How Can We Make Mental Health Services Better For LGBT People?

08 February 2021

How can we take positive and practical steps to make mental health services better for the LGBT+ community? We speak to Dr Elliott Carthy, a psychiatrist and YouTuber who creates content on mental illness and popular TV programmes. We also speak to Cole, a transgender man who will be sharing his experience of psychosis and his thoughts on the performativity surrounding gender and mental health services.


Ella: Hello, and welcome to the Royal College of Psychiatrists podcast with me, Ella Marchant. For LGBT+ history month, we have two wonderful speakers on the podcast. First, we have Dr Elliott Carthy, a psychiatrist and YouTuber who creates content educating people on mental health and reacting to popular shows like Scrubs and 13 Reasons Why. Next up we have Cole. Cole is a transgender man and an education manager working in Leeds. He will be sharing his experience of psychosis and the kind of help he received in the mental health services. Both Elliot and Cole will be discussing how we can take practical steps to make mental health services better for the LGBT+ community. Dr Elliot begins by describing what it's like to be openly gay and working in psychiatry.

Dr Elliot: I think right now, actually I find psychiatry to be a very welcoming and opening place, at least for a gay person like I am, but we haven't always been on the right side of history to put it mildly. I started this YouTube channel probably a couple of years ago. I just dabbled in things a little bit because I've always thought that psychiatry doesn't have quite a big enough presence on social media really, which is where information is shared now.

I think we've got to keep up a little bit more to make sure that we're spreading the reality of what we do rather than people still believing that we practice in the way that we may practice 30, 40 years ago. I think that psychiatry does have a bit of a complex relationship with the LGBT+ community. We have medicalised homosexuality for a long period of time. It's actually only a few decades ago that we stopped doing that and I think we haven't always been on the right side of history and I think it's important that we acknowledge our mistakes from the past and we learn from them. The only way we do that is by being transparent about things.

Ella: Absolutely. Is this what inspired you to start talking about psychiatry on YouTube?

Dr Elliot: In part, I think that there's a lot of-- YouTube is a weird place. There's a lot of opinions on there. A lot of opinions that can be masquerading as fact. There's a lot of pseudoscience that's out there as well. I think it's our duty as doctors and scientists as well, to make sure that we're spreading truth and accuracy and evidence-based information. I noticed that psychiatry didn't have much of a presence on YouTube and that's even come down to learning about the science side of things and studying for exams.

There's lots of surgeons and medics and other types of physicians on there that are teaching concepts, but there wasn't anything with psychiatry. There was a massive gap. I suppose in my small way, that's what I'm trying to address really is taking simple concepts around mental health and psychiatry that might be in the media or might be common talking points. Just trying to explain the evidence-base behind it, that combat some of the misinformation that's out there.

Ella: I do love how on your YouTube channel, you have slightly less serious videos where you're talking about like Netflix series, and then you have actually very educational videos, which is why would psychiatry be good for you? Why would you step forward into psychiatry as a discipline, et cetera, et cetera?

Dr Elliot: I think even when I'm watching the stuff that's on Netflix and on TV and talking about it, at the same time, I suppose I'm trying to get people to take away that they have an understanding of what depression is or what psychosis actually is but in a slightly lighthearted way because I think that's where a lot of people get their information about mental health and psychiatry at the moment. It comes from the media, it comes from social media as well. It comes to news articles. I think it's important that we can use those as examples to try and link those to some of maybe the drier scientific concepts but we use that to explain it with some degree of accuracy. I hope.

Ella: Completely. I think lots of people their first experiences of psychiatry might be TV shows like Hanibal for example.

Dr Elliot: Yes, I agree. I think that what we know is that more and more people are going to come into contact with a psychiatrist at some point or have somebody very close to them that is in contact with a psychiatrist. I think a lot of people, even when I speak to people, when I see people on call, and things like that still don't have quite an accurate representation of what we do right now. They worry that if you're going to see a psychiatrist that we're automatically going to section people or that our intention is just to give out more and more medications or that things like electroconvulsive therapy is still done really liberally in psychiatric wards, which is all stuff from decades ago, even then that's a bit hand up from what the reality was. I suppose I'm trying to use some of these common scenarios of people watching stuff on TV and Netflix to try and teach about what the accurate depiction of psychiatric care is right now to try and alleviate some of that fear and anxiety. If you do need to see a psychiatrist, we're here to try and help you, not just to restrict your liberty.

