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Specific populations - Chapter 19

LGBTIQA+ Family abuse and violence

Abuse and violence - Working with our patients in general practice
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‘My abuser and I were both raised in a homophobic world where violence against gay men was normalised. My abuser made a choice to control and abuse me. But without homophobia … perhaps he wouldn’t have had so many tools on hand to hurt me and to control me.’
Russell Vickery, LGBTIQA+ Representative, Victim Survivor Advisory Council

Key messages

  • LGBTIQA+ people experience family violence at higher rates than non-LGBTIQA+ Australians, in the form of intimate partner abuse/violence (IPAV) and violence within families of origin.
  • LGBTIQA+ Australians with other diverse identities – such as being multicultural or multifaith, having a disability, or Aboriginal or Torres Strait Islander people – may be at higher risk of family violence due to cultural sensitivities and marginalisation.
  • Health professionals need to understand that the experiences of discrimination, violence and abuse of LGBTIQA+ people in Australian society are associated with significant disparities in physical and mental health.1-5
  • Risk of suicide amongst LGBTIQA+ people in Australia is higher for those lacking family acceptance, and with histories of physical and sexual abuse.6 This needs to be understood, considered and addressed by the treating health professional where appropriate.
  • Significant barriers to help-seeking include fears of discrimination within service systems, and family violence care often being focused on heterosexual relationships, female victims/survivors and male perpetrators.
  • Primary care is an important location for identification of LGBTIQA+ family violence, support and referral to LGBTIQA+ inclusive services.
  • Primary violence prevention strategies can be incorporated into routine primary care for LGBTIQA+ people.

Lesbian, gay, bisexual, trans and gender diverse, intersex, queer, asexual (LGBTIQA+) represents a collection of diverse communities, and distinct and overlapping identities. In discussing these issues, it is particularly important to avoid common pitfalls in confusing or conflating sexual and gender diversity, or gender diversity (ie experiences of trans or non-binary people) and sex characteristics (ie the experiences of people with intersex variations).

Many LGBTIQA+ people enjoy happy and healthy lives, including positive and loving relationships. However, dominant social norms regarding sex, gender and sexuality in Australia have a significant influence on LGBTIQA+ people’s lives, resulting in experiences of inequality, stigma and discrimination.

LGBTIQA+ people are often made to feel there is something wrong with their bodies, identities and relationships because they do not fit normative ideas of ‘male’ and ‘female’, ‘masculine’ and ‘feminine’ or monogamous heterosexuality. Despite increasing recognition and legal protection of human rights, LGBTIQA+ people continue to report high levels of harassment, violence and abuse in many different areas of their lives.5, 7-9

A Victorian population-based study conducted in 2017 found that LGBTIQA+ people were more likely to experience discrimination in the past year than non-LGBTIQA+ people, including 56.1% of trans or gender-diverse adults, 39.9% gay or lesbian, and 31.5% bisexual, queer or pansexual respondents compared with 15.6% in non-LGBTIQA+ adults.10 Some LGBTIQA+ people underutilise health services and delay seeking treatment due to actual or anticipated experiences of stigma and discrimination from service providers.11, 12

These experiences of discrimination, violence and abuse are associated with significant disparities in general health4, 5 and mental health.1-3 Risk of suicide among LGBTIQA+ people in Australia is higher for those lacking family acceptance, and with histories of physical and sexual abuse.6 It is important to understand this social context for LGBTIQA+ people, which also frames their experiences of family violence.

For a glossary of terms, refer to A Language Guide: Trans and Gender Diverse Inclusion  and LGBTIQ+ Inclusive Language Guide.

Prevalence of LGBTIQA+ intimate partner and family violence

There is a lack of population-level data on violence and abuse experienced by LGBTIQA+ people. This is a result of population-level surveys, including those conducted by the Australian Bureau of Statistics not including adequate questions around sex characteristics, gender identity and sexuality. This limits both an understanding of the size of the LGBTIQA+ population, and the potential for disaggregated analyses of experiences of violence and abuse. Similar issues exist in the collection of health service data.13-15

Research focus on LGBTIQA+ people is a relatively recent, reflecting the social marginalisation of these communities. A growing body of research shows higher levels of intimate partner abuse/violence (IPAV), sexual violence, and violence within biological families among LGBTIQA+ people.

