EXECUTIVE SUMMARY
HEALTH NEEDS OF THE LGBTIQA+ COMMUNITY IN THE MURRUMBIDGEE
The HeALTH needs OF THE LGBTIQA+ COMMUNITY
Members of the LGBTIQA+ community experience poorer health outcomes overall, compared to the general population. In general, these health inequalities have been found to be the consequence of a range of intertwining social, cultural and political factors such as heteronormative social and cultural preferences, minority stress associated with sexual orientation, gender identity and sex characteristics, victimisation, discrimination (individual and institutional) and stigma.1 Poorer health outcomes can be further exacerbated for LGBTIQIA+ people living in regional areas given they experience more limited access to specific services.2
The Murrumbidgee Primary Health Network (MPHN) identified a need to develop a comprehensive Health Need Assessment for the LGBTIQA+ community. This work was commissioned by MPHN as a partnership between ACON and Urbis. This needs assessment has been developed in consultation with the LGBTIQA+ community and primary health care providers to better understand and support the health needs, and barriers and enablers to accessing services and supports for the LGBTIQA+ community in the Murrumbidgee
Key findings from this needs assessment strongly align with the findings from the ACON NSW Regional Community Survey conducted in 2020 on LGBTIQA+ health and wellbeing, as well as the strategic pillars established in the NSW LGBTIQ+ Health Strategy 2022-2027.3 Strong parallels can be drawn between our findings and two NSW LGBTIQ+ Health Strategy strategic pillars; delivery of high quality, safe, inclusive and responsive health care, and capturing data on sexuality, gender and intersex variations at the point of care and population level.4
Our Methodology
This work was informed by a review of the research about the unique health needs of the LGBTIQA+ community.
Our engagement with the LGBTIQA+ community was tailored and purposeful. We used a mixed methods approach, collecting quantitative data through an enhanced version of the HNA survey delivered by MPHN and qualitative data gathered via stakeholder focus groups and semi-structured interviews co-facilitated by Urbis and ACON
We spoke with people who identified with a range of gender identities and sexual orientations from across the Murrumbidgee region. This ensured a variety of voices were heard and incorporated into this needs assessment. A broad range of primary health care providers were consulted including GPs, sexual health nurses, allied health staff, and social services staff.
Data was analysed and triangulated and is reported here.
In detail, our approach included:
Research review Analysis of anonymous survey data (n=47)
2 small groups and 2 semi-structured interviews with consumers (n=7)
2 focus groups with health care providers (n=18)
Note: The findings presented in this report reflect the views and opinions of individuals who voluntarily participated in the survey and consultations. It is important to note the sample of respondents may not representative of the LGBTIQA+ population in the Murrumbidgee region more broadly. The data collected may be subject to self-selection bias, as individuals who chose to participate may have unique perspectives or experiences that differ from those who did not take part. Therefore, the findings should be interpreted with caution and may not accurately reflect the broader population's views or experiences.
1 Zeeman, L., Sherriff, N., Browne, K., McGlynn, N., Mirandola, M., Gios, L., et al. (2019). A review of lesbian, gay, bisexual, trans and intersex (LGBTI) health and health care inequalities. European Journal of Public Health, 29(5), 974-80.
2 Dentato, M. (2012). The minority stress perspective. Retrieved from https://www.apa.org/pi/aids/resources/exchange/2012/04/minority-stress
3 ACON. (2020). ACON Regional Community Survey Snapshot. Received from ACON.
4 NSW Ministry of Health (2022). NSW LGBTIQ+ Health Strategy 2022-2027.
KEY FINDINGS
HEALTH NEEDS OF THE LGBTIQA+ COMMUNITY IN THE MURRUMBIDGEE
This needs assessment provides a snapshot of quantitative data collected and identifies four areas of interest for the LGBTIQA+ community and primary health care providers. It concludes with setting out several key recommendations for service planning in the MPHN.
Health and wellbeing
▪ The LGBTIQA+ respondents face compounded disadvantage with a lack of local service availability exacerbated by the need to access specific services that are safe, inclusive and appropriate.
