06 June 2021
This month we have two very special PrideCasts to celebrate Pride month! We will be talking to Dr Sarah Stansfeld and Lesley Fraser about gay conversion therapy, active steps the government could take to support the LGBTQ+ community, and of course, the difficulties among patients and staff that have arisen during the pandemic.
For more resources, please visit our LGBTQ+ page.
Ella: This month we have two very special podcasts to celebrate Pride, where we will be talking about gay conversion therapy, active steps that government could take to support the LGBTQ community, and of course difficulties among patients and staff with which have arisen during the pandemic. On part one of our pride podcast, we have Sarah Stansfeld. Sarah is a consultant child and adolescent psychiatrist working in Manchester. She specialises in working with adolescents, and is a member of the Royal College's Rainbow Special Interest Group. We also have Lesley Fraser, who works on the same team as Sarah. Lesley is a senior mental health practitioner and a cognitive behavioral therapist.
Thank you both for joining me today. Sarah, we're going to start with you. Could you tell us a little bit about your day-to-day work and your day-to-day life, I suppose.
Sarah: Hi, my name is Sarah Stansfeld. I'm a consultant child and adolescent psychiatrist, and I work with older adolescents, so teenagers ages 16 and 17, and I work in a community team with lots of lovely colleagues, including Lesley, who's here with me today. My day-to-day work is meeting with young people. The kind of young people who come to our service, the kind of situations they might be in, or problems that they're coming with, are people with depression, with different types of anxiety problems, things like social anxiety, or obsessive compulsive disorder. We see quite a lot of young people who are presenting crisis with their mental health, and they might have thoughts of harming themselves or even thoughts of wanting to die.
Quite a lot of our work is about supporting people through crisis times. We also take a developmental approach to assessing people. Thinking about whether there might be a difference in their neuro-development like autism spectrum condition or ADHD - attention deficit hyperactivity disorder. Then because we're seeing older teenagers, we do also fairly often see people who are in the first stages of mental illnesses like psychosis, or bipolar disorder. Those are the kinds of things that I might be talking to people about.
Day-to-day, I'd be seeing young people for assessments to get a detailed look at what's going on and help to get an understanding of that, and I also think about treatment. One of the treatments I offer is medication, alongside the therapies that other members of our team like Lesley's able to offer.
I might think about, is the medication right to be started? And then also to meet young people for follow ups, to check their on right medication, if it's helpful, and to check if they have any side effects. As well as meeting with young people, we also work together as a team, so there's quite a lot of case discussions, and thinking about treatment plans and how to keep people safe.
Quite a lot talking together with team members. We also spend time liaising with other professionals, like colleges and social services, for instance. Then in addition to that, there's quite a lot of paperwork and computer work to get done.
Ella: Lesley, could you tell us a little bit about your day-to-day and how it might differ from Sarah's.
Lesley: My name is Lesley, and I'm based in the same team as Sarah. I'm a cognitive behavior therapist and senior mental health practitioner. A lot of my work is doing the initial assessment. Sometimes we do due to our services when somebody may have presented from A&E or when they're in crisis.
A major part of my work is ongoing psychological therapy with young people, but as Sarah says, also liaising with different services that will support the young person, so potentially the college that they're going to because we just work with 16 and 17 year olds. The college or school, sixth form, et cetera, Career Services -potentially to try and get young people involved in those, or other older voluntary services as well that may be more suitable for them to access some support there as well.
We work as a multidisciplinary team, so discussing cases together really. We're from different disciplines. We have social workers, counsellors, nurses, psychiatrists within our team also, senior psychologists, then obviously, we've got a management team as well.
Ella: Lesley, if there was a young person listening and they heard about therapy but they didn't really know what that involved, what would your therapy, because that's a big part of your--
Lesley: Yeah, their engagement in therapy, we talk to young people about what therapy involves. It's not just about turning up for therapy sessions, but also their collaboration within that. Then also becoming their own therapist really, really understanding what is maintaining the problem. So about behaviors and thought processes, et cetera, that are keeping the difficulties going really on what changes to make so therefore throgh therapy what small changes can they make between sessions and challenging negative thinking processes. About really being on board with that and what engagement in therapy actually means. We really do a lot of work within that getting young person ready for that.
