‘Do you have a girlfriend?’

It was a two-day training course, on the Autism Diagnostic Observation Schedule. We were watching recordings of a Clinical Psychologist administering an ADOS with children and young people. In one recording, a five-year-old boy was asked 'do you have a girlfriend?' in the section concerning marriage and long-term relationships. No-one else picked up on the fact that this question had been framed like this, or even asked at all. I stayed silent. I didn't want to come across as nit-picking. We were supposed to be analysing how the child answered the questions, not how the questions were asked.

As an openly gay woman, I am exposed to LGBTQ+ inclusive language regularly. The LGBTQ+ community is a huge part of my identity. Naturally, I am going to recognise a lack of LGBTQ+ inclusive language in my workplace. I have noticed other similar interactions with children and young people during my time in my new Assistant Psychologist role in the Neurodevelopmental Assessment Pathway in Child and Adolescent Mental Health Services (CAMHS), in a way that I didn't when working with adults in mental health settings. I have never seen a mental health practitioner ask a child what pronouns they use, and have only seen practitioners assume the gender of a child based on how the child looks.

This is important. The words we use – or do not use – carry more power than we realise. If used inaccurately or carelessly, terminology can silence, exclude and dismiss certain people and their personal experiences. Members of the LGBTQ+ community are disproportionately affected by mental health issues that are often traced to issues with societal and self-acceptance. It is therefore vital that mental health practitioners use LGBTQ+ inclusive language when speaking to clients, colleagues and the wider public. By doing this, we can create a safe environment to increase the likelihood of LGBTQ+ people discussing their issues and engaging with mental health services.

To reflect on how, why and the repercussions of this, I will apply the reflective model which Gary Rolfe and colleagues outline in their 2001 book, Critical reflection in nursing and the helping professions. In its simplest form, it takes the format of 'What?', 'So what?', 'Now what?'.

What?

The Neurodevelopmental Assessment Pathway in CAMHS assesses children and young people for Autistic Spectrum Disorder (ASD) and Attention Deficit and Hyperactivity Disorder (ADHD). Deficits in developing, maintaining and understanding relationships is part of the criteria for an ASD diagnosis in the DSM-5. As part of the assessment process for ASD, many children are asked about their views on marriage and long-term relationships as this is included in the ADOS.

From the ADOS assessments I have witnessed, the conversations can easily lead to a discussion between the young person and staff member about whether the young person has any romantic connections themselves. This is where I have noticed a lack of LGBTQ+ inclusive language with children and young people. For example, if the young person being assessed for ASD is a boy, the question by the staff member has most commonly been framed as 'do you have a girlfriend?'. If the young person is a girl, the question is 'do you have a boyfriend?'.

I have also been surprised at how often young children (under 12 years old) are asked if they have a 'boyfriend' or a 'girlfriend'. When I was a child, I had absolutely no idea about romantic relationships in this way. It's not that I did not know if I liked boys or girls; I simply did not think about my peers in a romantic way when I was that age.

From the positive changes I have witnessed during interactions with adult clients in mental health settings in my prior job roles, LGBTQ+ inclusive language skills develop through the discarding of preconceived notions. For example, by asking the client, rather than assuming, their sexuality or gender, and asking them which pronouns they use. With adult clients, mental health practitioners can usually just ask these sorts of questions when they meet the client in order to construct an inclusive environment.

Thinking about this more deeply, I realised it may be more difficult to use LGBTQ+ inclusive language with children compared to adults. With an adult client who identifies as a woman, a mental health practitioner can use LGBTQ+ inclusive language such as 'do you have a partner?' rather than 'do you have a boyfriend?' to demonstrate awareness that not everyone is heterosexual. However, with a child, 'partner' seems too 'adult-like' and it's likely the child will not understand the romantic assumption behind the word.

Asking 'are you in a relationship with anyone?' seems another age-inappropriate question for young children and they may not understand the meaning behind the question. When it comes to asking a child about pronouns, this again seems 'adult-like' and it is likely that the child will not understand the question and how to answer it.

Developing rapport with children is crucial, and therefore asking difficult and demanding questions on meeting the child may make rapport more difficult to establish. It is also important to note that an LGBTQ+ inclusive attitude is something that is learned through experience, exposure and education. In this view, parents and carers may not have had these important conversations with their child yet, or may not plan to. This is something to bear in mind as some children and families may not be ready to initiate and understand these conversations, and staff must also be aware of cultural differences around this topic and adapt accordingly.

Therefore, on deeper reflection, LGBTQ+ inclusive language between mental health practitioners and children is perhaps more challenging and intricate than it first seems.

So what?

The lack of LGBTQ+ inclusive language with children in mental health settings is concerning and needs to be considered in a wider context.

