“Our feelings are valid” – reviewing the lesbian, gay, and bisexual affirmative approaches in a mental health setting

Abstract

In recent years, although research into support mechanisms for managing distress experienced by Lesbian Gay and Bisexual (LGB) communities has increased. Stigma-related discrimination related to sexual minority status remains. This is further compounded by stigma against mental illnesses thus creating double jeopardy. This review will outline recent discoveries by exploring existing theories highlighting factors that explain health disparities for cisgender LGB people. It appears that the experience of the LGB population and the use of psychological therapies is varied across the spectrum. Some focus upon symptom reduction as part of the experience, but others talk about not being validated. Some mention minority stress constructs, alongside the psychological mediation framework, which offers a potential theoretical understanding of the experiences of the LGB population who receive psychological therapies.

Keywords:

• Minority stress
• bisexual
• gay
• CBT
• therapies

Background

In recent years support mechanisms for managing distress experienced by Lesbian Gay and Bisexual (LGB) communities has increased but stigma related to sexual minority status remains. This is further compounded by the stigma of mental illnesses thus creating a double jeopardy. Thus, different types of stigma related problems exist which can contribute to sexual minority individuals going back into the closet (Bachmann & Gooch, 2018). This Stonewall survey carried out by Bachmann and Gooch (2018) found a high level of discomfort in disclosing sexual identity in the workplace, because of the witnessed discrimination. Nearly half of the respondents (47%) had witnessed abuse and micro-aggressive acts like being outed by colleagues. Heteronormative patterns are not surprisingly dominant, and these describe a world where heterosexual expectations and attitudes are dominant. Surprisingly the most vulnerable age group is 18–24 years (Johnson, 2012) where more than half (58%) are affected. It is possible that this is the age when most sexual minority individuals tend to come out.

Among lesbian and bisexual women have rates of substance misuse twice that of heterosexual women as (Duvivier & Wiley, 2015). If we consider cisgender LGB individuals (relating to the person whose gender identity corresponds with the sex assigned at birth) suffer from depression and low – self-esteem disproportionately to their cisgender heterosexual counterparts (Herek & Garnets, 2007; Marshall et al., 2011; Kosciw et al., 2012). This review will outline recent discoveries by exploring existing theories highlighting factors that explain health disparities for cisgender LGB people.

Disparities in mental health outcomes for LGB people

As we know that rates of various psychiatric disorders are much higher in sexual minorities

King et al. (2008) noted that LGB individuals are 1.5 times more likely to be at a higher risk of developing mental health problems like depression, anxiety and twice as likely to commit suicide. Stonewall (2013) discovered a 7 per cent increase in many disorders like anxiety and depression when compared to the cisgender straight population. Other researchers have found that alongside mental health problems there is also co-morbid difficulties like substance misuse, suicidal ideation and low self-esteem to be highly prevalent (Cochran & Mays, 2000a,b; Gilman et al., 2001; Goldbach et al., 2014; Herrell et al., 1999). In the Netherlands study by Sandford (2017) showed a lifetime prevalence of major depression among lesbians at 44.2% and straight women being 20%. The Canadian Community Health Survey by Gravel and Béland, (2005), found that a lifetime prevalence of affective disorders is evident, measuring 11.4% lesbians, 25.2% bisexuals compared to 7.7% among straight women. This would suggest an indication that LGB populations are susceptible or more sensitive to mental health problems but not proven. But already it can be seen that the bisexual group register higher when compared to gay and lesbian figures. it is worth looking at potential causative factors. Research into the experiences of LGB people and psychological therapies can be broadly positioned into 3 groups. Firstly, Minority stress (MS) views that mental distress is caused by sexuality-related stigma. Second is the psychological mediation framework and finally, embracing the shame. First looking at group-specific minority stressors to understand the risk differences in cisgender LGB communities. Meyer (2003) proposes that the cisgender LGB group suffer from being marginalised and are stigmatised by the heteronormative group.

