LGBTQ+ cultural competency of Irish mental health professional students

Abstract

Introduction

The LGBTQ+ community is often discriminated against and stigmatized resulting in greater psychological and emotional stress compared to heterosexual and cisgender people. Consequently, poorer mental health is often observed in this community. To alleviate these disparities, mental health professionals need to be culturally competent. Therefore, LGBTQ+ cultural competency was explored in a sample of Irish mental health professional students.

Methods

A questionnaire was circulated among Irish students in mental health programmes. Out of approximately 700 students, 66 competed the survey, of which 23 identified as LGBTQ+.

Results

In terms of cultural competency, participants reported significantly higher attitudinal awareness compared to basic knowledge and clinical preparedness. Further, cultural competency was lower for transgender clients. LGBTQ+ patient education significantly predicted cultural competency when controlling for demographic variables. Three themes were generated from the open answers: experiences of cultural competency training, affirmative but uninformed, and recommendations for implementing training.

Conclusion

To provide adequate, affirmative care, cultural competency training should be a mandatory component of all mental health professional programmes.

Keywords:

• LGBTQ+ cultural competency
• mental health professional students
• LGBTQ+ patient education
• mental health

Research into the Irish LGBTQ+¹ community began with the Supporting LGBT Lives study (Mayock et al., 2009). This was the first study to explore the experiences and issues impacting the mental health and well-being of LGBTQ+ people in an Irish context. Over the next few years, Ireland witnessed a change in the socio-political climate, largely brought about through legislative change, such as the Marriage Equality and the Gender Recognition Act (Marriage Act, 2015; Gender Recognition Act, 2015) and changes in the wider sociocultural understandings of sexual and gender identities (Russell & Fish, 2016). This indicated a need for further research. In 2016, the LGBT Ireland Report was published (Higgins et al., 2016). This research further examined the mental health and well-being of the Irish LGBTQ+ community. The report surveyed over 2000 people from the community, making it the largest study of LGBTQ+ people in Ireland to date.

Results of the report indicated that a large proportion of the LGBTQ+ participants were experiencing similar levels of well-being to the general population. However, the same levels of positive mental health and wellness were not seen for respondents aged 25 and under. When comparing these findings to the My World National Youth Mental Health Study (Dooley & Fitzgerald, 2012), Higgins et al. (2016) found that young LGBTQ+ people in Ireland had two times the level of self-harm, three times the level of attempted suicide, and four times the level of severe stress, anxiety, and depression. These findings are consistent with research conducted on LGBTQ+ youth outside of Ireland (Russell & Fish, 2016).

In addition to differences across age groups, the report revealed that there is also a “hierarchy of risk” across LGBTQ+ identities. Intersex, transgender, and bisexual people reported poorer mental health outcomes compared to gay men and lesbian women in Ireland (Higgins et al., 2016). In 2013, a report published by the Transgender Equality Network Ireland (TENI) found that 82% of transgender and gender non-conforming (TGNC) people in Ireland are living with depression, 73% are living with anxiety, and 55% felt they had experienced a mental health crisis at one point in their lives (McNeil et al., 2013). These findings support the global trends indicating that even within the already marginalized LGBTQ+ community, TGNC individuals have worse mental health outcomes relative to cisgender and LGB people (Su et al., 2016). In sum, there is clear and consistent evidence to indicate that mental health problems are elevated among the LGBTQ+ community.

Considering this, mental health practitioners have a unique opportunity to intervene and alleviate these concerns through their service provision. However due to their own personal experiences and socialization, health care providers often hold negative attitudes and implicit bias against the LGBTQ+ community (Morris et al., 2019). As the socio-cultural climate in Ireland progresses, it is important to ensure the LGBTQ+ community has access to adequate mental health care. LGBTQ+ cultural competency training is recommended to ameliorate these disparities and encourage mental health practitioners to address their biases (Bettergarcia et al., 2021). It is common for educational programmes to offer no cultural competency training for mental health students (Nowaskie, 2020; Nowaskie & Patel, 2020, 2021). As a result, health care practitioners are often unable to provide culturally sensitive care to their LGBTQ+ clients and patients (Carabez et al., 2015). Therefore, this study aims to explore the LGBTQ+ cultural competency of mental health students in Ireland and the relationship between LGBTQ+ patient experience and cultural competency.

