The Royal Australian and New Zealand College of Psychiatrists (RANZCP) is concerned that a disproportionate number of Australia and New Zealand’s lesbian, gay, bisexual, trans, intersex and queer/questioning (LGBTIQ+) populations experience mental illness and psychological distress. Evidence shows that the discrimination and marginalisation experienced by LGBTIQ+ people increases the risk of developing mental health issues, and also creates barriers to accessing supportive services. This position statement provides an overview of some of the key issues relevant to mental health and LGBTIQ+ identity, and makes recommendations for enhancing the mental health sector’s responsiveness to the needs of LGBTIQ+ people.
- A disproportionate number of Australia and New Zealand’s LGBTIQ+ populations experience mental illness and psychological distress.
- People who identify as LGBTIQ+ are at increased risk of exposure to institutionalised and interpersonal discrimination and marginalisation which increases vulnerability to mental illness and psychological distress.
- LGBTIQ+ identity has historically been criminalised, pathologised and invisibilised by the legal and medical institutions of Australia and New Zealand although many of these institutions are becoming increasingly inclusive.
- Mental health policy and practice for LGBTIQ+ people should be informed by the prevalence and aetiologies of mental disorder and distress among this population group, along with consideration of the need for culturally competent and sensitive services.
- Particular consideration should be given to the needs of individual population groups within LGBTIQ+ populations including young people, older people, and Indigenous people.
- Using the right terminology is important when discussing issues of sexual orientation, and sex and gender identity. Which term is correct can vary considerably according to time, community attitudes and individual preferences.
The RANZCP acknowledges the importance of using appropriate terminology when discussing issues of sexual, sex and gender identity (Smith et al., 2014). Inclusive language engenders respect and promotes visibility for important issues, and this is integral to improving the health of the LGBTIQ+ population (AHRC, 2015). The text box below provides an overview of some key terms used in Australia and New Zealand. Clinicians should, however, be mindful of the importance of individual preferences regarding terminology and identity, as well as preferred pronouns. Clinicians should never refer to someone with the use of terms or pronouns against the individual’s wishes. For example, an individual may wish for the pronouns ‘they/them’ to be used, so as to avoid gendering, and this should be respected. Clinicians should also be aware of the rapidity with which language and terminology can change and develop in this area. Clinicians should undertake additional research or inquiry with relevant organisations as appropriate (please refer to the list of resources below for more information).
Key terminology in Australia and New Zealand
- The acronym LGBTIQ+ refers collectively to people who are lesbian, gay, bisexual, trans, intersex, queer (see below) or questioning (those who are exploring their orientation and identity). The ‘+’ is used to include people with alternative sexual, orientation, or sex or gender identities who do not identify with the terms contained within the ‘LGBTIQ’ acronym.
- The term LGBTIQA+ may also be used. The ‘A’ may refer to people who identify as asexual (LGBTQIA+ Resource Center, 2018) or alternatively to allies of LGBTIQ+ communities (Kelly, 2014).
- The word queer can be used to refer to a sexual or gender identity that is non-binary. The term has been historically used as a derogatory word but has recently been ‘reclaimed’ by some individuals as a political term as a means of challenging homophobia. People may therefore have varying relationships to the word, and some may find it offensive (Smith et al., 2014).
- Sexual diversity can include people who are lesbian, gay or bisexual, as well as a range of other expressions of sexuality. This may include people who identify as asexual (experiencing an absence of sexual attraction, distinct from celibate) or pansexual (experiencing sexual or romantic attraction that is not based on gender identity or sex) (Smith et al., 2014).
- Trans, or TGD (trans and gender diverse) are commonly used to describe a broad range of non-conforming gender identities or expressions including transgender, agender (having no gender), bigender (identifying as both a woman and a man), or non-binary (neither woman nor man).. The term transsexual may be used to refer to a person who has an internal sense of gender that differs from their birth sex. Some people may describe themselves as MTF/M2F (male-to-female), FTM/F2M (female-to-male), AFAB (assigned female at birth) or AMAB (assigned male at birth). The terms genderqueer and gender fluid are also used to refer to shifting gender identity.
- Using preferred names and pronouns is important for TGD people. This may be ‘he/him’, ‘she/her’, ‘they/them’ or ‘zi’/zem’.
- Some Aboriginal and Torres Strait Islander peoples use the term sistergirl to refer to male-assigned people who live partly or fully as women and brotherboy to refer to female-assigned people who live partly or fully as men (Smith et al., 2014).
- Takatāpui as a self-descriptor is often used by Māori to describe non-binary gender and/or sexual identity. Specific meaning can vary depending on context (Henrickson, 2006).
