“It’s just as remarkable as being left-handed, isn’t it?”: exploring normativity through Australian physiotherapists’ perspectives of working with LGBTQIA+ patients

ABSTRACT

Introduction

Individuals identifying as lesbian, gay, bisexual, transgender, queer, intersex, asexual and other related identities (LGBTQIA+) experience challenges with healthcare, including physiotherapy. To understand potential contributions to poor experiences, this study explored physiotherapists’ experiences and perspectives about working with members of LGBTQIA+ communities.

Methods

This study employed a qualitative research design, suitable for exploring the experiences and perspectives of individuals within the physiotherapy context. The sample consisted of physiotherapists working in Australia who participated in a larger survey study. Data were collected via semi-structured interviews which were audio-recorded and transcribed verbatim. Data analysis was conducted using a relativistic and queer theoretical framework with a reflexive thematic approach.

Results

Eighteen physiotherapists with diverse sexual orientations participated in the interviews. While all participants identified as women or men, not all used binary gender pronouns. Five key themes were developed: 1) “anti-discrimination” regarding choice of language and providing safe environments; 2) “current and historical discrimination” against LGBTQIA+ individuals; 3) “taking an equality approach” when working with LGBTQIA+ patients; 4) “knowledge of LGBTQIA+ health” in a broad sense and specifically with transgender and gender-diverse people; and 5) “managing own reactions” with respect to individual biases and discomfort.

Conclusion

Underpinning all themes was the overarching concept of cis/hetero/endonormativity. Assuming normativity when working with LGBTQIA+ patients, is likely to have negative effects on patients’ mental health, the therapeutic relationship and quality of care. In order to improve diversity, safety, inclusion and equity of care for LGBTQIA+ individuals, it is vital that normativity within physiotherapy is challenged.

KEYWORDS:

• Gender identity
• healthcare disparities
• physical therapists
• sexual and gender minorities
• social discrimination

Introduction

Despite increasing social acceptance and visibility for people with lesbian, gay, transgender, queer, intersex, asexual and other related identities (LGBTQIA+) in Australia, health disparities still exist (Perales and Campbell, 2019). Members of these communities have disproportionately high rates of cancer, physical inactivity, asthma, and cardiovascular disease compared to cis/heteronormative populations (Fredriksen-Goldsen et al., 2013; Mereish and Poteat, 2015) as well as higher rates and risks of anxiety, depression, self-harm and suicide (Cochran et al., 2007; Haas et al., 2010; McNeil, Ellis, and Eccles, 2017). To address health inequities, the Australian government has implemented various strategic plans for: physical health (NSW Ministry of Health, 2022; Victoria State Government, 2022); mental health and suicide prevention (National LGBTI Health Alliance, 2016); and drug and alcohol use (Commonwealth of Australia Department of Health, 2017). Although these policies and strategies exist (Healthy People, 2020) yet LGBTQIA+ communities continue to face discrimination in healthcare settings (Ayhan et al., 2020; Romanelli and Hudson, 2017) creating an additional barrier to good health.

Barriers to accessing culturally appropriate healthcare occur at both individual and system levels for LGBTQIA+ communities. At the individual level stigma, fear including internalized homophobia, and previous experiences of discrimination (Alencar Albuquerque et al., 2016; Ayhan et al., 2020; Romanelli and Hudson, 2017) can contribute to reluctance to disclose identity, delay in accessing services, and receiving sub-optimal care (Mayer et al., 2008). Practitioners’ knowledge, attitudes and beliefs toward LGBTQIA+ individuals can also contribute to: explicit and implicit discrimination (Quinn et al., 2019); healthcare access; and individuals’ health (Romanelli and Hudson, 2017). At the system level, barriers to culturally appropriate care include inequitable treatment of LGBTQIA+ communities through healthcare and social services and policies for example gender-binary intake forms, policies that do not recognize same-sex partners, denial of health insurance coverage due to same-sex relationship (Romanelli and Hudson, 2017; Smith and Turell, 2017) and the lack of LGBTQIA+ content in healthcare curricula (Tollemache, Shrewsbury, and Llewellyn, 2021). Societal stigma and cis/heteronormative assumptions in the healthcare context are likely to underpin negative healthcare experiences (Klein and Elboim-Gabyzon, 2021; Sabin, Riskind, and Nosek, 2015), avoidance of preventative health services and contribute to the health disparities experienced by LGBTQIA+ communities (Kitts, 2010).

