What lesbian visibility means for the NHS and why leadership matters

The moment I realised the true power of visibility came as I was watching LGBTQ+ colleagues come out across an entire organisation.

It happened because I’d been consciously visible as a lesbian senior leader. I hadn’t done anything extraordinary. I’d simply stopped hiding.

That didn’t happen by accident. I’d chosen to make myself visible to all staff because of an experience years earlier that fundamentally changed my perspective – and my actions.

Earlier in my career, I’d worked at the Department of Health (as it was then). Until that point, I’d never really had to “come out” at work. Many colleagues had known me since medical school; they’d witnessed my early romantic dramas first-hand. My sexual orientation wasn’t a secret; it was simply known.

At DH, things were different. Every colleague assumed I was heterosexual. Overnight, I felt forced into a secret I hadn’t chosen. You might be surprised how often colleagues casually asked about my boyfriend or husband, and every time I froze. Correcting them felt impossible. I wasn’t aware of a single, out, queer person in the whole department, and that silence spoke volumes.

I was afraid. Afraid of being rejected. Afraid of being treated as “other”. Afraid it would harm my career.

And yet, every time I let an assumption stand and with every half-truth and omission, I felt complicit in my own invisibility. The moral injury was real. So was the constant low-level anxiety of having to remember which version of myself I’d shared with whom. That cognitive and emotional labour took its toll. It affected my performance, my confidence, and my sense of belonging.

When I finally did come out, the relief was immediate. I felt freer. Lighter. Able to do my best work again.

But it wasn’t easy. It was often awkward and uncomfortable. Some people treated me differently and not always for the better. And every time I had to unwind assumptions I’d previously allowed to form, it felt hard.

That experience changed me. I promised myself that if I ever found myself in a leadership role, I would be visibly out, so that nobody in my teams would have to feel trapped in an inauthentic story the way I had, as if being LGBTQ+ was something to hide, or feel ashamed about.

I got that opportunity when I became assistant medical director at a big healthcare company. Suddenly, I had senior visibility across a significant organisation with many people reporting to me. I made a deliberate decision: I would be openly, actively visible as a lesbian leader.

Every time I spoke openly about being a lesbian, my heart raced. I felt physically sick with anxiety. But I kept going.

And then something shifted.

People began coming out across the organisation, at every level, from administrative staff to directors. Several told me they’d never dared before. Seeing a senior gay woman thriving in their workplace made all the difference.

That was the moment I truly understood something fundamental: being out isn’t only about personal authenticity or individual wellbeing. As leaders, we have a responsibility to those who are watching, unsure, scared, and wondering whether it is safe to bring their whole selves to work.

The research I carried out for my book Breaking the Rainbow Ceiling bears this out. Visible LGBTQ+ leadership is one of the most significant enablers of LGBTQ+ people thriving and progressing at work.

But visibility is not without risk and it would be dishonest to suggest otherwise.

The NHS Staff Survey tells us that LGBTQ+ staff are more likely than others to experience bullying and harassment from managers, colleagues, patients, and patients’ families.

Lesbians working in the NHS experience discrimination at a higher rate (10 per cent) than heterosexual female staff (8 per cent). That is not a marginal issue. It directly affects retention, engagement, leadership pipelines, and ultimately the care we deliver. My research found that LGBTQ+ people are more likely to be excluded, overlooked for promotion, and dismissed. I have personally had recruiters indicate, explicitly, that my being a lesbian made me less appointable.

The decision to come out is a personal one. The choice to be visible is not a neutral one and everyone must make that decision for themselves. That should include understanding the personal and wider benefits.

That is not an abstract concern. It is central to our work.

Visibility must be intentional. ‘Breaking the Rainbow Ceiling’ found that LGBTQ+ leaders routinely overestimate how visible they are, particularly in large organisations. To have real impact, we must speak openly in staff meetings, in written communications, internally and externally, often far more than feels comfortable, to achieve meaningful and sustained impact.

Time and again, when I make myself actively visible, particularly when it requires courage, LGBTQ+ staff tell me it matters. My organisation’s staff survey shows increased engagement. Some colleagues have told me they applied to work with us, or chose to stay, because they saw an executive leader speaking openly about being a lesbian and understood that this meant they, too, would be safe to thrive authentically.

This extends beyond the workforce. In a health system serving a diverse population, visible differences around decision-making forums disrupts groupthink, fuels innovation, and drives better outcomes.

LGBTQ+ people should not merely be seen — they must be present, included, and contributing lived experience where it might otherwise be absent. This is not a “nice to have”. It is essential to improve.

It’s not just what happens behind the scenes. Inclusion is part of quality care.

That fear of being “other”, of being rejected or diminished, is the same fear that keeps LGBTQ+ patients from seeking healthcare at the most effective moment. Across the NHS, LGBTQ+ people are less likely to seek preventative care and more likely to present with more severe illness as a result. Visible LGBTQ+ leadership builds trust in the health system. It signals safety. It can, and does, save lives.

I remember too clearly what it felt like to believe I was the only lesbian in my entire workplace. I remember the weight of it. And I know from colleagues who have told me directly that being seen makes it possible for others to breathe. When it comes to the NHS, inclusion is a workforce and a service inclusion issue. Visibility shapes who feels able to lead, who feels safe to speak up, and who ultimately trusts us with their care.

Lesbian visibility isn’t optional in the NHS. It never was.

Dr Layla McCay is director of policy at the NHS Confederation and executive lead of the Health and Care LGBTQ+ Leaders Network. You can follow Layla on Bluesky.