- People born with intersex variations encompass a diversity of experiences. Intersex traits are a naturally occurring biological phenomenon, with at least 40 different variations. People may use diagnostic or chromosomal labels for their variations, including XXY, Complete Androgen Insensitivity, XY Woman, Swyer Syndrome or Turner Syndrome (OII Australia, 2009).
Statistical information about LGBTIQ+ populations in Australia and New Zealand is limited. It is estimated that 9% of Australian men and 15% of Australian women report same-sex attraction (Rosenstreich, 2013). At the 2016 Australian Census there were around 46,800 same-sex couples, representing around 1% of all couples in Australia (ABS, 2016). Equivalent statistics are not currently available for New Zealand though questions about sexual identity are being considered for inclusion in the 2018 census (Statistics New Zealand, 2018).
Statistical information on gender diversity in Australia and New Zealand is scarcer still although how best to gather this information is being considered for both the Australian and New Zealand censuses (Statistics New Zealand, 2018; ABS, 2018). One study of New Zealand high school students found that approximately 1.2% identify as trans (Hyde, 2014).
There are no firm figures for people with intersex variations, and estimates range considerably although 1.7% of the population is broadly accepted as an evidence-based approximation (OII Australia, 2013).
LGBTIQ+ identity has historically been criminalised, pathologised and invisibilised by the legal and medical institutions of Australia and New Zealand. Many gay or bisexual Australian and New Zealander men have a lived experience of sodomy laws, which were repealed in 1986 in New Zealand and between 1975 and 1994 in the various jurisdictions of Australia (Crameri et al., 2015). Approximately 72 countries worldwide continue to legislate against homosexuality, including 8 where homosexuality is punishable by death (Duncan, 2017).
Many LGBTIQ+ people also have a lived experience of their sexual identity being defined as a mental disorder or abnormality. The Diagnostic and Statistical Manual of Mental Disorders (DSM) included homosexuality in its diagnostic classifications until 1973, and ‘ego-dystonic homosexuality’, indicated by a persistent lack of heterosexual arousal causing distress, until 1987 (Mendelson, 2003). Similarly, the International Statistical Classification of Diseases and Related Health Problems (ICD) previously included homosexuality as a ‘sexual deviation’ or ‘mental disorder’. ICD-10, published in 1992, included diagnosis code F66, ‘sexual maturation disorder’; indicated by experience of uncertainty about gender identity or sexual orientation which causes anxiety or depression (Mendelson, 2003). ICD-11 has undergone significant revisions to ensure that disorders relating to sexuality and gender identity reflect contemporary evidence while appropriately distinguishing between health conditions and private behaviours (Reed et al., 2016).
Legal and medical institutions are becoming increasingly inclusive. Same-sex marriage was legalised in New Zealand in 2013 and in Australia in 2018. The RANZCP supports marriage equality based on the evidence that legislative inequality has a significant and deleterious impact on mental health (beyondblue, 2015; Obergefell v. Hodges, 2015) and conversely, that there is a strong link between improved health outcomes and legislative change of this sort (Kealy-Bateman and Pryor, 2015; PHAA, 2015). Further, sexual orientation change efforts, or other often non-consensual therapies intended to change the sexual orientation of a person, are now broadly understood to be harmful and unethical (RANZCP, 2015).
There is still a significant amount of work to be done in fostering more inclusive institutions, however, and this is discussed below in more detail. Greater awareness of intersex and gender diverse identities in particular is urgently needed to begin to address the high vulnerability and low mental health outcomes of these groups.
People who identify as LGBTIQ+ are at increased risk of exposure to institutionalised and interpersonal discrimination and marginalisation which in turn increases vulnerability to mental illness and psychological distress (King and Nazareth, 2006). Mental health outcomes for the LGBTIQ+ populations of Australia and New Zealand are amongst the lowest of any demographic (Chakraborty et al., 2011).
In Australia, LGBTIQ+ people have very high rates of suicidality. One study have found current suicidal ideation is experienced by 20% of trans people and 15.7% of lesbian, gay and bisexual people (Rosenstreich, 2013). However, these numbers increase dramatically among subpopulations; for example, one study found 38% of young trans and gender diverse people experienced suicidal ideation (Smith et al., 2014) while another found that 84% of AFAB/FTM people had thought about suicide with 35% attempting it (Jones et al., 2014).
LGBTIQ+ people also experience high rates of mental illness. One study into the mental health of trans and gender diverse people found more than half of participants (57.2%) had been diagnosed with depression during their lives, the majority of which (43.7%) were experiencing clinically significant depressive symptoms at the time. The study also found high lifetime rates of anxiety diagnoses (39.95%). Same-sex attracted people are up to twice as likely to experience anxiety disorders and three times more likely to experience affective disorders compared with the broader population (Rosenstreich, 2013; ABS, 2007).