Challenging cis/heteronormativity in the healthcare context and addressing gaps in practitioner knowledge may improve experiences of healthcare for individuals with LGBTQIA+ identities and experiences. Practitioner knowledge, attitudes and beliefs have predominantly been explored among nursing and medical students and professionals (Carabez et al., 2015; Ussher et al., 2022; Wahlen et al., 2020). This research highlights gaps in knowledge and education about LGBTQIA+ health needs and the relevance of diverse gender identities and sexual orientations to healthcare (Ayhan et al., 2020; Carabez et al., 2015; Kitts, 2010; Shetty et al., 2016). Health practitioners lack knowledge about transgender and gender diverse health and have limited knowledge about health prevention strategies specific for LGBTQIA+ communities (Shetty et al., 2016; Ussher et al., 2022; Wahlen et al., 2020). Some healthcare practitioners also believe that gender and/or sexual identity is not relevant to their area of practice (Carabez et al., 2015; Kitts, 2010; Shetty et al., 2016). This belief may lead to avoiding inquiry about diverse identities or making errors (Shetty et al., 2016; Ussher et al., 2022). Despite similarities, it is likely there are nuances related specifically to the physiotherapy context that are not addressed in the existing research.

There are a limited number of studies that have explored the intersection between LGBTQIA+ identities and experiences with physiotherapy. A study conducted in Israel found that physiotherapists’ own gender, sexual orientation and religiousness may affect attitudes toward LGBTQIA+ individuals (Klein and Elboim-Gabyzon, 2021). In a US study, more than half of participating physiotherapists indicated they had between very low and average knowledge about LGBT health and that the majority were “tolerant” rather than “respectful” of LGBT individuals (Burch, 2008). Research also suggests that students studying physiotherapy report a lack of educational curricula around LGBTQIA+ issues and concurrently have a perceived lack of knowledge about LGBTQIA+ health (Areskoug-Josefsson and Gard, 2015; Brenner et al., 2022; Watts and Sampanis, 2022). Despite these gaps in knowledge, many physiotherapy students and professionals hold non-rejecting views (Burch, 2008) and positive attitudes toward members of LGBTQIA+ communities (Brenner et al., 2022; Klein and Elboim-Gabyzon, 2021). While this is positive, healthcare professional comfort may not always translate into comfort and perceived competency from a patient perspective.

From the perspective of LGBTQIA+ individuals, many describe negative experiences impacting quality of and satisfaction with healthcare. Notably, individuals describe microaggressions, perceived discomfort of health professionals, overt discrimination, misgendering, and erroneous assumptions when accessing healthcare (Quinn et al., 2019; Romanelli and Hudson, 2017; Smith and Turell, 2017). While these experiences with other areas of healthcare are likely similar; there are also unique contextual challenges related to body-focussed professions such as physiotherapy (Ross and Setchell, 2019). When accessing physiotherapy, LGBTQIA+ individuals face additional challenges, including concern with disclosure of identity or misgendering due to physical proximity, observation of the body, touch and undressing, and physiotherapists’ lack of knowledge about LGBTQIA+ specific health needs, and particularly transgender and gender diverse health needs (Ross and Setchell, 2019).

With research highlighting the healthcare experiences for LGBTQIA+ individuals, it is important to explore how physiotherapists perceive working with members of this community. To our knowledge, there is no research that explores physiotherapists’ perspectives on, and experiences of, working with LGBTQIA+ persons in Australia. Addressing the dearth of research within physiotherapy and LGBTQIA+ healthcare, the aim of this study is to explore how physiotherapists in Australia experience working with members of the LGBTQIA+ community. Understanding physiotherapists’ perspectives will facilitate the development of targeted strategies to improve healthcare provision for LGBTQIA+ people.

Methods

Design

This study was based on interviews of a subsample from an online survey study of physiotherapists and their experiences, attitudes and knowledge pertaining to LGBTQIA+ communities and healthcare needs in the context of physiotherapy (Ross and Setchell, 2021). The study employed a qualitative research design, suitable for exploring the experiences and perspectives of individuals within a specific context, and was underpinned by relativism, informed by queer theory. A relativistic framework is a theoretical perspective that emphasizes the relative nature of knowledge and understanding; that is that knowledge is constructed and interpreted through social and cultural contexts, and that there is no single objective or absolute truth (Braun and Clarke, 2013). Queer theory is a critical framework that challenges normative assumptions about gender and sexuality, and examines the ways in which power and privilege shape these identities and experiences (Sullivan, 2003). With these underpinnings, we sought to understand and critique the ways in which societal norms, power structures and perspectives shape the way or ways in which physiotherapists in Australia experience working with members of LGBTQIA+ communities. The research team included physiotherapist-researchers and a physiotherapy student who all identify as part of the LGBTQIA+ community. The study was approved by the Institutional Human Research Ethics Committee (approval #: 2020000770).

