Messages from rainbow rangatahi to mental health professionals in training

ABSTRACT

Past research has shown significant inequities in mental health outcomes between rainbow and non-rainbow people, particularly for youth. Rainbow youth report mixed experiences when accessing support, signalling the need for increased rainbow competency training for mental health professionals (MHPs). While previous research has explored the experiences of rainbow young people, little research has sought direct messages from rainbow youth to training MHPs. The current study presents a thematic analysis of messages from rainbow rangatahi (14–24 years) to training MHPs. We identify six themes: (1) check your assumptions, (2) treat us with empathy and respect, (3) earn our trust, (4) you need to self-reflect, (5) balance getting to know me with educating yourself, and (6) hear our stories. Participants’ responses describe their experiences within the mental health sector and in life, and their recommendations for what practitioners should both implement and avoid in their practice. We reflect on whether current recommendations for MHPs working with rainbow people align with these messages. Finally, we discuss the possibility of personal narratives enacting social change. The findings of the current study reflect the need for rainbow cultural competency training, grounded in the voices of rainbow people, to become mandatory for all MHPs.

KEYWORDS:

• LGBT
• mental health
• rainbow
• therapy
• thematic analysis

In Aotearoa New Zealand and internationally, research has shown significant inequities in mental health outcomes between rainbow people (of diverse genders, sexualities, and sex characteristics) and non-rainbow people, particularly among youth (Rees et al. 2021). Rainbow people consistently report significantly higher rates of depression, anxiety, and suicidal ideation (Connelly et al. 2016; Fenaughty et al. 2021; Tan et al. 2020) and difficulties accessing mental health care (Higgins et al. 2021; Tan et al. 2021; White and Fontenot 2019). Rainbow people report numerous barriers when accessing care, including practitioner incompetence regarding rainbow issues and terminology, leading to an ‘educational burden’ placed on rainbow people seeking help (Fraser et al. 2022; Haywood and Treharne 2022; McCann and Sharek 2014; Mizock and Lundquist 2016), and the pathologisation of clients’ sexuality and gender identity (Tan et al. 2021). Pathologisation occurs when practitioners treat rainbow identities as disordered (Riggs et al. 2015). Historically, the pathologisation of sexuality and gender diversity has contributed to the stigmatisation of rainbow people in healthcare settings, several of whom were subjected to inhumane practices in attempt to change their sexual orientation (Drescher 2015; Bennett and Brickell 2018). Despite progress to depathologise and destigmatise gender and sexuality diversity in Aotearoa (e.g. the Homosexual Law Reform (1986) and the Conversion Practices Prohibition Legislation Act 2022) rainbow people in Aotearoa still report fears of mistreatment when entering mental health systems today (Rees et al. 2021). Despite this context, there has been little research investigating what rainbow youth themselves wish for practitioners to know. The current paper seeks to address this gap within the literature, by asking rainbow rangatahi their messages to mental health professionals (MHPs) in training.

Definitions

Throughout the current study, we use the terms ‘rainbow community’ or ‘rainbow people’ as umbrella terms, encompassing people who are transgender or gender-diverse; who are not heterosexual; and/or who are intersex. Other terms (e.g. LGBTQIA+, sexuality and gender diverse, and queer and trans) are commonly used throughout past literature – we use authors’ terms when discussing past research. ‘Rangatahi’ is the indigenous Māori term for youth (Moorfield, 2011); and cissexism and heterosexism refer to the denigration, stigmatisation, and denial of non-cisgender, and non-heterosexual identities (Herek 1990; Serano, 2007).

Support experiences and access to care

Access to high-quality mental health care is vital when addressing mental health concerns among rainbow community members, particularly for adolescents (Fraser et al. 2022; Tan et al. 2021). However, previous research has shown that rainbow and non-rainbow people experience barriers to accessing support (Tan et al. 2021; New Zealand Government 2018; White and Fontenot 2019). In Aotearoa, mental health care can be funded through a referral from a general practitioner (Manatū Hauora Ministry of Health 2022), however previous research identifies lengthy wait times, an overstretched and underfunded public system, and clients being turned away due to their mental health not being ‘bad enough’ (New Zealand Government 2018, p. 54). These barriers often lead people to seek private mental health care – however, these appointments are costly, estimated to cost between $130-$200NZD per session (Consumer NZ n.d.). Like the public system, private mental health care is also difficult to obtain – in a survey of 271 private practice clinicians in New Zealand, a majority reported wait-times of between three and twelve months, frequently turning away multiple people per week due to high demand (New Zealand College of Clinical Psychologists 2022).

When care can be accessed, its quality varies greatly, particularly for rainbow people. The results of several UK and Irish studies (Ellis et al. 2015; Higgins et al. 2021; McCann and Sharek 2014) indicate that rainbow community members experience numerous barriers to receiving adequate mental health support, including: limited availability, practitioners lacking adequate cultural competencies when working with rainbow people, and the pathologisation of clients’ rainbow identity. These results were supported by Rees and colleagues (2021) in their qualitative review of 14 studies spanning the UK, Ireland, New Zealand, and the Netherlands on the mental healthcare experiences of LGBT community members.

Despite these concerning findings, mental health care has been described as ‘healing’ and ‘transformative’ (White and Fontenot 2019, p. 204) for trans and gender non-conforming people when practitioners are proficient and comfortable when discussing gender; when they used clients’ self-determined names and pronouns; and when they did not pathologise their clients’ gender identity (White and Fontenot 2019).

