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Introduction
Stark inequalities exist around LGBTQIA+ (lesbian, gay, bisexual, transgender, queer, intersex, asexual/aromantic and other sexual and gender minority, including non-binary) rights internationally, including the death penalty in at least seven countries.1 However, the last 50 years have seen huge strides towards social acceptance and legal provisions for LGBTQIA+ people in western countries (specifically, Western Europe, the Americas and Australasia).2 Same-sex sex has been legalised and anti-discrimination protections, equal marriage, civil partnerships and same-sex adoption introduced.3 Similarly, the Global Acceptance Index4 suggests that LGBTI (My terminology and abbreviations reflect the specific wording of the study described, so, for example, Flores’ (2021) global acceptance index includes lesbian, gay, bisexual, transgender and/or intersex participants only) social acceptance has dramatically increased since 1980. Despite these improvements, LGBTQIA+ people experience multiple mental health inequalities compared with our heterosexual and cisgender (non-trans) peers.5 6 This editorial explores the mental health inequalities of LGBTQIA+ communities in western countries, examines why they occur and considers what nurses can do about this.
What are LGBTQIA+ people’s mental health inequalities?
Multiple systematic reviews7 and meta-analyses8 have established that globally LGBTQIA+ people are at higher risk of mental disorders, self-harm, suicidality and substance misuse than our heterosexual and cisgender (non-trans) peers.5 6 9 10 For example, King et al’s meta-analysis of 25 studies published between 1967 and 2005 found that LGB people are twice as likely to attempt suicide and 1.5 times more likely to experience anxiety or depression than heterosexuals.6 Sadly, little has changed in the last 20 years; Wittgens et al’s meta-analysis of 26 post-millennial studies found lesbians and gay men are twice and bisexual people 2.7 times more likely to experience mental health disorders than heterosexuals.5 In addition, Pinna et al’s systematic review of 165 articles suggests that transgender people experience more mental health disorders than heterosexual and cisgender LGB folk10 while Scandurra et al’s systematic review of 11 studies found non-binary and genderqueer people, that is, people who do not identify as having either female or male gender,11 12 have worse mental health than cisgender and other transgender folk.9
It is important to understand that LGBTQIA+ people are not one homogenous group, but rather multiple distinct communities with unique mental health inequalities.13 For example, lesbian and bisexual women are at greater risk of substance dependence than gay and bisexual men, who themselves are more likely to attempt suicide,6 with bisexuals at greater risk of depression than lesbians and gay men.5 However, while the mental health inequalities of LGBTQ and non-binary people are established, far less research has considered the experiences of our wider community (eg, asexual, aromantic, intersex people, etc). What little evidence does exist suggests they also have worse mental health than heterosexuals.14–17 These inequalities are likely underpinned by LGBTQIA+ sub-communities’ different experiences of stigma, prejudice and barriers towards health, as I will now explore.
What explains these mental health inequalities?
Critically, it is not some inherent characteristic of LGBTQIA+ people that causes our mental health disparities. Instead, they result from the multiple sources of stigma we experience, including homophobia, transphobia, biphobia and misogyny, alongside unequal laws and social provisions.18–21 This is explained by Meyer’s Minority Stress theory22 23 which argues that, along with the everyday stresses and strains of life (eg, relationships, health, finances, etc), minority groups experience additional stressful situations (called ‘stressors’) that are unique to them. Some minority groups likely experience more stressors than others (eg, consider the current anti-trans climate compared with LGB acceptance24) and some experience multiple forms of discrimination (eg, black lesbians experience racism, homophobia and misogyny) producing even greater oppression, known as ‘intersectionality’.25 26 We know that stress has a significant impact on our mental and physical health,27 28 so these additional stressors, which are unique to our sexual and gender minority status, underpin LGBTQIA+ communities’ mental health inequalities.29–32 Indeed, multiple international studies have confirmed that minority stress creates negative mental health outcomes. Mongelli et al’s review of 62 studies found that depression, suicidality and substance use were related to higher levels of minority stressors among LGBT people29 while Valentine et al’s systematic review of 77 studies found stigma and discrimination contributed to mental health problems among transgender and gender non-conforming people.32 Overall then, the evidence is clear that the stigma and discrimination LGBTQIA+ people experience, even in relatively liberal western countries, have created mental health inequalities.
What about healthcare?
Disappointingly, LGBT people even face discrimination and stigma when accessing healthcare. While individual practitioners, teams and services may offer supportive care, multiple systematic reviews,13 21 33–38 covering over 520 international studies, found that LGBTQI folk reported ignorance, prejudice, stigma and homophobia (including verbal and physical abuse) from healthcare practitioners, heteronormative and cisnormative attitudes (ie, assuming everyone is heterosexual and non-trans) and even denial of healthcare. Moreover, some healthcare providers reported uncertainties around terminology, unease around gender identity and sexual orientation and ignorance of LGBTQI health needs.21 35 36 Indeed, Rees et al’s integrative review of 14 studies suggests that mental health services can even reinforce LGBT stigma, when staff lack knowledge around our unique needs.13 Heteronormativity, failure to use correct gender pronouns and dismissal of bisexuality were key examples of negative experiences, with similar issues found across multiple health services including alcohol,39 intimate partner violence,40 long term35 and cancer41 services. Furthermore, the entirely detrimental and hugely degrading42 LGBT conversion ‘therapy’, more properly considered conversion torture,43 is banned in only 16 countries worldwide.44 Since a wealth of evidence confirms that LGBTQIA+ people also experience multiple physical health inequalities compared with our heterosexual and cisgender peers,21 45 46 addressing our negative healthcare experiences becomes even more pressing.
What can nurses do about this?
Fortunately, there are multiple ways to reduce stigma, discrimination and, consequently, the mental health inequalities of LGBTQIA+ communities. Increasing social acceptance, as well as repealing remaining anti-LGBTQIA+ legislation, will improve our everyday lives. While some businesses’ Pride Month displays feel like insincere ‘rainbow-washing’,47 work is beginning to develop safe spaces online48 and in real life49 50 so LGBTQIA+ communities feel safe year-round. Similarly, organisations are increasingly recognising the importance of sexual and gender minority inclusive equality, diversity and inclusion workplace initiatives.51 In terms of healthcare provision, multiple systematic reviews52 53 demonstrate that LGBTQ+ training for healthcare professionals enhances staff competency and comfort while improving LGBTQ+ patient outcomes. Similarly, multiple voices have called for LGBT+ training to be integrated into student nursing and other healthcare practitioner training.52–57 Although some curriculums have been implemented,52 56 58 existing training may not be sufficient to remove inherent LGBT+ biases among healthcare practitioners,52 necessitating further research and development. Clearly, engendering these shifts is a huge undertaking, that will require a multisectoral, collaborative approach. As a first step, alongside Dr Hazel Marzetti, I am developing Scotland’s Interdisciplinary LGBTQIA+ Mental Health Network, funded by the RSE. This will bring together healthcare professionals, academic researchers, statutory and third sector services, policymakers and, crucially, LGBTQIA+ communities to foster collaborative opportunities and develop interdisciplinary solutions.
Overall, then, a wealth of international evidence, primarily from western countries, shows that LGBTQIA+ communities experience worse mental health than heterosexuals, with gender-minority people experiencing worse mental health inequalities than cisgender folk. While policy, social, clinical and educational solutions exist, we urgently need interdisciplinary action to implement and critically review these initiatives at local, national and international levels to end LGBTQIA+ communities’ current mental health crisis.
References
Footnotes
X @JamieFrankis
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.