▪ For LGBTIQA+ people who have a disability, there are additional barriers to accessing support that is safe, appropriate and welcoming. The intersection of disability with gender identity and sexual orientation can also lead to more complex health needs.
▪ There were high levels of health literacy amongst consumers consulted, yet they experienced challenges in identifying, understanding and navigating health services. Additional difficulties would be experienced by those with lower health literacy levels.
▪ Mental health, social isolation and sexual health were key concerns for the LGBTIQA+ community.
Social and community connection
▪ While consumers felt connected to their local community with high rates of community engagement and participation, they did not feel a strong connection to their local LGBTIQA+ community.
▪ A lack of local LGBTIQA+ community connection created concerns for both consumers and health care providers about rates of loneliness and social isolation, particularly in relation to the elderly/ageing LGBTIQA+ population.
Health service inclusivity and access
▪ Consumers lacked knowledge of safe and inclusive guidelines and frameworks that could be used to identify safe and inclusive services.
▪ There are financial challenges for consumers in accessing safe and specific services for treatment and medication that are exacerbated in regional and rural areas due to the need to travel long distances for access.
▪ A lack of specialised services and supports for the LGBTIQA+ community related to family planning, sexual health services and gender affirming care were key concerns for consumers.
▪ Mental health was the dominant health challenge noted by consumers. Access to mental health services across the PHN region differed based on locality and was compounded by a perceived lack of LGBTIQA+ inclusive mental health services.
Consumer and provider communication
▪ Consumers frequently reported delaying or avoiding care for fear of discrimination or judgement from health care providers, which could lead to long term negative health consequences.
▪ Consumers and health care providers strongly desired a referral network to reduce reliance on word-of-mouth recommendations and improve health care system efficiencies.
▪ Consumers had concerns about data handling and experienced the burden of repeatedly needing to provide information about their gender identity and sexual orientation due to inconsistent systematic data collection, capturing processes and tools.
▪ Consumers and health care providers strongly expressed a need for education and training to strengthen understanding of the LGBTIQA+ community and reduce the onus and burden on consumers for educating health care providers.
LIMITATIONS
Limitations to this HNA should be noted. Broadly, research on the LGBTIQA+ community largely consists of survey data of varying sample sizes and representativeness, limiting the ability to relate findings to the whole LGBTIQA+ population and compare with the general population. Furthermore, there is a lack of comprehensive population data available in Australia for the LGBTIQA+ community.
The survey design was based on the existing HNA survey used by MPHN with additional questions about LGBTIQA+ community member’s health needs, and barriers and enablers to accessing services and support. This report is not a comprehensive report of all survey data collected but is focused on the detailed health information provided, and the relevant demographic information. Three consumer survey responses were excluded from the sample as those individuals did not reside within the PHN region. Whilst a broad range of stakeholders were involved in consultations, the overall the sample size was small (n=25) and is not a representative sample of the LGBTIQA+ community or health care providers in the region.
TERMINOLOGY
We recognise that language and terminology to describe gender identity and sexual orientations continues to evolve. The terminology used in this HNA reflects consultation with ACON, the NSW LGBTIQ+ Health Strategy 2022-2027, and the time of writing.
LGBTIQA+ is used throughout this HNA in reference to lesbian, gay, bisexual, transgender and gender diverse, queer, intersex, asexual and the + represents people of other diverse sexualities and genders not captured in the letters of the acronym.
Please refer to the LGBTIQ+ Health Strategy 2022-2027 Terminology for definitions we have adopted in this document.
LGBTIQA+ IDENTITY: SURVEY SNAPSHOT
These demographics are taken from consumer survey respondents' quantitative data.
Sexual orientation (n=44) 48% 7% 16%
Gay or Lesbian Different terms includedAsexual and Pansexual 27% Bisexual 2% Prefer not to answer
Residence by Geographic Area
Total area
126,124 Km2
n=6 (14%) didn’t identify their town of residence
border (n=4) Wagga wagga (n=18)
4% Identified as Aboriginal and/or Torres Strait Islander (n=2)
9% People identified as culturally and linguistically diverse, a migrant, refugee or person of colour (n=4)
36% Neurodivergent (n=16)
20% Living with disability or long-term health condition (n=9)
02 LGBTIQA+ HEALTH AND WELLBEING
KEY FINDINGS
The LGBTIQA+ community faces compounded disadvantage, and this is exacerbated for consumers who also have a disability. The lack of local service availability is further complicated by the need to access services that are safe, inclusive and appropriate. Further, the intersection of disability with gender and sexual orientation compounds health needs and barriers to accessing safe and inclusive care.
