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Breaking down barriers

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This post accompanies Dani’s talk at DFTB23 in Adelaide

It was Winter 2021—the height of the COVID-19 pandemic. We were in lockdown. We worked through tonnes of PPE, masks, aprons, and gloves in the emergency department. We were exhausted. Our patients were scared. Headlines were terrifying.

One of our nurses worked in the vaccination centre on her days off. A 17-year-old registered with just the first initial – S. The nurse asked their name. They said, “Sarah… But I was Sam.” The nurse gave Sarah the vaccine. In the end, Sarah started crying and said, “I was so scared about coming because I was afraid someone would say something that upset me. But I saw your rainbow badge, and I knew you’d be ok. You treated me so well.”

The nurse sent me a text with Sarah’s story, and it made all the hard work we’d been doing to improve LGBTQ+ access to health worth it.

Rewind to Spring 2019. I’d recently moved to Ireland from the UK and started working in a paediatric ED in Dublin. I was back in Scotland for the RCPCH Annual Conference.

The plenary talk was by an old colleague of mine, Dr Mike Farquhar. A London Paediatrician, Mike told the story of growing up gay in Margaret Thatcher’s conservative Britain in the 80s and 90s, the hostile environment towards LGBTQ+ people, and the feeling of isolation.

Mike talked about the Stonewall School Report and told us that

  • Almost half of LGBTQ+ young people in the UK reported bullying at school
  • Two-thirds of trans young people reported the same

He talked about the impact this sense of marginalisation had on mental health. On depression, anxiety, self-harm and suicidality. How two-thirds of LGBTQ+ young people felt they didn’t have an adult they could confide in. 

And how negative attitudes in the NHS meant many LGBTQ+ people avoided healthcare settings for fear of how they’d be treated.

Mike told his story and then told us about an initiative he’d brought into the Children’s Hospital where he worked—the NHS Rainbow Badge. A small part of a solution, helping both to raise NHS staff awareness of the issues LGBTQ+ people face, and at the same time signalling support to LGBTQ+ patients and families – a sign of “inclusion”.

And so I started doing some research. And I found that the statistics that had moved me in the UK were all too familiar worldwide. 

The statistics

In Australia and New Zealand

  • 1 in 2 LGBTQ+ young people self-harm
  • 2 in 3 contemplate suicide. 
  • 1 in 4 attempt suicide. 

This is 5 to 6 times higher than their non-LGBTQ+ peers and is higher again for trans young people.

15% of Australian young people identify as non-heterosexual or cis-gendered, 16% in New Zealand. These young people come to our EDs, are admitted to our wards, and are seen in our outpatient clinics.

Sadly, psychosocial determinants of health are worse in LGBTQ+ young people internationally. Homelessness affects 1 in 10 LGBTQ+ young people in Australia, with only half feeling supported by their families, lower for non-Caucasian young people. Drug and alcohol use is higher, with 1 in 4 LGBTQ+ young people reporting to have used illegal drugs in the last six months.

Eating disorders are sadly also much higher in LGBTQ+ young people, particularly those who are trans. Transgender young people are 4 times more likely to have an eating disorder than their cisgender peers.

Minority stress due to a culture of stigma and discrimination leads to poorer mental health. LGBTQ+ young people are much more likely to be bullied and marginalised, with 2 in 3 LGBTQ+ young people in Australia say they don’t always feel safe at school.

The Health Gap

The role of healthcare professionals in creating a safe environment is crucial to improving LGBTQ+ young people’s experiences of and accessibility to healthcare.

And yet LGBTQ+ young people avoid healthcare encounters because of fears of discrimination.

  • Approximately half of LGBTQ+ people in Australia feel healthcare providers lack knowledge and sensitivity to LGBTQ+ issues, 
  • And a third of LGBTQ+ young people in New Zealand feel they can’t access health when they need it.

This leads to a gap between healthcare professionals and LGBTQ+ young people. A gap that is difficult to traverse.

