#OTalk 27th October 2020 – Improving LGBTQIA+ and Gender Representation in OT – #OTalk Series (UK Focus) –

Welcome to the third in this #OTalk Series on Improving Diversity in the OT Profession with this one taking part next week on #WorldOTDay.

Do check out the transcripts of our previous chats here – on BAME https://otalk.co.uk/2020/07/13/otalk-21st-july-2020-improving-bame-representation-in-ot-otalk-diversity-in-ot-series-uk-focus/ and Disability https://otalk.co.uk/2020/08/23/otalk-25th-august-2020-improving-disability-representation-in-ot-otalk-series-uk-focus/ Representation, and do also put the 15th December in your diary for an Update on where we are now and to take a look at what our key priorities for 2021 should be in order that we keep taking this forward.

In the UK-based context of societal assumptions of cisgender* and heterosexual ‘normatives’, this chat is actually exploring two different aspects of diversity – gender identity and sexual orientation, aspects of diversity which are commonly summarised and abbreviated under the umbrella of the LGBT+ acronym (lesbian, gay, bisexual, transgender and plus representative of additional diverse identities for example, queer or questioning, intersex and asexual). These two topics often get conflated and confused, and so they are combined not because they are one and the same, but to try and dispel some myths and misconceptions.

*cisgender (cis) is the word used to describe people whose gender identity, their personal experience of gender, is aligned with the sex with which they were assigned at birth.       

Transgender (trans), in its’ simplest and most encompassing sense, is the antonym of cisgender and, again in its’ most encompassing sense, is the term used to describe gender identity not congruent with sex assigned at birth.

Similarly, non-binary is an umberella term for people whose gender identity may sit outside of the polar binary of male or female. Non-binary people may or may not identify as trans and vice versa.

Please see AOTI’s excellent 2019 publication LGBT+ Awareness and Good Practice Guidelines for Occupational Therapists (available at: https://www.aoti.ie/news/AOTI-LGBT-Awareness-and-Good-Practice-Guidelines-for-Occupational-Therapists or refer to https://www.stonewall.org.uk/ for further consensus definition of terms.      


With huge thanks to @hspenceruk and @Hunter_2802 for their input in preparing this chat and accompanying blog post.

First up I think that when people think of gender representation in OT they, like me, have a tendency to think of the binary – i.e. that there are more female than male OTs. In thinking this, are we perpetuating societal binary ‘norms’ and overlooking the diversity of gender identity and expression beyond the commonly perceived binary? And what implication does this have in terms of diversity, wellbeing and accurate representation of our workforce? The image below is a helpful visual representation of how we may consider and understand gender beyond a polar binary, but do take a look at the link https://www.genderbread.org/resource/genderbread-person-v1 for the original image and a discussion about its limitations.

Genderbread Person Image  which features a gingerbread person and 4 'scales' which look at Gender Identity, Gender Expression, Biological Sex and Sexual Orientation.



Hannah (@hspenceruk) has particular interest in this topic area and completed their MSc research project around understandings of gender variance and relevance to occupational therapy practice from which they intend to publish in due course. In the meantime, they had this to add:

Acknowledgements of multiple-fold injustices (occupational, health and otherwise) experienced by trans, non-binary and gender diverse populations are plentiful alongside what are arguably longstanding societal assumptions of cisnormativity. With respect to healthcare settings in particular, a report recently published by the LGBT Foundation (2020) highlighted  that ‘80% of trans people experience anxiety before hospital treatment due to fears of insensitivity, mis-gendering and discrimination (LGBT Foundation, 2020, p.60)’. Though potential campaign agenda biases must be acknowledged, similar statistics are echoed through research by the likes of Stonewall and the Government Equalities Office, easily obtainable through a quick Google search.

A lack of understanding among multi-disciplinary healthcare professionals across general health care services is a dominant theme throughout research such as that cited above, though there is a relative absence of either occupational therapy-specific research or mention of occupational therapy elsewhere. This essentially reiterates that theme of lacking knowledge and understanding of the specific needs and experiences of trans, non-binary and gender diverse populations, particularly with respect to specific occupational needs as are the unique focus of our profession. Take, for example, our pre-chat challenge (see below).   

What does all of the above mean for us as occupational therapists, evidence-based professionals, working towards optimum health, participation and quality of life for our service users and as part of a diverse workforce?

With respect to sexual orientation, Hunter (@Hunter_2802) previously carried out a literature review around LGB (lesbian, gay and bisexual) identity disclosure as part of his research project and subsequent conference presentation entitled  ‘In Or Out?? Which is it to be? and What do OT’s need to know???’ from which, together with experience in practice, he draws below:

As a gay OT, I felt sexual identity disclosure has significant occupational impacts, as we are all occupational beings. I want to make a point, this research was done in 2015, so there may be more articles published since. However, at the time the following findings were identified and since this, in practice I have experienced and observed similar issues. And so,  a summary of key elements of my research that are most relevant for all OT students, OT’s and academics. The 8 themes were:
        1)       Disclosure and Non-Disclosure have negative and positive health and wellbeing implications.
            2)       Support systems have a significant impact on disclosure and are impacted by disclosure with both perceived and actual negative and positive implications.
            3)       Identity is significantly impacted by disclosure and non-disclosure or repression.
            4)       Demographical factors such as age, religion, culture, ethnicity and social economic status have impacts on individual disclosure/non-disclosure.
            5)       Disclosure is a process often beginning with self-identification/self-disclosure, disclosure to friends and then family; with different extents of disclosure.
            6)       Fear of perceptions, expectations and actual reactions has significant implications on occupation, health and wellbeing.
            7)       Occupational and activity based impacts emerged significantly as a result of both positive and negative disclosure experiences.
            8)       Heterosexism and Homophobia were commonly experienced which had implications on individuals occupations, health and wellbeing through disclosure and non-disclosure.