Mental health issues are the most reported personal health issue for LGBTIQA+ consumers and also the biggest concern reported about the community as a whole.
Health
Identifying and accessing appropriate services is challenging even for consumers with high levels of health literacy. Generally, consumers who participated in the HNA consultations had high health literacy levels yet still found it challenging to identify, navigate and understand the services required to support their health and wellbeing.
Consumers must frequently manage the assumptions that are made about them by health care providers. Consumers described having to deal with both heteronormative assumptions and assumptions made on the basis of gender identity and sexual orientation.
Life satisfaction
Consumers are often open about their LGBTIQA+ identity, but negative experiences and discrimination in health care are common
77% of people are always open about their sexuality / gender identity
23% of people do not disclose their sexuality / gender identity publicly
Many respondents had encountered negative health care experiences or discrimination due to gender identity and/or sexuality. 43% Yes (frequently/ occasionally) 57% No
Mental health was the most frequently identified personal health issue and the biggest concern for the LGBTIQA+ community overall
In addition to mental health, respondents were also concerned about social isolation and suicide rates in the LGBTIQA+ community.
“What health challenges do you experience? (n=35, multiple responses allowed)
“What do you think are the five most serious health and wellbeing concerns for the LGBTIQA+ community in this area?” (n=43, multiple responses allowed)
Consumers regularly navigate the assumptions made about them by health care providers
“There is no well-educated trans informed doctor / mental health assistance readily available.”- Consumer
“There is an assumption that I am sexually promiscuous because I'm a gay man. [I’ve had] refusal to engage in discussion about my sexual health needs. Only with 1 doctor - some are very good but then they leave town after 3-6 months.”
- Consumer
“Asexuality needs to be understood as normal, not either a health or psychological problem. It also needs to be understood that most of us, if not all of us, still need relationships and connection … this topic needs to be normalised in health and mental health.” - Consumer
“Doctors always assume straight. I went to get a referral for fertility treatment and was told to track ovulation and have more sex.”
- Consumer
SOCIAL AND COMMUNITY CONNECTION
KEY FINDINGS
Consumers felt connected to their local community but not to the LGBTIQA+ community. The overall sentiment from consumers towards their local community was positive with high rates of community engagement and participation. In contrast, many consumers reported that they did not feel connected to the LGBTIQA+ community. This aligns with participants’ high levels of concern related to rates of social isolation in the LGBTIQA+ community.
Loneliness and social isolation is a key concern expressed by both health care providers and consumers. Health care providers and consumers described a general lack of specific social community supports for LGBTIQA+ people. Strong relationships and connection to community were seen as important protective factors in addressing loneliness and isolation, particularly for people who are elderly/ageing.
A positive picture of the local community
More than two out of three survey respondents felt proud of their community, that their community was resilient in the face of challenges and indicated members of the community got involved in local issues and activities.
Strong sense of local community connection
The majority of survey respondents felt included in their community, empowered to participate in activities and get involved in local decision-making.
Ioftenparticipateincommunityactivities(n=44) IreallyfeellikeI'mpartofthiscommunity(n=44)
A stark lack of connection to the LGBTIQA+ community
While the majority of respondents rated themselves as feeling connected to their local community, this did not align with a sense of connection to their local LGBTIQA+ community.
65% of respondents reported they do not feel connected to their local LGBTIQA+ community
54% of consumers reported they often or occasionally have experienced discrimination in their local community based on gender and/or sexual orientation
Some participants believed that a lack of targeted social community support may lead to loneliness and isolation, particularly among the aging/elderly LGBTQIA+ community.
“We need recreational services for LGBTQI+ folks that haven’t got an age bracket, too many have a 20 something cut off...like we all of sudden don't need support or want a community after the age of 25...”
