Aboriginal and Queer Identity/ies in Western Australia: When There is a Need to Know in Therapeutic Settings

Background

Aboriginal and Torres Strait Islander people who are LGBTQ+ are highly likely to experience discrimination or inappropriate responses from a range of health, education, community and social support organizations (Hill et al., 2020; Markwick et al., 2019; Wilson et al., 2016). This discrimination may be experienced as racism toward them as Aboriginal people, or homophobia/queerphobia or both. Aboriginal and Torres Strait Islander people may also experience discrimination and lateral violence from within their own communities (Bennett, 2014; Clark & Augoustinos, 2015).

The invisibility of the perspectives of LGBTQ+ peoples and particularly of Aboriginal and Torres Strait Islanders peoples has historical and colonialist antecedents in Australia. The absence of queer histories in the Australian academic curriculum in the pre-colonial and colonial past has been questioned by historians and queer writers (Bayliss, 2015). Scrimshaw (2018) contends that this absence is not because there is no documented evidence of homosexual activity in this period, but because telling the queer histories of Australia disrupts conventional ideas about pre-colonial and colonial history. This absence results in a range of health, educational and social science graduates (who may go on to work in diverse roles in health, education and social support services) not being aware of the possibility of a ‘queer’ Australian history (Bayliss, 2015).

As a result of experiencing racism, discrimination and a silenced ‘queer’ history, Aboriginal and Torres Strait Islander people who are LGBTQ+ may not feel comfortable about sharing either one or more aspects of their identity, whether this is their Aboriginality or their LGBTQ+ identity, to workers employed in a range of social support, health, or educational services. The same experiences and history similarly may affect the views and perspectives of Aboriginal and non-Aboriginal workers in these services, resulting in Aboriginal and Torres Strait Islander LGBTQ+ people not receiving the services they need (Diversity Council of Diversity Council Australia, 2018; Singh & Major, 2017).

With these issues of racism, lack of knowledge and discrimination in mind the broad theoretical approaches to this research incorporate theories developed by Australian Indigenous scholars and other international social science and cultural studies scholars, including concepts such as ‘intersectionality’, ‘hybridity’ and ‘cultural-interface’ (Carlson, 2020; Crenshaw, 2015; Nakata, 2007; Paradies, 2007). The concepts informing these theories are useful for describing the lived experiences of Aboriginal and Torres Strait Islander people living in Western Australia who are gender and sexuality diverse. Of these concepts, the theoretical approaches of ‘intersectionality’, ‘hybridity’ and ‘cultural-interface’ have been those that most influenced our approaches to framing and analyzing the findings used in this article.

Intersectional theory is particularly useful for framing the findings from the current study, to show how erasure, discrimination and invalidation of Aboriginal LGBTQ+ peoples is based in multiple systems of oppression. The research team adopts an approach to intersectionality that places Aboriginal LGBTQ+ people and their perspectives as a diverse group at the centre of the research (Choo & Ferree, 2010). Our understanding of this theoretical approach incorporates what Etherington et al. (2020, p.1) describe as ‘the interface between social identity factors and the structures of power’. The concept of intersectionality can also include the multiple ways in which other social determinants faced by LGBTIQ+ peoples can co-exist with what Bonson (2016) describes as ‘the kaleidoscope of social inequalities’, often overcome by Aboriginal people, which include racism, intergenerational trauma and socio-economic disparity (p. 24). Other research describes how intersectionality is a useful concept to understand how LGBTQ+ status intersects with social exclusion, stigma, micro aggressions and abuse (Fredriksen-Goldsen et al., 2014; Hudson and Romanelli, 2020). Several international research studies discuss how much of health research has failed to recognize the heterogeneity within LGBTQ+ communities and how diverse sexual identities intersect with gender, social status, race and ethnicity (Adams et al., 2013; Fredriksen-Goldsen et al., 2014; Hudson and Romanelli, 2020).

Whilst it is important that the social determinants of health are considered, there needs to be a nuanced approach to this. It is deleterious to use a social determinants of health approach to position gay men, for example as‘inherently sick and self-destructive’, (Adams et al., 2013, p. 887). In another study evaluating the quality of mental health services for gay and bisexual men, Ferlatte et al. (2018) caution that counsellors should not assume mental health issues are a consequence of being queer but rather because of the homophobia that is experienced by LGBTQ+ people.

Bennett and Gates (2019), highlight that in Australia, Aboriginal people are just as likely to be ‘intersectional’ not only as LGBTQ+ people but also within culturally diverse communities (and not just white ones). Both LGBTQ+ and Indigenous social identities presuppose a diversity of ways in which people may identify. The ‘cultural interface’ is a term that describes a social context within which Aboriginal and Torres Strait Islander people are both circumscribed and limited by western discourse and colonialism, as well as agents who are negotiating and creating possibilities (Nakata et al., 2019). Paradies (2007) also describes a space where Indigenous people may feel pressured to choose between black/white dichotomies rather than adopting an idea of identity that avoids essentialism and instead embraces hybridity and fluidity of identities. This does not necessarily mean, however, that individuals are always able to openly identify with specific identities all the time. An individual’s chosen identity or identities may not be recognized as valid by some people, including those working in organizations where LGBTQ+ Aboriginal people are seeking health, education and social support services (Singh & Major, 2017).

