Received date: 19 April 2010 Accepted date: 27 May 2010
This paper focuses on an aspect of diversity and anti-discrimination training in social care which has been marginalised in social care training and social work education, namely good practice with lesbian, gay, bisexual and transgender (LGBT)people. It discusses some key good practice points for working with LGBT people, derived both from the research and from people who use and provide services. A brief overview of the evidence for the need for specialist training in diversity and antidiscriminatory approaches to working with LGBT people is given. An innovative, free online social care training resource on working with LGBT people is offered as a solution to some of the sector training and good practice development needs. The paper also provides the legal, policy and research context to emphasise the urgent need for such a programme.
• The evidence shows that health and social care practice with LGBT people needs to improve, particularly in the light of recent equalities legislation and the social care personalisation policy.
• Relationship-based working focused on building trust and understanding the individual and their context, history and culture will enhance LGBT people’s experience of using services. However, this requires specialist training.
• Although there is evidence that anti-discrimination and diversity training is an effective approach to ensuring that LGBT people can access appropriate and culturally sensitive health and social care services, such training is not widespread, and there is no standard approach in social work education at present.
• It introduces a new free online multi-media and film resource designed to give social care practitioners and other stakeholders direct access to the experience and expertise of service users, carers and practitioners from or working with the LGBT community.
• It provides a brief overview of current research into social care training needs relating to LGBT issues, which is then complemented by key messages from service users and practitioners in the film resource, giving an overall picture of the priorities for training and good practice.
• The paper is written in the ‘standpoint epistemological’ tradition, and is therefore informed by the lived experience and user perspectives of the authors, as well as by the research evidence.
equality, good practice, LGBT people, online resources, training
The most direct way to improve the standard of social services offered to lesbians and gay men is to change the training of social workers.
Greater London Council Gay Rights Working Party, quoted in Cosis-Brown, 2008, p. 268)
This paper focuses on an aspect of practitioner diversity and anti-discrimination training in social care, and discusses some key good practice points for working with lesbian, gay, bisexual and transgender (LGBT) people. It introduces an innovative, free online social care training resource on working with LGBT people, and provides the legal, policy and research context to emphasise the urgent need for such a programme. ‘Working with LGBT People’ is one of a series of Social Care TV programmes which focus on service user, carer and practitioner experience and the promotion of good practice in all aspects of social care. Social Care TV is described as the online channel for everyone involved in the social care sector, from managers to front-line staff, and from trainers to the people who use care services. This online resource aims to provide direct access to the experience and expertise of people who are involved in all aspects of the social care sector through a series of short films and links to multi-media and e-learning resources. It offers unique video-based training resources and general interest programmes that reflect the issues, challenges and rewards in current social care practice. Downloadable transcripts of each film are available. The freely available online nature of Social Care TV means that the user has control over what and when to watch, along with enhanced access to the literature that supports the key messages contained and signposts to other useful online resources. The Social Care TV films focusing on good practice in working with LGBT people were commissioned in response to an evidenced need for more targeted education and training on this topic.
Since the 1967 Sexual Offences Act which decriminalised male homosexuality in the UK, LGBT people have been slowly claiming their civil and human rights, and this is now affecting the way that social care and health services are designed and delivered (Cant, 2009; Fish, 2009). The most recent antidiscrimination legislation to protect LGBT people is the 2010 Equality Bill. Among other things, this Bill places a new duty on public bodies to take account of the needs of LGBT people when designing and delivering services, a measure which will have a direct impact on the provision of health and social care services to their community. The Bill acknowledges the potential for dual discrimination. For example, people may identify as gay and be black, transgendered and disabled (Government Equalities Office, 2010). Previous legislation prohibited discrimination in goods and services on the grounds of sexual orientation (Equality Act (Sexual Orientation), 2007). The promotion of increased choice and control over social care services inherent in the personalisation reforms (Department of Health, 2007; Carr, 2010) also has implications for how services should be operating to focus on the unique needs and aspirations of the individual person, taking into account their sociocultural context and support networks. This should include ensuring that strategic local commissioning accounts for the particular needs of the local LGBT community, so as to provide members of that community, particularly older people,with genuine choice about their care and support. As recent research into LGBT equalities and local governance showed, ‘there is added value in partnerships between people who are lesbian, gay, bisexual and trans and service providers, managers and commissioners’ (McNulty et al, 2010, p. 5). These legislative and policy drivers mean that statutory health and social care services and staff will have to become more culturally aware and culturally competent if they are to provide safe, accessible and acceptable services for the LGBT community. Indeed, good practice knowledge shows that ‘what is important to lesbians and gay men as service users and carers is that first social workers have the ability to form effective relationships’ (Cosis-Brown, 2008, p. 271).