In New Zealand, LGBTIQ+ people are similarly vulnerable. Gay men experience mental health problems at over five times the rate of opposite-sex attracted men, with an estimated 28.6% of same-sex attracted men having attempted suicide and 71.4% reporting suicidal ideation, compared with 1.6% and 10.9% of heterosexual men respectively (Adams et al., 2013). A survey of New Zealand secondary students found that 20% of same-sex attracted students had attempted suicide in the past year, compared with 4% of their opposite-sex attracted peers (Rossen et al., 2009).
The birth of an intersex child continues to be treated as a ‘psychosocial emergency’, leading to non-essential medical interventions from infancy (Latham and Barrett, 2015). Across Australia and New Zealand it has been found that intersex adults exhibit psychological distress at levels comparable with traumatised non-intersex women, such as those who have experienced severe physical or sexual abuse (Rosenstreich, 2013).
Considerations for mental health policy and practice
Diversity of experience
Concern that medical professionals will not have an understanding of their identity is commonly identified by LGBTIQ+ people as one of the key barriers to accessing timely supports (Smith et al., 2014). Psychiatrists should maintain an up-to-date understanding of the key issues for this population, including an understanding of the prevalence of mental health issues, as well as the importance of making sensitive enquiry, avoiding assumptions, and using inclusive language.
Different groups will have various specific needs and sensitivities linked to personal and historical backgrounds. For example, international research shows that bisexual people have the highest rate of mental health issues of any sexual identity group, and often experience marginalisation and discrimination in ways distinct from people who are gay or lesbian (Barker et al., 2012). People
Mental health and related services must be safe spaces for LGBTIQ+ people. That is often not the case with many people too fearful to disclose matters relating to their sexual identity and relationships. This presents a significant barrier to care, leaving many people without access to services with which they feel comfortable enough to explore sensitive health matters. Tis may be particularly so in rural areas where access to culturally competent services may be limited with privacy considerations further compounding access issues.
Health, aged care, child and adolescent, family violence and other services should take steps to promote inclusiveness and cultural safety for LGBTIQ+ people (Crameri et al., 2015). This includes ensuring assessment forms, databases and other mechanisms for collecting information avoid assumptions and discriminatory language (Ansara, 2015). Services should also consider registering with relevant LGBTIQ+ health directories and displaying inclusive signage. Services should make reasonable steps to accommodate the needs of LGBTIQ+ consumers, including recognising partners, addressing personal care issues and ensuring privacy.
Children and adolescents
During adolescence, young people undergo biopsychological development phases during which they must establish their social and sexual identities. This can be a particularly challenging period for young LGBTIQ+ people, and a time of heightened vulnerability to mental health issues (Smith et al., 2014).
At this critical juncture, experience of homophobia, transphobia and heteronormativity can be devastating (Robinson et al., 2014). An Australian survey of gender variant and sexually diverse young people found that almost two thirds had experienced homophobia and/or transphobia, and that more than two in five young people interviewed had had thoughts of self-harm (41%) and/or suicide (42%). In addition, 33% of respondents reported having self-harmed in the past, and 16% had attempted suicide (Robinson et al., 2014). LGBTIQ+ young people are at particularly high risk of suicide in the period prior to ‘coming out’, or identifying oneself as LGBTIQ+ to others (Rosenstreich et al., 2013). Family support and acceptance can enhance outcomes for LGBTIQ+ children and adolescents across a range of indicators (Smith et al., 2014).
For children and adolescents experiencing gender dysphoria, puberty can be a time of particularly severe emotional distress. Child and adolescent psychiatrists are the primary care managers and decision-makers for this group, in collaboration with other specialists such as paediatric endocrinologists (Australian Paediatric Endocrine Group, 2010). International consensus guidelines recommend that adolescents who fulfil minimum criteria undergo treatment to (reversibly) suppress puberty, generally with the use of gonadotrophin releasing hormone (GnRH) analogues (WPATH, 2012; Hembree et al., 2009). Evidence suggests good outcomes associated with this approach (Wallien and Cohen-Kettenis, 2008). In New Zealand, this can be undertaken following rigorous assessment and diagnosis, and after obtaining informed consent (Counties Manukau District Health Board, 2012). In Australia, it should occur in accordance with treatment guidelines from the Royal Children’s Hospital Melbourne (Telfer et al., 2018).
