Submission to:
NSW Mental Health Commission
Towards a draft Strategic Plan for Mental Health in
NSW – The Life Course and the Journeys
October 2013
About ACON
ACON is New South Wales’ leading health promotion organisation specialising in HIV and LGBTI
health. Incorporated in 1985 as the AIDS Council of NSW, ACON has been widely recognised as an
innovative, successful organisation which has adapted to changes in the HIV epidemic and
responded early to emerging health issues among our communities.
ACON has been at the forefront of advocacy around issues relating to HIV and to LGBTI health,
drawing on our close connections to community to identify emerging issues and create dialogue
around these issues with policy makers and researchers.
ACON has also worked alongside researchers and partners to build a stronger evidence base around
HIV and gay men’s sexual behaviour and LGBTI health, much of which has subsequently affirmed the
issues identified by our communities.
ACON has an ongoing commitment to improve the mental health and wellbeing of our communities,
as evidenced by the commitments made in our Mental Health Strategy 2010 – 2013 and our current
Strategic Plan 2013 - 2018. We have, over a long period of time, undertaken advocacy work to
address the social determinants of mental health, including in the areas of discrimination, school
environments and homophobic violence.
We have also addressed mental health concerns directly in advocacy around health strategies and
alcohol and other drug treatments. We have projects that address the impacts of alcohol and drug
use, counselling and social work supports and housing supports. More recently we have undertaken
specific projects, such as the Peace of Mind Project that directly addressed the mental health literacy
of our communities and the capacity of service providers to offer inclusive services.
General Comments
ACON welcomes the production of the working paper ‘Towards a draft Strategic Plan for Mental
Health in NSW – The Life Course and the Journeys’ and the opportunity to comment on it. We think
that it is an excellent piece of work that will assist in the improvement of the mental health response
in NSW.
ACON believes that a whole of government approach is required to address the full range of issues
posed by mental health across the population, including the issues for LGBTI people. We appreciate
and acknowledge the recognition of LGBTI people as a distinct population with specific needs,
however we believe more is needed than inclusion in a catch all reference to diversity.
It is important for the strategic plan to articulate in more detail how LGBTI issues can be embedded
across the strategy, including how to achieve the desired outcomes. While a separate strategy might
not be required, a sub-strategy or action plan will be required to measure outcomes and to ensure
accountability.
We understand that the NSW Government is in a tight budgetary position. In our submission we
have therefore paid particular attention to activities that will have a high impact with minimal cost.
While accepting that this is the case currently, ACON would like to see incremental increases in the
budget to address mental health across the state.
Looking to the future we would like to see a significant increase in funding such as that previously
seen under the state disability plan ‘Stronger Together: A new direction for disability services in NSW
2006-2016’.
The Current system
The response to mental health in NSW has a number of strengths, but we agree with the NSW
Government and the NSW Mental Health Commission (NMHC) that the mental health system is
characterised by under investment, with the rate of expenditure on mental health and related
services disproportionate to the burden of morbidity from mental ill health. The response to mental
health in NSW is also characterised by discontinuity of service and this is coupled with a greater
reliance on institutionalisation than in other states of Australia.
ACON is also concerned that there has been a significant under-resourcing of community mental
health services in NSW. This has led to the reliance on institutional models of care. It is likely to have
limited the ability of the community mental health sectors responses to be flexible and responsive to
individuals’ needs.
Addressing these issues will be important to improving mental health in NSW. We note that this has
been recognised, as shown by the establishment of the NMHC and policies to guide its work. This is
an important step on the journey to creating a system that appropriately responds to the mental
health needs of the NSW population.
The response to mental health in NSW has a number of strengths. NSW has seen a positive
engagement with the recovery based approach to mental health. This approach has not been taken
on sector wide, but there have been pockets of excellence and the community mental health sector
has been engaging in discussions on its usefulness and on implementation.
NSW has also made some strides to recognising the close relationship of mental health and alcohol
and other drug issues. There have been attempts to integrate the approaches to both of these areas
and this has led to positive outcomes for some people.
The Future Mental Health System
ACON believes that a less institutional system that invests in prevention, mental health literacy and
greater integration between all levels of support, is required. This will require greater involvement
and connectedness between the community mental health services, clinical services and greater
involvement of community, friends, and chosen support networks.
Clearer recognition of LGBTI people as a priority population group is required to ensure that the
health disparities that exist between our communities and the broader population are addressed.