Participants and procedures

Physiotherapists currently practicing in Australia were invited to participate in an interview upon completion of an online survey. Those who opted-in (n = 28) were contacted to provide additional information, obtain consent and to schedule the interview. We conducted semi-structured interviews with physiotherapists working across varying clinical areas to obtain more in-depth insights about how attitudes and beliefs about working with LGBTQIA+ communities do, or do not, play out in clinical practice. Iterative analyses during data collection determined participant numbers; when there was sufficient repetition and depth in the data, recruitment and data collection ceased. Participants were interviewed by a physiotherapy student trained in semi-structured interviewing and unknown to the participants. Demographic data including gender identity, sexual orientation, and pronouns were collected verbally at the beginning of the interview. All interviews were conducted online via conferencing software (Zoom) between December 2020 and February 2021, audio recorded and transcribed verbatim.

Analysis

Data were analyzed qualitatively using reflexive thematic analysis as outlined by Braun and Clarke (2013) using a relativistic and queer theoretical framework (McCann and Monaghan, 2020). This involved analyzing the data through the lens of social constructivism and recognizing that all knowledge is constructed through social interactions and is therefore relative. All members of the research team identify as part of the LGBTQIA+ community and were sensitive to normative assumptions and open to engaging multiple and conflicting worldviews of gender identity and sexual orientation (Bosia et al., 2019). Data analysis involved five iterative stages. First, CN read the entire interview transcripts and recorded preliminary notes in relation to the study aim. Then, CN re-read the dataset to create initial codes and organize into preliminary themes, continuously refining analyses in the context of the entire dataset. Next, all authors discussed the analyses to further refine the themes and subthemes. CN then coded all data to fit within these themes and subthemes. The last step involved the authors discussing final refinements to analyses. Any conflicting ideas were included in the reporting. The study followed the guidelines for quality analysis in reflexive thematic analysis (Braun and Clarke, 2021).

Results

Participants

A total of 18 physiotherapists (65%) were interviewed. Participants were between 25–55 years of age, all identified as women (56%) and men (44%). Although we invited participants to describe their gender in an open text box, none chose to add other gender identities such as non-binary or trans. Physiotherapists had between three and 35 years clinical experience across musculoskeletal (44%), sports (22%), and pelvic health (22%) settings (Table 1). Participants reported their sexual orientation to be heterosexual/straight (50%), gay (22%), gay/lesbian (17%), bisexual (5.6%) or pansexual (6%).

Table 1. Participant characteristics.

Characteristic	Participants (n = 18)
Age (years), median, range	33, 25–55
Gender Identity, n (%)
Woman	10 (56)
Man All other identities	8 (44)0 (.0) 0 (0.0)
Relationship status, n (%)
Married	9 (50)
Partnered	4 (23)
Single	2 (11)
Engaged	1 (6)
In a relationship	1 (6)
Separated	1 (6)
Pronouns, n (%)
He/him	8 (44)
She/her	6 (33)
She/her, they/them	3 (17)
Mrs	1 (6)
Sexual orientation, n (%)
Heterosexual/straight	9 (50)
Gay man	4 (22)
Gay woman/lesbian	3 (17)
Bisexual	1 (6)
Pansexual	1 (6)
Clinical experience (years), median, range	11, 3–35
Geographical location, n (%)
Large city	12 (67)
Regional	6 (33)
Area/subdiscipline, n (%)
Musculoskeletal	8 (44)
Sports	4 (22)
Pelvic health	4 (22)
Rehabilitation	3 (17)
Orthopaedics	2 (11)
Other	5 (28)
Site of practice^a, n (%)
Private	10 (56)
Hospital	8 (44)
University	2 (11)
Other	4 (22)
Highest obtained level of education, n (%)
Masters/postgraduate	8 (44)
Bachelor ± Honours	6 (33)
PhD	4 (22)

^aParticipants were able to select multiple options.

Thematic analysis

Five themes and a number of subthemes were formed through our analysis of the interviews (Table 2). Themes were: 1) “anti-discrimination” with respect to language chosen with patients and providing safe environments; 2) “current and historical discrimination” against LGBTQIA+ people; 3) “taking an equality approach” to working with LGBTQIA+ patients; 4) “knowledge of LGBTQIA+ health” broadly and specifically in relation to gender-diverse health; and 5) “managing reactions” including their potential biases and judgment and their own discomfort. Physiotherapists who identified as part of the community appeared to have more insight into LGBTQIA+ health issues and relevance to physiotherapy treatment; however, there were also some non-LGBTQIA+ allies who also had considerable insight into issues faced by the LGBTQIA+ communities.

Table 2. Themes and subthemes produced in the analysis of participating physiotherapists.

