1. Eddie McCann PhD RN RPN FHEA Trinity College Dublin
LGBT Minds: Lesbian Gay Bisexual and Transgender People’s Experiences of Mental Health Services
Eddie McCann PhD RN RPN FHEA
Trinity College Dublin

2. Overview Stigma and discrimination
Social exclusion (Vision for Change 2006)
Psychological distress (King et al. 2008)
Internalised self-hatred and shame (Cochran 2004)
Mental health risk (Kuyper & Fokkema 2011)
As well as the available Irish studies, such as Supporting LGBT Lives and Visible Lives - A review of the international published work included studies conducted in Australia, Canada, UK.
Some of the identified issues include: institutionalised prejudice, social stress, social exclusion, homophobic and transphobic hatred, bullying and violence and an internalised sense of shame about one’s sexuality. Furthermore, there can be an increased susceptibility to alcohol and drug misuse as well as suicidality and deliberate self-harm issues (Cochran et al. 2004).

3. Study aim and objectives
Explore LGBT people’s experiences of mental health service provision in the Republic of Ireland
Objectives:
Experiences of access
Identify barriers and opportunities
Identify good practices and service gaps
Develop practice framework

4. Study design Exploratory mixed methods
Survey which could be completed electronically, by telephone or by post 
In-depth interviews with a sample of participants whom had completed the survey

5. Inclusion criteria
Over 18
LGBT
Service use last 5 years

6. Survey Advisory group input Existing tools e.g. Visible Lives
35 questions
Demographics
Sexual orientation and gender identity
Mental health status
Mental health service use
Service Experiences
2 open ended questions (suggestions for improving services and further comments)
Many of the questions related to individual thoughts, feelings, beliefs and the person’s experiences in relation to mental health services

7. Recruitment and data collection
Survey pilot (n=5)
Invisibility and hard to reach
On-line, post, telephone
Website:
LGBT and mental health ) organisations (n=170)(information and posters), press
Pilot: In order to test the survey for content and face validity, a pilot survey was conducted with 5 participants. These participants were recruited from an LGBT organisation in Dublin and all participants fitted the inclusion criteria. Each participant was asked to complete the survey and to provide feedback and suggestions in order to improve it. Participants’ feedback was mostly positive describing the survey as useful and appropriate for the population.
Recruitment.
To distribute the survey we used a variety of approaches:
A multi-pronged ‘methodological triangulation’ recruitment strategy was adopted in order to promote the survey and increase the amount of people who might hear of the study. We hosted a copy of the survey on-line. We knew from previous research that a high proportion of the gay and lesbian population has access to the internet.
LGBT and mental health organisations, including hospitals and clinics (n = 170) throughout the country were sent packets with study information. Each packet contained a letter from the principal investigator inviting organisations to participate in the study by advertising the study through the posters and explanatory leaflets that were included in the mailing packet, as well as postal questionnaires. Also, LGBT and mental health organisations were sent s requesting that they pass on the study information and to link to their lists. Press releases were prepared for the HSE Bulletin, GLEN newsletter and the LGBT press. Identified organisations agreed to put details of the study on their Facebook pages. Data collection for the survey ran for six months from March 2011 to August 2011.

8. Ethics and protection TCD approval granted
LGBT guidelines (Kandirikirira 2004)
Anonymity
Signed consent
Support
Data storage
At all times, the wellbeing of participants was central to the study. Both survey respondents and interview participants were provided with detailed information about the study and issues related to confidentiality and anonymity. Survey respondents were ensured that their survey responses could in no way be linked to them. The researcher informed interview participants that their audio file and transcript would use a code and that any potentially identifiable information they provided would not be included in any published report. It was emphasized that participants were under no obligation to participate in the study and that they could withdraw at any point without penalty. They were also informed that if they did choose to participate, they did not have to answer any question that they did not wish to. Furthermore, participants were encouraged to ask any questions they might have about the study. Completion of the survey was taken as consent and all interview participants signed an informed consent form. At the end of surveys and interviews, all participants were provided with a list of mental health and LBGT support organizations in case they wish to contact them. All study files, including audio recordings, transcripts and surveys, were stored in accordance with the Data Protection (Amendment) Act 2003.

