The experiences and support needs of people with intellectual disabilities who identify as LGBT: A review of the literature

Recognizing and Addressing Health Care Barriers for Transgender and Nonbinary People Living With a Chronic Illness or Disability

This paper explores the health care experiences of individuals who are transgender and/or nonbinary (TGNB) and live with a chronic illness and/or disability (CI/D). Using an interpretivist epistemological worldview and an intersectional lens, the research team explored the compounded barriers faced by this patient population and propose solutions for improving their care. The study conducted in-depth interviews with TGNB individuals who self-identified as having a CI/D to understand their health and health care experiences. The interdisciplinary research team, which includes individuals with diverse backgrounds and experiences related to gender identity and CI/D, analyzed the data thematically using an iterative interpretive approach. Participants described barriers such as diagnostic overshadowing and provider skepticism that were exacerbated by their dual TGNB-CI/D identities. Participants interacted with health care systems frequently due to ongoing medical needs, which increased the likelihood of negative encounters like misdiagnosis, inappropriate questioning related to their gender identity, and skepticism of their CI/D. Gaslighting experiences further eroded trust in health care providers and contributed to health care inequities. The lack of LGBTQ+ competent care, coupled with discriminatory attitudes, led some participants to forgo seeking essential health care services altogether. Participants identified several strategies to mitigate barriers, including advocating for LGBTQ+ competent care through provider education and training; structural changes to address financial barriers and insurance issues; leveraging telehealth services; and increasing community support networks. By enacting the suggested actionable solutions, which were grounded in participants' voices and experiences, the health care system can reduce disparities and provide better, more affirming health care to this group.

Exploring the Intersection of Gender Diversity and Intellectual Disability: A Scoping Review With a Focus on Clinical Care

BACKGROUND

Little research has been conducted solely exploring gender diversity in people with intellectual disabilities. This review explores the literature, discusses the prevalence, and identifies clinical best practices for people at the intersection of gender diversity and intellectual disability.

METHOD

A scoping review was conducted utilising PRISMA methodology of the following databases: PubMed, CINAHL Complete (EBSCO), Cochrane Library (Wiley), Dissertations & Theses Global (ProQuest), PsycInfo (EBSCO), Scopus and Web of Science.

RESULTS

Five hundred seventy five titles and abstracts were screened, 61 full-text articles were reviewed and 17 met inclusion criteria. Four major themes were identified: prevalence, trauma and co-occurring mental health disorders, barriers to care and best practices.

CONCLUSION

This review highlights the lack of research and provides valuable insight into the experiences of people with gender diversity and intellectual disability. Further research is needed to understand the prevalence and explore the intersection and experience of gender-diverse people with intellectual disabilities.

Increasing Opportunities for Healthy Sexual Socialization in LGBTQ+ People with IDD: The Role of LGBTQ+ Organizations and Community

In the current intersectionality-focused discourse within sexuality research, individuals existing at the convergence of intellectual and developmental disabilities (IDD) and lesbian, gay, bisexual, transgender, and queer+ (LGBTQ+) are often overlooked. Individuals with IDD face difficulties acquiring sexual knowledge and skills due to limited opportunities for sexual socialization, misconceptions concerning sexuality and IDD, lack of comprehensive sexual education, restricted support from staff and caregivers, and a lack of community experiences that facilitate the development of healthy sexuality. When an individual with IDD identifies as LGBTQ+, these disability-related barriers can exacerbate the stigma and discrimination some LGBTQ+ people experience. Using the intimate justice framework, we explore avenues to support and foster inclusivity within the LGBTQ+ community for members with IDD. Several recommendations were identified from the literature search, including logistical considerations and using accessible language for outreach events, presentations, workshops, training, and other activities and opportunities for sexuality education while challenging disability-related stigma in LGBTQ+ spaces.

