Rose*, a 31-year-old bi+ woman who has struggled with depression for most of her life, didn’t commit to a therapist until her mid-twenties. When she finally did, her therapist consistently “made comments about how I didn’t seem very into [dating women] and maybe it wasn’t for me,” she recalls. She says her therapist even asked if she was “using” her attraction to women as a way to avoid the relationship problems she had with men.
The reality was that Rose was nervous. She was unsure of what being bisexual meant for the rest of her life, and wasn’t convinced that she was “queer enough,” she says. She needed support and affirmation during this time. Instead, Rose says her experience in therapy, which belittled and undermined her sexuality, made it more difficult to wade through the process of bettering her mental health.
There are more than nine million LGBTQ+ people in America, and about 52 percent identifies as bisexual or Bi+, according to a report released by the non-profit think tank Movement Advancement Project (MAP). There are many wonderful things to celebrate about being bi+, which is defined as being attracted to or having physical and sexual relationships with people of different genders. However, it can also make navigating the world much harder, since biphobic stereotypes still persist within and without the LGBTQ+ community. Think: assuming bi+ people just can’t commit, are just gay or straight people who can’t “decide” what “team” they’re on, or are simply “greedy.”
Emotionally, biphobia is harmful, but it has larger consequences than hurt feelings. Biphobia can persist even in professional spaces where people seek care—which has critical implications for the physical and mental well-being of bi+ people.
Biphobia in health spaces
Brian A. Feinstein, PhD, a research assistant professor at the Institute for Sexual and Gender Minority Health and Wellbeing at Northwestern University, says that bi+ people have higher rates of mental and physical health problems than heterosexual, gay, and lesbian people—such as an increased risk of substance abuse, cardiovascular disease, cancer, and sexually transmitted infections (STIs). The concerning trend is true for mental health issues, too; research shows that bi+ people are at elevated risks of suicidal ideation and are more likely to have mood or anxiety disorders.
Yet often bi+ people report biphobic comments from the very professionals from whom they seek care. This was true for Rose, and it certainly was true for Charles*, a bi+ transgender man. In a primary care physician’s office for a first visit about a stomach issue, his doctor shamed him about for having had eight sexual partners within a year. “I felt so on edge because of the slut-shaming and the assumptions there that I didn’t even get into telling her the gender of my partners,” Charles says.
Assumptions that a person has to be equally attracted to men and women in order to be bi+, that a person has to have had sex with people of different genders in order to be truly bi+, or that a person in a monogamous relationship is no longer bi+ are all examples of biphobia playing out in real life. Adriana Joyner, LMFT, a bi+ woman who is a therapist herself, says that when a person’s sexuality is “repeatedly, frequently, and persistently minimized or questioned, or even worse, degraded, it takes a significant toll on a bisexual person’s mental health.”
The impact of biphobia on medical care
Beyond the very real mental health impact, biphobia within medical environments ends up making it harder for patients to be open about their sexual orientation, explains Gillian Deen, MD, MPH, the Senior Director of Medical Services at Planned Parenthood Federation of America. Indeed, a 2013 study found that nondisclosure rates among bisexual men and women (39 percent and 33 percent respectively) were higher than among gay men and lesbian women (10 percent and 13 percent.)
This has serious implications for health. If a patient is determined not to be a pregnancy risk because of assumptions about their sexual partners, for example, they may not be offered contraception, Dr. Deen says, which could put a bi+ person at risk of an unwanted pregnancy. “Having clear information about a person’s sexual partner may also lead to different recommendations about routine STI testing, due to different prevalence rates among different communities,” she adds.
Similarly, Dr. Feinstein says that because bi+ men are less likely to be open about their sexual orientation, they’re less likely to receive prevention services like testing or pre-exposure prophylaxis (PrEP), the medication that prevents HIV transmission. This means that bi+ men who are living with HIV are also less likely than gay men with HIV to even be aware of their HIV status, Dr. Feinstein says.
The fear of being misunderstood can also prevent patients from seeking out the healthcare they need. Joyner says the work that goes into finding a competent, bi-affirming therapist has prevented her from going to therapy in the past. “There are so few therapists that are truly knowledgeable and affirmative toward diverse sexualities or that understand the uniqueness of being bisexual or pansexual that I’m wary to taking a chance on a new therapist,” she says.
How to combat the problem
Given the physical and mental health issues that bi+ people face, the fact that many of them aren’t comfortable disclosing their sexuality to their doctor should be a wake-up call to medical professionals to change their approach when treating bi+ patients. Doctors need to understand that “a patient’s current or past sexual partners aren’t necessarily indicative of their whole sexuality,” says Dr. Deen. Instead, asking patients about their partners’ anatomy instead of gender often provides her with the information she actually needs to properly care for her patients. However, when providers make assumptions and judgments, “it can make patients lose faith in our ability to provide the health care they need,” says Dr. Deen.
Dr. Feinstein says that the only way to truly help patients is to listen to them. “If someone tells you they have a same-gender partner, don’t assume they are gay. If someone tells you they have a different-gender partner, don’t assume they are heterosexual. And if someone tells you they are bisexual, believe them and don’t ask them to ‘prove’ it by asking them if they are more attracted to one gender than to other genders,” he says.
Those skills don’t necessarily come overnight, and unfortunately, medical schools aren’t necessarily providing LGBT-specific, bi+-inclusive cultural and health competence training for students. although with the prevelance of health issues about Bi+ populations, they absolutely should be, according to recommendations from MAP. It’s only been recently that signs of potentially changing times have occurred, with schools like the University of Louisville incorporating LGBT training into their med school curriculums.
Dr. Feinstein believes that healthcare providers do want to help their patients, which means they have to take a more active interest in biphobia and how not to perpetuate it. “Doctors and therapists should be engaged in ongoing continuing education in cultural competence and structural competence,” says Herukhuti Sharif Williams, PhD, a scholar whose work focuses on sex research and education. One potential place to start: accessible online learning modules to teach current doctors how to be LGBTQ+ affirming. He also suggests that doctors maintain personal relationships with people in the communities from which their patients come, “so that they have a personal stake in the outcomes for members of those communities.”
Until every medical professional gets on board, there are thankfully many LGBTQ+ health organizations around the country that support people of all identities, like The Center in New York City. There are also online resources like the Bisexual Resource Center to help fill the gaps for those who don’t have ready access to an openly bi-affirming healthcare center.
As Dr. Feinstein says, there are people in healthcare fields who care, and plenty of peers who want to provide support to their bi+ patients. It’s just a matter of getting more and more people educated and on board.
*Name has been changed for privacy.
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