Similar trends have been identified in Aotearoa. Participants in the Counting Ourselves Survey (Tan et al. 2021) cited practitioners’ lack of competence and knowledge regarding trans issues as a reason they avoided seeking care. In a similar manner, a report examining rainbow people’s access to mental health and addiction services within the Auckland District Health Board area also highlighted trans-specific barriers to accessing care (Birkenhead & Rands, 2012). Trans participants reported experiencing stigma and discrimination within mental health care services, as well as a shortage of skilled practitioners with experience in working with trans people (Birkenhead & Rands, 2012). Our previous research identified a range of positive and negative experiences reported by rainbow rangatahi when accessing mental health care (Fraser et al. 2022). Over half of participants experienced heterosexism and around a quarter reported that their MHP required further education on rainbow issues, focused on the client’s identity when it was not relevant to their care, and seemed uncomfortable when they came out (Fraser et al. 2022). Rainbow rangatahi reported positive experiences when their MHP focused on the issue they sought to discuss, seemed knowledgeable about rainbow issues, and when they affirmed and validated their client’s identity (Fraser et al. 2022). The widespread nature of poor mental health care reported by rainbow populations within Aotearoa has led to longstanding calls to improve MHPs competency in rainbow issues (Welch et al. 2000; Adams et al. 2013; Garcia et al. 2023).

Mental health training in Aotearoa

In Aotearoa, guidelines for working with sex, sexuality, and gender diverse clients cite mental health practitioners’ ethical duty to provide affirming care that respects their client’s identity and dignity (New Zealand Psychologists Board 2019). These guidelines outline essential and aspirational skills for clinicians when working with rainbow clients. Essential skills include practitioners engaging in self-assessment and reflection; appropriate language use (i.e. matching clients’ own language and understanding common rainbow terms). They also include clinicians completing a ‘comprehensive assessment’ (New Zealand Psychologists Board 2019, p. 12), including asking clients if they wish to talk about their sex, sexuality or gender, and discussing their past experiences (e.g. coming out, previous discrimination); allowing the client to determine the focus of the session; seeking further supervision and training; and knowing when to refer the client when needed (as a last resort) (New Zealand Psychologists Board 2019).

However, research has indicated that little training is provided for health professionals in Aotearoa for working with rainbow people, and that teachers themselves report lacking necessary expertise to teach about LGBTQI health care (Taylor et al. 2018). To date, there has been little research investigating how rainbow cultural competencies are taught to MHPs in New Zealand, however, clinical psychology students and practicing clinicians have reported a distinct lack of knowledge about rainbow issues and hesitancy around working with rainbow people (Birkenhead & Rands, 2012; Haywood and Treharne 2022). Importantly, these students and clinicians also showed a significant desire and willingness to learn more (Birkenhead & Rands, 2012; Haywood and Treharne 2022).

With such little training given to MHPs in Aotearoa, it comes as little surprise that some practitioners feel ill-equipped to support rainbow rangatahi seeking help (Birkenhead & Rands, 2012). It is vital that training given to MHPs for working with rainbow rangatahi is grounded in their voices – as such, we must ask what rainbow rangatahi themselves deem important for MHPs to know.

The current study

Previous research has identified significant mental health inequities among rainbow rangatahi, and a range of barriers when accessing care due to an overstretched system and lack of practitioner knowledge. However, while we know about experiences reported by rainbow rangatahi within the mental health sector, and what MHPs themselves wish to know about providing care to rainbow people, little research has investigated direct messages from rainbow rangatahi to training MHPs. The current study seeks to give voice to rainbow rangatahi by asking: what messages do rainbow rangatahi have for MHPs in training?

Method

Procedure

The current study used qualitative survey data collected as part of a wider project examining rainbow people’s mental health support experiences in Aotearoa. The research was community-based, partnering with several rainbow organisations (RainbowYOUTH, Gender Minorities Aotearoa, and InsideOUT Kōaro) who provided feedback at each stage of the research process. Community-based research involves active collaboration with community members, seeks to reduce power disparities, and ultimately benefit the community participating in the research (Israel et al. 1998; Wallerstein and Duran 2006). This was vital to promote a safe and positive research environment for rainbow participants. The survey was informed by previous literature (e.g. Liddle 2000; McCann and Sharek 2014; Shipherd et al. 2010; Veale et al., 2019) and our research team’s thematic analysis of interviews with 34 rainbow young adults about their experiences of accessing mental health support in Aotearoa (see Fraser 2020, for the full study protocol). Participants were recruited using a flyer that was distributed on the social media pages of our research partners and sent out to New Zealand rainbow organisations, community organisations focused on youth wellbeing, professional organisations representing a range of mental health professions, and community spaces such as libraries, community centres, universities, and schools.

People were invited to participate in the research if they: (1) identified as queer, takatāpui¹, LGBTQIA+, trans, nonbinary, MVPFAFF+², or questioning; (2) were aged 14 or above; and (3) had accessed mental health support in New Zealand.³ Participants were invited to enter a draw to win a $50 supermarket voucher after completion of the survey. Ethics approval was obtained from Victoria University of Wellington Human Ethics Committee. Additional support was implemented for participants aged 14 and 15 years old, which suggested that they completed the survey with a support person present and offered a range of support services to contact should they have felt any distress upon survey completion. Data were collected between October and November 2018.