  • IPAV is experienced at similar or higher rates in same-gender relationships compared to heterosexual relationships.16-19
  • The Victorian Population Health Survey 2017 data showed that 13.4% of LGBTIQA+ adults had experienced family violence in the past two years compared with 5.1% of non LGBTIQA+ adults.10 All types of family violence listed were significantly higher, with emotional/psychological abuse being most prevalent (Figure 19.1).
  • There are indications of higher rates for bisexual women compared to lesbian or heterosexual-identified women17, 20, 21 and for trans and gender-diverse people compared to cisgender people.22, 23 For a glossary of terms, refer to A Language Guide: Trans and Gender Diverse Inclusion  and LGBTIQ+ Inclusive Language Guide.
  • There is limited research into the violence experiences of people with intersex variations;24 however, there is some evidence for violence within families, peers and schools including body shaming.
  • Sexual violence is much higher for LGBTIQA+ than non-LGBTIQA+ people, with the Victorian Population Health study showing seven times the rate of sexual abuse (Figure 19.1).10 Reported experiences by Australian trans and gender-diverse people are even higher, with 53.2% of the 1434 trans and gender-diverse respondents reporting sexual violence and coercion.25
  • Many LGBTIQA+ people experience violence and abuse within their biological family or ‘family of origin’, although this is often not defined as family violence. A number of studies have focused on the impact of negative relationships between parents and LGBTIQA+ young people, particularly relating to ‘coming out’ and experiences of violence or abuse arising out of familial rejection.26-28 While there is less research focus on experiences of abuse in childhood, some studies have found that lesbian, gay and bisexual young people are more likely than heterosexual siblings to experience verbal, physical and sexual abuse.29

‘I became ashamed about being gay, about being sexually attractive and about having sexual desires. It was like going back into the closet.’
David, age 27 years

‘She had a drug, gambling and mental illness problem and would steal my money, threaten to self-harm, actually self-harm, and yell abuse at me.’
Sarah, age 37 years

Source: Another Closet 2014

Figure 19.1. Types of family violence comparing LGBTIQA+ and non-LGBTIQA+ Victorians<sup>10</sup>

Figure 19.1. Types of family violence comparing LGBTIQA+ and non-LGBTIQA+ Victorians10

Reproduced with permission from: Victorian Agency for Health Information. The health and wellbeing of the lesbian, gay, bisexual, transgender, intersex and queer population in Victoria. Findings from the Victorian Population Health Survey 2017. Melbourne: VAHI, 2020.

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Risk factors for family violence specific to LGBTIQA+ people

As well as the usual risk factors for family violence, additional risks have been identified for LGBTIQA+ people who are victims/survivors and/or perpetrators.30, 31 These can be summarised as minority stress experiences32 and include:

  • internalised homophobia
  • being HIV positive
  • experiences of LGBTIQA+ based discrimination
  • higher rates of complex trauma experiences.

Intersectional influences on LGBTIQA+ family violence

LGBTIQA+ people who experience marginalisation or minority status in other areas of their life can be more at risk of family violence. This includes people from conservative religious backgrounds, or some multicultural communities, including recent arrivals, refugees and people seeking asylum.33, 34 Cultural sensitivities can lead to unique forms of family violence for LGBTIQA+ people, including:

  • family exile
  • forced marriage
  • honour abuse
  • corrective rape
  • conversion therapy.

For example, research conducted in New South Wales with Arabic-speaking communities suggest that LGBTIQA+ people have reported family assault, confiscation of mobile phones, banned access to sympathetic family members and other forms of intimidation due to their stigmatised LGBTIQA+ status.33, 34

‘I have been bashed by a family member for shaming the family [.] Talks at family gatherings that being GLQ [gay, lesbian, queer] is due to corruption of the WEST. The Imam and sheikh claiming that the death penalty is the punishment for GLQ.’
A lesbian woman, age 30 years35

Community, organisational, religious, cultural and extended family connections can also be important sources of support for LGBTIQA+ people.35

LGBTIQA+ people with disability are at higher risk of family violence, due to reliance on family as carers and policing of their diverse sexual or gender identities.36 Older LGBTIQA+ people often have a history of rejection by families of origin, and of concealing their intimate relationships from others.37 This can create a situation in which IPAV is not revealed and is potentially tolerated for long periods. Living in rural or regional areas of Australia can exacerbate issues of isolation, and fear of negative responses to disclosure of same-gender relationships from family, communities or healthcare providers. Disclosure of violence in those relationships can be even more difficult.