A growing body of evidence from overseas and Australia reveals significant disparities in the mental
health status of LGBTI communities and individuals relative to either general community or
heterosexually identifying samples. There is not the space here to enumerate all of these here, but
among the most significant are:

Higher rates of anxiety and depression among gay men, lesbians, bisexuals and transgender
people (Ritter et el 2012, Hillier et al 2008, Carman et al 2012, Leonard et al 2012, Couch et
al 2007)


Higher rates of attempted suicide, suicidal ideation and self-harm, especially among younger
people (Hillier et al 2008, Hillier et al 2010)
Higher rates of suicidal ideation among GLBT adults than in equivalent studies of
heterosexual adults (Suicide Prevention Australia 2012, Ritter et al 2012)
We would presume rates of severe mental illness to be no different to the general population. There
is however little data on rates of severe mental illness in our communities, a consequence of the lack
of inclusion of sexuality indicators in much research and service provider/health care data sets.
Research indicates that there are higher rates of drug and alcohol use and dependence in LGBTI
communities, which may influence the rates of severe mental health issues amongst our
communities
We see two broad areas of action, which are low cost and high impact, and could have a significant
impact on these issues. We understand that there is no growth money associated with the
development of the NMHC Strategic Plan and therefore believe that these low cost - high impact
activities should be prioritised until the budgetary situation improves.
The first is that mental health services broadly need to be accessible and appropriate to LGBTI
people. This can be achieved through capacity development work similar to that which we
undertook through the Peace of Mind Project and the National LGBTI Health Alliance’s Mind Out
program.
The Peace of Mind Project sought to give LGBTI community members the skills to help each other
and also ran a series of workshops targeting community members and mainstream service
providers. These service provider workshops will continue to be offered in partnership with Gay and
Lesbian Health Victoria.
The second area is undertaking specific actions to address the significantly higher rates of suicidality
(including attempted suicide), anxiety and depression that are seen in our communities. These
include continued advocacy around discrimination, schools curricula and homophobic violence,
along with increasing the mental health literacy of our communities and working in partnership with
the mental health sector to develop appropriate interventions and services to prevent or address
mental ill health and promote mental wellbeing.
The issues affecting LGBTI populations and their solutions should be embedded across this strategic
plan, and in our view can be achieved with minimal additional investment. In order to address the
mental health needs of the LGBTI population, ACON suggests that the strategic plan incorporate the
following five broad strategies:
1) Ensuring a mental health workforce that is inclusive of LGBTI consumers
Appropriate mental health care and promotion for LGBTI populations can be delivered at a
low cost by the ongoing development of a culturally competent workforce. This can be
attained through inclusivity training and the promotion of consumer-centred care which is
non-judgmental and holistic.
A systematic approach to the education and training of a LGBTI inclusive health care
workforce is needed. The introduction of a LGBTI inclusivity module for all health care
professionals in training, delivered in collaboration with the LGBTI community, may be a first
step.
2) Early intervention for LGBTI youth
Mental health issues are found in greater prevalence amongst LGBTI populations compared
to the general population. In particular, the research suggests that younger LGBTI people are
at an increased risk of depression, anxiety disorders, self-harm and suicide due to their
experiences of heterosexist discrimination and abuse (Cochran et al, 2003; Cochran & Mays,
2009; Sandfort et al, 2001; Brennan et al, 2010; King et al, 2008).
In order to begin to reduce this inequity early intervention programs must be actively
inclusive of LGBTI youth. Innovative and meaningful interventions must be developed that
are attractive to youth but that also respect their journeys of self-discovery and identity
formation.
3) Inclusion of LGBTI populations within broader mental health promotion and mental health
literacy campaigns
A potentially cost effective way of building mental health literacy among LGBTI populations
is the inclusion of LGBTI specific issues and imagery in larger public health and community
erected campaigns. This will not only continue to normalise LGBTI populations in society but
also draw attention to unique community needs. These campaigns will also have greater
impact if tailored marketing and communication strategies along with distinct execution to
effectively reach LGBTI populations are offered.
4) Specialist mental health and D&A services for LGBTI populations where necessary
The development of specialist mental health and D&A services for LGBTI populations may be
necessary in some cases, as an adjunct to inclusive generalist services.
Research shows that inclusive generalist services are acceptable for many issues, but that
some LGBTI people and sub populations require or strongly prefer specific interventions.
This is especially the case where the resultant behaviours and challenges involve direct
discussion of sexuality and sexual behaviours. Implementation-based research could provide
an innovative way to develop new models that effectively address mental health and D&A
issues for LGBTI communities.