Participants

Due to the current study’s focus on messages from rainbow rangatahi, participants were restricted to those between the ages of 14 and 24 years (M = 19.3, SD = 2.89) who answered the question: ‘If you had a room full of training MHPs in front of you, what would you want to tell them?’. This resulted in a sample of 521 participants of the 955 rangatahi who participated in the wider survey. Most participants indicated that they were gay or lesbian, or attracted to multiple genders (28.4% and 49.6%, respectively), while the remaining participants identified as asexual (9.8%), queer (5.4%), or something else (6.8%). Regarding gender, 21% of participants were nonbinary, 48.3% were women (44.3% cisgender and 4.0% transgender), and 18.3% were men (10.0% cisgender and 8.3% transgender). 12.3% of participants identified their gender as ‘something else’. For a further breakdown of participant demographics, including other intersecting identities, see Table 1.

Table 1. Participant demographics.

Sexual Orientation	n (%)	Ethnicity	n (%)
Gay/lesbian	147 (28.4)	Pākehā	464 (89.1)
Multiple Gender Attracted	257 (49.6)	New Zealand Māori	83 (15.9)
Asexual	51 (9.8)	British	43 (8.3)
Queer	28 (5.4)	Chinese	13 (2.5)
Something else	35 (6.8)	Indian	10 (1.9)
Gender	n (%)	Samoan	9 (1.7)
Woman		Another Ethnicity	67 (12.8)
Cis	230 (44.3)
Trans	21 (4.0)
Man
Cis	52 (10.0)	Urban/Rural	n (%)
Trans	43 (8.3)
Nonbinary	109 (21.0)	Big city	310 (59.8)
Something else	64 (12.3)	Medium city	78 (15.1)
Intersecting Identities	n (%)	Small city	50 (9.7)
Low Socioeconomic Status	70 (13.4)	Town	48 (9.3)
Physical Disability	42 (8.1)	Rural area	32 (6.2)
Neurodiverse	142 (27.3)	Age Bands	n (%)
Sex Worker	13 (2.5)	14–17	170 (32.6)
Migrant	18 (3.5)	18–21	176 (39.5)
Faith/Religious	57 (10.9)	22–24	145 (27.9)
Polyamorous	88 (16.9)
Homeless/Unstable Housing	6 (1.2)

Note: Ethnicity percentages add up to more than 100% as participants were able to select multiple ethnicities.

Data analysis

We analysed the data using reflexive thematic analysis, which involves engaging in a process of continual examination and reflection about our own positionality and experiences in relation to the data (Braun and Clarke 2006, 2019). The first author (a cisgender, heterosexual, Pākehā woman) led this analysis for her postgraduate thesis and was supervised by the last author (a cisgender, mostly straight, Pākehā and Māori wahine who was responsible for the original data collection). The second (transmasculine and Pākehā) and third (queer, takatāpui, Māori and Pākehā) authors provided recommendations and support for both the parent study and the current study.

We had numerous discussions about the implications of an outsider researcher leading the data collection, then passing this data on for analysis by another outsider researcher. These conversations continued into the review process for this manuscript. Initially, authors two and three were acknowledged for their role, rather than listed as co-authors. A helpful reviewer highlighted the tokenistic nature of this involvement. As such, we approached our collaborators, apologised for our failure to offer an opportunity for co-authorship earlier in the process, and asked if they might take a substantive role in our revisions for publication.

We share this because good reflexive work involves questioning one’s own assumptions and motivations, including how to engage in research without contributing to the vast history of outsider researchers speaking for and over marginalised voices (hooks, 1990). Despite choosing a research question specifically designed to give voice to rainbow rangatahi, and taking a critical realist perspective (which states that knowledge is socially located and informed by experience; Braun & Clarke, 2013), we (authors one and four) reproduced the same exploitative processes we were aiming to challenge by recognising the importance of consultation and collaboration in research, but not the importance of credit for the end product. We encourage other outsider researchers (or insider-outsider researchers; Dwyer and Buckle 2009) to consider how community-based student research can appropriately credit community collaborators.

Following Braun and Clarke’s (2006) six step process for thematic analysis, the first author familiarised herself with the data by reading and re-reading over all 521 responses, making note of initial thoughts as she went. She then generated data-derived codes, giving each response equal and thorough attention, often allocating multiple codes to each response. She engaged in ‘complete coding’, through which she sought to capture ‘anything and everything of interest’ in the data (Braun & Clarke, 2013, p. 206). Data were coded twice overall, at both semantic (descriptive, e.g. ‘body language is important’) and latent levels (capturing the underlying meaning, e.g. ‘cissexism’). Once the first author had coded all the data for the second time, she collated these codes and generated potential themes. Theme generation was an iterative process, where the first and last authors met and re-examined these themes through the lens of our research question and adapted them to better tell the overall ‘story’ of the dataset, and to ensure they encompassed the ‘messages’ from participants to MHPs in training. All authors then met to review the final analysis, and to make final revisions.

Analysis

We identified six themes that encapsulate the messages that rainbow rangatahi had for MHPs in training. The themes are as follows: (1) check your assumptions; (2) treat us with empathy and respect; (3) earn our trust; (4) you need to self-reflect; (5) balance getting to know me with educating yourself; and (6) hear our stories. Typographical and grammatical errors have been corrected for readability and demographic information about participants’ gender, sexuality, and age have been included for context, but discussed in the analysis only when participants oriented to it themselves. Pseudonyms are used throughout.

Theme 1: check your assumptions

Participants emphasised that MHPs should avoid making assumptions about their mental health or rainbow identity; several participants simply stated, ‘don’t assume anything’. Many participants stressed the impact that these assumptions could have on their relationship with their MHP.

“Something as simple as assuming the gender of previous partners knocks a lot of trust and confidence” – Fiona, cis lesbian woman, 22 years.