Even if it's a case of-- because we've got quite this small window, the 16, 17-year-olds about having a positive experience within our team with a view to maybe returning to therapy at a later date, if that's more appropriate, maybe when they're in adult services, but them knowing really what therapy would be about, and it's something that they would be involved in, as well.
Ella: As we slowly emerge out of the pandemic, what do you think the impact of COVID has been like on your patients?
Lesley: It's been really tricky, because I particularly work with lots of young people who might suffer with anxiety disorders or presenting symptoms of anxiety disorders. For instance, Sarah touched on social anxiety earlier on. The COVID in the lockdown is almost been like an enforced avoidance of social situations, which, for months, I suppose has left those young people in what they would call their comfort zones to start off with. But actually in the long run it has actually really impacted negatively. Now that we're starting to come out of it, we've been starting for a little while, or as they were returning to college, that was really, really difficult because that enforced isolation really impacted upon that a lot.
I'm sure, obviously, the impact of the lockdown and the pandemic on a young person that might be suffering with symptoms of OCD, or generalised anxiety disorder, this uncertainty - we live in an uncertain world anyway - but this huge uncertainty that we lived with for over a year has really impacted upon that. We're seeing a lot more young people coming through with those difficulties.
Sarah: Yes, I think you made some really good points to that. I suppose, for me, some of the young people who've been most affected by the pandemic are those who live with very difficult home situations, the people who have unhealthy relationships at home, who perhaps are in abusive situations at home, we know that this has a huge impact on people's mental health. There's a huge amount of evidence for that.
What's happened during the pandemic is all of those everyday escapes that helped people cope with that have been taken away, and all at once. Those things that people might do to cope, like spending time staying with friends or relatives, having time with their friends, going into face-to-face schooling, having other family members be able to go out to their jobs. When all those things are taken away, that can make things very, very difficult. That's certainly something that I've seen some of the young people we've been working with.
Ella: How does being part of the LGBT community influence the way you both connect with patients and service users?
Sarah: We were just talking about it.
Lesley: Yes. I mean, I suppose, for me, there is an increased understanding of potential stigma of discrimination that can be faced, and especially the young people that we're working with are not necessarily out or out everywhere, and about that being stilted in our language and the language that we use, and that's hard in itself, but about where they feel safe to be out where they don't feel safe to be out.
That increased understanding about that, but, however, is quite dangerous, I suppose to fall into that trap to think that well, I'm not the expert on what that is, and I don't necessarily know their experience. We all are empathic practitioners that work within our teams. It's always about really trying to really understand that from the young person's point of view, and we're not making assumptions just because you think you know already.
Sarah: I was thinking about this question. I think it has given me a bit of an insight into the shame that people can carry with them, and when you're growing up, and I think people internalise that and carry that with them. That has a huge impact on your self-esteem and your sense of self-worth, which is really a key building block in having good mental health. I think that's something that's something I have learned from being part of the LGBT community, that I do carry into my practice.
Ella: The patients that you see might not necessarily be out and be openly LGBTQ, they might not openly be gay, might not openly be trans. How do you make sure that you create a space where they can be out, I suppose?
Sarah: As part of our assessment process, when a young person comes in to our service, part of our... to take in details with demographics, it's just all part of that, so we ask a young person how they might identify their gender, their sexual orientation, we ask them about pronouns, we potentially introduce ourselves with our own pronouns, so that it's just enabling, it's just part of that process. Obviously, we touch the obvious, they don't have to say. We meet quite a lot of young people who might say that they're not sure, and they prefer not to say, and that's absolutely fine too, but we do it as just part of that initial process.
