Mark Elkins 

My name's Mark Elkins, and I'm the editor of Journal of Physiotherapy. I'd like to start this podcast by acknowledging the Turrbal and Jagera people's land of Meanjin as the original owners and custodians of the lands on which we meet, work and learn. We pay our respects to elders past, present and emerging. I'm joined today by Carrie Taylor and Megan Ross, and I'll ask them to introduce themselves and their affiliations. Carrie.

Carrie Talyor 

I'm Carrie Taylor. I'm a generalist musculoskeletal physio, part time researcher with UniSA in a persistent pain group. And I'm neurodivergent and that I'm autistic.

Megan Ross

I'm Megan Ross. I'm a postdoctoral research fellow at the University of Queensland, and I primarily conduct research in telehealth and the LGBTIQ space.

Mark 

So today's podcast is about inclusive and affirming practice. And I wonder, Carrie, could you start by explaining the sorts of conditions that are grouped under the term Neurodivergent?

Carrie 

So Neurodivergents is a huge, huge umbrella to describe heaps of conditions. Most people be really familiar with autism, ADHD and things like complex tic disorders like Tourette's, which have been, you know, talked about in the news. But they may not also know that it includes things like learning disorders or learning difficulties, I should say, and movement difficulties. And some people will also include acquired brain differences as well.

Mark 

And so do you think it's beneficial or unhelpful to have so many diverse conditions lumped under that banner?

Carrie

No, I think it's actually great because it can bring a whole community of people together alone. They may feel actually quite isolated, but under that Neurodivergent banner, it actually is a good unifying term and it just promotes diversity and inclusion.

Mark 

And Megan, I guess I'd ask you the equivalent question. There's there's an awful lot of genders and sexualities under the LGBTQIA plus alphabet. Do you think there are pros and cons of that grouping?

Megan 

Yeah, I mean, again, I think including us all under one banner of LGBTQIA plus means that it is inclusive and that together we are, you know, a bigger group in terms of advocating for certain things. But I think it is also really important to consider that within that umbrella, people's experiences and identities are different and that means that people will have different needs. So we cannot assume that everybody within the LGBTQIA place experiences things in the same way.

Mark 

And I guess both groups, Neurodivergent and LGBT, are discussed a bit more in the literature. Do you think that that's because there's increased prevalence or increased recognition? What do you think is leading to that sort of greater appearance in the world?

Megan 

So particularly diverse genders, but also diverse sexual orientations have been around for ever, for thousands of years. If you look back to pre colonization, you know, there were lots of indigenous groups that had very prominent diversity in terms of gender and sexual orientation and with colonization came the sort of overarching binary structures. And so that meant that then there was a period of time where people were hiding themselves and that looked like the prevalence was very low.

Megan 

And so now we're just coming back to with having changes in policies and, and, you know, changes in acceptance. That means that more and more people feel like they're able to be visible and out. So it looks like prevalence is increasing when in reality people are just being able to be themselves and express themselves.

Mark 

Do you think it's the same with Neurodivergents?

Carrie 

Yeah, completely agree with with Megan in that there's evidence for Neurodivergent back before the 1700s. I recently somebody described to me the poem of fidgety Phil, who describes like an ADHD kid who's really naughty, but this comes from Victorian times. He was just seen as the naughty kid. But if you look at his traits, it's very ADHD and there will always be the people say, Oh, there's been an explosion of diagnosis, but there's also been recognition and understanding growth.

Carrie 

So for me, you know, I've always been neurodivergent, but I was only diagnosed last year.

Mark 

So do you think it's enough for physiotherapists to just understand the various groups that are represented under these two banners, or do you think they need more than just knowing what the terms refer to and the diversities within each under each banner?

Carrie 

I think there's that there's this both in. You need to understand each of the conditions. I think, like Megan said, each individual group has its own qualities and quirks, if you like, and you need to understand those. But that then enables you to tailor your treatments and your goal setting and everything out to that person. So it is individualized so you can understand it as an umbrella, you know, neurodivergents then you can understand into that silo that condition, and then you can understand further down, you know, coming down the funnel, what for that person is going to make the biggest difference to the things that you can do for them as a physio.

Megan 

I think similarly as well, understanding the potential experiences for each person who is part of the LGBTQI plus community is important. But I think the most important thing is a patient centered approach, because if we then consider intersectionality. So if you just understand that someone is gender diverse and then don't consider that they might also be neurodivergent, or they might also be from a culturally and linguistically diverse background or they might be Aboriginal and Torres Strait Islander heritage as well.

So I think understanding that there will be differences in experiences and and different needs, but then being able to modify and make sure that you are taking a patient centered approach to consider the person beyond their LGBTQI identity as well, I think is probably the most important part.

Mark 

So I guess everything we've been discussing up to now has been kind of a little bit theoretical and overarching. Maybe you could give us a few examples of the types of needs or sensitivities that people attending a physiotherapy practice might happen, and obviously you probably can't cover everything, but if you could give us a few diverse examples just to give us a scope of the range of things that might come up.