Themes Subthemes	Description
Anti-discrimination Language choice Providing a safe physical environment	Encompasses perspectives that anti-discrimination practices are important, and some uncertainty about how to enact them appropriately. Perceived importance of using appropriate and sensitive language with LGBTQIA+ patients to avoid discrimination. Uncertainties physiotherapists’ described about how to approach this.Physiotherapists’ understanding of providing safe environments for LGBTQIA+ clients. Included displaying flags in clinic, having inclusive intake forms and being sensitive to body exposure. Physiotherapists’ uncertainty about whether “advertising” that they are LGBTQA+ friendly is necessary.
Physiotherapists’ understanding of LGBTQIA+ discrimination	Encompasses physiotherapists’ understanding of discrimination that has and continues to exist for LGBTQIA+ communities in general society, as well as healthcare contexts. There were no subthemes.
Taking an equality approach	Physiotherapists’ approach to providing equal treatment for all patients, including those who identify as LGBTQIA+. Uncertainties physiotherapists described about how, and why it is necessary, to provide equitable, rather than equal, care. There were no subthemes.
Knowledge of LGBTQIA+ health	Encompasses a lack of knowledge and understanding of broad LGBTQIA+ needs and those pertaining specifically to people who are transgender and/or gender diverse.
Health needs of LGBTQIA+ communities	Physiotherapists’ levels of understanding about LGBTQIA+ health needs, and the relevance to physiotherapy practice, as well as their perspectives of the intersection between LGBTQIA+ identity and mental health/social stress.
Specific health needs of gender-diverse people	Physiotherapists’ understanding of importance to gain more knowledge relating to transgender and gender diverse health needs.
Managing own reactions	Physiotherapists descriptions of managing their own reactions were related to two key areas; managing their own inherent biases and judgment, and managing their feelings of discomfort.
Managing biases and judgment	Physiotherapists reflected on instances in which they had to manage their own biases and reactions about LGBTQIA+ identities and acknowledged the need for and importantance of being reflexive in clinical practice.
Managing feelings of discomfort	Physiotherapists described situations where they felt uncomfortable during interactions with clients who identify as LGBTQIA+ and the potential impact these feelings may have on therapeutic relationships.

LGBTQIA+ = lesbian, gay, bisexual, transgender, queer, intersex, asexual or related identities.

Theme 1: anti-discrimination

This theme describes participating physiotherapists experiences of, and perspectives about, actively using anti-discrimination practices to support the LGBTQIA+ community. There were two subthemes: 1) choice of language with LGBTQIA+ clients; and 2) providing a safe environment.

Choice of language with LGBTQIA+ clients

Physiotherapists described the importance of choosing appropriate terminology when working with LGBTQIA+ communities, primarily in relation to gender pronouns and assumptions about partners’ genders. For example, Rene (40, female, lesbian) said:

… Since I’ve been treating the LGBTQIA community, I tend to not use binary sex terms anyway. I will use they/them quite often because then there’s less chance of misidentifying.

Other physiotherapists were more uncertain how to ask patients about their gender identity, with one participant saying:

I don’t really know how to do it in a nice way and in an appropriate way. (Liam, 33, male, heterosexual)

Despite uncertainty about how to use inclusive and appropriate language with LGBTQIA+ clients, almost all physiotherapists identified that it is an important aspect of anti-discriminatory practices.

Providing a safe physical environment

Physiotherapists described a range of strategies they use to create safe environments for LGBTQIA+ communities. Strategies included displaying flags that represent allyship and inclusion for the LGBTQIA+ community in clinics, not being overcurious, having “other” as an option for gender identity on intake forms, leaving the room when a patient is undressing and being sensitive to body exposure and touch. Many physiotherapists recognized that it was their responsibility to provide a safe environment when asking about LGBTQIA+ identity. While Zane described that it was his responsibility:

… to make the place safe before you can start asking the questions (31, male, gay)

Other physiotherapists were uncertain about how to provide safe environments appropriately and sensitively.

Grace recalled reading:

… about making sure that you’ve got a little rainbow flag visible, but then I’m not sure if that seems like you’re pandering … . (46, female, heterosexual)

Others did not see the need for visible displays of inclusion but were not opposed to it:

I don’t feel like we need to internalized it, but I would be happy to … . (Harriet, 35, female, heterosexual)

These perspectives and providing a safe environment were related to the importance of anti-discrimination practices when working with individuals who identify as LGBTQIA+.

Theme 2: physiotherapists’ understanding of LGBTQIA+ discrimination

This theme encompasses physiotherapists’ understanding of current and historical discrimination against LGBTQIA+ communities, and how this can impact present interactions with healthcare professionals and services. Many physiotherapists recognized social discrimination and the subsequent psychosocial impacts from coming out, bullying and not being accepted. Liam (33, male, heterosexual) said that:

I suppose social discrimination is probably… I would have hoped things have improved but I would imagine that could be a difficult thing for people, if there’s discrimination and bullying and things going on in their life.

Another participant reflected on the importance of this understanding:

I think actually trying to even just [gain] the basic understanding that people who don’t identify as heterosexual, the history and the underlying fear or worry of not being accepted or treated equally … is another important thing to understand. (Finley 28, male, gay)

A smaller number of physiotherapists had a more nuanced understanding of historical discrimination. These physiotherapists acknowledged the historical pathologization of diverse sexual and gender identities, and the HIV/AIDS pandemic. For example, as a member of the community, Eliza (50, female, lesbian) felt that she was:

… just used to [LGBTQIA+ identity] being frowned upon in society … Especially in the 80s when all the AIDS stuff came out, HIV, and a lot of their young men were infected and dying of that.