Minority stress and the LGBTQ+ community in Ireland

It is important to note that although the LGBTQ+ community experiences disproportionate levels of psychosocial problems, this is not related directly to their identity (Fredriksen-Goldsen et al., 2014). These findings can be attributed to experiences of discrimination, bullying, and harassment due to these identities being highly stigmatized (Bockting et al., 2013; Kaniuka et al., 2019). This concept was formulated by Meyer (2003) using the minority stress model and has been expanded and adapted to include TGNC people (Hendricks & Testa, 2012; Meyer, 2015). This model specifies several external (discrimination, prejudice, heteronormative bias) and internal conditions (internalised homophobia or transphobia, hyper vigilance) leading to chronic stress, which contributes to the negative health outcomes found in this population (see De Vries et al., 2020 for a detailed model of LGBTQ+ minority stress).

When examining societal stressors for LBGTQ+people in Ireland, Higgins et al. (2016) found that participants reported experiences of victimization and harassment in their day-to-day lives. Overall, 75% of the participants had been verbally abused due to their LGBTQ+ identity. Gay men, transgender people, and intersex people reported experiencing the highest levels of harassment and violence in public. Further, there had not been a significant reduction in these experiences since the original Supporting LGBT Lives study (Mayock et al., 2009). Differences in mental health outcomes across age groups and identity subpopulations likely reflects the “hierarchy of progress” in reducing homophobia in Ireland compared to transphobia and biphobia (Higgins et al., 2016). Despite the changing socio-political climate in Ireland, these findings reveal that the LGBTQ+ population in Ireland are still vulnerable and mental health issues are pervasive. Considering the effects of minority stress, it is essential for this population to have access to adequate and culturally competent mental health care.

LGBTQ+ individuals’ experiences of Irish mental health services

In 2014, McCann and Sharek (2014b) surveyed a sample of people in the LGBTQ+ community to examine the challenges faced and areas of good practice when accessing mental health care in Ireland. Most respondents indicated that their mental health professionals lacked knowledge about LGBTQ+ issues. Participants noted the prevalence of heterosexist attitudes, such as health care staff automatically assuming they were heterosexual or cisgender. Heterosexism refers to subtle, yet often more prevalent instances of oppression that lead to health disparities for LBGTQ+clients (Morrison & Dinkel, 2012). Following this survey, a series of interviews were conducted (McCann & Sharek, 2014a). Participants expressed the need for services to be a place where people would be treated with dignity and respect, highlighting that mental health practitioners need to be educated about LGBTQ+ issues. A lack of LGBTQ+ specific knowledge from health providers is a commonly cited problem for people across a range of primary care settings (Campbell et al., 2023). More recently, a report was published summarizing the results from the LGBT Ireland Report (Higgins et al., 2016). This study examined LGBTQ+ young people’s perceptions of barriers to accessing mental health services in Ireland (Higgins et al., 2021). From the cohort of young LGBTQ+ people (participants aged 14 to 25), 80% of respondents indicated that barriers existed. Many specified mental health practitioners lack of competence to provide LGBTQ+ affirmative care as one of the main barriers, especially regarding TGNC identities.

Although most of the research on TGNC mental health in Ireland has been derived from research on the wider LGBTQ+ community, it is important to note that this population face a unique set of barriers when accessing mental health services. This is compounded by the “hierarchy of risk” identified in the LGBT Ireland Report, where transgender participants reported poorer mental health outcomes compared to gay men and lesbian women (Higgins et al., 2016). Considering this, Delaney and McCann (2021) conducted research to explore, in depth, the experiences of transgender people within the Irish mental health service. Participants emphasized the importance of affirmative experiences within the mental health services. Clinician knowledge and understanding of the transition process, trans identity, and the challenges facing the community all contributed to experiences of affirmation for participants in this study. On the other hand, they also noted that a lack of knowledge on the practitioner’s behalf resulted in transphobic and non-affirming experiences. Finally, non-affirmative experiences relating to a lack of knowledge severely impacted the therapeutic alliance. This often resulted in participants prematurely terminating their use of services. It is important to note that these findings are not unique to the Irish context. A recent systematic review of qualitative research regarding the experiences of psychological therapy amongst TGNC people found that non-affirmative experiences in therapy were common outside of Ireland as well (Compton & Morgan, 2022).

