Recognising and addressing the mental health needs of the LGBTIQ+ population

Purpose 

This position statement provides an overview of issues relevant to mental health care for lesbian, gay, bisexual, trans, intersex and queer/questioning (LGBTIQ+) people in Australia and New Zealand, and makes recommendations for enhancing the mental health sector’s responsiveness to their needs. Such improvement is needed because a disproportionate number of Australia and New Zealand’s LGBTIQ+ people experience mental illness and psychological distress. The discrimination and marginalisation experienced by LGBTIQ+ people increases the risk of developing mental health conditions, and also creates barriers to accessing supportive services.

Definition

The acronym LGBTIQ+ refers collectively to people who are lesbian, gay, bisexual, trans, intersex, ‘queer’ (see below) or ‘questioning’ (exploring their orientation and identity), as well as people with alternative sexual, orientation, or sex or gender identities who do not identify with the other terms.

Sexual orientation refers the people toward whom one is sexually or romantically attracted, and is a separate concept from gender identity.[1]

Intersex traits are a naturally occurring biological phenomenon, with at least 40 different variations including XXY, complete androgen insensitivity, Swyer Syndrome and Turner Syndrome.

Terminology

The RANZCP acknowledges the importance of using appropriate terminology when discussing issues of sexual, sex and gender identity.[2] Inclusive language engenders respect and promotes visibility for important issues, and this is integral to improving the health of LGBTIQ+ people.[3] The key terminology section below provides an overview of some key terms used in Australia and New Zealand.

It is important to be mindful of the importance of individual terminology preferences when talking about someone’s sexual orientation or gender identity. Using the individual’s preferred terms, especially pronouns, is very important for trans, gender diverse and non-binary people. Healthcare providers should not refer to someone using terms or pronouns that are against the individual’s wishes. For example, an individual may wish to be referred to by the pronouns ‘they and them’ so as to avoid the gendered pronouns ‘she’ and ‘he’, and this should be respected. It is important to also be aware of the rapidity with which language and terminology can change and develop in this area, and to consider additional research or inquiry with relevant organisations as appropriate (please refer to the list of resources below for more information).

Key terminology

• 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 or alternatively to allies of LGBTIQ+ communities.[4, 5]
• The word queer can be used to refer to a sexual or gender identity that is non-binary. Historically a derogatory term, the word has recently been ‘reclaimed’ by some individuals as a means of challenging prejudice.[2] People may therefore have varying reactions to the word and some find this offensive.[2]
• Sexually diverse people include those 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).[2]
• People born with intersex variations may choose to use diagnostic or chromosomal labels for their variations, including XXY, Complete Androgen Insensitivity, XY Woman, Swyer Syndrome or Turner Syndrome, but many reject medical terms that include the word ‘disorder’ (e.g. disorders of sex development’).[6]
• Homophobia encompasses a range of negative attitudes and feelings such as hatred, disgust, contempt, prejudice and fear towards those who identify as, or are perceived as being non heterosexual.[7]
• Transphobia is hatred, disgust, contempt, prejudice or fear expressed towards people who are gender variant.[7]
• 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). 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 term genderqueer is used to refer to gender identity that does not conform to sociocultural norms. Gender fluid is used to refer to gender identity which shifts over time.
• For TGDNB (trans, gender diverse and non- binary) people, preferred pronouns may include ‘he/him’, ‘she/her’, ‘they/them’ or neopronouns like ‘zi/zem’.
• Some Aboriginal and Torres Strait Islander peoples use the term sistergirl to refer to sex assigned at birth males who live partly or fully as women and brotherboy to refer to sex assigned at birth females who live partly or fully as men.[2]
• 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.[8] There are several Māori words for transgender people, including whakawahine (trans woman) and whakatāne (trans man).[9]
• In Pacific Island cultures, there are a number of gender-diverse identities including the Samoan fa’afafine and Tongan fakaleiti.[10]
• Gender variance: expressions of gender that do not match that predicted by one’s sex, including people who identify as transgender, transsexual, gender queer, or intersex.[7]
  
