/ CHHS17/006

Canberra Hospital and Health Services

Clinical Guideline

Dhulwa Mental Health Unit (DMHU):Practice sensitive to gender identityand sexual orientation

Contents

Contents

Guideline Statement

Scope

Section 1 – Providing an environment sensitive to consumer’s gender identity and sexual orientation

Section 2 – Physical environment

Section 3 – Staff guidelines for gender sensitive practice

Section 4 – Search of consumers

Section 5 – Use of seclusion and restraint

Implementation

Related Policies, Procedures, Guidelines and Legislation

Definition of Terms

References

Search Terms

Guideline Statement

Background

Due to the small size of the ACT population and as the only secure mental health facility in the ACT,the Dhulwa Mental Health Unit (DMHU) provides mixed gendered accommodation. It is important for the unit to provide treatment, care and support that is responsive to the diversity of consumer’s gender identities, sex characteristics and sexual orientations.

Gender identity is an individual’s sense of self, appearance, mannerisms or other gender-related characteristics. Individuals may have a range of gender identities including female, male or non-binary.

Gender is a key marker of identity and a strong predictive factor connected to health and wellbeing outcomes. The expression and experience of mental health issues can thus be understood in the context of gender. This ‘gendered’ understanding relates to risk factors, prevalence, manifestations of symptoms, experiences of symptoms and effects of treatment.

Gender-sensitive practice (see definition of terms) is informed by knowledge and understanding of differences, inequalities and varying needs of women and men (including those who are transgender and intersex), and non-binary people (see definition of terms) and the interrelationship of gender identity with:

  • childhood and adult life experiences such as trauma and/or abuse histories and experiences of discrimination
  • day-to-day social, family and economic realities such as poverty, housing situation and primary care of children
  • expression and experience of mental health and/or alcohol and drug issues
  • pathways to services, treatment needs and responses such as help-seeking behaviour and the type of service sought
  • cultural and community background, and
  • physical health issues such as risk factors and responses to medication.

Sexual orientation describes whether someone is bisexual, lesbian, gay, heterosexual or asexual (see definition of terms). It encompasses a person’s romantic, emotional, physical and/or sexual attraction to other people.

The discrimination and abuse experienced by people who are lesbian, gay and bisexual is an important factor to their mental health. A person’s sexual orientation may affect the types of services they feel comfortable approaching and the responses they receive from these services; their willingness to seek support if they have been a victim of sexual harassment, bullying or assault9 and their self-esteem, confidence and sense of self-worth.

Services responsive to peoples sexual orientation will, among other things, provide training to staff on sexual orientation so that staff are equipped to provide treatment, care and support that is sensitive to a person’s orientation, will provide an waiting room environment that contains materials for people of all orientations and may provide options for people to indicate their identity on intake forms, and use appropriate pronouns when relating to people.

Impacts of mental illness and mental disorder

Mental illness may impair a consumer’s judgement and may make them more vulnerable to sexual assault and harassment in mixed gender units. Individuals whose gender identity or sexual orientation differs from the majority in a unit may also be at increased risk of harassment, bullying and discrimination.

Sexual disinhibition (see definition of terms) is a feature of some psychiatric disorders, and may result in some consumers acting in ways they might not otherwise do. Sexually disinhibited behaviour can be embarrassing, distressing and potentially dangerous for the person exhibiting the behaviour as well as for those that may be exposed to it. It can also negatively impact on existing relationships and for those that have experienced a prior incident of sexual assault or harassment, being exposed to this behaviour can trigger strong feelings of fear and anxiety. Sexually disinhibited behaviour also has the potential to make consumers exhibiting this behaviour vulnerable to sexual assault or harassment.

Consumers may need protection from acting in ways that interfere with their treatment or their longer term wellbeing. This may include instituting practices to prevent some consumers from harassing or assaulting others in the unit.

There is a high prevalence of exposure to or experience of personal trauma, including sexual abuse and violence among people who experience mental illness. The influence of violence can persist long after the abuse has stopped9.

Females

Research indicates that:

  • the ratio of females to males in secure psychiatric hospitals is 1:51 and
  • the safety of females in mixed gender units reduces when separate, female only spaces are not available2.

Internationally, surveys of female consumers in mixed gendered mental healthunits have shown that women are more vulnerable and often feel threatened by male consumers. Specifically, sexual harassment and assault of female consumers is more common on mixed gender units. Providing safe spaces for female consumers has been recommended consistently by consumer advocacy groups and mental health services for this reason. The risks appear to be greater in acute wards3.

Separating male and female consumersmay not adequately reduce risks of violence, bullying or abuse of some groups of consumers towards others and may inadvertently contribute tosome consumers being disadvantaged. For instance, if there are only a small number of women in the unit, limited rehabilitation programs may be directed to the majority, i.e. men. Likewise, depending on the mix of women in the unit, grouping women together may increase the risk of violence intimidation, threats and abuse between female consumers and create an unhealthy milieu4. Endeavours to ameliorate these risks require a holistic approach as outlined in the remainder of this procedure.

