By Heather Stewart, MA
Bisexual or “bi” identified people are a significant portion of the larger LGBTQ+ community, with studies suggesting they make up just over half of the larger LBGTQ+ population. Within the bi community itself, there is substantial diversity as well. For example, “bisexual” is the sexual orientation category most self-identified by trans people (25% of trans people identify as bisexual) and people of colour are more likely to identify as bisexual than white people.
Yet, despite representing such a large portion of the LGBTQ+ community, bi people experience routine erasure – they are often lumped in with their gay or lesbian counterparts, or not accounted for at all, and their experiences are often rendered invisible, incomprehensible, and incoherent. Simply put, bisexual people have a difficult time being recognized as bi, and they often have their experiences obscured, questioned, doubted, or dismissed by those around them (including fellow LGBTQ+ community members).
The erasure of bisexual people and their experiences leads to a variety of negative consequences, including lack of social or legal support systems, psychological difficulties pertaining to alienation or lack of belonging, and more. One of the most damaging consequences involves the variety of health disparities experienced by bisexual identified people. Some examples include:
-Bisexual people experience higher rates of anxiety, depression, and other mood disorders than their heterosexual, gay, and lesbian counterparts
-40% of bisexual high school students had seriously considered suicide, compared to 30% of gay and lesbian students and 12% of heterosexual students.
-Bisexual people have higher rates of heart disease, compared to their heterosexual counterparts
-Bisexual women experience higher rates of all cancers, including breast cancer, than their heterosexual counterparts
And there are others.
Of course, the risk of health disparities is worsened for those members of the bi community who are also members of other marginalized groups, such as bisexual women, trans and nonbinary bisexual people, bisexual people of colour, and disabled or poor bisexual people, among others.
There are several reasons that such health disparities persist among bisexual communities, and I will not attempt to cover them all here. However, it is important to note that there are structural and institutional barriers to treatment, as well as gaps in knowledge about bi people as a result of historical and ongoing erasure in medical research, literature, and training. While these are certainly important dimensions of the problem, in this blog I want to highlight one problem in particular. This is the problem of microaggressive interactions experienced by bisexual people in medical contexts, which can have long term impacts on the kind and quality of medical care they receive.
Microaggressions refer to routine, subtle, and seemingly insignificant comments, gestures, or slights, whether intentional or unintentional, which convey negative or unfriendly messages to members of marginalized groups. Microaggressions can harm their targets in a variety of ways, and are particularly toxic given their frequency; those who experience microaggressive slights are likely to experience them often and in multiple social or institutional contexts.
As socially marginalized people, bi people are likely to experience microaggressions.
Microaggressions targeted at bisexual people draw on social stereotypes and biases against bisexuality. These include but are not limited to the common ideas that bisexuality is “just a phase,” that bisexual people are in fact heterosexual or gay or lesbian, that one can only claim bisexuality if they have had romantic and/or sexual relations with people of multiple gender identities, that bisexual people are non-monogamous or are promiscuous, and so on. Microaggressions rooted in these stereotypes occur when people make seemingly subtle comments to bi people, such as:
-Introducing them as straight (or lesbian or gay) based on the gender of their partner
-Referring to a bi person as “bi-curious” when they are out as bi
-Asking a bi person about threesomes, polyamory, or otherwise assuming that they are non-monogamous
-Asking about past sexual experiences with people of same and non-same gender
And so on.
In a medical context, such microaggressions can be particularly damaging, since receiving good health care depends both on trusting the person responsible for your care, as well as being truly understood by that person.
An example of a microaggression that a bi person might experience in a medical setting is the following:
Physician to cis-female, bi patient: Have you had any new sexual partners?
Patient: Yes, I have. Only one, and we have been monogamous for six months.
Physician: What are you doing to prevent pregnancy?
Patient: I cannot possibly get pregnant.
Physician: No method is 100%… Are you using any contraception? Condoms? Birth control pills?…
In this case, if the patient was not out as bi to her physician, the physician erased the possibility of her being bisexual by assuming that unless told otherwise, the patient’s new sexual partner must be of the opposite sex. If the patient was out to her physician, then the physician’s comment suggests that he ignored this part of her, or didn’t take it seriously, or didn’t think it was important enough to remember. In either case, the physician has committed a microaggression, and specifically, one that calls into question the patient’s very identity as bi. This can be true whether or not the physician meant to question his patient’s identity. Microaggressions are sneaky that way.
Consider another example, this one from a testimony given by a 23-year-old bisexual person who sought medical attention after a sexual assault. She describes that upon arriving at the medical center, the healthcare team immediately began gendering her attacker as “he,” and seemed confused, and even doubtful, that a sexual assault could have been perpetrated by a woman. She recalls the burden of having to educate her health care providers about the realities of same-sex sexual assault – a difficult burden given the traumatic circumstances. Having her attacker automatically gendered as a “he” constitutes a microaggression – one that reflects a lack of awareness or ability to consider sexual assault beyond the scope of opposite-sex assault.
While both of these microaggressions can occur without the health care providers meaning to do any harm, these seemingly small comments and slights can build up over time, causing bisexual people to lose trust in health care providers, and possibly even stop seeking medical care. In the case of the 23-year-old victim of sexual assault described above, she recalls coming to distrust that health care providers will take her experiences seriously, or be able to understand them at all. As a result, she avoids routine checkups, noting that she is “23 and I’ve only had one pap smear and one gynecological visit.”
When bi patients experience routine microaggressive comments and dismissals, they begin to avoid care, even when it is needed. When bi people are not seeking healthcare, the health disparities they face are likely to worsen.
Furthermore, those that do seek care may choose not to disclose their bisexuality: Studies show that bisexual people are far less likely than their gay or lesbian counterparts to inform their health care providers of their sexual orientation: 39% of bisexual men and 33% of bisexual women report not disclosing their sexual orientation to their health care professionals, compared to only 13% of gay men and 10% of lesbians who did not disclose their sexual orientation. Since openness and communication with one’s health care provider are central to achieving the best care possible, and ultimately good health outcomes, anxiety about coming out to health care providers can cause bi people to miss out on an opportunity to receive the care they deserve.
These reasons are why it is essential that health care providers begin to recognize microaggressions, understand their significance, and work to avoid committing them.
Health care providers, in order to be in a position to give the best care possible to bi patients, ought to spend time educating themselves about the realities of bisexual identity, as well as the biases they may have (even if only implicitly). This can help them to start overcoming the anti-bi stereotypes that drive microaggressions in the clinic.
Health care providers should also take steps that neutralize the harms of microaggressions when they do occur. One way to do this is by incorporating environmental signals in the clinic that they are LGBTQ+ aware and inclusive (i.e., having LGBTQ+ inclusive pamphlets, posters, etc. present). They should also use affirming language and gender-inclusive language when they are unsure of the gender identity and/or sexuality of their patients and/or their patients’ sexual or romantic partners. This can prevent unintentionally microaggressing their bi patients.
And, larger institutions that oversee medical practice, such as the American Medical Association and hospital organizations, need to continue to adopt LGBTQ+ friendly policies, and ensure that their members adhere to them.
And while the burdens of receiving good care should never rest on bi patients (or any other marginalized patient) alone, bi patients (to the extent that they have the resources and options to make choices) should use their networks to learn about where to access LGBTQ+ affirming providers. Every patient deserves the opportunity for quality and comprehensive health care, given to them by someone who respects and understands them. To the extent that there are health care providers trying to offer this, we ought to entrust them with our care.
Heather Stewart, MA, is a PhD candidate at Western University.