“When they first introduce themselves and ask about our lives they should ask about our sexuality in order to stop awkwardness when they begin to assume that you’re straight” – Jess, cis pansexual female, 16 years.

Many responses (including Fiona above) framed cis- and heterosexist assumptions as ‘simple” acts that can have wide-reaching implications for their rapport with their MHP, breaking trust and creating barriers between the client and clinician. These responses were consistent with previous literature which shows that cis- and heterosexist assumptions are frequently experienced by rainbow people in mental health care settings (Rees et al. 2021), with 51% of rangatahi from the wider sample reporting that their MHP had assumed they were cis or straight (Fraser et al. 2022). Jess’ response stresses the importance of MHPs making space for diverse sexualities to prevent the ‘awkwardness’ that can occur when they assume their client is straight, which can indicate that the clinician has not considered these identities as an option, or that they may be hostile to them (Fraser 2020).

Participants also expressed concerns that their MHP would not take their mental health struggles seriously based on their appearance or how they presented in the room. Many participants framed these responses in terms of their concern that they would be dismissed for ‘looking’ or ‘seeming’ okay.

“Please listen to what I'm saying and take note of it. There's a reason I've come in for help. Don't discredit me because I ‘seem okay'”. Kate, demisexual, cis woman, 19 years.

Kate’s statement reflects their opposition to having to prove their suffering mental health to their clinician – they state that MHPs should listen to what they say is wrong, rather than rely on non-verbal shortcuts to determine whether they need care. Given the chronic under-resourcing of the New Zealand mental health sector (New Zealand Government 2018), it is perhaps unsurprising that clinicians may take visual shortcuts to determine the severity of a client’s needs, however, Kate stresses that MHPs should take a client-led approach – they have sought help ‘for a reason’ and should be listened to, rather than dismissed.

Another assumption that participants wanted their MHPs to avoid was that all rainbow people’s needs were the same, from what they wished to talk about in therapy to their experiences in general.

“The ways a person identifies can be central to who they are and irrelevant to the conversation simultaneously. It will not always be something that naturally comes up so you shouldn't make assumptions.” – Lucy, pansexual/demisexual, cis female, 22 years.

“Don't assume you know the queer and trans community because you have read something about it. Get to know each person for who they are and never assume, just ask politely” – Kim, lesbian, genderfluid, 22 years.

Lucy’s response is reminiscent of many responses throughout the data, where participants stressed that their gender and sexuality may be incredibly important to them as individuals, and simultaneously irrelevant in the context of therapy. This also aligns with previous research where rainbow people reported that their MHP focused significant amounts of time discussing their identity, against their client’s wishes (Fraser et al. 2022). Similar responses (such as Kim) emphasised that what may apply to them will not apply to all members of the rainbow community – for some people, their identity will be central to them as people, for others it will be less so; some people may wish to discuss their experience coming out, others may not. Many participants simply instructed training MHPs to avoid assuming anything.

Theme 2: treat us with empathy and respect

Participants highlighted the need for MHPs to treat them with the respect and empathy they deserve as people seeking care. This included respecting clients’ boundaries when they indicated they did not want to discuss something, as well as their right to privacy. Many participants also emphasised their right to care, regardless of the MHP’s own biases.

“Be kind. Please think before you speak and just be kind – the people coming to you are so vulnerable and probably scared out of their minds. Please, be open, be gentle, be kind.” – Kealagh, pansexual, nonbinary person, 18 years.

“If a queer person is coming to you for support, they've dealt with so much to get there. Offer everything you can to them in your time, your resources and your compassion. They've earned it.” – Mark, pansexual, cisgender guy, 17 years.

The emphasis on kindness and respect featured prominently throughout the data. Kealagh stressed the vulnerability of people seeking mental health care; their repetition of the words ‘be kind’ throughout their response stresses the importance of MHPs maintaining a gentle and empathetic presence for their clients. Mark states that a queer person seeking help has been through ‘so much to get there’ – this could be interpreted in several ways, including the stigma, discrimination, and microaggressions experienced by rainbow people (Rees et al. 2021; Tan et al. 2021), or the many barriers to accessing care generally (New Zealand Government 2018). Regardless, Mark’s response implies that rainbow clients are particularly in need of compassion from their MHPs.

Some participants, such as Vincent below, stated that MHPs need to respect their clients’ right to confidentiality. Such responses emphasised that clinicians should avoid asking about their client’s gender or sexuality in front of their parent(s) or sharing any information without their consent.

“If your patients don’t want other people knowing, then don’t tell other people. Shouldn’t be that difficult” – Vincent, gay, cis male, 17 years.

In many responses concerning clients’ rights to privacy, such as that from Vincent, it was unclear whether the participants were referring to their privacy concerning their mental health status or their rainbow identity. However, ethical guidelines for patient confidentiality in New Zealand state that clients’ information should be shared only in limited circumstances, often relating to their safety (New Zealand Code of Ethics Review Group 2008; New Zealand Association of Counsellors 2020) – therefore it is unlikely that a clinician should ever need to disclose their client’s rainbow identity(ies) without their consent. This is particularly important, given that, should a young person be outed to an unsupportive family, they may be placed in harm’s way (Snapp et al. 2015).

Finally, many participants also expressed that they have a right to care and respect, regardless of their MHP’s biases or opinions.

“To be more accepting of all that come to you for help and to put their issues before your opinions to ensure they’re getting the help they need.” – Josh, bisexual, trans male, 14 years.

