Key points from the MindOut Conference presentation by Ruth McNair June 2014
The mental health of lesbian, gay, bisexual, transgender, intersex and queer (LGBTIQ) people is more likely to be worse than that of the general population. Population based results from the Australian National Survey of Mental Health in 2007 showed at least twice the rates of depression, anxiety and substance use problems compared with heterosexuals (unfortunately gender identity was not included in this study). Multiple studies also indicate that mental ill-health rates differ across the LGBTIQ spectrum, with lesbian and gay people having generally higher levels of mental health, bisexual and queer-identifying people in between, and transgender and questioning people much lower levels.
The underlying reasons for these differences are not yet well understood, although it is clearly complex. Questions arise including whether discrimination is the major determinant, or violence experiences, or lack of social support, or something deeper and more structural. It is very important to develop an understanding of the specific reasons for mental health issues in order to create a society-wide and meaningful response that does not pathologise LGBTIQ people and communities.
I would like to propose that the available evidence for social and legal determinants of LGBTIQ mental health relate to three over-arching influences on our mental health, which are sexual or gender identity (at an individual level), intersections (at a social level) and social inclusion (at a societal level). These help to explain why over half of the LGBTIQ population can live generally happy and healthy lives free from the burden of mental health problems, while others do not.
1. Sexual and/or gender identity
Identity can influence mental health in positive or negative ways. LGBTIQ people apply varying levels of importance to their sexual or gender identity. High identity importance is associated with high levels of public disclosure and a need to socialise within LGBTIQ communities. Low LGBTIQ identity importance results in low need to disclose and more socialising with mainstream communities. So, on the one hand, higher levels of openness can lead to better health, and better health care, while at the same time exposing people to higher levels of discrimination. On the other hand, lower levels of openness, can lead to greater marginalisation, more difficulty connecting with like-minded community, but less likelihood of experiencing overt discrimination. Supporting individuals to express their identity in positive ways, while knowing how to avoid harmful responses from others can help mental health.
Intersectionality is a helpful feminist theory that recognises that we all live with multiple identities, and therefore are members of multiple communities. It is common that some of these identities are mainstream, while others are marginal and stigmatised. If we live with multiple marginalised identities this can increase levels of stress, discrimination and therefore the mental health burden. I suggest that our intersecting identities can influence our mental health in three ways:
- our various individual identities can conflict, so our mental health relies on being able to reconcile these to reach a comfortable place within ourselves,
- intersections within the LGBTIQ communities can divide us if we focus on our differences, but our mental health will improve if we respect diversity while connecting across our similarities,
- intersections between LGBTIQ and mainstream communities. It is clear that increasing numbers of straight allies can influence better social attitudes. For example, coming out for young people into a supportive family and/or peer network positively influences their mental health.
3. Social inclusion
Structural stigma is a recently coined term, meaning “societal-level conditions, cultural norms, and institutional policies that constrain the opportunities, resources, and wellbeing of the stigmatised” (Mark Hatzenbuehler and Bruce Link, 2014). There is emerging evidence that if LGBTIQ people live in areas with high levels of structural stigma, such as areas with no same-sex relationship legislation, this increases their mental ill-health and substance use, and reduces their life expectancy by a staggering 12 years on average. Conversely, living in areas that are inclusive, such as those with non-discrimination or anti-bullying policies, improves health. Intersectionality theory encourages systemic responses that focus on multiple areas of discrimination at once.
In summary, through understanding these linked influences on LGBTIQ mental health of identities, intersections and inclusion, we can deliberately encourage the areas that we know improve our mental health at each level. There have been some important initiatives aimed at individuals (such as ‘it gets better’), at families and communities (such as various anti-homophobia campaigns, gay-straight alliances, the safe schools coalition), and at social inclusion (limited inclusion in some research, in legislation). At this stage, I believe that our efforts should be targeted in all areas, but particularly on reducing structural stigma during this politically conservative time. Examples include continuing the push for marriage equality, arguing for all national datasets to include gender identity and sexual identity questions, and constantly challenging homo/bi/transphobic language and assumptions. Then we can rightfully expect that our mental health will be strong and resilient.