We had the wonderful opportunity to speak with Dr Fiona Bisshop, a GP located in Brisbane who is dedicated to improving the provision of care available to LGBTQI+ patients.
James: Hi Fiona! If you don’t mind, can you tell us your pronouns?
Fiona: My pronouns are She/Her.
James: You have a really profound career working with LGBTQI+ people, particularly trans patients, when did you first get into this field?
Fiona: It’s a bit hard to answer. I started seeing my first trans patient 22 years ago. I started working in the LGBT space when I did the HIV prescribers course and moved to a practice that had a big cohort of LGBT patients. The trans side of it really started in 2012 when the sexual health clinic started turning away trans patients (due to politically fuelled funding issues). My cohort really grew from that moment on. I started discovering that there wasn’t much in the way of guidelines or help, and because I ended up seeing so many trans patients, I started writing talks and delivering education.
James: What are the big differences in the treatment of LGBTQI+ people between now and back then?
Fiona: I guess there’s a lot more being said around it. When I first started as a med student homosexuality was still officially “not OK” in Queensland. Now we gave legalised same-sex marriage in this country, which I really never saw coming in those days. One of the huge shifts for me was a change of focus from the early 90s when a lot of gay health was centred around HIV and AIDS in a really palliative way. There was a lot of suffering and loss in the community which was just awful. Now there has been such a shift in the way we perceive and manage HIV. People very rarely die from HIV anymore – and when it does happen it’s usually someone whose slipped through the net. But we have effective and tolerable treatments that work. The transformation of HIV care has been an amazing thing to live through.
I think another huge change is that trans people have become more visible. Because of this people feel more comfortable coming forward and identifying that way and getting affirming treatment. Those are some of the really big changes that I have loved being a part of.
James: What motivated your interest to work with HIV and trans patients?
Fiona: My interest in HIV stemmed originally from being a microbiologist before medicine (I have an honours degree in microbiology and been involved with HIV research). Being a member of the gay community I also had friends who were affected by HIV, and I wanted to be a part of the medical workforce that treated it. That got me into the space and into a clinic that saw that as their core patient cohort. The trans part really came along with it. I guess it was serendipitous, I wasn’t intentionally seeking trans people, but once I met them and their friends, I loved it so much and I just knew it would always be a part of my life. I didn’t know it would be a big part of my career in this way and I never imagined that I would be the president of the national trans health organisation [AusPath– more on this later!]
James: Were you worried about being vocally supportive of LGBTQI+ people back then?
Fiona: As a med student I was completely inside of the hospital. Some friends and I tried to get some community there, but it was very hard because there were heaps of gay people who never identified themselves. When I started as a resident in the hospital system, that was hard. I felt really uncomfortable with people knowing. It was a really intolerant time in the mid-90s, and I was in a hospital out in the sticks…I just didn’t feel comfortable. For three years I was in the hospital I didn’t come out to anyone.
James: What allowed you to be more comfortable with yourself and start to present as LGBTQI+ at work?
Fiona: I think being more autonomous. Going into General Practice I was obviously a GP registrar for a while so I wasn’t working in my own practice, but I would do things like put a photograph of my partner on the desk. I wouldn’t say anything, but if people asked, I wouldn’t make a secret of it. When I moved to a practice that I knew was accepting I just went crazy! You know, here I am!
Another thing is that it may not have been as bad as I thought it was, but I didn’t have the agency or confidence to be who I was. I didn’t feel comfortable disclosing, and probably if I was higher up the hierarchy it might have been different. But as an Intern, you can’t get any lower in terms of status.
James: We have made some amazing steps forward in terms of the provision of care we can offer LGBTQI+ patients, but what improvements do you think we need to make?
Fiona: It’s been a long time since I’ve been involved with curriculum, but I think that still needs a lot of work. The content is still seen as this like “other” thing, and it needs to be much more normalized. In part that has happened in the community as we have things like gay marriage and rainbow causes etc. but I do think that curriculum tends to be conservative, and that people going into the courses don’t get enough exposure. For instance case studies – you don’t have to make every case study with a gay patient about them being gay!
Another thing is this idea of the Trans Broken Arm Syndrome. For many trans patients, as soon as they seek medical care, Doctors make it all about their trans identity. You can go to hospital with abdominal pain and its appendicitis, but they want to know whether you’ve got testicles, your testosterone levels, and they focus on this one particular thing that has nothing to do with why you’ve presented.
James: Do you have any advice for people who want to offer better care for their LGBTQI+ patients?
Fiona: Wanting to provide better care is already the first step in being an ally. The next step is to make it clear to your patients that you want to provide care – such as having a rainbow badge or any other markers of acceptance. There are heaps of online resources, so it’s a matter of going and finding those. Particularly when it comes to trans medicine. AusPath have a list of all the endorsed guidelines too. It’s just important to be really open with your patients and to be non-judgemental and accepting, and to ask them what it is they need. And to not make assumptions – assumptions are really good at keeping people hidden. What is your proudest moment from the last 20 years?
One of the things I’m proudest of is that I have been able to help so many people get onto hormonal treatment and actually be able to affirm themselves. That’s been so gratifying to me. I’ve learned so much along the way, and I don’t claim to know all the answers, but being involved in that has been amazing.
I did also manage to win Health Professional of the Year at the QC awards four years in a row! I have all the trophies on my desk.
James: Do you have any advice for LGBTQI+ patients who want to seek medical care but are afraid of being met with intolerance?
Fiona: Unfortunately there is still quite a lot of homophobia and transphobia out there in the medial fraternity. I understand why patients might be quite fearful of going to the doctor, particularly in remote communities. A strong message that I would like to send is that you don’t have to put up with that attitude. It can be difficult when there is this power dynamic, but they are providing this service for you. You have the right to question their opinions and the right to see another healthcare provider. It pays to do some research before you go. Especially if you’re trans, it’s very helpful to know who you should go and see. You may not have much choice depending on where you live, but it’s good to get into groups that talk about these things.
James: You’re also involved with research; can you tell us a little about that?
Fiona: Research has grown from the fact that working in the trans medicine space, I realise that there is not enough published data and very little properly conducted research that actually addresses some of the key areas in gender affirming hormone therapy. Like comparing the outcomes and risks of different types of hormone preparations and in the case of trans women looking for blockers. There are really simple questions that haven’t been answered. One of the projects I am on is evaluating how little cyproterone acetate is necessary to suppress testosterone - no one has ever asked that question before!
James: Can you tell us a little more about AusPath?
Fiona: AusPath started as a networking group in 2009 at a world trans health conference in Norway when a bunch of Australians there bumped into each other. At that time the people on the board were psychiatrists. That’s one great way that things have changed within trans health, we are no longer focused on pathologizing and diagnosing, rather we focus more on affirmation.
AusPath now has 300 members form around Australia and a huge number are GPs. We have moved from being a niche area to one that is more general and attracts a diverse range of health specialists, such as endocrinologists, researchers, GPs, as well as psychologists and psychiatrists. There are also so many trans members who are board members. When AusPath started the board was this medical imposing “we will tell you what you can do with your bodies”, now its half run by trans people.
James: Fiona, my final question – what advice would you have for your younger self?
Fiona: I saw that question before, and I thought to myself I don’t know what I would say…apart from buy shares in Amazon. I would have loved to have been less fearful. Ultimately fear is what holds you back from being yourself and from doing what you really want to do. Most of the time the fear is unfounded. Sometimes the fear is founded, and you have to overcome it anyway. I would have liked to have been told it was all going to be OK and I could just be myself.