Inclusive communication with LGBTIQ+ clients
People who are lesbian, gay, bisexual, transgender, intersex or queer (LGBTIQ+) can face unique challenges and disparities in quality of care when accessing services. Experiences of stigma or discrimination when accessing non-LGBTIQ+ specialist services can affect service engagement and potentially impact individuals' health and wellbeing outcomes for segments of LGBTIQ+ communities (Perales, 2016). Evidence suggests that a lack of inclusive communication contributes to the anticipated and actual discrimination that can prevent LGBTIQ+ people from accessing the help they need (Brooks et al., 2018; Jones, 2016; Smith, Jones, & Ward, 2014). Drawing on a rapid review of the evidence, this guide outlines why inclusive communication matters and what works to ensure inclusive communication, and supports practitioners to use this evidence in their decision making when working.
1 Variations of the acronym LGBTIQ+ exist. Acronym choice can vary depending on the groups or issues being discussed and the available evidence. The acronyms used in this guide reflect the research conducted.
Why does inclusive communication matter for LGBTIQ+ clients?
LGBTIQ+ inclusivity means acknowledging and respecting that diversity in sexual orientation, gender identity and sex characteristics is a normal part of life. When inclusive communication is present, it is verbal (through comfort with LGBTIQ+ language), written (in intake forms) and visual (the display of LGBTIQ+ flags or imagery), and is linked to feelings of safety and being welcome (Ayhan et al., 2019; Brooks et al., 2018; Davison, Queen, Lau, & Antonio, 2021; Goldhammer, Maston, Kissock, Davis, & Keuroghlian, 2018).
The evidence on why inclusive communication matters for LGBTIQ+ clients in child, family and community welfare services is limited (McNair et al., 2018; Robinson et al., 2020). This guide draws on additional evidence from health care and educational settings, including surveys with community samples of LGBTIQ+ people, first-hand accounts of help seeking by LGBTIQ+ people and systematic reviews assessing the evidence on inclusive communication in relation to LGBTIQ+ help seeking.
Service providers who assume all clients are heterosexual, cisgender or have innate sex characteristics that fit medical norms for female or male bodies can have a negative impact on LGBTIQ+ people (Ayhan et al., 2019; Jones, 2016). Evidence from systematic reviews on the barriers and facilitators to care for LGBTIQ+ people suggest that not using inclusive communication can result in increased stress, anger, a fear of poor treatment and a fear of rejection (Brooks et al., 2018; Smith et al., 2014). LGBTIQ+ clients are therefore more likely to delay seeking help and are less likely to disclose their sexual orientation, unless they have a provider who helps facilitate that disclosure (Hinchliff, Gott, & Galena, 2005).
Disclosure to practitioners can provide critical information about an individual's networks of support, as well as particular health and social care needs (MacCarthy et al., 2021). When intake forms use inclusive language, it provides an opportunity for LGBTIQ+ clients to record who they are (Brooks et al., 2018) and helps build accurate evidence for targeted health promotion (McNair et al., 2018).
A lack of inclusive communication can have consequences for engagement in education and health. An Australian survey of 189 trans and gender diverse young people found that when teachers used inappropriate language at school over half (54%) reported difficulty concentrating in class, had lower marks and missed days of school (Smith et al., 2014). Around two-thirds (66%) felt excluded due to discriminatory language and around one-third (30%) reported that negative past experiences with health professionals had prevented them from seeking mental health care (Smith et al., 2014). Inclusive communication does not only relate to language use. Meaningful engagement requires understanding of the distinct inequalities that LGBTIQ+ communities face and how that shapes communication. For example, people with an intersex variation can experience invasive medical interventions that shape their experience seeking help (Australian Human Rights Commission, 2021).
What works to ensure inclusive communication with LGBTIQ+ clients?
The evidence on what works to ensure inclusive communication with LGBTIQ+ clients is drawn from health care and educational settings. LGBTIQ+ clients are not a homogenous group, and have been found to feel most included when the following elements are displayed:
- Affirmative approach: Provide a proactive and positive reception to LGBTIQ+ individuals and their families. Practitioners understand that sexual orientation, gender identity and variations of sex characteristics are different concepts that relate to each other in different ways for all people across the life course (Brooks et al., 2018; Duckett & Ruud, 2019; Jones, 2016; von Doussa et al., 2016).
