Out On The Couch
The fight for LGBTQ+ rights has come a long way, but the battle for acceptance is far from over. Therapists working with clients who are members of the LGBTQ+ community commonly see elevated rates of mental health challenges in this population, including anxiety, depression, trauma, disordered eating, and even suicidal ideation (Young & Fisher-Borne, 2018). Many of these mental health struggles are partially or fully the product of oppressive practices and structures which remain unchallenged in our society. As a mental health professional, becoming aware of these harmful structures and how they affect your clients is essential to providing affirmative care. Here are some of the most prominent challenges facing the LGBTQ+ community today.
An issue facing the LGBTQ+ community is how basic healthcare services are often frustratingly out of reach. As previously mentioned, LGBTQ+ people are at a much higher risk of anxiety and depression and also tend to have a higher rate of substance abuse, which can cause serious physical health issues if not appropriately treated (Gnan et al., 2019). It is also worth noting that lack of gender- and sexuality-affirming care is often a barrier to LGBTQ+ people seeking treatment for mental health or substance abuse issues. This is unsurprising, given the healthcare system’s historic ignorance and even abuse when it comes to marginalized communities (Dentato, 2017). On top of these factors, even when medical care is available and non-discriminatory, LGBTQ+ people are twice as likely to be uninsured as non-LGBTQ+ people (Knoepp et al., 2022). And even when they are insured, LGBTQ+ patients face structural gatekeeping that prevents them from receiving appropriate care (Shapiro & Powell, 2017). Procedures like fertility treatment and gender-affirming care are especially difficult to access.
The frustrating truth is that many members of the community just have trouble finding medical professionals they feel comfortable with — who don’t exoticize or infantilize them (Shapiro & Powell, 2017). Just taking the time to listen to LGBTQ+ patients, trusting that they know what they are experiencing and what they need, seems like a low bar for any healthcare provider. Sadly, it remains a bar that medical professionals frequently fail to reach (Burton, 2015). The history of modern healthcare is full of gatekeeping and the pathologizing of LGBTQ+ existence. The esteemed psychiatrist and psychoanalyst Jack Drescher has layed out a detailed timeline of how “homosexuality” has evolved in our social consciousness over the years (2016). In the first Diagnostic and Statistical Manual (DSM) released by the American Psychological Association (APA) back in 1952, mental health professionals were instructed to diagnose homosexual behavior as “Sociopathic Personality Disturbance” (Drescher, 2016). This was changed to “Sexual Deviation” by 1968 in the DSM-II, and it was just in 1973 that the American Psychological Association finally voted to remove “Homosexuality” as a disorder and replaced with “Sexual Orientation Disturbance.” This was not the end, however! The DSM-IV, which came out in the year 2000, still contained the diagnosis of “Sexual Disorder NOS” which was frequently used to pathologize LGBTQ+ folk as “hypersexual” and “deviant actors.” In addition, the ICD-10 (International Classification of Diseases), which is maintained by the World Health Organization (WHO), didn’t remove homosexuality from its ICD classification until 1992. Today, it still carries with it the construct of ego-dystonic sexual orientation (Burton, 2015).
It should be no surprise that LGBTQ+ patients harbor anxious fears when it comes to the modern healthcare system. Most of us would not feel eager to seek treatment from professionals trained to pathologize our identities or disbelieve our lived-experience. These failures are not ancient history. They are living with us today, and allow those most in need of our help to fall through the cracks of our healthcare system.
Employment and Housing Discrimination
There are few things more important to survival than having a roof over your head and food on the table. Obtaining these key elements prove nearly impossible when an individual is locked out of housing markets or denied employment. A number of states in the US have passed laws protecting LGBTQ+ residents from these kinds of discriminatory practices, but far too many have failed to enact legislation. Even states that have taken steps to protect these minorities regularly fail to properly enforce these protections when necessary (Smith, 2020). There are far too many stories of long-term employees finally mustering the courage to come out of the closet only to face hostility in their workplace.
A similar scenario plays out with tenants and landlords all across the nation. LGBTQ+ tenants may be cast aside by a queerphobic landlord with little legal support or substantial recourse (Permenter, 2012). It is no wonder that a striking 22% of LGBTQ+ individuals live in poverty, and 17% have experienced homelessness, statistics made more dire when adjusted for racial discrimination (Wilson et al., 2020). Federal legislation like The Equality Act has long been stalled as lawmakers squabble over issues like recognition of more than two gender identities (Zalot, 2019). Another commonly debated issue is the role of religious organizations in supporting LGBTQ+ community members, and whether these organizations have a right to refuse to serve them (Zalot, 2019). The discourse these debates produce actively diminishes and marginalizes the lived experiences of oppressed communities by turning them into a bipartisan issue rather than a human rights concern.
These structures of inequality create and sustain an environment where being a member of the LGBTQ+ community is a threat to a queer person’s own wellbeing as well as the people they they love. Recent experiences with major global events like a pandemic or a recession, have starkly demonstrated how marginalized communities are the first to be affected and often the last to recover (Goldsmith et al., 2021). This destabilization can make basic survival feel like a tenuous balancing act. Whether at the hands of a major event or individual instance of discrimination, the threat of poverty and homelessness is constant for LGBTQ+ people, and can become grim reality at almost any moment.
