Please note: This article contains subject matter that may be triggering to some individuals.
Individuals in the LGBTQ+ community seek therapy at higher rates despite facing extra barriers to receiving mental health care. In one study, only 40% of LGBTQ respondents were “very satisfied” with their therapy experience, and it was even lower for youth, transgender, bisexual, queer, and LGBTQ people of color.
Given these realities, how do we reduce or eliminate the LGBTQ+ mental health care barriers?
A lack of adequate LGBTQ+ mental health training, cultural humility, and validation are the most significant barriers to LGBTQ+ people receiving proper mental health care. This is about clients having access to culturally informed and knowledgeable LGBTQ-affirmative therapy.
Barrier #1: Psychology’s Abusive History
Let’s admit it—psychology has a mired history of unconscionable and damaging views of the LGBTQ+ population. The psychological field has pathologized this population with mental health disorders including homosexuality, sexual orientation disturbance, ego-dystonic homosexuality, transvestitism, transexualism, gender identity disorder, gender dysphoria, and gender incongruence. The subsequent mental health stigmas attached to sexual and gender diversity have impacted policies that limit housing, adoption, marriage, employment, and public accommodations.
Supposed “treatments” have centered around changing LGBTQ+ people, which has historically included electric shock, aversive conditioning, ice-pick lobotomies, chemical castration, testicle implants, masturbatory reconditioning, and various forms of conversion therapy.
The psychological field in general has been too slow to shift these abusive practices to instead advocate for the rights, health, and well-being of LGBTQ+ people.
Barrier #2: Conversion “Therapy” in Disguise
Many therapists still believe that being LGBTQ+ is a developmental delay, less mature, sinful, or even self-destructive. These same therapists might believe they’re being a blank slate—or not otherwise imposing their religious, political, or psychological belief systems onto their clients—but many don’t recognize that their tone, non-verbal cues, and selected words can make their bias pretty obvious to LGBTQ+ clients.
Because LGBTQ+ people are forced to contend with a world that doesn’t often acknowledge their existence—or if they do, they’re used as scapegoats for society at large—this community learns to be hypervigilant for any signs of bigotry or discrimination.
Even though there’s greater recognition in most parts of the United States and some other parts of the world about the dangerous, ineffective, and harmful consequences of conversion therapy, it still exists. In attempt to bypass the laws against conversion therapy in the US, conversion therapists call what they do something else that sounds more palatable, like “Sexual Attraction Fluidity Exploration in Therapy” (SAFE-T) or “Reintegrative Therapy.”
Conversion therapists often have other deceptive marketing strategies—stating on their websites that they specialize in working with LGBTQ+ issues, healthy sexuality, gender identity inferiority, attachment issues, and sex addiction. This creates further confusion for LGBTQ+ clients in knowing how to access affirmative care.
Individuals who’ve been subjected to conversion therapy are even more wary and cautious about therapy, for legitimate reasons, and yet are in greater need to combat the detrimental effects of conversion “therapy”.
Barrier #3: A Lack of Cultural Humility
Most therapist graduate programs don’t adequately prepare therapists to work with the LGBTQ+ community. If they do offer something, it’s often a one-off course or a small part of a larger cultural diversity class. Heterocentrism and cisgenderism are common in higher learning institutions. Most instruction and case vignettes are geared toward white, cisgender, and heterosexual populations. It’s no wonder that therapists can feel unprepared or even overly confident about their ability to meet LGBTQ+ clients where they’re at.
It’s not enough for therapists to be tolerant, accepting or friendly toward their LGBTQ+ clients. It’s one thing to have voted for marriage and family equality. It’s another to know how to talk to LGBTQ+ clients about internalized homophobia, biphobia, transphobia, and racism.
Knowing and caring about someone who is a member of a sexual or gender minority isn’t the same thing as knowing how to deconstruct their history of oppression and provide guidance for ways to increase awareness and healing as well as create healthier defenses against daily microaggressions.
In addition to being LGBTQ+ friendly, therapists need to continuously increase their knowledge and deepen their understanding of various cultures for the entire course of their careers. This includes recognizing the intersections of differing oppressions and how they exponentially increase mental health risk factors. Using a lens of cultural humility allows therapists to recognize that there is no end to learning about the LGBTQ+ community mental health needs—even for LGBTQ+ therapists.
Barrier #4: Neutrality vs. Validation
In similar ways that we need to be anti-racist and not just non-racist in a society built and maintained on white supremacy, neutrality is not enough when working with the LGBTQ+ population. As Howard Zinn said, “You can’t be neutral on a moving train.” Marginalized communities already face invalidation, discrimination, and violence, so to be a blank slate in the midst of this is to further harm our clients that are in dire need of attending to these wounds—let alone having them acknowledged appropriately.
Dismantling LGBTQ+ mental health barriers requires recognizing these impediments to our clients’ mental health and well-being. It means acknowledging the harm the psychological profession has done directly and been complicit with. It means recognizing the “conversion-therapist wolf in sheep’s clothing” that discredits our work. It means being culturally humble enough to continue our learning and deepen our understanding.
Every person has inherent value and worth. And every client deserves to have their identity understood and actively affirmed. As mental health providers, we can work together to increase access to LGBTQ+ culturally affirmative care.
1. First, Do No Harm: Reducing Disparities for Lesbian, Gay, Transgender, Queer and Questioning Populations in California https://www.nccdglobal.org/sites/default/files/publication_pdf/first_do_no_harm.pdf
2. Bidell, M. (2016). Mind our professional gaps: Competent lesbian, gay, bisexual, and transgender mental health services. Counselling Psychology Review. 31. 67-76.
3. Foronda, C., Baptiste, D., Reinholdt, M.M., & Ousman, K. (2016). Cultural Humility: A Concept Analysis. Journal of Transcultural Nursing: Official Journal of the Transcultural Nursing Society, 27(3), 210-217. https://pdfs.semanticscholar.org/898b/95cda1d468e5d1346ba3ba04e53f3311b437.pdf? _ga=2.56494056.274851668.1543593291-1615620809.1543593291
4. Conversion Therapy and LGBT Youth by The Williams Institute, UCLA School of Law https://williamsinstitute.law.ucla.edu/wp-content/uploads/Conversion-Therapy-LGBT- Youth-Jan-2018.pdf
5. Drescher, J. (2015). Queer diagnoses revisited: The past and future of homosexuality and gender diagnoses in DSM and ICD. International Review of Psychiatry, 27(5), 386-395, DOI: 10.3109/09540261.2015.1053847