Unfortunately, there is little research that investigates the experiences of LGBTIQA+ Aboriginal and Torres Strait Islander people, but this intersection is likely to be important both in understanding experiences of abuse and violence, along with ways of responding and engaging communities.

Finally, LGBTIQA+ people who form their own families can have particular risks for family violence. These have been outlined in a forthcoming study in Victoria.38 These risks include specific experiences around parenting in LGBTIQA+ parented families, such as family formation stress, isolation from family and friends, and gendered norms around parenting.

Recognising and responding to LGBTIQA+ family violence

GPs play a significant role in supporting LGBTIQA+ patients, their partners and families, to recognise and respond to abuse and violence, and its aftermath. GPs can also play a role in the primary prevention of abuse and violence experienced by LGBTIQA+ communities, by demonstrating awareness and recognition, and promoting pride in LGBTIQA+ bodies, identities and relationships.

Existing models for responding to family violence have focused on the significant problem of men’s violence against women. While this is valid and necessary, there are some indications this can perpetuate silence around LGBTIQA+ experiences of family violence, making it harder for LGBTIQA+ people to recognise and label their experiences as family violence.39, 40 For example, men’s experiences as victims/survivors of family violence are rarely considered, and likewise women’s experiences as perpetrators. Trans and non-binary people may have very diverse experiences too. Accessing inclusive and knowledgeable services for each of these groups is difficult.

There are also specific barriers to help-seeking, including a lack of understanding of the unique forms that abuse and violence can take for LGBTIQA+ people, fear of stigma and a lack of faith in institutions such as police, the judicial system or the family violence service system, which has historically focused on men’s violence against women.41 Other barriers include the perpetuation of myths that violence does not occur in lesbian relationships or that violence in gay male relationships is less serious as both partners are men.42

‘But I think where I’ve seen or experienced violence in an intimate partner relationship because if you’re both queer or you’re both trans, you’re both trying to survive in a world that wants to kill you, basically. And by exposing your partner, even if they’re being abusive or violent towards you, by exposing them to interactions with police or the criminal legal system, or prison, it could, could basically … be the death of them. And it’s far worse than the sort of abuse or violence that is being done within that relationship.’
A queer, transgender woman, age 30 years6

Figure 19.2. Barriers to identification of LGBTIQA+ family violence

Figure 19.2. Barriers to identification of LGBTIQA+ family violence

© Copyright State Government of Victoria
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Recent work analysing the drivers of family violence for LGBTIQA+ communities, and drawing on feminist theories and models, suggests that perpetration of abuse and violence are linked to violence-supporting attitudes, including views that LGBTIQA+ bodies, people and relationships are less valid, healthy or worthy (Figure 19.3).44 These attitudes increase the likelihood that abuse and violence is condoned or accepted by both LGBTIQA+ people and the health and social care system.

‘I guess it’s partly systemic; that the system doesn’t accommodate for diversity. There’s also that workers or professionals aren’t aware of the different kind of issues that might arise in a LGBTIQA+ family.’
Lesbian parent38

Figure 19.3. Socio-ecological drivers of LGBTIQA+ family violence<sup>44</sup>

Figure 19.3. Socio-ecological drivers of LGBTIQA+ family violence44

Reproduced with permission from: Carman M, Fairchild J, Farrugia C, et al. Pride in prevention: A guide to primary prevention of family violence experienced by LGBTIQ communities. Melbourne: Rainbow Health Victoria, La Trobe University, 2020.
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The general practice response to abuse and violence experienced by LGBTIQA+ communities needs to be comprehensive across the whole practice. This starts with an inclusive practice approach and moves to specific upskilling of all staff regarding safety and confidentiality in the context of family violence. It involves all practice staff in primary care:

  • understanding the full range of families of LGBTIQA+ people, including families of origin, families with biological and non-biological or non-birth parents, and families of choice
  • recognising there are specific experiences and triggers of family violence for LGBTIQA+ people
  • encouraging disclosure of LGBTIQA+ identities and expressions to clinical staff
  • ensuring the practice record systems allow documentation of the full range of LGBTIQA+ identities
  • supporting LGBTIQA+ clients to recognise abuse and violence within their relationships.