Major health and well-being research pertaining to LGBTQ+ Australians rarely focuses on Aboriginal and Torres Strait Islander same sex attracted or gender variant individuals. For example in major research exploring LGBTQ+ issues in Australia, Leonard et al., (2010); Jones, 2012); fail to explore the Aboriginal/Queer intersection. As Bonson (2017) highlights, this is also the case for ‘Growing Up Queer’ (2014) a major study conducted by the Young and Well Cooperative Research Centre. A more recent study that has explored the experiences of Transgender young people in Western Australia also identified that research was required with a focus on Aboriginal and Torres Strait Islander Trans people as this is currently lacking (Strauss et al., 2017). A recently published report on the health and well-being of Australian young LGBTQ+ people (aged 14–21 years) did include young Aboriginal people although it was acknowledged by the authors that more targeted research specifically with Aboriginal and Torres Strait Islander people is needed (Hill et al., 2021). These observations are also reflected in a range of international studies that demonstrate how LGBTQ+ populations are diverse and that groups within the broader category of LGBTQ+ may differently experience unmet needs when accessing health services (Adams et al., 2013; Ferlatte et al., 2018; Fredriksen-Goldsen et al., 2014; Petrie & Cook, 2019; Uink et al., 2020).

The power relations within the broader LGBTQ+ community can result in queer people not all being equal under this umbrella term. Whilst this might not be intentional, policies or rights that respond to gay and lesbian people may be emphasized over those for trans, gender-fluid or Indigenous peoples who are LGBTQ+ (Flores et al., 2015; Strauss et al., 2017). In one of the few studies that reports on the experiences of Aboriginal LGBTQ+ people living with a disability there is an invisibility in the ‘main-stream’ LGBTQ+ policies and discrimination laws (Leonard & Mann, 2018). Whilst there is research that is now critically investigating the experiences of older LGBTQ+ people, there is limited peer reviewed research literature that discusses what is needed for older Aboriginal and Torres Strait Islander LGBTQ+ people (Petrie & Cook, 2019).

An example of how Aboriginal LGBTQ+ people experience health services differently to non-Aboriginal gay and bisexual men is discussed in an Australian study that investigated the take up of HIV prevention tools such as pre-exposure prophylaxis (PrEP). This study found that Aboriginal gay and bisexual men were less likely than non-Aboriginal men to know about or have taken up this preventative health intervention. The authors argue that this is because Aboriginal gay and bisexual men in their study are less likely than non-Aboriginal gay and bisexual men to be part of mainstream gay culture which tends to be construed as an implicitly white monolith. Aboriginal gay and bisexual men therefore experience less exposure to health prevention and promotion information and interventions (Hope & Haire, 2019).

As Clark and Augoustinos (2015) asserts the racism and domination of white gay men within the LGBTQ+ support organizations and ‘movement’ in Australia needs to be acknowledged and addressed. Clark and Augoustinos (2015) also advises Aboriginal LGBTQ+ people to be cautious about how they collaborate and work with non-Aboriginal LGBTQ+ ‘experts’. The author asserts that whilst non-Aboriginal LGBTQ+ experts may purport to represent Aboriginal and Torres Strait Islander peoples it needs to be established that they have undertaken a meaningful, immersive, equitable and truly collaborative approach to this.

There is a paucity of research examining why the recognition of Aboriginal LGBTQ+ identities is relevant in a range of therapeutic settings (Bonson, 2017). Gavrial (2013) emphasizes the importance for health services and health researchers to recognize the ‘simultaneity of oppressions and the ways in which having different combinations of marginalized identities may impact well-being’, (p. 42). The ways in which Aboriginal and Torres Strait Islander people identify as LGBTQ+ is diverse and intersects with their cultural identity/ies. For example Sullivan and Day (2019, p. 1) describe these as being sometimes specific to Aboriginal culture in Australia, such as ‘Sistergirl or Brotherboy, as well as those who identify as lesbian, gay, bisexual, transgender, intersex, non-binary, gender-fluid and a variety of other articulations of self’. According to (Bonson, 2017, p. 2) ‘Sistergirl is considered a culturally, as well as a socially, accepted term to describe Aboriginal and Torres Strait Islander Transgender people who identify as female, while Brotherboy is considered a culturally, as well as a socially, accepted term to describe Aboriginal and Torres Strait Islander Transgender people who identify as male'.

Research that explores the experiences of LGBTQ+ clients (not Aboriginal-specific) when accessing a range of health services identifies that whilst staff may not be overtly homophobic; or may even be ‘LGBTQ+ friendly’ this does not necessarily result in appropriate service delivery to this target group (McGlynn et al., 2019, p. 1). This may be because staff do not believe clients who are LGBTQ+ experience problems that are different, or that they just assume all clients presenting to them are cisgender or heterosexual (McGlynn et al., 2019). Another study has argued that even for those people who are knowledgeable and aware about LGBTQ+ issues, the ways in which gender is constructed in binary terms is pervasive (Sumerau et al., 2019). These authors and others (Diversity Council Australia, 2018; Singh & Major, 2017; Uink et al., 2020) advocate for organizational staff to undertake the professional development that will enable them to understand the fluidity of multiple and intersecting identities.

A range of Australian and international research studies explore the reasons why it is important for organizations, and their staff, to acknowledge and consider the needs of LGBTQ+ clients in their policies and service models. These studies also report that clients who are intersex or transitioning are particularly at risk of experiencing ignorance and discrimination from a range of services and are required to ‘educate’ staff themselves about LGBTQ+ issues related to their health or educational outcomes (Strauss et al., 2017; Waling et al., 2019; Zeeman et al., 2014).