These discussions exposed the varying levels of knowledge about current and historical discrimination, and the impact on experiences of healthcare for individuals who identify as LGBTQIA+.

Theme 3: taking an equality approach

This theme relates to physiotherapists’ perceptions that the “right” approach is to treat everyone the same, without providing extra care or sensitivity. These physiotherapists explained the importance of treating everyone the same, despite differing, and intersecting identities and experiences. For example, one participant said:

I’d like to think that I treat all people equally, irrespective of their background …. (Frank, 51, male, heterosexual)

This perspective also included ideas that physiotherapy, as a healthcare profession, requires impartial and equal provision of care to everyone, for fear of appearing judgmental if this was not done. An example of this is demonstrated by Mark, when he described being:

wary to make a deal of someone’s sexual orientation … because I wouldn’t want them to feel that I was making any sort of judgement or that I was treating them differently because of that. I try to treat everyone equally. (Mark, 50, male, heterosexual)

Despite good intentions, this perspective was underpinned by a lack of understanding of systemic inequalities and the need for equitable approaches to healthcare. Other physiotherapists recognized this and demonstrated a higher level of knowledge and understanding, by describing that they treat every patient differently, to work toward providing equal outcomes for people who have experienced marginalization. For example, Luke said:

I treat every patient differently. Unfortunately, with this population sometimes, it’s that equity versus equality. You want to strive to treat everyone equally; however, there are some groups that, in order to be equitable, you have to do more for them … (32, male, heterosexual)

The equity approach discussed by Luke demonstrates an understanding that people’s different experiences, identities and backgrounds may require additional or modified care to achieve the same outcomes and was recognized by only some physiotherapists in this study.

Theme 4: knowledge of LGBTQIA+ health

This theme describes physiotherapists recognizing their lack of knowledge pertaining to LGBTQIA+ specific health needs. There were two subthemes: 1) broad LGBTQIA+ health needs; and 2) specific health needs of gender diverse people.

Health needs of LGBTQIA+ communities

This sub-theme relates to physiotherapists’ discussions about knowledge of broad LGBTQIA+ health needs, and how that may relate to physiotherapy treatment. These discussions tended to revolve around being uncertain what constitutes an LGBTQIA+ health need, feeling ill-equipped to address LGBTQIA+ health needs if they arose and relevance to physiotherapy from the psychosocial perspective. Many physiotherapists said they were unsure what specific health needs of LGBTQIA+ communities are, and that this influenced their perceived competence. For example:

I don’t know what their specific health needs are, and so I don’t know whether I am equipped or ill-equipped to deliver them” (Casey, 31, male, heterosexual). Another participant said: “I suppose that means that if I have come across it [instances of LGBTQIA+ specific health needs] clinically, then I’ve been wonderfully ill-equipped”. (Liam, 33, male, heterosexual)

Perceptions about whether LGBTQIA+ identity is relevant to physiotherapy were mixed. Some physiotherapists did not think it was relevant at all:

The majority of people that I’ve seen would be lesbian or gay, or bi … it’s just as remarkable as being left handed, isn’t it?. (Grace, 46, female, heterosexual)

Others described that it was only relevant to physiotherapy from the psychosocial perspective. Many physiotherapists discussed psychological impacts relating to gender and/or sexual identity, including depression and anxiety, where identity has:

… impacted their psychological wellbeing.” (Mark, 50, male, heterosexual)

In terms of social stressors, several physiotherapists identified discrimination, bullying and workplace or family stressors that may impact the social wellbeing of LGBTQIA+ individuals. Brooklyn highlighted that there are social challenges for LGBTQIA+ individuals in conservative regions, which may include:

… bullying in the workplace. (Brooklyn, 32, female, heterosexual)

Challenges with acceptance from family members was highlighted by Eliza, who said:

I’ve got friends that were kicked out of home. So, it [growing up as LGBTQIA+] can and still is, I think, traumatic for some people. (50, female, lesbian)

Physiotherapists had varying levels of knowledge and understanding about broader aspects of health and wellbeing that may be relevant to LGBTQIA+ communities.