Meyer’s distal stressors

Meyer, (2003) states that LGB people must use behaviours like sexuality identity concealment, sex and substance misuse to mediate the high-stress levels. Meyer (2003) distinguishes two main types of stressors-distal and proximal. Furthermore, there are two types of distal stressors, the first is discrimination inspired incidents (DII), including grievous bodily harm, bullying and verbal abuse. This part of the theory has strong evidentiary support to suggest adversity and stress does link to mental illness problems like depression (Argyriou et al 2021). Other studies have suggested this too but for instance Brown (1993) and Dohrenwend (2000) an LGB sample was not considered. These findings are generalised to the LGB population and that the distal stressors (DII) may explain and is well documented to be a link to mental illness and for the health disparities within the LGB groups (Herek & Garnets, 2007; Major & O'Brien, 2005; Miller & Kaiser, 2001; Pachankis & Goldfried, 2006).

Being exposed to violent incidents and bullying can lead to depression, low self-esteem and internalised homophobia (D’Augelli et al. 2006). These authors also found double victimisation had occurred in those who experienced a violent distal stressor incident. On reporting such incidents, respondents faced hostility by the police due to stigma. According to the Stonewall survey (Stonewall 2013) which reported nearly a quarter of crime victims were advised to change behaviour. For example, lesbians were asked to behave and be more feminine in order to avoid being attacked again. Otis and Skinner (1996) had reported that LGBT people who have not been involved in a violent distal stressor incident reported higher self-esteem, less suicidality and lower internalised homophobia.

Another distal stressor (DSS) in Meyer’s theory is being discriminated against because of sexual status. Studies have found differences between LGB and straight groups for earning potential (Gates et al., 2007) and job take up offered (Fasoli & Hegarty, 2020). Looking at earning potential Gates et al. (2007) discovered in the population analysis study that gay men earn between 10-32% less than straight men in the same job. Fasoli and Hegarty (2020) found gay/lesbian sounding voices were more likely to result in not being chosen for a leadership role. Significantly straight selectors were more likely to rate lesbian and gay voices as being poor performers or deemed to be incompetent than their straight counterparts.

Meyer’s proximal stressors

Proximal stressors include a negative self-concept that is homophobic in nature suffering and is internalised. Internalised homophobia being defined as heteronormative expectations and discriminatory attitudes are unconscious without question. This leading to concealment behaviours and increased sexual compulsive behaviours for fear of rejection leading to psychopathology. Indeed Petruzzella et al. (2019) suggest that there was no significant link in the Balsam and Szymanski, (2005) study investigating distal and proximal stressors with violence. Also referenced are two other studies to support that no correlation exists like Otis et al. (2006) investigating house damage and arson distal stressor (DII) and workplace distal stressor (DSS) in Barrantes et al. (2017). But it is not true of the former study as Balsam and Szymanski (2005) in the results section register a significant relationship for those who had experienced a lifetime of discrimination and stigma was indeed found. A combination of both distal stressors and proximal stressors was a strong predictor of interpersonal violence.

This leads to the next theory called the psychological mediation framework which accepts in part Meyer’s theory but also incorporates other general stresses into the experience too.

The psychological mediation framework

The psychological mediation framework (PMF) is one proposed by Hatzenbuehler (2009) who suggests that all three aspects i) psychiatric epidemiology; ii) group-specific stressors and iii) general psychological processes interplay to develop a deeper understanding of the gaps in knowledge. It is hoped that by combining all three that the interplay will make clear the contribution from each of the three parts to understand the intersects relating to them. The psychological aspects in Meyers (2003) theory would suggest that distal and proximal stressors create the condition for vulnerabilities to mental health problems.

Hatzenbuehler (2009) in the PMF suggests a transactional approach in which both LGB and straight communities share similar psychological processes. For instance, stressful conditions of growing up in an invalidating risky home environment render the person unable to regulate emotions (Lineman et al. 2007). Which may correlate with other problems like interpersonal difficulties and having a sense of intrinsic low self-esteem. According to the framework stressors albeit from different sources link to disabling consequences and the greater potential of mental health problems to develop.