The LGBTIQA+ patient’s journey through the clinic must be inclusive at all stages (Figure 19.4).

Figure 19.4. Stages of the patient journey in general practice

Figure 19.4. Stages of the patient journey in general practice

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Waiting room and reception – creating an LGBTIQA+ inclusive environment

Encouraging disclosure of family violence for any patient starts at the front door, as they need to feel they will be believed, acknowledged and supported. This is even more important for LGBTIQA+ patients who may have experienced negative attitudes from healthcare providers in the past.45

There are readily available Australian tools to assist practices become LGBTIQA+ inclusive. One example is the Rainbow Tick, an accreditation program and framework.

Key areas for general practices to consider include:

  • helping reception staff understand how to greet LGBTIQA+ patients
    • using appropriate language
    • making no assumptions about sex, gender or sexual identities
  • ensuring that new patient intake forms include LGBTIQA+ lives, for example:
    • gender identity markers: female, male, transgender, non-binary, agender, prefer not to say, other
    • relationship status rather than marital status
    • sexual identity markers lesbian, gay, bisexual, heterosexual
    • including an option to declare intersex status
  • displaying materials and images in the waiting room that represent and welcome LGBTIQA+ people are important signs that the practice is safe and inclusive.

LGBTIQA+ data collection for medical records

The Victorian Government Family Violence Data Collection Framework (2019) provides a comprehensive guide to the data that should be included in medical records.43 Currently, many medical software programs do not yet uphold these standards. Practices need to use work-around solutions to include LGBTIQA+ identities in their records.

Pronouns and titles

  • These should be clarified with all patients and documented. This might be on intake forms and/or in the consultation.
  • Individuals may use she/her, he/his, they/them or another set of pronouns.
  • Titles such as Mr, Ms and Mrs are generally not necessary on letters or referrals and software can be modified so that these are left blank. Where a title is required on documentation it is best to provide the option of Mx, which is used by some non-binary people.

Gender identity

  • The Australian Bureau of Statistics Standard for Sex, Gender, Variations of Sex Characteristics and Sexual Orientation Variables46 has been developed to standardise collection of data relating to sex, gender, variations of sex characteristics and sexual orientation. Gender is a socially constructed concept.
  • Recommended categories are:
    • male
    • female
    • non-binary
    • agender
    • prefer not to say
    • other (please describe).

A two-step approach to data collection about gender is encouraged. This is to allow identification of more trans people, as some binary transgender people refer to themselves as trans male or trans female, and others just use male or female.

  • In addition to a gender question, the second step could be either:
    • ‘What gender was assigned to you at birth?’ with options male, female, prefer not to say, or
    • ‘Do you identify as transgender?’ with options yes, no, prefer not to say.

Sexual identity

  • Suggested question: ‘How do you describe your sexual orientation?’
    • straight or heterosexual
    • gay, lesbian or homosexual
    • bisexual or pansexual
    • asexual
    • another – please describe
    • don’t know
    • prefer not to say

Sex

  • Suggested question: ‘Do you have an intersex variation?’
    • yes
    • no
    • prefer not to say

Sex characteristics

This refers to chromosomal, hormonal and reproductive characteristics, including secondary characteristics arising from puberty. Innate variations of sex characteristics, also termed ‘intersex variations’ or ‘differences/disorders of sex development’ refer to traits that are perceived to vary from medical or social norms for female or male bodies.

