Why we need Queermed
Discrimination in Germany. A status quo
We all want to be healthy. We want to go through life without severe health restrictions. No or at least little pain. Physically or mentally. We give birth and need professional support. There are doctors and therapists in a wide range of specialisms for this. According to the UN Convention on Human Rights, health is a
human right (Article 25, UN Charter of Human Rights), and health is also included in the German Basic Law. These two points already state that the health of all people is one of the highest goods in our world.
It would actually be easy. We look for a practice near where we live, or near work, university, wherever, or simply search the internet for a practice telephone number and make an appointment. This is how it is for many people in Germany, for others the search and visit to a practice or clinic is a major hurdle:
In 2021, a study commissioned by the Federal Anti-Discrimination Agency found that 26.4% of people had experienced discrimination in the last two years, including in the healthcare sector. That is a quarter of all participants in the study.
The Afrozenus of 2020, the largest survey of Black, African and Afro-diasporic people in Germany and currently unique in its scope and wealth of information on the lives of Black people in Germany, found that in the last two years at the time of the survey, 64.5% of respondents had experienced discrimination in healthcare.
The reasons for discrimination vary. Half of all HIV-positive respondents in a study by Deutsche Aidshilfe alone have experienced discrimination due to their HIV status.
At the same time, Queermed’s recommendations revealed that only a fraction of practices have any accessibility criteria at all. Of the current 550 recommendations, only 188 have been labelled as ‘accessible for wheelchair users’. 85 have a lift, 54 have step-free access to the practice. And at only one practice does the doctor speak German sign language (DGS). Such information is also rarely found in an internet search. How are people with disabilities supposed to be able to visit surgeries and access healthcare at all?
‘I will not allow considerations of age, illness or disability, creed, ethnic origin, gender, nationality, political affiliation, sexual orientation or social status or any other factor to come between my duties and my patient.’
Intersectionality: When several levels interact
Discrimination on the basis of personal characteristics, be they based on skin colour, country of origin, culture, language, educational status, sexual orientation, gender identity, disability or other reasons, constitutes discrimination. According to the German constitution, we should be protected from this. But the reality is different. A distinction needs to be made between personal and institutional discrimination. On the one hand, people are obstacles in our lives that deny us access to necessary healthcare or make it very difficult for us to access it, while on the other hand, it is institutions such as hospitals that knowingly or unknowingly discriminate against patients.
We need to understand that people can experience discrimination on the basis of individual characteristics, but also through several characteristics at the same time. This means that the reality of a Black man’s life can be different from that of a Black queer person. In the Afrocensus mentioned above, this aspect of multiple discrimination against Black cis women and Black TIN people (trans*, inter and non-binary people) posed an additional problem.
Intersectionality affects all of our lives. We can benefit from some characteristics, such as being white, while other characteristics, such as disability or our gender identity, expose us to experiences of discrimination in different contexts. This means that not all people in a particular group can and must have had the same experiences. As a result, people belonging to a certain group must not be ‘lumped together’. Each person, each patient, must be treated individually and their respective needs, fears and wishes must be recognised and respected.
How discrimination takes place in the healthcare sector
Discrimination in the healthcare sector can be very individualised. In some cases, it can be very direct and personal situations with the practice staff and/or the doctor. Racist comments can be direct or take the form of microaggressions.
‘Microaggressions are everyday comments, questions, verbal or non-verbal actions that predominantly affect marginalised groups and reinforce negative stereotypes. They can be made or uttered both intentionally and unintentionally. Although they are often not meant to be hurtful, they can make people feel unsafe and uncomfortable. Microaggressions may seem small or insignificant in the moment, but they add up and can make people feel like they don't belong...’
It is often due to the unconscious and unreflected behaviour of healthcare professionals, therapists and doctors that such microaggressions occur.
In the aforementioned study ‘Discrimination risks and protection against discrimination in the healthcare system’, it was found that people with personal experience of migration in particular visit medical specialists significantly less often than people without experience of migration. The same applies to preventive medical check-ups: be it for dental check-ups, cancer or other topics. The intersectional connection between migration background, gender identity and social status in relation to the utilisation of healthcare is also evident here.
The problem also arises with the lack of language skills. Both in the case of patients who may have only come to Germany a few years ago and elsewhere, it is also clearly noticeable how rare English-language services are on the Internet within German practices and clinics. Even jameda does not offer any English-language pages; only for some time now has this doctor search portal had a microsite in Ukrainian with a small selection of Ukrainian-speaking practitioners.
Through my work at Queermed and looking at hundreds of websites, I realised at some points that although doctors could, in their opinion, provide treatment in several languages, how is the person who can’t even click through the website menu because everything is only in German supposed to know that?
The bureaucratic hurdles are incredibly high compared to other countries and represent a discrimination factor that many people have to face.
People with a non-white, heteronormative reality of life are often less informed about their rights and the healthcare services available in their neighbourhood.
Body weight is also a discriminatory factor in healthcare, as it was in the 2020 Afrozensus, from unnecessary and inappropriate comments to misdiagnosis and the sheer focus on body weight as the patient’s only problem, which conversely can lead to more and more serious health problems than treating patients with respect from the outset, regardless of their body shape and weight.
What the legal basis for doctors looks like
In addition to the Basic Law, there are also medical guidelines that exist in the LGBTQIA* sector, for example:
- German S3 guideline with the title: “Geschlechtsinkongruenz, Geschlechtsdysphorie und Trans-Gesundheit: S3-Leitlinie zur Diagnostik, Beratung und Behandlung”(“‘Gender incongruence, gender dysphoria and trans health: S3 guideline on diagnostics, counselling and treatment’” (AWMF)
- International guidelines by WPATH and APAAPA
- Guidelines relating to body-modifying treatments (hormone therapy, Deutsch et al 2016, garahm 2013, Surg-LL.)