Sexual Self-Determination of Individuals with Intellectual Disabilities-A Possible Philosophical Conceptualization and Resulting Practical Challenges

(1) Background: Self-determination is one of the central values of many societies. Self-determination concerns many areas of life, including sexuality. Unfortunately, the sexuality of individuals with intellectual disabilities (IID) is often discriminated against, and even in their everyday care, sexuality is often given too little space, not least because of knowledge deficits of parents and staff. A practicable conceptualization of sexual self-determination is a prerequisite for helping IID to achieve self-determined sexuality. The aim of this paper is to formulate such an applicable conceptualization and to discuss related challenges. (2) Method: This paper uses Harry Frankfurt's hierarchical conception of desires and the WHO definition of sexuality to develop a suitable understanding of sexual self-determination. (3) Results: The mentioned concepts offer promising tools to develop a conceptualization of sexual self-determination with high practical applicability. (4) Discussion: Sexual self-determination involves decision-making processes in relation to the different dimensions of sexuality. IID do need support to come to these decisions. Challenges that might be involved with such decision processes will be discussed.

Mental health support experiences of rainbow rangatahi youth in Aotearoa New Zealand: results from a co-designed online survey

A substantial body of research documents high rates of mental health problems in rainbow communities, however little is known about the experiences of rainbow young people who access mental health support in New Zealand. Here, we present analysis of quantitative survey data from 955 rainbow and takatāpui rangatahi (aged 14-24) collected in collaboration with rainbow community organisations. We find that rainbow rangatahi report mixed experiences in mental health settings and commonly worry about discrimination and lack of knowledge on the part of mental health professionals. We also report significant differences in mental health support experiences based on a range of demographic variables, including gender, intersex status, age, location, and ethnicity. Finally, we consider a range of actions mental health professionals can take to improve service provision, and how these findings can improve the quality of mental health support for Aotearoa's rainbow rangatahi.

The devolution of eugenic practices: Sexual and reproductive health and oppression of people with intellectual disability

Early 20th century eugenicists propagated a system of ideas, values and dispositions that constituted adults with intellectual disability as the antithesis of the paradigmatic citizen, and a biological threat to society. The eugenic schema was encoded in sex-segregated institutionalization and, in many places, forced sterilization. These eugenic practices are no longer sanctioned. However, eugenic practices did not disappear. In this paper we argue that the eugenic schema is now encoded and purveyed through a multiplicity of social arrangements and practices that deny adults with intellectual disability the respect, opportunity and means necessary to participate on a par with others in social life. Such practices include, for example, covert or coerced contraception, and discriminatory child welfare interventions leading to high rates of custody deprivation. Drawing on relational theory, we problematize normative assumptions of embodiment and citizenship, which give rise to attributions of incapacity, and argue that adults with intellectual disability need what all other adults need to make and effect choices concerning their sexuality, relationships and parenthood, i.e., recognition, opportunity and support.

Gender Identity, Disability, and Unmet Healthcare Needs among Disabled People Living in the Community in the United States

Disabled adults and transgender people in the United States face multiple compounding and marginalizing forces that result in unmet healthcare needs. Yet, gender identity among disabled people has not been explored, especially beyond binary categories of gender. Using cross-sectional survey data, we explored the rates of disability types and the odds of unmet healthcare needs among transgender people with disabilities compared to cisgender people with disabilities. The rates of disability type were similar between transgender and cisgender participants with two significant differences. Fewer transgender participants identified physical or mobility disability as their main disability compared to cisgender participants (12.31%/8 vs. 27.68/581, p < 0.01), and more transgender participants selected developmental disability as their main disability compared to cisgender participants (13.85%/9 vs. 3.67%/77, p < 0.001). After adjusting for sociodemographic characteristics, the odds of disabled transgender participants reporting an unmet need were higher for every unmet need except for preventative services.

Social educator students' readiness to address sexual health in their future profession

BACKGROUND

Norwegian social educator students' attitudes towards addressing sexual health are unknown, even if their future clients often have needs related to sexual issues.

PURPOSE

To investigate social educator students' readiness to address sexual health in their future profession.

METHODS

In 2019, 213 social educator students (response rate 34%) responded to the Students' Attitudes towards addressing Sexual Health Extended online questionnaire.