- Consumer
LGBTIQA+ consumers feel safe in their community, but not always respected
Consumers felt MPHN communities were safe places to live, but conversely, 65% felt that not all groups were treated with respect.
Mixed views on access to community and support groups
Survey responses indicate only some respondents (53%) can access community and support groups that met their needs. Additionally, only 24% ranked community events as one of best things about living in their town. This could indicate community and support groups could be better at being safe and accessible for the LGBTIQA+ community.
“I can access community and support groups that meet my needs” (n=43)
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04 HEALTH SERVICE INCLUSIVITY AND ACCESS
KEY FINDINGS
Consumers lack knowledge of guidelines and frameworks that indicate safe and inclusive services. There is a lack of public awareness and knowledge of supportive programs such as the Pride in Health and Wellbeing membership program by ACON, and the Rainbow Tick Accreditation Program, through The Australian Council on Healthcare Standards (ACHS).
Accessing safe and specific services can be costly for consumers. There are specific financial challenges associated with treatment, medication, and need to travel for health care that impacts the LGBTIQA+ community.
Access Challenges specific to LGBTIQA+ consumers
(n=30, multiple responses allowed)
There are a lack of specialised services for the LGBTIQA+ community in the region. Tailored, safe, and appropriate assisted fertility and family planning, and sexual health services were key gaps for consumers. Gender affirming care was also identified as particularly difficult to access by both consumers and health care providers.
Access to mental health services across the region differed based on locality. Consumers and health care providers noted access within the Wagga Wagga region was adequate, but access in other regions was very limited.
“I look for affirming places if I need a professional…anxiety will prevent me from accessing services. I have overall good mental health, but I have a lot of fear about accessing services.” - Consumer
Experiences receiving tailored and appropriate health care services were mixed
“In the last 3 years, how would you rate your experiences with health care providers or services in relation to your LGBTIQA+ identity?” (n=44)
Respondents experienced general difficulties accessing services
Similar to other population groups in the Murrumbidgee region, survey respondents primarily stated accessing required services was difficult, particularly specialist doctors, allied health and mental health services.
CareServices(n=39)
Health(n=43)
Key Barriers and Challenges to Service Access
“Another issue to health care out here is there’s only one medical practice that bulk bills, we’ve got like 6 and 1 of them bulk bills and of course getting into that one you’re going to have to wait like a month but that’s an overall sort of health care concern that impacts everyone.”
- Consumer
[About Post-Exposure Prophylaxis information] “You don't even see them in your doctor's surgery, there's nothing. They've got everything else …, but nothing about [PEP]"
- Consumer
“GP access, community health. Zero sexual health clinic is a fail for all community members but especially the LGBTIQA.” - Consumer
“Mental health/counselling and GPs, specialists and allied health services are incredibly hard to access in small regional towns. Some of us in the community have to travel hours away just get the help we need which is disappointing.”
- Consumer
Health(n=44)
Doctor(n=44)
(n=44)
Verydifficult Difficult Easy Veryeasy
Concerningly, IN response to a lack of access to safe and inclusive services, some consumers concealed their LGBTIQA+ identity and avoided care
I access mainstream services and don’t disclose my gender identity or sexual orientation
“How do you overcome limitations or barriers to accessing safe and appropriate health services?” (n=34, multiple responses allowed)
I avoid accessing services unless absolutely necessary
I travel to access LGBTQIA+ appropriate services
I use telehealth services
Identifying safe and inclusive services is challenging
Consumers surveyed said health care services in the region only sometimes display signs or symbols that indicate inclusion and safety for the LGBTIQA+ community (n=44).
“When I attend health care services, I see symbols that indicate inclusion and safety for the LGBTIQA+ community”
Consumers use a variety of methods to assess the safety and inclusiveness of health services
“How do you decide whether a health service is safe and suitable for you as an LGBTIQA+ person?” (n=38, multiple responses allowed)
I’m askedabout mygender and sexuality in a culturally appropriate way by staffand/or in service documentation I look for visible symbols of inclusion at the service
Staff at the service use inclusive and affirming language
I receive a referral or recommendation from a community member
Consumers aren’t confident that symbols are truly indicative of inclusive services
Another way
Participants expressed differing views and confusion about the use of LGBTIQA+ Rainbow Tick, an accreditation by The Australian Council on health care Standards (ACHS). Some consumers were unsure if it genuinely signalled a safe and accepting health service or was a tokenistic display.
