Understanding LGBTQ+ Mental Health

Risks to LGBTQ+ Community Members

The LGBTQ+ community is incredibly diverse, and each of these identities manifests in an individual in a unique way. Many people claim more than one of these identities.

Unfortunately, each of these identities (separately or together) carries risks of persecution, isolation, and reduced health outcomes.

Intersectionality is a framework for understanding how multiple forms of inequality overlap and can create barriers for people.

When someone identifies as a member of multiple oppressed populations, they can face compounding stigma, prejudices, and challenges related to each identity.

Because of this, when a person who identifies as LGBTQ+ is also a member of another marginalized population, the impact on mental health is even greater. For example, a Black transgender woman would contend with cisgenderism, sexism, as well as racism.

It’s important to understand why members of the LGBTQ+ community often experience mental health concerns. It’s not because of an innate fear of their own identities, but rather because members of this community face so many threats.

Coming Out

Coming out is an important step for anyone who has realized they are gay, bisexual, transgender, or otherwise different from what many people (erroneously) believe to be the “norm” of heterosexual, cisgender identity.

When a person comes out, they are freer to express who they really are and can begin to live a life that is more representative of them and their needs.

Society has made strides in accepting people for their identities. In the U.S., the past two decades have seen legislation protecting the rights of LGBTQ+ people in areas including marriage, adoption, and military service. LGBTQ+ people are also more broadly represented in media, sports, and politics.

However, such acceptance has created a backlash effect on LGBTQ+ mental health. State legislation increasingly targets LGBTQ+ youth and adults in areas including health care, education, public places, services, as well as drag performances and entertainment. Bills targeting transgender people, in particular, are growing more common.

As GLAAD points out, the majority of anti-LGBTQ+ bills fail to become law. However, public discussion and questioning of the humanity of LGBTQ+ people create proven harm, including an impact on mental distress among young people.

Members of the LGBTQ+ community can face rejection, discrimination, and health disparities. Hate crimes, which are on the rise for many marginalized populations, are also high for LGBTQ+ people.

As many people are coming out earlier and at younger developmental ages, they may face criticism and discrimination when they are less emotionally prepared to handle it. This can also have detrimental effects on their development.

Coming out can be a frightening experience. Just as voices of pride and allyship have been amplified in recent years, sadly, harmful messages have grown louder, too.

Rejection and Isolation

Unfortunately, coming out isn’t merely an issue of being courageous enough to do so. Many people experience serious social consequences, some from close family members or friends.

Young people often forge connections in school, clubs, sports, and other social groups. However, in an unaccepting environment, LGBTQ+ kids and teens can be bullied and ostracized.

Facing the rejection and isolation they know or suspect will come, LGBTQ+ people may choose to keep their identity hidden even from those closest to them. This may cause them to become isolated even without sharing their identity.

Older adults in the LGBTQ+ community are also especially vulnerable to isolation. Seniors are already at greater risk for loneliness and social isolation due to loss of family and friends and other factors.

However, senior adults identifying as LGBTQ+ came of age in a world that was even harsher to the community. They are more likely to have cut ties with an unsupportive biological family, missed out on finding a partner, or struggled to find supportive friends.

Pride centers and other community organizations can serve as safe, welcoming spaces for LGBTQ+ people of all ages. Such organizations can provide emergency services, connect people to counseling and medical services, sponsor social activities, and more.

According to Day, representation in areas such as entertainment and sports also plays an important role in decreasing a sense of isolation even when people do not feel safe to come out.

“It’s vital that we have LGBTQ+ representation in popular culture so that if you don’t have someone who is in your immediate vicinity, you can see it and at least know that it exists,” he says. “And when you grow to a place where you’re able to come out, you’ll realize you’re not alone.”

Discrimination and Microaggressions

Discrimination and bullying are two major consequences of claiming one’s identity and can have adverse effects on LGBTQ+ mental health. The ramifications take their toll in the form of fear, anxiety, depression, and PTSD.