Josh’s use of the word ‘more’ suggests that the level of acceptance among MHPs is lacking and needs to improve. They also emphasise their expectation that MHPs may let their prejudices interfere with the provision of adequate care for rainbow clients. Similar responses stressed that if MHPs are unable to confront and address these biases, they are in the wrong profession. The emphasis on respect and kindness throughout the data is cause for concern – as stated previously, mental health practitioners in Aotearoa have an ethical obligation to ensure that each of their clients is treated with respect and dignity, and to provide their services in a way that affirms their clients’ diverse sexuality, sex characteristics, or gender (New Zealand Psychologists Board 2019). These responses indicate that some rainbow rangatahi expect that they may not be treated with empathy or kindness in mental health care settings.

Theme 3: earn our trust

This theme captures the importance of trust and rapport-building from MHPs; responses of this nature emphasised that the process of ‘opening up’ takes time, so MHPs must have patience.

“Everyone is different and sometimes it will take a while to learn about a person but it isn't easy to come out to a complete stranger sometimes.” – Jason, bisexual, cis male, 16 years.

Many of these responses, including that of Jason above, framed coming out to a MHP as something that would take time – as Jason states, MHPs are still initially ‘complete strangers’ to their clients. Despite what a MHP in training might assume, they do not gain their clients’ trust by virtue of their position alone. Some responses even framed the MHP/client dynamic as a barrier to be overcome:

“That I don't like therapy and therapists. However I'm still conflicted about that because I know therapy has helped a lot of people I know” – Victoria, cis female, lesbian, 17 years.

Victoria went on to state that, after a period of unwillingness to ‘open up’, they would eventually want to talk about the difficulties they were experiencing in their life, such as school, relationships, and their body image. Given much of the previous literature's findings on rainbow youths’ mental health support experiences (Fraser et al. 2022; Tan et al. 2021; McCann and Sharek 2014), it perhaps comes as little surprise that many rainbow rangatahi feel that their trust in an MHP needs to be earned.

Many respondents suggested ways MHPs can create safe spaces for their rainbow clients. Some participants suggested that MHPs can signal safety via visual cues in their office – rainbow flags, name tags with pronouns, space for clients to indicate their pronouns on intake forms. Importantly, these visual representations of inclusivity need to be followed up with action.

As discussed above, many participants stressed that MHPs should avoid making assumptions about their clients’ rainbow identity (or lack thereof) – participants often communicated this through an emphasis on inclusive language. Many participants stated that MHPs using neutral and inclusive language, such as: clinicians using ‘partner(s)’ instead of ‘boyfriend’ or ‘girlfriend’; sharing their own pronouns; and adopting the language their clients use to describe themselves. In the parent study for this research, over 90% of participants indicated that their MHP using inclusive language was either ‘helpful’ or ‘extremely helpful’ (Fraser 2020). It is also a relatively simple action for MHPs (whether in training or practicing) to incorporate into their practice; as Emma states: ‘Inclusive language is SO SO EASY’.

Many participants, such as Eva and Tony below, emphasised the importance of non-verbal cues, such as clinicians showing surprise or discomfort versus a comfortable and casual attitude to their client’s rainbow identity.

“A casual attitude means a lot to me, because it reaffirms from a professional point of view that I am accepted. I want to be able to come out as casually as I can before moving on to the issues that I sought counselling for, and not have to worry about whether my counsellor will judge me for my orientation.” – Eva, bisexual, cis female, 19 years.

“It's really obvious for some people when you're faking concern or trying to hide that you're uncomfortable. Pretty much anything like that. It makes the person you're talking to feel like you're just going through the motions and it starts to feel pointless” – Tony, gay, male, 23 years.

These responses emphasise the importance of practitioners providing a validating presence in their practice, ensuring clients do not have to guess whether their practitioner will judge them, and that clients feel listened to and affirmed by their MHP. Tony particularly stresses that this must come from a place of genuine care on the part of the clinician. These responses also reflect previous findings on identity-affirming care, which show that providing a validating presence for rainbow clients leads to a safer environment and better therapeutic outcomes (Benson 2013; White and Fontenot 2019), and the harms of failing to provide such care, such as the alienation of clients from mental health support (Tan et al. 2021). This is significant given that 25% of the wider sample of rainbow rangatahi in this study reported that their MHP seemed surprised or uncomfortable when they came out (Fraser et al. 2022).

Theme 4: you need to self-reflect

Participants commonly stated that training MHPs need to confront their biases before they practice, and some requested they seriously reflect on their motivations for entering the profession in the first place.

“Just like their commitment to cultural competency regarding te Tiriti o Waitangi and bi-cultural practice, they need to be aware that there are subsets of our communities that are still on the margins. To work with us, they need to be aware of their assumptions, bias and engage in critical reflection to work through potential discriminatory beliefs” – Zoe, bisexual, cis woman, 24 years.

Zoe compares rainbow cultural competency with that of te Tiriti o Waitangi – a founding document in New Zealand outlining the Crown’s (the New Zealand Government’s) obligations to tangata whenua (the people of the land, i.e. Māori). They state that, ‘just like’ MHPs’ commitment to bicultural practice, MHPs should hold rainbow cultural competencies in a similar regard. For example, the core cultural competencies for clinical psychologists in New Zealand focus largely on proficiency regarding te Tiriti o Waitangi and bi-cultural practice (New Zealand Psychologists Board 2018). Commitment to rainbow cultural competencies, while briefly mentioned in the guidelines, are not emphasised to the same extent (New Zealand Psychologists Board 2018). It is important to note, however, that there is a wide body of literature showing that the mental health sector has largely fallen short of adequately meeting their obligations under te Tiriti o Waitangi as well (Abbot and Durie 1987; Brady 1992; Johnstone and Read 2000; Skogstad et al. 2005).