Ella: Completely. I think in the UK, there is still a belief that if you're interacting with any kind of mental health professional in a way you're perhaps broken, whereas, in certain states in America, it would be seen as very regular and very routine to see a mental health professional

Dr Elliot: Particularly, with therapy. You're right in that. I think people seeing a therapist routinely maybe as a little bit more of a common thing in the States than it is here, but I think there is a lot of fear that people have about seeing a psychiatrist about what label is going to be put on them about I'll be going to let me go home or are they going to make me stay in and what the future looks like as well. I hope that just by trying to be a little bit more present on social media, a little bit more light-hearted but at the same time, try and be evidence-based and accurate, that it takes some of that fear away and that our specialty is looked at in the same way that other medical specialties are looked at. Ideally, psychiatry as a specialty is looked at in the same way that the cardiology is looked at or gastroenterology or pediatrics, for example.

Ella: Do you find that working in mental health is a place where you can be open and be yourself?

Dr Elliot: From my own personal experience working as a psychiatrist, yes. I've never encountered any issues with colleagues and things like that about being open about my sexuality. I think as a psychiatrist, you are speaking to people at the most psychologically vulnerable that perhaps they've ever been in their life. You meet people that have been through all different types of trauma, all different walks of life, from so many different cultures. I think we will be very bad at our job if we weren't open about trying to empathise with those people and those experiences, even if they're alien to us on a personal level. I've only had positive things to have experienced. I think other people, I can't speak for other people and I hope that anybody that's had an interaction with me also feels that they've been able to be open with me about whatever it is that they're struggling with.

Ella: What would you like to change about mental health services for the LGBTQ community?

Dr Elliot: Specifically, for the LGBTQ community, we need to build trust with the community because at the moment, and if you look at surveys and stuff that comes up from Stonewall, there was one about staff attitudes survey that came out about the NHS a few years ago. A lot of people from our community don't trust us. They don't trust it's a safe place. They don't trust that we know how to handle LGBTQ+ specific health issues. Because they don't trust us, it's difficult for them to be open. If they're not open with us, it makes it difficult for us as a profession to know where our community sits in terms of risk with mental health.

We know that there's higher rates of depression and anxiety and substance misuse within the LGBTQ+ community than the general population. We know that. It's very difficult to put numbers to that. It's very difficult to then get accurate data around those things. Then try and do trials to improve our care and to make things better. I think before we can do much, we have to build trust and that happens on an individual level in every consultation we have. I think that very simple things could be done.

For example, when you sign up when you're coming in through A&E, for example, if you need to see a psychiatrist, there should be a blank space for you to put your pronouns in just in the same way that you can choose what your title is and write down what your name is. You should be allowed to put your pronouns in without having to be asked or prompted for it so that you don't get misgendered, we should be having gender-neutral bathrooms, which requires absolutely no change in infrastructure. Just change the sign and I think just simple gestures like that, hopefully try and convey the idea that it's a safe space for our people from the community.

On a more specialist level as well, I would like to see more integrated services between different parts of medicine. I remember being a medical student and going to a place called Dean Street in Soho on my sexual health rotation. It's an HIV and sexual health clinic and it was incredible. This is going back six or seven years now, where they had a lot to do with sexual health. There was a bit to do with substance misuse and addiction. There was a lot of psychological support that was there all under one roof.

I would like to see that become a more commonplace thing where at the same time we can have psychiatrists that have got an interest in mental health needs in our community with addiction specialists, with sexual health specialists that can all sit in one room and be able to share their expertise to try and support patients in a much wider and broader range. That's my idealistic view, unfortunately, with the privatisation of things like addiction services it's difficult to make that reality at the moment but that's my pie in the sky dream.

Ella: Could you explain a little bit more about what you mean by integrated services for those that might not know what that means?