- Beyond assumptions: Use open questions that do not assume someone is heterosexual and cisgender (Croghan, Moone, & Olson, 2015; Grant, Nash, & Hansen, 2020; Pennay et al., 2018). Practitioners understand that sex characteristics and gender do not exist on a binary of male or female or a binary of masculine and feminine behaviours (Intersex Human Rights Australia, 2021).
- Competence with language: Demonstrate comfort when using LGBTIQ+ language and match organisational inclusion (Croghan et al., 2015; Kirubarajan, Patel, Leung, Park, & Sierra, 2021; von Doussa et al., 2016). Practitioners show a willingness to let clients authentically represent their lives and their chosen terms (Rossi & Lopez, 2017).
Table 1 provides examples for each of these three elements.
|Element of inclusive communication||Facilitates inclusive communication||Creates a barrier to inclusive communication|
|Use of gender pronouns||'Hi Alex, before I introduce you, what are your pronouns?'||'This is Alex, she's the new client.'|
|Asking someone's pronouns is always better than making an assumption based on how they look. The language a person uses doesn't automatically align with what they were presumed at birth, their name, or how they appear or sound. Asking pronouns ensures a client is not misgendered.|
|Using gender neutral language||'Good morning everyone! Tell me about your partner/spouse.' |
'The person in the waiting room is about to come in for counselling.'
|'Good morning ladies! Tell me about your boyfriend/husband.' |
'The woman in the waiting room is about to come in for counselling.'
|When language is not gender neutral, it assumes everyone is cisgender and heterosexual (Croghan et al., 2015; Keating, Muller, & Wyers, 2021). The use of non-assuming, neutral language and asking open questions without assuming sexual orientation, gender identity or sexual characteristics can indicate you are comfortable with diversity (Grant et al., 2020). It also avoids assumptions made on someone's presentation, clothing or body (TransHub, 2021).|
|Accepting differences in families||'What does your parent(s) or caregiver(s) do?'||'What does your Mum and/or Dad do?'|
|Children have a better chance of thriving when the uniqueness of their family is acknowledged and respected (Liang & Cohrssen, 2019). Assuming a family has heterosexual, cisgender or biologically related parents can privilege the role of the birthing parent above other relationships (Shields et al., 2012) and/or create an assumption that the birthing parent is a woman (Duckett & Ruud, 2019).|
|Competence with language|
|Acknowledging diverse sexual and/or relationship status and sexual orientations||'Have you had some recent conflict with your boyfriend, Sam? Has there been violence at home?'||'Have you had some recent conflict? With a man? I thought you were seeing a woman last time you came in. I don't know what you call him. Let's skip over those details for today.'|
|Competence with language involves a knowledge of terms and comfort using them. Discomfort discussing LGBTIQ+ intimate relationships can demonstrate embarrassment, bias or unease, which creates a barrier to service provision. Hostility or discrimination can accompany discomfort with language and this can exclude LGBTIQ+ people from equitable and safe support (Ayhan et al., 2019; Hill, Bourne, McNair, Carman, & Lyons, 2020; Hill et al., 2021; Poštuvan, Podlogar, Zadravec Šedivy, & De Leo, 2019). Competence with language involves building it into organisational processes (e.g. intake forms) (Kirubarajan et al., 2021; von Doussa et al., 2016) and comfortably including partners in decisions where appropriate (Croghan et al., 2015).|
Using evidence for decision making
The available evidence suggests the following inclusive measures are adopted.
- Communicate in a way that welcomes LGBTIQ+ clients. Avoid assumptions and talk openly with clients, while also taking active steps to protect clients' privacy after the conversation and through the use of formal HR processes (Goldhammer et al., 2018).
- Take the lead from clients. Recognise different preferences for disclosure and whether disclosure is relevant to the service being provided (Pennay et al., 2018).