“It's not enough to just have good intentions and to believe you aren’t homophobic. You've got to have more awareness than that.” Nora, queer/gay/lesbian, cis woman, 21 years.

Nora emphasises that even those with ‘good intentions’ need to engage in a process of self-reflection – this involves MHPs examining both conscious and unconscious bias to the best of their ability. Many participants also sought to remind training MHPs that their suffering mental health was not the result of their identity, and that their rainbow identity was not the result of trauma. Such responses indicate that many rainbow rangatahi perceive a bias among MHPs against rainbow people, reflecting previous findings that many rainbow individuals have experienced bias in therapy firsthand (Fraser et al. 2022; Tan et al. 2021). Participants stressed that if MHPs in training were unable to put these biases behind them, they should reconsider being in the profession at all.

Theme 5: balance getting to know me with educating yourself

Throughout the data, two seemingly contradictory messages were consistently identified; an emphasis on the educational burden placed on rainbow clients seeking care, and that if MHPs did not understand something, it was okay for them to ask.

The emphasis on rainbow education was prominent – many participants stated that MHPs needed to be educated on rainbow issues and identities, including understanding people’s pronouns, labels, minority stress, and the intersectionality of inhabiting multiple marginalised identities (e.g. the unique struggles faced by rainbow people who are migrants, ethnic minorities, and/or neurodivergent/disabled), as well as being educated on other cultural competencies such as Tikanga Māori (the incorporation of Māori values and customs into practice). Within these responses, many participants, such as Tom and Tui below, stressed the emotionally and financially taxing nature of having to educate their MHPs.

“To ask for pronouns and do their research. It is exhausting to have to educate everyone around you about rainbow topics.” – Tom, panromantic/demisexual demiboy, 17 years.

“I have wasted SO much paid time during my mental health journey explaining things that had little or nothing to do with the reason I was there. GPs & psychotherapists alike didn't have even a basic understanding of sexual orientation and gender identity. It not only wastes time and stresses me out financially; it also brings up minority stress during consultations and layers it on top of my initial problem … ” Tui, bisexual cis woman, 22 years.

As discussed previously, accessing mental health care in New Zealand can be a costly endeavour, particularly when clients spend significant amounts of time in-session educating their MHP. Tui positions themselves as ‘one of the luckiest’ of their friends regarding mental health support experiences, because their position as a cisgender woman meant they did not have the additional burden of also having to explain their gender, but ‘just’ their sexuality to their MHP. This touches on the intersectionality of experiences within the rainbow community – that trans and gender diverse people may experience stigma and discrimination unique to their gender identity that cisgender rainbow people may not (Su et al. 2016; Tant and Samuels 2021).

Many participants also indicated they would tell training MHPs that if they are unsure about something, it is okay to ask questions, if done respectfully, such as Participant 236 below.

“If you don't understand something relating to the LGBT experience, ask, there's no shame in not knowing something, but make sure you do it in a polite and respectful way” – Nate, pansexual, nonbinary/gender nonconforming, 17 years.

“Sexuality means different things for everyone so you need to check out what it means to the person you're working with. Ask lots of questions and don't make assumptions … ” – Ximena, bisexual, cis female, 24 years.

Nate highlights many respondents’ preference for MHPs to ask questions, rather than remaining ignorant about rainbow issues and experiences. Upon initial examination, these responses could reflect a contradiction in the data – some rainbow rangatahi did not wish to be burdened with educating their MHPs, while others would rather educate them than have their MHP remain ignorant. However, both response types reflect the need for MHPs to have foundational knowledge regarding rainbow issues – if clinicians had sufficient knowledge about rainbow issues and identities, these questions would not need to be asked to clients in the first place. These responses also reflect the need for MHPs to take a client-led approach – practitioners must find the balance between having sufficient foundational knowledge about rainbow issues and identities while also getting to know their clients as individuals. Ximena notes that ‘sexuality means different things for everyone’ – reflecting the distinction between a practitioner asking questions to get to know their client (e.g. ‘what does your bisexuality mean for you?’) versus asking their client to educate them about rainbow issues generally – (e.g. ‘can you explain bisexuality to me?’).

Theme 6: hear our stories

The sixth and final theme captures the participants who responded to this question with their personal experiences – both within the mental health sector, and in life. Many responses were indicative of the structural barriers within the New Zealand mental health care system (New Zealand Government 2018). In these responses, participants detailed their experiences within the mental health sector that were not necessarily related to their rainbow identity, but to structural barriers to support, including long wait times, difficulty accessing care, and the need for change.

“The mental health support we get is not good enough – and not just in terms of sexuality/gender. I have multiple experiences not related to me being queer where I have not gotten what I needed from the professionals I went to. I have been turned away from support, I have had appointments cancelled as I walk in the door (multiple times by the same person), and I have been given a nurse when I went to [Child, Adolescent and Family Services] looking for support for my mental health. Because of this, I have only ever felt confident enough to bring up my sexuality with 1 professional (out of the 6 I've seen).” – Hannah, asexual, questioning gender, 17 years.

Hannah uses their experience within the mental health sector as a teaching tool, highlighting the multiple experiences they have had being turned away from the mental health care, and being sent to a nurse, presumably in place of a MHP.⁴ They then reflect on how this has impacted on their ability to feel comfortable with practitioners – resulting in them discussing their sexuality with only one out of six MHPs they have seen. This emphasises that encountering structural barriers to support not only impacts whether a person can receive care but can damage the client/therapist relationship once care is finally accessed. Other responses of this nature stressed the disenfranchisement they feel with MHPs, one participant stated, ‘I would not bother because they have never considered my advice’, suggesting that their previous attempts to enact change have gone overlooked.