5) Addressing the structural and social determinants of the mental health disparities found
amongst LGBTI populations, utilising a whole of government approach
In order to ensure a safe and healthy environment for LGBTI populations, we must continue
to partner with the all sectors of government to promote inclusive environments. A whole of
government approach to mental health promotion is necessary to best address not only the
needs of LGBTI populations but all groups in NSW.
There is also a need for better data collection of LGBTI indicators in mainstream research
and service provision as this will help to better identify who is at risk of poorer outcomes,
patterns of service provision potentially effective interventions. Similar work is being
undertaken by other government agencies including the NSW Ministry of Health and the
Australian Government Department of Health and Department of Social Services.
The life course model that the draft strategic plan presents is a useful and comprehensive way to
view mental health across time and place.
We would like to provide the Commission with feedback on how the life course model can be
applied to LGBTI populations. Please refer to Appendix A for a description of LGBTI-specific concerns
along the life course and interventions that could begin to address these concerns.
Conclusion
ACON looks forward to fulfilling our role in improving the mental health of the LGBTI communities
we serve.
We will continue to engage in advocacy for our communities, including focusing on antidiscrimination protections, anti-violence work, the Proud Schools program, sector capacity
development, the Pride in Diversity workplace inclusion program and making policy submissions to
relevant inquiries.
Improved services are necessary to meet the needs of LGBTI populations. ACON is committed to
working in partnership with the mental health sector to provide our communities with better mental
health awareness, mental health literacy and with effective health promotion and prevention
campaigns.
ACON currently has no dedicated ongoing mental health funding, however we believe we can
achieve this work with only a modest investment from the state government.
We are committed to working in partnership to address our communities’ needs and look forward to
future collaboration with the commission and relevant government agencies and Ministries to
ensure we are able to address the mental health outcome disparities seen across the LGBTI
population.
Appendix A
LIFE COURSE MODEL
The life course model that the draft strategic plan presents is a useful and comprehensive way to
view mental health across time and place.
We would like to provide the commission with feedback on how the life course model can be
applied to LGBTI populations. The following section will describe LGBTI-specific concerns along the
life course and interventions that could begin to address these concerns.
1)
Building community resilience and wellbeing
A growing body of evidence from overseas and Australia reveals significant disparities in the mental
health status of LGBTI communities and individuals relative to either general community or
heterosexually identifying samples.
There is growing agreement among both researchers and community that the mental health
disparities seen among LGBTI communities are in large part a consequence of
homophobic/heterosexist or transphobic/cisgenderist discourses and their cultural consequences,
noting the still high rates of verbal and physical abuse directed at our communities.
Fear of discrimination remains a powerful associate of anxiety across the age spectrum. Other
factors associated with higher risk of depression for non-heterosexual populations have been
identified as residential context (those living in rural, regional or outer metropolitan areas)
victimisation (verbal, sexual or physical) and experiences of stigma and discrimination.
That said, the majority of LGBTI lead happy, healthy and productive lives, and an understanding of
the factors that contribute to resilience is important to identifying strategies to address these
disparities. They note Australian research which has found a positive impact arising from a sense of
belonging to gay communities (McLaren et al 2007).
Carman and co-authors identify being in a relationship and a sense of belonging to GLB community
as protective factors from depression for non-heterosexual populations (Carman et al 2011). US
studies of resilience among transgender youth and people of colour have identified common
‘resilience themes’ including self-worth and self-esteem, awareness of oppression, connection with
community and a sense of personal mastery.(Singh et al 2009, Singh and McKleroy 2011,Grossman
et al 2011).
These individual factors of resilience are influenced heavily by environments and the extent of social
inclusion.
For instance, a recent study from Massachusetts (Hatzenbuehler et al 2012) shows a marked impact
of marriage equality on the mental health and wellbeing of LGBTI people. In this study mental health
service use among gay men and the attendant costs had declined in the two years since same sex
marriage was legalised, regardless of whether men intended to marry or not.
A study from California found significantly less distress among same sex married partners compared
to those with no formal legal recognition of their relationships (Wight et al 2013). Both of these
studies suggest that the mental health dividends from acts of social inclusion such as marriage
equality can be significant.
ACON has therefore worked consistently to address these social determinants by, for instance,
advocating for better schools education around homophobia and bullying, addressing violence and
abuse through anti violence campaigns and services, and to build resilience through implementing
programs to support community attachment.
More recently, through our Peace of Mind program, we have implemented a series of workshops
intended to help community members identify and respond to mental distress among their peers,
family or friendship networks.
These workshops demonstrated good outcomes for those who attended – however it is our
observation that most of those who attended had a high level of personal investment in mental
health issues as a result of their own or a loved one’s mental health experiences.
