Considerations for Working with LGBTQIA+ Displaced Persons

Original Editor - Jeniffer Chepkemoi and Laura Gueron from The Center for Victims of Torture as part of the PREP Content Development Project

Top Contributors - Naomi O'Reilly, Jess Bell, Kim Jackson, Stacy Schiurring, Tarina van der Stockt, Kirenga Bamurange Liliane and Robin Tacchetti  

Introduction

"Some say that sexual orientation and gender identity are sensitive issues. I understand. Like many of my generation, I did not grow up talking about these issues. But I learned to speak out because lives are at stake, and because it is our duty under the United Nations Charter and the Universal Declaration of Human Rights to protect the rights of everyone, everywhere." UN Secretary General, Ban Ki-moon to the Human Rights Council, 7 March 2012

This quote from 2012 may reflect the feelings of many - that sexual orientation and gender identity are sensitive issues to discuss and learn about. However, our LGTBQIA+ patients are fellow community members and are counting on us to provide optimal and respectful care for them. The quote below, also from Ban Ki-moon, former Secretary General of the UN, is an impassioned plea for fair treatment of all, and for preventing discrimination based on sexual orientation and gender identity. He brings up important issues: in many societies and cultures, disapproval of LGTBQIA+ community members is very powerful, but that discrimination and mistreatment must be prevented and rejected.

"As men and women of conscience, we reject discrimination in general, and in particular discrimination based on sexual orientation and gender identity. When individuals are attacked, abused or imprisoned because of their sexual orientation, we must speak out… Today, many nations have modern constitutions that guarantee essential rights and liberties. And yet, homosexuality is considered a crime in more than 70 countries. This is not right. Yes, we recognize that social attitudes run deep. Yes, social change often comes only with time. But let there be no confusion: where there is tension between cultural attitudes and universal human rights, rights must carry the day. Personal disapproval, even society’s disapproval, is no excuse to arrest, detain, imprison, harass or torture anyone, ever. "  UN Secretary-General Ban Ki-moon, 10 December 2010

The United Nations Speaks Out: Combating Discrimination based on Sexual Orientation and Gender Identity brochure is available in Russian, English, Spanish and French. It explains that the "prohibition against discrimination under article 26 (of the International Covenant on Civil and Political Rights) comprises also discrimination based on sexual orientation.” Powerful quotes from world leaders, including the above 2010 quote from Ban Ki-moon are also included.

Estimates of the LGBTQIA+ community vary country by country. Being a member of the LGTBQIA+ community is illegal in many countries, including 35 African countries. Moreover, participating in private, consensual same-sex activity can carry the death penalty in eleven countries. Thus, it is difficult to get accurate estimates of percentages of people who identify as being LGBTQIA+. In a study in the United States by Newport, 4.5% of individuals identify as being lesbian, gay, bisexual, or transgender.

Human Dignity Trust tracks legal issues related to LGBTQIA+ community and provides resources and legal support to defend the human rights of LGBTQIA+ people around the world.

Terminology

It is important to understand appropriate terminology to use for gender identity and sexual orientation, as well as appropriate pronouns to use, especially when working with gender non-binary and transgender clients. There are many clearly written guidelines to assist with terminology. While even well-intentioned rehabilitation professionals can make mistakes in how they refer to clients, it is crucial to apologise when mistakes are made and to commit to continuing to grow and to learn. It is also important to remember that what is acceptable in one country or language may be offensive in another context. Thus, it is important to learn what is acceptable in the communities in which you work.

Sexual Orientation

Describes sexual attraction only, and is not directly related to gender identity. The sexual orientation of transgender people should be defined by the individual. It is often described based on the lived gender; a transgender woman attracted to other women would be a lesbian, and a transgender man attracted to other men would be a gay man.

Lesbian 

Term used to describe female-identified people attracted romantically, erotically and/or emotionally to other female identified people.

Gay 

Term used in some cultural settings to represent males who are attracted to males in a romantic, erotic and/or emotional sense. 