Dr Elliot: Usually, whenever you see somebody from a mental health team, it's never just one person's opinion that will inform your care. You will have a psychiatrist but there's usually meetings where a psychologist might be consulted or a social worker or an occupational therapist and things like that. We work in a multidisciplinary way. I think we know within the LGBTQ+ community if we look at some of the specific health needs, we know there's higher rates of mental illness, there's higher rates of depression, there's higher rates of anxiety. We know there's high rates of substance misuse, so drug and alcohol misuse and actually the pattern of drug use is sometimes quite unique within our community. When we think about things like chem sex, for example. Then we've also got the sexual health needs that are quite different to outside our community as well. These things are all linked in with each other. It would be nice if there was a service that had expertise in all of these areas. There's this sort of teamwork throughout medicine, all of which is specialised and catered towards the LGBTQ+ community and their health needs.

Ella: It makes me feel very special when you mentioned occupational therapists, because both my parents do that. It makes me feel warm inside for some reason. Okay. Thank you so much, Dr Elliot. It was so lovely to speak to you. We'll come back to you soon. Next, we have Cole. I'm so happy to have you on the podcast. Cool.

Cole: I am very excited to be here.

Ella: Could you please introduce yourself and tell us a little bit about your experiences with mental health services?

Cole: I'm Cole. I'm a 24-year-old transgender man and I know with my experiences within the mental health services, I have been extremely privileged in that I had mostly positive personal experiences, but I have also had experiences with friends, with family where I know they haven't had the best experiences either. One of my most positive experiences is with my own family GP. I'd been with this GP since moving back from university. She'd taken over my primary care for my gender clinic as well as any gloves that needed doing.

I felt like after I left university and moved back to the North, back to Leeds, I didn't feel like I had any purpose. It was very difficult to find a job. I just got this incredible degree from a really great university and there was just nothing out there that I could apply to. Then added on top, moving back in with parents is very difficult on young people as well because you've gone from having all this independence to having to live back like you're a child again. I think that really affected me in a way that I didn't have the autonomy that I had at university as I'd become so independent that I felt that I was slightly trapped.

Then adding being transgender into that and finding out who I am as a person, starting my transition. It was a very difficult time. The first person I went to was my GP. Initially, getting that GP appointment was very, very difficult. You do have to go through the receptionist who may not be as trained on these matters and it took my mum, brilliant person to actually say to the receptionist, "If something is not done today, that will be a medical emergency on your hands. I do expect to see a doctor today."

That's really how my mental health journey, real mental health journey started as I had already been with a therapist throughout school, throughout university. This is when it was a time in my life when I really needed that help to pull me from rock bottom and rarely.

Ella: Yes. Aren't mums the best?

Cole: Oh, truly, honestly, all of my friends say everybody needs my mum. She's absolutely brilliant and if it wasn't for her, I wouldn't have received that incredible help that I did. I don't know what place or where I would be today without her doing that for me.

Ella: Am I right in thinking that when you did see a psychiatrist, it was largely a good experience? You mentioned when we were emailing each other, that it was a consultation that happened in your living room.

Cole: Yes. The basic backstory is of course, moved back from university. Mental health started to deteriorate with the loss of autonomy, with a loss of feeling like I had no purpose. I started hearing voices, I started hallucinating and feeling generally like somebody was watching me constantly, which of course is a very early sign of psychosis. Having a parent who had worked in the NHS for a very long time, these were all red flags to her.

They both sat me down and said, we need to ring a doctor for you. Of course, I went to the GP the next day, spoke to her about everything that had gone on. The main aim was to ensure that I felt safe and I felt supported as she had supported me for quite up to a year at that point, the family GP. Then within the first two weeks from that appointment, two weeks later, I had a psychiatrist sat in my living room, as I felt this was the best place for me to begin that journey. It was somewhere I felt comfortable and somewhere where I could be free to have a cry or open up, as it was my own personal space, which she ensured was something that I felt throughout our sessions as well.

Ella: Thank you so much for sharing that with us, Cole. Were you experiencing an episode of psychosis?