Research into health (particularly mental health) and social care provision for LGBT people in the UK suggests that there is an urgent need to develop more sensitive statutory services, to support specialist support organisations and to address staff education and training needs (Browne, 2007; National Institute for Mental Health in England, 2007; Carr, 2008; Cant, 2009; Equality and Human Rights Commission, 2009; Pennant et al, 2009). For example, it has been noted that ‘in mental health provision, lesbians and gay men have reported insensitive and sometimes hostile treatment by professionals despite being proportionally greater users of services’ (Fish, 2009). In social care a similar picture is emerging,with a survey by the former Commission for Social Care Inspection (CSCI), now a part of the Care Quality Commission (CQC), showing that 45% of lesbian, gay or bisexual people who responded had experienced discrimination when using social care services. However, the research also revealed that, of the 400 providers surveyed, only 9% had carried out any equality work on sexual orientation. In contrast, one-third of those providers had promoted racial or disability equality (Commission for Social Care Inspection, 2008). More broadly within wider local authority activity, it has been noted that the implementation of sexualities and trans equalities policies is ‘uneven’, with the result being ‘inconsistent performance across authorities’ (McNulty et al, 2010, p. 5). It therefore appears that LGBT equality training and policy implementation are at best patchy and at worst non-existent in statutory social care services, yet research clearly shows that:
Well-designed and inclusive equalities training programmes were identified as crucial to reducing people’s levels of discomfort and fear, and improving their understanding of how people who are lesbian, gay, bisexual and transgender experience inequalities. A common theme was the need for training that equips practitioners to challenge discriminatory and disrespectful behaviour by service users and colleagues.
(McNulty et al, 2010, p. 15)
Attention also needs to be paid to the fact that LGBT people are from diverse cultural, racial and social backgrounds, and can often encounter quite complex forms of multiple discrimination (Fish, 2008; Fanshawe and Sriskandarajah, 2010). The Safra Project (2003) study of lesbian, bisexual and transgender Muslim women’s experience of accessing legal and social services showed that, in some cases, social services had failed to protect or support the women because of issues of ‘cultural sensitivity’ with regard to their families, an issue that needs to be addressed in equality and diversity training. Other research evidence points to the need for ‘developing trust through working together [which] can lead to a useful unpicking of tensions between ... the L, G, B and T in the LGBT cluster, and between the range of experiences and ‘‘voices’’ within each of the lesbian, gay, bisexual and trans communities’ (McNulty et al, 2010, p. 5). Overall, such service user experience and research findings have led some to conclude that mainstream health and social care services can be institutionally homophobic, with a tolerance of discrimination against LGBT people which also affects staff who are lesbian, gay, bisexual or transgendered (Hunt et al, 2007).
Despite the evident need, socialwork and social care education and training have yet to develop a standardised and strategic response to the urgent need to address discrimination issues and good practice for LGBT people (Mule´, 2006; Carr, 2008; Fish, 2008). As one author has noted, ‘LGB issues are marginalised or excluded from pre- and post-qualifying social work curricula content’ (Fish, 2009, p. 52). In order to respond to the significant need for training resources aimed at raising staff awareness and improving practice with LGBT people who use social care services, the Social Care Institute for Excellence (SCIE) commissioned a Social Care TV programme on working with LGBT people. Because ‘user involvement ... with LGB people [is an] essential tool in the design and delivery of services’ (Fish, 2009, p. 58) and training, the programme features five people from the LGBT community who have experience of using health and social care services. Having LGBT people telling their stories is a powerful and direct way of raising awareness of the issues and, as research suggests, hearing the experience and stories from LGBT people directly can help people to engage with and challenge moral, religious or social prejudices or misconceptions about LGBT people: ‘Knowing gay people makes a crucial difference’ (Hunt and Valentine, 2008, p. 2).
The Social Care TV programme consists of five films which explore the experiences of LGBT people who have interacted with social care practitioners, and which consider what their needs are in relation to person-centred care. The key messages cover issues such as gender, adoption, mental health, disabilities, learning disabilities, sexuality, dementia, end-of-life care and personal budgets. Each film is led by the service user and discusses issues such as discrimination, stigma, double discrimination (three of the people featured in the films have one ormore disabilities aswell as being lesbian or gay), dignity, social exclusion and the need to feel safe enough to come out and be open about their sexuality to professionals. Most strikingly, all of them agree that much is down to luck rather than standard good practice in receiving quality person-centred care if one is from the LGBT community. As Helen Jones from MindOut, a specialist LGBTmental health service provider, explains in the film, ‘in a sense it’s more luck whether you get a good service, or not, than good planning, and it shouldn’t be down to luck’ (Alison’s story, Social Care TV, 2010a).