Lesley: I think that's right. I think being able to just ask in a non-judgmental way sometimes is enough. The other thing I would say is, we're really lucky to work in this team, which has had a lot time to think about the needs of our age group of 16 or 17-year-olds. We have a waiting room that's strewn with Pride flags and trans-Pride flags, and a collage of different LGBTQ leaflets and photos of our participation group doing Pride makeup, and we all wear rainbow lanyards.
It might seem like a small thing, it might just seem like decoration, but I think it's really important. I think as gay people, we are quite attuned to look for signs, and signals, and codes that the person you're speaking to is a safe person. That might be a haircut, or a style of dress, or a casual comment that they make when you're in a social situation. Things are easier now than they were. That makes you feel like this person is safe. I can be open with them, and I can share with them who I am, I don't have to keep that hidden.
I think that works in social situations, but also works in services. If you can have these little signals around, whether that is just a rainbow flag up on the wall that says, "This is a safe place to talk," I think people do pick up on that. It's not unusual for me to speak to somebody who talks about their sexuality or their gender identity for the first time, and that always feels like a great privilege if that does happen.
Ella: Such an enormous privilege when someone comes out to you, says, "Actually, no one knows this, but--" It just shows that you've created an amazing space for them.
Lesley: Yes, absolutely.
Ella: Speaking more about the relationship between mental health services and the LGBTQ community, there is a very difficult relationship between, especially, psychiatry and the LGBTQ community. How do you think that mental health professionals can seek to repair this?
Sarah: I don't think we can undo what happened. I don't think you can say, "Okay, let's make that better," and then it's now neutralised. That happened and it will be remembered, and it needs to still be being taught to the next generation of psychiatrists. We need to make sure that people know about that because if we forget history, then there is a risk that things can be repeated.
There's a temptation that people say, "Oh, well, that was years ago." It wasn't that long ago, that homosexuality was being seen as a mental disorder. I think it's important to remember that and to keep that in mind, and to learn from that. I think what we can do now is trying to build services that understand who LGBT people are, that involve LGBT+ people in service design, and try to create that comfortable space where people can talk and try to make sure that we're meeting people's needs, and that those services are being assessed and checked that they are doing that.
Lesley: Yes. As a team, I mean, we recognise what was Idaho day. I think it's classed as Idahobbit Day with the added now when the homosexuality was taken off the classification for mental health disorders? We've recognised that, Sarah's right, it wasn't relatively that long ago. I think it's just important that mental health professionals, that we're aware that yes the LGBTQ+ community are four times more likely apparently to struggle with mental health difficulties, but that is not because of their LGBTQ+ status. It's potentially because of society's attitudes towards discrimination. It's just important for us to remember that thing and move forward regarding that.
Ella: Moving on to our next question. Gay conversion therapy is still actually technically legal in the UK, and it's been an incredibly slow process. It still actually hasn't been banned. Why do you think this is?
Lesley: Well, it's hard to think about why that has taken so long because it has been going on for so long. We're aware that other countries in the world that maybe have-- maybe aren't quite as forward in changing different laws as the UK is, have banned this, so it's quite difficult to understand why it's taken so long. I know that the government is talking about they still need to consult with religious leaders or the leaders before this is banned, while saying it is abhorrent.
Sarah: I mean, I can't speak for the government about what's taking them so long, but I think they need to get their act together. For me, this doesn't feel like a very complex issue. It's called conversion therapy, but it's not therapy. This is abuse. There's nothing therapeutic about it.
Ella: It's quite shocking that someone actually left the board. There was a board moving this process forward. Someone left the board because it was taking such a long time to have this pass which just feels horrendous. So what active steps do you think her government could take to support the LGBTQ community? Of course, number one would be probably banning gay conversion therapy because this would send a message, for sure. Lesley, you mentioned something very interesting before, which is that people in the LGBTQ community are four times more likely to have mental health needs. Do you think there's anything the government could do to support them more?