Raising broader LGBTI community awareness of mental health issues is therefore a critical issue in
building community resilience and wellbeing. Rather than developing specific LGBTI awareness
campaigns, we believe that LGBTI specific executions of broader mental health awareness
campaigns, together with targeted marketing strategies in relevant media, would be a cost effective
way of increasing mental health literacy across the LGBTI community and encouraging uptake of
mental health awareness workshops and online interventions.
The LGBTI community also has extensive experience with stigma and discrimination, primarily in
relation to sexual orientation, gender identity and HIV-related stigma. Much resilience has been built
in combating these forces. The lessons learnt can be used to inform the fight against mental health
stigma.
2)
The best start
The limited research to date on the health and learning outcomes of children in same sex parenting
arrangements indicate that they do no worse than those with mixed sex parents. Herek (2006)
indicates that LGBTI and heterosexual relationships do not differ in their essential psychosocial
dimension; that a parent’s sexual orientation is unrelated to her/his ability to provide a healthy and
nurturing family environment. However, sustaining these outcomes requires some effort on the part
of the mental health system and society more broadly.
LGBTI parents experience many challenges that are unique and can impact on their mental health
and their children’s mental health. The stigma and discrimination often experienced by LGBTI people
adds to the already stressful experience of becoming a new parent. Additionally, many LGBTI people
experience social isolation and often do not have the family support that other groups may have.
The disparities experienced in reproductive rights and the practical considerations of surrogacy and
adoption can also strongly impact anxiety levels and mood. Lesbian and bisexual women have also
been shown to experience post-partum depression at higher rates than their heterosexual
counterparts (Ross et al 2007).
The barriers and stressors that impact the mental health of LGBTI families can be addressed in
simple and cost effective ways. The creation and coordination of social support networks for LGBTI
parents is a critical way that the community can support itself and that parents can learn from each
other. The creation of these support networks can arise from existing community mental health
programs or can be facilitated by the community itself.
Furthermore, to address the mental health issues of LGBTI populations, a clinical nurse consultant
could be dedicated to caring for LGBTI parents across the state, with a focus on post-partum
depression among lesbians.
3)
Troubled kids
Although many gay and lesbian adults may not be aware of their sexual orientation during
childhood, transgender and intersex adults are often very aware at an early age that their assigned
gender or sex does not match their own understanding of their gender or sex.
Children who are gender questioning or who manifest gender non-conforming behaviour appear to
be at a higher risk of developing mental health issues later in life (Bartlett et al. 2000). This depends
however on how these issues are handled by parents and other caregivers. Many parents of children
who are gender questioning experience stigma and battle with feelings of shame.
Awareness of how to appropriately respond to these issues must be promoted for these children to
have the opportunity to develop in ways that match their understandings of gender and sex. In order
to accomplish this, the education sector must be incorporated into the solution. Inclusivity training
could be a way forward; teachers must be aware of these issues and work together with parents and
health professionals to understand the experiences of gender questioning and intersex children.
4)
Healthy transitions
Youth and young adulthood is a critical stage of the life course for the prevention and early
intervention of mental health issues. This stage is especially important for LGBTI youth as they
experience a higher prevalence of anxiety disorders, depression and suicide than their peers in the
general population (Cochran et al, 2003; Cochran & Mays, 2009; Sandfort et al, 2001; Brennan et al,
2010; King et al, 2008).
It is at this stage that many LGBTI youth come to terms with their sexual orientation and gender
identities. As a consequence of their quest for self-identity, many LGBTI youth are subjected to
experiences of violence and homophobia which can very negatively impact on their mental health
(Hillier et al. 2010).
It is critical that we support and care for these youth at this most vulnerable time. Many LGBTI
people migrate to urban centres and also loose family support at this time. They often enter
workplaces that do not accept them and as a result face increased occupational stress.
There are two areas that require specific focus to improve the mental health of LGBTI people at this
life stage. First, work must be done with the school system to address bullying and homophobia.
Furthermore, in the school setting, we are concerned that the most recent draft National Health and
Physical Education curriculum has failed to address sexuality at all and has taken out references to
homophobia and transphobia. This leaves school aged Australians poorly equipped to manage their
sexual and mental health, and leaves teachers with no basis on which to engage students around
issues of sexual diversity, acceptance and inclusion.
Secondly, the breakdown in family support that some LGBTI youth face, especially in rural areas, as a
result of stigma and the migration of LGBTI people to urban centres needs to be counteracted by the
community.
We can learn from and build on work that is already occurring to support LGBTI youth at this critical
moment in their lives.