RESULTS

Most of the social educator students felt comfortable and ready to address sexual health in their future profession, but thought they had insufficient competence and education concerning sexual health. There were gender and age differences when discussing sexual health among persons with intellectual disabilities.

CONCLUSION

Despite most Norwegian social educator students feeling ready to address sexual health, they needed additional competences and education. Further research is needed concerning the effectiveness of educational interventions targeting competence in sexual health, to ensure sufficient support for clients in this field.

Social inclusion of LGBTQ and gender diverse adults with intellectual disability in disability services: A systematic review of the literature

BACKGROUND

Lesbian, gay, bisexual, transgender, queer (LGBTQ) and gender diverse adults with intellectual disability experience exclusion within disability services.

OBJECTIVE

This review explores the experiences of social inclusion/exclusion of this cohort in the context of disability services.

SEARCH METHOD

A systematic search was conducted of peer-reviewed research published between January 2014 and April 2019. Five databases returned 66 articles plus three from hand searches.

APPRAISAL AND SYNTHESIS

Nine articles were included in this review. The Critical Appraisal Skills Programme tool was used to assess the quality of the research. NVivo 12 was used as a tool to organise the articles.

RESULTS

Marginalisation of LGBTQ adults with intellectual disability in western societies is mirrored in disability organisations. There remains a dearth of research into experiences of transgender people with intellectual disability who use disability services.

CONCLUSIONS

Research into interventions that support the inclusion of this cohort in disability support services is needed.

Sexual Experiences and Perspectives of Adolescents and Young Adults With Intellectual and Developmental Disabilities

The purpose of this study is to understand the sexual experiences and perspectives of adolescents and young adults (AYA) with intellectual or developmental disabilities, how they are receiving sexual education, and how sexual education can be tailored to their needs. This qualitative study utilized semi-structured focus groups and interviews with eight AYA with intellectual or developmental disabilities from January 14 to May 7, 2019. Data were analyzed using a constant comparative approach. Participants reported a diverse range of sexual experiences and an interest in marriage and parenting in the future. Two themes emerged for how AYA are learning about sexual health information: through formal (school, doctors’ visits, or from caregivers) and informal education (peers, siblings, self-exploration, or Pop Culture). Sexual education can be tailored to this population by addressing educational gaps (pregnancy, contraception, sexually transmitted infections, intimacy, and sexual activity) and by implementing specific participant recommendations (proactive, inclusive education with real-life examples). With a growing emphasis on disability rights to sexual education among individuals with intellectual or developmental disabilities, it is vital to understand AYA’s experiences, perspectives, and current understanding of sexual health information so that we can design a program specifically tailored to meet their unique needs.

Securing sexual justice for people with intellectual disability: A systematic review and critical appraisal of research recommendations

BACKGROUND

People with intellectual disability contend with significant restrictions to their sexual expression and partnered relationships. This review examines the types of recommendations scholars offer in their qualitative research involving participants with intellectual disability discussing sexuality and intimate relationships.

METHOD

A systematic review of peer-reviewed studies published between 1972 and July 2018 yielded a sample of 26 studies. Thematic analysis was used to taxonomize scholars' recommendations.

RESULTS

Six distinct forms of recommendations were identified. The most frequently offered and most strongly emphasized recommendation across studies aimed to change individuals with intellectual disability. In contrast, a minority of studies prioritized engaging individuals as informants, eliciting individuals' wishes, enabling relationships and fostering ideological change. No studies placed the greatest weight on promoting systems change.

CONCLUSIONS

Recommendations in the literature have predominantly emphasized individual as opposed to environmental changes. I consider the ramifications of this and argue for a reorientation towards systems change.

'Conflict versus Congruence': A Qualitative Study Exploring the Experience of Gender Dysphoria for Adults with Autism Spectrum Disorder

An emergent evidence base indicates a higher prevalence of autism exists amongst people attending gender identity clinics. This qualitative study explored adults' with autism experiences of coming to understand and address their gender dysphoria (GD). Data were collected and analysed using Grounded Theory. Ten adults with autism and GD undertook semi-structured interviews. A tentative theoretical framework of common processes involved in understanding and addressing GD for individuals with autism was developed. The experience is captured in the core category-Conflict versus Congruence. A key finding was the impact of autism as a barrier but sometimes a protective factor in participants' understanding and addressing GD. Participants appeared to achieve greater personal congruence and wellbeing upon transition. Nevertheless, conflicts remained as they navigated the social world with a continuing fear of hostility and sense of difference due to having two stigmatised identities.

