Supporting LGBT Patients - Andi Smart
Research on the lesbian, gay, bisexual, transgender population (LGBT) population and mental / physical ill health highlights complexity. It appears that those within the LGBT population are at a significantly higher risk of developing poor physical health, compared to that of their heterosexual counterparts (Hudaisa, Zeshan, Tahir, Jahan and Naveed, 2017). There is, for example, a strong link between mental and physical ill health, sexual health and wellbeing; substance misuse and smoking or binge drinking (Marshal, Friedman, Stall, & Thompson, 2009; Trocki, 2005; McKirnan & Peterson, 1989). The Centre for Disease Control and Prevention data (2014) recognises that gay and bisexual men are at an increased risk of prostate, testicular, anal and colon cancer. Bowen and Boehmer (2007) suggest an amplified risk of cancer for lesbian and bisexual females. Many studies recognise how anxiety / stress / Post Traumatic Stress Disorder (PTSD) and / or bipolar are (up to) 4 times more prevalent within the LGBT population, than the heterosexual community (Needham, 2012; Meyer, Dietrich & Schwartz, 2008; King et al, 2008). Therefore, in view of this research, keeping your knowledge up-to-date with ongoing training and CPD, reading around LGBT mental and physical health issues and challenges; as well as learning from others who are skilled in communicating with, and caring for, LGBT individuals is important, even crucial for best practice. For example, lesbian women are more at risk for certain cancers due to the prevalence of obesity, nulliparity, or later pregnancy. Lesbian women are susceptible to many of the same sexually transmitted infections as heterosexual people and gay men. Thinking that this population is not at risk for these STIs can result in lack of appropriate screening and treatment. In addition to HIV infection, gay men may be at higher risk for anal cancer and can be particularly susceptible to body image issues in the desire to be attractive to other men; as well as more likely to experience a variety of cancers resulting from increased obesity and use of tobacco and alcohol (Dermer, Smith & Barto, 2010).
Bostwick, Boyd, Hughes, West, & McCabe (2014) and The European Union Agency for Fundamental Rights (2014) highlight how discrimination is heavily associated with the development of mental and physical ill health in LGB individuals. King et al (2008) recognises that LGB people are 1.5 times more likely to develop depression and anxiety, due to stigma and discrimination, compared to those who identify as heterosexual. Barker (2012) highlights that bisexual people most frequently experience mental and physical ill health problems, including cancer, depression, anxiety, self harm and / or suicidality. Pachankis (2006) found that gay men reported a greater fear of discrimination through social communication and interaction – with language and the way individuals are addressed being key. In view of this, I suggest reading around LGBT language. For example, do you know the meaning of asexual, gay, lesbian, bisexual, pansexual, agender, cisgender, transgender, gender fluid and queer? If not, see our glossary of terms attached to the end of this article. This will help you in not only communicating with the individual and filling out paperwork, but also in recognising that it is possible that the individual might have faced challenges associated with their non-binary gender and / or sexual identification. Also, if the individual sees you have an understanding, this might help to build trust and mutual respect. If you have a ward folder, print off a copy and put this in. Or, if you have an equality noticeboard – print a copy off and attach.
Research relating to heteronormativity and the heterosexist society, and how this impacts on mental and physical ill-health of the LGBT population is abundant (Schilt & Westbrook, 2009; Schippers, 2007; and Butler, 2004). Heteronormativity has been defined by Gale (2008; 11) as “the enforced compliance with culturally determined heterosexual roles and assumptions about heterosexuality as ‘natural’ or ‘normal’”. Understanding heteronormativity and heterosexism can be difficult, as it is still very engrained in our society and communication. There is a resource here; http://www.ghjru.uct.ac.za/sites/default/files/image_tool/images/242/schools/Ch7/CH7EX2Final.pdf on the University of Cape Town’s Gender Health and Justice Research Unit website with some great tools to examine this and help understanding, but in its most basic form, avoiding heterosexism and heteronormativity might be as simple as asking whether someone has a ‘partner’ or ‘significant other’ instead of whether they have a ‘boyfriend’ or ‘husband’, excluding the other genders. Ron De Kloet, Joels & Holsboer (2005) recognise that LGBT individuals, under relentless explicit and implicit stress from a heterosexist and homophobic society, via plentiful signs and signals as to how to behave – what is ‘right’, ‘normal’ and ‘natural’ - develop extreme biological stress responses (a heightened alert). This then feeds into mental and physical ill health. In view of this research, healthcare staff should expand their own knowledge and understanding around sexual orientation and gender identity – which includes how the individual identifies with and experiences the world. Sexuality has long been defined as heterosexual by the dominant society, yet – in reality – sexuality encompasses a spectrum of needs, desires, and / or behaviours that can be fluid and changing over time.
With a view to better understand why the LGB population experiences vulnerability and mental / physical ill health, Meyer (2003) developed Minority Stress Theory. This theory recognises that LGB individuals experience diverse, individualised stressors related to victimisation, discrimination and / or prejudice. These distinct LGB-specific stressors, on top of everyday (universal) stressors, disproportionately compromise the mental health and wellbeing of this population. Meyer (2003) recognises three distinct stress processes. The first are objective / external stressors, which include structural and institutionalised discrimination. The second is hyper-vigilance: when victimisation / rejection / discrimination is expected. The third is internalised homophobia, including social discrimination and stigma. This model does a very good job in highlighting that LGBT individuals have a long history of discrimination at the individual and institutional levels, including the healthcare system. Often, I have witnessed LGBT individuals scan the environment to determine if it is a safe place to reveal personal information, especially about sexuality. Some have spoken in a muffled voice, and others lied – all because they felt unsafe. So, as professionals, we need to recognise the importance of a safe and inclusive environment and how this impacts on disclosure – not just of sexuality but also of health needs. On my ward, I have symbols of inclusiveness (the rainbow flag) on noticeboards, as well as posters with diverse imagery, which includes information on LGBT-specific healthcare needs, which can help to let people know that it’s safe to share information about sexuality openly with the staff team.
