Bad. Fabulous. Tough.
For many LGBTQ people, living with difference is tough. There are well documented challenges across the lifespan, including bullying, hate crime, abandonment, and self-acceptance, all of which have huge implications for mental health. Historically, our needs have been supported by the communities that we identify with, through peer support, understanding, and a shared sense of pride. But the relationship between LGBTQ people and mental health services has been a difficult one. Services and the wider system of researchers and policymakers that inform them have at best failed to understand the needs of LGBTQ people, and at worst have colluded with damaging ideas about difference, with effects that can still be felt to this day.
In the early 19th century, sexuality began being studied scientifically, mostly from the position that difference was an abnormality, a disease to be cured. This status not only legitimized discrimination, and the perception of LGBTQ people as “less than”, it also led to some abhorrent practices in the name of medical treatment. As the fields of psychology and psychiatry developed throughout the 20th century, a number of treatments to “cure” non-heterosexual people were invented around the world, their descriptions reading like the acts of horror movie ghouls: ice pick lobotomies, electroshock, chemical castration, and aversion therapy. The last known lobotomy to treat homosexuality was in 1951 in the USA, but the other treatments, many including hospitalisation, are well documented throughout the 1960s in the UK.
While the work of researchers including Kinsey and Hooker in the 1950s made some steps to recognise LGBTQ people as normally functioning human beings, it would be a long time for the relationship with the mental health system to be improved. Homosexuality was included as a mental disorder in the influential Diagnostic Statistical Manual (DSM), and wouldn’t be dropped completely until the revised third edition in 1987. The World Health Organisation (WHO) only removed homosexuality from the International Classification of Diseases (ICD) in 1992, 25 years after the Sexual Offences Act partially decriminalised homosexuality in the UK. For trans people, the most recent ICD includes ‘gender incongruence’ in a new chapter on sexual health, finally removing it from the category of mental health, and making steps toward ending pathologisiation that has led to some trans people feeling alienated by mental health services.
Since the 1970s, the LGBTQ community itself has attempted to respond to this lack of understanding, through setting up support groups, producing information, campaigning and establishing organisations like Switchboard, the LGBTQ helpline. For many, these initiatives have been lifesaving. But the community now faces great challenges, with the closure of LGBTQ spaces which may be reducing the opportunities for people to access vital social support. Funding cuts are also causing the closure of LGBTQ-specific support services, which have expertise in issues facing the community. This limits the choice people have in where they access support, as well as impacting on the mental health of vulnerable people, especially those on a low income.
Mirroring the shift in society’s attitudes in recent years, the mental health system has
made strides towards changing its approach so that it is better equipped to support the range of individuals who need it. The field of psychology continues to develop theories, but crucially with the aim of understanding the LGBTQ experience. This has included theories around identity and the process of coming out for practitioners to use with LGBTQ clients. Working with difference is included in professional training programmes, and publications have explored adapting evidence-based interventions such as Cognitive Behavioural Therapy (CBT) to LGBTQ specific issues. Surviving funding cuts, organisations like Switchboard, Pink Therapy, and Metro Centre continue to help LGBTQ people to find the right support for them. The increase in openly LGBTQ mental health practitioners and decision makers like MPs and commissioners has also allowed for increased discussions around how services can best support people, often with limited resources, as well as influencing national policy. These shifts have meant that the NHS has created some services to better meet the specific needs of LGBTQ people, with world class services established including the Tavistock’s gender identity development service and Dean Street’s chemsex support service, both in London.
But there is still a great deal of work to be done to build appropriate mental health services for LGBTQ people that are accessible, relevant, and trustworthy – particularly if you don’t live in a major city. Recent data suests that LGBTQ people in the UK are 40% more likely to experience depression than the general population, twice as likely to end their lives by suicide, and seven times as likely to take drugs. A third of gay men, a quarter of bisexual men, and over 40% of lesbians have experienced negative or mixed reactions from mental health practitioners when they disclosed their sexual orientation. Many approach services cautiously, knowing that they may not be understood, be pathologised, or have little say over who they see and the values they may hold. For some young people, getting a referral to access support may require their family GP or school to be involved, while many older people with experience of the past abuse of the healthcare and justice systems have little faith in them. There is often a further barrier to accessing mental health services for people from Black, Asian and other minority backgrounds, who report increased stigma within their communities around discussing their mental health.
Conversion interventions are of course still practiced, and while they may sound far more subtle, they are no less damaging than their predecessors and are based on the same assertion that homosexuality can be ”cured”. Under the guise of counseling, support groups, and “spiritual interventions”, they claim to change the sexuality of individuals despite no valid scientific evidence of efficacy; there are many survivors who attest to the harm the experience of conversion has caused. The UK government’s recent research into the experiences of LGBTQ people found that 5% had been offered such interventions, often by faith organisations. As a result of this research the government published a 75 point plan to improve the lives of LGBTQ people, with action to prevent the use of conversion interventions in the UK being a key priority.
Historically, the mental health system has understood LGBTQ people as both bad and mad, and has been instrumental in maintaining discrimination. The government’s recent LGBT Action Plan, announced in July, makes a commitment to appointing a national LGBT health adviser focusing on reducing the heath inequalities for LGBTQ people, and to explore ways to
improve the care they receive from services. The challenge for this advisor will be meaningfully engaging with LGBTQ people and providing space for them to openly discuss their mental health, their sexuality and the challenges currently facing the community. It will also be important for them to reflect on the past, and the ripple effect that has limited the scope of available support and caused hesitancy to access it. For the LGBTQ community, history has taught us about the importance of supporting each other, claiming the spaces where we can be open, and campaigning for our right to be treated with dignity and respect. We all have a role to play, whether signing a petition, taking part in consultations, or simply checking in with a friend who is having a hard time.