Cole: Yes. Basically, what they concluded after going through the initial assessment, after going through those chats, there was that diagnosis of that really early stage psychosis, which was quite scary to hear, especially at the age of 21. I was just really glad that I had finally found some answers as to why I was feeling the way that I was feeling, and not being embarrassed or ashamed about it rarely.

Ella: How did you arrive at the point of enlisting mental health services? Did you have encouragement from your friends and your family? Of course, we've already talked about your mum. Did you have friends that were experienced in a similar thing?

Cole: Yes. Being part of the transgender community, we have circles and friends everywhere, all over the country but especially where I live in Leeds, there's such a big transgender community who I felt I could really turn to. I have friends who have gone through the mental health services, who have both had good and bad experiences. They were there to fully support me, but also my siblings, they were a real catchment for me. They really caught me when I felt like I was falling. I have an older sister who - we're joined at the hip basically. She's always been there for me to chat about mental health too. I feel like we have a very good two-way corridor for conversation in regards to my mental health because they know, especially in these times that talking about mental health is so important at the moment.

Ella: What do you think you would change about the mental health services for the LGBTQ community?

Cole: I think from my own personal experiences, before initially getting that appointment with my family GP, I was put forward to another GP who instantly said to me, "Oh, you're having these issues because you're transgender." I think that is that like Dr Elliott was saying, that everything is medicalised because you're gay or because are bisexual, or because you're transgender. That is the reason why you're mentally ill. Whereas in fact, it's so much more complex than that, people are complex. I feel like that, I don't know whether there needs to be some training to say these things they may affect somebody's mental health, especially about coming out, going to terms with that gender dysphoria, family issues at home, or generally just been uncomfortable within themselves, but there is more to people than just their sexuality or their gender, and it's not always the cause of their mental health issues.

I think what they could also do, I'm not sure, I'm not a psychiatrist, but is there something within training for LGBTQ+ people in psychiatry for them to learn about the community and the history of the community, so then they can feel and empathise with what the community is also currently going through. I think just in general, what I'd change about the mental health services is accessibility. Again I have friends who have quite complex mental health needs, and it's very difficult for them to access any help whatsoever because they're taken to one mental health team and then they're told, "Actually, your case is too severe for us, please speak to these people." Then when they go to the next mental health team they're sent back to the original team because that case again is too severe. They've just been constantly passed round, and as a person who's had good experiences, it's very difficult for me to sit and watch people I know go through that, especially those I know who are also having issues with their sexuality and also their gender dysphoria. I think those are the changes that I would make to the mental health services.

Ella: Absolutely. It must be extremely confusing and there must be a loss of trust there when you get taken from one specialist to another.

Cole: Yes, most definitely. I completely trusted my psychiatrist 100%. I think she found out more than anything about anyone has ever got to know about me, really getting into the depth of things. Being transgender wasn't a big thing for her. She was really trying to get to the bottom of why I didn't feel like I had a purpose, or I felt like I wasted my time at university, that I just possibly couldn't live anymore. I feel with a lot of LGBTQ+ people, again, many of them, unfortunately, have come from family homes, or backgrounds where they're just not accepted, so they're not as confident to open up about their own thoughts and feelings, and how that is affecting their mental health.

Because they feel once they open up, that they're going to be shot back down, or they're going to be told, "Oh, it's because you're gay, or it's because you're transgender, or it's because you're a lesbian." I feel that's just where minds need to change. It needs to be this open conversation between psychiatrists and the LGBTQ+ community, for them to feel this is a two-way corridor. Psychiatrists are doing their best, as Dr Elliot was saying, to be more open, and to be more accessible. I also believe, that as a community, we do also need to open up and talk about our mental health issues. May that be online, may that be on forums, going to different events at work. I feel there needs to be just more openness in regards to mental health overall.

Ella: If people could take away one thing from listening to the podcast today, what would it be?

Cole: I feel what they could take away is again, what Dr Elliot was saying about being open, and also for psychiatrists. Also, for the LGBTQ+ community to be more open. Reach out to your friends who are struggling, especially in times of COVID, but who've been struggling for a long while. It takes a couple of seconds to send a text to somebody, and I'm sure that would mean the world to them, even if they didn't answer for a week.