  

Population

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 or having had sexual contact with someone of the same sex, although only approximately 2% actually identify as lesbian, gay or bisexual.[11]

At the 2016 Australian Census there were around 46,800 same-sex couples, representing around 1% of all couples in Australia. [12] Limited statistics on sex, gender and sexual orientation are available in New Zealand.[13] The 2018 General Social Survey found 1.1% of New Zealanders identified as gay/lesbian, with 1.9% identifying as bisexual.[14]

Statistical information on gender diversity in Australia and New Zealand is limited. How best to gather this information is being considered for both the Australian and New Zealand censuses.[13, 15] One study of New Zealand high school students found that approximately 1.2% identify as trans.[16]

There are no reliable figures for people with intersex variations, and estimates range considerably, although 1.7% of the population is broadly accepted as an evidence-based approximation.[17]

Background

Human sexuality is diverse. People can be lesbian, gay, or bisexual or a range of other expressions of sexuality. People who identify as LGBTIQ+ identity have historically been criminalised, pathologised and made invisible 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.[18, 19] More than 60 countries worldwide continue to criminalise consensual same-sex conduct, including five where the death penalty may be imposed.[20]

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. [21] 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.[21]
Sexual orientation change efforts (‘conversion’ or ‘suppression’ therapy) or other often non- consensual therapies intended to change a person’s sexual orientation to heterosexual, are now broadly understood to be harmful and unethical.[22]

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.

A number of Australian jurisdictions and New Zealand have implemented legislative change in order to allow variation to sex on birth certificates without a person first having to undergo surgery. [23-25] In some jurisdictions, sex on birth certificate change can be made by self-determination without having undergone hormonal therapy and without a report from a health professional.

There is still a significant amount of work to be done in fostering more inclusive institutions. 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 poorer mental health outcomes of these groups.

Evidence

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.[26] Mental health outcomes for the LGBTIQ+ populations of Australia and New Zealand are amongst the poorest of any demographic.[27] However, it is important to note that poor mental health is not inherent in LGBTQI+ identities.[28]

LGBTIQ+ people around the world experience high rates of mental illness. In a retrospective study, Reisner et al (2015) found higher rates of depression, anxiety, suicidal ideation and self-harm in youth who identified as transgender.[29]

An Australian study of 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 (43.7%) of whom were currently experiencing clinically significant depressive symptoms.[30] The study also found high lifetime rates of anxiety diagnoses in this cohort (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.[11, 12]

In Australia, LGBTIQ+ people have very high rates of suicidality. One study has found current suicidal ideation was experienced by 20% of trans people and 15.7% of lesbian, gay and bisexual people.[11] However, these numbers increase dramatically among various LGBTIQ+ groups. A recent survey among Australian trans and gender-diverse young people aged 14–25 years reported that 79.7% of participants had self-harmed, and 48.1% of trans young people had attempted suicide.[31] A study of female-to-male transgender people found over 80% of participants had thought about suicide and 35% had attempted it.[32]

In New Zealand, many LGBTIQ+ people also experience poor mental health outcomes. A national survey found a third of people who identified as bisexual experienced poor mental wellbeing, compared with 22% of straight/heterosexual people and 21% of gay or lesbian people.[14] In a survey of trans and non-binary people, over a third had attempted suicide in their life and 12% had attempted suicide in the past year.[33]

The birth of an intersex child continues to be unnecessarily treated as a ‘psychosocial emergency’, leading to non-essential medical interventions from infancy.[34] 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.[11] 

Considerations for mental health policy and practice

Diversity of experience

Concern that medical professionals will not understand their identity is commonly identified by LGBTIQ+ people as one of the key barriers to accessing timely supports.[2] Psychiatrists should maintain an up-to-date understanding of the key issues for this population, including the prevalence of mental health conditions and the importance of making sensitive enquiry, avoiding assumptions, and using inclusive language.