According to The Williams Institute, almost half of those who identify as LGBTQ+ have faced unfair treatment, job discrimination, or harassment in the workplace at some point in their lives.

To avoid discrimination, many LGBTQ+ employees engage in “covering” behaviors—actively concealing their opinions, thoughts, and feelings in an effort to fit in.

Even those who don’t face tangible consequences in their careers still face microaggressions: subtle insults directed at marginalized people. Microaggressions directed towards the LGBTQ+ community can include heterosexism, such as assuming a woman’s partner is male or neglecting to address someone by their correct pronouns.

Whether intentional or unintentional, such communications are harmful.

Medical Mistrust and Health Disparities

Many people in the LGBTQ+ community fear getting medical assistance, even for conditions that are unrelated to their identity.

In medical settings, LGBTQ+ people can be misgendered, judged for their sexual behavior, and blamed for having or transmitting sexually transmitted diseases. They can even receive unwanted physical contact or verbal harassment. Because of this, even the act of receiving basic medical care can be traumatizing.

Facing such possibilities, members of the community may avoid medical treatment and go on to experience health consequences.

Lack of Adequate Mental Health Care

As with physical health care, mental health care brings its own challenges related to discrimination, harassment, and misunderstanding.

Clinicians may lack cultural competency or the ability to navigate the identities and backgrounds of people in the LGBTQ+ community (let alone intersecting identities, such as ethnicity). This makes it even more difficult for those who gay, lesbian, bisexual, transgender, and other sexual and gender minorities to get the help they need.

Unfortunately, even compassionate professionals often lack the training necessary to give LGBTQ+ mental health its due. Some clinicians lump all members of the community together, which not only fails to acknowledge the unique humanity of LGBTQ+ people, but also makes it difficult to provide the appropriate care.

Culturally competent therapy can help LGBTQ+ individuals confront barriers and mental health symptoms.

According to the National Alliance on Mental Illness (NAMI), when members of the LGBTQ+ community confront barriers and symptoms in the presence of an LGBTQ+ mental health professional, they can have better health outcomes and experience recovery.

Homelessness

Research shows that LGBTQ+ youth experience homelessness at a rate at least twice that of their heterosexual, cisgender counterparts. They are also more likely to die at a younger age and to experience other adversities.

Because of the rejection, isolation, and lack of mental health care they face, many members of the LGBTQ+ community can struggle to carry out the basic business of life, from working to finding housing. The problem can be even greater when members of this population have certain additional cultural identifiers.

Fear of Hate Crimes and Sexual Violence

Fear takes its toll on LGBTQ+ mental health. Many people within this community live in a constant state of terror that they or their loved ones will suffer because of their sexual orientation, gender identity, or other characteristics. Dangers from hate crimes and sexual violence take a serious toll on LGBTQ+ mental health.

According to the FBI Hate Crime Statistics from 2020, more than 20% of hate crimes occurred due to the offender’s feelings about the victim’s sexual orientation. An additional 2.5% of offenders committed crimes because of the victim’s gender identity.

The Robert Wood Johnson Foundation states that 57% of LGBTQ+ people have experienced slurs, and 53% have experienced offensive comments about their identity. Additionally, 15% of LGBTQ+ individuals reported that people have acted afraid of them because of their sexuality or gender identity.

Conversion Therapy

Conversion therapy, now often called reparative therapy, is one of the most serious dangers to LGBTQ+ mental health.

This is a practice whereby people in the lesbian, gay, bisexual, transgender, queer, intersexual, or asexual individual’s life attempt to use physical and psychological techniques to “turn them straight.”

Conversion therapies are often faith-based: some religious communities believe that minority sexual orientations and identities are morally wrong.

Conversion therapies’ techniques range widely, all with the intent to “cure” the affected individual, and include:

• Prayers over the person
• Abuse
• “Corrective” rape
• So-called counseling
• Threats of homelessness or shunning
• Exorcisms

Unfortunately, these “treatments” are not nearly as scarce as they ought to be, and a significant percentage of LGBTQ+ community members (7%, according to a UK source) have been subjected to or offered them.

