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Pride Month is a time to celebrate the rainbow of LGBTQ+ identities in all their diverse splendor. But the community still faces considerable discrimination and stigma. Even with all the progress that has been made, it is fitting to focus on the mental health issues, and their remedies, that beset some members of this large, varied population.
Let’s start with a couple of basic questions: Do people identifying with one or more groupings under the LGBTQ+ umbrella suffer higher rates of mental illness than people who do not identify as such? And what are the similarities and the differences between the mental health needs of LGBTQ+ patients compared to those belonging to the straight majority?
Dr. Jessica Spellun, a psychiatrist at Weill Cornell Medicine, provides thoughtful responses to these questions. She begins with an assessment of how far her own field of psychiatry has come in its view of people who do not conform to the usual gender roles and preferences assigned to people in our culture: “We have come a long way,” she says, “but we still have a ways to go.
She is particularly concerned with the welfare of those who are more likely to experience discrimination due to combinations of their LGBTQ+ identity and other dimensions such as race, class, religious beliefs or physical abilities.
That sounds complicated, she acknowledges. But as a field, psychiatry is all about dealing with the complexities of the human condition. That is why practitioners like Dr. Spellun set high standards for their own field, and for medicine generally.
The first step, she says, has to do with training the next generations of physicians and psychiatrists: “We need to strip away what remains of the assumptions we used to have. In earlier versions of the Diagnostic and Statistical Manual of Mental Disorders (DSM), which sets guidelines for diagnosis and treatment of people with mental illnesses, we used to emphasize pathology in patients who self-identified as lesbian, gay, bisexual or any other deviation from the ‘straight’ norm.” That has changed in recent years. But there is a deeper change that needs to happen in the larger society. “What we need to recognize and embrace is that all identities are valuable,” she says.
It is no accident that higher rates of mental illness are seen among LGBTQ+ individuals compared to their straight counterparts. Factor in social stigma, inequity and being part of an underrepresented group, and it starts to become clear why that is the case.
Consider the so-called social determinants of health: education, income, employment, a sense of safety within the community, food sources and the cost of living, for example. Those on the lower rungs of the ladder are far likelier to have unmet needs. Then, add in prejudice and rejection.
“Individuals who experience higher rates of mental illness are those who may be more prone to internalizing a deeply negative view of themselves,” says Dr. Spellun. “We see that this psychological distress may lead to:
Matthew Tirelli, a psychiatric nurse practitioner at Weill Cornell Medicine, explains that while the umbrella term is LGBTQ+, “it’s important to recognize that every member of the community faces individual challenges, requiring a person-centric approach to care.
“Stigma, shame and the risk of suicide are much higher among the transgender members of the larger community,” he continues. “For example, rates of suicide go up when families insist on ‘dead-naming’ a trans family member: using the person’s given name as opposed to the one they have chosen and identify with. Dead-naming takes away the trans individual’s agency—their ability to make decisions for themselves.”
Tirelli was an original co-founder of the Compass Program at NewYork-Presbyterian Hospital, which provides services and gender-affirming care for transgender children and teens with the full participation of their families.
The Weill Cornell Wellness Qlinic is a student-run clinic staffed by medical trainees offering short-term, free mental health care to uninsured and underinsured members of the LGBTQ+ community in New York City. These are the patients that might be left out and left behind by our scattershot health care system.
“Students and trainees who volunteer and work for the Wellness Qlinic aim to bridge a gap in care for a potentially marginalized group,” Dr. Spellun says.
To keep the medical field moving toward greater tolerance and acceptance of LGBTQ+ people and their identities, Dr. Spellun names one concrete, specific change that should be extremely doable: expanding the hours spent in classroom instruction and clinical training in LGBTQ+ mental health.
She also expresses a larger, more aspirational wish that the medical community, along with the rest of us, give up the attachment to binary thinking in the form of male and female as representing the totality of sexuality and gender. “We need a multi-faceted language for describing gender diversity in all its nuances,” she says. “Actually, Gen Z has made great strides in coming up with one.”
Tirelli has a vision for change as well: “People need to step back and trust others to define themselves. It’s simple: Just let people be who they are.”
Still, beyond all the the subtleties of identity and the differences they represent, when it comes to mental health, members of the LGBTQ+ community are dealing with what everyone else is dealing with, Dr. Spellun reminds us: dissatisfaction with their lives, problems at work, problems in their relationships—what Zorba the Greek called the “full catastrophe” of life.
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