We've all been there where we're just too exhausted mentally to even reply to a text. I think what they should also take away is that there are people out there who have had good experiences, so please use them to comment on a post of theirs, or tweet them, or DM them on Instagram, anyway we can get to talk to them and say, "Is it okay if I ask you questions about your experience with the mental health services?" Just to give that bit of confidence back to the community as well.

Ella: Thank you so much, Cole. It's been so nice to speak to you. Cole and Elliot, it would be really nice if you had any questions for each other?

Elliot: Yes, Cole, thank you for being so open about your experiences there. It felt like a bit of a rollercoaster listening to it, let alone what you must have actually gone through yourself. I think you're right in that I've heard from a lot of other people that they're worried that they'll be cause and effect attributed to their sexuality, or their gender identity, or whatever their mental health crisis or difficulty is at that moment, that it's going to be caused by that.

I suppose it goes back to what I was saying before, in that we really need to try and have a better understanding of what risk our community poses towards mental health. That's not just the sexuality or the gender identity, that's the social stigma, that's the isolation, that's the prejudice and everything that comes with it. Sometimes the broader identity crisis that people are going through, that spread beyond just sexuality and gender identity. I completely agree with what you were saying.

My first question for you Cole is you talked about trying to increase accessibility and openness. On a practical level, what do you think we can change in the healthcare settings, in general, to make people that are LGBTQ+ feel safer when they enter the building? What simple gestures can we do to try to help people feel a little bit more comfortable when they enter the building so that we can try and foster some degree of trust, and openness?

Cole: Really great question. I think, for me personally, I don't want the mental health services, or the hospital to be performative. There is so many trusts, many businesses, many companies, who have this performative allyship, whereas, in fact, they're not actually doing anything to support the communities.

Cole: Sorry. I think what could be done, is like you were saying previously within this conversation, is gender-neutral bathrooms would be incredible. Again, like the conversation surrounding that at the moment, they are just bathrooms, we are just people. I think again like you were saying, having that pronoun box so then it's not made a big deal out of when somebody has to ask you your pronouns, or even being misgendered, which can sometimes still happen to quite a lot of people, unfortunately.

I think as well, not to be performative is going to be very, very difficult for hospitals and therapists and psychiatrists to be able to do, because they have good intentions, but again, it's key is having that longevity. How long can we keep that firm? Will it work in the long run? Will gender-neutral bathrooms work in the long run? Are there going to be policies and procedural changes that will enable that longevity for the LGBTQ community to feel comfortable within hospitals? I think that's where we really need to make that change is in the policies and procedures to ensure the longevity of the changes put in place.

Dr Elliot: Yes, I completely agree. I'm glad you agreed about the gender-neutral bathrooms side of things. A lot of bathrooms just have the word toilet on them. If you just change that to actually explicitly say, they're gender-neutral, it's a powerful message with no change in infrastructure or changing the way that the room is used in any way, shape, or form. I think that the performative I think, you say, yes, I agree. There's a lot of companies that are using rainbow lanyards and things like that, and they're giving them out to staff without any realisation of what that symbol means.

One of the best examples that I had experienced with just as a person that signed up to it, there was a thing called the rainbow badge project that was started by a paediatrician up in London. The idea was, this is a rainbow NHS badge that now, lots of people wear but it started out as something that you needed to sign up and pledged to be an ally, and there was actually something meaningful you needed to sign up to in order to be able to wear one of those things. You needed to be able to do that otherwise, you weren't given one. I think that was not performative, unlike what some of these lanyards and stuff can be at the moment where it feels like a bit of an empty gesture sometimes.

I think my other question to you Cole if that's all right is about some of the labels. Particularly the labels of gender dysphoria and gender identity disorder. Because from meeting people, I hear a lot of different opinions about what those labels mean to different people. Some people that I've spoken to think that they're important because they actually are the thing that gives you access. If you're diagnosed with something, then that gives you access to support and it gives you a framework and a structure. Other people feel that they're stigmatising and medicalising something that doesn't need to be medicalised. I find it's quite an individual thing from speaking to different people.