Males

Males in inpatient units who are heavily sedated are more vulnerable to sexual assault. When consumers who are sedated experience a sexual assault, the powerlessness they feel will often be magnified due to their loss of control and choice in such a situation9.

The impact of such an experience for a male will not in any way be more significant than for a female, but may give rise to other issues because of cultural/social expectations of men9.

Lesbian, gay, bisexual, transgender or intersex individuals

Lesbian, gay, bisexual, transgender or intersex individuals have been subject to increased social exclusion, bullying and violence, which may contribute to poorer mental health for some people5.

The National LGBTI Mental Health and Suicide Prevention Strategy (2017) states that:

  • Lesbian, gay, bisexual, transgender and intersex people and communities experience stigma, prejudice, discrimination, abuse, violence, isolation and exclusion associated with their genders and bodies.
  • This is coupled with the expectation that these experiences may happen at any time, creating a hostile and stressful social environment that impacts on mental wellbeing.
  • These experiences form a compounding factor in the strong links between mental illness and suicidal behaviour; social and economic circumstances; and key risk areas.
  • Key risk areas include stressful life events, unemployment, insecure housing, chronic illness, alcohol and substance use, and experiences of trauma or abuse.
  • Such experiences, in conjunction with existing predisposing risk factors, result in lesbian, gay, bisexual, transgender and intersex people having a heightened vulnerability to various mental health issues, in particular depression and anxiety, as well as an elevated risk for suicidal ideation.

Key Objective

DMHU recognises the challenges associated with providing treatment, care and support that is sensitive to consumer’s gender identity and sexual orientation within a mixed gender ward. This Clinical Guideline articulates how staff at DMHU will provide, treatment, care and support for all consumers residing at DMHU, inclusive of their gender identity and sexual orientation.

All DMHU staff will have completed Mental Health, Justice Health, Alcohol and Drug Division gender sensitivity and inclusion training and can competently address issues of gender sensitivity and inclusion with consumers and carers. This ensures that all treatment, care and support provided to consumers by DMHU staff will be in accordance with their individual needs.

Alerts

This guideline should be read in conjunction with the Mental Health Act 2015,the Mental Health (Secure Facilities) Act 2016, Discrimination Act 1991, and the Dhulwa Mental Health Unit Model of Care.

The DMHU provides therapeutic treatment and allocates room and access to personal and recreational spaces in accordance with the consumer’s identified gender.

The DMHU recognises that all therapeutic care and management plan(s) must take into consideration the consumer’s gender identity and sexual orientation.

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Scope

This Clinical Guideline applies to all staff working inDMHU, including:

  • clinical staff
  • administrative staff, and
  • security officers.

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Section 1 – Providing an environment sensitive to consumer’s gender identityand sexual orientation

DMHU has a duty of care to provide a safe, therapeutic environment for all consumers. This includes protecting them from the unwanted behaviours of others, and behaviours of their own that they might not choose to engage in when well.

DMHU staff will endeavour to provide an environment sensitive to consumer’s gender identity and sexual orientation by:

  • promoting the right of all consumers to live in an environment free from violence, including violence based on gender identity or sexual orientation, sexual harassment, bullying and inappropriate sexual activity
  • balancing personal autonomy and decision making with the duty of care to provide a safe and therapeutic environment for all consumers
  • recognising the need of consumers for privacy and personal space, and that these needs may vary between different genders, sexual orientations and cultures

•recognising the need for routine identification of sexual risk in all consumers

•recognising the particular vulnerability of some consumers due to their history, illness, emotional turmoil or need

  • recognising that consumers from some cultural backgrounds may be affected by gender-based power relationships
  • understanding that different bodies are sometimes predisposed to different physical health issues, e.g. because of genetic factors, some people are more prone to illness such as asthma and diabetes, etc and can be impacted differently by side-effects of some medications
  • acknowledging their own gender and sexual orientation and the impact these may have on the consumers they have responsibility to provide care for6

•encouraging and modelling positive relationships and mutual respect between staff, between staff and consumers, and between consumers and their families

•responding sensitively and supportively to disclosures of past or current sexual assault, violence based on gender or sexual orientation, bullying and sexual harassment

•promoting personal self-care, respect, resilience and self-determination.

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Section 2 – Physical environment

2.1 General

Providing designated spaces for specific at risk groups of consumers can play an important role in helping them to feel safe and more relaxed as well as providing a space where supportive contact between others with a similar identity or orientation can be promoted9.

As necessary, DMHU will also provide lounges for recreation purposes exclusively for consumers of a specific gender identity. It is acknowledged that these lounges may change depending on the composition of consumers in the unit and the bedroom configuration of consumers at the time. This will be discussed and any modifications determined by the Multidisciplinary Team (MDT) during regular meetings.