Across all studies, participants feared that due to a lack of clinician knowledge, their LGBTQ+ identity could be pathologized, and seen as the cause of their mental health issues (Delaney & McCann, 2021; Higgins et al., 2021, 2016; McCann & Sharek, 2014a, 2014b). This is of notable importance due to the troubling history of psychology and the LGBTQ+ community. The field of psychology has pathologized LGBTQ+ identities and supported the view that they should be treated or fixed (Drescher, 2015). It has been a mere 50 years, since the American Psychiatric Association declassified homosexuality as a mental disorder (American Psychiatric Association, 1974). Only in the past 10 years, the classification of “gender dysphoria” replaced the previous diagnosis of gender identity disorder (American Psychiatric Association, 2013). This amendment was predicated on the belief that a diagnosis of gender identity disorder is inherently stigmatizing due to the assumption that diverse gender identities are disordered (Davy & Toze, 2018). Now, a discordance between gender identity and gender assigned at birth is increasingly understood as a common instance of human diversity rather than being inherently pathological (Davy & Toze, 2018). Yet, TGNC people still commonly report feeling as though their gender identity has been pathologized in therapy situations (Compton & Morgan, 2022).

LGBTQ+ cultural competency in mental health practitioners

A leading response to disparities in service provision is the development of mandatory cultural competency training for mental health professionals (Bettergarcia et al., 2021). Previous scholarship on multicultural competency primarily focused on ethnic and racially diverse client groups, and subsequently, it was extended to include various other populations (Bidell, 2017; Pieterse et al., 2009). LGBTQ+ cultural competency has gradually gained prominence and been embraced within the realms of health sciences and mental health disciplines, establishing itself as the ethical standard for providing clinical care (Bidell, 2017). Although differences in cultural competency guidelines exist, an informed, affirmative approach to LGBTQ+ care is recommended by the majority of health care organizations² (American Psychological Association, 2021; British Psychological Society, 2019; World Professional Association for Transgender Health, 2012).

In order to provide competent, ethical, and efficient care to LGBTQ+ clients and patients, institutions have collectively emphasized that practitioners must (1) recognize and address their own personal and societal biases and prejudices toward LGBTQ+ individuals, (2) develop appropriate clinical expertise and techniques for the effective treatment of LGBTQ+ clients/patients, and (3) acquire a functional understanding of the psychosocial and health-related aspects pertinent to the LGBTQ+ community (Bidell, 2017). Thus, for the context of this research we will be conceptualizing cultural competency using this “tripartite model,” encompassing awareness, skill development, and knowledge acquisition (Bidell, 2017). This model draws on earlier multicultural competency scholarship (Pieterse et al., 2009).

There are numerous studies demonstrating that LGBTQ+ cultural competency training and experiential training with LGBTQ+ clients can increase competency for health care practitioners (Kelley et al., 2008; Pratt-Chapman, 2021; Pratt-Chapman & Phillips, 2020; Strong & Folse, 2015). Malott (2010) concluded that “researchers have demonstrated that a single multicultural counselling course can positively affect variables related to multicultural competency” (p. 58). From the perspective of the clients, greater perceived multicultural competence of the therapist was associated with an increased likelihood of therapy completion, treatment satisfaction, and strength of therapeutic alliance (Anderson et al., 2019; Constantine, 2002; Fuertes et al., 2007). Undoubtedly, providing effective cultural competency training for mental healthcare providers is essential to support the LGBTQ+ community.

Based on numerous accounts from LGBTQ+ people in Ireland, there is evidence to suggest it is difficult to find affirmative, knowledgeable, and culturally competent mental health providers. It is common for mental health practitioners to receive little to no training as part of their programmes and to feel unprepared to work with LGBTQ+ clients (Graham et al., 2012). Being socialized in an environment that marginalizes sexual and gender minorities, unavoidably shapes their understanding and viewpoints regarding LGBT individuals (Morris et al., 2019). Even practitioners who hold more positive attitudes toward their LGBTQ+ clients, still tend to report lower skill and knowledge (Nowaskie, 2020). This results in a range of negative experiences including, heterosexist assumptions, avoiding discussing their LGBTQ+ identity at all, and the assumption that their LGBTQ+ identity is the cause of their mental health concerns (Delaney & McCann, 2021; Higgins et al., 2021; McCann & Sharek, 2014a, 2014b). Disparities in mental health care access and level of care can exacerbate psychosocial issues for LGBTQ+ people (Higgins et al., 2021) and people tend to avoid seeking mental health services because they have had a negative experience in the past (Delaney & McCann, 2021; Higgins et al., 2021; McNeil et al., 2013).