These statistics left me with a great sense of sadness. My crucial role as a paediatrician in bridging this gap became starkly apparent.

They challenged my internal assumptions and made me reflect on encounters I’d had with adolescents, the assumptions I was guilty of making, like asking the pregnant adolescent whether they had a boyfriend. Assuming by the very virtue of being pregnant that they were heterosexual and cis-gendered, they did not understand the statistics around teenage pregnancy in LGBTQ+ young people. Nor the increased risks of sexually transmitted infections, the association with mental health because of the constant microaggressions, and the marginalisation imposed by a heteronormative society.

Pronouns

It took some practice, but I got better at introducing myself with my pronouns, asking a young person what they’d like me to call them, what pronouns they’d like me to use, whether I can share those pronouns with other healthcare professionals or with their parents, being clear around confidentiality and making the space safe for the young people in front of me.

I wanted to ask all young people to allow those who were gender diverse to be able to answer naturally rather than feel they had to correct me. I found, with time, that I liked saying right at the start of all consultations with young people, “Hi, I’m Dr Dani, I see on the paperwork in front of me your name is Luke, is that the name you’d like, because some people prefer different names?” And I’d volunteer my pronouns and ask, “What pronouns do you use?”

Using preferred names and pronouns is powerful; it builds rapport and shows you’re safe. Trans and non-binary young people tell me this minimises gender dysphoria that may be associated with the use of their old name or pronouns.

HEEADSSS

I adapted my HEEADSSS assessment – asking how they felt at home, whether they felt safe and supported, and whether they were out to their family. I learned to broach topics sensitively, introducing an idea as something OTHER young people do or think and whether THEY knew anyone with those thoughts and whether THEY had those thoughts too.

Asking about education – whether they felt accepted, understanding the impact bullying could have on their self-esteem.

They took an interest in activities, understood that acceptance in sports and clubs could be challenged, explored the sites they visited on their phones, and whether they had support from other LGBTQ+ young people or adults.

Pushing aside my heteronormative frameworks of sex, asking about relationships and partners, not boyfriends or girlfriends, asking about how they met their partners, whether this was safe, and whether they knew where they could go for sex advice.

And exploring stigmatising social environments, peer victimisation, and RESILIENCE factors such as anti-bullying policies and curricula in school and family connectedness and support.

Clinical preparedness

And then COVID struck, and Ireland went into a national lockdown. Amidst tonnes of PPE, hot zones, cold zones, cancelled clinics and social distancing, mental health presentations to the ED were exploding – lockdown was devastatingly affecting our young people. We couldn’t sit back and do nothing. Adapting my behaviour to be inclusive for LGBTQ+ young people wasn’t enough.

So, we looked at practice within our departments across Dublin’s three paediatric EDs and urgent care centres. We used the LGBT-DOCSS, a validated research tool of clinical competency in caring for LGBTQ+ patients, to explore how our staff felt about caring for LGBTQ+ young people.

The LGBT-DOCSS assesses competency across 3 domains: attitudes, knowledge and clinical preparedness. We found that our staff held great attitudes, but only scored moderately well in the knowledge domain. But what was more eye-opening was that their clinical preparedness scores were in the low zone, even lower when asked about caring specifically for young trans people.

Although our staff held positive attitudes towards LGBTQ+ young people, positive attitudes alone are insufficient to provide quality care.

Education

Our staff wanted and needed more education. But we were in the middle of a pandemic, so we turned to the online forum. Using 60 minutes of online education, including a DFTB post on being an ally, we asked our staff to fill in the LGBT-DOCSS validated tool again to see if the education had any impact.

Like many educational studies, things looked good two weeks later. Clinical competence scores improved across all three domains, and we were thrilled to see the biggest climb in clinical preparedness.

But what was incredible to us was that these scores continued to climb. Three months later, the LGBT-DOCSS scores in all 3 domains had increased, with the biggest climb in clinical preparedness.