Lesley: As you rightly said, obviously banning the conversion therapy would be a huge message that would be sent out to society to do that to make that illegal, but also as well I honestly believe that within school settings as part of PHSE as part of sex education, to make that inclusive for young people regarding same sex relationships that those relationships are talked about. We haven't got section 28 anymore. Just about - every relationship is equally as valid and for young people to be able to hear that, that they're not invisible and they're not ignored.
Sarah: Yes. I suppose I would answer that from the mental health perspective, is we need to keep increasing funding in mental health services across the age range but obviously our view is particularly with children and young people. As you said, there is this higher prevalence of mental mental disorders in LGBT+ people. The situation is at the moment there's not enough of the service to meet the need in the community. What that unfortunately means is that the thresholds in children and young people's mental health services end up getting higher. Then you lose an opportunity for that early intervention which can prevent problems from getting worse.
I think the government actually is putting more money into children and young people's mental health services, but that needs to keep going and momentum needs to keep going and that will benefit not just the LGBTQ+ community but all young people. The other thing we see is gender identity services at the moment are not very accessible for the young people we work with. We're able to make the referral, but the waiting lists are very long, geographically people have to travel a long distance. Young people who often don't have the resources to do that, and may not have the support with parents to take them to those appointments. There has been a lot of talk about this, but I think making those services more accessible needs to be a priority as well.
Ella: Earlier, when we were talking about lockdown, I just wanted to go back into that and ask you about any personal difficulties that you might have had during the pandemic, and how did you deal with these; these might have been emotional difficulties or practical difficulties, for example, not being able to be face to face with people any more?
Lesley: Practicalities - we had to think very, very quickly, and our managers very much thought on their feet regarding how are we going to do this, and we work in quite a closed space where we are also about half at home and half in work , and how we then provided a decent service for the young people that we work with that can be as good as we could manage at that time. We very quickly had to start using technology that we're not used to doing, so we were doing video phone appointments, et cetera. We've always continued to offer face-to-face appointments with some young people. How we could try and do that safely for them and also for us with all that stress that was going on. It was a huge challenge that we did.
Sarah: It's interesting what you say about the video, because that was very new for us. We weren't very technological before, and that moved very quickly. It shows what you can do when you have to. I was very optimistic, really, when we started using video, that we'd be able to get a whole group of young people who struggled to make it to appointments might be able to engage, and this would be really beneficial for people. Actually, what I learned through that was the barriers for people being able to access mental health services, which I probably did already know, but I think I was feeling very optimistic [chuckles] are more complicated than that.
The barriers are much more about people's complex lives. In order to attend a video appointment, you still have to remember the time of the appointment, have access to a device, make sure that it's charged, be awake, make sure that somebody has got you out of bed.
Have some privacy. We do see young people who may be living in quite chaotic situations, so they might be sofa surfing, moving between different people. Sometimes you can get hold of them when they're living with one person, but not another person. Actually, technology didn't make any of that any easier. [chuckles] That's one thing I found.
On a personal point of view, I've had a pandemic of two halves because I was on maternity leave for the first part, and that was certainly a more lonely, more difficult intensive than I had envisioned that it would be.
I think the ways that I coped with that were making sure that I tried to stay as connected as I could with family members and with friends over all the technology that everyone's been using: WhatsApp and Zoom and everything, making sure that I got out as much as we were allowed to. I'm lucky to have some green space near me, and I have a dog who demanded to go out quite a lot. That was definitely very good for me. I think that was helpful. The other thing that actually really helped was coming back to work. It's such a busy and absorbing job and a real privilege to get back to working with young people and hearing about people's lives. That's definitely made a huge difference.
Ella: How has it been coming back from a maternity leave that you had during lockdown? Do you feel like you had the good time with your new baby, and you're back at it, or would you've like to have just had the whole 15 months at home?
Sarah: Oh, no, it was good coming back because it was great being with my baby, and she's been a great distraction from everything, but it was good to come back because what I hoped the maternity leave would be like would be being with my baby and spending time with other mums and getting to know people and socialising. That wasn't the experience. Actually, being able to come back to work, to see my lovely colleagues and to be occupied with trying to help young people to feel better, has really helped to get that balance back in my life rather than being in the house all the time. I'm not really a person with a natural stay in the house all the time person.