The present study

Although the research calls for increased LGBTQ+ cultural competency training and experiential training with LGBTQ+ clients (American Psychological Association, 2021; Nowaskie, 2020), to date there have been no studies exploring LGBTQ+ cultural competency of Irish mental health workers. This study aims to address this by investigating the overall LGBTQ+ cultural competency of mental health professional students in Ireland. As students are active members of current programmes, this will characterize the present LGBTQ+ cultural competency training and education practices of mental health programmes in Ireland. In addition, it will examine their level of training and patient experience and whether this predicts cultural competency. Drawing on previous literature, it is hypothesized that mental health students will have more positive attitudes compared to basic knowledge and competency (H1) Considering the hierarchy of progress, it is hypothesized that cultural competency regarding transgender identities will be lower compared to sexual minorities (H2). Finally, it is hypothesized that LGBTQ+ patient education and LGBTQ+ patient contact will significantly predict cultural competency (H3). To explore these issues in more depth, open answer questions will be included in the survey to allow participants to give further comments about their LGBTQ+ cultural competency and training.

Method

Design

This study employed a self-report questionnaire to collect both quantitative and qualitative responses to investigate the LGBTQ+ cultural competency of Irish Mental Health students. Mental health profession constituted any profession specified by the Health Service Executive, excluding medical students (Health Service Executive, 2021). The survey comprised 25 questions that measured demographics, LGBTQ+ experiential variables, and LGBTQ+ cultural competency. Participation in the survey was voluntary and anonymous. Initiation and completion of the survey constituted as consent.

Participants

In total, 98 people took part in the survey. After initial analysis, 32 participants were removed due to incomplete responses. Subsequent analyses were conducted on the remaining 66 participants. Participants were aged between 21 and 78 with a mean of 32.2 and standard deviation of 11.86. Each subsample of participants who identified as LGBTQ+ was insufficiently large to test for group differences. Therefore, participants were either coded as having an LGBTQ+ identity or not. Overall, 23 of the participants identified as a member of the LGBTQ+ community.

Measures

Political orientation

To measure political orientation, general social and economic conservatism was assessed by averaging two items on 10-point scales, “In general, how liberal or conservative are you on social issues?” (1 = very liberal; 10 = very conservative), and “In general, how left-wing or right-wing are you on economic issues?” (1 = very left-wing; 10 = very right-wing). Lower scores indicate more politically progressive views.

Socio-economic status

SES was measured using Adler’s ladder where higher values indicate a higher SES.

LGBTQ+ experientials

Patient contact

Participants were asked whether they had completed any clinical practice. Participants who had completed clinical practice were asked how often they ask for the gender and sexual identity of their clients/patients and how many LGBTQ+ patients/clients have you worked with? (“LGBTQ+ patient contact”). Participants who had not completed any clinical practice were coded as working with zero LGBTQ+ patients/clients.

Patient education

LGBTQ+ patient education, was measured using two separate variables. Participants were asked: (1) How many hours of LGBTQ+ patient education have you received in your current programme? (“LGBTQ+ curricular hours”) and (2) How many hours of LGBTQ+ patient education have you ever received? (“LGBTQ+ total hours”).

Training satisfaction

In addition, participants were asked to rate their satisfaction with their training on LGB and transgender identities on a scale of 1 (very dissatisfied) to 5 (very satisfied). Participants were also asked if their current programme had adequately trained them regarding LGB and transgender identities (1 = disagree, 5 = agree) (Table 1).

Table 1. Demographic variables.

Variable	n = 66	M (SD)
Age		32.2 (11.86)
Gender Identity
Female	52
Male	11
Non-binary	3
Sexual Identity
Lesbian	4
Pansexual	2
Gay	2
Heterosexual	43
Questioning	2
Demisexual	1
Queer	1
Bisexual	9
Choosing not to label, but not heterosexual	1
Prefer not to say	1
Programme
Clinical Psychology	5
Applied Psychology	6
Counselling Psychology	3
Occupational Therapy	19
Psychology	16
Psychotherapy	14
Child & Adolescent Psychology	1
Educational & Child Psychology	1
Advanced Healthcare	1
SES		6.24 (1.76)
Political Orientation		3.24 (1.63)

Cultural competency

LGBTQ+ cultural competency, was measured using the LGBT-Development of Clinical Skills Scale (LGBT-DOCSS; Bidell, 2017). This is a well validated, reliable interdisciplinary clinical self-assessment for health and mental health providers regarding LGBTQ+ healthcare (Bidell, 2017). It measures clinical preparedness, attitudinal awareness and basic knowledge. It is composed of three scales with 18 items. Overall LGBTQ+ cultural competency was calculated by adding up all 18 items in total. Eight items were reverse coded so that higher values indicated a higher LGBTQ+ cultural competency. Following this, a composite score was made by calculating the items’ mean. Composite scores were calculated for each sub scale as well, attitudinal awareness and clinical preparedness are composed of seven items, while basic knowledge has four items.

