By Astrid Van Den Broek
Winter 2004-05, Vol 8 No 2
After Lisa works through all the complicated emotions that accompany heading into a substance use treatment program, she swings the clinic’s front doors open and heads to reception. She’s given a questionnaire that asks for some basic personal information. The top of the list? Married, single, widowed or divorced. As a lesbian happily ensconced in a lifelong partnership, Lisa’s not sure what to check off, what is most relevant to describe her relationship. She leaves the list blank, unsure of how to handle it.
When Lisa meets with a counsellor to discuss her problem with alcohol, she reveals how the stress around being lesbian has contributed to her substance use. But the counsellor stops her right there, suggesting that the issue isn’t really relevant to the treatment process, so it’s probably a good idea not to bring it up in group therapy. It’d be too much of a distraction, after all.
In an age where depictions of sexual minorities have become a fixture of mainstream television, it’s hard to believe that such treatment of gay, lesbian, bisexual and transgendered (LGBT) people still exists. But then again, no wonder: These two communities – the LGBT community and health care professionals – have a checkered past when it comes to working together.
“It was only in 1973 that the Diagnostic Statistical Manual dropped homosexuality as a diagnosis,” says Dr. Roy Gillis, an assistant professor with the Department of Adult Education and Counselling Psychology at Toronto’s Ontario Institute for Studies in Education. “Until very recently, the LGBT and health care communities haven’t worked well together.” Some psychiatrists and psychologists were even doing reparative or “reorientation” therapy, which added more damage to the relationship. “But we have made some progress since then,” says Gillis, who teaches a course in counselling topics in sexual orientation and gender identity. More and more it’s being recognized that members of the LGBT community have very specific health needs that must be addressed in treatment.
Many advocates believe that building a better relationship and meeting the health needs of the LGBT community means that health care providers must develop a better understanding of the unique issues faced by this population. “They have different life experiences that need attention,” says Farzana Doctor, a therapist in private practice and former manager of Rainbow Services, a program run by the Centre for Addiction and Mental Health in Toronto that offers counselling for lesbian, gay, bisexual, transgender and transsexual people with substance use issues.
“One thing people need to understand is the coming out process; that’s a universal LGBT experience – coming out to oneself and figuring out the timing and allies to come out to,” says Doctor. Other differences are cultural norms often misunderstood by the heterosexual community, such as the affection gay men show each other and the assumption that it’s purely sexual; the impact of homophobia; and dealing with life in a heterosexist world.
Michele Clarke is a health promoter with Toronto-based Sherbourne Health Centre, which provides primary care services to diverse communities, including the LGBT community. She agrees that its members may experience health issues differently than heterosexuals. “For example, why people smoke or use drugs or why they’re depressed might be different.”
So what’s being done about these concerns? While there are many smaller initiatives stemming from professional organizations, medical schools and from the LGBT community itself, many say the collaborative approach needs to be bigger and more national in scope and coverage.
“There are health care providers, psychologists, social workers and psychiatrists who are more queer-positive,” says Gillis. But not surprisingly, they tend to be located in larger cities and don’t represent the majority of health care practitioners. “There’s still a large degree of distrust within the LGBT community about revealing things and about health care providers’ reactions in the medical field and in psychiatry,” says Gillis.
While much work needs to be done to address these unique issues, one significant effort has been made at the national association level. In 2001, the Canadian Psychological Association formed the Sexual Orientation and Gender Identity Issues Committee to examine issues in mental health care. “But that’s fairly recent,” says Gillis. “In the United States, the American Psychological Association and the American Psychiatric Association have done a lot more around these issues and have a bigger force and more education.” In fact, Alexandria, Virginia, is home to the National Association of Gay and Lesbian Addiction Professionals (NALGAP), a 25-year-old association dedicated to preventing and treating addiction in LGBT communities.
That links into another force pushing for increased education for health care professionals – the LGBT community itself. For example, the Toronto-based Rainbow Health Network, comprised of several community groups, is making the rounds to hospitals to teach professionals to address the needs of LGBT clients. That’s not surprising for a city like Toronto, which is home to a diverse and vibrant LGBT community.
But then move west to Saskatoon, Saskatchewan, where the Canadian Rainbow Health Coalition was formed in 2001. “Our project is focused on trying to get curriculum into medical colleges, nursing colleges and schools of social work,” says Gens Hellquist, the coalition’s executive director. “We’re also trying to partner with professional associations that are responsible for ongoing training to get workshops for people already working in the field. We’re working with the accreditation bodies for medical, nursing and social work schools on having some curriculum mandated as part of their evaluation.”
