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Embracing diversity in adult social care
– Coming out

We live in a world which is becoming ever more accepting and appreciative of people being open about their sexuality and their gender identities, but many are still ‘going back into the closet’ when they need support. Professor Trish Hafford-Letchfield from Middlesex University shares latest research and best practice in supporting people to be open about their identities in care.

It is safe to say that working positively and inclusively with people who have diverse sexual and gender identities can be a very challenging area for social care, yet numerous research studies have shown that this remains a peripheral issue for the workforce.

This is despite evidence showing that the LGBT+ community experiences higher incidence of mental health issues, such as anxiety and depression, suicide and problematic substance use, and that their general health can be worse than that of heterosexual or cisgendered people. Additionally, findings from research with LGBT+ adults indicate that they lack confidence in care services, causing a reluctance or delay in seeking help.

This is primarily a result of people’s previous experiences of discrimination, but is also down to a continuing lack of clear direction in working with members of the LGBT+ community, and a distinct absence of targeted policies and practice guidance. Opportunities have been made to remedy this within generic policies impacting on care (such as in mental health, dementia and ageing), but they have so far been disappointing and have only paid cursory attention to the LGBT+ community’s specific needs and circumstances.

As well as this, people could face discrimination, or fear facing discrimination, in services such as care homes and supported housing, where other residents might be intolerant of living with LGBT+ people who are open about their sexuality and gender identities. These fears must be seen in the context of the enormous disparities and inequalities that LGBT+ people face.

There is also an issue in the idea that some professionals and care workers might operate from the presumption that all people identify as heterosexual or cisnormative (meaning that we see people with a fixed stereotyped gender). Whether or not this is true for a social care professional, the idea itself makes it very difficult for people using services, and their carers, to talk openly about their lives and relationships.

The scope of the issue

In 2018, Government commissioned a national survey with over 108,000 LGBT+ respondents to find out more about the prejudices they are facing. Some of the findings make for difficult reading in light of perceived progress – LGBT+ people reported being less satisfied with their life than the general UK population, with particularly low scores for transgender respondents.

More than two thirds of LGBT+ respondents said they still avoided holding hands with a same-sex partner for fear of a negative reaction from others. Verbal harassment or physical violence is an ever-present experience which was significantly underreported, and ‘conversion’ or ‘reparative’ therapy offered to ‘cure’ people with different identities is still present in UK society. This all feeds in to how people will feel about being open about their sexual and gender identities in later life and in health and care settings.

In fact, respondents confirmed that disclosure or ‘coming out’ to care staff remains uncommon and 21% of transgender respondents said their specific needs were ignored or not taken into account when they accessed, or tried to access, healthcare services in the 12 months preceding the survey. This included being subject to inappropriate curiosity and avoiding treatment for fear of discrimination or intolerant reactions.

Changing the story

As a result of the findings, Government has launched an action plan, so that the sector can expect, or will already see:

  • LGBT+ people’s needs being taken into account in health and social care regulation via the Care Quality Commission (CQC), which will improve how it inspects the experiences of LGBT+ people in adult social care.
  • Improved monitoring of sexual orientation and gender identity supported by best practice guidance. In social care, this includes understanding the benefits of asking people and their carers about their sexual and gender identities and developing a monitoring standard so they know what to expect.
  • Improved support for LGBT+ people with learning disabilities through a review, collation and dissemination of existing best practice guidance, advice and training regarding LGBT+ issues and learning disability.
  • The appointment of a national LGBT+ health adviser (Dr Michael Brady) to provide leadership on reducing the health inequalities that LGBT+ people face, together with relevant statutory organisations and professional associations so as to embed LGBT+ issues into services.

Additionally, a major review of the needs of older LGBT+ people was launched in May this year, via a national summit on LGBT+ ageing. This provided the groundwork for a series of recommendations for providers and professionals to take forward. These included:

  • Embedding an educational standard for teaching LGBT+ ageing issues within social care training courses and degrees.
  • Providing cultural sensitivity training for staff.
  • Nominating members of staff as LGBT+ advocates, supported by extensive training on the specific health and social care needs of the LGBT+ community.
  • Providing inclusive social spaces within services, dedicated to LGBT+ people.
  • Reaching out and partnering with LGBT+ organisations when developing service improvements.

Useful free resources have also been made available on Diversity Trust’s website to support organisations in training and developing action plans.

The key to better care

An integral part of person-centred support is ensuring that every individual is respected and can discuss their support needs with sensitive staff who are confident about working with people from diverse backgrounds, with different family set-ups and life histories. In this respect, LGBT+ people don’t necessarily need special treatment, but they shouldn’t have to explain or feel they need to justify their lives or relationships, especially at a time when they may be in crisis.

They likely want many of the same things as non-LGBT+ people in similar circumstances, such as assurance that they can continue to live the lives they choose, but they might also need extra support to enable them to be open about their identity so that this can be achieved.