05
CONSUMER AND PROVIDER COMMUNICATION
KEY FINDINGS
Consumers regularly described delaying or avoiding care. The fear of being discriminated against or judged led participants to avoid or delay seeking care. Additionally, participants avoided accessing health care providers with religious affiliations for fear of not receiving safe and accepting health care.
Consumers and health care providers strongly desired a referral network. A strong referral network and connected system for health and community services is lacking, which means consumers and providers are forced to rely on word-of-mouth recommendations.
Systematic data collection and sharing is inconsistent. This causes the LGBTIQA+ community to be concerned about data handling and privacy. It also requires them to incur the burden of repeatedly having to disclose their sexual orientation and gender identity.
Consumers and health care providers strongly expressed greater need for education and training. Health care providers’ clinical and general knowledge and understanding about the LGBTIQA+ community is improving but heteronormative assumptions are still common. The onus and burden often lies on the patient to educate their providers
LGBTIQA+ acceptance is improving but knowledge is still lacking
Both participants and health care providers expressed that while there is more acceptance of the LGBTIQA+ community, there is still a general lack of understanding of the unique needs of this group. Positively, the majority of respondents described providers as being willing to develop their knowledge. “In your experience, do health care providers possess adequate clinical knowledge and understanding of the unique health care needs and priorities of LGBTIQA+ people?” (n=41)
No, but providers are willing to develop their knowledge
Yes, levels of knowledge are typically adequate
Noandproviders don’tseeit as relevantfor theirpractice
No, and providers expect me to provide this information
No andproviders seem unwilling to develop their knowledge
Onus and burden
Focus group participants noted that the onus and burden of educating providers about LGBTIQA+ community needs fell on them (sometimes in times of crisis) when accessing health care services.
"I liked [the health care provider], but again, I had to educate him about stuff, because even I wasn't having issues related to being gay it was just in explaining my life I had to clarify things for him so he would understand the narrative, just understand actually what I was telling him...that was stressful in the moment being in a mental health crisis" - Consumer 7%
consumers are generally comfortable with disclosing their LGBTIQA+ identity to health care providers (where relevant)
“How comfortable are you with disclosing your LGBTIQA+ identity to health care providers?” (n=44)
I’m comfortable but it depends on the situation
I disclose this information only if I think it’s relevant to my healthcare
.
I’m comfortable and always (or almost always) disclose this information
I generally don’t disclose this information
I never disclose this information
Consumers are frequently not asked about their sexual orientation and gender identity appropriately by health services
Both consumers and health care providers indicated that data about gender and sexual identity was not routinely collected. Additionally, providers identified that health care records systems often do not provide options to systematically capture gender identity and sexual orientation.
When I attend health care services I am asked in a culturally appropriate way about my sexual orientation (n=44)
When I attend health care services I am asked in a culturally appropriate way about my gender identity (n=44)
Many Consumers have concerns about how their data is collected and handled
“Do you have concerns or considerations regarding the collection and handling of data related to your gender and sexual identity within the health care system?” (n=44, multiple responses allowed)
I have no concerns about collection and handling of data
I have concerns about potential discrimination
.
I have concerns about the accuracy and detail of how my information is recorded
I have concerns about how this data is relevant to my care
I have concerns about confidentiality of my data
Requiring repeated disclosures from consumers adds to concerns about the safety and inclusivity of services
Repeatedly requiring consumers to disclose details about their sexual orientation and gender identity raises concerns about the safety and inclusion of services for a range of reasons including:
▪ An increase in the likelihood of consumers having to manage a negative reaction from a provider
▪ An increased chance that sensitive information may be mishandled or not kept confidential
Education
is critical to supporting the consistent delivery of safe and inclusive
care
Both consumers and health care providers identified that education and training was required to enhance health care providers’ understanding of the unique needs as well as the diversity of the LGBTIQA+ community. Education and training can also help mitigate bias and discrimination and equips health care providers with the knowledge and skills necessary to provide safe and inclusive care. Receiving safe and inclusive care fosters trust between patients and clinicians which may reduce care avoidance behaviours
“Having to navigate an “outing” every time we access any services can be draining. It’s better now, but it’s still that moment of having to navigate it.”