Success in gaining support for its mandate is slow, but it is coming. This year, the coalition received funding from the Primary Health Care Division of Health Canada to increase health care access for the LGBT community across the country. The project, which runs until 2006, will not only create partnerships with fellow associations and accreditation bodies, but will also help create bridges between health care providers and the LGBT community.
Still, many argue that these bridges need to be built earlier, that the intense training involved needs to be done at an earlier stage in providers’ careers, namely, at the school level. “Things are changing at that level,” says Hellquist, who points out that McMaster University in Hamilton, Ontario, and the McGill University School of Social Work in Montreal, Quebec, are doing good work in this area. “But such programs are still too few and far between and often rely on instructors who themselves are queer to bring it up, or a professor who’s forward thinking,” says Hellquist. “Students may get somebody from a local gay organization to speak to a class, which is a start, but you can’t talk about the many complex issues in a 55-minute class.” And that’s where some of the work Hellquist’s recent Health Canada funding will go toward – improving LGBT education in medical schools.
The Health Canada funding is actually the first national nod at addressing the issue beyond the community level. While local initiatives seem to be taking place in large cities, smaller towns and cities are being left behind, which is creating a desperate need for some kind of national, even provincial, initiative. “For years, our government has relied on the fact that everybody has a health card and that means everybody has equal access,” says Clarke at the Sherbourne Health Centre. “But in the last decade, it’s begun to dawn on people that things like the social determinants of health are involved. Everybody having a health card does not mean equal access. Steps need to be taken to improve access.” Clarke believes that’s why the United States is ahead of Canada on this issue. “In the United States, you have to pay for health care, so it’s really clear to see how barriers pop up. Community mobilization has created ways to increase access to health for various communities because otherwise, nobody could afford health care.”
But perhaps we’re missing the million-dollar question: Wouldn’t sending LGBT community members to self-identified LGBT health care professionals address the needs of that community best? “There’s a place for gays-only treatment,” says Joseph Amico, President of NALGAP. “But it doesn’t mean that a straight therapist can’t help. There are certain times when the client may need the assistance of gay-identified help, but it’s not necessary.”
“Besides,” says Farzana Doctor, “it should really be about choice.” The bottom line is that LGBT clients should be seeing professionals trained in LGBT issues. “Sometimes it’s the LGBT professionals who have that training and knowledge because they live in the community and have experienced a lot of the same things,” says Doctor. “But not all LGBT professionals are necessarily going to be good for this work because we all internalize the messages we’ve learned about what it means to LGBT. Just because someone is LGBT doesn’t mean they’ve challenged those ideas within themselves. It’s really about training and offering clients the choice to go wherever they want.”
Training, notes Doctor, doesn’t end with merely one course or one class. “We’ve all been taught what is normal and what is healthy, which are very subjective terms filtered through whatever is the dominant social lens, and often, the lens is people who are gender-conforming and people who are heterosexual,” she says. “The real point is getting people to deconstruct. ‘What have I learned all my life about what it means to be a heterosexual or gay or trans or bisexual person?’ ‘What’s true about that and not true?’ It’s an ongoing process, and that’s why training takes a lot of time and needs to be ongoing.”
Building a better relationship and meeting the health needs of members of the LGBT community means that health care providers must develop a better understanding of the unique issues faced by this population.
• Be educated on the “coming out” process: “It makes LGBT folks unique,” says Joseph Amico, president of the National Association of Lesbian and Gay Addiction Professionals. “Early on, many feel they have a shameful identity inside, and shame is a huge word. Nothing draws addiction like shame.”
• Be familiar with LGBT culture and terminology: Know your terms, so you can identify, for example, the differences between “polysexual,” “queer” and “homosexual.”
• Be welcoming: Placing stickers or symbols such as the Rainbow flag or pink triangle within your work setting, as well as hanging diversity-oriented posters and posting a non-discrimination statement that you will provide equal care, can provide much comfort to clients.
• Encourage candidness: Reiterate that discussions are confidential and use open body language to encourage communication.
• Be aware of heterosexism: Use open terms such as “partner” or "significant other,” and be aware that much of the world is seen through the heterosexist perspective.
• Stay current: Keep on top of laws and social and other issues that affect the LGBT community.
Sources: Asking the Right Questions 2