Ella: Could you both tell me about someone in the LGBTQ community that inspires you? This might be a close friend or someone you've never actually met.
Lesley: There's so many, and we've got them scattered all around the buildings, on doors, et cetera. I suppose somebody that I was thinking about is the boxer Nicola Adams. I think she's very inspirational because she's never hidden her sexual orientation, but also it's not all of her. Her sexual orientation doesn't encompass her, It's one of her identities. I just think she's a sound representative really.
Sarah: Yes. Obviously, Leslie has been inspiring me. The person I chosen, at the moment my big inspiration is RuPaul Charles. I have been on the search for joyful uplifting TV to get me through the long pandemic nights. I'm very late to the RuPaul's Drag Race Game, but since I've discovered it, I've watched many seasons over this latest lockdown. It's joyful, and it's fun, and it's silly. It had me laughing. That's really helped with the pandemic. Also, I think the inspiration comes from, because it's so fun and silly, I can see people watching it with their families. I can see families starting to open their minds a bit to, well, to people of different sexualities, but also to play with gender and to have fun with what is masculine, what is feminine? I think that's hugely powerful and hugely disruptive to the norms that are in our society, but because it's done so lightly with so much fun, I think that's how people get engaged with it.
And the other thing about it is, we see a lot of young people who really struggle with their body image. That has a huge impact on their self-esteem. I think when I was growing up, and this is still the case now, there was a template of how you should look to look beautiful. Your looks, you could either try to make yourself look as close to that as possible, or you could turn your back on it and say, "Well, I'm not taking part in any of those things."
What RuPaul's drag race does is say, "It's okay for anyone to look beautiful and fabulous, and celebrate any body shape or aesthetic or whatever your taste is."
It's bring your own template, show us what you think is beautiful, and then take it as far as you can. Let's push it, let's be as creative as possible and really celebrate it. Again, I think that's incredibly powerful. That's my absolute inspiration at the moment.
Ella: I definitely think that's the first time that psychiatry and RuPaul will be potentially in the same podcast.
Sarah: RuPaul, I love you.
Ella: That's perfect. I like that you've gone for serious and you've gone for light relief at the same time. Yes, that's great. I was just wondering, is there anything else that you would like to be asked so that we can go into it in a bit more detail? Do you think there's anything that you'd like to mention you think patients have been through, or anything that you think staff have been through that you think is important to mention over this past year?
Sarah: I think this has been a very stressful year for staff. I think people are aware of that. That's not--- Just us in the NHS, I think everybody who is working. We've been lucky in a way that our jobs are secure and we know that we've got a job, and so many other people in society have faced that uncertainty or actually losing their job and the financial consequences of that.
It has been very stressful to staff, but then you've got to put it into that context. I think we've seen that, and I think we've tried our best to be supportive to each other, but then there's that natural distance of the team being split in half being at home, half being in at one time or another, or team meetings that used to all be together in a physical space, and now separated and done over technology.
The ability that we used to have to just go to each other's desks and discuss things has been disrupted by working from home, so you've got to be creative about how you support staff.
Lesley: Yes, absolutely. I echo all of that.
Sarah: I just wanted to credit to Vicky our team manager who's been brilliant.
Lesley: Yes, absolutely. We're very lucky we're in jobs, we're not faced with that financial situation of that worry that millions of other people have faced. We are mindful of that.
Ella: Thank you. I think that's a really good note to end it on. If you would like more information on the topics discussed today, please go to our website which is www.rcpsych.ac.uk. Then select 'About the College' and select equality, diversity, and inclusion. A huge thank you, both Sarah and Lesley, for lending their perspective to the podcast and helping us to celebrate Pride. Thank you for listening to the Royal College of Psychiatrists podcast with me.