- Consumer
“But I still feel that in all services there still could be a great deal of education around the needs of people in the Rainbow Community because they feel that there are judgements made and so if they are feeling that then I would have to say they are probably right and you know I think that yeah there’s not been a lot of education around in the communities.”
- Provider
Providers told us:
“It's not a regular everyday thing for me but it is for you, I am willing and wanting to learn"
- Provider
“As GP’s we can be the person that channels them to all the right directions so all the more reason for GP’s to be able to know who are the people who can be part of that team locally because it’s a big deal for people to have to travel.”
- Provider
[about training needs] “Education of primary health professionals about LGBTIQA+ health concerns and inclusive language. Access to professionals who are able to support people experiencing gender or body dysphoria."
- Provider
"I think the broader aspects of really educating people it almost needs to be in every level of health and health adjacent [services]"
- Provider
The LGBTQIA+ community told us:
“Never asked my pronouns or identities. Always misgenders me and some don’t update their systems with my name change and transition even after I asked.”
- Consumer
"I think I did tell every midwife, every time I met a new midwife at an appointment, for the first time…[my sexual orientation] wasn't on my information"
- Consumer
“I have been publicly deadnamed in front of people in a waiting room even though they said they'd address me by my preferred name which is now my legal name. I've had GP's refuse to treat me simply because I'm trans.”
- Consumer
“I've had experiences with the mental health services where the worker was supportive in theory, and not at all hostile, but didn't have the understanding of uniquely gay relationship and sexual health issues - therefore in a mental health crisis I was having to educate the worker which was stressful at a time when stress was the number one indicator of likelihood of self-harm.”
- Consumer
RECOMMENDATIONS
Support practices and primary health care providers to enhance safety and inclusion and implement effective methods of data collection
Support the development of referral networks and pathways
Practice systems and procedures should be developed to collect demographic and identityspecific data appropriately from the LGBTIQA+ community to reduce the burden placed on individuals to manage information.
Benefits for the LGBTQIA+ community Benefits for providers
LGBTIQA+ consumers have broader access to inclusive service providers. The burden is no longer on them to disclose their identity in every care experience, and they feel safe and comfortable when receiving care.
Consistent collection and provision of data allows providers to gather all relevant information needed to provide appropriate care.
Facilitate access to training on LGBTIQA+ awareness and inclusion for health care staff
Providers and consumers cited the lack of appropriate and specialised referral networks as a barrier to care. Pathways should be established to link consumers and providers to inclusive services as well as those providing specialised screening or care for the LGBTIQA+ community.
Health care staff should be supported to access broader training on ways to develop more inclusive practice for the LGBTIQA+ community, as well as education about the unique health needs and experiences of this community.
LGBTQIA+ people will have improved access to providers that are able to meet their unique health and social needs. They will have greater opportunities to receive multi-faceted and appropriate care and may reduce care avoidance.
Providers will have access to a wider network for referrals of LGBTIQA+ patients. These pathways can act as entry points for the provision of holistic and multi-disciplinary care.
Support connectedness for the LGBTIQA+ community
While there was a strong sense of connection to the local community, many respondents lacked connection to their LGBTIQA+ community.
The onus on individuals to educate providers on their health needs and experiences will be reduced and there will be improved access to supportive and knowledgeable providers
Providers will develop knowledge and skills to deliver appropriate support and care to LGBTIQA+ consumers and have access to opportunities to continually improve their practice.
There will be increased social and community connections among LGBTIQA+ peers and improved access to social support from people who have similar lived experience. LGBTQIA+ community members will also have connections to health care providers in a lower stakes setting.
Community events, health forums or working groups can act as accessible entry points to connect health care providers and the LGBTIQA+ community outside of a clinical setting.