Megan 

Sure. So for me the simplest thing is making sure that there is some kind of visibility, that the clinic is a safe space. So that could range from having some form of signage, whether it's at the front or if it's at the reception desk that you are an LGBTIQ safe space, inclusive intake forms, so forms where you have more than two options for gender or sex, and that you consider actually asking both gender and maybe not even sex.

Sometimes it's not necessarily relevant, allowing people's space for them to put their pronouns or to put a chosen name so that people can refer to them in a way that is affirming. That would be my first sort of steps training. Obviously, then into specific needs for the community. In terms of physiotherapy care, I might be looking at people who present, who are gender diverse and maybe they either wear garments that affirm their gender lack of mind that might be associated with musculoskeletal discomfort, pain, stiffness, that sort of thing.

Or it might they might present with, you know, altered postures or things like that. So very simply, they're the sorts of of things that you could be understanding and acknowledging to, you know, to look at your physiotherapy management to make sure that you are being inclusive in that way.

Carrie 
Yeah, communication's a key thing. You know, it's often said that autistics may not make good eye contact and that I'm not speaking for every autistic person. Obviously some people are really good at it, some people hate it, some people can mask. And I is a comment and you know, when you're delivering a treatment session and you're trying to engage with the person, I've been traditionally trained in sort of things like motivational interviewing, you know, body language, rapport and things like that.

And you may not feel that you're getting that with the person if you're not getting eye contact for a neurotypical passion. And it's understanding that you're still getting a really good connection with that person, they don't have to be looking at you and you shouldn't, as a therapist, come away from the session thinking, Oh, I didn't connect with them.

I got a really bad outcome because they did, you know, they were sat there playing with things while they were talking to me. And, you know, I don't think they were paying any attention. Go with what works for them and find out, you know, do they find eye contact difficult? Is it something that you actually can deliberately overt your gaze so you're not making them feel uncomfortable that they have to try and mask they have to try and make these accommodations for you as a neurotypical person.

You should be on the other end of it saying, you know however, You communicate, it's fine. You may even have non mouth words speaking people. So you know that they may be texting you even in a session to communicate. They could use an augment if communication device. All of those things are fine, but it's not something that we see or get taught about every day.

And in training, I think that's important to know that all forms of communication are valid and you should be ready for it to happen in your session. And it may be that the person that comes to you who's neurodivergent isn't a diagnosed neurodivergent person. So you don't have a flag up front going, Hey, this person is going to definitely have this issue and I'm going to have to accommodate you have to go with the flow.

Mark 

So if there was, say, someone in private practice, where would they get resources or training or how could they upskill themselves in this area?

Carrie 

Oh, firstly, I would actually say just build your awareness of the Neurodivergent community and of the different conditions that fall within that. So you start to get an understanding. There isn't really a central resource, if you like. I think that's an area that we could do to build on as a as a profession. But I'd say go on Facebook, Instagram, follow Neurodivergent people.

I've actually put a list of resources actually on my own website for people to go in as a starter so they can go and just check some people out, find out what the issues are in particular communities and then go from there. So I'm hoping myself to develop more material in the future because I can't see that there's a there's no central repository where you can just go, you know, it's like going to Coles and pick an off the shelf.

You've got to search around to Coles, Aldi, Woolies everywhere to find you, find your neurodivergent footer.

Mark 

And what website is that? The one.

Carrie 

That. So that's my own personal, health for keeps dot com dot au

Mark 

Megan what would you recommend for people who are in private practice and what sort of training.

Megan 

Yeah. So this year with a PRF grant actually released an LGBTIQ affirming physiotherapy resource which is accessible to all physiotherapists, APA members for free and non members for a small fee that was co-designed with the community. So I yep received some funding from the PRF to co-design it, develop it based on the research that I did and it is yeah, it's available so that would that is specific to the physiotherapy profession as well.

So when I started to look in this area in terms of research first there was no research at all and then there were also no resources that were targeted or tailored to physiotherapy practice. There are lots of places similar to what Carrie has just said. There are lots of places where you can go for general information about the community or maybe general information for health professionals that address things like intake forms and the clinic, sort of setting broadly, but it's not really specific to what we do as a physiotherapy profession.

So that was where the gap was that I saw. So that would be the place I would go for physio specifically. Yeah.

Mark 

And if someone does that and seeks that training and then upskilling and then they offer a welcoming and affirming practice, do you think there are advantages just for the LGBT participants or the Neurodiverse participants, or do you think there are wider advantages than that?

Megan 

Absolutely. I think there are wider advantages. The first sort of section of of the resource that I developed is getting us to just challenge normativity broadly. So getting us to sort of challenge our own assumptions and biases. And that would include other intersectional communities or, you know, just challenging what is perceived as normal and things that have been positioned as abnormal.

And I think so if you can do that and if you can reflect on on that, then that means that you would be a better practitioner for everyone. I think that's my perspective anyway.

Mark 

Carrie, do you agree that there would be advantages beyond just advantages for the patients? But would there be advantages for the practice for the physiotherapist, for the broader community if practices could be more affirming?