We wondered why our staff continued to become even more confident in caring for LGBTQ+ young people over time. Staff told us that learning about the barriers to health for LGBTQ+ people and how to adapt their behaviour to be an ally had challenged their internal assumptions and helped them make small changes in their interactions with all young people presenting to the ED. Asking about pronouns and preferred names became easier with practice, and motivated, they sought out other information and education.

Rainbow badge

This was so powerful and helped us with our next plan: to launch the HSE rainbow badge. A local CAMHS service had used Mike Farquhar’s NHS model to introduce the rainbow badge to the health service in Ireland; a small lapel pin worn on a lanyard or scrubs, acting as a small but powerful symbol that the wearer was someone an LGBTQ+ person could trust.

Like the NHS rainbow badge, the model is opt-in, not a free badge ‘just because’. Staff have to actively sign up for the badge and its values, participate in education about LGBTQ+ health needs and sign a pledge to say that they, the wearer, would be an ally in health.

We launched a social media campaign and watched as the HSE Rainbow Badge spread across Ireland like wildfire – to date, over 50 organisations have launched the badge, and many more are getting funding. Our CAMHS friends sent the CEO of the Irish health service a badge, which he wore during the daily televised national COVID-19 communications, as did his successor (I’m still not sure if he just inherited the first guy’s with the job or signed the pledge to get his own, but I don’t think it matters – wearing the badge sends such a powerful message within Ireland).

Our final piece of research has been to see how our staff have found wearing the badge. Responses have been positive, both in terms of interactions with other staff and with young people and their families. There’s an overwhelming feeling of pride in taking part in the initiative, the message the badge sends to LGBTQ+ staff and patients, and pride in representing the community in healthcare.

It’s also described as a symbol of safety and inclusion for patients and their families. But more than this, staff members who identify as LGBTQ+ feel accepted by other staff members when they see them wearing the badge. The impact on workplace culture is amazing.

A Call to Action

And so this is your call to action.

You don’t have to launch a national health service badge, but you CAN challenge your internal assumptions.

You use your own pronouns when speaking to young people, and ask them how they’d like you to address them.

You can adapt your HEEADSSS assessments with the knowledge of the associations of being LGBTQ+ and be inclusive in the language you use, pushing away heteronormative norms.

You can go on to educate yourself further to understand the needs of your local LGBTQ+ population rather than relying on an LGBTQ+ young person to educate you.

You can use the LGBT-DOCSS in your department to see how clinically prepared your staff feel.

(And maybe even introduce a departmental or hospital rainbow badge where you work if you don’t already have one.)

Of course, more must be done to bridge the gap between LGBTQ+ young people and healthcare. This is only the start. But it’s a good start.

Some further reading

“You Get To Exhale Now?” @DrMikeFarquhar. This Twitter thread sparked an explosion of NHS Rainbow Badges across the UK. Dr Mike Farquhar is a paediatrician in London, and presented this amazing plenary at the Royal College of Paediatrics and Child Health conference in 2019 

If you’d like tips on introducing a rainbow badge at work, here’s the HSE Rainbow Badge implementation pack. It includes examples of funding applications and comms strategies. The badge won the Irish Healthcare Awards 2021 Equality Initiative of the Year.

The LGBT-DOCSS research tool is described here. Bidell MP. The Lesbian, Gay, Bisexual, and Transgender Development of Clinical Skills Scale (LGBT-DOCSS): Establishing a New Interdisciplinary Self-Assessment for Health Providers. J Homosex. 2017;64(10):1432-1460. doi: 10.1080/00918369.2017.1321389. Erratum in: J Homosex. 2019;66(9):1308. PMID: 28459378.