Different groups within the LGBTIQ+ population will have various specific needs and sensitivities linked to personal and historical backgrounds.

Cultural competence

Mental health and related services must be safe spaces for LGBTIQ+ people. This is often not the case, with many people too fearful to disclose matters relating to their sexual identity and relationships. This fear presents a significant barrier to care, leaving many people without access to services with which they feel comfortable to explore sensitive health matters. This may be exacerbated in rural areas where access to culturally safe and culturally competent services may be limited, with privacy considerations further compounding barriers to access.[35, 36]

An important aspect to providing culturally safe care is self-reflection. Practitioners should reflect on their own biases, the assumptions that they may have about sex, sexuality and gender, and how their views might impact their work, especially with LGBTIQ+ people.[37, 38]

Health, aged care, child and adolescent, family violence and other services should take steps to promote inclusiveness and cultural safety for LGBTIQ+ people.[18, 35, 36] This includes ensuring assessment forms, databases and other mechanisms for collecting information avoid assumptions and discriminatory language.[35, 36, 39] 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+ people, including recognising a person’s partner, addressing personal care issues and ensuring privacy.

Children and adolescents

During adolescence, young people develop 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.[2, 40]

At this critical juncture, experience of homophobia, transphobia and heteronormativity can be devastating.[7] In 2014, an Australian survey of gender variant and sexually diverse young people found that almost two thirds had experienced homophobia.[7] In 2021, an Australian survey of young people identifying as LGBTIQA+ found participants reported high levels of psychological distress, poor mental health and suicidality, with almost two-thirds of participants reported having ever been diagnosed with a mental health condition. One in 10 participants reported having attempted suicide in the past 12 months, and one in four had attempted suicide at some point in their life. Recent suicide attempts were most prevalent amongst trans and gender diverse participants. [40] LGBTIQ+ young people are at particularly high risk of suicide in the period identifying themselves as LGBTIQ+ to others (‘coming out’).[11]

Family/whānau  support and acceptance can enhance outcomes for LGBTIQ+ children and adolescents across a range of indicators.[2, 41, 42]

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.[7] 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 around one quarter of the participants reported having avoided medical services due to this experience.[2] In New Zealand, around 6% of same- or both-sex attracted secondary students reported that they did not go to the doctor due to worries about the doctor’s views on their sexual orientation, or fear that the doctor would disclose their sexuality to others.

Access was a bigger issue for same- or both-sex attracted students; over one-third reported that they had not been able to access health care in the last 12 months when they had wanted to, compared with around 18% of opposite-sex attracted students.[43]

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.[44] 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.[3, 45] 

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.[46, 47]

Visibility in data and research

Detail relating to LGBTIQ+ populations is currently lacking from administrative and generic research data. These gaps impact on policy, practitioners, and funding for these 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.[11, 48] The need for enhanced statistics and research must be carefully balanced with the entitlement of each person to privacy and dignity, and such data collection and research undertaken with sensitivity and awareness.[49] Data collection must also allow for capturing the diversity within LGBTIQ+ populations.[48]

Sexual and family violence

Statistics indicate that LGBTIQ+ people experience family and sexual violence at rates similar to, or higher than, heterosexual women.[33, 50] 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.[51]

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.[52] In Māori culture, and a small number of remote, traditional Aboriginal and Torres Strait Islander cultures, such as the Tiwi Islands, people of diverse gender or sexuality have traditionally been included and supported.[53]

Many other LGBTIQ+ Indigenous people experience multiple levels of marginalisation and discrimination and in some cases 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.[54, 55] Similar issues may be faced by LGBTIQ+ people from other culturally and linguistically diverse communities.

