Taking pride in our content and communities: Understanding the mental health needs and barriers for LGBTQ+ communities across the globe.

***Content Warning: Some of the topics discussed below may be triggering for some readers, including discussion of suicidality and abuse. Please use your discretion when engaging with this content.

June is Pride Month and a good opportunity for PLOS Mental Health to continue shining a spotlight on the LGBTQ+ community – specifically the existing challenges that need to be overcome in order for society to progress and provide safety for all. Although there has been a lot of progress over the years, the fact that these conversations need to continue, and that barriers and stigma are still widespread, means that progress has not been adequate.  

Our Lived Experience Focus Group recently encouraged us to continue to be consistent and persistent when challenging the status quo and advocating for historically marginalized communities. Critically, such efforts must always be globally-inclusive. Understanding the needs of one group of people who are part of the LGBTQ+ community will not shed enough light on the needs of another – even if there are similarities. Intersectionality, which was coined by Kimberlé Crenshaw over 30 years ago, recognizes that different parts of a person’s social and political identity creates unique circumstances. No two people have the same needs – even if their circumstances share similarities. We must strive to fully understand the impact of…

• Race & Ethnicity
• Regional Variations
• Economic Disparities
• Religion & Culture
• Role Model Representation

…and many more factors that make us all unique. 

Race & Ethnicity

A few months ago, PLOS Mental Health published an article from Dr Andrew Ghobrial and colleagues at UCL and London School of Hygiene and Tropical Medicine, which explored how the intersection of sexual orientation and ethnicity shapes mental health experiences and service access for Cis-gender Asian, Black and Latin American men who have sex with men (MSM) in the UK. Following a series of interviews with 29 MSM over the age of 18, authors considered three meta-themes, which explored 1) Background, culture and upbringing, 2) Sexuality and manifestation of mental health issues, and 3) Barriers and facilitators to accessing mental health services. With respect to culture and upbringing, authors report that across all ethnicities participants felt that meeting expectations of stoicism and masculinity came at the cost of presenting a true version of themselves with regards to their sexual orientation. This was especially pronounced in participants from Black African and Black Caribbean backgrounds.  Participants who grew up in environments that encouraged mental health discussions however felt better equipped to manage their well-being.

So having African culture growing up, sexuality was never talked about so it was a secret and the father in the house at the time had a very toxic masculinity atmosphere, he was abusive while also didn’t have time for sadness or crying and we had to be ‘real men’ from young.” 18-25, Mixed White & Black African, gay, London – Participant in Ghobrial et al.

Those who experienced childhood trauma, abuse or early sexualization described direct links between such experiences and mental health struggles in adulthood as well as disempowerment and internalized shame that their sexual orientation was transgressive during a formative time in their lives.

With respect to sexuality in the present, many participants described mental health coping mechanisms that involved excessive use of alcohol, drugs or sex. They also described being less open about their well-being in their social circles. In short, many developed what felt like a parallel life. But some protective factors were identified – most frequently, inclusion within a network of gay people. Interestingly, younger participants felt more able to openly talk about their mental health and those who felt that their sexuality did not have an impact on their mental health appeared to have removed sexuality from their sense of self. In addition, pressure to appear resilient was especially prominent in participants from Asian and Latin American backgrounds whilst young black men in the study felt more pressure to conform to perceived hypermasculine norms. 

Finally, when considering barriers and facilitators to accessing mental health support, those who had accessed professional support had largely positive experiences and were more likely to return for support if needed – though comfort levels varied depending on mental health professional demeanor. Interestingly, many described private support (Vs National Health Service) as ‘better quality’, which comes with barriers dependent on financial means. Some participants avoided seeking support due to stigma – specifically fearing that their sexuality would be on their medical records. 

Overall, Ghobrial et al. highlight the importance of multi-system and interdisciplinary interventions to facilitate discussions surrounding mental health within Asian, Black and Latin American MSM communities. They call for the association between poor mental health and transgressing gender norms to be challenged.

Regional Variations

An interesting finding from the above study is that location also played a role in help seeking behavior. Those in rural areas for instance more frequently described struggles when it came to finding suitable support in terms of both mental health professionals and LGBTQ+ social networks. So, it is not surprising that, although there will be commonalities, facilitators and barriers will vary in different parts of the world. In April, PLOS Mental Health published a study, which addressed a very similar question to Ghobrial et al., but in the USA. Dr Alyssa Lozano and colleagues from University of Miami explore barriers and facilitators to behavioral health treatment among 235 Latino sexual minority men in South Florida. The authors specifically identify seven multilevel barriers and four multilevel facilitators:

Barriers:

1. Lack of mental health service knowledge
2. Lack of perceived need or urgency of support
3. Stigma and mistrust
4. Lack of mental health professionals with LGBTQ+ affirming expertise
5. Limited access to services/appointments
6. Insurance Issues
7. Language and immigration concerns

Facilitators: 

1. Peer support
2. Support with navigating mental health services
3. Mental Health provider demeanor
4. Affordability (if covered by insurance or low cost)

In terms of themes, many of these echo the findings of Ghobrial et al. However, when we dig into the specifics, we see some differences and we also see that language and immigration concerns appeared to be more prevalent among the study participants as well as the role of insurance (given the differences in health systems in the UK Vs US). 