Parents' experiences of transition from hospital to home of a child with complex health needs: A systematic literature review

AIMS AND OBJECTIVES

To critically appraise primary research on the views and experiences of parents of children with complex health needs during the transition from hospital to home.

BACKGROUND

Children with complex health needs frequently transition across and within healthcare systems, due to their age, care needs and ongoing health conditions. Repeated and unplanned admissions are significantly higher for children with complex health needs. Yet parents, as the primary providers of care, report being unsupported and unprepared during the transition from hospital back to home due to poor communication, inadequate discharge planning and education, resulting in stress and anxiety within the home environment.

DESIGN

Systematic review following PRISMA guidelines.

METHODS

A systematic search was completed of the databases CINAHL, MEDLINE, PsycINFO, EMBASE and the Cochrane Library Review between January 2009 and September 2019. Data were extracted, categorised and analysed using a thematic analysis approach. An adapted CASP qualitative assessment tool was utilised for quality assessment. All included articles were marked for validity and relevance to current research with an overall score from 0-20.

RESULTS

A total of 13 studies of mixed quality were identified. CASP quality scores ranged from 13-18. Four themes emerged highlighting parents' experiences of the emotional processes, communication, coordination and support and resources when transitioning from hospital to home.

CONCLUSIONS

Hospital discharge and transition from hospital to home is a complicated and at times frustrating process for parents of children with complex health needs. Parents report being exhausted and stressed during this often-challenging period of adjustment which was perceived as a difficult and emotional process. There is a clear lack of support available for parents both from hospital and community services.

A deviation too many? Healthcare professionals' knowledge and attitudes concerning patients with intellectual disability disrupting norms regarding sexual orientation and/or gender identity

BACKGROUND

People with intellectual disability (ID) have few role models for sexual expression and behaviour, and those who identify as LGBTQ experience dual marginalization. The aim of this study is to explore knowledge and attitudes concerning patients with both ID and norm-breaking sexuality and/or gender identity among healthcare professionals in habilitation centres.

METHOD

Data were collected from four focus group interviews that included 19 healthcare professionals from child and adult teams at two Swedish habilitation centres. Data were analysed using thematic analysis.

RESULTS

Three themes were identified as follows: heteronormative treatment in health care, barriers for inclusion and possibilities for inclusion.

CONCLUSIONS

Norm-breaking sexuality and gender identity are still relatively invisible in habilitation centres. People with ID are still predominately desexualized and perceptions regarding their sexuality are lagging behind the rest of society. Conditions that allow for more LGBTQ-affirmative practice were described by the teams that have undergone LGBTQ training.

Citizen science to further precision medicine: from vision to implementation

The active involvement of citizen scientists in setting research agendas, partnering with academic investigators to conduct research, analyzing and disseminating results, and implementing learnings from research can improve both processes and outcomes. Adopting a citizen science approach to the practice of precision medicine in clinical care and research will require healthcare providers, researchers, and institutions to address a number of technical, organizational, and citizen scientist collaboration issues. Some changes can be made with relative ease, while others will necessitate cultural shifts, redistribution of power, recommitment to shared goals, and improved communication. This perspective, based on a workshop held at the 2018 AMIA Annual Symposium, identifies current barriers and needed changes to facilitate broad adoption of a citizen science-based approach in healthcare.

The views and experiences of families and direct care support workers regarding the expression of sexuality by adults with intellectual disabilities: A narrative review of the international research evidence

BACKGROUND

There is a growing and evolving research evidence base regarding sexuality issues and adults with intellectual disabilities. However, the experiences and views of families and direct care support workers and their support and development needs in the topic area are unclear.