Bisexual 

A person who is physically and/or sexually attracted to more than one gender. This attraction does not have to be equally split between genders and there may be a preference for one gender over others.

Queer 

An umbrella term which embraces a matrix of sexual preferences, orientations, and habits. “Queer” used to be used almost exclusively as a slur but now some members of the LGTBQIA+ community use it as a term of pride. In some countries, the term, “queer” is used commonly, but in others, it is not used.

Asexual

Someone who does not experience sexual attraction, or who has a little or no interest in sexual activity.

Intersex

Someone whose sex assigned at birth is difficult for a doctor to categorise as either male or female. A person whose combination of chromosomes, hormones, internal sex organs, gonads, and/or genitals differs from one of the two expected patterns.

Gender Identity

A person’s sense of being masculine, feminine, or another gender. More and more, it is realised that gender identity and gender expression, are expressed along a continuum.

Sex

Has historically been referred to as sex assigned at birth, based on assessment of external genitalia, as well as chromosomes and gonads. In everyday language, it is often used interchangeably with gender. However, there are differences, which become important in the context of transgender people. Because it is commonly subdivided into ‘male’ and ‘female’, this category does not recognise the existence of intersex bodies.

Transgender 

A person whose gender identity differs from the sex that was assigned at birth. May be abbreviated as "trans.” A transgender man is someone with a male gender identity and who was assigned female identity at birth; a transgender woman is someone with a female gender identity who was assigned male identity at birth. A non-transgender person may be referred to as cisgender (cis=same side in Latin).

Gender Expression 

The outward manner in which an individual expresses or displays their gender. This may include choices in clothing and hairstyle, speech and mannerisms. Gender identity and gender expression may differ. For example, a woman (transgender or non-transgender) may have an androgynous appearance, or a man (transgender or non-transgender) may have a feminine form of self-expression.

Gender Non-Conforming (GNC)

An umbrella term for anyone whose gender expression does not match societal expectation (Similar term: Gender Variant)

Gender Binary 

The idea that there are only two genders – male/female or man/woman and that a person must be strictly gendered as either/or.

Genderqueer 

A gender variant person whose gender identity is neither male nor female, is between or beyond genders, or is some combination of genders. Can include a political agenda to challenge gender stereotypes and the gender binary system. (Similar term: Gender Non-Binary)

Outdated Terminology to Avoid

Transvestite or Transgendered: Instead use transgender

Homosexual: Instead use gay, lesbian or bisexual

Lifestyle Preference or Lifestyle Choice: Instead use sexual orientation

Treatment of LGBTQIA+ People

In many countries, LGBTQIA+ individuals face intense discrimination and the threat of violence and persecution, at times even from family members. Alessie et al. describes emotional, sexual and physical abuse of children who identify as LGBTQIA+ by family, schoolmates, teachers and religious leaders in their country of origin. Oftentimes, when they would report the abuse to others, they would be further punished and victimised. At times, they would be made to go to counselling or to “conversion therapy”, which is considered to be a form of torture by the United Nations. Those who are intersex often endure human rights violations, starting from infancy, where in some countries family members and physicians choose a gender for the infant or young child when the child is too young to determine their gender.

Common Health Issues

There is a large body of research showing that LGBTQIA+ clients have increased incidence of many non-communicable diseases, including heart disease and diabetes. Research shows that hormone therapy for both transgender men and women may increase triglycerides. Transgender men on testosterone often have increased LDL and decreased HDL cholesterol. Transgender people appear to have an increased risk of myocardial infarction and death due to cardiovascular disease, and transgender men on hormonal therapy typically have increased systolic blood pressure and at times, elevated diastolic blood pressure.