Specific health needs of gender diverse people

While physiotherapists could recognize the relevance of physiotherapy for trans and gender diverse health, their understanding of gender diverse specific health needs was limited. Physiotherapists acknowledged the importance of understanding gender diverse health needs, but also identified their own lack of knowledge and skills. Common areas in which physiotherapists felt their knowledge was limited included correct use of pronouns, gender affirming surgeries, hormone therapy and perceived complexity of gender identity. For example, Dean said:

I think there are challenges that are unique to the transgender community, that I wouldn’t feel like I am a hundred percent across … I think there would be things that I’m aware of, but I’m not confident in addressing. Things like your pronouns, gender identity, potentially body issues if they were transitioning. (33, male, gay)

When discussing how approaching treatment with a transgender client may differ to other members of the LGBTIQA+ communities, Luke said:

that it is more complex to discuss… I don’t know. It’s just because of the whole gender identity thing adds another layer. (32, male, heterosexual)

This was not always the case. A few physiotherapists who appeared to have clinical experience working with trans and gender diverse individuals were able to identify the importance of modifying care for these clients. For example, this was demonstrated by Rene, who said

… just because someone’s taking testosterone and they feel stronger and they’re bulking up quicker … we still have to take it slower … than a man that has been assigned male gender at birth … . (40, female, lesbian)

It was rare that physiotherapists demonstrated this higher level knowledge on gender diverse health; however, some physiotherapists identified the relevance to physiotherapy and expressed an interest in training and further education in this area.

Theme 5: managing own reactions

This theme encompasses physiotherapists’ discussions about how they manage their own reactions of judgment and discomfort when working with LGBTQIA+ people. There were two subthemes: 1) managing biases and assumptions; and 2) managing feelings of discomfort.

Managing biases and assumptions

This sub-theme describes how physiotherapists approached consciously managing their own biases and assumptions when working with people who are part of LGBTQIA+ communities. Physiotherapists described working to challenge a range of ingrained cis/heteronormative assumptions that they noticed in their thinking. For example, Luke reflected that in the past, when meeting a young homosexual man, he had once thought:

“Oh, were they hitting on me? … ” and explained that he was “ … not proud of it … .” (32, male, heterosexual)

Another participant described making:

… a conscious effort to remind myself, because I knew that if I wasn’t thinking hard about it, I would look at the patient and think, you look quite masculine, I’m going to call you a him or he. (Taylor, 27, female, pansexual)

Rene (40, female, lesbian) also described that to avoid making assumptions, it is:

really the background processing of the clinician that is different when working with LGBTQIA+ clients is.

In these efforts to challenge biases and assumptions, these physiotherapists demonstrated reflexive practice, which is an important aspect of providing culturally responsive care.

Managing feelings of discomfort

This sub-theme describes physiotherapists navigating their feelings of discomfort when working with individuals who identify as LGBTQIA+. This included discomfort during client interactions, reflecting on the cause of discomfort and the idea of discomfort being a useful way to engage in reflexivity. Frank reflected on taking a client who was positive for human immunodeficiency virus (HIV) though a hospital procedure to obtain a sputum sample (for pneumocystis pneumonia; PCP) and recalled feeling:

… apprehensive and uncomfortable about being required to carry out these tests. (51, male, heterosexual)

Frank said he was:

… ashamed to admit that I was not as compassionate with those men as I should have been and that his apprehension and discomfort was not because I had any specifically deep rooted homophobic views or thought processes, but that I was caught up in the in the whole vilification of the gay male community as being a significant spreader [of HIV at the time]. (51, male, heterosexual)

Frank further reflected on the HIV pandemic, saying there were:

… even government television advertising campaigns that had images of the Grim Reaper bowling a ball down an alley with young kids and families and stuff set up as the as the pins that were being knocked over at the end … . it was designed for shock value … But also had this secondary effect, a quite significant vilification effect of that particular [group] in the community. (Frank, 51, male, heterosexual)

Although rare, some physiotherapists conceded that their own feelings of discomfort during interactions with LGBTQIA+ clients were likely to stem from their social attitudes and beliefs about gender and/or sexual orientation (e.g. trans/homophobia). These physiotherapists described engaging in critical thinking, identifying the root of their discomfort and reflexively challenging these beliefs to improve future interactions. For example, Luke said that:

If I’m uncomfortable in a situation like that, [I question] what is it that’s making me uncomfortable. Am I uncomfortable in myself, my own hegemonic masculinity, or my own viewings of myself or that population?. (32, male, heterosexual)

In this way, physiotherapists described a deeper process of reflection, examining the potential impact of their own actions, thoughts and feelings of discomfort on the client and themselves (Cunliffe, 2009). This reflexive practice can have a positive impact on interactions as it will likely reduce the potentially negative impacts of physiotherapists’ ingrained biases. For example, one participant described understanding the impact physiotherapists’ own feelings of discomfort can have on the therapeutic relationship. Harriet said:

Often I think physios can feel uncomfortable and then that can block the subjective and the treatment and the relationship between the patient and the physio … (35, female, heterosexual).

Acknowledging these potential impacts on interpersonal relationships and clinical outcomes is an important aspect of improving experiences of physiotherapy for individuals who identify as LGBTQIA+.