Other studies have asserted that LGBTQ+ people are largely invisible in health promotion, mental health and suicide prevention strategies (Ferlatte et al., 2019; Jacobs & Morris, 2016). Crameri et al. (2015) emphasize the need for policy makers to acknowledge the needs and visibility of older LGBTQ+ people when accessing aged care services. In a more recent study, Petrie and Cook (2019) discuss the importance of educating aged care staff in supporting the diverse sexual or gender identities of LGBTQ+ residents. Ferlatte et al. (2019) assert that workers in health and support services require education to recognize and respond to the double stigma resulting from the homophobia that LGBTQ+ people experience and the mental health issues that result from this discrimination.

The urgent need to address the double-barrelled racial discrimination and homophobia experienced by Aboriginal and Torres Strait Islander people who are LGBTQ+ has previously been highlighted by Bonson (2017). At its most extreme, such ‘double-discrimination’ has been linked to suicide, homelessness, social exclusion and bullying experienced by Aboriginal and Torres Strait Islander LGBTQ+ people at rates considerably higher than for the non-Aboriginal population (Bonson, 2016; Bonson, 2017; Clark & Augoustinos, 2015; Diversity Council of Australia, 2018; Dudgeon et al., 2015; Wilson et al., 2016). More recently, the social and emotional well-being issues experienced by young Aboriginal and Torres Strait Islander people identifying as LGBTQ+ such as racism, homophobia, queer phobia and lack of access to appropriate services, and the need for research that properly investigates these experiences has also been documented (Uink et al., 2020; Hill et al., 2020; Hill et al., 2021; The GOANNA Survey 2, 2020). These studies and reports highlight the important role that health, education, social and community service staff can play in providing safe and inclusive environments for Aboriginal and Torres Strait Islander LGBTQ+ people seeking care.

A central question for this exploratory research project (Hill et al., 2020) is how provision of genuinely inclusive service responses for Aboriginal and Torres Strait Islander people identifying as LGBTQ+ can be developed. An important element in addressing this broad question is the necessity for health, community and social support staff to acknowledge and recognize that ‘treating everybody the same’ may not be an adequate response for Aboriginal and Torres Strait Islander clients who also identify as LGBTQ+ (Crameri et al., 2015; Petrie & Cook, 2019; Sullivan & Day, 2019).

Whilst ‘treating everybody the same’ may be considered by organizational staff as contributing to equitable and even-handed ways to provide services to those who are LGBTQ+; the reality may be more complex. For example Fredriksen-Goldsen et al. (2014) assert that human rights concepts need to link to the social determinants of health and include ‘principles of participation, non-discrimination, transparency and accountability’, and acknowledge that LGBTQ+ people experience more negative health outcomes than the rest of the population (p. 660).

Collectively, the findings of previous studies suggest that recognition and understanding of clients’ LGBTQ+ identity/ies is central to the development of truly inclusive services (Adams et al., 2013; Bonson, 2017; Ferlatte et al., 2018; Fredriksen-Goldsen et al., 2014; Uink et al., 2020; Wilson et al., 2016). As such, a first step in the development of truly inclusive care is for organizational staff working in a range of physical health, mental health, education, community and social support services is to understand the ways in which LGBTQ+ identity is relevant for Aboriginal and Torres Strait Islander clients.

The Current Study

This study, (Hill et al., 2020) draws on findings from the first phase of research activity with a range of health, community and educational support services, including Aboriginal Community Controlled Health Organizations located in metropolitan centres in Western Australia. Specifically, we asked 54 staff, from five focus groups and three interviews, located in metropolitan centres in Western Australia, to consider the relevance of LGBTQ+ identity when providing services to Aboriginal and Torres Strait Islander LGBTQ+ clients. Participants were drawn from all levels of the organizations and included CEO’s (n=6), Aboriginal Health Workers (n=3), Student Support Workers (n=12), Case Workers (n=5), Clinical Counsellors (n=4), Youth Educators (n=4), Family Support Workers (n=3), Alcohol and Drug Workers (n=6), Managers of Clinical Governance, (n=2) Resource Officers (n=4) and front desk staff (n=5).

Focus group and interview participants were invited to participate in the study by invitation of the research team through professional networks. Leading investigators from the research team who identify as both Aboriginal and LGBTQ+ met with organizational staff to present the aims of the research and to seek guidance about research directions and processes that were culturally respectful. Participation in the research at both broad organizational and individual staff member levels was voluntary. Individual participants were provided with information both written and verbal about the research aims and research activities. All individual participants signed a consent form. The research team were guided by the five key principles developed by the Lotwija Institute which include that research team act for the benefit of Aboriginal people, engage with Aboriginal people and that the research is led by Aboriginal people and develops the Aboriginal research workforce (Lotwija Institute https://www.lowitja.org.au/research).

Qualitative Methodology

This paper presents the findings and analysis based on the focus group and interview discussions as well as the individual written responses to specific questions as part of the focus group research activities. This mixed-methods approach is well established as appropriate for research concerned with health service delivery and for research projects that are concerned with social justice (Castro et al., 2010; Fisher, 2013; Jason & Glenwick, 2016; Tariq & Woodman, 2013).