Theories and respective limitations

These two theories have some limitations and may be incorporated into newer ways of thinking about the mental health risk. According to Petruzzella et al. (2020) in their study suggest that a significant positive correlation exists independently to link that general stressor and not distal or proximal stressors had a relationship with increased alcohol usage. Thus, linking that general stressor like financial worries etc play a part in the LGB mental health as well. This is not different to the research looking at specific group related stressors (Fingerhut et al., 2010; Pachankis et al., 2015) which also significantly suggests a relationship to mental health within minority stress viewpoint.

Studies addressing the vulnerability factors like alcohol usage with the MS theory link have proven inconclusive. There appears to be no difference in alcohol usage from the wider general population. The study was consistent with studies on the cisgender heterosexual population looking at general stressors and increased alcohol intake.

This is the danger in some circles of the MS theory becoming polarised that all problems are related to stigma but not the other aspects of life that link to general stressors.

But the general psychological processes are not clearly defined because primarily the research looking into group comparison does find a higher rate in LGB groups when compared to the cisgender heterosexual population for problems like suicide, substance misuse and depression.

But not all group related stressors will lead to mental health problems. Others posit that resilience can be fostered in the light of such difficulties (Broadway-Horner, 2017). It appears that the response to discrimination is either not recognised or is a deliberate attempt to view things positively or realistically (Goffman, 1963). It seems that resilience is a factor that may be best understood from a queer theory’s perspective called – Embracing the shame.

‘Embracing the Shame’ from the queer theory camp offers the idea of emboldening the individual by becoming resilient. Goffman (1963) suggesting that gay men might see stigma related difficulties as a silver lining, approaching the problem as an opportunity rather than as a threat.

Psychological therapies and their applicability to LGB people

These theories need to be considered when looking into research related to psychological therapies and their applicability to LGB people. Resilience in the face of stigma thus leading to a positive psychological stance versus the disorder and the explanations for factors that create them. Petruzzella et al. (2020) conclude that whilst they could not find a link for the MS theory, they would support the idea of specific training and information for clinicians. To ensure that a clear understanding of both distal and proximal stressors alongside general stressors be disseminated when working with gay and bisexual men. Goldblum et al. (2017) suggest otherwise, that minority stress is significant and can be used to aid understanding into possible treatment ideas across a range of therapeutic traditions like Cognitive Behaviour Therapy (CBT), Interpersonal Therapy and Acceptance and Commitment therapy. They posit that specific targeting of intervention to reduce MS is needed (Safren & Rogers, 2001).

The psychological mediation framework has evidentiary support in finding a significant relationship between psychological processes and specific problems. Problems that span across the sexuality spectrum like emotion – dysregulation (Hatzenbuehler et al., 2009), hopelessness (Safren & Heimberg, 1999) and isolation (Eisenberg & Resnick, 2006; Plöderl & Fartacek, 2005). It would support the idea that LGB people are more susceptible to these processes than their straight counterparts but may not explain mental health disparities (Hatzenbuehler, 2009).

A case study looking at the direct application of psychological therapies for a gay man with social phobia did find a small change when using a CBT protocol (Walsh & Hope, 2010). But then halfway through treatment, the therapist reformulated the problem incorporating discussions about sexuality. Following this, a significant reduction in symptoms occurred. Which would appear to be a proximal stressor overlapping with the Hatzenbuehler (2009) psychological mediation framework and not solely MS.

Sexuality blind data

Indeed, when investigating the use of psychological therapies for LGB communities, Budge et al. (2017) state that the lack of psychotherapy research upon the LGB community is due to the assumption that all psychotherapy treatments is a ‘one size fits all' approach. Earlier in 2007, the British Association of Counselling and Psychotherapy (BACP) in a review carried out by King et al (2008) found many gaps in the knowledge. The one size fits all approach seems to be the major problem in the psychotherapy data (Wampold & Imel, 2015). This may be due to the evidence-based movement in psychotherapy and health sciences with its reliance on Randomised Controlled Trial (RCT) as the gold standard and so look at high numbers in gender sets like male/female (Abrahamson, 1999). Thereby not only is sexuality not included but also trans and non-binary people are factored out of the power calculations (Heyvaert et al., 2016).