Here is a brief summary of the guidelines mentioned:
S3 guideline
This S3 guideline on diagnostics, counselling and treatment for trans* and other people was published in 2018. Members of the German Society for Sexual Research (DGfS) and the German Trans* Association, among others, worked on these guidelines. These guidelines, which result from the guidelines of the Bundesverbrand trans*, are intended to bring professionals and those seeking treatment closer together. Above all, the aim is to strengthen understanding on the one hand, and on the other, to familiarise people with their own rights and thus strengthen the self-confidence of those seeking treatment.
‘But if trans* people suffer from the fact that their gender and body do not match according to today's standards, this can lead to so-called pathological suffering. Medical measures that harmonise the body with one's own gender can then help.’
While the ISD-10 still officially applies in Germany, the WHO’s ICD-11 was published in 2018, which no longer lists transgender as a mental disorder.
There is a separate guideline for children and young people, which has recently expired and where new guidelines are already being worked on. The new guidelines are due to be finalised at the end of March 2023. At the same time, the surgical guidelines for ‘Sex reassignment surgery for gender incongruence and gender dysphoria’ will hopefully be finalised this year and published in a timely manner.
Not just ‘anyone’ can produce guidelines, because there are careful guidelines for all medical guidelines, which are also emphasised once again in the guidelines:
Systematic literature research, a representative committee and structured consensus-building are required. The scientific and careful approach is intended to guarantee that the guidelines comprehensively promote respectful treatment and an improvement in the recovery process for trans* people.
The guidelines also include a checklist for patients that can be used to check whether the practice is a good and safe place (keyword: safe space). This can be an opportunity for doctors and therapists to reflect, particularly with regard to their own privilege and understanding of the power imbalance between doctor/therapist and patient.
Recommendations of the WPATH (World Professional Association for Transgender Health)
The current 7th edition of the ‘Standards of Care’ from 2001 is available in 18 languages and is intended to provide clinical guidance for healthcare professionals in the treatment of trans* and gender non-conforming people. It covers various medical specialities: general medicine, gynaecology, urology, reproductive options, voice and communication therapy and therapeutic areas.
Like the S3 guidelines, the document focuses on medical professionals, but is also recommended for individuals, friends, families and other institutions, as it provides extensive information on the need for respectful and medically consistent treatment of trans* patients.
Recommendations of the APA (American Psychiatric Association)
Of course, these guidelines do not represent an absolute collection, but they do show that there is certainly information available for specialist staff to inform themselves in this area and, if necessary, to become more aware of experiences of discrimination within their own practice/clinic.
Further training opportunities for doctors & therapists
There are many opportunities for doctors and therapists to receive further training on various topics. This educational work is very often carried out by people from the respective communities. In the following list, there are a number of possibilities to look for further training opportunities:
- https://www.regenbogenportal.de/
- https://www.bundesverband-trans.de/angebote
- https://www.waldschloesschen.org/de/
- https://www.praxis-vielfalt.de/
Queermed also offers lectures and workshops. Books written by activists and those affected can also be used for general further education to draw attention to social and institutional problems such as racism, homophobia and trans*hostility. Queermed maintains a list of books, which is constantly being expanded and can be a source of inspiration.
At the same time, there is a guide on Queermed for sensitised interaction with patients, which provides assistance for self-reflection in dealing with various discrimination issues.
What patients can do in the event of discrimination
The first empowering step for patients is to be aware when discrimination has taken place in the healthcare system. This includes knowing what rights patients have in the event of discrimination and what steps they can take.
As the Federal Anti-Discrimination Agency notes, it is not yet legally clear whether the General Equal Treatment Act (AGG) can also be applied in the healthcare sector.
From a legal perspective, doctors are restricted in their desire to refuse treatment in accordance with (Section 7 (2) sentence 2 of the (Model) Professional Code of Conduct of the German Medical Association (MBO)) by the Geneva Pledge, among other things. If we transfer the legislation on the AGG to these professional regulations, this would reinforce the point that not treating patients on the basis of racist attributions is not legal.
First and foremost, patients are free to choose their practice as long as it does not report overcrowding or has no free therapy places. In the event of discrimination, patients are of course free to cancel their current practice and care immediately and start looking for a new practice.
In addition to the possibility of contacting various counselling centres, there are also separate anti-discrimination offices. In hospitals, there may be separate complaints offices or quality assurance centres where patients can report cases of discrimination.
It is also possible to file a complaint with the respective medical associations in the respective federal state. There are separate chambers for therapists. Among other things, the Gay Counselling Service Berlin has a guide for those affected by discrimination in the healthcare sector, which lists the various options.
Legal action is only possible with the availability of legal resources, which can be a hindering factor.
Supporting Queermed’s work
As it will not be possible to completely prevent people in Germany from experiencing discrimination in the near future, in addition to the active further training of prospective and existing practitioners, there is a need for ways for patients who have experienced discrimination to avoid these experiences as far as possible. With the help of Queermed, positive recommendations can be shared with other people across Germany.
Ideally, this project would not be necessary. However, as long as there are still many people who receive no or poor treatment for health problems due to discrimination, Queermed offers a point of reference to highlight the doctors and therapists who offer a safe space for everyone, regardless of their origin, appearance, disability or sexual orientation.’
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