- Learn common LGBTIQ+ terms. Consider how sexual orientation, gender identities and variations of sex characteristics might influence the service required. For example, they can help to understand a client's network of support (Brooks et al., 2018; Kirubarajan et al., 2021; Lim et al., 2021).
- Signal inclusivity to all clients. Place LGBTIQ+ related posters or stickers in your office or wear a LGBTIQ+ related lanyard (Brooks et al., 2018; Kirubarajan et al., 2021).
- Participate in training. LGBTIQ+ specialist organisations run a variety of training packages that can increase your knowledge and confidence (Brooks et al., 2018; Lea, Brener, Lambert, Whitlam, & Holt, 2021).
- Research information about specialist services for LGBTIQ+ care. Make appropriate referrals when misunderstandings or issues beyond mainstream service expertise arise (Smith et al., 2014).
- Update content to ensure it is inclusive. Written content on websites, brochures and newsletters can be the first point of contact for clients. Inclusive content assists in welcoming LGBTIQ+ clients (using visual depictions or signs of diversity and inclusive language) (Croghan et al., 2015; Goldhammer et al., 2018).
- Develop inclusive registration forms and privacy protocols. Inclusive forms allow people to be recognised for who they are. They can be developed alongside ABS Standard for sex, gender, variations of sex characteristics and sexual orientation variables and can be a first step towards inclusivity for a new client, alongside the protection of their privacy (Brooks et al., 2018; Pennay et al., 2018).
- Increase staff knowledge of LGBTIQ+ issues and needs. LGBTIQ+ specialist training and accreditation can help embed inclusive practices across an organisation. Using inclusive language without corresponding knowledge of LGBTIQ+ issues and needs risks further client disengagement (Lim et al., 2021; McCann & Sharek, 2014).
The evidence for decision making on inclusive communication for LGBTIQ+ people is emerging. There are limited studies on the unique differences and preferred language of each group of LGBTIQ+ people. The absence of population-level studies asking questions about sexual orientation, gender identity and sex characteristics makes it difficult to draw direct links between inclusive communication and the health and wellbeing of Australian LGBTIQ+ communities (Perales, 2019). For this reason, a client-centred approach can help address the gaps in evidence. For example, language is changing and is used differently by various age groups. Older LGBTIQ+ people may have less knowledge or comfort with current terminology (e.g. terms that have been reclaimed but were considered derogatory such as queer). To address this, practitioners can ask clients what language they use (Fredriksen-Goldsen, Hoy-Ellis, Goldsen, Emlet, & Hooyman, 2014; MacCarthy et al., 2021).
These questions are designed to support practitioners to reflect on their practice with their team and consider how this evidence can be drawn on in their decision making.
- Gender, sex characteristics and sexual orientation are all separate concepts. A person's gender does not necessarily mean they have particular sex characteristics or a particular sexual orientation, or vice versa. Can you use Research matters: What does LGBTIQ mean? and LGBTIQA+ communities: Glossary of common terms to discuss your understanding of these concepts and the terminology related to each?
- Inclusive language guides provide general advice based on limited evidence. What are some ways to ask someone how they describe themselves and how could you use those terms in your conversation?
- How does your own sexual orientation or gender identity and your attitudes, beliefs and upbringing affect the assumptions you make about clients, their partners and families?
- Mistakes can happen with pronouns or language use. What are some ways that you can briefly correct your language in public or private, and continue the conversation without drawing further attention to the client?