Common LGBTQ Mental Health Issues

The following list of mental health concerns is not restricted to the LGBTQ+ community.

However, as with all other segments of society, these issues are common to those who face higher-than-average amounts of stress, have to fight for their identity to be recognized or accepted, face confusion and/or persecution in their everyday lives, and generally feel unsafe or unseen.

The prevalence of mental health issues varies among different parts of the LGBTQ+ population.

For instance, the challenges a gay cis man faces in life may be different from those of a gender-nonconforming bisexual person. This is not to say that anyone’s experiences are more or less valid or difficult, just that there is natural variation.

It is important to note that the LGBTQ+ community is varied. There is a range of individuals within it. Those who provide care must understand how to treat each person in the way that best suits them.

Anxiety and Depression

Anxiety and depression are two of the most common forms of mental illness, both in the LGBTQ+ community and in heterosexual, cis populations. These conditions can have detrimental effects on everyone, including children, adolescents, young adults, and older generations.

LGBTQ+ people are 2.5% more likely to experience anxiety and depression than their heterosexual counterparts, according to the American Psychiatric Association.

Depression manifests as low enthusiasm for activities that normally create feelings of joy and satisfaction, loss of interest in everyday self-care and social situations, and decreased success in school, work, and home environments.

It’s important to distinguish between depression and sadness.

The latter is situational, resulting from discrete events, such as the death of a loved one or the loss of a job. When a person is sad, they can still enjoy activities and people they love.

Depression, however, is different. It can make someone feel isolated, hopeless, and disgusted with themselves.

Rather than creating states of listlessness and disinterest, anxiety manifests as hyperawareness and a constant feeling of being on edge or afraid. Anxiety is the feeling that there is a threat present—which in the case of LGBTQ+ mental health, is often justified.

As with depression, situational anxiety is normal. Waiting for the results of a medical test or to find out about a big promotion naturally creates anxiety.

On the other hand, a constant state of worry about both little and big things is likely a sign of potential anxiety or a related disorder.

Post-Traumatic Stress Disorder

PTSD arises as a result of traumatizing experiences that someone hasn’t adequately processed. Members of the LGBTQ+ community are particularly susceptible to PTSD.

Trauma can arise from a number of upsetting factors, including but not limited to:

• People not being supportive of coming out
• Abuse at the hands of family members or partners
• Verbal harassment, bullying, and discrimination
• Learning about bad things happening to peers, friends, or partners
• Conversion therapy

Any of these can impact LGBTQ+ behavioral health for the worse.

Eating Disorders

Recent studies show that LGBTQ+ status is linked with disordered eating. Members of the community experience a greater incidence of eating disorders and disordered eating behavior than their heterosexual and cisgender counterparts.

According to research compiled by the National Eating Disorders Association (NEDA), gay males were 12 times more likely to report purging than heterosexual males, and females who identified as lesbian, bisexual, or mostly heterosexual were about twice as likely as heterosexual women to report binge eating at least once per month in the last year.

Risk factors for eating disorders are higher for those identifying as LGBTQ+. Research shows that when a person experiences stigma or shame or conceals their sexual or gender identity, their risk of developing an eating disorder increases.

Other factors are also involved. For example, body dissatisfaction is higher among sexual minority men than heterosexual men. According to research, gay and bisexual men may feel more pressure to maintain a lean and muscular physique. Body dissatisfaction has been linked with several negative health outcomes, including depressive symptoms.

As conceptualized by the minority stress model (MSM), even though most difficulties faced by members of minority groups can’t cause direct health problems, they contribute to stress that creates such issues. Eating disorders are one manifestation of minority stress.

Suicide

All of the above can increase suicide risk for an LGBTQ+ person. It is critical that if you are a member of this community or care about someone who is, you know the signs of suicidal thoughts and behaviors as well as preventative strategies.