Research from Schilt & Westbrook (2009) highlights that the LGBT population might internalise negative fears about what it is to be LGBT, in a blatant and / or subtle form (Burn, Kadlec & Rexer, 2005) through direct and / or indirect discrimination / stigma and / or physical and mental abuse (Dermer, Smith & Barto, 2010). These studies, as well as many others (Coston and Kimmel, 2012; Eliason, Dejoseph, Dibble, Deevey & Chinn, 2011; and Goffman, 1963), highlight how LGBT individuals face constant discrimination, harassment, inequality; as well as heterosexism / heteronormativity from many health and wellbeing-related services, meaning mental ill health needs are not being met.
According to McDermott, Hughes, Rawlings (2018), social disadvantage, social class and social isolation are key determinants of mental ill health within the LGBT population. Namaste (2000) evidence that individuals from the LGBT population, especially transgender people, experience higher levels of marginalisation and social exclusion / isolation, compared to heterosexuals. This creates further challenges for LGBT individuals, who are experiencing mental ill health, to access support / services. Morgan (2012) found that social status, cost, a lack of ‘cultural safety’ and the ‘systems’ capability to deliver services that suitably recognise the diversity of the LGBT population, specifically those who are bisexual are substantive barriers to accessing mental health services. There is also limited research on what can be done to support those in the poorest social conditions from developing mental ill health. So, think about you can provide information that offers support and advice on accessing services. Do you have a LGBT-specific information sheet available? If not, is this something you could request or put together and make available to all (remember, not everyone is open about their sexuality) alongside other sources of support?.
Finally, always remember that the LGBT individual in front of you has taken a courageous step when seeking out support and disclosing personal information about their lives and lived experiences. Therefore, having as encouraging and affirming a care experience as possible will make it more likely the individual will seek future care in a timely manner. To support this process, you could become more aware of resources specifically designed for LGBT individuals, and making referrals as appropriate (e.g., LGBT support groups, LGBT smoking cessation groups and / or LGBT-specific AA meetings) will convey that you care enough to become informed about their particular LGBT-specific needs.
The quality of your interaction can truly make a difference to someone’s health - and life - so keep learning and growing and show kindness to all. You will save lives.
Some good websites that can help you further your understanding include:
Barker., M., Richards., C., Jones., R., Bowes-Catton., H., Plowman., T & Yockney. (2012) The bisexuality report: Bisexual inclusion in LGBT equality and diversity.
Bostwick., W., B., Boyd., C., J., Hughes., T., L., West., B., T & McCabe., S., E. (2014) Discrimination and mental health among lesbian, gay, and bisexual adults in the United States. American Journal of Orthopsychiatry, 84(1), 35-45.
Dermer., S., B., Smith., S., D & Barto., K., K. (2010) Identifying and correctly labeling sexual prejudice, discrimination, and oppression. Journal of Counseling & Development, 88(3), 325–331. doi:10.1002/j.1556-6678.2010.tb00029.
King., M., Semlyen., J., See Tai., S., Killaspy., H., Osborn., D and Popelyul., D. (2008) Mental disorders, suicide, and deliberate self harm in lesbian, gay and bisexual people: a systematic review. BMC Psychiatry 2008;8(70).
Marshal., M., P., Friedman., M., S., Stall., R & Thompson., A., L. (2009) Individual trajectories of substance use in lesbian, gay and bisexual youth and heterosexual youth. Addiction, 104, 974–981.
McKirnan., D., J and Peterson., P., L. (1989) Alcohol and Drug Use among Homosexual Men and Women: Epidemiology and Population Characteristics’ in Addictive Behaviors Vol. 14.
Meyer., I., Dietrich., J & Schwartz., S. (2008) Lifetime prevalence of mental disorders and suicide attempts in diverse lesbian, gay, and bisexual populations. Am J Public Health. 2008;98(6):1004–6.
Needham., B. (2012) Sexual attraction and trajectories of mental health and substance use during the transition from adolescence to adulthood. J Youth Adolesc. 2012;41(2):179–90.
Pachankis., J., E & Goldfried., M., R. (2006) Social anxiety in young gay men. Journal of Anxiety Disorders, 20, 996-1015.
Pachankis., J., E. (2007) The psychological implications of concealing a stigma: A cognitive-affective-behavioral model. Psychological Bulletin, 133, 328-345.
The Centre for Disease Control and Prevention (2014) Lesbian, Gay, Bisexual, and Transgender Health Data, retrieved from https://www.cdc.gov/lgbthealth/index.htm - accessed 11th October 2018.
Trocki., K., F (2005) Reports of Alcohol Consumption and Alcohol-Related Problems among Homosexual, Bisexual and Heterosexual Respondents: Results from the 2000 National Alcohol Survey’ in Journal of Studies on Alcohol 66(1).
An experienced (c15 years) Mental Health Practitioner, Andi’s specialisms are Autism and Dementia Care, as well as having a strong interest in disability advocacy, sociology and equality.
Andi currently works in Education as a subject specialist and, as well as assessing achievement and participating in Internal and External Quality Assurance, helps to develop qualifications for Awarding Organisations.
In September 2017, Andi commenced the Master of Arts in Social Work at Sussex University.