OPINION PIECE

 

The role of occupational therapy serving LGBTQIA+ people: Retrospective perceptions of an occupational therapist

 

 

Sannet Tintinger^I; Thabani Ncwane^I; Naazneen Ebrahim^II

^IDepartment of Occupational Therapy, Steve Biko Academic Hospital, Pretoria, South Africa. Sannet Tintinger: ORCID https://orcid.org/0000-0003-0973-9007. Thabani Ncwane: http://orcid.org/0000-0003-4079-6122
^IIDepartment of Occupational Therapy, Tara the H Moross Psychiatric Hospital, Johannesburg, South Africa. ORCID https://orcid.org/0000-0003-4182-9686

Correspondence

 

 

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ABSTRACT

INTRODUCTION AND AIM: LGBTQIA+ people constitute a minority group that navigate their occupational engagement within a historically entrenched system of oppression. This opinion piece addresses a subject matter that is increasingly garnering attention from the international health science community, yet it remains insufficiently explored in South African occupational therapy dialogues. The aim of this paper is to stimulate critical reflection among occupational therapists on the discourses that underpin our daily practice. By utilising the person-environment-occupation model, we seek to demonstrate the unique and essential role of occupational therapy in serving LGBTQIA+ people within the South African context.
CONCLUSION: Although occupational therapists are trained to consider all aspects of a person, discussions around gender are rarely emphasised in undergraduate training or clinical practice. This opinion piece demonstrates the roles that occupational therapists may play when working with LGBTQIA+ people to provide services that are holistic and relevant to their needs and contexts. Recognizing the impact of everyday occupational therapy practices on LGBTQIA+ individuals is crucial, requiring a commitment to inclusivity and continuous reflection within the field of occupational therapy.
IMPLICATIONS FOR PRACTICE:
Occupational therapists can play an important role in serving LGBTQIA+ individuals when they are committed to recognizing how dominant discourses about this group can be sustained through the everyday practices of delivering occupational therapy.

Keywords: person-environment-occupation model, occupational engagement, occupational consciousness, occupational justice, gender discourse

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INTRODUCTION AND BACKGROUND

This opinion piece focuses on a subject matter that is increasingly gaining the deserved attention of the international health science community. Discourses regarding LGBTQIA+ people are rarely examined in South African occupational therapy. LGBTQIA+ is an acronym used to describe a spectrum of terms related to sex, gender identity, gender expression, sexuality and sexual orientation¹. The LGBTQIA+ acronym is also used to describe a minority group that continues to navigate their occupational engagement within a historically oppressive system. Occupational therapists carry the onus of occupational consciousness - the "ongoing ... recognition that dominant practices are sustained through what people do every day"^2:488. In the primary author's experience, it may unintentionally occur that occupational therapists' everyday practice in clinical settings sustain the oppressive discourses regarding the LGBTQIA+ people. The authors hope to prompt critical reflection amongst occupational therapists of their daily practice serving LGBTQIA+ individuals and to demonstrate this by using the person-environment-occupation model³ in the distinctive role occupational therapy has in the South African context.

The genesis of this exploration emerged from a clinical encounter in Pretoria, South Africa, involving Lethabo*, who was referred to occupational therapy after a motor-vehicle accident. Lethabo sustained a traumatic fracture-dislocation of the thoraco-lumbar junction (T12-L2) resulting in paraplegia and had co-morbid diagnosis of HIV and depression. Lethabo was assigned female at birth (AFAB) but identified as male. On admission, Lethabo was placed in a female ward based on the observable features used to categorise patients according to their sex. Lethabo declined the occupational therapy activities of practicing dressing in ward gowns, facial grooming with cosmetics, and nail care using nail polish. Inadvertently, these gender-based activities traditionally used in occupational therapy to support patients' adjustment to their new disability had not honoured Lethabo's gender identity. Instead, occupational therapy made the adjustment more strenuous and marginalised Lethabo's reality daily.

This experience prompted the authors to delve into the impact of everyday occupational therapy practices with LGBTQIA+ people. The aim of the opinion piece is to stimulate dialogue in the South African occupational therapy community about how, at a clinical level, the daily practices of occupational therapists can promote occupational justice for LGBTQIA+ people. The intention of occupational justice is to critically think about how the daily practices of occupational therapy can uphold the right of every individual to meet their basic needs and reach their potential in a way that is specific to the individual and their engagement in meaningful and diverse occupations⁴. One can only imagine how differently the outcomes of Lethabo's journey in occupational therapy could have been had personally meaningful occupational engagement been emphasised in every stage of the process -from the comprehensive assessment, throughout patient-centred goal setting, and as a central tenet in every session's activity choice, facilitation, and evaluation.