Research shows that lesbians and bisexual females are more likely to be overweight or obese. They may also be less likely to access preventive services for cancer. LGTB older adults are five times less likely to have accessed health and social services due to fear of mistreatment and stigmatisation. This, in turn, can lead to them having undiagnosed and untreated chronic health conditions such as hypertension, diabetes and various forms of cancer. LGBT youth are 2 to 3 times more likely to attempt suicide that heterosexual youth. 

• A webinar titled: “Diabetes, Heart Disease, and LGBTQIA+ Populations” from the National LGBTQIA+ Health Education Center at the Fenway Institute, as well as an educational brochure called “Diabetes Prevention and Management for LGBTQ People” by the same institute are excellent resources for health care professionals.

Gay and transgender individuals have higher rates of HIV/AIDS than the general population. Displaced persons living in urban settings often do not have access to adequate services or a means of making money, as they may not be legally allowed to work. Thus, they may at times be forced into trading sex for food or money, which also increases their risk of contracting HIV. Rehabilitation professionals can play an important role in the health care team in helping to educate clients about decreasing HIV transmission rates, through the following:

1. Correct and consistent condom use
2. Anti-retroviral therapy
3. Reducing risky behaviours

At times, it may also be crucial to refer individuals to social work and other international non-governmental organisations (INGOs) or non-governmental organisations (NGOs) to help reinforce the above three recommendations. For example, an individual does not have access to enough food due to a lack of money. As a result, they are not taking their anti-retroviral medications as they are supposed to be taken with food. They feel sick if they take them on an empty stomach. It could be crucial to refer to them to organisations that can provide food or money to purchase food.

Some studies show that alcohol abuse rates are three times higher among members of LGTBQIA+ community than heterosexual community members. Cigarette smoking rates are 63% higher and LGBTQIA+ individuals have an elevated risk for depression, anxiety and suicide. There are also typically higher rates of illicit drug use than in LGTBQIA+ individuals.

Trauma Unique to Members of LGTBQIA+ Communities

Nearly all displaced persons have been through many traumatic experiences and some have been tortured. Many have lost family members and friends to war or other conflict related violence. What is unique to members of the LGBTQIA+ displaced persons community is that many of them have been bullied, and / or verbally and sexually abused since childhood. This might have occurred if they were perceived as being “different” or “too feminine” for a boy or “too masculine” for a girl, or caught engaging in sexual activity with someone of the same gender.

Unlike other displaced persons, LGBTQIA+ community members are often persecuted and even killed by family members once their sexual identity is discovered. LGBTQIA+ individuals often need to flee from countries where there is no civil war and where torture and other human rights abuses against heterosexual individuals may be uncommon. LGBTQIA+ clients can be permanently rejected by all family members, friends and by their country and community at large. In addition, LGBTQIA+ displaced persons are often re-victimised once they arrive in hosting countries, which are commonly low- and middle-income countries (83%), and which may have laws in place banning homosexuality.

As will be mentioned under "The Role of Social Work" section below, the financial, housing and other needs of LGBTQIA+ displaced persons may be even greater than the needs of other displaced persons, whether in urban or camp settings, because of the severe homophobia and violence against LGBTQIA+ community members. Often, if an LGBTQIA+ displaced person reports victimisation to the police, they may be arrested for being LGTBQIA+ and, at times, experience gender-based violence while in prison.

LGBTQIA+ displaced persons often don’t feel safe seeking out medical care or other services, as they do not know if the organisation will be welcoming to them and if they will feel and be safe. A key role of rehabilitation professionals is to contact different organisations and ask questions in order to get the sense of whether they are LGBTQIA+ friendly. They may also be able to determine if there is a certain staff member at the organisation who has special sensitivity or interest in working with this population. In Nairobi, the Centre for Victims of Torture arranged a resource fair for LGBTQIA+ clients. Members from organisations providing resources for housing, education, livelihood, health care including HIV prevention and treatment and legal services were present. They could meet informally with staff members, provide brochures with addresses and phone members, and help clients to feel comfortable. The event was well attended and afterwards, many clients reported that they felt safer reaching out to the NGOs for support as they felt that they knew that at least one staff member was supportive and welcoming to them. 