All of the individuals involved in the films, some of whom are quoted here, had experienced both positive and negative reactions with regard to their sexual orientation or gender identity from social care and health practitioners. The negative responses left them feeling wary of disclosure and expectant of discrimination. However, some social care staff were capable of culturally appropriate, person-centred practice, looking to learn and adapt in order to foster a supportive environment in which the individual felt safe and respected as an LGBT person. According to Roger, an older man whose male partner needed to go into residential care, ‘Just watching, making a mental note of the things that surround the person, will enable the person working in the home to give out the right signals to make the resident feel safe’ (Roger’s story, Social Care TV, 2010b). Some of the discrimination that was experienced by the individuals in the films was due to misconceptions and lack of professional competence in supporting LGBT people in certain social care settings. Alison recalls her difficulty with the response of some of her home care workers: ‘There is this myth that if you’re a lesbian you want to sleep with every woman you meet, which is absolute nonsense’ (Alison’s story, Social Care TV, 2010a). Doug describes how managers in his residential home responded to him being open about his sexuality: ‘they were concerned about the ability of other residents to be able to cope with the fact that I might be gay, and asked me to keep quiet around other residents, which felt a little wrong really’ (Doug’s story, Social Care TV, 2010c).
Richard, who is gay and has a learning disability, has very clear messages about the double discrimination that he has experienced with regard to his disability and his sexuality: ‘It becomes very difficult to express your sexuality if you have a learning disability, because society in general expects you to be asexual or not to be interested in sex’ (Richard’s story, Social Care TV, 2010d). According to Alison, ‘They can get the mental health side but not the physical disability, so when you have got both and you’re gay as well ... it’s too much for them to take in at any one time!’ (Alison’s story, Social Care TV, 2010a). The films also reflect other challenges, such as the impact of personalisation and new equalities legislation on creating more appropriate mainstream and specialist services for LGBT people, as well as fair and inclusive assessment, and continuity and consistency between health and social care providers and the need to balance rights, risks and responsibilities in supporting people to connect with the gay scene and LGBT support networks.
Both the research evidence and the individuals in the films highlight the importance of training. As Helen Jones emphasises, ‘Training very much needs to go along with a commitment from the top down to improving service for LGBT people, and I think without that even very enlightened, very good practitioners may not get the support they need in order to effect real change in services’ (Alison’s story, Social Care TV, 2010a). Nick, a trans man with experience of the adoption process, makes the following point: ‘Ifwe could get better training for adoptive services and help adopters to understand that there are laws that protect and they don’t have to do things that compromise them or make them uncomfortable in any way’ (Nick’s story, Social Care TV, 2010e). This is echoed in the supporting resource, Core Training Standards for Sexual Orientation:
Inclusive services require health and social care staff ... whether concerned with the delivery of frontline services or strategic and policy development, to be aware of the current discrimination experienced by lesbian, gay and bisexual people, to understand the impact of prejudice and discrimination on lesbian, gay and bisexual communities, and to develop well-informed attitudes and approaches to LGB people in all aspects of service delivery.
(Cree and O’Corra, 2006, p. 11)`
The message from both the Social Care TV films and the research evidence is that social care and health practitioners and service providers need to offer a safe environment for LGBT people. They need to support the service user or carer in their right to be open about their sexuality should they so choose, and treat them with equal dignity and respect. Some challenges may exist in relation to terminology and fear of saying the wrong thing, coupled with balancing the rights of the individual and the responsibility of the service provider. However, the availability of clear guidance, training and literature on supporting LGBT people, such as Prism’s How to be LGBT Friendly (Prism, 2008) and the Care Quality Commission’s How we Promote the Rights of People Whatever Their Sexual Orientation (Care Quality Commission, 2008), can enable practitioners to increase their knowledge of LGBT people, and give them the opportunity to tackle any misconceptions or prejudices they may have. Better relationship-based practice will lead to more LGBT people feeling safe to come out when they use services, thereby enhancing their confidence in becoming fully involved in their social care and support planning and provision (Cosis-Brown, 2008). Ultimately, the reward for practitioners, service users and carers is the establishment of confidence and trust, which can lead to better outcomes for a group of people who have long been overlooked and marginalised in health and social care services. By using the videos and additional resources to start debate and discussion and enable change, Social Care TV gives practitioners the opportunity to listen to these people directly and to learn from their experiences, because in social care and health practice ‘We need each lesbian and gay man to be seen as a unique individual within her/his own context, and an understanding that this will include her/his social and political current and historical context’ (Cosis-Brown, 2008, p. 270).
• Social Care TV – Working with LGBT People: www.scie.org.uk/socialcaretv/topic.asp?guid= f616877d-62a1–4718–9c0e-f6a0ba1a7526
• Social Care TV – Home: www.scie.org.uk/social caretv/default.asp
• Social Care Institute for Excellence (SCIE): www.scie.org.uk
This paper is written in a personal capacity and does not necessarily represent the views of the Social Care Institute for Excellence. The authors would like to thank all those involved in the films.