A participatory, social action research methodology has ensured that the research team regularly checked in with the Advisory Group which included Elders and Senior Aboriginal leaders, community forum members, research partners and participants. This contributed to the relevance and appropriateness of methods and research direction (Ackermann et al., 2006; Belone et al., 2014; Cho & Trent, 2006; Davies & Dodd, 2002; Kendall et al., 2011; Leeson et al., 2016; Smith & Noble, 2014; Thompson & Pascal, 2012; Wain et al., 2016). In keeping with being genuinely guided by Aboriginal community members, which included Elders, Aboriginal and LGBTIQ+ people from community, education, health and social support services, the study focused on the local geographical region (Western Australia) rather than undertaking a national study. The groundwork for conducting this research was established through genuine community consultation and engagement with Advisory group, community forum members and research partners to ensure culturally respectful and sensitive research protocols were used (Kendall et al., 2011; Laycock et al., 2011; Wain et al., 2016; Watego et al., 2021). Three of our participating research partners are Aboriginal Controlled Community Health Organizations located in a metropolitan centre of Western Australia.

The Chief Investigator of the study is a Noongar man (an Aboriginal person from Whadjuk Country, where the study is based) who identifies as LGBTQ+. The research team is led by Aboriginal people who also identify as LGBTQ+. These researchers have well established ties and networks to both the Aboriginal and LGBTQ+ communities in Western Australia. This is important and in keeping with an Indigenous research framework that values the ‘relational’ ways for doing research with and for Aboriginal people and also adopts a ‘decolonizing’ approach whereby the concerns and worldviews of Aboriginal people are at the centre of the research (Mertens et al., 2013; Singh & Major, 2017: Laycock et al., 2011; Wain et al., 2016). Another study has highlighted the importance of encouraging decolonizing processes and personal narratives in enabling improved understanding of the health, social and emotional well-being needs of Aboriginal peoples (Geia et al., 2017).

The leadership and involvement of Aboriginal researchers and research assistants who are known to the local Aboriginal communities has meant that organizations (particularly those with Aboriginal staff) have felt safer and ‘less judged’ to talk about the issues. The research team reassured participants they were not being individually evaluated, but rather we were exploring the attitudes, systems, organizational cultures and philosophies that might support or detract from providing inclusive services for Aboriginal LGBTQ+ clients. All focus groups and interviews were led and facilitated, or co-facilitated, either by Aboriginal or Aboriginal LGBTQ+ researchers from Western Australia. The opportunities for our Aboriginal and Torres Strait Islander research team to conduct research informed from LGBTQ+ perspectives has enabled the space to, “fully develop the critical capacities for Indigenous knowledge, philosophy and analysis” (Moreton & Robinson, 2015, p. xvii).

Our translational research strategy prioritizes research that will make a difference in the direct service provision for Aboriginal and Torres Strait Islander LGBTQ+ people. The research team have worked closely in partnership with three Aboriginal Community Controlled Health Organizations at all stages of the research process, including research scope and direction, research questions, methods and translation. Translation of study results is also informed through ensuring compliance with the communique on Indigenous Data Sovereignty, whereby data that is collected about Aboriginal and Torres Strait Islander peoples is analyzed and interpreted by Aboriginal and Torres Strait Islander researchers and translated in ways that directly benefit their communities (Australian National University, 2016). These approaches acknowledge the appropriateness of ensuring local knowledge informs the development and delivery of tailored interventions that respond to the diversity within Aboriginal and/or Torres Strait Islander LGBTQ+ communities in Western Australia.

The research was initially approved by Murdoch University Ethics Committee and subsequently by Edith Cowan University Ethics Committee. All participants were given verbal and written information about the research project and provided with information about what their involvement would entail. All participants provided their written consent and were informed that they could withdraw at any time without consequence to themselves or their families, and that they were entirely free to refuse answering any or all questions during the research activities. Throughout the project, the researchers ensured that participants’ stories and experiences were collected with respect and sensitivity. The researchers were guided by the NHMRC National Statement on Ethical Conduct in Research involving Humans (2007) and the NHMRC Values and Ethics: Guidelines for Ethical Conduct in Aboriginal and Torres Strait Islander Health Research (2018). The researchers also sought the guidance of Noongar Elders and Senior people and followed protocols required by cultural groups. The eligibility criteria for participants was

• A person currently employed in a health, social support and/or education organization based in Western Australia that provided or potentially provided services for Aboriginal and/or Torres Strait Islander people who are also LGBTQ+.

Focus Groups, Interviews and Individual Written Responses

Focus groups. Four health services and one group made up of participants from three university educational student support services participated in the focus groups (n = 5 focus groups, n = 49 participants). Three of these focus groups were among Aboriginal-specific services (n = 32 participants), with the remaining two groups from non-Aboriginal-specific services. Whilst not individually identifying focus group organizations (for confidentiality reasons) the spread of issues responded to included social and emotional well-being, mental health, alcohol and other substance use, sexual health, chronic health, accommodation and refuge services, medical services, and student education and support services. Focus group discussions were conducted in a semi-structured fashion by the facilitators with a range of questions about how participants individually considered the needs of and responded to Aboriginal and/or Torres Strait Islander LGBTQ+ clients as well as how they were supported by their organization to do so.

The focus groups were also facilitated or co-facilitated by Aboriginal researchers with connections to the local Noongar community and who were trusted. Focus group facilitators reassured participants verbally and in writing that discussions were confidential and that individuals would not be individually identified. The participants were also advised that if they wished to discuss issues individually with a researcher that this was an option for topics that might be sensitive or of a confidential nature.

