LGBTQ homelessness: time to act for better patient health

LESBIAN, gay, bisexual, transsexual and queer (LGBTQ) Australians are rarely considered as a vulnerable population in health and social care, but this needs to change.

The LGBTQ group’s over-representation in homelessness is a clear example. While around 13% of heterosexual Australians have ever experienced homelessness, 26% of bisexual and 34% of lesbian or gay Australians have had this experience. LGBTQ people are also more likely than heterosexuals to have repeated episodes of homelessness, and are two to three times more likely to have stayed in crisis accommodation or slept rough. Currently, there is no Australian dataset that includes any gender identity questions, so we cannot cite statistics for transsexual and gender diverse people; however, homelessness services are consistently reporting a huge increase in attendance of transsexual and gender diverse people over recent years.

This has also been reported in Canada, the US and the UK, with between 20% and 40% of users of youth homelessness service being LGBTQ.

Uncovering reasons for LGBTQ vulnerability to homelessness was one of the aims of a recently completed research project conducted at the University of Melbourne and Swinburne University of Technology. We found both structural and personal factors at play.

Structural factors included overt discrimination based on homophobia, biphobia or transphobia manifesting in violence and harassment. This often occurred in shared houses, social or public housing, and within homelessness services, resulting in a lack of safety. There were also common experiences of structural ignorance, which included heteronormativity or cis-genderism (assuming that everyone is heterosexual, and/or identifies in their birth-assigned gender), that created marginalisation. Personal factors then interconnected with these structural problems. Family conflict was a very important trigger at a personal level, resulting in leaving home at a young age, loss of community connection, and ultimately loss of trust. Vulnerability was compounded by resulting mental health and substance use issues for many people.

The ongoing marriage equality debate has highlighted some of the LGBTQ-based discrimination still prevalent in many areas of Australian life, and the impact this can have on mental health. However, the debate could not achieve the depth of understanding needed on the wider effects on the lives of many LGBTQ individuals. When a young person’s identity is rejected by their family to the extent that they no longer feel safe at home, this can have a devastating and lifelong impact. We spoke to mid- to older aged people who were still dealing with the resulting disengagement from education, the workforce, peers, community and family.

Health care services have a responsibility to understand these LGBTQ-specific homelessness pathways to enable more targeted and appropriate care. Many homelessness service workers spoke of their lack of knowledge about the specific needs of these clients, despite the high number presenting to their service. Likewise, LGBTQ people expressed concern that workers did not know what terminology to use, how to create safety in accommodation services, or where to refer them for LGBTQ peer support. Many young LGBTQ people did not present to homelessness services in the first place for fear of discrimination within the service from other clients, or concern that they would be forced to return to their family.

By contrast, some wonderful services have arisen in recent years which exemplify good practice. These include LGBTQ-specific services for young people vulnerable to homelessness such as Twenty-10 in Sydney, the Freedom Centre in Perth, Open Doors Youth Service in Brisbane, and the Diversity Project at Kildonan Uniting Care in rural Shepparton. The Family Access Network in Melbourne has embedded a LGBTQ-specific service within their wider mainstream homelessness services, providing peer support groups and transitional housing. They are frequently asked for advice by other service providers, which they willingly offer.

Nevertheless, there is a pressing need for national LGBTQ guidelines for the housing and homelessness sectors that will make this information more accessible. The University of Melbourne project team is leading the development of these guidelines over the next few months in collaboration with the National LGBTI Health Alliance. These will then contribute to raise awareness and to support training initiatives in the sector.

This is not just a homelessness specialist issue. Doctors within the wider health care system have many roles to play.

First, we need to raise our awareness that any of our patients, especially LGBTQ patients, could be struggling with insecure housing. We can sensitively inquire, support and guide them to appropriate services, as well as inform ourselves of LGBTQ specific needs.

Second, involvement in advocacy for this population group is crucial. Bringing the LGBTQ group to the attention of medical educators and researchers to build competency and evidence is sorely needed. The recent Australian Medical Association position statement on marriage equality is an example of advocacy at work, and should encourage other health professional bodies to consider LGBTQ people.

Finally, the many health and social policies at state and federal level that do not mention LGBTQ people need urgent attention. We should make it our business to highlight these gaps and argue for a more inclusive and responsive health care system for LGBTQ Australians.

Dr Ruth McNair is a GP with clinical and research interests in lesbian and bisexual women’s mental health, sexual health, same-sex parenting, and LGBTQ health care and homelessness. She is a member of the Victorian Government LGBTI Taskforce.

To find a doctor, or a job, to use GP Desktop and Doctors Health, book and track your CPD, and buy textbooks and guidelines, visit doctorportal.