|Title||How can this resource support you?|
|LGBTIQ+ Inclusive Language Guide||This guide has been produced for Victorian Public Sector employees. It explains how to use language respectfully and inclusively when working with and referring to LGBTIQ+ people.|
|Inclusive Services for LGBT Older Adults: A practical guide to creating welcoming agencies||This guide for service providers and LGBT organisations who work with LGBT older adults explains how to best serve and support them.|
|Rainbow Tick Standards: A framework for LGBTIQ cultural safety||This resource provides a guide to the six LGBTIQ-inclusive practice standards used in Rainbow Tick accreditation. It is designed to support organisations to improve the quality of care and services they provide to LGBTIQ service users, staff and volunteers.|
|TransHub||This website has been produced for all trans people in NSW, their loved ones, allies and service providers. It includes: an inclusive language guide; social, medical and legal guides to gender affirmation for trans communities; and information for employers, partners and colleagues.|
|Inclusion Guide to Respecting People with Intersex Variations||This guide provides information about who intersex people are, what inclusion is, helpful terminology, ways to measure inclusion, intake forms and research, and a checklist on using appropriate terminology.|
Inclusive communication involves a proactive approach to learning about and affirming diversity. Inclusivity is not about being an expert in LGBTIQ+ relevant language and experiences. When looking to adopt inclusive language, there isn't a single set of terms that results in inclusive communication. Little evidence exists on when, how and how much to acknowledge diversity in service interactions. While we know the importance of having identity acknowledged in treatment interactions, people differ on how much attention should be placed on it and when it is relevant (Pennay et al., 2018). Evidence suggests that when practitioners go beyond assumptions, affirm diversity and display a competence with language, it can improve service engagement and may have a beneficial impact on the health and wellbeing outcomes of LGBTIQ+ people.
- Australian Human Rights Commission. (2021). Ensuring health and bodily integrity: Towards a human rights approach for people born with variations in sex characteristics. Sydney: Australian Human Rights Commission.
- Ayhan, C. H. B., Bilgin, H., Uluman, O. T., Sukut, O., Yilmaz, S., & Buzlu, S. (2019). A systematic review of the discrimination against sexual and gender minority in health care settings. International Journal of Health Services, 50(1), 44-61. doi:10.1177/0020731419885093
- Brooks, H., Llewellyn, C. D., Nadarzynski, T., Pelloso, F. C., Guilherme, F. D. S., Pollard, A. et al. (2018). Sexual orientation disclosure in health care: A systematic review. British Journal of General Practice, 68(668), E187-E196. doi:10.3399/bjgp18X694841
- Croghan, C. F., Moone, R. P., & Olson, A. M. (2015). Working with LGBT baby boomers and older adults: Factors that signal a welcoming service environment. Journal of Gerontological Social Work, 58(6), 637-651. doi:10.1080/01634372.2015.1072759
- Davison, K., Queen, R., Lau, F., & Antonio, M. (2021). Culturally competent gender, sex, and sexual orientation information practices and electronic health records: Rapid review. JMIR Medical Informatics, 9(2). doi:10.2196/25467
- Duckett, L. J., & Ruud, M. (2019). Affirming language use when providing health care for and writing about childbearing families who identify as LGBTQI+. Journal of Human Lactation, 35(2), 227-232. doi:10.1177/0890334419830985
- Fredriksen-Goldsen, K. I., Hoy-Ellis, C. P., Goldsen, J., Emlet, C. A., & Hooyman, N. R. (2014). Creating a vision for the future: Key competencies and strategies for culturally competent practice with lesbian, gay, bisexual, and transgender (LGBT) older adults in the health and human services. Journal of Gerontological Social Work, 57(2-4), 80-107. doi:10.1080/01634372.2014.890690
- Goldhammer, H., Maston, E. D., Kissock, L. A., Davis, J. A., & Keuroghlian, A. S. (2018). National findings from an LGBT healthcare organizational needs assessment. LGBT Health, 5(8), 461-468. doi:10.1089/lgbt.2018.0118
- Grant, R., Nash, M., & Hansen, E. (2020). What does inclusive sexual and reproductive healthcare look like for bisexual, pansexual and queer women? Findings from an exploratory study from Tasmania, Australia. Culture Health & Sexuality, 22(3), 247-260. doi:10.1080/13691058.2019.1584334