AIMS

The aim of this narrative review was to explore the views and experiences of families and direct care support workers in relation to the expression of sexuality by adults with intellectual disabilities and to identify their distinct support and development needs.

METHODS AND PROCEDURES

A comprehensive search of relevant databases from May 1998 to June 2018 was undertaken. Included studies had to address specific criteria: peer reviewed papers, the use of appropriate research methods, and focus exclusively on the individual views and opinions of families and direct care support workers. The search of relevant databases yielded 313 hits. Following the application of explicit inclusion and exclusion criteria, 11 papers were deemed suitable for the review. The PRISMA checklist was utlised in the process. Quality was assessed using a recognized framework.

OUTCOMES AND RESULTS

The data were analysed and key findings highlighted issues for families and direct care support workers including: attitudes and beliefs; fear of abuse, exploitation and harm; new technologies; supporting developments in practice; and education and training programmes.

CONCLUSIONS AND IMPLICATIONS

Families and direct care support workers have specific support and education needs. Future healthcare initiatives need to be developed that are fully responsive to the identified concerns and requirements of families and direct care support workers.

A narrative review of the literature about people with intellectual disability who identify as lesbian, gay, bisexual, transgender, intersex or questioning

This narrative review of the research literature presents a summary about the key issues facing people with intellectual disability (ID) who identify as lesbian, gay, bisexual, transgender, intersex or questioning (LGBTIQ). The aim of this review was to consolidate research of the topic; to identify whether any pilot studies reporting social/sexual/educational interventions had been published; and to offer some perspective on the type of future research required to better inform policy, practice and theory that may lead to better outcomes for people with ID who identify as LGBTIQ. Almost all of the research literature on the topic is either exploratory or descriptive which serves to outline the range of issues faced by people with ID who identify as LGBTIQ. Urgently needed as the next step, however, is a concerted effort to conduct a range of innovative educational and social interventions with collection of targeted and appropriate outcomes data.

Sexuality issues and the voices of adults with intellectual disabilities: A systematic review of the literature

BACKGROUND

There is a growing and evolving research evidence base regarding sexuality issues and adults with intellectual disabilities. Individuals can face challenges, including the right to express their sexuality and to access necessary education and supports.

AIMS

This systematic review explores sexuality experiences, the views and opinions of adults with intellectual disabilities and highlights areas for future practice developments.

METHODS AND PROCEDURES

A comprehensive search of relevant databases from January 2006 to December 2016 was carried out. Included studies had to address specific criteria including: peer reviewed papers, the use of appropriate research methods, and focused exclusively on the individual views and opinions of people with an intellectual disability. The search of relevant databases yielded 230 hits. Following the application of explicit inclusion and exclusion criteria, 23 papers were deemed suitable for the review.

OUTCOMES AND RESULTS

The data were analysed and key themes were identified that included: autonomy v's risk of harm, knowledge and sexuality, relationships and intimacy, self-determination and taking control, and encouragement and supports.

CONCLUSIONS AND IMPLICATIONS

Adults with intellectual disabilities need education and support to express their sexuality and to meet individual needs.

When holistic care is not holistic enough: The role of sexual health in mental health settings

AIMS AND OBJECTIVES

To explore the preparation that mental health nurses receive to address sexual health in practice.

BACKGROUND

People who use the mental health services often have complex sexual health needs. Mental health nurses are well placed to offer support. However, this rarely happens in practice, and therefore, people's sexual health needs are not being routinely addressed. It is not known why this is the case.

DESIGN

Systematic review and meta-ethnography.

METHODS

EBSCO, PsycINFO, MEDLINE and ASSIA databases were searched using Booleans with Mesh and key terms including "mental health nurse" and "sexual health". Date range was June 2006 to June 2016. Discursive papers were excluded. Included papers (n = 7) were synthesised using a meta-ethnographic approach.

RESULTS

The search yielded seven studies. Five key themes were identified: the (not so) therapeutic relationship; personal values dictating professional ones; institutionalised fear; being human; and education: the answer but where is it?