Read our first study, published in ADC: Kelleher ST, Barrett MJ, Durnin S et al. Staff competency in caring for LGBTQ+ patients in the paediatric emergency department. www.adc.bmj.com/content/early/2023/04/25/archdischild-2022-325151

Four years on, we’ve come full circle as Sean Kelleher (our amazing first author) presented the study in the plenary session at the RCPCH  annual conference in May 2023, winning the Dr. Michael Blacow Memorial Prize. The Twitter thread of the full talk is here: https://twitter.com/danihalltweets/status/1661322646972243970?s=20

Badgie.co is an Australian company, co-founded by Ollie, a paramedic who saw first-hand the power of a visual symbol of allyship. Visit their website for rainbow merchandise, including stickers and badges.

Minus 18‘s mission is to lead change, build social inclusion, and advocate for an Australia where all young people are safe, empowered, and surrounded by people who support them. Visit their website for badges, stickers and more.

Australasian references

Hill AO, Lyons A, Power J et al. Suicidal Ideation and Suicide Attempts Among Lesbian, Gay, Bisexual, Pansexual, Queer, and Asexual Youth: Differential Impacts of Sexual Orientation, Verbal, Physical, or Sexual Harassment or Assault, Conversion Practices, Family or Household Religiosity, and School Experience. LGBT Health. 2022 Jul;9(5):313-324. doi: 10.1089/lgbt.2021.0270.

Hill AO, Lyons A, Jones J et al. (2021) Writing Themselves In 4: The health and wellbeing of LGBTQA+ young people in Australia. National report, monograph series number 124. Melbourne: Australian Research Centre in Sex, Health and Society, La Trobe University. ISBN 978-0-6450256-2-0 DOI: 10.26181/6010fad9b244b

Hill AO, Bourne A, McNair R et al. (2020). Private Lives 3: The health and wellbeing of LGBTIQ people in Australia. ARCSHS Monograph Series No. 122. Melbourne, Australia: Australian Research Centre in Sex, Health and Society, La Trobe University.

Fraser G, Brady A & Wilson MS (2022) Mental health support experiences of rainbow rangatahi youth in Aotearoa New Zealand: results from a codesigned online survey, Journal of the Royal Society of New Zealand, 52:4, 472-489, DOI: 10.1080/03036758.2022.2061019

Sutcliffe K, Ball J, Clark TC & Fleming T. (2023). What would help young people who feel down? Voices of young people. A Youth19 Brief. The Youth19 Research Group, The University of Auckland and Victoria University of Wellington, New Zealand. Youth19 (squarespace.com)

Engel L, Majmudar I, Mihalopoulos C et al. Assessment of Quality of Life of Transgender and Gender-Diverse Children and Adolescents in Melbourne, Australia, 2017-2020. JAMA Netw Open. 2023;6(2):e2254292. doi:10.1001/jamanetworkopen.2022.54292

Chiang SY, Fleming T, Lucassen M,et al. Mental Health Status of Double Minority Adolescents: Findings from National Cross-Sectional Health Surveys. J Immigr Minor Health. 2017 Jun;19(3):499-510. doi: 10.1007/s10903-016-0530-z. PMID: 27866305.

Clark TC, Lucassen MF, Bullen P et al. The health and well-being of transgender high school students: results from the New Zealand adolescent health survey (Youth’12). J Adolesc Health. 2014 Jul;55(1):93-9. doi: 10.1016/j.jadohealth.2013.11.008. Epub 2014 Jan 14. PMID: 24438852.

And a couple of other references

Diemer EW et al. Gender identity, sexual orientation, and eating-related pathology in a national sample of college students. J Adolesc Health 2015;57:144–9.doi:10.1016/j.jadohealth.2015.03.003

Calzo JP et al. Eating disorders and disordered weight and shape control behaviors in sexual minority populations. Curr Psychiatry Rep. 2017; 19(8): 49

Author

  • Dani Hall is a PEM consultant in Dublin, member of the DFTB executive team and senior clinical lecturer on the Queen Mary University of London and DFTB PEM MSc. Dani is passionate about advocating for children and young people, and loves good coffee, a good story and her family. She/her.

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