            I’m not going to go into the themes in details, but the key points involved were people would need to self-affirm and self-disclosure prior to disclosing to close friends, then if positive experiences were to happen they would disclose further, if not then they would not. However; the impacts of this was that where positive experiences and affirmation happened; internalised homophobia was diminished, yet where this was not the case it reduced future disclosure.

            More importantly, disclosure in itself was identified as a need. Disclosure had impacts on identity, where negative experiences and non-disclosure occurred it could fragment identifies; with development of heteronormative identities for self-preservation from stigma and threats   to traditional expectations of the individual. Disclosure also had impacts such as conflicting with cultural identifies, which as Occupational therapists, we know identity is core to activity  and vice versa.

            People with negative disclosure experiences had detrimental impacts on mental and physical health, occupational participation, engagement in detrimental occupations, increased risky sexual behavioural and detrimental impacts on vocational/academic performance. Conversely, positive experiences increased self-acceptance, and a core characteristic of positive disclosure experiences is the presence of positive relationships. On the other hand, there were fears of losing family, losing work, losing friends and impacts on occupational performance and satisfaction. Positive relationships are a key part of positive disclosure experiences; having an affirmative and positive LGB environment also led to positive experiences of disclosure, with increased occupational satisfaction and participation.

            Finally, in terms of demographics, due to what’s going on I am going to focus on Race and LGB identity. With Race, individuals experienced a dual level of discrimination; with experiences of racial and sexual identity disclosure also having negative impacts. So Race is a key factor, but also considering more people are coming out at a younger age another factor to consider is have their coping mechanisms to manage reactions to disclosure matured/developed enough, or do they need support with that.

            Implications
            Occupational Therapy emphasises dignity and equality, but to do this the profession needs to recognise and challenge the heteronormativity and heterosexism that exists. By doing this, positive LGB disclosure environments and interventions can be developed and facilitated. It is clear the therapist is responsible in providing the appropriate environment, tools and skills to facilitate this so as to enable optimal occupational satisfaction, fulfilment and participation. However, without knowledge about disclosure and its impacts, it is something that cannot be expected to be put into practice within Occupational Therapy.

            In the process of conducting my review, there was a significant lack of LGB identity disclosure literature within the Occupational Therapy/ Science fields. This lack of evidence indicates a lack of education is identified. Having knowledge about disclosure is important, not just to provide equitable and equal assessment/intervention, but also to provide a safe and inclusive profession where both therapists and students can be their authentic selves. Hence there is a key need for an education base surrounding disclosure and sexual identity which would enable our students, academics and practitioners to develop practices to be more      inclusive and person centred. Furthermore, the lack of research specific to this endeavour was concerning considering it is a topic which is so socially important and impacts on mental and physical health.


            While I have had some experiences myself which for now I will keep personal, the many experiences of other LGB OT practitioners I have spoken to have shown me that heteronormative practices and heterosexism being pervasive throughout teams, practices and places of employment. These can leave you feeling isolated, outcast and discriminated against, which is why the call for research, education and continued professional development is ever more important; not just to better ourselves and better serve our patients/clients/service users, but also so we can be that truly person-centred profession with positive affirmative environments in which we can work and also gain that occupational satisfaction, participation and enjoyment!


Chat Questions

We have a challenge for you before the chat. Pop the word Transgender and the acronym LGBT into any of the OT Professional Bodies web pages, RCOT, WFOT, AOTI etc. and try the Physiotherapy ones, e.g. CSP, too. What did you learn?

1. What did you learn from the pre-chat challenge? What is your reaction to this?

2. Do you perceive Occupational Therapy as a profession to be informed and inclusive with regards to specific needs of LGBT+ populations as service users and as part of the workforce? Do you think that it is necessary/relevant for OTs to have knowledge and understanding of LGBT+ identities? (Why/why not? If yes, how could this be best facilitated?)

3. Do you feel you provide colleagues and clients with safe spaces to live authentically? Are you aware of any commitment to LGBT+ needs within your workplace setting?


4. Having read the blog post and considered answers to the above, what does that mean for us as occupational therapists, evidence-based professionals, working towards optimum health, participation and quality of life for our service users and as part of a diverse workforce?


5. Are there any actions you have taken to increase knowledge and understanding regarding the specific and diverse needs and experiences of LGBT+ populations? What actions will you take forwards to make your workplace more inclusive with respect to gender and sexuality?

Releasing on the day of this chat, and World Occupational Therapy Day – 27th October 2020 is the e-book – ‘We Are OT’ that serves as a space to discuss the benefits and challenges of being a ‘diverse’ part of the OT workforce. It uses narratives to pose reflective questions to challenge your practice, and looks at how you support and uplift your colleagues.

The ebook will be priced at £1.99 with the option of adding an additional donation. All profits to go to a scholarship fund. The link to buy will be on my website on the 27th Occupation4Life.

Kirsty