Carrie 

Yeah, if practices can be more affirming, you're going to be accounting for around 20% of the population who are considered neurodivergent. So it's a big chunk of people and your business is going to be if it's a business or an organisation, it's going to be made to be more welcoming and people will come back. You know, a lot of people in the Neurodivergent community are put off coming for health care because it's not affirming to them.

People aren't treated respectfully or accommodated in the ways that they need, and therefore they give up on health care. And that can often lead to health outcomes that could have been prevented. So that's going to benefit your business by people coming back is going to benefit that person by getting the treatment they need and it's going to benefit the wider community because that person's going to be, you know, optimising what they can do with the treatment that you've provided.

Mark 

I feel like I've been kind of directing all the questions, but I'd like you to get an opportunity to talk about you've both made presentations here at the APA conference here in Brisbane. Are there other things that you've presented here that you haven't touched on yet? With my questions.

Megan 

I think together we have both sort of covered the things that I will be presenting on. I think one of the biggest concerns for me in this area is that I think that the profession is changing, but initially I think that there was a lack of recognition about why this might be important to physiotherapy broadly, because a potentially physios don't feel like there are specific health needs for the LGBTQI plus community in the context of physiotherapy.

Or it could be that they sort of approach, you know, they treat people respectfully and don't necessarily see the need for potentially modifying things so that you get equitable outcomes as opposed to treating people equally. And I think that that is going to be the initial sort of part of my presentation. So it's just setting up why we need to consider LGBTQI plus affirming practice in physio.

And then I'll be stepping people through how you can do that.

Mark 

So Carrie, what about you? Do you think there is material that you’ve that you're presenting at the conference that we haven't touched on yet?

Carrie 

Yeah, I think there's a bit more about the why we should be looking at making accommodation and understanding the Neurodivergent community better in terms of trauma that has been caused in the past and the health inequalities that neurodivergent people have experienced. And you know, for anyone listening, a trigger, a trigger warning here in that if you're autistic, there's a relative risk 4 to 9 times greater of being at risk of suicide just in terms there as a start, because life generally is tougher for you as an autistic or an ADHD person.

And so you've got that initial barrier even to get somewhere in terms of health care. So the understanding why is really important.

Mark 

So Carrie, where would you think research in your field needs to go from here?

Carrie 

Oh, it's a it's a massive field to include and to research. I think one of the biggest areas that there is research in, but I don't think it's been specific enough is the crossover between Neurodivergents and other health conditions. So for example, in the Neurodivergent community, you may be more likely to have some of the conditions are rarer in the general population, but more prevalent in your neurodivergent populations so things like ehlers-danlos or hypermobility the pelvic pain and endometriosis area, mental health conditions as well.

So I think there should be further research into that because Megan earlier talked about intersectionality about and crossover and I don't think we have enough information and we also don't have enough reporting at the moment. There's very few studies will report on the neuro type of a person. They may they probably only do base gender or sex at birth type reporting.

I don't think I've seen anything in terms of neurodivergent in a general study that is not focused on something like autism or ADHD. So I think we could actually develop our research methodologies much better to be more inclusive and more specific so we can actually draw out, perhaps in our persistent pain groups. Well, was there a difference with those people who had persistent pain?

Did they fall into a particular neuro type or were we seeing, you know, some other result that may be attributed to neuro type that could be a way to go. In terms of neurodiversity affirming care as well as much of the what I'm putting out there is based on what I see in the Neurodivergent community, we don't actually have any reference material, research material that actually says does this actually help people?

Does it help them feel more satisfied with the treatment they receive with they just access to their health care? Does it help them get better outcomes for health? We don't we don't know that at the moment. And so that's actually an area that we could go into further to know that if we can provide these neuro diversity affirming services from anywhere from intake of a person, like Megan was saying earlier, with things like forms to actually the delivering of care, setting goals and treatment programs, do we know that that would then provide better outcomes for people?

Mark 

What about you, Megan? Where do you think your research needs to go?

Megan 

I think still the impact of having physios that are better educated to work with these communities, we don't know yet whether that influences how people experience the professional, how patients experience the profession. That is quite tricky to do, particularly in a short period of time. We do need a bit longer. So for me, I think that we do need to look at embedding more into the undergraduate curriculum so that then in time we could have physios who are practicing, who have learned these sorts of things in their undergrad and then maybe we could look at patient experiences with the profession again.

I also think that then there is a whole area of research that is looking at specifically the LGBTQI plus community and the impact or the efficacy of physiotherapy that's affirming for them. So looking at potentially the impacts of a physiotherapy program for people who are trans or gender diverse, may that be in terms of pain or musculoskeletal conditions or maybe if we're looking down the pelvic health rout, are there physiotherapy approaches that mean that we can influence outcomes in these specific communities?

We're starting to do a little bit of that. I have some additional funding to develop some more advanced education for practicing physiotherapists, which we're doing at the moment. So I guess in time evaluating the, you know, the change in clinicians knowledge and practices after a period of time would be one other area of research that we could that we should actually be looking at.

Mark 

Yeah, certainly important things still to be looked at, but it all looks pretty promising. Well, thank you both so much for your input into the podcast. It was a really good discussion and I hope you enjoy the rest of the conference.

Megan 

Thanks for having me.

Carrie 

Thank you.