While many displaced persons are subjected to sexual torture, LGBTQIA+ clients are subjected to “corrective rape”, which is committed in an attempt to change one's sexual identity. Types of torture experienced by LGBTQIA+ clients include electric torture to the genitals, being stoned, and beaten on their genitals.

Treatment Principles

How to Ensure Safety, Comfort and Acceptance in Groups

Where possible, it is ideal to have separate groups for LGBTQIA+ clients who have a preference for being with other LGBTQIA+ clients for their safety and comfort level. At the Center for Victims of Torture in Nairobi, which is the only programme which offers specialised physiotherapy services for LGBTQIA+ clients, members of this community are typically given the choice between being in an LGBTQIA+ specific group or a group with clients of their gender. Whenever the LGBTQIA+ client is in a non-specific group, it is crucial that the rehabilitation professionals do not disclose the sexual identity of the client. Many times, non-LGBTQIA+ displaced persons may be quite homophobic. Thus, the LGBTQIA+ clients may not feel safe and choose not come to rehabilitation services. 

Need to Work with Trauma Informed Care

It is critical that rehabilitation professionals work with LGBTQIA+ clients respectfully and through the use of trauma-informed care. This includes offering clients choices such as door open or closed, parts of body to work on, etc. Clients should be touched only with permission. Choice should be given about whether any clothing is removed. Some clients, especially those who may be transgender, and who are in some form of transition, may not feel comfortable exposing their bodies. Invitational language should be used, with more of a tone of suggestion and offering rather than commanding, so as to avoid re-traumatising clients. 

Specialised Needs for Transgender Clients

Transgender clients may have special needs which rehabilitation professionals such as physiotherapists can address. For example, transgender men may bind their breasts tightly by tape or bandages to minimise the appearance and size of breast tissue. At times, there can be pectoral pain from the pressure of the compression, which may reduce from the use of heat, trigger point massage and stretches. Many transgender displaced persons will not have access to hormone therapies or to surgeries for gender affirmation or gender confirmation due to funding or other access issues. Approximately 80% of displaced persons live in lower or middle income countries where these procedures may not be available even for nationals of that country who have the financial means. There are four possible steps which transgender people may choose or be able to access:

1. Social affirmation
2. Hormone therapy
3. Legal/document changes
4. Surgical affirmation

For those who have surgery to add or remove breast tissue, there may be pain or swelling which can also respond well to exercise, massage and other treatments. There can also be pain or swelling in the genital area, either from compression, wearing garments to minimise the size of the penis or from surgeries to alter and to change the genitals. Exercise, cold or other treatments can help with these concerns as well. In addition, after transgender clients have “bottom surgery” of their genitals to affirm their gender, physiotherapists have an important role in neuromuscular retraining of pelvic floor muscles, teaching clients to do soft tissue/scar tissue work, and providing patient education about the management of healing tissue and health for life.

In the United States Transgender Survey, which was conducted in 2015, 54% of respondents reported that they were verbally harassed, 24% physically assaulted and 13% sexually assaulted while in school. In addition, 30% reported having been homeless at some point of their life. 29% of transgender respondents reported living in poverty, as opposed to 14% of the general population. 39% of transgender individuals reported having experienced serious psychosocial distress in the month prior to answering the survey questions, compared to only 5% of the general US population. 40% had a lifetime history of suicide attempt compared to 4.6% of the general population. 55% of transgender individuals who were attempting to obtain insurance funding for gender affirming surgery were denied funding, as were 25% of those who were trying to obtain funding for hormone therapy. This study showed that among more than 2200 transgender clients, rates of post-traumatic stress disorder, depression and anxiety went down for those who perceived themselves to be in supportive communities and for those who had started to have gender confirmation procedures, such as the use of hormone therapy or surgeries.