Interviews. Five participants drawn from the community (n = 2), health sector (n = 2), and an LGBTQ+ advocacy service (n = 1) completed one-on-one interviews with a member of the research team. There were four individual interviews and one interview with two participants resulting in five research interview participants in all. These were conducted utilizing an appropriate culturally sensitive research method informed by ‘Research yarning’ (Bessarab & Ng’Andu, 2010). They were an opportunity for participants to bring up issues that they wanted to discuss about the topic. The interviews were offered as a supplement to focus group participants who had more to say or those who wanted to discuss issues confidentially. One of the interview participants from an advocacy service did not participate in any of the focus group activities. The interview participants were able to bring up issues they wanted to discuss and explore and were not structured by the interviewer.

Focus Group and Interview Participants

All participants were over the age of 18. The majority were working for organizations in the Perth metropolitan area. One interview participant was working in the North-West of Western Australia. Participants were not explicitly asked to identify as Aboriginal and/or Torres Strait Islander or LGBTQ+. Nonetheless, most participants from Aboriginal-specific services identified as Aboriginal. At least a third of participants from the education support service focus group self-identified as Aboriginal people, whilst a non-Aboriginal health service focus group only had one Aboriginal person present. Several participants across the focus groups and interviews identified as LGBTQ+ or non-binary.

Focus on the Relevance of LGBTQ+ Identity

The relevance of LGBTQ+ identity in the consideration of the kinds of service responses required formed a significant part of the discussion within the focus groups and interviews. In consideration of participants who may have felt some hesitation in addressing this issue openly in a group, the research team provided participants with an opportunity to also respond individually and confidentially in writing. Participants were asked to respond to the following two-part question.

“1a. Are there situations where you respond to clients and think that LGBTQ+ identity is not relevant? 1b. If so, in which situations do you think that applies?”

The research team acknowledges that the phrasing of the question may have contributed to participants assuming there were situations when identity was important and may not have done so if the question had been asked in a different way.

All participants from focus groups were handed a proforma with the question. They were asked to individually reflect on the question and then write their responses down underneath. They were given 15 minutes to reflect and write their response and were asked not to discuss their responses to increase the likelihood of confidential and honest responses. Whilst some participants provided only one or two sentences, most of the participants wrote two or three paragraphs.

Data Analysis

The focus group and interview discussions and interviews were analyzed by thematic analysis and were guided by Aboriginal-led participatory research methodologies (Kendall et al., 2011; Leeson et al., 2016; Wain et al., 2016). Focus group discussions and interviews were recorded on an audio recorder. These recordings were later transcribed by a professional transcription service. They were also listened to by members of the research team and key points and themes were documented and discussed. This also provided an opportunity for the researchers who had conducted the focus groups and interviews to recall non-verbal impressions and clarify where there were areas of disagreement and consensus. The transcripts of the focus groups and interviews were read and re-read several times by two members of the research team, one of whom was an Aboriginal and LGBTQ+ person. These were then discussed and shared again with the wider research team and key themes and sub-themes were identified. These were then organized into a matrix under each participating organization and then further expanded and refined to show common themes, unique themes, further reflections and aberrations. The matrix was then distributed again to the research assistants and researchers who had facilitated the focus groups and interviews for their feedback and clarification if needed. The written responses were collected after each focus group and transcribed onto an Excel spread sheet by an administrative support person. The original written responses were also checked by a member of the research team to ensure transcription into the spreadsheet was accurate. These written comments were analyzed by lead researchers who identified key and sub-themes for inclusion in the matrix of organizational results. Whilst a scale was not used the textual analysis of the responses was organized under the terms ‘never’ ‘some of the time', ‘sometimes', ‘all the time', ‘always', these being terms participants used to describe their responses. This enabled the researchers to analyses the diverse contexts of when these terms were used and explore what was similar or different between those who described ‘never’ and those who described ‘sometimes’ or ‘always'.

A summary of the results was then presented to all participating organizations at an all-day workshop to check for veracity and accuracy of key findings. Their feedback and further commentary were included in the analysis. There were no major areas of disagreement about the findings or how they had been interpreted by researchers. There were some instances where there were different views from individual workers within the same organization, but where this was the case these have been identified and discussed as showing that participants were at different levels of awareness and knowledge about the issues.

LGBTQ+ Identity and Human Rights

A minority of organizational participants for this study adopted the view that human rights for Aboriginal LGBTQ+ clients was fundamental in considering how best to provide services for them. The Australian Human Rights Commission states that ‘equality and freedom are fundamental human rights for all people’, (2014, Face the Facts). In Australia, The Sex Discrimination Act (1984) (SDA) made it unlawful to discriminate against a person because of gender identity, sexual orientation or intersex identity. Since 2017, however, changes to this law enable discrimination against LGBTQ+ people whereby, ‘religious bodies’ and ‘educational institutions established for religious purposes’ ‘can discriminate against people on the basis of certain attributes protected by the SDA’, (Australian Human Rights Commission, 2017).

The participants who described a client’s LGBTQ+ identity as always relevant connected this view to ideas of basic human rights and respect. These participants also viewed a person’s identity as central to all aspects of their life and were more likely to state that it was important not to make an uninformed assumption about a client’s LGBTQ+ status. This was because they considered there was a potential for those clients who chose not to share their identity at first presentation to do so later. Among these participants, knowing a client’s LGBTQ+ status; or not assuming that a client was heterosexual and/or cisgender meant valuing client’s human rights and ensured that workers were using non-discriminatory, non-heterosexist language and practices.

I think that a person’s identity is always relevant. It is the core of who they are and to assume it is not relevant in any context would be de-humanizing (Focus group participant, Aboriginal-specific health and social support service).