CONCLUSIONS

The findings illustrate the complexity of supporting people with mental health and sexual health needs. They show the discomfort many nurses have about broaching sexual health. Arguably more than with most issues, personal values impacted strongly on professional practice. Understanding the depth and multifaceted nature of these themes is important, because strategies can then be developed to mitigate the barriers to best practice. For example, the findings presented here offer a framework from which structured education and support can be built.

RELEVANCE TO CLINICAL PRACTICE

There is a need for Mental health nurses to be more responsive to concerns around sexual health and it should be routinely included in their practice. This study illuminates why this is not currently the case. By understanding this, remedial action can be taken by nurse educators. Implications are also discussed in relation to policy, research and practice.

Women Who Love: An Explorative Study on Experiences of Lesbian and Bisexual Women with a Mild Intellectual Disability in The Netherlands

Empirical research that addresses sexual orientation in people with an intellectual disability (ID) is limited, and very little is known regarding the personal experiences of lesbian and bisexual women with ID. This study set out to answer the question: What are the experiences of lesbian and bisexual women with a mild intellectual disability in the Netherlands? Ten lesbian and bisexual women (average age of 33 years) with a mild intellectual disability took part in our study comprising of semi-structured interviews. Participants reported that they had found it hard to talk to others about sensitive subjects such as their sexuality, and had been left to figure out information regarding their sexual orientation without support or guidance. Our results point to a lack of information, sexual education and role models when it comes to lesbian sex and women with an intellectual disability. Social contact was often limited, and participants experienced difficulties finding a partner. Furthermore, participants often had to cope with mental health problems and had struggled with loneliness, depression and addiction. Last but not least, our participants reported that they had been discriminated against. Coming out (revealing your sexual orientation) is not easy when you have an intellectual disability. To enable women with ID who have lesbian or bisexual feelings to understand and secure their sexual rights in their daily lives is important. Therefore, it is necessary to provide support in the following domains: sexual education and training, social contact and assertiveness.

Education Needs of Families of Transgender Young People: A Narrative Review of International Literature

Education plays a crucial role in the lives of families of transgender young people and mental healthcare practitioners are well-placed to support families in this regard. This paper reports findings from a narrative review of 31 papers that explored the education needs of families of transgender young people. The emergent themes were synthesised to develop a five-stage model that depicts the role of education in the lives of these families. Key themes included: (i) learning that a family member is trans; (ii) family responses; (iii) accessing education and information; (iv) impact on the individual; and (iv) moving beyond the individual. The key implications for mental health practitioners, families, and future research are discussed.

Mediated pathways, negotiated identities: a critical phenomenological analysis of the experience of sexuality in the context of intellectual disability

Questions of sexuality and intellectual disability have now moved beyond the institutional era, and contemporary sexual health interventions have gradually been reconfigured in terms of social participation, partnership and normalising approaches. That being said, they also appear to be part of a complex negotiation process between support systems for individuals identified as having an intellectual disability. The aim of this study was to provide a better understanding of the experience of affective (sentimental and emotional) and sexual (identity and value-mediated) expression in the context of intellectual disability, as well as related factors of influence. Inspired by a critical theoretical framework and a phenomenological methodology, this research shows that these experiences are part of a negotiation process that is simultaneously systemic and intimate. It is systemic because it responds to knowledge systems specific to intellectual disability and sexuality, thus authorising a variety of interventions focused on normalising the individual. It is also intimate because these practices involve every axis of affective existence, from inhabiting restrictive spaces to reconfiguring people’s intimate relationships with themselves and others. Through these findings, nursing’s ability to recognise and advocate for this group’s sexual needs and rights is called into question.

Experiences of adults with intellectual disability who identify as lesbian, gay, bisexual, transgender, queer or questioning, intersex or asexual: a systematic review protocol

REVIEW OBJECTIVE/QUESTION

The purpose of this systematic review is to identify, appraise and synthesize the best available qualitative evidence on the lived experiences of adults with intellectual disability who identify as lesbian, gay, bisexual, transgender, queer or questioning, intersex or asexual in mainstream society.