LGBTQ+ children form a group in society which needs our support. LGBTQ+ children and young people face the same risks as all children and young people, but they are at greater risk of abuse. For example, they might experience homophobic, biphobic or transphobic bullying or hate crime. They might also be more vulnerable to or at greater risk of sexual abuse, online abuse or sexual exploitation.

Section 28, a piece of legislation from 1988 prohibiting the discussion of LGBTQ+ issues and identities in schools, only came to an end in 2003 in England and Wales. Section 28 shaped a country where LGBTQ+ identities and issues were 'othered' and shamed. School playgrounds became an environment of misinformation, ignorance and bullying and LGBTQ+ children did not have access to vital learning opportunities and support. Staff in schools could not discuss LGBTQ+ issues or use any language relating to LGBTQ+ identities and did not effectively address bullying of suspected LGBTQ+ students. The repercussions of Section 28 are still prevalent. The Section 28 legacy continues through the uninformed generation in our society who lack awareness of the LGBTQ+ issues they were denied access to in their younger years.

One way mental health workers can tackle this legacy is by ensuring every child has the chance to see themselves, their family and the full diversity of society reflected in their healthcare. By using LGBTQ+ inclusive language, we can play our part in ensuring that all children in mental health settings are informed about the heterogeneity of sexuality and gender, that LGBTQ+ children feel understood and seen, and that none-LGBTQ+ children can learn how to be an ally to their peers as they get older.

Despite the challenges posed by adapting LGBTQ+ inclusive language for children, I believe LGBTQ+ inclusive language needs to play a bigger role in interactions between mental health practitioners and children in mental health settings. If we start using LGBTQ+ inclusive language and questions with people when they are young, it will slowly become normalised and these children will grow up in a world where they are used to questions and conversations like this. For example, although asking a child what pronouns they use seems 'adult-like', this can be asked in a child-friendly way. Simplifying it to something like: "When people speak about me, I like them to say 'she' and 'her'. What about you?" is one option. Simple changes in language can make a huge impact.

If the topic comes up, rather than asking a young boy if he has a girlfriend, practitioners could ask about 'a school crush' or if they 'like anyone as more than a friend'. But let's also consider if this question even needs to be asked to a child of such a young age. Are we pushing western values regarding marriage onto young people? What about children who don't want marriage or a relationship? Should they even be encouraged to consider this yet? What about different cultures? Should young people, regardless of an ASD diagnosis or not, be expected to understand marriage and long-term relationships?

Now what?

Self-education is of course key, but more person-centred and intimate training could help to support staff members in providing LGBTQ+ inclusive care with confidence. Problems that may arise from simple oversights or mistakes made by well-meaning staff who lack understanding about how to interact with LGBTQ+ people can be tackled.

I recently attended a four-hour training session named 'Transgender Awareness Training: Working with Transgender and Gender Diverse Communities'. It was led by Jessica Lynn, a world-renowned transgender advocate, educator and activist whose experiences as a transgender woman and parent led her to dedicate her life to spreading awareness and acceptance for gender non-conforming communities around the world. This session was the best training I have ever received. Rather than learning through clicking buttons on a computer, I heard a real, heart-breaking and empowering life story. This inspired me to educate myself more in my own time and make it my own issue to become more LGBTQ+ inclusive in my practice and everyday life. More sessions like this for NHS staff could positively impact attitudes and encourage proactive behaviour in the workplace regarding LGBTQ+ inclusivity.

We also need to act and speak out when we need to. During that ADOS training, I was shocked at what I saw, but I did not speak out at the time through fear of rocking the boat. Yet if no-one ever speaks out, nothing will change for the better. Each of us can play our part in improving mental health settings for LGBTQ+ people that need us.

If used widely, adapting LGBTQ+ inclusive language to meet the needs of children and young people will have a knock-on effect. With time and persistence, LGBTQ+ inclusive language will gradually synthesise into adult mental health settings and wider society. Those children in CAMHS who go on to need mental health support when they are an adult will have had a positively LGBTQ+ inclusive experience in CAMHS and, hopefully, will be more prepared to engage with adult mental health services knowing staff will be inclusive of the LGBTQ+ community.

It's understandable that new terminology and acronyms can take time for people to get their heads around and be able to use it confidently without fear of offending anyone. Mistakes and slip ups are expected. But this is an opportunity to ask questions and learn. At the core of the NHS is the belief that healthcare is for everyone, irrelevant of background, race, ethnicity, religion, class, age, sexual orientation and so on. Making simple updates to our language can bring underrepresented voices to the fore, and make LGBTQ+ people feel included and valued.

• Anna McNulty (she/her) is an Assistant Psychologist, Neurodevelopmental Assessment Pathway & ADHD Post-Diagnosis Pathway at Rotherham CAMHS.