies during consultation
brought up discomfort for some participants. As transgender and non-
binary people often experience judgement about their bodies,
41
physiotherapy’s intimate nature (touching, undressing, close observa-
tion of the body) may at times render it uncomfortable. Similar
discomfort has been noted in physiotherapy settings with other
‘vulnerable’populations.
23
In order to avoid judgement, participants
sometimes concealed their gender or withheld personal/health
0% 20% 40% 60% 80% 100%
Physiotherapists use gender-neutral language
There is an option for 'non-binary' on forms
Physiotherapy workplaces display a small rainbow flag in the reception area
Physiotherapy clinics' images show a range of people of different genders/sexualities
Physiotherapists receive LGBTIQ+ diversity training
Physiotherapists are more aware of health issues specific to LGBTIQ+ people
Percentage of participants
Proposed recommendation
Really don't like this idea Don't like this idea Not sure about this idea Like this idea Really like this idea
Figure 1. Participant responses to proposed recommendations to improve LGBTIQþpeople’s experiences with physiotherapy. LGBTIQþ= lesbian, gay, bisexual, transgender,
intersex, queer or related identities.
Research 103
information that may have been important for their well-being.
Non-disclosure may impact psychological health
42
and, when rele-
vant to physiotherapy management, could be associated with poorer
physical health outcomes. Self-care improves when people of diverse
gender and/or sexuality feel comfortable to disclose LGBTIQþ
health issues to practitioners.
43
Consistent with other areas of health-
care,
19,35,39,44
the current findings recommend diversity training for
physiotherapists in LGBTIQþ-specific health issues (particularly trans-
gender health) to move towards greater trust for physiotherapists and
their clinics to be considered safe spaces. Although there is a paucity of
physiotherapy-specific resources in this area, there have been recent
developments, including an Australian educational video
45
and non-
academic articles in national physiotherapy publications.
46,47
This study found that many LGBTIQþpeople experienced, or
feared, discrimination related to their sexuality and/or gender iden-
tity while attending physiotherapy. For example, participants re-
ported resistance to use of preferred pronouns. Such discriminatory
behaviour is unacceptable, as both enacted and expected discrimi-
nation have significant negative effects.
48
Fearing discrimination
suggests that physiotherapy may feel like a non-accepting environ-
ment, but may also be related to previous negative experiences or
participants’own anxieties. Although this study is the first to explore
this in physiotherapy, LGBTIQþpeople experiencing discrimination
has been widely reported elsewhere in healthcare.
38,49–53
Despite
legislative advances in many countries,
54
significant gaps remain in
delivering equitable healthcare for LGBTIQþpeople.
55
Access to and
utilisation of healthcare is adversely affected by experiences of
discrimination like those seen in the current study.
44,56,57
The current findings highlight physiotherapists’lack of under-
standing of specific health issues for the LGBTIQþcommunity,
particularly transgender health. A similar lack has frequently been
reported across healthcare professions.
34,58,59
While the complexities
of transgender healthcare and requirement for specialist training are
acknowledged, there is a pivotal role physiotherapists could play,
including in pelvic health.
60
Consistent with other areas of health-
care,
61
participants in the current study strongly supported training
for physiotherapists in issues specific to LGBTIQþhealth. A recent
systematic review of LGBTIQþhealth inclusion in undergraduate and
professional healthcare training
55
highlighted the need for develop-
ment of evidence-based curricula covering terminology, stigma and
health issues specific to LGBTIQþpeople.
62–64
Inclusion of these
recommended areas in undergraduate and professional development
programs offers a way forward to improving physiotherapy experi-
ences of LGBTIQþpeople.
There are a number of methodological considerations when
applying these findings beyond the context of this study. The study
was conducted in Australia, which has relatively progressive laws (eg,
same-sex marriage was legalised in 2017) and attitudes towards
people who identify as LGBTIQþ. The findings are likely to be most
relevant to similar contexts. Further, the recruitment approach
(convenience sample) and uncertainty about uptake rate make it
unclear how common the experiences of physiotherapy reported in
this study are. For example, the results may disproportionately
represent people who are active in online LGBTIQþcommunities or
who access LGBTIQþservices, as these were some of the foci of
recruitment strategies. Nevertheless, with the large sample and di-
versity of participant characteristics, findings are likely to be fairly
representative. It is also possible people who had experienced
problems were more likely to respond to the survey. The study tried
to minimise this effect by using neutral wording in study recruitment
material. Finally, as this study focused on physiotherapy patients and
did not explore the LGBTIQþidentities of physiotherapists, it would
be beneficial to further research how this influences these
encounters.
Conclusion
Physiotherapists provide care for diverse people with unique
healthcare needs. This study’sfindings highlight that people who
identify as LGBTIQþcan experience challenges when attending
physiotherapy. Some people fear receiving, or have experienced,
discriminatory care, which may have negative consequences,
including patients withholding information important to their care,
or avoiding attending physiotherapy. Like any health professional,
physiotherapists have a responsibility to care for the well-being of all
patients, which includes providing a safe environment to discuss all
relevant aspects of their bodies and lives. Improved education of
physiotherapists and implementation of participant-suggested
changes offer ways forward for improving physiotherapy for
LGBTIQþpeople.
What is already known on this topic: Some people who
identify as LGBTIQþreceive suboptimal care in a variety of
health professions, including medicine, nursing, mental health,
and peri-natal care. However, there has been no research to
investigate how people who identify as LGBTIQþexperience
physiotherapy.
What this study adds: People who identify as LGBTIQþcan
experience challenges when attending physiotherapy, such as:
physiotherapists making incorrect assumptions about LGBTIQþ
patients; patients having concerns about revealing some infor-
mation and receiving discriminatory care; and physiotherapists
lacking knowledge about transgender health issues. Physiother-
apists could become more aware of health issues specific to
LGBTIQþpeople and adopt other strategies to make their prac-
tice more inclusive of this population.
eAddenda: Appendix 1 can be found online at DOI: https://doi.
org/10.1016/j.jphys.2019.02.002.
Ethics approval: This study received ethics approval from the The
University of Queensland Human Research Ethics Committee
(2018000797).
Competing interests: Nil.
Source of support: Nil.
Acknowledgements: The researchers would like to thank the
participants and the numerous people and organisations who helped
with study recruitment. Thank you to Laetitia Coles for providing
expert review of the analysis.
Provenance: Not invited. Peer reviewed.
Correspondence: Megan H Ross, School of Health and
Rehabilitation Sciences, University of Queensland, Australia;
Email: megan.ross@uqconnect.edu.au
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