Strengths among the LGBTIQ+ populations and protective factors

While LGBTIQ+ populations often experience discrimination and inequities in health outcomes, it is important to also acknowledge their strengths, and be aware of factors that support positive mental health outcomes. For example, as mentioned above, support from and connection with family/whānau can be a strong protective factor. Where appropriate, health services can provide information and advice to family/whānau on how to support their child.[2, 41] People may also gain strength and support from their LGBTIQ+ community, and a deep sense of pride through expressing their identity. [37]

Supporting intersex people

Psychiatrists and mental health services should recognise and validate intersex identities, with awareness of individuality and complexity. Decisions about the medical and surgical care of intersex babies, children, adolescents, and adults should be informed by perspectives of lived experience, human rights, dignity, family and cultural perspectives, thorough informed consent, and the avoidance of unnecessary interventions. Psychiatrists and mental health multidisciplinary teams can support people, families, and clinicians to tolerate uncertainty and celebrate diversity.

Recommendations

• The needs of LGBTIQ+ people should be included in all national health frameworks and strategies.
• Health services should take steps to accommodate the needs and ensure the cultural safety of LGBTIQ+ people.
• All training programs for medical, nursing and other health service staff should include cultural sensitivity training in LGBTIQ+-specific issues, including how to create a safe space for people to talk about their identity, the importance of using chosen name and pronouns consistently, and removing heteronormative biases from interviewing methods.
• Consideration should be given to the benefits of health promotion strategies and service accreditation standards for the provision of culturally appropriate services for LGBTIQ+ 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 divergent views of the individual and their family/whanau. 
• In undertaking clinical assessment and interviews, psychiatrists should reflect on their practice to ensure it is inclusive of diverse sexual and gender identities and that their language and approach avoids heteronormative or gender-binary assumptions.
• 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 people, Māori and people from other ethnic minorities who identify as LGBTIQ+ should consider the intersection of LGBTIQ+ identities with issues such as traditional gender roles, community acceptance and the impact of multiple layers of discrimination.
• LGBTIQ+-specific services, including for LGBTIQ+ people experiencing sexual and family violence should be supported with ongoing funding.
• 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.
• Psychiatrists and mental health services should recognise and validate intersex identities, with awareness of individuality and complexity. Decisions about the care of intersex babies, children, adolescents, and adults should be evidence-based and informed by perspectives of lived experience, human rights, dignity, family, and cultural perspectives, through informed consent, and the avoidance of unnecessary interventions.
• Psychiatrists must have regard to the relevant laws and professional standards in relation to assessing capacity and obtaining consent, including the RANZCP Code of Ethics.
• Enhanced statistical information and research into LGBTIQ+ mental health is required which should be undertaken with sensitivity and with individual and community consultation and participation. 

Additional resources

• RANZCP Position Statement 60: Sexual orientation change efforts
• Australian Professional Association for Trans Health (AusPATH): Peak body for professionals involved in the health, rights, and well-being of trans, gender diverse and non-binary people.
• Professional Association for Transgender Health Aotearoa (PATHA): Professional organisation working to promote the health, wellbeing, and rights of transgender people.
• World Professional Association for Transgender Health (WPATH): Non-profit, interdisciplinary professional and educational organisation devoted to transgender health.
• American Medical Association’s LGBTI resources include resources for promoting inclusiveness in health services and information for health practitioners.
• Australian Government Guidelines on the Recognition of Sex and Gender provide guidance for incorporating LGBTIQ+-awareness into data collection.
• Mental Health Professional Online Development includes a topic on ‘Mental health for same sex attracted persons’.
• Australasian Journal on Ageing: Special Issue: LGBTI Ageing and Aged Care Special Edition, Volume 34, Issue Supplement S2, pages 1–44.
• LGBTIQ+ Health Australia: Peak health organisation in Australia, providing health-related programs, services and research.
• Another Closet: An online resource for people in LGBTIQ+ relationships who are, or may be, experiencing domestic and family violence.

Further reading

Royal Australian and New Zealand College of Psychiatrists Position Statement 103: Recognising and addressing the mental health needs of people experiencing Gender Dysphoria/Gender Incongruence.

Responsible committee: Practice Policy and Partnerships Committee 

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Disclaimer: This information is intended to provide general guidance to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.