Another crucial role for the health care team caring for transgender clients is to perform an “anatomical inventory”, which is updated on a regular basis, in order to help direct preventative screening. The body parts on the inventory include the penis, testes, prostate, breasts, vagina, cervix, uterus and ovaries. Examples were given of transgender men getting breast cancer, which was quite advanced upon detection, as medical staff had not advised them to have screening of their remaining breast tissue and transgender women developing prostate cancer. As physiotherapists and rehabilitation professionals, we can bring up these topics with our clients and encourage them to seek out referrals to needed health screenings from their physicians.

The authors of this survey recommended that all patients be screened for sexual orientation and gender identity in order to ensure more appropriate care. While patients may initially feel unsafe about answering these questions, one possible way to explain them is to say “we have begun to ask patients about their sexual orientation and gender identity so that we can provide optimal, affirmative care.” As with all clients, it is important not to assume gender identity or sexual orientation. For example, rather than saying, “Mrs. Lee, what would you like to focus on in treatment today?” One could say “What would you like to focus on in treatment today?” Or, rather than asking, "Do you have a husband or wife I could teach to do these stretches/manual techniques with you?” Instead saying “Do you have a partner I could teach these activities to?"

It should be recognised that gender is increasingly described as being on a continuum, rather than just having two genders on opposite ends of this continuum. Some transgender individuals do not fully identify with male or female gender but as something different or even undefined. It is crucial to ask clients what they prefer to be called, and to simply apologise if you call the person by the wrong name or pronoun. Many transgender individuals (45%) report that they have needed to educate their medical professionals about how to work with transgender people. It is important to not make comments such as the following: “Wow! You look just like a real woman.” It is also crucial for co-workers to feel comfortable in gently correcting those whom we work with in order to help to sensitise them. For example, when hearing a colleague refer to a patient by the wrong name, one could say “My understanding is that this patient prefers to be called “Jane” and not “John.”  If hearing a colleague making fun of a transgender client after they leave the clinic, one could say “those kinds of comments are hurtful to others and do not help to create a respectful work environment.”

Centre for Victims of Torture Experience of Working with LGBTQIA+ Community

Developing Group Treatment

Before the Centre for Victims of Torture started to offer specialised services for members of the LGBTQIA+ community, all clinical staff members received training, watched videos and had discussions about the specialised needs of LGBTQIA+ community members. There were staff members who originally were not comfortable working with this population, most staff had never learned about these specific needs before and few had worked with LGBTQIA+ community members previously.

It may be ideal to invite staff from other organisations who have expertise in working with LGBTQIA+ clients to lead trainings and to sensitise staff to be prepared to provide optimal care for LGBTQIA+ clients. The Pan-Commonwealth Human Rights, Gender & Sexual Diversity Training Toolkit includes eight modules which are designed to sensitise colleagues and members of the public to:

1. Increase participants’ knowledge of the rights and dignity of LGBTQIA+ people
2. Increase participants’ understanding of the challenges faced by LGBTQIA+ people in accessing public services as a result of homophobia, biphobia and transphobia
3. Challenge participants’ existing biases and prejudices to enable better support of the community
4. Build the participants’ capacity to plan and implement training with other public sector workers

Another international organisation, Organization for Refuge, Asylum and Migration (ORAM), which is a subsidiary partner of Alight, is an international organisation that advocates for sexual and gender minority asylum seekers and refugees fleeing persecution and violence. It also provides a wide range training materials and other resources which can be very useful.

Because working with LGBTQIA+ community members became a very important part of the counselling and physiotherapy work in centres for victims of torture, especially in Nairobi, and because it is crucial that all staff members respect and can work effectively with LGBTQIA+ clients, interview questions have been added about previous experience and comfort level working with this community. 