Open ended questions

In total, three supplementary questions were included in the survey to allow participants to give further comments about their LGBTQ+ cultural competency training: (1) Are you satisfied with your training on LGB/Transgender identities? We would really like to hear more about this; can you explain your response to the question? (2) My current programme has adequately trained me regarding LGB/transgender identities. We would really like to hear more about this; can you explain your response to the question? and (3) Is there anything else you would like to say about LGBTQ+ mental health care?

Rather than conducting an analysis of the entire qualitative data corpus the open-ended questions are organized by topic and interweaved with the quantitative analysis.

Procedure

The survey was distributed by email to 21 course directors and coordinators in the Education and health sciences faculties across five Irish universities. These courses have an average of 30 students per year. The survey was also distributed across several social media platforms, Facebook, WhatsApp, and Twitter. A snowball sampling method was used, participants were encouraged to share the survey with people once they had completed. Responses were collected over the course of four months.

Results

Overview of analyses

To begin, the number of LGBTQ+ extracurricular hours were calculated by subtracting the LGBTQ+ curricular hours from the LGBTQ+ total hours. Frequencies and means of demographics, experiential variables, and cultural competency scores were calculated. Reliability analyses were conducted using Cronbach’s alpha coefficients for each scale, i.e., attitudinal awareness, basic knowledge, clinical competency (see Table 2). Paired samples t-tests were conducted to evaluate differences in participant’s attitudinal awareness, basic knowledge, and clinical competency (H1). Differences in cultural competency for sexual minorities and gender minorities was also calculated (H2). Independent samples t-tests were conducted to compare cultural competency for those who have had clinical experience and those who have not. Relationships between variables were examined using simple correlations (see Table 3). A hierarchical linear regression was conducted to examine if LGBTQ+ patient contact significantly predicts LGBTQ+ cultural competency (H3), when controlling for demographic variables known to influence competency (Bidell, 2005, 2017; Boskey et al., 2019).

Table 2. Mean, SD, and α for cultural competency scores.

Variable	M	SD	α
Cultural Competency	5.07	0.88	0.77
Attitudinal Awareness	6.59	1.11	0.93
Basic knowledge	5.36	1.30	0.75
Clinical Preparedness	3.39	1.43	0.84

Table 3. Correlations between variables of interest.

		1	2	3	4	5	6
1	Cultural Competency	1
2	Clinical Preparedness	0.674**	1
3	Attitudinal Awareness	0.645**	−0.072	1
4	Basic Knowledge	0.766**	0.221	0.597**	1
5	LGBTQ+Patient Exposure	0.356**	0.426**	0.038	0.168	1
6	LGBTQ+Patient Education	0.345**	0.468**	0.037	0.122	0.267*	1

*p < 0.05, **p < 0.01.

Training and patient experience

Irish mental health students reported low LGBTQ+ patient contact and low LGBTQ+ patient education. Majority of participants (66.7%) received zero hours of LGBTQ+ patient education in their current programme, 68.2% received no extra-curricular training, and 47% received no LGBTQ+ training at all. For those who had training, the mean curricular training was 15.14 hours (SD = 28.26) and the mean extra-curricular training was 15.95 (SD = 22.45). Overall, 65.2% of participants reported being “Very Dissatisfied” or “Dissatisfied” with their training on LGB/transgender identities. Further, 78.8% of participants “Disagreed” or “Somewhat Disagreed” that their programme had adequately trained them regarding LGB identities, whereas 81.8% “Disagreed” or “Somewhat Disagreed” that their programme had adequately trained them regarding transgender identities. In total, 47 participants completed clinical practice. Of those who had completed practice, the average number of LGBTQ+ patients seen was 6.91 (SD = 14.2; see Table 4). Further, 54.5% of respondents reported “Never” or “Rarely” asking for the sexual identity of their clients/patients. Whereas 44% reported that the “Never” or “Rarely” asking for the gender identity of their clients/patients.

Table 4. Means and SD of LGBTQ+patient education and LGBTQ+patient exposure.

LGBTQ+Experientials		N	M (SD)
Curricular Hours	Yes	22	15.14 (28.26)
	No	44
Extra-Curricular Hours	Yes	21	15.95 (22.45)
	No	45
Clinical Practice and Mean LGBTQ+Patient Exposure	Yes	47	6.91 (14.2)
	No	19

These results were further emphasized by the participant’s responses to the open-ended questions. As such, these responses were organized into two distinct categories: (1) experiences of cultural competency training and (2) recommendations for training, which summarizes the student’s expressions about how training should be implemented.