Mainstream health services may not always seem relevant or accessible to LGBTIQ+ children and adolescents, many of whom report feeling uncomfortable about approaching, and having to ‘come out’ to, health professionals (Robinson et al., 2014). One study of gender diverse and transgender young people in Australia found that over half had experienced at least one negative experience with a healthcare professional, and one quarter of the participants avoided medical services due to their gender presentation.
LGBTIQ+ identity and ageing
Many older LGBTIQ+ people have a lived history of direct discrimination by legal and medical institutions, as discussed above. These experiences can create ongoing barriers to accessing aged care, mental healthcare and other supports (Brown et al., 2015). Older LGBTIQ+ people experience anxiety regarding whether their needs will be met in a dignified manner as they age, and some report feeling forced ‘back into the closet’ due to the lack of availability of inclusive services (Latham and Barrett, 2015).
With an increasing proportion of the populations of Australia and New Zealand aged over 65, mental health and aged care facilities must consider the needs of the ageing LGBTIQ+ population. This includes how LGBTIQ+-specific needs intersect with dementia, personal care needs, end-of-life decision-making and advance care plans (Barrett et al., 2015; Hughes and Cartwright, 2015).
Visibility in data and research
There are many gaps in administrative data and generic research relating to LGBTIQ+ populations. More consistent statistical information is required, as well as more research into LGBTIQ+ mental health, including protective factors, comorbidity, effective interventions and specific issues faced by high-risk population groups (Rosenstreich, 2013). Enhanced statistics and research must be carefully balanced with the entitlement of each person to privacy and dignity and undertaken with sensitivity and awareness (Imran, 2012).
Sexual and family violence
Statistics indicate that LGBTIQ+ people experience family and sexual violence at rates similar to, or higher than, heterosexual women (Fileborn and Horsley, 2015). Despite this, current policy and program responses to family violence tend to be geared towards heterosexual relationships, with some notable exceptions (see additional resources below). A Senate inquiry into family violence in Australia found a lack of data, reporting and understanding of the impact of violence in LGBTIQ+ communities as well as a lack of services and programs. Of particular concern is the acute shortage of appropriate housing for LGBTIQ+ survivors of family violence (SFPAC, 2015).
Aboriginal and Torres Strait Islander and Māori LGBTIQ+ people
People from Aboriginal and Torres Strait Islander or Māori backgrounds who are LGBTIQ+ often face particularly complex layers of discrimination and identity (Tovey, 2015). A small number of remote, traditional Aboriginal and Torres Strait Islander cultures, such as the Tiwi Islands, have traditionally included and supported people of diverse gender identities. However, many other LGBTIQ+ Indigenous people experience multiple levels of marginalisation and discrimination (National LGBTI Health Alliance, 2013). Some may face rejection from their community, or alternatively be required to renegotiate cultural and spiritual standing, including gender-specific roles in ceremonies and the community, and the passing on of knowledge (Creative Spirits, 2015). Similar issues may be faced by LGBTIQ+ people from other culturally and linguistically diverse communities.
- Psychiatrists should maintain an up-to-date understanding of LGBTIQ+ issues, including appropriate referral pathways should specialised support be required. Psychiatrists should be mindful of balancing the sometimes diverse views of the consumer and their family or carer.
- In undertaking clinical assessment and interviews, psychiatrists should ensure enquiries into LGBTIQ+ identities are undertaken with sensitivity, avoiding assumptions in language and approach.
- All training programs for medical, nursing and other health service staff should include basic cultural sensitivity training for LGBTIQ+-specific issues such as how to elicit disclosures and remove heteronormative biases from interviewing methods.
- The needs of LGBTIQ+ people should be included in all national health frameworks and strategies with consideration given to the benefits of health promotion strategies service accreditation standards for the provision of culturally appropriate services for the LGBTIQ+ communities.
- Services should make reasonable steps to accommodate the needs and ensure the cultural safety of LGBTIQ+ people.
- Services for older people should consider the intersection of LGBTIQ+ identities with issues such as dementia, end-of-life decision-making and advanced care plans.
- Services for children and adolescents should maintain an awareness of the particular stressors faced by LGBTIQ+ young people, including issues to do with ‘coming out’, experience of bullying and the potentially traumatic experience of puberty for gender diverse young people.
- Services working with Aboriginal and Torres Strait Islander peoples and Māori who identify as LGBTIQ+ should in particular consider the intersection of LGBTIQ+ identities with issues such as traditional gender roles, community acceptance and the impact of multiple layers of discrimination.
- Enhanced statistical information and research into LGBTIQ+ mental health is required which should be undertaken with sensitivity and awareness.
- Services for LGBTIQ+-specific services, including for LGBTIQ+ people experiencing sexual and family violence should be supported with ongoing funding.