Role of Social Work

In many low- or middle-income countries, where between 80 and 85% of refugees live, there is a great deal of homophobia and laws formalising discrimination. Members of the LGBTQIA+ displaced persons community are often faced with eviction once their LGBTQIA+ status is discovered. Thus, they may need urgent assistance from social work for housing, so that they do not become homeless. They may also have severe financial struggles. If they are involved with livelihood activities such as selling goods in the market or hawking them, and their LGBTQIA+ status is discovered, their items are often destroyed or their businesses are boycotted. Social workers can refer people to NGOs or INGOs for financial assistance or information about other livelihood programming. In addition, social work staff can refer those victimised by the police or soldiers for legal assistance. Finally, one of the other roles of social work is to refer people for emergency medical assistance. For members of the community who are HIV+ or who have other chronic medical conditions and who are having difficult accessing affordable or free medical care, having a timely referral by social work can be the difference between life and death. 

For many years, the Center for Victims of Torture programme in Nairobi did not have a social worker on staff, so the physiotherapy and counselling staff formed close connections with NGO and INGO partners in the field and facilitated referrals independently. 

Aftercare Group for LGBTQIA+ Displaced Persons

After several years of leading LGBTQIA+ specific physiotherapy and counselling groups in Nairobi, the Center for Victims of Torture sought out funding and decided to create a specialised interdisciplinary aftercare group for those clients who had completed counselling and often physiotherapy, but who continued to have significant issues and needs. As described above, members of the LGBTQIA+ displaced persons community living in Kenya struggle with issues which are unique to them, and were deemed to need additional support. Before the COVID-19 pandemic struck Kenya, two groups of 10-14 participants each were lead three times per year, in two different geographic locations in Nairobi in order to be accessible to the most people possible. 

The aftercare model was developed based on research about issues and needs of LGBTQIA+ Communities around the world. An article by Lytle et al. about the use of positive psychology emphasises the need for those working with members of the LGBTQIA+ community to help individuals and groups to identify positive coping mechanisms and to identify and utilise individual character strengths. While physiotherapists obviously do not provide mental health services, it is still important for physiotherapists to emphasise the strengths of the client when prescribing home programmes, and when encouraging home adherence to pain reduction and other physiotherapy programmes.

Over the course of the Aftercare programme’s six weekly sessions, the following topics are addressed:

1. Introductions, assessment, and acknowledging continuous trauma in the LGBTQIA+ community;
2. Safety and how to make choices that support safety and coping skills in the face of continuous trauma and homophobia;
3. Healing from shame and victim blaming;
4. Concept of a chosen family and how to mitigate family and community of origin rejection and the ambiguous loss that comes with it;
5. Reconstructing identity and meaning by acknowledging the different place in identity development, internal conflicts, and working to find new meaning; and
6. Navigating access to services and resources in the context of discrimination and homophobia. 

An essential part of the Aftercare programme is the training and development of peer facilitators from the LGBTQIA+ displaced persons community who had received both counselling and physiotherapy. These individuals reach out to potential participants and explain the aftercare programme, co-lead the sessions, and are available to support clients between sessions as needed. As they are members of the same persecuted community, the peer facilitators have a great deal of credibility and connection with the Aftercare group members. 

Counsellors, physiotherapists and a social worker are all involved in leading the groups. Physiotherapists lead portions of the sessions involving mind-body connections, breathing, grounding, sleep and pain reduction and about ways to incorporate exercise into daily routines.

At the first and last sessions, a brief assessment is completed with each participant by a counsellor, peer facilitator or physiotherapist. This includes questions which are taken from existing evaluation tools used with LGTBQIA+ clients about self-acceptance and self-esteem, social support and connectedness, identity and access to resources. A majority of clients show improvement in at least several of the sections. 

Clients are invited to share examples of the negative or discriminatory actions which they have experienced in order for them to be acknowledged and processed, followed by sharing examples of their strength. The groups also brainstorm strategies for resisting brutality from the police and others, and integrating with the host community.