Experiences of cultural competency training

When asked to further explain their satisfaction with their level of LGBTQ+ cultural competency training, most participants expressed that they had received little to no curricular education. This was prevalent across the majority of the mental health care disciplines represented in this study. Further, knowledge and training on transgender identities was even less pervasive.

I am a qualified social worker, and completed a 4-year BSS degree on this. There was little, if any, discussion of LGBTQ identity and specific issues. You could discuss it, or include it in an essay if you were interested, and that was well received by the lecturers, but they never had specific lesson plans on this. The same applies to my psychology postgrad. […] If there was little talk of queer cis issues, there was none on specific trans issues.

—Participant number 44, Female, Lesbian

It simply didn’t come up on either my undergraduate psychology degree or my master’s in psychotherapy studies …. Very disappointing given the need for psychotherapy to be in a position to support all clients.

—Participant number 53, Female, Heterosexual,

Although the research regarding the LGBTQ+ cultural competency training of Irish mental health workers is lacking, studies from other countries and across other health care disciplines indicate that health care workers often report a distinct lack of training. In one UK study, Parameshwaran et al. (2017) assessed medical students’ efficacy in health situations among LGBTQ+ patients. Results indicated that 84.9% of students had received no LGBTQ+ education. Students admitted feeling a lack of clinical preparedness and having a lack of knowledge regarding LGBTQ+-specific health care terminology. Similar results have been found for medical students in the US and Canada (Obedin-Maliver et al., 2011) and across other health care disciplines such as nurses and social workers (Carabez et al., 2015; Logie et al., 2015). The disparities in cultural competency training across different LGBTQ+ identity groups, i.e., gender minorities vs sexual minorities, supports the idea of a hierarchy of progress in reducing homophobia in Ireland in comparison to transphobia (Higgins et al., 2016). This sentiment was directly referenced by one participant when reflecting on their training on LGB identities vs transgender identities:

… Although I think the levels of fear and ignorance are higher in relation to trans people, especially since marriage equality passed, I think L & G are more accepted, even if it’s just in a surface level, homo-normative way sometimes

—Participant 19, Female, Bisexual

Participants who were satisfied with their level of training tended to have sought extracurricular training. Extracurricular training was pursued through formal and informal means. Examples of formal extracurricular training included educational trainings and workshops organized outside or within the university.

I’m very satisfied with my training because I have seeked out training not as part of courses but as separate undertakings for me. I have trained with the HSE on sexual health promotion for example—I have trained in how to work with trans clients—you name it and I’ve tried to find training to help me help clients! … I’ve learned about social policy, rights, inequality in health care provision, peer support groups, abortion, loss, identity, abuse etc etc. I try to keep up to date and I want to help people who attend with me for therapy

—Participant number 37, Female, Heterosexual

Participants also noted that when extracurricular training was organized through the university, it was not mandatory for students to attend. Several other studies note that health professionals report a lack of access to LGBTQ+ cultural competency and, even when training is available, it may not be mandatory (Deliz et al., 2020; Lyons et al., 2010; Price et al., 2005).

I’ve had no dedicated classes on LGBTQ+ identities, within my undergrad in psychology and within my current master’s in applied psychology …. During my master’s I also attended a seminar organized by the university on LGBTQ+ mental health but that had nothing to do with my course, it was university-wide.

—Participant number 11, Non-binary, Not Heterosexual

Thought the workshop by LGBTI+Ireland was really great, would appreciate if this is a mandatory part of all healthcare courses rather than an optional/self organised workshop.

—Participant number 15, Female, Bisexual

Informal extracurricular education involved personal experience, such as, experiential learning with or from clients, being LGBTQ+ themselves, learning from friends or fellow students, independent reading, and the internet. Personal experience as a means of gaining cultural competence was identified in other studies that looked at LGBTQ+ educational training for medical students (Sanchez et al., 2006). Learning from or with clients was a particularly common response among participants:

I feel that this is something I have had to learn through independent reading and experiential work with clients.

—Participant number 14, Female, heterosexual

I learned more from my clients in practice.

—Participant number 60, Non-binary, Lesbian

The British Psychological Society note that “it is not acceptable to expect clients to provide knowledge of GSRD [Gender, Sexuality and Relationship Diversity] through clinical contact. While clients will elaborate individual meanings for them personally, general understanding must be obtained outside of the clinical encounter.” (British Psychological Society, 2019, p. 15). While it is important for mental health providers to be open to learning from their clients, TGNC patients often report having to educate their practitioners about specific trans issues, often before they are assessed (Vermeir et al., 2018). This places an unfair burden on the LGBTQ+ community, particularly for TGNC clients and patients (Bradford et al., 2013). Within the classroom setting, participants who identified as LGBTQ+ also noted how they felt the need to educate their peers in situations where they felt misinformation being spread:

There has been little to no mention of LGBTQ+ identities within my course. Anytime it has been mentioned, I have ended up educating others because they mentioned wrong/inaccurate information.