According to the National Alliance on Mental Illness (NAMI), LGBTQ+ high school students are more than four times as likely to have attempted suicide than their heterosexual or cisgender peers. The numbers are eight times higher for transgender adults compared to the general U.S. population.

The American Psychiatric Association reports that older adults within the LGBTQ+ population face the challenge of ageism in addition to LGBTQ+ stigma. Roughly 31% of older adults within the population report depressive symptoms, and 39% have had serious thoughts of suicide.

Substance Use and Misuse

One way that people attempt to deal with poor mental health is through substance use. Drugs and alcohol can temporarily numb the pain that comes with anxiety, depression, fear, PTSD, alienation, and isolation. Often, substance misuse will eventually lead to addiction if left untreated.

While there are no definitive studies on the rates of substance use and misuse in LGBTQ+ communities, the National Institute on Drug Abuse reports that sexual minorities have higher rates of substance use and substance use disorders than people who identify as heterosexual.

Drug misuse can lead to its own dangers unrelated to gender or sexual minority status, including:

• Loss of jobs and housing
• Damage to relationships
• Physical abuse and sexual violence
• Higher rates of STDs

Many of these issues can affect even very young people.

Youth Mental Health in the LGBTQ+ Community

While LGBTQ+ mental health is an issue worth taking seriously at any age, it is of special concern when it comes to young adults, children, and teens. Mental illness, eating disorders, trauma, and substance use can have particularly far-reaching consequences at this age.

It is the responsibility of families, schools, communities, and health care providers to do the most they can to prevent such situations from arising wherever possible.

According to The Trevor Project:

• More than half of transgender and nonbinary youth have seriously considered suicide in the past year
• Nearly half of LGBTQ+ youth reported wanting and failing to receive mental health counseling
• Three-quarters reported discrimination at least once in their lifetime
• 13% reported undergoing conversion therapy, and of those, 83% were under the age of 18

Moreover, according to the CDC, lesbian, gay, and bisexual youth in grades 7-12 were more than twice as likely to have attempted suicide as their heterosexual peers.

Barriers to Care and Treatment

It is important to address the many barriers to care that exist in the LGBTQ+ population and explore the right treatment options.

Any time you have a minority group with different characteristics and needs than the majority population, barriers will exist. As a society, we must address these barriers. Just because they exist does not mean they are permanent or unsolvable.

We need to acknowledge the difficulties of treating a group whose unique challenges aren’t yet fully understood and aren’t taught to the entire pool of health care providers.

The most significant barriers to care include:

• Judgment of same-sex or otherwise non-heterosexual activity
• Decreased access to services in Black and Hispanic communities
• Harsh language during care
• Outright denial of care related to gender or sexual orientation
• Culturally inappropriate care
• Scarcity of mental health resources
• Mental health stigma within ethnic minorities
• Cost

How To Address LGBTQ+ Mental Health Issues

Understanding barriers to care gives us the opportunity to build better ways of addressing LGBTQ+ mental health.

Below are some of the most important challenges to confront in homes, schools, healthcare systems, places of worship, and community centers.

Reduce Stigma

Stigma is perhaps the most important factor to address in LGBTQ+ mental health. Societal judgment of sexual and gender identities is common and very harmful.

We can reduce stigma by speaking up when we see injustice. Allies and LGBTQ+ community members alike can be good listeners, openly share their support for LBGTQ+ communities, and cultivate places to have open, honest conversations.

Medical and mental health settings should lead the way in ending stigma since these are places where LGBTQ+ people may need the most support.

Trauma-Informed Care

The high degree of trauma to which many LGBTQ+ people are subjected, combined with the lack of available support, means these folks must often devise their own coping strategies. Coping can sometimes take a negative form, such as when people turn to drugs and alcohol.

Trauma-informed care can help people develop more positive strategies, such as finding support from other LGBTQ+ people.

Speaking openly about romantic and sexual emotions can help, as can talking to mental health professionals who understand the effects of trauma. This will, in turn, reduce the incidence of repression, anonymous sex, drug dependency, and suicide.