Participants tend to be engaged, contributing and sharing their experiences within the group, and appreciative of the opportunity to participate in the programme. Each participant sets personal goals and strategises ways to develop coping mechanisms to address their individual challenges. Prior to this activity, many clients stated that they had very long-term goals, which were beyond their control and ability to influence. For example, many clients’ goals revolved around being resettled in a third country. Clients were excited to learn how to set realistic, achievable goals to improve their current lives in Nairobi and see progress and success in the short-term. Many of the participants form supportive connections with others in the groups which continue after the six sessions are over, and from these connections feel less isolated.

The following Webinar from July 23, 2020 (52), about reclaiming identity among LGBTQIA+ survivors of torture and other forms of trauma, includes presentations from the Centre for Victims of Torture Social Worker, Physiotherapist, Mental Health Clinical Advisor, Funder, and the UN Independent Expert on Protection Against Violence and Discrimination Based on Sexual Orientation and Gender Identity, includes stories about some of the beneficiaries of the Aftercare Programme.

The following are four blog posts by the Center for Victims of Torture about the Aftercare Group, which can give a more personal view of the problems facing LGTBQIA+ displaced persons in Nairobi.

1. From Trauma to Hope: Extending Care to Refugees in Nairobi:
   • Blog by Psychotherapist Trainer Elizabeth Mbuti Muli, October 24, 2017, about the experiences of a gay man from Uganda in both his home country and in Kenya.
2. Peter's Story:
   • Blog by Center for Victims of Torture Service Users experiences, October 20, 2017
3. Aftercare - Ongoing Support for the LGBTI Refugee Community at CVT Nairobi:
   • Blog describing the LGTBI Aftercare Program, August 24, 2018, with an emphasis on the multidisciplinary care
4. Innovative New Aftercare Program Helps LGBTI Survivors in Nairobi:
   • Blog about the LGTBI Aftercare Program after it had been through many cycles of work, June 5^th 2018, with description of the role of peer facilitators.

Peer Facilitator

Interview with a lesbian client who now works at the Centre for Victims of Torture as a peer facilitator of her experiences accessing services. From her experience, she compliments the Center for Victims of Torture for creating a safe space for this community and recommends that other organisations reach out to something that she would like other facilities dealing with LGBTQIA+ clients to emulate. LGBTQIA+ individuals feel safer when they recognise the environment as welcoming. The peer facilitator suggests using pictures that have LGBTQIA+ flags, together with words from a rehabilitation professional that convey acceptance and safety, which can in turn encourage clients to open up about their past history. Creating and maintaining welcoming therapy spaces will promote LGBTQIA+ clients’ journey of healing.

Members of the LGBTQIA+ community also need a high level of confidentiality and assurance before they feel safe to share their histories and to be willing to be examined by rehabilitation professionals. Many clients are living in unsafe environments where there is a lot of stigmatisation. If the clients have a negative experience at medical clinics and other spaces, this may hinder them from seeking rehabilitation services in the future. Some clients may need reassurance that if there are security cameras in a building, that they are not there to record them, but only there to try to deter criminal activities. 

The peer facilitator shared that it is important for the rehabilitation professionals not to provide undue special attention for LGBTQIA+ clients but to treat them with the respect and kindness which they would provide to any client. She felt that special attention or any type of condescending tone may reduce their self-esteem.

Having received physiotherapy services she now feels empowered. She had had severe back pain, joint stiffness, fatigue, poor sleep and headaches. This was affecting her activities of daily living but now she can do a lot of work easily, which has made her develop the habit of doing exercises and this has also improved her sleep hygiene. It is for this reason that she started looking for a job when she finished receiving counselling and physiotherapy. She gained access to employment through the Center for Victims of Torture as a Peer Facilitator. This peer facilitator reports that she now feels more comfortable interacting with others, and is pleased to give back to the LGBTQIA+ Community through her work.