—Participant number 48, Male, Queer

Despite the positive responses from participants who had accessed LGBTQ+ education and information through extracurricular means, this highlights a serious issue with current training programmes. If LGBTQ+ cultural competency training is not mandatory, students will need to pursue education on their own accord. As a result, extracurricular trainings tend to attract students who are already sympathetic to LGBTQ+ issues, whereas attendance is resisted by those who hold negative views toward or are completely unaware of LBTQ+issues (Ellis, 2009). This sentiment was directly represented in one participant’s response:

I have a good level of knowledge due to doing my own research but still there is a high level of ignorance among the staff of my course and many of my classmates. If people don’t go out of their way to educate themselves, for the most part the ignorance persists.

—Participant number 19, Female, Bisexual

Therefore, LGBTQ+ cultural competency training is recommended as a mandatory component of all health care curriculums (McCann, 2015). It is important to note that there were exceptions to this. Two participants mentioned that they had accessed adequate training through their course:

They have provided teaching on the topic and a range of further resources and reading.

—Participant number 65, Male, Gay

This was well covered in the module.

—Participant number 57, Female, Heterosexual

This may be indicative of the disparities in training across different courses. Alternatively, this could indicate a lack of understanding regarding what it means to provide culturally sensitive care. When examining nurse’s LGBTQ+ cultural competency, although majority of participants said they were comfortable with LGBTQ+ patient care, the researchers found that many of their comments indicated they were not providing culturally sensitive care (Carabez et al., 2015). This is why an informed, affirmative approach to LGBTQ+ care is recommended by the majority of health care organizations (American Psychological Association, 2021; British Psychological Society, 2019; World Professional Association for Transgender Health, 2012).

Recommendations for training

Many participants included recommendations on how to implement or improve LGBTQ+ cultural competency training. Some participants felt that their course had provided them with a broad set of tools to approach general cultural competency, touching on health disparities for different groups. However, this was usually ineffective in increasing competency:

I’ve taken courses in my undergraduate degree that focused on health disparities for different groups so each course touched on LGBTQAI+ health and overall issues that one may face, but it is not as much education as I would like. I feel like the classes would have a few lectures dedicated to the subject but them move onto something else.

—Participant 28, Female, Heterosexual

Similarly, a US study examining cultural competency training for psychologists found that although majority of respondents had received training, most felt that their training was insufficient and would benefit from more (Benuto et al., 2018). Research indicates that broad multicultural courses do not appear to increase competencies with LGBTQ+ clients (Hope & Chappell, 2015). If training is to be implemented, it needs to be comprehensive and effectively develop practitioner’s skills across the various competency domains. On the other hand, most participants felt that their courses were entirely lacking in any understanding of cultural competency.

I think that in my experience so far, very little attention is given to the experience of anyone outside the “heteronormative” experience. Similar issues exist in relation to the experience of people from different cultural, class, or disability backgrounds

—Participant 1, Male, Heterosexual

It hasn’t been a topic of education for me in any course I’ve had on social psych, developmental psych, individual differences, psych health applications, or in relation to any topics relating to psychopathology/clinical/counsellor psych. … However, in saying this, there is also very little education in psychology programs about how cultural, sex, or race differences can exist. So although it is important to educate students on LGBTQ+ matters, it is not the only thing I find lacking.

—Participant 36, Male, Gay

This is a common finding across studies looking at cultural competency training for mental health practitioners (Graham et al., 2012; Israel & Bettergarcia, 2017; Nowaskie, 2020). This is particularly important when considering queer clients who may be experiencing multiple forms of oppression. For example, negative experiences in mental health services are even more common for LGBTQ+ people with other marginalized identities, such as LGBTQ+ people of color or immigrants (Filice & Meyer, 2018). Unfortunately, the white perspective still dominates the literature on supporting LGBTQ+ clients (Brockenbrough, 2015). That is why recommendations for LGBTQ+ cultural competency training often include integrating intersectionality and social justice (Pieterse et al., 2009).

