Both healthcare workers and LGBTQ+ (lesbian, gay, bisexual, transgender and queer) people report low competence among psychologists, healthcare workers and others working in mental health services, according to the new research from the Norwegian Research Centre for Sexual Health (CENCE) at the Department of Psychology, University of Oslo.
The reports "LGBTQ+ health-seeking" and " Mental health care providers' perspectives on providing care for the LGBTQQ+ individuals" summarize knowledge from Norway and Scandinavia, and also draw on international data. The reports reveal inadequate guidelines and procedures relating to LGBTQ+ people seeking mental healthcare.
Assume that a partner is of the opposite sex
PhD candidate Jacob Evje is one of the researchers behind the report that examines queer people's experiences of seeking mental healthcare. He says education about LGBTQ+ people is inadequate both during training programs and within individual treatment institutions.
- Teaching and training are most often introduced by individuals who are passionate about the topic and feel that someone must take on the task, says Evje. He believes many therapists are afraid of making mistakes and therefore avoid addressing the possibility that someone may be queer.
- It can mean the therapist automatically assumes the patient or client who comes to the first session is heterosexual. If it is a woman who talks about her partner, the therapist will often assume the partner is of the "opposite" sex, says Evje.
He also points out that people with gender incongruence (the experience that one's gender does not match the gender assigned at birth) are often referred to as "he" or "she", even though the person may prefer the gender neutral "they".
Long experience of being overlooked
- For LGBTQ+ people using health services, it is important to be seen as who they are. If this goes wrong from the outset, it is easy for someone seeking help for mental health problems to lose confidence in the system and to feel overlooked, says Evje.
He emphasizes that queer people are a patient group with a long experience of being overlooked and also of being harassed.
Both Evje and his colleague, researcher Anna Ivanova, who authored the report on mental health workers' perspectives on providing care to LGBTQ+ patients, stress that both reports uncover the same problems. Therapists and other healthcare workers generally lack necessary knowledge. According to the researchers, this must be addressed on three tightly interwoven levels:
- Individual level: knowledge, attitudes, skills
- Organizational level: routines, training, managerial support
- Structural level: legislation, funding, culture
Patients have to teach the therapist
- A common strategy among mental healthcare providers is to choose not to talk about gender identity or sexual orientation. Many do not know how to ask. Some are also afraid of offending patients who identify as heterosexual by raising such questions, says Anna Ivanova.
She emphasizes that many therapists' and other healthcare workers' apprehension can have serious consequences for LGBTQ+ people, who are already more vulnerable to depression, mental health disorders, suicide and violence than the rest of the population.
Jacob Evje stresses that many LGBTQ+ people are also exposed to exclusion, prejudice and discrimination.
- Someone seeking mental healthcare is often worn down and exhausted. If they then have to spend a lot of time explaining to a therapist what it is like to be queer in Norway these days before they can talk about their own mental health problems, it becomes an extra burden and may be enough to lose faith in the therapist, says Evje.
He believes it would be a great advantage if everyone working in mental health had basic knowledge of LGBTQ+ people's vulnerable situation from the outset.
The right to equal healthcare
Jacob Evje reminds us that equal healthcare for all is a statutory principle in Norway and other countries, and that the very varying level of competence encountered by LGBTQ+ people in mental health services, as revealed in the reports, must be addressed.
Anna Ivanova agrees. Both she and Evje stress that knowledge and competence are not the sole responsibility of individual therapists or healthcare workers.
- Knowledge about meeting LGBTQ+ people must be included as a compulsory component in training programs. There must be common procedures in hospitals and clinics. Continuing education for existing clinicians must also be mandatory, says Evje.
The two researchers find it particularly interesting that Rosa kompetanse (FRI's national competence raising program on gender and sexual diversity) reports that it is those mental healthcare workers who already have competence about LGBTQ+ people that ask for more knowledge.
- It is the same people at the clinics that also try to share expertise or acquire expertise from outside. Paradoxically, Rosa kompetanse finds that therapists with little or no competence often perceive that they have sufficient knowledge on the subject, says Anna Ivanova.
Standard intake forms
Jacob Evje and Anna Ivanova call for common national standards for all clinics; a shared system so it is no longer down to individuals or individual clinics to invent "their method". One example is standard procedures before the first consultation in mental health services that have been tried successfully in Sweden.
- Intake forms that allow people to tick boxes for gender identity, sexual orientation, who their next of kin are, etc. will prevent the therapist from making mistakes at the first meeting with the client, Ivanova believes. Both she and Evje stress that mental healthcare providers must learn to ask questions that make LGBTQ+ people feel seen and heard. It is particularly important that the patient feels safe enough to tell what is troubling them. Often their mental health problems are also affected by being LGBTQ+ in a heteronormative society, according to the researchers.
Don't beat around the bush, and don't probe excessively
- Once you've practiced, it isn't difficult to ask the right questions as a provider. Just start with fairly open questions such as - "Is it important for you to talk about sexuality and gender? Is this something that would help you if we spent more time discussing it?" says Evje, who has little time for therapists who beat around the bush and play guessing games.
- If the answer is no, you have at least asked. If the answer is yes, you can simply continue, he says.
He does, however, advise against those therapists who dig and ask very detailed questions, almost out of curiosity.
- It is important to be professional in the role of a therapist, says Evje, adding that overly forward therapists are in the minority.
- The problem is usually that clinicians ask too few questions to LGBTQ+ people. Jacob Evje and Anna Ivanova believe a standardized approach will make things far more predictable for LGBTQ+ people seeking mental health care.
- Feeling certain that a mental health provider and the healthcare system understand their situation will increase trust in health institutions, which is crucial for LGBTQ+ people. Hopefully this will lead to many more people in need to seeking mental health services and feeling seen and understood, says Jacob Evje.
Some facts about LGBTQ+ people
- Statistics from Bufdir (The Norwegian Directorate for Children, Youth and Family Affairs) show that 5 to just over 10 percent of the population are lesbian, gay, bisexual or have sexual orientations other than heterosexual. It is harder to estimate the proportion who are transgender or intersex.
- More young people than older people identify as lesbian, gay or bisexual, and more women than men identify as queer.
- There is insufficient data to estimate how many in the population are transgender. A study from the Netherlands shows that 0.3 per cent of the population aged 15 and over identify as non binary/genderqueer, 0.4 per cent identify as trans man and 0.3 per cent as trans woman.