- Hill, A., Bourne, A., McNair, R., Carman, M., & Lyons, A. (2020). Private Lives 3: The health and wellbeing of LGBTIQ people in Australia (ARCSHS Monograph Series No. 122). Melbourne: Australian Research Centre in Sex, Health and Society, La Trobe University. Retrieved from www.latrobe.edu.au/__data/assets/pdf_file/0009/1185885/Private-Lives-3.pdf
- Hill, A. O., Lyons, A., Jones, J., McGowan, I., Carman, M., Parsons, M. et al. (2021). Writing Themselves In 4: The health and wellbeing of LGBTQA+ young people in Australia (ARCSHS Monograph Series No. 124). Melbourne: Australian Research Centre in Sex, Health and Society, La Trobe University. Retrieved from www.latrobe.edu.au/__data/assets/pdf_file/0010/1198945/Writing-Themselves-In-4-National-report.pdf
- Hinchliff, S., Gott, M., & Galena, E. (2005). 'I daresay I might find it embarrassing': General practitioners' perspectives on discussing sexual health issues with lesbian and gay patients. Health & Social Care in the Community, 13(4), 345-353. doi:10.1111/j.1365-2524.2005.00566.x
- Intersex Human Rights Australia (IHRA). (2021). Intersex for allies [Fact sheet]. Sydney: IHRA. Retrieved from ihra.org.au/allies
- Jones, T. (2016). The needs of students with intersex variations. Sex Education, 16(6), 602-618. doi:10.1080/14681811.2016.1149808
- Keating, L., Muller, R. T., & Wyers, C. (2021). LGBTQ+ people's experiences of barriers and welcoming factors when accessing and attending intervention for psychological trauma. Journal of LGBT Issues in Counseling, 15(1), 77-92. doi:10.1080/15538605.2021.1868376
- Kirubarajan, A., Patel, P., Leung, S., Park, B., & Sierra, S. (2021). Cultural competence in fertility care for lesbian, gay, bisexual, transgender, and queer people: A systematic review of patient and provider perspectives. Fertility and Sterility, 115(5), 1294-1301. doi:10.1016/j.fertnstert.2020.12.002
- Lea, T., Brener, L., Lambert, S., Whitlam, G., & Holt, M. (2021). Treatment outcomes of a lesbian, gay, bisexual, transgender and queer alcohol and other drug counselling service in Australia: A retrospective analysis of client records. Drug and Alcohol Review. doi:10.1111/dar.13303
- Liang, X., & Cohrssen, C. (2019). Towards creating inclusive environments for LGBTIQ-parented families in early childhood education and care settings: A review of the literature. Australasian Journal of Early Childhood, 45(1), 43-55. doi:10.1177/1836939119885304
- Lim, G., Waling, A., Lyons, A., Pepping, C. A., Brooks, A., & Bourne, A. (2021). The experiences of lesbian, gay and bisexual people accessing mental health crisis support helplines in Australia. Psychology and Sexuality. doi:10.1080/19419899.2021.1904274
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- Perales, F. (2019). The health and wellbeing of Australian lesbian, gay and bisexual people: A systematic assessment using a longitudinal national sample. Australian and New Zealand Journal of Public Health, 43(3), 281-287. doi:10.1111/1753-6405.12855
- Poštuvan, V., Podlogar, T., Zadravec Šedivy, N., & De Leo, D. (2019). Suicidal behaviour among sexual-minority youth: A review of the role of acceptance and support. The Lancet Child & Adolescent Health, 3(3), 190-198. doi:10.1016/S2352-4642(18)30400-0
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- Rossi, A. L., & Lopez, E. J. (2017). Contextualizing competence: Language and LGBT-based competency in health care. Journal of Homosexuality, 64(10), 1330-1349. doi: 10.1080/00918369.2017.1321361
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- TransHub. (2021). Allies: Educators. Sydney: TransHub. Retrieved from www.transhub.org.au/allies/educators
- von Doussa, H., Power, J., McNair, R., Brown, R., Schofield, M., Perlesz, A. et al. (2016). Building healthcare workers' confidence to work with same-sex parented families. Health Promotion International, 31(2), 459-469. doi:10.1093/heapro/dav010
This guide was written by Claire Farrugia, who at the time of writing was a Senior Research Officer with the Child Family Community Australia information exchange at the Australian Institute of Family Studies. The author would like to thank Riona Taylor from Odyssey House, Morgan Carpenter from Intersex Human Rights Australia and Elizabeth Duck-Chong from ACON for reviewing this guide.
Featured image: © GettyImages/Tassii