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This policy of the Australasian College for Emergency Medicine (ACEM; the College) outlines the underlying principles, philosophies and strategies to meet the emergency health care needs of people who identify as lesbian, gay, bisexual, transgender, queer, intersex, asexual, Irawhiti, Sistergirl, or Brotherboy (LGBTQIA+ISB) in Australia and Aotearoa New Zealand.

This policy provides a framework for the development and implementation of practices to ensure safe, high-quality, culturally competent and culturally safe careto improve health outcomes for people who identify as LGBTQIA+ISB in Australia and Aotearoa New Zealand.

This policy does not address the experience or needs of LGBTQIA+ISB staff who work in emergency departments (EDs) in Australia and Aotearoa New Zealand. However, it is hoped that the recommendations outlined will promote a safe and inclusive culture that also benefits staff.

This policy is applicable to all EDs in Australia and Aotearoa New Zealand.

Lesbian

Lesbians are same-sex attracted females, often women but not always.

Gay

Gay males are same-sex attracted males, often men but not always.

Bisexual

Bisexuals are individuals who are attracted to both males and females or to people of both the same gender and another one.

Transgender

There is no universal definition but generally someone whose gender identity differs from that typically associated with the sex they were assigned at birth. An individual may also identify as ‘transsexual’ if they desire medical assistance to change secondary sex characteristic, however this is more often people who transitioned prior to the 21st century. Some individuals who are non-binary in gender or gender-queer also identify as trans.

Queer

Queer is an umbrella term for people who are not heterosexual and/or are not cisgender, more likely to have been born before 1980. Q can also refer to questioning.

Intersex

An intersex person was born with physical, hormonal or genetic features that do not fit the typical expectations for male or female bodies; there are about 40 different variations. Many of these people do not identify as a member of the LGBTQIA+ISB community. They can have any gender and any sexual orientation. Many people do not even know their own intersex status until puberty, until they attempt to have a child or even ever. Surgery in infancy to ‘create’ a more standard male or, more commonly, female body remains legal in Australia despite significant intersex activism to end the practice of non-consensual surgical alterations.

Asexual

Asexual refers to a person who feels no sexual attraction or desire. This term can refer to a person with any sex and gender. A can also refer to aromantic.

Irawhiti

Irawhiti is an umbrella term in Aotearoa New Zealand for Māori and Pasifika binary trans person, non-binary, transsexual, agender, tāhine, irahuri, whakawāhine, tangata ira tāne, fa'afāfine, fa’atama fakaleiti, leiti, akava’ine, genderqueer and others who identify as outside the gender binary.

Sistergirl

Sistergirl is an Aboriginal and/or Torres Strait Islander trans category for people born male but identify as a category other than man. Non-trans but gender non-conforming Aboriginal and/or Torres Strait Islander males may also use this term.

Brotherboy

Brother boy is an Aboriginal and/or Torres Strait Islander trans category for people born female but identify as a category other than woman. Non-trans but gender non-conforming Aboriginal and/or Torres Strait Islander females may also use this term.

Other terms +

Other terms include: Pansexual = attracted to people of all sexes and genders. Polyamorous = a form of ethical or consensual non-monogamy that involves having romantic and/or sexual relationships with multiple partners at the same time. Allies = supporters of people in the LGBTQIA+ISB community.

ACEM recognises that all Australians and New Zealanders ‘have the right to access health care services that meet their needs; to be cared for in an environment that is safe and enables them to feel safe; to be treated as an individual, with dignity and respect; and to have their culture, identity, beliefs and choices recognised and respected’. [1]

LGBTQIA+ISB people experience worse health outcomes and additional barriers to seeking health care compared to the general population in Australia and Aotearoa New Zealand. Despite significant advances in legal and social frameworks in Australia and Aotearoa New Zealand, many LGBTQIA+ISB people continue to experience stigma and discrimination, and/or the ongoing negative impacts of historical stigma and discrimination.

A 2020 study of LGBTQIA+ISB adults across Australia found that: [2]

• One third of participants had experienced verbal assault, one quarter experienced harassment and one in ten experienced sexual assault during the past 12 months because of their sexual orientation or gender identity.
• Participants had lower self-reported general health and well-being compared to the general population.
• Rates of mental illness, psychological distress and suicidality were much higher than the general population.
• The percentage of patients presenting to hospital who felt their sexual orientation and gender identity were well respected were only 55.2% and 35.4% respectively.
• Two thirds of participants responded that it was “very” or “extremely” important to them that healthcare services were LGBTQIA+ISB inclusive.

In a 2019 study of transgender and gender diverse (TGD) adults across Australia: [3]

• 41.3% of respondents who required emergency care did not attend the ED because of fears related to their gender identity. 58% cited fear of mistreatment or discrimination as the reason for not seeking medical care.
• One in five had been refused general healthcare.
• Within a healthcare setting, 14.2% had been verbally harassed, 5.7% had experienced unwanted sexual contact and 2.3% had been physically attacked.