Identification and assessment of LGBTIQA+ family violence

An important first step in the clinical encounter is to encourage disclosure of diverse sex, gender and sexual identities. Even if clinic paperwork offers these options, individuals may choose not to disclose until they are talking with a clinician. Facilitation of disclosure includes:

  • using inclusive language for gender, sexual orientation and sex status
  • asking about pronouns and name, which may differ from the Medicare-listed name
    • making no assumptions
    • using the patient’s terms for their own body and identities
    • asking directly about relationships and family
    • number of intimate partners
    • genders of intimate partners
    • living arrangements
    • family definitions – biological and/or chosen family
    • children – both biological and non-biological.

Picking up cues for possible family violence related to both victims/survivors and perpetrators and then exploring the issue sensitively can involve:

  • defining various behaviours as violence including emotional abuse, financial abuse, sexual coercion, cyber bullying and online abuse, spiritual abuse
  • asking about current and past experiences of violence in relationships and/or in family or origin
  • inquiring whether LGBTIQA+ status is used as an abuse strategy, for example:
    • deliberately disclosing a partner’s LGBTIQA+ status or HIV status publicly against their will
    • not acknowledging, or invalidating, a partner’s sex, gender or sexual identity
    • isolating the person from LGBTIQA+ community or friends
  • understanding the role, if any, of alcohol or drugs in fuelling violence
  • asking about general experiences of homophobia, biphobia, transphobia or stigma related to intersex variations and how these may be affecting the family violence
  • asking about other marginalising issues that may be involved
    • disability (eg is a carer abusive in relation to LGBTIQA+ status?)
    • culture and/or faith
    • Aboriginal and Torres Strait Islander identity
  • asking about the physical and emotional effects of violence and trauma – both past and current
    • self-esteem
    • isolation from community or friends
    • mental health issues
    • direct and indirect physical health issues
    • any children in the family who may have witnessed or been victims
    • using violence as perpetrators due to experiences of trauma
  • clarify preferred community connections and whether these are LGBTIQA+ or not
  • understanding help-seeking already used and preferred, in the context that a very small proportion of LGBTIQA+ people who experience family violence seek professional support or report the violence to police.

‘I was using forms of violence in a recent relationship, like I was getting angry because they were triggering past traumas for me … and I had to go to counselling to understand what the f… was going on.’
Axel, queer, non-binary, community member, age 30s47

Management of LGBTIQA+ family violence

It is important to have a framework for understanding the specific issues related to LGBTIQA+ family violence. A socio-ecological model is commonly used to understand the drivers of violence.48 GPs can act at each level of this model to prevent and respond to violence: 

  • Societal level
    • Advocacy for change for society to be more inclusive
    • Challenging social norms, particularly around gender stereotypes, that marginalise and drive violence
  • System and institutional level
    • Supporting LGBTIQA+ inclusion in systems such as data collection, police and family violence support systems
    • Understanding legislative supports such as anti-discrimination laws in your state or territory
  • Organisational and community level
    • Ensuring practice policies are visibly inclusive of LGBTIQA+ people
    • Promoting pride and cultural change within the workplace to be a safe and inclusive environment for LGBTIQA+ staff, including acknowledging LGBTIQA+ days of significance such as IDAHOBIT (International day against homophobia, biphobia, intersex and transphobia) or Transgender Day of Visibility
    • Supporting patients’ schools and workplaces to be LGBTIQA+ inclusive (eg supporting the Safe Schools initiative)
    • Engaging with local police LGBTIQA+ liaison officers
    • Assisting with primary prevention through education of families of origin – parents, siblings, grandparents about LGBTIQA+ lives and relationships
  • Individual level
    • Affirming patients’ LGBTIQA+ identities
    • Helping patients to label their experiences as family violence
    • Supporting and encouraging police involvement as needed (and directed by the patient), such as obtaining intervention orders
    • Referring to LGBTIQA+ specific and/or inclusive family violence services including shelters, counselling services

For services

Training

For LGBTIQA+ people

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  44. Carman M, Fairchild J, Farrugia C, Parsons M, Power J, Bourne A. Pride in Prevention: A guide to primary prevention of family violence experienced by LGBTIQ communities. Melbourne: Rainbow Health Victoria, La Trobe University, 2020.
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