Healthcare and young people: challenges relating to gender and sexual identity

Healthcare environments are by default heteronormative and like other societal spaces, contribute to the isolation, exclusion and erasure of young people who are gender (transgender, non-binary, gender fluid for example) and sexual minorities (lesbian, gay, bisexual and pansexual for example). Simple changes in individual healthcare approaches can help mitigate some of the negativity faced by this cohort and reduce the additional disadvantages faced by gender and sexual minorities who are also from Black and Minority Ethnic (BME) communities, those with disabilities and those from deprived socio-economic neighbourhoods.

What is happening in the National Health Service (NHS) in the UK?

  1. Three in five NHS staff do not believe sexual orientation is relevant to healthcare.
    Three quarters of staff have not received any training in health needs of gender and sexual minority patients.
  2. 25% of front line staff have heard colleagues express homophobic, transphobic and biphobic opinions.
  3. The Government National LGBT Survey Report showed a lack of understanding about and commitment to the needs of gender and sexual minorities who try to access healthcare services across specialisms.
  4. There is a lack of awareness that being a gender and sexual minority does not in itself cause mental health problems or create health inequalities. It is the result of the negative environments that LGBT+ young people grow up in and have to navigate.
  5. Only half of young LGBT+ people feel safe and supported in the NHS and more than half have experienced NHS staff making incorrect assumptions about their identity. As a result many seek help from friends and the internet which means that information received is not always safe or accurate.

Wider health needs of LGBT+ young people

Overall health LGBT+ young people are less likely to access sports clubs and exercise facilities due to homophobic experiences, gender-specific rules, bullying and harassment in same-sex changing facilities. This continues into later life. Therefore LGBT+ people are less likely to have safe spaces to keep healthy. This can contribute to the higher prevalence of disorders in eating practices and a greater degree of substance abuse.

Stress LGBT+ young people have a higher prevalence of persistently elevated levels of stress due to stigma, bullying, concealment of identity and internalisation of negative attitudes. Remember that they are also faced with general stressors associated with adolescence such as academic and social pressures. So these can compound the problem which means that the prevalence of suicide ideation, depression, anxiety and self-harm among LGBT+ young people is much higher than their heterosexual peers.

Uncertain homelife The majority of young LGBT+ people still hide their gender and sexual identity at home. These young people tend to have higher rates of self-harm and are more likely to be forced to leave home when they come out to their parents. Perceived and actual discrimination contributes to a reluctance to seek help. In addition, many LGBT+ who are also religious or from faith backgrounds are unable to reach out to spiritual leaders for fear of being ostracised.

What can healthcare staff commit to do?

Inclusive language: Respect chosen names and pronouns. This is a crucial part of identity and asking a trans and non-binary young person what pronouns they prefer is important as a sign of respect and building trust. Misgendering causes significant distress to young trans people and is likely to seriously affect the patient-healthcare worker relationship also. Use inclusive language in all patient and family communications. Not making assumptions about patients’ identities, and adapting the way you listen and speak, will reduce both experienced and perceived stigma and discrimination in healthcare.

Confidentiality: expect to reassure LGBT+ young people numerous times about confidentiality. Do not be dismissive about their anxiety and fears. Affirm any disclosed identity and offer acceptance and support wherever possible. Make sure you are sensitive to the needs of BME LGBT+ young people who often find it harder to talk about their gender and sexual identity because of the additional experience of race discrimination and prejudice compared to their white peers. The same applies to those with mental health concerns.

Visible signifiers: display posters and resources supporting LGBT+ young people and families. If you have rainbow lanyards or pin badges or pronoun badges do try to wear them. Encourage all staff in your area to have signifiers available – not all LGBT+ young people will be out, but just seeing the signifier can help them feel less anxious and afraid.

Education: seek out and undertake regular education opportunities to embed learning about gender and sexual diversity. Make sure there are trained allies in your team who can help new staff learn as they work. Encourage inclusion of LGBT+ young people issues in undergraduate and postgraduate curricula. Make sure any spiritual support workers have been trained in LGBT+ inclusion and awareness. Contact the Equality team for Q&A sessions or regular training to make sure all your staff are aware of issues faced by LGBT+ young people and that they regularly think about those issues.

Transgender history: it is inappropriate to ask questions about a patient’s gender if it is unrelated to their medical presentation. It would be appropriate to ask what name the patient would like to be called, and which pronouns they use. Make a note in the records and ensure all staff use the correct pronouns and names.

Terminology

Gender and sexual diversity (GSD): relates to a person’s many facets – biological sex, gender identity and expression, and sexuality. It is a term used to recognise human diversity across these dimensions.

Gender and sexual minorities (GSM): are people whose gender, sexual orientation or biological sex characteristics differ from what is typically expected by a culture or society. GSM may not identify as lesbian, gay, bisexual and transgender (LGBT). For example there are many men who have sex with men (MSM) who do not identify as gay or bisexual. Some women who enjoy romantic or sexual relationships with both women and men may not identify as bisexual. A person can have any number of reasons for choosing to describe themselves as something other than LGBT and this should be respected. In some parts of the world, it is because that person lives in a restrictive legal environment that would place them at risk if they openly identified as LGBT. GSM are treated unfairly in almost every society. This unfair treatment includes stigma and discrimination which directly impacts health and interferes with access to healthcare services.

LGBT+: lesbian, gay, bisexual, transgender. The ‘t’ signifies it is an inclusive phrase that encompasses a number of other identities. LGBT+ incorporates the spectrum of gender and sexual minority identities.

Pronouns: used to refer to a person you are talking about (e.g. he/him or she/her). People can choose the pronouns they feel most comfortable with using, and these should be respected at all times. Gender-neutral pronouns are pronouns which do not associate a gender with the person being talked about (e.g. they/them or xe/xim).

References

Coker TR, Austin SB, Schuster M (2010) The health and health care of lesbian, gay and bisexual adolescents. Annual Review of Public Health 31, 457

Juster RP, Hatzenbuehler ML, Mendrek A et al. (2015) Sexual orientation modulates endocrine stress reactivity, Biological Psychiatry 77:668-76

Scourfield J, Roen K, McDermott L (2008) Lesbian, gay, bisexual and transgender young people’s experiences of distress: resilience, ambivalence and self-destructive behaviour. Health Social Care Community 16, 329-36

Summervile C. (2016) Unhealthy Attitudes: Stonewall

Transgender Equality. (2016) In House of Commons Womens and Equality Committee. London: The Stationery Office Limited.

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