These barriers may be additionally exacerbated for people who are non-dominant in other aspects of their identity as well, for example those who identify as Aboriginal and/or Torres Strait Islander or Māori, those from a migrant or refugee background, those who speak English as an additional language, those in rural and remote settings, those experiencing homelessness, mental illness, disability, neurodivergence, substance dependence or with low health literacy or experience with the criminal justice system.

Negative experiences accessing health care can lead to avoidance of timely engagement in care, including accessing emergency care. EDs can take actions that demonstrate to these communities that they are safe and welcome when seeking care.

4.1 General

People who identify as LGBTQIA+ISB have the right to access respectful and inclusive emergency care, and to be physically and psychologically safe.

EDs should consider introducing proactive measures to foster a sense of belonging and inclusion for all LGBTQIA+ISB people seeking care. Examples may include signage indicating that diversity is welcome here, displaying an intersex-inclusive Progress Pride flag or sticker at the department’s entrance, encouraging staff to wear a pin or badge with their pronouns, displaying signage indicating that homophobia and transphobia are not tolerated in the facility and the like.

4.2 Assessment and management

EDs should have policies and procedures in place to ensure that LGBTQIA+ISB people are not discriminated against in seeking emergency care and that they are physically and psychologically safe while accessing care. Aboriginal and/or Torres Strait Islanders, Māori and Pasifika who also identify as LGBTQIA+ISB should have access to care that is both culturally safe for them as members of these Indigenous or First Nations communities and appropriate for their sex, gender and/or sexual orientation.

EDs should have processes in place to receive and manage reports of disrespect, discrimination, harassment or abuse based on sex, gender, gender identity, sexuality and other identity characteristics.

There are many reasons why it can be important to ask questions about a person’s sex at birth, sexuality, gender diversity or other domains encompassed within the LGBTQIA+ISB community to provide high quality care. However, it is important that questions are asked only for the purpose of resolving the presenting issue and to be able to treat the person with respect, e.g. using their preferred name and pronouns, rather than to satisfy the curiosity of the clinician.

Connected to this, it is important not to make assumptions about a patient’s family situation and to use inclusive language to support the patient.

4.3 Administration

EDs should have processes in place to ensure that patients are referred to both publicly and in clinical settings by their preferred name and pronouns, recognising that these may not match the patient’s legal identity documents, Medicare registration or prior medical records.

4.4 Education and training

All ED staff should be provided with education to support a culture of safety, belonging and inclusion for LGBTQIA+ISB patients and their families/whānau. Education should support staff to:

• Maintain an inclusive and non-judgemental approach to communication and history taking.
• Recognise and welcome diverse identities and family structures.
• Maintain professionalism while working with patients and families from whom they have different values or belief systems.
• Respect patient confidentiality, acknowledging that people may not be open about their LGBTQIA+ISB identity in all settings
• Demonstrate cultural awareness and humility.

Clinical staff in the ED should be provided with education to ensure they have a working knowledge of medical issues that are either specific to, or frequently encountered in, the LGBTQIA+ISB community, such as:

• Specific stressors that may precipitate mental health or behavioural crisis, for example: coming out, rejection from family or community groups, homophobia/transphobia (both internalised and explicit), targeted violence and hate crimes, or minority stress.
• Family and domestic violence and abuse (FDVA), recognising that LGBTQIA+ISB people are at increased and unique risk.[4] [5] There is a particular risk of rejection and violence from parents/siblings/birth families in addition to intimate partners. This is especially important to recognise for children and young people or those with a disability.
• LGBTQIA+ISB people may be subject to threats of disclosure without consent, leveraging community stigmatisation as a form of coercive control.
• Responding to sexual assault, in recognition that LGBTQIA+ISB people are at increased risk. [6]
• Medical aspects of gender-affirming care for transgender people including hormone therapies and surgical treatments. Awareness that the ongoing medication needs of transgender people may need to be considered especially if unrelated to presenting conditions.
• HIV management, pre-exposure prophylaxis (PrEP), and non-occupational post-exposure prophylaxis (nPEP).
• Post-surgical complications for both trans and intersex populations; the latter may have had surgery against their will in childhood that leads to a lifetime of scarring, pain and/or identity issues.
• Reluctance to engage in primary and preventative health measures due to fear of medical practitioners’ lack of understanding of their identities. [7]

5. Related Documents

ASHM. Pre-exposure Prophylaxis (PrEP) Clinical Guidelines. 2023.

ASHM. Post-exposure Prophylaxis after Non-occupational and Occupational Exposure to HIV. Australian National Guidelines. 2023.

ASHM. Australian STI Management Guidelines. 2021.

AusPATH. Australian Standards of Care and Treatment Guidelines for Trans and Gender Diverse Children and Adolescents. 2018.

WPATH. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. 2022.