This topic has been examined by occupational therapists globally. The following section uses the person-environment-occupation model as described by Strong et al.⁵ to structure how occupational therapists have come to understand their role in serving LGBTQIA+ people, including how to address the personal, environmental and occupational factors that affect meaningful occupational engagement for LGBTQIA+ people.

 

UNDERSTANDING THE REALITIES OF LGBTQIA+ PEOPLE

It is crucial to unpack the diversity of LGBTQIA+ people and the contextual factors that shape their everyday realities. LGBTQIA+ individuals face complex challenges influenced by personal, environmental, and occupational factors.

Personal factors

Identifying as an LGBTQIA+ person impacts one's core identity, self-acceptance and agency, which influences mental health. Stress, anxiety, and depression affect LGBTQIA+ people four times more compared to the general South African population³. LGBTQIA+ people also face higher risks of suicidality⁶, their social health is affected by fear of discrimination, stigmatization6 and religious objection⁷ which compels them to conceal their gender identities and isolate themselves, and hinders authentic occupational participation. Furthermore LGBTQIA+ people develop risky behaviours (i.e. substance abuse, unprotected sex, sedentary lifestyles)⁸, disability and chronic health conditions (i.e. asthma, arthritis, obesity)⁹.

Environmental factors

Historical, sociocultural, and healthcare contexts play pivotal roles in shaping LGBTQIA+ people's experiences. Historical marginalization, perpetuated through Apartheid laws^3,6, has lingering effects on LGBTQIA+ people's engagement. Societal ideologies, despite progressive legal reform in South Africa, continually contribute to homophobic and transphobic attitudes, and perpetuate discrimination and violence against LGBTQIA+ people^3,6. Moreover, socio-economic conditions such as poor access to acceptable healthcare and targeted health programmes^3,8,10, unemployment, household poverty, and food insecurity largely impact the health outcomes and occupational engagement of LGBTQIA+ people^6,11.

Occupational engagement

LGBTQIA+ people face significant changes to their occupations during the processes of coming out and transitioning^10,11 including losses (such as self-consciousness, social disapproval)¹² and gains (such as reduced stress, closer interpersonal connections and greater confidence^12,13) and loss of relationships, educational marginalisation, stunted professional growth^12,14. Coming out and transitioning largely impacts LGBTQIA+ individuals' ADL and iADL satisfaction¹⁰, patterns of sleep and rest¹⁵, gender expression through grooming patterns and choice of clothing¹³, likelihood of obtaining a school-leaving qualification⁶ their career choices⁷, and their likelihood of being employed, promoted, and earn equal salaries^ Occupational therapists must consider these changes when addressing the unique needs of LGBTQIA+ individuals.

 

ENABLING OCCUPATIONAL ENGAGEMENT FOR LGBTQIA+ PEOPLE

Understanding the realities of LGBTQIA+ people is essential for occupational therapists to play a role in promoting occupational justice and addressing factors that influence their occupational engagement. Occupational therapists may encounter LGBTQIA+ individuals in settings for reasons unrelated to their gender or sexual identity, or for issues specifically related to coming out or transitioning, in which case their gender identities and/or sexual orientation is the focal point of intervention10. In both contexts, the occupational therapist must consider LGBTQIA+ people holistically through a process of collaboration to determine and address their unique occupational needs¹⁵. This is done working with the individual person, creating an enabling environment, and enabling meaningful occupational engagement.

Working with the person

Mental health

Holistic occupational therapy necessitates attention to the mental health of LGBTQIA+ people in both medical and psychiatric settings. Direct interventions may include facilitating psycho-education of their diagnoses, facilitating sessions on balanced living, relaxation techniques and life skills (such as assertiveness training, conflict management, healthy coping strategies), or establishing positive self-concept, self-esteem and body image through therapeutic activity^10,12,16. Indirectly, occupational therapists may offer emotional support, creating supportive groups for LGBTQIA+ members, or facilitating engagement in therapeutic activities that allow creativity, relaxation or social connection¹⁵.