“I See you”

Another aspect for consideration is gay affirmative therapy but is problematic as the field have many definitions but the one offered here is that gay affirmative therapy is ethically driven to help, understand with acceptance in an active sense to ameliorate the effects of heterosexism (Langdridge, 2007). Langdridge (2007) would argue that the positive affirmation part is what distinguishes it from routine ethically driven therapy, questioning the heteronormative expectations and experiences.

O’Shaughnessy and Spokane (2013) point out that many counsellors/psychotherapists may know about LGB issues and have received diversity training but register low in self–efficacy in delivering diversity specifically in the therapy/counselling session. On the website-based study using case vignettes and therapist/counsellor responses, they found that those whose personality are open to new experiences were stronger in the LGB case conceptualisation abilities. These include counsellors/psychotherapists who had LGB friends also highly correlated to include LGB identity/related issues in the conceptualisation and were not susceptible to sexuality-blindness or political correctness ideology that leads to ignoring key facets of identity like sexuality for fear of offending others (Doane & Bonilla-Silva, 2003; O’Shaughnessy & Spokane, 2013).

Unsurprisingly studies that investigated marginalised populations have been viewed as lacking rigour, and those that withstand peer review processes remain low in number (O’Shaughnessy & Spokane, 2013; Johnson, 2012). However, according to Owen et al. (2018), it is difficult to see how the adaptations of the psychological therapy approach for the LGB populations can be made to treat gay-specific stressors if indeed one is needed. LGB populations reportedly are high users of therapy services but is lacking drive in the wider healthcare context with little dissemination or knowledge exchange formats (Johnson, 2012). Rimes et al. (2018) in a large service audit focussing within the Increased Access to Psychological Therapies within National Health Services, UK (NHS) found some interesting differences within the LGB patients. Rimes et al. (2018) state that treatment outcomes were not significantly different between straight or gay men. This may indicate that minority stress is not relevant but then was not a factor for analysis. Indeed, LGB affirmative therapy or a specific LGB therapeutic protocol was not under investigation but rather to see if mainstream therapies help LGBT problems. Lesbian and bisexual women showed a small reduction in symptoms but differed according to lifespan, ethnicity and employment status. But the bisexual group was highlighted as one that did not significantly improve and would suggest further investigation.

Recommendations for a LGBT friendly mental health setting

• Try not to assume the heteronormative experience applies to the LGBT experience. Some LGB persons may have more than one partner. The life partner, the sex buddy and the play mate. Try not to psycho-pathologise a normal experience.

• Allow couples or friends to hold hands, cuddle and express affection in hospital wards.

• The polyamorous experience is more common with younger people and so may state more than one partner on a healthcare form. This is especially true for the bisexual experience.

• To ensure language used by the clinician is not excluding bisexual people

• Don’t assume that LGBT people are not parents

• Don’t assume that everyone is ‘out’ as evidence is emerging that university graduates are returning to the closet once they have secured a job.

• Evidence shows that therapists who self - disclose sexuality, allowing patients to know sexuality appeared to aid the therapist-patient experience more than those who did not.

• High usage of alcohol and drugs maybe a symptom of Minority stress and not an addiction. Formulating the minority stress experience may help to reduce the problem drinker and drug user much more than labelling them as addicts.

However, no studies exist to address minority stress as a stand-alone problem to be treated using psychological therapy. LGB affirmative therapies address in general terms some stigma related difficulties but have not been conceptualised as MS (Johnson, 2012) with aids offered to straight clinicians (Kort, 2008). There are studies available that look at specific traditions like CBT for problems treated like e.g., alcohol dependence or using motivational interviewing with CBT. This may be because there is no one theory that best incorporates the problems encountered by LGB people. Rather better to factor in gay-specific stressors alongside general stressors when measuring the impact of psychological therapy.

In conclusion, it appears that the experience of the LGB population and the use of psychological therapies is varied across the spectrum. Some look at a focus on symptom reduction as part of the experience, but others talk about not being validated. Some mention minority stress construct, alongside the psychological mediation framework, which offers a potential theoretical understanding of the experiences of the LGB population in psychological therapies.

Disclosure statement

No potential conflict of interest was reported by the author(s).