Whilst many of the individual workers described working with a person or client centred approach toward service delivery, the potential for this to conflict with the broader organizational culture or Board of Management was highlighted as a sensitive issue. This was particularly for those Aboriginal workers who were employed in Aboriginal health community controlled organizations. Participants discussed the tensions between delivering a service that was open and inclusive of Aboriginal LGBTQ+ people, whilst also respecting the views of Elders and staff members who may hold religious, traditional and conservative views about Aboriginal culture and LGBTQ+ people:

But we can't impose that [being open about LGBTQ+ issues] because there are staff members who have very strong religious views. And I guess, from an organizational position, our Board of Directors have spoken about being an LGBTI gay space, it hasn't been fully informed into practice by - we have a cultural safety policy which really emphasizes the way we connect and engage with Aboriginal and Torres Strait Islander mob. But we don't have any inclusion of that queer sector at the moment. So today's low participation had demonstrated to me that there is still old ways of thinking [about being Aboriginal and LGBTQ+]. (Focus group participant: Aboriginal specific health and support service).

Interview participants discussed the questions of identity with more detail and were more likely to highlight the issues for specific groups under the broader LGBTQ+ category. This may be because these were the participants who were more likely to work more intensively and extensively with Aboriginal and/or Torres Strait Islander LGBTQ+ clients.

The Importance of Identity and Client- or Person-Centred Approaches

Several international and Australian studies have emphasized the importance for designing and developing health policy and social support services that respond effectively to clients who are LGBTQ+. Furthermore, that these are flexible enough to respond to the fluidity and diversity within the category of LGBTQ+ (Adams et al., 2013; Ferlatte et al., 2018; Fredriksen-Goldsen et al., 2014; Hill et al., 2021; Strauss et al., 2017). The results from this research study show that whilst organizational participants were mostly supportive of this view, for some this was qualified when considering a client’s LGBTQ+ status.

For these participants LGBTQ+ identity was not relevant all the time. This was not because participants thought it was unimportant; rather that they viewed their current way of providing services was adequately responsive to the diversity of clients using their services. A variety of reasons were provided in support of these more qualified views. A majority of these were linked to ideas about client- or person-centred approaches to service delivery. The literature describes ‘client-centered’ or ‘person-centered’ care as being non-directive, non-judgemental, relational, accepting and places the client at the centre of care (Novotna et al., 2011; Santana et al., 2017). These were terms used by participants to explain how they responded (or anticipated they would respond) to Aboriginal LGBTQ+ clients. These participants maintained that if their practice were truly person-centred then the issue of LGBTQ+ identity disclosure (or not) would be directed by their client and not by them.

Participants explained how person-centred care philosophies informed their responses:

It would depend on the person - if it is relevant to the person in all situations, then it should be relevant to the person working with that person also. (Written response, participant in focus group, Aboriginal-specific health and community support organization).

Just over half of participants also questioned whether a person’s LGBTQ+ identity was as important as their presenting health or support need conditions in certain circumstances.Address a person’s needs firstly, I do not have to know the person’s sexual orientation unless they feel comfortable enough to share with me. (Focus group participant, Aboriginal-specific health and social support organization).

I think it is relevant in all situations, just the importance level that varies. For example, if they present with a medical condition such as chest pain I am more concerned about medical history than sexual orientation. If somebody presents with suicidal ideations and is young then their sexual orientation may be the cause of it, then that may need to be addressed immediately. Being relevant justifies and validates their choices and their ability to make their own choices. (Focus group participant, Aboriginal-specific health and social support organization).

For other participants there were situations where LGBTQ+ identity was important, for example referral to appropriate health and/or support services and other situations where it was not important. This was when the person was applying for a scholarship or a routine medical appointment that was not directly associated with their sexual or gender identity.

Other organizational participants emphasized that the service being culturally safe and inclusive for Aboriginal and Torres Strait Islander clients was most important and that this was needed before other considerations (such as those for LGBTQ+ clients were addressed).

There is a big difference as to whether they are identifying as an Aboriginal person or an Aboriginal person who also identifies LGBTIQ. So, I think that is just something that is an ongoing struggle Aboriginal people face in accessing services irrespective of what those services are. And then I think the added layers of identity can compound, the I guess struggles, people have in accessing services. (Focus group participant, Aboriginal specific health and social support service).

The quotes above show how Aboriginal LGBTQ+ people may need to negotiate ‘added layers of identity’ when presenting at services and for workers too there is a juggling of competing priorities. Workers need to make decisions for each client about what should be at the centre of a person’s care. For some, these considerations result in LGBTQ+ identity being less important than other factors such as Aboriginality, or the specific health issue the client is presenting with.

Inclusive Communication and Language

Participants who adhered to client- or person-centred approaches also emphasized that communication with clients should use language that was inclusive and non-judgemental. This was the case for participants from both Aboriginal-specific and mainstream (not Aboriginal-specific) services. Whether or not the client openly self-identified as LGBTQ+ was not considered relevant with participants stating the onus was on organizational staff to use open and un-biased communication to ensure they were always inclusive:

A written response to this question:

…It is always possible someone will identify as LGBTQ so maintaining the appropriate language and attitude is always relevant (Written response, Aboriginal specific health and social support service).

There was also an acknowledgement by participants that clients had good reasons to feel unsafe about openly identifying as LGBTQ+ and, therefore, it was important for organizational staff to use open and un-biased language and ensure they knew of referral pathways and supports for Aboriginal and Torres Strait Islander people who identified as LGBTQ+.