Physical health

Occupational therapists also need to be involved in health promotion activities and use educational approaches to increase awareness among the LGBTQIA+ people about the risks and available help for substance abuse, HIV, chronic diseases of lifestyle, and mental illness, as well as on safe sex practices, medication adherence and coping mechanisms^15,17. The Guidelines for Good Practice with Lesbian, Gay and Bisexual Clients¹⁸ recommend that health professionals employ an affirmative approach to this education, such as refraining from using educational materials that pathologise or stigmatise clients, and preferably using open language (for example, using the term 'partner' instead of 'husband' or 'wife')¹⁸.

Social health

The occupational adaptation during the coming out or transitioning processes may include dealing with occupational losses through embracing the positive changes of these processes¹³. Occupational therapists can support this process by creating a supportive social environment, as well as facilitating self-acceptance, processing of internalised stigma, and strengthening personal resilience against external stigmai0'ii. Occupational therapists may also enable social health for LGBTQIA+ people through mediating the coming out or transitioning processes in their social, religious, cultural or familial groups, facilitating social networking for clients in the LGBTQIA+ community (i.e. connecting to advocacy groups), or facilitating warm parent-child relationships through family counselling and education^10,14,18.

Creating an enabling environment

Pollard and Sakellariou¹⁷ state: "To address the needs of marginalised populations, occupational therapy may need to re-evaluate its relationship with biomedical discourses to prioritise social concerns"^17:1. Therefore, occupational therapists need to contribute to the transformation of societal factors which restrict the occupational engagement of LGBTQIA+ people.

Advocacy

Advocacy can range from participating in projects aimed at structural, legislative and policy changes, to challenging negative attitudes on social media, or developing sensitivity training programs for the clinical staff where one works^10,17,18. The knowledge gained through working with the LGBTQIA+ people should also be shared with occupational therapy students and other members in the multi-disciplinary team. This will not only allow opportunities for advocacy for this minority group's needs, but also about the role that occupational therapy has to play in LGBTQIA+ healthcare. However, advocacy may be complicated by time and resource constraints. Beagan et al.i5 suggest that occupational therapists can start small by changing LGBTQIA+ people's experience of their environment, especially their healthcare environment. One way to do this is by creating an occupational therapy context that reflects trans-positive care⁹, for example by enquiring about and using patients' preferred pronoun, ensuring patients understand and give verbal consent to all interventions, and displaying policies of non-discrimination in visible spaces^9,18.

Trans-Positive Care

Trans-positive care requires that occupational therapists interrogate their unquestioned patterns of providing services and ingrained assumptions¹⁰. According to Beagan et al.¹⁵, this process requires a willingness to set aside one's religious and cultural beliefs, scrutinise one's heteronormative and cisnormative patterns of working with patients (i.e. the use of gendered grooming therapeutic activities based on clients' biological sex), and identify one's learning gaps when serving this group9. Occupational therapists should explicitly question how our everyday clinical practices sustain the dominant discourses and perpetuate oppressive discourses regarding LGBTQIA+ people in order to be tied to the liberation of the communities we aim to serve.

Occupational Consciousness

According to Ramugondo^2:497, occupational consciousness refers the minority group's "alertness to how human occupation intersects with dominance and perpetuates inequality and oppression", which is followed by transgressive acts using occupation as the mechanism to disrupt such oppression². Occupational therapists should empower LGBTQIA+ people to question and resist dominant discourses that inform and limit their everyday occupational participation² This can be through supporting LGBTQIA+ clients' abilities to insist on their rights of non-discrimination, to confront discriminating discourses when perpetuated in their social circles, workplaces or educational institutions, and to become involved in the political discussions and policy writing that pertains to their occupational engagement in society².

Enabling meaningful occupational engagement

The role of occupational therapy is especially pronounced during and after the coming out and transitioning processes for LGBTQIA+ people¹⁵. Beagan et al.¹⁵ describe gender performance as a learned behaviour that can be taught. The difference, compared to typical occupational therapy approaches with cisnormative, gender-conforming clients, is that LGBTQIA+ people are not only re-learning or adapting occupations previously known to them, but also learning new, gendered occupations that may be foreign to themi0'i3. A few examples of facilitating these changes in occupational engagement include:

ADL and iADLs

Occupational therapists should collaborate with clients about their occupational needs regarding their ADLs, as these will be heterogeneous. Certain clients may experience dysphoria during their ADL routines and require assistance to incorporate adaptive techniques to manage anxiety or to minimise their direct contact with their genitalia (i.e. using a long-handled sponge)^10,12. Occupational therapists may also address issues of rest and sleep and can advise LGBTQIA+ individuals who struggle with anxiety or dysphoria on relaxation techniques, life balance, anxiety management, and sleep hygiene practices¹³. Sexual practices may change drastically for an LGBTQIA+ person before, during, or after coming out or transitioning, and occupational therapists can provide education on positioning, safety, hygiene practices, as well as social skills training (i.e. dealing with a changing body image)¹⁰. Occupational therapists may focus on enabling the person's performance of new ADL activities to express their gender (i.e. hair styling, shaving, cosmetics) through training, reinforcement and feedback¹⁴.