9. Profiles N (%) Age range 18-64 125 (100) Cultural background
White Irish
White Non-Irish
Asian
Other
104 (84)
16 (12)
2 (2)
Area living
Urban
Rural
89 (72)
34 (28)
Gender identity
Male
Female
Transgender
46 (37)
68 (55)
3 (2)
7 (6)
Sexual orientation
Gay
Lesbian
Bisexual
Heterosexual
52 (42)
41 (33)
19 (15)
1 (1)
12 (10)
70% University or college
‘other’ gender identity all provided additional text, including queer, genderqueer, lesbian trans woman, intergendered, transgender female and transgender male. MUST use these
‘other’ sexual orientation, including dyke, queer, pansexual, omnisexual, transgender, transsexual and those who did not identify with any particular label.

10. Gender identity disorder 10 Post traumatic stress disorder 9
Diagnosis (n=97) %
Depression 74
Anxiety 51
Sleep disorder 22
Eating disorder 18
Gender identity disorder 10
Post traumatic stress disorder 9
Bipolar disorder 8
Obsessive compulsive disorder
Personality disorder
Substance-related issues 5
Schizophrenia 3
Other
People could tick more than one response…….
Other diagnoses received included self-harm (n = 2), Asperger’s syndrome, cyclothymia, panic disorder, paranoid schizophrenia, temporal lobe epilepsy, and trichotillomania.

11. Services used Out patient clinic (n=83) Psychiatric Hospital (n=27)
Day hospital (n=18)
Day centres (n=16)

12. Survey-service experiences 1
Could not discuss LGBT identity (33%)
Professionals should know identity (65%)
Feared negative reaction (16%)
Feel professionals lack LGBT knowledge (64%)
Not sensitive to LGBT issues (37%)
Seek out LGBT friendly services (42%)
Partners not acknowledged (40%)
Agree or disagree with several statements around gender sensitivity issues

13. Survey-service experiences 2
Non-inclusive language use by staff (40%)
Disclosure and negative reaction (30%)
Helped improve mental health (80%)

14. Engagement and staff attitudes
Ensure an atmosphere of comfort and acceptance to encourage LGBT people to be completely honest and treat people with dignity and respect.
Having been in an abusive lesbian relationship I received very little sympathy from some psychiatrists I have seen and it has even been suggested to me that my life will stabilize when I find a man.
Many respondents were critical of their treatment by mental health practitioners and were concerned that important issues that were raised were largely being ignored. Heteronormative assumptions were generally made by mental health practitioners. Expectations around the creation of a therapeutic environment as well as the attitudes of practitioners are provided by the following responses:

15. LGBT identities
I've noticed the term 'Borderline Personality Disorder' being applied far to readily to anyone who identifies as LGBT, thus dismissing the validity of the person’s sexual orientation
While mental health professionals were usually willing to read up on issues related to trans* people, and many were willing to learn, there was little understanding of: -The way many different aspects of one's identity can overlap to cause stress related to social oppression.
LGBT identity is a fundamental part of who the person is and not the reason for mental health issues. In terms of mental health and wellbeing, identity was often considered unimportant or irrelevant. The pathologising of LGBT identities was a major concern for some of the respondents:
Trans people in Ireland. One psychologist, psychiatrist, endocrinologist

16. Partner and carer supports
My partner is trans. I feel this is an incredibly underserved group, both trans people and their partners, and I find it difficult to have my experiences understood by mental health practitioners across the board when it comes to this issue specifically.
The significant needs of families and carers have traditionally been an area of neglect within mental health practice. Often partners and carers experience the emotional impact of the person’s distress, as one respondent reported:

17. Treatment options
I wasn't comfortable coming out to my mental health provider (psychiatrist) and did not feel they would be sensitive or even try to help me with any LGBT issues. They were not willing to help (apart from medications) with any other mental health issues I was experiencing. This is very different to some to my experiences I had in the UK, where I did get access to CBT, counselling, psychotherapy, mindfulness etc. and was able to feel comfortable addressing LGBT issues - and all free of charge.
Many of the respondents expressed concern about the limited access to talking therapies and the over reliance on prescribed medications. The therapeutic potential of alternative approaches to psychotropic drugs were recognized:
Some of the approaches identified by respondents included individual and group psychotherapies. However, the perceived challenges and shortcomings within the present mental health system were apparent for some respondents:

18. +ve service experiences
I am currently an outpatient attending a day hospital for 14 months. As an LGBT person I felt respected and at ease with the staff I encountered. When I mentioned in passing that I was a lesbian I was asked to share my coming out experiences etc and received good feedback from my counsellors and psychiatrist and was offered leaflets/advice etc. I must admit I was kind of amazed but pleasantly surprised.
Positive experiences
Some of the more positive experiences recounted involved people feeling understood, feeling valued, given time to express themselves and being listened to, all important issues in terms of recovery:

19. -ve experiences
Area psychiatrists are paid by the HSE. Some refuse to deal with transgender patients. These people should either be trained in trans issues or stop ignoring those who need their help.
Health system in Ireland is archaic and severely under-funded. I cannot get access to a qualified therapist to support me with ongoing issues as a result of a history of child sexual abuse.
Mental health services in Ireland are awful in general not just with LGBT. I was put on anti-depressants at the age of 15 by my G.P when I told her I was feeling down due to my parents splitting up. I didn't see any mental health professional until the age of 18. And then only saw her twice. Very little came of 20 minutes talking.
Almost 90% of respondents (who commented) had something negative to say about the challenges facing mental health services in Ireland. Lots of talk around attitudes, funding, access, supports, over reliance on medication.

20. Increasing awareness of LGBT issues
Continue to destigmatise mental health; educate our society (at secondary level, 3rd level and society in general) more on mental health; get people talking about it. More programmes on TV
Educate staff and providers on Trans issues and the diversity of transgender experience in particular.
Several respondents suggested ways in which service providers may raise awareness of LGBT issues and tackle discrimination. These included displaying materials in hospital and clinic waiting areas to ‘acknowledge positive responses to LGBT people’ such as posters or leaflets as a way of ‘communicating acceptance and openness.’ One respondent felt that mental health services should ‘provide a clear mission statement that is inclusive of LGBT people and appreciates diversity’ and that providers need to ‘LGBT’ proof all policies, forms and training. Some respondents mentioned mental health practitioners and the need to appreciate diversity and ‘in no way assume a person’s sexual orientation or gender identity,’ as well as creating for General Practitioners ‘more awareness of LGBT specific issues when referring LGBT people to mental health services.’ One person thought that there should be an effort to ‘engage in a public relations or advertising campaign to alert LGBT people and the public in general about specific services. Some suggestions to address the challenges of discrimination included:
Education and training
Many respondents thought that a crucial part of staff development and training should involve diversity sensitivity in relations to LGBT issues in order to increase understanding among mental health providers:

21. Main concerns 1
Mental health professionals not adequately trained or educated in LGBT issues – gender sensitivity
LGBT identity an important part of who the person is, not considered relevant or important
Fear of coming out to mental health professionals
Lack of trust in health professionals
Assumptions made by health professionals re sexuality
Intense fear of institutionalisation – equated with total loss of control
Mental health professionals not adequately trained or educated in LGBT issues. Clear need for specific training in this area.
LGBT identity not the reason for mental health issues, but it is an important part of who the individual is, and it is not treated as such, considered relevant or important.
Trepidation coming out to mental health professionals, and health professionals generally. Distinct lack of trust.
Assumptions made by health professionals re sexuality (i.e. that everyone is straight)
Intense fear of institutionalisation – equated with total loss of control

22. Main Concerns 2 Trans community in need of support
No integration of services
Accessing services
Overreliance on pharmaceuticals
Isolation, stigma
Trans community in dire need of support – need for training for mental health professionals to support trans people and their families especially children. Need for dedicated, specialised support for trans community. No formally organised support, either direct or peripheral, for people going through transition. Peer support as principle source of support for trans people. No standardised services
No integration between services. Fragmentation and poor communication between existing services. This is particularly clearly illustrated by participants who are transgender, disabled, and HIV +
Mental health support + medical support for the tans community
Disability services + LGBT support services + mental health services
HIV medical support services + mental health services
Access: inadequate availability of mental health professionals (esp for trans community) long waiting lists, and prohibitive cost as barriers to accessing appropriate care and support.
Over-reliance on drug treatment. Overwhelming dissatisfaction with drug therapy, because of side effects and medication not working. Fear of addiction.
Sense that it is up to the individual themselves to source and fight for their own mental health support services. No formalised standardised pathway.
Isolation, stigma, complacency of HSE, sense of abandonment by authority.
Rural/Urban divide – linked to isolation of rurally located LGBT people. Greater access to support services in Dublin/ urban areas.

23. Advisory group:
Danika Sharek
Odhran Allen
Patrick Callaghan
Agnes Higgins
Thank you