According to the Los Angeles LGBT Center’s Finding Safety (2020) study examining gendered violence, LGBTQ+ populations experience a higher rate of violence than their cisgender, heterosexual (“cishet”) peers. This can be observed in multiple areas of LGBTQ+ life. For one, the Finding Safety study revealed that 1 in 5 hate crimes in the US are due to sexual orientation, while another 2% of those hate crimes are due to gender identity. At the intersections of gender-based violence and race, trans women of color face some of the highest rates of violence across all demographics, and each year sees a steady increase in homicide rates for TGNC individuals (Dinno, 2017; Gerstenfeld, 2019; Holt, 2020). Additionally, LGBTQ+ children and young adults remain significantly more susceptible to bullying and harassment in school than their cishet peers (Earnshaw et al., 2020). The 2020 Finding Safety report found that approximately 80% of the LGBTQ+ survivors who come to the STOP Violence Program at the Los Angeles LGBT Center have experienced intimate partner violence (IPV), and it is estimated that 1 in 5 LGBTQ+ relationships has occurrences of IPV overall (Holt, 2020). These statistics demonstrate how violence and the threat of violence confront LGBTQ+ individuals at almost every level of society, from public to private.
Complicating this issue further is the fact that there is an entrenched distrust of the criminal justice system in LGBTQ+ communities – one that is deeply justified by a history of mistreatment by law enforcement. For example, the celebration of Pride each year is a memorial to how LGBTQ+ folks fought back in the face of police oppression and violence during the Stonewall Riots (Stein, 2019). Distrust of the justice system combined with a decreased access to legal or social resources makes identifying and confronting the threat of violence a continuous struggle. This is another reason why it is important for therapists and other healthcare workers to remain educated as to how to provide safety and resources to the LGBTQ+ community. There is often nowhere else for queer people to turn, as most social safety nets have proven unable to prevent harm – if not actively inflicting it themselves.
It comes as no surprise that though adoption by same-sex couples is currently legal in all 50 states, LGBTQ+ people who want to become parents still face heavy discrimination from many adoption and social service agencies (Farr et al., 2020). For people who decide to pursue artificial insemination or surrogacy, many of these procedures are remarkably expensive or are not covered by insurance, locking many LGBTQ+ folks out of the healthcare systems that facilitate family-planning (Spoto, 2021). In some states, only the person who gave birth can sign a child’s birth certificate, meaning that any non-gestational parent immediately runs into frustrating red tape. These cases are typically resolved by having the non-gestational parent pursue a legal adoption of their child, an unnecessarily difficult process to simply be recognized as a parent (Levitt et al., 2020). This circus of discrimination is enough to keep many potential parents waiting for years, if not forever.
For many LGBTQ+ folks, coming “out of the closet” also means “packing up the closet” and moving away from their friends and family due to intolerance, hatred, and abuse in their home community. The brave and beautiful journey of self-discovery and self-love that leads someone to come out as their most authentic self often leads LGBTQ+ individuals to the abyss of cultural ostracization. This can manifest as threats to one’s safety, dangerous bouts with conversion therapy, exclusion from family and broader communities at work, school, or church, abuse by people in these communities, and (far too frequently) even death (Savin et al., 1998). Sometimes these threats and exclusion are direct and overt. Other times, they are subtle, slowly eating away at the LGBTQ+ individual until their heart, spirit, mind, and body are broken down and depleted. It is no wonder that LGBTQ+ individuals experience frighteningly elevated risk of suicide, dropout, homelessness, and hate crimes (Khan et al., 2017). Transgender youth are 50% more likely to consider suicide than their cisgender peers—a staggering statistic, and a call to action for communities and mental health practitioners everywhere (Khan et al., 2017). There is a reason that LGBTQ+ communities refer to “found family” and build healthy, supportive community structures for each other, welcoming anyone who has been cast aside and left behind. It is a beautiful response to such ugly circumstances.
This list is not an exhaustive exploration of the challenges facing LGBTQ+ communities. That list has already filled many, many books lining many, many shelves around the world. As time and culture move on, these challenges will shift, change, and take various forms. As clinicians and mental health providers, it is essential to remain abreast of how the landscape is changing and affecting our LGBTQ+ clients. Some days, it can feel like every step forward for progress and hope and love just results in two steps backward. But it is during those times when the work of therapy and community mental health becomes most important and when our gentle courage must shine the brightest. We must hold space for both the grief and the hope–that is the work of healing.
We can’t change the world at the snap of a finger, but we can take intentional steps to make it a more welcoming place. If you’re a mental health professional that wants to be a part of this change, the Affirmative Couch can help. We provide LGBTQ training for therapists who want to learn how to provide competent care to their LGBTQIA+ clients. Contact us today to learn more.
Learn more about working with LGBTQIA+ Clients
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