“I would want to ask whether how I feel is normal, whether there is a way to fix it or make me feel more comfortable with who I am, and where I could find more support (in person) for my problems.” – Tim, pansexual, gender unsure, 15 years.

Other participants shared responses that appeared to be for the purpose of help-seeking, such as Tim above – they are clear that if they were in a room full of training MHPs, they would use it an opportunity to receive support with their personal struggles and enquire about further mental health services. Similar responses detailed personal struggles with friends and family, bullying, difficulties they have had with coming out, and their current mental health status. It is unclear whether some of these responses were due to a misinterpretation of the question, or whether they intended to use these personal narratives as an educating tool or driver for change.

Discussion

The current study sought to give voice to rainbow rangatahi across Aotearoa, exploring their direct messages to training MHPs. Our analysis reveals a distinct lack of trust among many rainbow rangatahi toward the mental health profession. Typically, people do not make recommendations for things that they perceive as already happening – as such, these findings arguably reflect gaps in the provision of mental health services for rainbow rangatahi. Alternatively framed, these themes suggest that many rainbow rangatahi expect that practitioners may treat them without care or respect, make cis- and heterosexist assumptions, be uneducated about rainbow issues and experiences, and dismissive of their concerns. These messages align with the previous literature on rainbow people’s support experiences, where rainbow people have reported stigma, discrimination, pathologisation, and a lack of practitioner knowledge about rainbow issues and identities when accessing mental health care (Fraser et al. 2022; McCann and Sharek 2014; Rees et al. 2021; Tan et al. 2021; White and Fontenot 2019). This illustrates the need for MHPs, and the institutions that train them, to improve their rainbow cultural competencies and work to earn the trust of their young rainbow clients.

Encouragingly, these messages also largely align with the current recommendations for practitioners working with rainbow clients, suggesting that these recommendations are grounded in the voices and stories of rainbow people (New Zealand Psychologists Board 2019). However, these recommendations also state that clinicians should engage in a ‘comprehensive assessment’ which ‘should include as part of their assessment practice discussion of clients’ coming out journey … ’ (New Zealand Psychologists Board 2019, p. 12). As many participants stated, MHPs should avoid assuming their rainbow clients want to spend time discussing their sexuality or gender – this, in some cases, explicitly included their coming-out story. The framing of this recommendation could inadvertently pressure rainbow clients to share this information regardless of whether it is relevant to their care. While it is important for practitioners to consider how clients’ rainbow identities may inform their mental health experiences, participants’ accounts add important context to this recommendation: clients may only feel safe to discuss their gender or sexuality if they perceive the therapeutic setting to be one of trust and non-stigmatisation. To create an environment where clients can feel open to disclose or discuss their gender or sexuality, MHPs should prioritise building a foundation of trust and transparency within the therapeutic relationship before these discussions take place. Practitioners should be guided by the client in this discussion through asking open-ended questions about their gender or sexuality in a non-judgmental way and using respectful language, and being responsive if clients do or do not wish to talk about their gender or sexuality.

While it is positive that these recommendations generally align with these rainbow rangatahi messages, it should be stated that these recommendations are just that. They are not requirements for practice and are not explicitly taught to MHPs in training (Haywood and Treharne 2022; Taylor et al. 2018). This puts the onus on practicing MHPs to seek out rainbow cultural competency training themselves, and our analysis suggests that many MHPs are not doing so. We therefore argue that rainbow cultural competencies, grounded in the voices of rainbow people, be taught to MHPs as part of their qualification and that continued professional development to maintain these competencies, and time allotted to do so, become mandatory.

The results from the current study can be used to further inform the implementation of rainbow education for MHPs. Such training might include teaching the ‘basics’ of gender and sexual diversity, including neutral language, pronouns, definitions, minority stress, and intersecting identities. Emphasis should also be placed on the balance required when it comes to rainbow cultural competency – training might discuss how practitioners might balance their knowledge of rainbow identities and terminology, with avoiding using this knowledge to make assumptions about a client’s experience. For example, a clinician should be aware that rainbow people tend to report higher levels of mental distress due to the stigma and discrimination they may experience as the result of bigotry and cis- and heterosexism (Meyer 2003; Tan et al. 2021). However, they should also avoid assuming their client as an individual has experienced this, or that this is a reason they have sought help. For more information on the practice implications of the current research, see Fraser (2019).

Given many participants’ emphasis on MHPs’ need for self-reflection (with some participants stating that if MHPs could not confront and address their biases, they should reconsider being in the profession at all), further emphasis must be placed on how practitioners can identify and name biases, pinpoint any areas of discomfort, and explore their origins. Such reflective practice is consistent with the Core Competencies for the Practice of Psychology in Aotearoa New Zealand (New Zealand Psychologists Board 2018).

Strengths, limitations, and future directions

One strength of the current study was our large sample size – while ‘bigger is not inherently better’ (Terry and Braun 2017, p. 21) in qualitative research, the sample size did allow for a diverse sample, filled with rich and varied responses from participants across Aotearoa, including those from small- and medium-sized towns and rural areas. These were areas we were unable to include in our initial interview study (Fraser 2020). This was one of the benefits of using an online qualitative survey (Terry and Braun 2017), but was no doubt bolstered by the community-based nature of this research, collaborating with RainbowYOUTH, Gender Minorities Aotearoa, and InsideOUT Kōaro.