The LGBTQIA+ Community often has difficulty in accessing needed services especially if they live outside of Nairobi, or outside of large urban areas in other countries. Often members of the LGBTQIA+ Community have many symptoms but because of financial challenges they cannot afford to access needed services. Some organisations, such as the Center for Victims of Torture, provide free services, such as physiotherapy, counselling and social work, while others have fees for services. Some potential clients lack the knowledge of the role of rehabilitation and how it can play an integral part of their healing process from pain and other injuries. Many community members need a lot of sensitisation about how rehabilitation services can help to decrease chronic pain and to improve mobility even if the survivors have been displaced for many years and experienced traumatic events many years ago. Some LGBTQIA+ displaced persons have the awareness of the role of rehabilitation and the funding for needed payment for rehabilitation services, but they may have difficulty accessing welcoming therapists.  The interviewee mentioned that many LGBTQIA+ Community members fear discrimination, particularly those who are transgender, so they prefer to stay at home and not to attend rehabilitation services. For all of these reasons, it is crucial that therapists have adequate training, both in their initial training, and on an ongoing basis, on how to work optimally with members of the LGBTQIA+ community.

Summary

It is crucial that rehabilitation professionals treat LGBTQIA+ displaced persons with the same dignity and respect afforded to other clients. Rehabilitation professionals need to endeavour to create an open and accepting atmosphere when working with members of the LGBTQIA+ community. This will help to avoid the re-stigmatisation of these clients and help them to heal from pain and injuries. There are recommended ways for rehabilitation professionals to help LGBTQIA+ clients feel welcome in clinic spaces. As with all clients, it is crucial that confidentiality is closely guarded and that a client's LGBTQIA+ status is never disclosed, as they may not have shared this information with others.

Resources

Introduction to LGBTQ+ Competency Handbook for Physical Therapy

• Members of PTPROUD, a committee of the Health Policy and Administration Section of the American Physical Therapy Association, created a 27-page guide specifically for physiotherapists for working with LGBTQIA+ clients. The guide is written by physiotherapists who are LGBTQIA+ community members, so have both and understanding of the specialised needs of LGBTQIA+ individuals and a lived experience in how they have been treated. The guide includes reflection questions and part of the aim is for physiotherapists to respect and not just to tolerate those who are LGTBQIA+. A survey of physiotherapists in the United States of America showed that only 15% reported respecting their LGBTQIA+ patients. 

Healing Pain Podcast Episode 138 - LGBT Inclusion In Physical Therapy

• This is a podcast featuring a transgender physiotherapist, Chris Condran, speaking about inclusion in the physiotherapy profession. The podcasts includes a discussion on inclusion from the perspective of the physiotherapist and the patient.

National LGBTQIA+ Health Education Center

• The National LGBTQIA+ Health Education Center provides a wide range of free learning resources including webinars, publications, learning modules and videos on working with LGBTQIA+ clients, featuring ways to improve service delivery and care.
• LGBT Voices: Perspectives on Health Care is a 13 minute long video by the National LGBTQIA+ Health Education Center about improving medical care for LGBTQIA+ patients.

American Physical Therapy Association

• To Be All of Me is a blog written by Erin Kingham, an American physiotherapy student who is a lesbian.
• HHS Discrimination Decision Runs Counter to Profession's Values is an editorial about the need for non-discrimination when working with LGTBQIA+ patients.

Do Ask, Do Tell: Toolkit for Collecting Sexual Orientation & Gender Identity Information in Clinical Settings

• This toolkit, developed by the Fenway Institute, provides specific sexual orientation and gender identity questions that are recommended by national LGBT organisations and which have been shown to work with diverse patient populations served by community health centres in different parts of the United States. It also describes how to use the data to support clinical processes, and how to train clinical staff to interact with LGBTQIA+ patients in ways that are affirming and welcoming. Finally, the toolkit highlights other resources that health care providers can use to offer culturally and clinically competent care that reflects their LGBTQIA+ patients’ unique needs.

Do Your Business / Mind Your Business

• Free art campaign designed to increase bathroom safety for transgender and gender nonconforming people. Provide a range of printable posters that can be used as bathroom door signs, which are gender inclusive.