ACON has run a successful young men’s and women’s program which uses peer facilitators to
engage youth in health promoting groups and which also serves to build their social networks. The
Inspire Foundation and ACON are currently developing an “app”-based decision making tool to help
LGBTI youth with coming out and connect them to relevant services and social networks.
The Pride in Diversity program at ACON has engaged with employers to create more inclusive
workplaces that value diversity and protect LGBTI individuals entering the workforce.
ACON has also supported the NSW Proud Schools Program which has promoted LGBTI friendly
schools and addressed homophobia and bullying.
Continued work must be done with the LGBTI community, the education sector, employers and the
general public to ensure that LGBTI youth have safe places to “come out” in (should this be their
choice) and to build social capital. These supports for youth are essential in combating the increased
rates of mental illness experienced among LGBTI people across the lifespan.
5)
Towards a better life
There exists a lack of data on the prevalence of adult severe mental health among LGBTI
populations; more research is especially needed to understand how bipolar disorder, personality
disorders, psychosis and schizophrenia affect these groups. It is known that LGBTI populations
experience higher rates of anxiety and depression (Cochran et al, 2003; Cochran & Mays, 2009;
Sandfort et al, 2001; Brennan et al, 2010; King et al, 2008); however more research is needed to
understand how these groups experience and live with these illnesses over the life course.
The increased mental health issues associated with HIV infection also intersect with the broader
mental health concerns of these groups, as the majority of people with HIV in NSW are gay men
(NSW Ministry of Health, 2013). Interventions that address holistically the complex needs of LGBTI
groups are necessary to address both their mental health and sexual health concerns.
6)
Breaking the cycle
Data from the National Survey of Mental Health and Wellbeing (2007) indicates that drug use was
nearly three times more prevalent in homosexual/bisexual populations (15.74%) compared to
heterosexual populations (6.88%); drug dependence was found at about double the prevalence in
homosexual/bisexual populations (5.65%) compared to heterosexual populations (2.73%).
Public health interventions to reduce problematic drug use are essential to improving both the
mental and sexual health of LGBTI populations in NSW. A focus on alcohol is also necessary as it
continues to be widely misused and has serious physical health implications, both for LGBTI
populations and the general public.
ACON strongly supports keeping people with drug and alcohol issues out of the justice system and
strongly believes that the decriminalisation of drug use will lead to more openness and capacity to
refer consumers to appropriate services; as evidenced in the success of drug decriminalization in
countries such as the Netherlands and Portugal. ACON offers a specialist drug and alcohol
counselling service and a social work service which have had success in helping people to break the
cycle of drug use and mental health issues. We believe that there is a need for a specialist drug
service in addition to the broader inclusion of LGBTI concerns in the health system.
Implementation-based research could provide an innovative way to develop new models that
address mental health and D&A issues for LGBTI communities. ACON and a research partner could
collaborate and trial a LGBTI specific mental health service that could be housed at ACON. The
research could provide useful information about what worked well, suggestions for improvement
and a richer understanding of the population and the providers experience throughout the process.
7)
Body and soul
In general, despite the increased rates of mental health issues, the physical health of LGBTI
populations appears (while also recognising the absence of these communities from many large
scale public health research programs) much the same as the general population.
However, gay men in particular face higher rates of STIs and HIV which themselves lead to an
increased risk for physical and mental health problems (NSW Ministry of Health, 2013).
Also, recent data indicates that older LGBTI populations do experience higher rates of certain types
of cancer, mental health concerns and also obesity (Byles, 2013).
These increased rates of physical health issues impact the mental health of LGBTI populations. ACON
is addressing these issues through its current HIV/sexual health and healthy aging programs.
8)
Living long and strong
The increased rates of depression and anxiety found in LGBTI populations continue into older age
(Byles, 2013). The processes of social isolation and exclusion often have cumulative effects and leave
older LGBTI people with fragmented support networks.
It is essential that we build an awareness of the special needs of LGBTI elders and that we work in
partnership with a range of stakeholders to provide these people with opportunities to contribute to
society and be social.
Ongoing advocacy is also needed to ensure that LGBTI people are treated respectfully at aged care
facilities. Inclusivity training for aged care providers is an area that ACON has begun working in,
through rolling out a workforce development across NSW.
In this work, ACON has been greatly supported by the inclusion of reference to GLBT populations in
the NSW Government’s Healthy Ageing Strategy and by the Commonwealth Government’s efforts in
implementing a dedicated National Lesbian, Gay, Bisexual, Transgender and Intersex (LGBTI) Ageing
and Aged Care Strategy.
We would be pleased to be able to add the NSW Mental Health Strategy to this list of enabling policy
frameworks.
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