The concerns and issues raised here by participants are similarly reflected in the research literature that shows that whilst it may be appropriate for some LGBTQ+ people to be ‘out and proud’ for others the question of being open about one’s LGBTQ+ identity is a constant negotiation. Furthermore, the power relations of individuals within the category of LGBTQ+ are not equal, with those who are not white, or those who are trans, for example being more likely to delay or postpone medical or social support care (Flores et al., 2015; Fredriksen-Goldsen et al., 2014; Strauss et al., 2017).

A peer health worker from a health service stated that for some LGBTQ+ people, particularly trans clients, it was not possible to ‘hide’ their identity and therefore it was important that organizational staff knew how to respond appropriately, by not making assumptions about their gender identity. This participant also stated that anonymity was important for LGBTQ+ people who were engaged in sex work when accessing health services. The participant provided an example of a trans person being turned away from the Emergency Department of a major metropolitan hospital after being violently assaulted. So as not to identify this participant some of the wording (but not the intent or meaning) has been modified.

A very high level of anonymity is needed for trans sex-workers. Many have been turned away from that many services. A trans person was turned away from the emergency department after being violently assaulted. It was one of the few times they tried to access any health service and that is what happened on the first attempt. It is very difficult for trans and LGBTQ+ sex workers to feel ‘safe’ at any health service (Focus group participant, Health Service).

This finding shows how the intersectionality of this client as trans, a sex-worker and an Aboriginal person resulted in their being turned away from a health service at a time when they felt most vulnerable. It illustrates the racial discrimination and queerphobia that may be experienced and the need for Emergency staff at the hospital to be educated about how to respond in respectful and effective way to clients who may challenge their sense of who is deserving of care.

Four participants from an Aboriginal-specific health and social support service emphasized that, whilst clients’ LGBTQ+ identity was relevant, it was important that staff did not make assumptions about clients’ gender and sexual identity. This was particularly the case for those LGBTQ+ clients who did not openly identify. The use of appropriate language was considered an essential skill in these situations so that LGBTQ+ clients did not feel excluded. A written statement that exemplifies this point of view was

We need to use ‘open-ended’ questions to ensure we do not offend straight or non-straight people (Participant, Aboriginal-specific health and social support service).

The specificities of language use were important for university staff as well. A university lecturer provided an example about why identity was always relevant, and perhaps even more so, when a student did not openly identify as LGBTQ+.

Many years ago, when I was teaching a bridging course there was a student who hadn’t identified but I had a feeling he didn’t identify for a particular reason - another student had made a comment in the class and I had a word with that student. I think from then, that student saying that [homophobic statement], we lost that [LGBTQ+] student from that. And me as the teacher in that moment, I felt really awful that had happened while I was teaching in the class and I lost that student because of that, and it was me, maybe not setting up expectations at the beginning. I don’t know, but yeah. (Focus group participant, University).

The participant explained that, whilst the student was not ‘out’, the discriminatory language used by some students had contributed to the LGBTQ+ student feeling uncomfortable and unsafe in the classroom setting.

These findings show that being ‘out’ is a status that is particularly complex for those who are not white or gay. The Diversity Council of Australia (2018) found that for those with multiple and intersecting identities, being ‘out’ may result in being marginalized from one’s own culture. For people who are trans there may be reasons why they do not want to be ‘out’. Furthermore, LGBTQ+ people with intersecting identities may need to edit (choose when and if to share one or more aspects of their identity)and are always in the process of ‘self-editing’ particularly if they are part of a double or triple minority group (Diversity Council of Australia, 2018).

Why Identity is Always Important for Young, Trans and Intersex People

Interview participants from health, mental health and family support services emphasized that unless LGBTQ+ identities were considered relevant by service providers; clients would not receive safe or appropriate services. The importance of safe and responsive service provision was particularly emphasized for young people, trans and intersex clients seeking psychological and medical support and LGBTQ+ seniors seeking aged care services. These views are supported by previous studies exploring the experiences for non-Aboriginal young people, trans and intersex clients (Adams et al., 2013; Ferlatte et al., 2018; Hill et al., 2021; Petrie & Cook, 2019; Singh & Major, 2017; Strauss et al., 2017).

An example of how collectively health, education and social support services as a system were unresponsive to the needs of a young Aboriginal trans woman was described by two interview participants. They explained that this person was at risk of being ostracized by her community if she came ‘out’ and that, despite her identity being visibly gender non-conforming, a range of service providers were unable (or did not know how) to respond to her needs. Furthermore, this person was being pressured by her community to attend ‘traditional law’ and renounce her trans identity. Traditional law or ‘lore’ sets out the common features of acceptable and unacceptable behaviour in all aspects of life in Aboriginal communities and is defined and led by Aboriginal Elders and community leaders (Blagg & Morgan, 2004). The quote that follows describes the experience of the participants as outreach educators in facilitating educational group presentations to multiple health, education and social support services. They described the second time that they had been told about the same young trans woman:

Then we ran the second group, and in the second group, we didn’t mention that story [the previous time they had heard it] of course to anybody, it would have been very identifying had we done so. In that second group, sure enough toward the end of the four days, someone brought up the exact same young person. They were in contact with that young person in another capacity, and I think this person was a senior child protection worker, and said we have grave concerns for her safety if she is to attend law, and she is refusing. Her family is insisting and we have grave concerns for her safety, as we did, as everyone in the room did. We again asked people in the room, do you know, you're all the youth workers, the teachers, the doctors, the nurses, the child protection workers, where can this person - who can they talk to, where can they go, what is there? Nothing. (Two interview participants, mainstream health service).