Cole: In terms of the label of gender dysphoria, gender identity disorder, unfortunately, within the current system as it is you do have to have a diagnosis of gender dysphoria from the gender clinic if you're seeing a private gender clinic. There are many, many loopholes within the GIC that you do have to jump through. Even now, being almost five years on hormones, I'm two years post top surgery, I still feel that whenever I go to the GIC, or have a Zoom meeting now, which they are doing, which is fantastic for accessibility, I still feel that I have to over masculinised myself, to ensure that they don't change their mind.

That anxiety of them taking bac this diagnosis that was given to me because of the experiences that I had had throughout my entire life. It's also a topic of conversation at the moment about gender dysphoria is that needed to be transgender. There are many arguments on both sides but what I feel is that if you feel that there is something different, that you feel that you don't want to conform to society, then that itself, you don't need to have dysphoria, you just need to feel that you don't want to conform to femininity or masculinity.

That's something that's been built over hundreds of years which is-- especially nonbinary and genderqueer people, they are the ones who are especially having to jump through these loopholes in order to get that care from the gender clinics, which is awful to hear these stories. I see it every single day on the forums that I'm in or within the circles of friends that I'm in. There's people who are non-binary who have to over masculinised themselves or overly feminised themselves just to ensure that they get the hormones that they need, or they get that top surgery that they really, really want. I still think even within the progress that we have made in regards to being transgender within and the medical journey that comes with that for some people, not all is that it is still a very tick box saying, yes, you want to be hairy. Yes, you want to be a beard. Yes, you want to have top surgery. Yes, you what you want to take testosterone. It still feels like that sometimes that you have to tick all these boxes to ensure that you get a diagnosis but times are changing. Things are getting different. There are people out there who've gone into gender clinics saying, "I don't want to take hormones, but I would really like to have a top surgery because I feel dysphoria towards my chest." Or there's people going in and saying, "I'm having social dysphoria. I don't want any medical treatment, but I'd really like to talk to somebody about why I'm feeling this social anxiety surrounding my gender." The tides are turning, there is still a long way to go. I hope that answers your question.

Dr Elliot: Yes, and I thank you, Cole. Thank you for that. That was really in-depth. Thank you.

Ella: Well, is there anything that you would like to ask Dr Elliott?

Cole: Just a couple of questions. As I touched on earlier on within the conversation, LGBTQ people's mental health is very complex, so is, a lot of other peoples. However, do you believe that there should be a specific training on LGBTQ+ mental health and history and matters within your own development and training?

Dr Elliot: Yes, absolutely. I do. I've actually placed in-- Because I trained in Oxford. I'm doing a talk in a couple of weeks time as part of LGBTQ+ history month for our trust and a few weeks on the history of homosexuality in psychiatry and how it shaped over the years and how it got to where we are now. Because, history shapes where we are now, and that can be said for every part of medicine, law, religion, every part of society. We are a product of decades and longer of experience. I think that we haven't always been on the right side of history with regards to psychiatrists attitudes towards the LGBTQ+ community. I think an understanding of that from the staff's end would help people empathise with the patient end and some of the difficulties that they might be going through with things. I think just as a lot of patients that I've met, I think you spoke about the same thing, feel a bit worried about being open about their gender identity or their sexual identity because of what people are going to say and how that's going to be handled.

I think a lot of staff are worried about asking about it because they don't quite know what to do with the answer, or they're worried about putting their foot in it and saying something wrong and all of these things. So it ends up becoming the sort of elephant in the room that nobody acknowledges and that doesn't really help anybody. Yes, I think that looking at our history and how we've got to where we are now is really important and that could equally be said for other marginalised groups as well, understanding refugees, experience people from, from different ethnic backgrounds as well. I think that could be translatable to lots of different marginalised groups where we know that rates of mental illness are higher than the general community

Cole: Perfect. That is all of my questions. Thank you so much.

Dr Elliot: No problem. Thank you.

Ella: Huge thank you to talk to Dr Elliot Carthy and Cole for sharing their stories so openly with us and helping us to honor LGBT+ history month here at the College. If you would like further resources on LGBT+ mental health, then please head to our website, Go to the Members tab at the top of the screen and select rainbow SIG. Thank you for listening.

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