Education

Assessment of children with gender dysphoria should be done through observing play, and intervention should include collaborating with the parents, facilitating a warm parent-child relationship, making the school or teacher aware of the child's needs, and encouraging supervised peer support^14,18. In the adolescent population, parents should be encouraged to be involved in their child's process, and educated, counselled, or referred to other professionals to enable a supportive home environment¹⁸. For persons completing tertiary education, strategies to prevent abuse and to create a sense of belonging to the LGBTQIA+ people should be fostered by the occupational therapist, such as enabling the client to connect with a new social network^15,18.

Work

Occupational therapists can advocate for patients' employment rights throughout and after the transition or coming out process^9,19. Occupational therapists can assist the client with employability self-assessment, career exploration and decision-making, and educate clients on their employment rights^10,14. Occupational therapists may also focus on the development of pre-vocational and vocational skills for gendered work (i.e. gender expression through appropriate clothing)¹⁹. This may be extended to include supporting the client's disclosure in the workplace, facilitating workplace sensitisation training for employers and other employees and mediating negotiations with employers¹⁶.

 

OCCUPATIONAL JUSTICE FOR LGBTQIA+ PEOPLE

There is a multi-layered confinement of occupational therapists to render services optimally with LGBTQIA+ people and of LGBTQIA+ people to engage without constraint in their meaningful occupations. This is not a result of practical restraints linked to the health system alone, but it is also compounded by communities and sub-cultures that intentionally and inadvertently enforce restraint on individualism¹⁹. Trentham et al.¹⁸ describe these as 'tangled threads of oppression' within our health systems and society. Liberation of these systems that perpetuate the current discourses and health inequalities of LGBTQIA+ people can be achieved the "communal process and outcome of untangling, undoing, and reconfiguring systems of dominance that negatively impact health and limit the occupational possibilities of individuals, groups, and communities¹⁹. This is essential for LGBTQIA+ people to participate in meaningful and diverse occupations that meet their basic needs and enable them to reach their potential.

Whilst this task of liberation may seem large to tackle as an individual therapist working within these systems, we can start by viewing LGBTQIA+ people through a client-centred lens to reduce the impact of traditional gender expectations on the services we render. For example, we can question and change administrative processes at our operational level to enable clients to identify their gender pronouns when they are referred for occupational therapy instead of only offering traditional male and female tick boxes on our forms. Another everyday way to change our practices is by using and empowering others in our immediate context to use open and sensitive communication with LGBTQIA+ people, including explicitly questioning gender-based assumptions amongst our colleagues and social circles. As occupational therapists we need to uphold our core principle of understanding each client holistically within their context to ensure not only that the outcomes of occupational therapy are meaningful engagement, but that the therapy process in itself offers meaning and empowerment to LGBTQIA+ people.

 

CONCLUSION

Occupational therapists need to be cognisant of the person-environment-occupation matrix to provide services that are holistic and relevant to the needs and contexts of LGBTQIA+ people. This opinion piece emphasizes the roles occupational therapist can play in mental, physical, and social health, as well as in advocacy, creating enabling environments, and promoting occupational justice. Recognizing the impact of everyday occupational therapy practices on LGBTQIA+ individuals is crucial, requiring a commitment to inclusivity and continuous reflection within the field of occupational therapy.

Author Contributions

This article was written by Sanet Tintinger. Thabani Ncwane and Naazneen Ebrahim contributed and assisted in the rewriting of the article. All three authors agreed to the publication of this version of the article.

Declarations and conflict of interests

There are no conflicts of interest declared by the authors. The authors used the LLM (Large Language Model) ChatGPT to assist with the reducing of word count and for grammar checking.

 

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Correspondence:
Thabani Ncwane
Email: Thncwane@gmail.com

Submitted: 1 November 2022
Reviewed: 8 June 2023
Revised: 20 October 2023
Accepted: 20 October 2023

 

 

Editor: Hester M. van Biljon: https://orcid.org/0000-0003-4433-6457
Funding: No funding or grants were received.
* Lethabo is a pseudonym (identifying information has been removed to protect the confidentiality of the person described).