The recent Australian same-sex marriage plebiscite has enabled comparison of the Household, Income and Labour Dynamics in Australia Survey data between areas with predominant ‘yes’ and ‘no’ votes. It supported the minority stress theory, finding that lesbian, gay and bisexual people living in ‘no’ areas were significantly more likely to have worse life satisfaction and worse mental health.16 Marginalisation can also be a factor, in that LBQ women might be excluded from social networks. This can be especially the case for bisexual women, or those with a disability or cultural minority identity. Another pressing issue is the ongoing use of ‘gay conversion therapy’ in Australia (generally under the guise of religious instruction or support), which can be extremely damaging.17
For LBQ women presenting with mental health issues, GPs should explore the possibility of triggers including abuse, violence or marginalisation arising from sexual identity-based discrimination. This is essential to enabling appropriate management, including referral to LBQ-inclusive and knowledgeable counsellors (Table 1). Peer support and social connection is also important to building resilience and recovery for many LBQ women. Excellent national LGBTIQ peer support is available through the QLife program, which trains and maintains peer support workers in each state and territory for phone or online counselling (Table 1).
LBQ women are two to three times more likely than heterosexual women to drink alcohol at harmful levels, to smoke and to use illicit drugs.18,19 There are complex reasons for higher levels of use and misuse. First, substances can be used as self-medication in the face of minority stress; second, many LBQ women use substances as part of socialising with LGBTIQ communities (often in pubs, bars and clubs); and third, some LBQ women use substances as an integral part of their sexual or gender identity.20 These intersecting associations with substance use require complex interventions and targeted health promotion (Table 1).
Issues facing older LBQ women include isolation, a history of trauma, fear of homophobia when engaging with aged care services and difficulties with end-of-life planning.21 GPs have a role in advocating for the needs of older LBQ women through understanding whether they are partnered, who their chosen family is, how they want to engage with aged care services and finding appropriately trained providers. LGBTIQ-inclusive training in aged care services has been occurring nationally since the groundbreaking National LGBTI Ageing and Aged Care Strategy was released in 2013.22 There is also a new resource to support end-of-life planning that includes information about legislative protections (Table 1).
Minority intersection health issues
Subgroups of LBQ women that are even more disadvantaged include those with disabilities, those who identify as Aboriginal and/or Torres Strait Islander, refugee and asylum seekers, and those from minority ethnic or religious groups. The influence of multiple marginalised identities on health and wellbeing includes experiences of rejection or trauma, questioning the legitimacy of their sexual minority identities, and lack of social connection through not feeling included by any community.23