Many members of the LGBTQ+ community have justifiable medical mistrust based on past health care experiences. Mistrust can happen as a result of providers using incorrect pronouns, using inaccurate words for anatomy, or touching patients in a way that is uncomfortable.

Day says, “My vision for trauma-informed care in the LGBTQ+ community, is to always ask.”

For example, Day shares that when he examines a patient who identifies as LGBTQ+, he inquires, “Would it be alright if I listened to your heart and lungs? I’m going to place my stethoscope on your chest now. Please let me know if at any time this becomes uncomfortable. I would be happy to stop, and we can have a conversation or we’ll talk about it another day.”

Identity-Affirming and Gender-Affirming Care

Providers should always make the effort to give care tailored to an individual’s identity. The needs of a gay person are different from those of a bisexual, transgender, or asexual individual, for instance. Care needs to be offered on the basis of a person’s unique identity—or intersection of identities.

It is important to keep in mind that some people are still questioning their identities. If someone does not yet know how they identify, it can be harder for them to express their needs. In such cases, providers must still make every available effort to provide quality, customized care.

Inclusive environments are very important. Doctors’ offices and clinics, community centers, and schools should reflect the diverse range of people in the community through visuals, pamphlets, and language. Such messaging helps LGBTQ+ members feel safe and supported.

How To Find the Right Mental Health Professional

If you are looking for a mental health professional for yourself or a loved one, follow these steps:

• Consider carefully what you need in a provider
• Get referrals from schools, other health care providers, or community centers
• Make phone calls to see who is available
• Ask detailed questions of the provider to see if they can help
• Continue to see them regularly to build up the trust needed to openly discuss deep personal issues

Pillars of LGBTQ+ Mental Health Support

There are three main pillars of LGBTQ+ mental health support. These include:

• Family and allies
• School and community
• Mental health providers

How Family and Allies Can Help

The manner in which family and friends respond to sexual orientation, gender identity, or gender expression is critical. Families should always support the individual with love and without judgment. Where necessary, family therapy can be a positive addition to LGBTQ+ mental health care.

Family members can show support by joining organizations such as PFLAG, which supports and advocates for LGBTQ+ people and their families. According to Day, such resources are invaluable for educating friends and family members about the experiences of the LGBTQ+ community.

“What we find in the literature is that LGBTQ+ community members get tired of being the teachers. They need to be the ones who get the support,” Day shares.

“So, if you can look outside of the family to the community to learn more about it so you can make your family member feel more comfortable, that would be a wonderful thing.”

Anyone who wants to show support for the LGBTQ+ community can take political action by voting, advocating, and staying aware of the pressing issues in LGBTQ+ rights.

Allies can take part in local Pride efforts, such as festivals and parades. They can also make everyday efforts, such as wearing ally pride pins or speaking up when someone else makes a bigoted remark.

“Those are the things that create change,” Day points out. “There could be an LGBTQ+ person who is nearby and then realizes, ‘Okay, I have an ally here. This is somebody who is going to stand by my side.’ Being an ally is about being visible.”

The Role of Educators in LGBTQ+ Well-Being

Schools that offer LGBTQ+ support groups have experienced significant improvement in reducing suicide rates and victimization. All schools and community centers should aim to be gender-affirming, identity-affirming, and inclusive.

According to Day, educators of those who may be coming to terms with their sexuality or gender identity can be supportive by getting involved in gay student alliances and LGBTQ+ organizations, and otherwise identifying themselves as allies to the community.

“By doing so, young people will feel more comfortable in reaching out for guidance and understanding,” he says.

Best Practices for LGBTQ+ Mental Health Providers

Anyone who provides mental health care should follow best practices such as:

• Telling their patients that they ask the same questions of everyone to create an inclusive environment
• Asking people to describe themselves and their identity
• Remaining respectful of boundaries regarding private information
• Being frank and unemotional about issues surrounding sex, STDs, and identity
• Checking in on the patient’s support system
• Reinforcing inclusive, compassionate language in the office or clinic
• Asking about someone’s pronouns