Pride can be a unifying force that brings people together in a positive way to achieve a goal. Pride is also a feeling that arises from self-respect. During Pride Month, the LGBTQIA+ (lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual, and other genders and identities) community honors diversity, while also advocating for equality and acceptance.
Yet, many LGBTQIA+ individuals routinely face discrimination, ranging from biased public policies to subtle microaggressions to outright violence. Additionally, many individuals wrestle with their own sexual identities, resulting in deep distress. Depression, anxiety, and suicide are common behavioral health concerns.
As health service providers care for LGBTQIA+ patients, they must keep behavioral health and well-being top of mind. Knowing that LGBTQIA+ individuals experience behavioral health issues at a higher rate than heterosexual and cisgender individuals (those who identify with the male or female gender assigned at birth), care providers should consider screening all LGBTQIA+ patients routinely to ensure they receive appropriate care.
LGBTQIA+ and behavioral health conditions
A number of factors contribute to mental well-being for LGBTQIA+ individuals, just as they do for anyone. However, the prevalence of behavioral health issues is higher for LGBTQIA+ individuals, according to research.
The National Survey on Drug Use and Health (NSDUH), published in September 2020 by SAMHSA, notes that 7.6 million LGBTQIA+ adults had a mental health condition or substance use disorder (SUD) in 2019, reflecting an increase of more than 20 percent over the previous year. About 1.9 million LGBTQIA+ adults experienced both a mental health condition and SUD, representing 12.9 percent of the population. By comparison, 3.8 percent of the general population reported both a mental health condition and SUD.
Serious mental illness and major depressive episodes are on the rise for LGBTQIA+ communities, according to NSDUH. In 2019, 2.6 million LGBTQIA+ adults age 18 and older experienced serious mental illness — a significant increase from the 1.4 million reported in 2014. This figure represents more than 18 percent of the LGBTQIA+ population, compared with 5.2 percent of the general population.
Tragically, the rates of suicide and suicidal ideation for the population remains high with national statistics showing these trends are also increasing.
Serious thoughts of suicide
- LGBTQIA+ (age 18 to 25): 27.9%
- General Population (age 18 to 25): 11.8%
- LGBTQIA+ (age 26 to 49): 14.5%
- General Population (age 26 to 49): 5.3%
- LGBTQIA+ (age 18 to 25): 5.5%
- General Population (age 18 to 25): 1.8%
- LGBTQIA+ (age 26 to 49): 2.2%
- General Population (age 26 to 49): 0.6%
As the data demonstrates, suicide disproportionately impacts younger individuals. A 2020 national survey from the Trevor Group found among LGBTQIA+ individuals age 13 to 24, 40 percent seriously considered suicide in the previous 12 months, and 48 percent engaged in self-harm.
What’s most challenging about capturing an accurate picture of these serious behavioral health concerns is that the full range of LGBTQIA+ identities are not typically included in studies. In fact, SAMHSA didn’t begin to collect information on identity or sexual orientation for its studies until 2015. In general, this means the prevalence of behavioral health conditions could be under-reported or inaccurately reported in many studies and trend lines.
Factors driving behavioral health concerns
Identifying as LGBTQIA+ does not by itself cause a particular risk for behavioral health conditions, but fear, rejection, discrimination, bullying, and violence commonly experienced by the population is what often increases the risk. These influences permeate everyday life. Discrimination in the workplace can result in lower income or job loss for adults. Rejection by family can make home life difficult, and bullying at school can make it hard for youth to learn or make friends.
The Trevor Project survey found that 60 percent of LGBTQIA+ youth experienced discrimination. And 1 in 3 reported that they had been physically threatened or harmed in their lifetime because of their sexual orientation and/or gender identity. Something as simple as using a restroom that corresponds with their gender identity can cause discrimination for transgender and nonbinary youth.
Surprisingly, even healthcare providers demonstrate bias against LGBTQIA+ individuals. The American Journal of Public Health reported in 2015 that among heterosexual providers, implicit preferences largely favor heterosexual people over lesbian and gay people. While the study didn’t examine the effects related to the care these clinicians provide, it’s not hard to imagine the potential for reduced care quality as well as low patient satisfaction.
At the highest extreme, bias against LGBTQIA+ individuals can take the form of violence, which includes everything from pushing and shoving to fatal assaults. In fact, the Human Rights Campaign (HRC) Foundation — which has collected data on violent deaths since 2013 — reported that at least 37 transgender and gender non-conforming people were killed in 2020. It’s the largest number of deaths HRC has reported so far.
According to HRC, divisive and dehumanizing rhetoric contributes to “the toxic mix of racism, sexism and transphobia that drives this horrific violence.”
What care providers can do
As care providers strive to be more inclusive of the range of identities and the fluidity of gender, they can further refine their approaches to behavioral health concerns in the LGBTQIA+ community. Even more so, broader efforts are needed to address barriers to care for this underserved population.
The Trevor Project survey reported that 84 percent of the more than 40,000 youth respondents said they wanted counseling from a mental health professional, but only 38 percent received it. Inability to afford care was the most common barrier, followed by concerns about parents’ permission to obtain care and concerns about finding an LGBTQIA-competent provider.
For care providers, the most important action they can take is to ask their patients how they’re feeling and screen for mental health and SUD conditions. They should be open to having an honest discussion about behavioral health needs, referring to specialty care and LGBTQIA-competent providers when appropriate.
Some simple actions can also help care providers support LGBTQIA+ patients. For example, clinicians should understand the terms often used to identify gender, including “gender fluid” and “nonbinary.” Providers also might ask patients which pronouns they prefer or if they want to be called by a first name other than the one on their identification or insurance card.
Caring for the behavioral health needs of transgender and gender non-conforming patients helps to build more-inclusive systems of care. By doing so, providers can promote improvements in health equity and better serve their communities.