Providing lockable bedroom doors can greatly increase consumer’s sense of safety and security9. Each consumer will be provided with an individually programmed wristband on admission to the Unit. This wristband will allow the consumer access to their bedroom and associated areas. This wristband will prevent consumers from accessingareas, e.g. lounges or bathrooms assigned specifically to those of a different gender. Wherever possible, DMHU consumers will not occupy a bedroom that is either next to or directly opposite a consumer with a different gender identity.

2.2 Recreation areas for at risk groups only

2.2.1Use of the Enhanced Care Areas

The Enhanced Care Areas of Lomandra and Cassia Units each contain twobedrooms and a courtyard.

The MDT will determine the best use of the Enhanced Care Areas. In all but the most exceptional circumstances priority access will be given to consumers from at risk groups in the unit at the time, i.e. those from a minority gender or sexual orientation group.

In allocating accommodation in the Enhanced Care Areas, consideration should be given to:

  • the needs of all consumers on the Unit at the time, including:
  • age
  • gender identity
  • sexual orientation
  • culture
  • current mental state
  • current risk of violence towards specific consumer(s)
  • trauma history, and
  • each consumer’s unique clinical and risk profile.

Consumers from at risk groups may be given access to the Enhanced Care Area Courtyard to use as an area for rest and retreat even if the consumer mix on the Unit has determined that they are not allocated bedrooms in the Enhanced Care Area.

2.2.2 Rehabilitation Unit

On the Rehabilitation Unit, either the Mallee wing or Cassia wing may be designated for use by at risk consumers only, if the need arises.

2.3 The need for mixed-gender allocations

2.3.1 Documentation

Any decision to allocate a consumer to a bedroom either next to or directly opposite a consumer of a different genderidentity must be recorded in both consumers’ clinical record and reported in Riskman. This is a one-off, individual mixed-gender occurrence.

The Riskman notification for one-off,mixed-gender occurrence recording should include:

  • identification of the clinical area
  • reason for mixed-gender occurrence (capacity, flow, inadequate facilities, specific equipment /consumer safety requirements)
  • impact of the individual mixed-gender occurrence on affected consumers
  • type of mixed-gender occurrence (bed location, location of facilities)
  • whether the appropriate alternative clinical accommodation can be found
  • the time frame of the mixing, and
  • confirmation that the mixed-gender occurrence was discussed with the consumers and documentation to support this.This should also be documented in the Electronic Clinical Record (ECR).

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Section 3 – Staff guidelines for gender sensitive practice

To promote treatment, care and support that is responsive to all consumer’s gender identities and sexual orientations, all DMHU clinical staff should:

  • undertake professional development activities to ensure current knowledge of best practice gender sensitive care is incorporated into routine practice. This training may include:
  • working with families and carers
  • parenting roles
  • delivering trauma informed care
  • violence risk assessment guidelines
  • working with lesbian, gay, bisexual, transgender and intersex consumers
  • reflect on how practice can accommodate consumers’ needs and preferences in relation to their gender identity and sexual orientation in order to support consumers to feel safe and to optimise their wellbeing
  • seek professional supervision that encourages reflective practice in relation to gender sensitivity and safety, and sexual orientation
  • participate in team meetings that consider how to best meet consumers’ individual needs including culturally-appropriate practice in engaging with people from specific cultures, and interpretation of cultural identity with respect to gender, gender identity and sexual orientation5.

Staff gender mix will be considered in rostering and all efforts will be made to ensure that the gender of staff working with consumers is appropriate for the individual needs of consumers and the mix of consumers at DMHU at the time.

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Section 4 – Search of consumers

Wherever possible, any search of a consumer will be conducted by a staff member of the same gender identity as the consumer or a gender identity nominated by the consumer. Where this is not possible, a staff member of the same gender identity as the consumeror a gender identity nominated by the consumer will be present throughout the search. See DMHU Search Procedure for more information.

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Section 5 – Use of seclusion and restraint

The use of seclusion and restraint can be a traumatic experience for many consumers. Wherever the use of seclusion or restraint is required, clinicians will make every effort to avoid retraumatising or triggering events for consumers, particularly those with trauma histories (see MHJHADS Seclusion of a Person With Mental Illness or Mental Disorder Detained under the Mental Health Act 2015 Procedure for more information).

When physical restraint of a consumer is required,staff will endeavour to ensure that at least one staff member involved in the restraint is of the same gender identity of the consumer or a gender identity nominated by the consumeris involved in the restraint. See DMHU Use of Force Procedure for more information about restraint.

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Implementation

The contents of this procedure will be communicated through the following means to DMHU staff:

  • education
  • orientation documentation and sessions, and
  • leadership and governance expectations regarding adherence to policy, procedure and legislation. This is monitored when reviewing staff performance plans.

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Related Policies, Procedures, Guidelines and Legislation

Policies

  • ACT Health Work Health and Safety Policy
  • ACT Health Work Health and Safety Management System
  • ACT Health Incident Management Policy
  • ACT Health Consumer and Carer Participation Policy
  • ACT Health Language Services Policy
  • DMHU Search Policy
  • DMHU Use of Force Policy
  • DMHU Perimeter Security Policy

Procedures