Discussion

This is the first study to interview physiotherapists about their experiences and perspectives of working with individuals who identify as LGBTQIA+. Despite a general desire to provide culturally competent care, physiotherapists may interact in ways that lack sensitivity and inclusion. Interviewed physiotherapists described experiences and perspectives relating to at least one of the following themes: using “anti-discrimination” practices during interactions with LGBTQIA+ patients, “current and historical discrimination” against LGBTQIA+ communities, “equity versus equality” for LGBTQIA+ patients, “knowledge of LGBTQIA+ health” and “managing reactions” when working with LGBTQIA+ patients. The findings also highlight potential strategies to improve experiences of physiotherapy for people identifying as LGBTQIA+.

The results of this study speak broadly to two overarching concepts in the physiotherapy context. First, is the desire to do the “right thing.” Physiotherapists in our study spoke to themes and subthemes of antidiscrimination, equality, inclusive language, and knowledge about LGBTQIA+ health. Despite this desire, pervasive cis/het/endonormativity also underpinned all themes, and physiotherapists were unsure how to navigate this. Underlying normativity has been identified in other research exploring LGBTQIA+ identities in the context of physiotherapy. Studies of LGBTQIA+ physiotherapists working in the profession (Ross et al., 2022); attitudes and beliefs of physiotherapists in the USA and Israel about LGBTQIA+ communities (Burch, 2008; Klein and Elboim-Gabyzon, 2021); students in the UK and Sweden (Areskoug-Josefsson and Gard, 2015; Brenner et al., 2022; Watts and Sampanis, 2022); and physiotherapy clients with LGBTQIA+ identities and experiences (Ross and Setchell, 2019) have highlighted the pervasive cis/hetero-normativity within the profession. This speaks to pervasive normativity within the physiotherapy profession, rather than it being context specific. Despite differing geographical locations, varied legislation to protect LGBTQIA+ communities, and current social and political trends (i.e. legalization of same-sex marriage and the anti-trans rhetoric in North America) these studies highlight that like other healthcare professions (Morrison and Dinkel, 2012; Mulé et al., 2009) physiotherapy sits within a cis/hetero/endonormative medical model. A biomedical model is an approach to health that prioritizes the material (i.e. body) and overlooks the complex and overlapping social (i.e. identity) determinants that influence inequitable health and access to healthcare (Daley and MacDonnell, 2011). This approach may contribute to negative perceptions about, and experiences for, LGBTQIA+ individuals with physiotherapy systemically, despite attitudes and beliefs held by individual physiotherapists.

Understandably, assumptions of normativity have implications for clinical practice. Each theme described in this study may impact experiences of physiotherapy for LGBTQIA+ individuals and influences how physiotherapists work with the community. Physiotherapists described making assumptions about gender identity, family composition and sexual orientation, including the use of incorrect pronouns, misgendering and using exclusive intake forms (Morrison and Dinkel, 2012; Ross and Setchell, 2019). Individuals who experience implicit discrimination through erroneous assumptions, underpinned by cis/heteronormativity, can subsequently feel invisible and alienated (Fish and Bewley, 2010; McGeorge and Carlson, 2011; Quinn et al., 2019). These experiences can be particularly distressing for people who are transgender, non-binary or gender diverse. These negative experiences, and those where healthcare professionals enact implicit and explicit biases, create barriers to accessing care and can often result in unsafe situations and lead to break-downs in therapeutic relationships (Byrne and Tanesini, 2015; FitzGerald and Hurst, 2017; Quinn et al., 2019). These sequelae of cis/heteronormative assumptions contribute to the health disparities that exist in LGBTQIA+ populations (Kitts, 2010). Physiotherapists in this study demonstrated an understanding of what constitutes anti-discriminatory practice with respect to language and assumptions. Most physiotherapists understood that misgendering is harmful but described feeling uncomfortable asking questions about gender identity, so they did not appear insensitive or judgmental. To avoid their own discomfort, physiotherapists described a blanket-use of gender neutral language, which is not always appropriate (e.g. many trans men and women prefer the use of gender-affirming pronouns) (Ross and Setchell, 2019). Without subsequently modifying language to ensure use of correct pronouns, health professionals may neglect aspects of care that are important to some patients (Rossi and Lopez, 2017). To address the uncertainty around obtaining and using gender-affirming language, reducing implicit bias and stigma and knowledge of LGBTQIA+ health (McCann and Brown, 2018; Sekoni et al., 2017; Vela et al., 2022), evidence based training for physiotherapists should include both didactic learning and case-based simulations to facilitate application of knowledge in practice (Hagen and Galupo, 2014; Ross and Setchell, 2019). Targeted LGBTQIA+ educational interventions should be provided for physiotherapists, and subsequently measured for effectiveness in improving knowledge and provision of affirming care.