This might involve looking for opportunities to address sexual and gender identities within assessment and care planning, so that any identified needs are specified and agreed with people in their support plan. By asking more open questions when talking to people about their personal histories, the individual can be given an opportunity to share what is most important to them, including their LGBT+ status, intimate relationships and support networks.

Managers can also think about how the culture of their service gives clues about how a person’s identity will be respected, for example in how its marketing materials include positive images of LGBT+ people. Ensuring that staff are trained and able to respond appropriately when people come out is also important. Training in this area should be mandatory alongside other equality and diversity issues. Discussing issues regularly in team meetings and supervision can help link these issues to improving quality.

Where people are open about their identities, the tendency to ‘treat people all the same’ in some services fails to recognise that LGBT+ people might have very specific needs, that might differ from heterosexual or cisnormative people. These needs are also diverse within the LGBT+ community itself, particularly for bisexual and transgender members, and could require a sophisticated understanding of the needs and circumstances of LGBT+ people. For example, in social care, we need to be extremely sensitive to people in the difficult situation of living in one gender, and holding identification and documents in that gender, but a birth certificate and legal status in another.

Making sexuality OK

Regardless of sexual and/or gender identity, we must address how we acknowledge and engage with people using services and their carers regarding their intimate and personal relationships. The CQC’s guidance on relationships and sexuality in adult social care services is a valuable read for both CQC inspection staff and adult social care providers.

The guidance covers sex, masturbation, sensuality, physical intimacy, romance and physical attraction, gender identity, sexual orientation, personal dress, body image, personal grooming and sexual expression. It provides a reference point for discussing issues that may arise in care settings, including being proactive and responding to incidents. It is timely, in that sexuality will be integrated into the CQC’s key lines of enquiry and reminds us that sexuality is an area of practice not relegated to any specialist topic, stage of life or field of practice. Sexuality is recognised as a part of us and we should be able and supported to express it no matter our age, sexual orientation or gender identity.

Time to take action

Any guidance or recommendations need to be implemented with support for staff to develop their understanding, knowledge and skills. Implementation must also allow the space required to make sure the people who are using services and their loved ones are involved in decisions and activities that enrich and maintain their lifestyles and identities. Policies and working practices about relationships need to apply equally to all types of intimate relationships, including those between people with different sexual and gender identities.

Most importantly, LGBT+ harassment and homophobia need to be explicitly mentioned in safeguarding policies and included in training. It is important that staff and the people using services know who to contact if there are problems, such as the police liaison officer or advocates who can work with people – including staff – who identify as LGBT+.

There is still a long way to go, but the building blocks are getting there and we all need to come out of our comfort zones to be able to move on.

Professor Trish Hafford-Letchfield is Professor of Social Care at Middlesex University. Email: Twitter: @ArchwayDiva

How are you upholding the rights of LGBT+ people in your service? What are you doing to ensure they feel safe, secure and able to be open about who they are? Share your knowledge in the comments section below to help other providers improve practice.


Whilst, in the last two decades, significant legislative changes have transformed the rights and citizenship of our lesbian, gay, bisexual, transgender (LGBT+) population, namely the Human Rights Act 1998, the Civil Partnerships Act 2004, the Gender Recognition Act 2004, the Equality Act (Sexual Orientation) Regulations 2006, the Equality Act 2010, the Marriage Act (Same-sex couples) 2013 and the Care Act 2014 (in England), the legislative framework is only as effective as the practitioners and managers responsible for its implementation. For example, the Protections of Freedoms Act 2013 is an important one for social care, as it means men with historic convictions for consensual sex with other men can apply to have these removed from their criminal record.


Care Quality Commission (2018), Equally outstanding: Equality and human rights – good practice resource

Care Quality Commission (2019), Relationships and Sexuality in Adult Social Care

Dentato, M, Kelly, B, Lloyd, M & Busch, N (2018), Preparing social workers for practice with LGBT populations affected by substance use: perceptions from students, alumni, and service providers, Social Work Education 37:3, 294-314, DOI: 10.1080/02615479.2017.1406467

Diversity Trust (2019), Care under the Rainbow 

Dunk-West, P., Hafford-Letchfield, T. (2018), Sexuality, sexual and gender identities and intimacy research in social work social care: A lifecourse epistemology, London, Routledge

El-Zerbi, C. (2019), A review of the needs of older LGBT people in later life, Pink News and Aegon, edited by Ana Nanu

Government Equalities Office (2019), LGBT action plan: Improving the lives of Lesbian, Gay, Bisexual and Transgender People, London, HMSO

HMG (2018), National LGBT Survey: Summary report, London, HMSO

King A, Santos A C, Crowhurst (2017), Sexualities research: Critical interjections, diverse methodologies, and practical applications, London Taylor and Francis

Simpson, P., Almack, K., Walthery, P. (2018), ‘We treat them all the same’: The attitudes, knowledge and practices of staff concerning old/er lesbian, gay, bisexual and trans residents in care homes, Ageing and Society, 38(5), 869-899

Sommerville, C. (2016), Unhealthy attitudes: The treatment of LGBT people within health and social care services, London, Stonewall

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