So, whilst common themes emerge, local factors must be used to inform researchers and policy makers in order to improve mental health services and reduce disparities. 
Not only do we see differences in the barriers experienced between regions but also in the ways in which mental health can be understood and support can/should be delivered. For instance, at the start of this year, a study from Dr Mollie Ruben and colleagues at University of Rhode Island, Boston University and City University of New York demonstrated that nonverbal expressions of shame (e.g. shoulders slumped, chest narrowed) may predict suicidal ideation in LGBTQ+ adults – but only among those in rural settings as opposed to urban settings. Although these findings are preliminary and there are several limitations, they have potential implications for clinical practice and may eventually help mental health professionals to identify emotional distress more effectively and to modify interventions that support stigmatized populations.

Economic Disparities

Race and location are of course not the only factors, which contribute to mental health barriers for people in the LGBQ+ community. Economic disparities also shape mental health experiences. Last December, we published an article from Dr Udodirim N. Onwubiko and colleagues at Emory University and Johns Hopkins Bloomberg School of Public Health in which the impact of economic hardship on the stigma experienced by nearly 12,500 gay, bisexual, and other men who have sex with men (GBM) was examined. Those who experienced poverty also generally experienced more stigma and higher levels of psychological distress as well as more frequent suicide attempts compared to those with adequate income. Crucially, the psychological distress that was reported was more severe than levels found in earlier studies. This study uncovers the pivotal role of poverty in intensifying the impact of sexual stigma on the mental well-being of GBM. To further understand experiences and shed light on coping strategies, the authors separately consider four categories of stigma: 

1. Diverse stigma in multiple settings
2. Anticipated stigma in healthcare settings
3. Enacted and perceived stigma in family and social settings
4. Minimal experiences of sexual stigma 

They find that those who anticipate healthcare stigma tended to understandably avoid help-seeking, whilst those who experience more general stigma across all settings were found to develop a larger array of maladaptive coping mechanisms. The intensified impact of sexual stigma on mental health in the presence of economic hardship, which was mentioned above, applied across all categories of stigma. This emphasizes the necessity for comprehensive approaches that encompass addressing socio-structural factors. Future studies are needed to assess the effectiveness of tailored, stigma-informed mental health support, particularly within the context of poverty.

Religion & Culture

Many people find comfort in religion whatever and however they choose to practice. This becomes complex however when considering the intersection of religion of sexuality. In an international study from Hans Oh and colleagues (University of Southern California, Utah State University, Wheaton College, Southern Methodist University, Parc Sanitari Sant Joan de Déu and Anglia Ruskin University) the Healthy Minds Study, which includes data from over 100,000 people across 140 higher education settings, explores the associations between religiousness and depression. However it also examines whether these associations were moderated by religious affiliation and/or sexual orientation. The authors uncover a number of complex interactions. However, responses from participants who identified as being part of the LGBTQ+ community revealed that the protective effects of religion were diminished. For instance, among Christian and Muslim students, higher religious importance was associated with lower odds of depression, but this was only the case for heterosexual students – not in sexual minority groups. Authors also reported that bisexual students in particular experienced greater levels of depression if they identified as Buddhist or Mormon. Overall, the authors highlight that the association between religion and mental health is moderated by sexual orientation and the precise effects appear to vary with religion. Although the cross sectional nature of the study does not allow for causal inferences, it still enables us to appreciate just how unique needs are and that religious orientation should inform tailored interventions.

Role Model Representation

Finally, we know that representation is important – in any setting. Not just representation of identities, but also open discussions regarding mental health. At the end of last year, Katelyn Cooper and colleagues at Arizona State University considered the mental health of people who may be seen as role models for students in academia – and this includes those who openly identify as LGBTQ+. Specifically, they spoke to over 2000 science and engineering instructors. According to this study, instructors who identified as LGBTQ+ were more likely to report experiences of depression and anxiety (along with those who identified as women, white or Millennials). However, only 5.4% openly shared their depression experiences and 8.3% shared their anxiety. Reasons for not being open included a perception that mental health disclosures were irrelevant to their courses, and potential experiences of stigma. Thus, open discussions about mental health of role models in academia, including those who are part of the LGBTQ+ community is rare – despite students indicating that they would benefit from the disclosures. Given the high proportion of students who experience mental health difficulties, and the intensified experiences of those who are part of sexual minority groups, authors recognize the potential for instructors to serve as role models and call for more support to help them feel comfortable, and understand the need for disclosing. 

Nobody and nowhere should be exempt from striving for acceptance and safety

It is only through understanding everyone’s needs, and normalizing the goal to support these needs, that we can transform the LGBTQ+ mental health care and research landscape globally. There are varying degrees of stigma and safety in different parts of the world and as such, there is a need for locally-informed transformations. PLOS Mental Health has started to share specific calls for change. Last year, we published an Opinion piece and Essay that specifically called for transformations in Malaysia and the Philippines, respectively.

We hope to continue to build on the understanding that authors of the articles in this blog, and many others in PLOS Mental Health, have contributed to. Our message throughout the year, not just this month, is that nowhere should be exempt from striving for acceptance, safety and support for all.