Physiotherapists in this study expressed the importance of providing equal care for all patients, regardless of sexual orientation, gender, race and socioeconomic status. Consistent with the desire to do the right thing, an approach that focuses on equality, rather than equity is likely to result in unequal outcomes for marginalized populations, even if this is unintentional. Equal treatment that focusses on applying the same processes and procedures to all patients may result in neglect of individual patient needs and produce inequitable health outcomes as a result (Smith and Turell, 2017). Conversely, healthcare that promotes equity, rather than equality, aims to reduce and eliminate health disparities resulting from marginalization through the means of high quality, and patient-centered care (Braveman, 2014). At times this means that marginalized groups who face increased risk of poor health may need particular attention and/or alternative treatment approaches in order to attain the highest possible standard of health (Braveman, 2014). Despite physiotherapists in this study reporting they approach touch, disrobing and observation sensitively across all population groups, LGBTQIA+ individuals have reported discomfort in such situations (Ross and Setchell, 2019). Discomfort about these aspects of physiotherapy have been reported by other populations where judgments may be made about a patient’s body (Setchell, Watson, Jones, and Gard, 2015) and speaks to situations that may require different (but not higher/lower quality) approaches to care. Physiotherapists who are aware of, and sensitive to these situations are likely to apply alternative, patient-centered approaches and may improve comfort and safety in physiotherapy interactions for LGBTQIA+ individuals.

Healthcare that is affirming and inclusive has positive impacts on mental health, and contributes to greater undertaking of preventative health measures (McKay, Tran, Barbee, and Min, 2023). Physiotherapy care that is inclusive and affirming is similarly likely to address negative experiences of physiotherapy reported by LGBTQIA+ patients (Ross and Setchell, 2019) and may contribute to better overall health and wellbeing. Despite physiotherapists reporting that they lack specific LGBTQIA+ health knowledge, the ability to provide inclusive and affirming care does not require specialist clinical knowledge. Cultural safety training for LGBTQIA+ communities may help develop physiotherapists’ capability to provide patient-centered, gender-affirming care, that is accepting of, and sensitive to, diverse identities, experiences, and patient needs. Cultural safety requires acceptance and sensitivity of diverse identities, experiences, and needs, as well as reflexivity to challenge one’s own unconscious biases and assumptions. Patient-centered and gender-affirming care can, and must, be provided by all physiotherapists regardless of knowledge of LGBTQIA+ specific health needs or specialist clinical area.

The findings of this study should be considered within context. Data were collected from physiotherapists practicing in Australia, where institutional factors (i.e. same-sex marriage and anti-discrimination policies) and societal attitudes toward LGBTQIA+ communities are relatively progressive. As such, findings from this specific geographical and cultural context are most applicable and relevant to contexts with similar institutional policies and societal attitudes. Another consideration is the use of a convenience sample for participant recruitment; physiotherapists who are active in LGBTQIA+, research and/or advocacy may be overrepresented in the sample. It is possible participating physiotherapists had a higher than usual level of knowledge and experience working with LGBTQIA+ clients, and the positive attitudes of physiotherapists in our study may be due to the greater representation of LGBTQIA+ identifying physiotherapists in our sample compared to Australian population estimates (Australian Bureau of Statistics, 2018; Wilson, Temple, Lyons, and Shalley, 2020). Ultimately, this may have contributed to greater knowledge and more inclusive perspectives, attitudes and beliefs. The diversity of participant demographics and characteristics, however, likely inform fair representation of the broad physiotherapy profession. Finally, researchers’ own perspectives will have influenced data collection and analysis although our positioning as both physiotherapists (or physiotherapy students) and from different parts of the LGBTQIA+ spectrum would have added some complexity. The theoretical lens we used brought a particular perspective to the research. Queer theory was used to understand and analyze the experience and perspectives of physiotherapists (i.e. it considers marginalization and oppression). The methodological approach recognizes that there may be different perspectives and constructions of the knowledge and experiences and that the researchers own perspective will influence the data collection and analysis.

Conclusion

The physiotherapists in this study demonstrated some understanding of anti-discriminatory approaches when working with LGBTQIA+ patients, and a desire to do the right thing. Despite this, many were uncertain about how to approach aspects of sexual orientation and gender-affirming care, and treated patients equally rather than equitably. As the healthcare professional, it is the responsibility of the physiotherapist to create a welcoming environment and provide safe, affirming care for all patients, including LGBTQIA+ patients. To improve the cultural safety and healthcare outcomes of LGBTQIA+ patients, education for physiotherapy students and professionals, as well as further research into knowledge gaps must be addressed.

Acknowledgments

The authors would like to thank Tami-Lorrie Dawson for conducting the interviews and the participants for their contribution to the study. This research is funded by a 2019 Physiotherapy Research Foundation Seeding Grant. JS is supported by an NHMRC Fellowship (APP1157119).

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

The work was supported by the National Health and Medical Research Council [APP1157119]; Physiotherapy Research Foundation.