While the use of a qualitative survey allowed for many rich and diverse responses, it occasionally led to difficulties with interpretation, bringing us to a limitation of the current study. Some responses gave little context for their answers, which ultimately restricted the conclusions we were able to draw. For example, some participants responded with short statements, such as stating that they would have ‘a lot’ to say without elaborating further, thus limiting our analysis for these responses.

What is arguably both a strength and a limitation to this research was the wording of the survey question. The question, ‘If you had a room full of training MHPs in front of you, what would you want to tell them?’ allowed for participants, as stated above, to share what they deemed important for training MHPs to know. This resulted in a wide range of responses that highlighted rainbow rangatahi experiences within the mental health sector and recommendations for what MHPs should both implement and avoid in their practice.

However, there were also many responses which could be interpreted as help-seeking that did not appear to align with the initial aim of the study. Such responses may have resulted from the ambiguity of the question – it is possible that these participants interpreted the question as ‘if you had the opportunity, what would you tell a MHP?’. Despite this potential ambiguity, these responses share important insights into lives of many rainbow rangatahi in New Zealand and highlight the existing need for affirming mental health support. Ledwith (2005) describes personal narratives as ‘vehicles for critical consciousness’ which, when taken seriously, can result in a ‘collective process for social justice’ (Ledwith 2005, p. 259).

A further limitation to our study was that, despite endeavours to recruit hard-to-reach minorities within the rainbow community, (e.g. ethnic minorities, those with physical disabilities, and migrants), our data reflected limited involvement from members of these groups. This is likely because minorities within the rainbow community are a hard-to-reach group within an already hard-to-reach population (Ellard-Gray et al. 2015). Therefore, the messages in this study are reflective of predominantly cisgender, able-bodied Pākehā and Māori, living in stable housing, in larger cities in Aotearoa. More participants from these minority groups might have resulted in more messages about specific intersectionality within the rainbow community – for example, the unique experiences of rainbow people living in rural or isolated areas (Nic Giolla Easpaig et al. 2022). Therefore, conclusions about messages from rainbow rangatahi across Aotearoa as a whole cannot be drawn from this dataset.

Our data was collected in 2018, and the subsequent COVID-19 pandemic has had a significant worldwide impact on the provision of mental health care. Recent international research has indicated that rainbow youth experienced unique stressors during COVID-19, including increased mental distress due to socially isolating with unsupportive family and the loss of access to in-person social support services (Fish et al. 2020). Internationally, and in Aotearoa New Zealand, COVID-19 also resulted in the increased use of telehealth appointments for mental health concerns (Officer et al. 2023), as well as the development of those specially geared toward supporting LGBTQ + youth (Craig et al. 2021). Future research could explore rainbow rangatahi experiences of telehealth counselling, or messages for MHPS providing mental health support by distance.

The current study adds to previous literature by exploring direct messages rainbow rangatahi had for training MHPs. Further research might seek to expand this enquiry to messages from older rainbow people. Older rainbow people are more likely to report internalised stigma, with many having lived much of their lives prior to the advancements toward the rights of rainbow people in recent decades (Fredriksen-Goldsen et al. 2013; Yarns et al. 2016). They are also an under-served part of the community, both in research and social support (McGovern et al. 2016). As such, their unique experiences would likely result in important messages which differ to those of rainbow rangatahi.

Finally, recent work by Curtis and colleagues (2019) argues that cultural safety, rather than cultural competency, is required to achieve health equity for indigenous and minoritised ethnic groups. Although we have used ‘competency’ framing in line with previous rainbow literature, professional bodies such as the New Zealand Psychologists’ Board, future research could also explore what it would mean to shift from competency to safety in rainbow training for MHPs.

Conclusion

The current study sought to give voice to rainbow rangatahi, by asking them their messages to training MHPs. Six themes were identified in the data: check your assumptions; treat us with empathy and respect; earn our trust; you need to self-reflect; balance getting to know me with educating yourself; and hear our stories. These messages reflect the wide range of experiences and concerns of rainbow rangatahi, as well as the need for rainbow education for MHPs in Aotearoa. The current study suggests that the training and professional development of such competencies are made mandatory for practitioners, and that this training be grounded in the voices of rainbow rangatahi.

Acknowledgements

We are grateful to all the rainbow rangatahi who participated in this study – ngā mihi nui ki a koutou, thank you for your time and for trusting us with your stories. We would like to thank RainbowYOUTH, InsideOUT, Gender Minorities Aotearoa, and all the other rainbow community organisations and advocates that made this project possible.

Disclosure statement

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

Additional information

Funding

This work was supported by Marsden Fund [Grant Number 18-VUW-162].

Notes

1 Takatāpui is a reclaimed Indigenous Māori umbrella term encompassing non-cisgender, non-heterosexual, and /or intersex Māori people (Kerekere 2021).

2 MVPFAFF+ is an umbrella term for Pasifika rainbow identities including Mahu, Vakasalewa, Palopa, Fa’afafine, Akava’ine, Fakaleiti [leiti], Fakafifine (PrideNZ 2011).

3 Our use of umbrella terms has shifted over the course of the wider research project. Initially we tended towards use of “queer, trans, and intersex”, which is why “rainbow” was not included in our recruitment flyer; we changed this following survey data collection in response to feedback from our community partners, who were increasingly moving towards use of “rainbow” for its inclusivity and brevity.

4 It is unclear whether Hannah interpreted being sent to a nurse to mean that their mental health was not being taken seriously, or that this nurse was not qualified to assist with their mental health. However, it should be noted that nurses in New Zealand are often trained in and can specialise in mental health care (McKinlay et al. 2011).