Lesbian, gay, bisexual, transgender and/or queer (LGBTQ) individuals often face significant barriers when accessing mental health services. Barriers to care include discomfort or fear of disclosing LGBTQ identity because of real or perceived homophobia, biphobia, and/or transphobia, a patient’s own internalized homophobia, biphobia, and/or transphobia, and heterosexist and/or cisgenderist assumptions on intake forms and during health care encounters.1
Moreover, the historic and continued pathologization of LGBTQ identities by the medical/psychiatric community, including previous experiences or stories of “corrective” or “reparative” therapies as well as the historical inclusion of homosexuality in DSM (removed in 1973) and the controversial continued inclusion of gender dysphoria in the DSM IV, may contribute to mistrust of mental health professionals on the part of individuals who identify as being part of sexual and/or gender minority groups.2
The concept of “dual alienation” is the idea that individuals who belong to more than one marginalized group are doubly marginalized.3 Individuals with mental health issues who identify as LGBTQ belong to at least two traditionally marginalized groups. If they also happen to belong to other marginalized groups because of their race, ability, socioeconomic status, or any other factor, the marginalization they experience is cumulative and much more complex.4
Moreover, individuals who identify as members of sexual and gender minorities experience increased risk for some mental health issues. For example, LGB-identified individuals have a 2 to 6 times higher lifetime risk of suicide and/or depression than the general population.5 Among trans-identified individuals, the statistics on suicidality are staggering, with 77% of respondents in one Canadian study reporting that at some time in their lives they had seriously considered suicide and 43% reporting they had made at least one suicide attempt.6 In a large study of people who identify as gender variant (6450 participants), 41% reported attempting suicide at some point in their lives.7
This increased risk for various mental health conditions in this population is mostly a result of discrimination, marginalization, and homophobia, biphobia and/or transphobia, rather than something inherent to having an LGBTQ identity. LGBTQ-identified individuals experience increased vulnerability to mental health issues due to a variety of factors, including bullying, violence, discrimination, heterosexism/cisgenderism, homophobia, biphobia and/or transphobia, and potentially, the loss of support and rejection by friends and family.8 As an example of the potential detrimental effects of rejection by family, in a large study of LGB-identified youth, those who came from highly rejecting families were more than 8 times as likely to have attempted suicide than LGB peers who reported no or low levels of family rejection.9
Dr Veltman is Associate Professor, Department of Psychiatry and Behavioural Neurosciences, McMaster University; Psychiatrist, Hamilton Assertive Community Treatment Team, Dual Diagnosis Team, and LGBTQ Mental Health Clinic, St. Joseph’s Healthcare, Hamilton, ON, Canada. Dr La Rose is Assistant Professor, School of Social Work, McMaster University, Hamilton, ON. The authors report no conflicts of interest concerning the subject matter of this article.
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