This is an example of how despite there being services across health, education and child protection sectors available for Aboriginal clients, for those who identify as LGBTQ+ the system does not respond adequately. This is a finding reflected more broadly, for example Fredriksen-Goldsen et al., (2014) describe how LGBTQ+ clients are ‘health disparate and underserved’, (p. 654) and argue that health promotion models and health policy need to respond to the social position and intersectionality of LGBTQ+ clients.

When LGBTQ+ Identity is Invisible

The results of this research study found that a minority of organizational workers did not acknowledge Aboriginal LGBTQ+ people’s experiences of Family and Domestic Violence and how in turn, they were able to access emergency or refuge accommodation. A minority of organizational staff from an Aboriginal-specific service that provided a range of health, housing and community support services stated that whilst LGBTQ+ identity could be relevant in certain health situations, that it was not relevant when referring clients to accommodation services or refuges. This shows that organizational workers in a range of health and social support services require education about how Family and Domestic Violence and issues of homelessness affect Aboriginal and Torres Strait Islander LGBTQ+ people.

An assumption was made by a focus group participant that LGBTQ+ people did not use the accommodation or refuge services.

I work in a women's refuge where the focus is on escaping Domestic and Family Violence or other crisis. This is an area I feel LGBTQ identity is not relevant. We have not been faced with accommodating someone LGBTQ yet (to my knowledge). (Written response, focus group participant, Aboriginal-specific health and social support service).

This participant’s view reflects more widely held views that people who are LGBTQ+ do not experience family and domestic violence. This is despite Royal Commission research in Australia reporting that LGBTQ+ people are at least as likely (if not more likely) to experience family and domestic violence. LGBTQ+ people are also less likely to seek support due to a lack of appropriate support services including crisis accommodation (Campo & Tayton, 2015; O’Halloran, 2015). This invisibility of LGBTQ+ clients’ needs extended more broadly to homelessness services in general.

A clinical nurse specialist working in a community mental health service raised concerns about medical workers (particularly doctors and surgeons) and a lack of training about LGBTQ+ issues. This participant highlighted the homelessness experienced by Aboriginal LGBTQ+ clients.

Unfortunately, the general medical staff, they haven’t taken up the bat and ball at all with LGBTIQ stuff. They are probably more aware of the Aboriginal stuff but not the LGBTIQ. I don’t know what that’s about. There needs to be a big shake and shout coming from the top. There needs to be a huge push. A lot of our clients experience homelessness too and that’s incredibly difficult when so many accommodation services are incredibly binary “male” or “female.” The services across the board we have for LGBTIQ folk need to be more robust. Consideration of LGBTIQ issues need to be written into policies and data collection of services. (Clinical nurse, mainstream mental health support service).

The view of this participant was that, whilst LGBTQ+ identity should not be used to single out clients or assume they require special treatment, LGBTQ+ identity was nevertheless always relevant in the sense that language and responses should be inclusive so as not to alienate any given client at any time.

Why LGBTQ+ Identity Would Never be Relevant

A minority of participants described a client’s LGBTQ+ status as never being relevant when providing services. These comments did not appear to be associated with being overtly homophobic or discriminatory, but rather ensuring equity of service and adhering to the values of the organizations they represented. The emphasis here was on a particular kind of interpretation of ‘person/client-centered’ or ‘inclusive’ service models. Three participants from an Aboriginal-specific health and family support service stated through written responses that ‘everyone should be treated the same', ‘regardless of LGBTQ+ status'. An example of this view and how LGBTQ+ was only ever relevant in certain situations follows:

Within client/center relationships, sexual orientation should not be relevant in any scenario other than advice or treatment directly related to LBGTQI orientation (at risk). (Written response, Aboriginal-specific health and social support service).

Thus, although it was only found among a minority of participants, there was a view that a client’s LGBTQ+ identity was not relevant because staff believed, presumably, that LGBTQ+ clients would receive the same level of care as non-LGBTQ+ clients. This view aligns with an ‘equal opportunity’ view on equality. That is that all clients should be treated similarly regardless of race, gender, sexuality, age, marital status, pregnancy, family responsibilities, political or religious beliefs (See: Western Australian Equal Opportunity Commission, 2021, http://www.eoc.wa.gov.au/your-rights; http://www.eoc.wa.gov.au/substantive-equality), and contrasts with the newer notion of equity which does not result in ‘treating everyone the same’ but rather considers equality in relation to the differences and requirements of diverse people.

The following written response provides an example of this kind of approach.

The right to approach our service - their sexuality should not be a factor in whether or not we're able to assist them (Written response, participant, Aboriginal-specific service).

This view was also associated with not being judgemental, so proponents position themselves as not discriminating because someone was LGBTQ+.

Everyday situations as a care coordinator you come across a diverse range of people, as health professionals we are not judgmental and do not specifically go out of our way to find out if a person identifies as LGBTIQ. (Written response, participant, Aboriginal-specific service).

Whilst these responses appear well intentioned, they reveal the possible incompatibility with what workers interpret as a person-centred approach. That is in the effort to be non-judgemental and open, health workers who do not use language and communication that is LGBTQ+ inclusive may inadvertently provide a less safe, effective or inclusive service for those Aboriginal and/or Torres Strait Islander people who are LGBTQ+.