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Supporting the Mental Health Needs of LGBTQ+ Patients: Providing Affirming and Inclusive Counselling and Support Services

By: Anne Peiris


Content Warnings: suicide, mental illness


Over the last few decades, the profound impact of our mental health on our lives and the critical importance of mental healthcare have been growing facets of the public consciousness. Though there is no denying the relevance of mental health in everyone’s lives, not everyone’s susceptibility to mental illness or experiences in receiving mental health care are alike. Identity and the social experiences that come with it can be influential in mental health outcomes. People of gender and sexual minorities are more likely to have adverse mental health experiences than straight or cisgender people.


Understanding Sex, Gender, and Sexuality

What is sex? 

Sex is mainly a biological term that refers to various markers that people use to assign individuals into sex categories. It is important to understand that sex categories are not nearly as clear-cut as they are made out to be. A person’s chromosomes or genitals may not always align with the ‘sex’ that we would be tempted to categorize them into. This is the case with many intersex individuals. Therefore, it is more accurate to think about sex as a continuum rather than a strict male–female binary.


What is gender? 

Gender refers to people’s internal experience of gender and is not necessarily related to biological features. Transgender individuals do not align with the gender they were assigned to at birth. One thing to note is that the term transgender does not indicate anything about whether a person has medically transitioned; whether or not they have transitioned does not diminish the validity of their gender identity. There are several gender identities including but not limited to cisgender women and men, transgender women and men, nonbinary people, genderqueer people, and more. Folks who do not identify as cisgender would be considered a gender minority.


What is sexuality? 

Sexuality or sexual orientation refers to a person’s attraction to others or lack thereof. Attraction can refer to both sexual or romantic attraction, and someone’s understanding of their sexuality can be dynamic throughout their lifetime. There are many sexualities including but not limited to being straight, gay, lesbian, bisexual, asexual, and more. For our purposes, sexual minorities will refer to folks who do not identify as straight.


Current Mental Healthcare for 2SLGBTQIA+ Individuals

Before discussing the mental health experiences of 2SLGBTQIA+ individuals, we should be mindful not to conflate mental illness with queer identities. Doing so can result in increased stigmatization of those identities which can worsen the mental health of people of those identities. Instead, we should be aware that various factors affect the mental health of gender and sexual minorities and that individuals can have vastly different experiences based on their social and material circumstances.


People of gender and sexual minorities experience higher rates of mental illnesses such as depression (Steele et al., 2017) and alcohol addiction (Pennay et al., 2018) than the general population, and trans folks also have higher rates of suicidal ideation and suicide attempts (Veltman & Chaimowitz, 2014). Experiencing microaggressions and discrimination, the inaccessibility of gender-affirming care, and experiencing systematic exclusion from many social support services all negatively impact mental health. 


Despite their elevated need, many queer and trans people report feeling that they have unmet mental health needs (Steele et al., 2017). One reason for this is the difficulty of accessing healthcare for queer and trans people. People have reported experiencing negative reactions from healthcare providers after disclosing their sexuality in the form of homophobic or transphobic rhetoric or even being denied care (Veltman & Chaimowitz, 2014). If you are made to feel unsafe in a doctor’s office, a place where you are already in such a vulnerable position, it can make the prospect of receiving care impossibly daunting. 


Additionally, trans and queer people are more likely to be lower income and categorized into a lower socioeconomic status (SES) group (Steele et al., 2017). Even if mental healthcare for lower-SES communities is subsidized by the government, they may not have access to diversity-competent mental healthcare providers. Having a healthcare provider who doesn’t have a thorough understanding of the impact of identity on mental health can be detrimental to the person who is receiving care. Whether through overt homophobia and transphobia or unintentionally harmful language, a lack of compassion or understanding can cause more harm than good. Having access to mental healthcare does not necessarily mean that a person has access to good quality mental healthcare.


Queer and trans people may also report unmet mental health needs because of the heavy reliance on the biomedical model to treat mental illness (Steele et al., 2017). Overburdened healthcare systems, encouragement from pharmaceutical companies to prescribe their medications, and the tendency to view biological causes for mental health illnesses as more valid than psychosocial causes can all contribute to this reliance on the biomedical model of mental healthcare. However, prescribing medications is not always a sufficient replacement for psychosocial interventions such as talk therapy, and its lack of acknowledgement of people’s social contexts, especially for queer and trans folks who experience social stigma, means that it may not be a sustainable route for mental health care.


How Can We Do Better?

Queer and trans people benefit from receiving care that is conscious of their identities and their lived experiences. One simple but important way that mental healthcare can be improved is by being cognizant of the language that is used when providing care. Harm can be done unintentionally by using language or terminology that undermines a patient’s identity, so taking the time to learn the correct terminology and also being mindful of individual preferences is a necessary action to take. For example, referring to a non-binary Indigenous person as being two-spirited despite them never using that term to describe themselves can invalidate their identity. While the term two-spirit is unique to Indigenous people, that does not require that every gender-nonconforming Indigenous person identify as such. 


Following in the vein of being mindful of individual preferences, it is important to understand the role that a person’s sexuality plays in their life. In doing this, it is crucial not to subscribe to cis-heteronormative biases. An example of avoiding such a bias is asking all patients about their relationship with their gender sexuality instead of only asking queer and trans patients. Doing this allows a clinician to be more aware of sexuality in a way that does not treat cisgender or heterosexual people as the default or norm. Clinicians should take care to recognize and affirm a patient’s sexuality (Daley, 2010). However, the extent to which sexuality is focused on should also change dynamically with patients. Patients who place reduced salience of their sexualities on their identities benefit less from acknowledgement and affirmation of their sexuality (Pennay et al., 2018).


Another thing that can help support the mental health of queer and trans people is encouraging engagement with queer and trans communities. Finding safety and joy with people with shared lived experiences can be an excellent form of support outside of clinical settings. One study found that engaging in bisexual community activities reduced the impact of internalized binegativity on levels of depression (Lande et al., 2017). Having an affirming community network is an accessible and crucial form of care.


References

Daley, A. (2010). Being Recognized, Accepted, and Affirmed: Self-Disclosure of Lesbian/Queer Sexuality Within Psychiatric and Mental Health Service Settings. Social Work in Mental Health, 8(4), 336–355. https://doi.org/10.1080/15332980903158202

Lambe, J., Cerezo, A., & O’Shaughnessy, T. (2017). Minority stress, community involvement, and mental health among bisexual women. Psychology of Sexual Orientation and Gender Diversity, 4(2), 218–226. https://doi.org/10.1037/sgd0000222

Pennay, A., McNair, R., Hughes, T. L., Leonard, W., Brown, R., & Lubman, D. I. (2018). Improving alcohol and mental health treatment for lesbian, bisexual and queer women: Identity matters. Australian and New Zealand Journal of Public Health, 42(1), 35–42. https://doi.org/10.1111/1753-6405.12739

Steele, L. S., Daley, A., Curling, D., Gibson, M. F., Green, D. C., Williams, C. C., & Ross, L. E. (2017). LGBT Identity, Untreated Depression, and Unmet Need for Mental Health Services by Sexual Minority Women and Trans-Identified People. Journal of Women’s Health, 26(2), 116–127. https://doi.org/10.1089/jwh.2015.5677

Veltman, A., & Chaimowitz, G. (2014). Mental Health Care for People Who Identify as Lesbian, Gay, Bisexual, Transgender, and (or) Queer. Canadian Journal of Psychiatry. 59(11), 1–7.


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