Another important aspect of cultural competency highlighted by participants was the inclusion of education for staff members. If staff are not equipped with knowledge of the LGBTQ+ community, there is a risk that the training mental health providers receive may perpetuate outdated and harmful content (Bettergarcia et al., 2021). For example, many participants found that when LGBTQ+ material was present in the course curriculum, it was often undermined by uninformed staff:

It was raised once in class by a peer in relation to a client on placement, which promoted a discussion. Beyond this though, no information, or learning has been given. The lecturers engagement in the discussion that did take place was poor. He was not offensive, but clearly lacked knowledge or confidence in this area.

—Participant 52, Female, Pansexual

There has been little to no mention, and when it has been mentioned it’s been wrong/inaccurate.

—Participant 48, Male, Queer

With competency, teachers and trainers can effectively facilitate discussions regarding the LGBTQ+ community and create a safe learning environment for everyone (Bettergarcia et al., 2021; Weeks et al., 2018). This is especially important considering that members of the class may also be members of the LGBTQ+ community. For example, one participant, found that a staff member from their course was explicitly transphobic:

In addition, I regrettably looked up a high-up member of staff from my course on twitter recently and discovered that one of their recent tweets was complaining about people stating their pronouns and generally caring about others’ pronouns. This person is my thesis supervisor. I’m non-binary and I haven’t come out to them yet, and now I know I definitely won’t. I’m glad I haven’t done it before finding out about their views because I don’t know if I’d be safe in their presence if they did know about my identity. It horrifies me that someone with their views is teaching future psychologists, on a master’s level, and practicing as a psychologist and psychotherapist alongside that too.

—Participant Non-Binary, Not Heterosexual

Educators in health care often feel unprepared to teach LGBTQ+ health issues (Sirota, 2013). In a review that looked at the effectiveness of training mental health professions in queer affirming care, Bettergarcia et al. (2021) found that most studies failed to examine the effects of trainer qualities. Considering participant’s negative experiences in the classroom, this highlights universities’ responsibility to also provide training for their staff. This sentiment was summarized by one participant:

It would be great to see all the staff—and every university—be trained in these issues, so the curriculum could evolve, and write something in each course’s mission statement/equivalent document about a dedication to equity in healthcare through education of the clinicians of the future on the issues faced by LGBTQ+ people in accessing appropriate healthcare.

—Participant 19, Female, Bisexual

Another key recommendation from participants was the inclusion LGBTQ+ voices in the training process.

I think it is very important for health care providers to be trained and aware of the issues that might arise specific to providing quality LGBTQ+ health care and to have done our own personal work on looking at our hidden biases that might impact on the work. I also think this needs to be done in consultation with people from the LGBTQ+ community.

—Participant 14, Female, Heterosexual

LGBTI+ Ireland covered some of this in their workshop but would have appreciated more time to understand the topic more deeply. Also peer led workshops work well I think—much harder for healthcare professionals to hold their biases when they have met and spoken to a member of the trans community.

—Participant 15, Female, Bisexual

This has also been recommended in other studies looking at training programmes. For example, one study examined cultural competency training for aging service providers. This intervention used a panel of older LGBTQ+ adults to provide personal accounts during their training sessions (Leyva et al., 2014). After the training, service providers reported more positive attitudes and increased skills, with non-LGBTQ+ trainees reporting the most gain. When using personal accounts as a means of training, it is important to use a diverse range of voices from the LGBTQ+ community, such as LGBTQ+ transgender people, bisexual people, disabled people, and people of color (Bettergarcia et al., 2021).

Paired and independent samples t-tests

Paired samples t-test were conducted to evaluate whether there was a significant difference in participant’s cultural competency across subscales (see Table 5). Irish student mental health practitioners reported significantly higher attitudinal awareness (AA) compared to basic knowledge (K), t(65) = 9.12, p < .001, d = 1.12 and clinical preparedness (CP), t(65) = 13.89, p < .001, d = 1.89. They also reported significantly higher basic knowledge than clinical preparedness, t(65) = 9.39, p < .001, d = 1.71.

Table 5. Paired samples T-tests results.

		Mean Change (SD)	t	df	p	Cohen’s d
Pair 1	AA – K	1.23 (1.1)	9.12	65	<.001	1.12
Pair 2	AA – CP	3.21 (1.88)	13.89	65	<.001	1.89
Pair 3	K – CP	1.98 (1.71)	9.39	65	<.001	1.71

Similar cultural competency items that differed based on patient type (i.e., LGB vs. transgender) were analyzed using paired sample t-tests to determine whether there were differences in competencies between LGBTQ+ subpopulations. Irish student mental health practitioners reported significantly less training and supervision t(65) = 2.14, p = .036, d = .75, experience t(65) = 3.66, p < .001, d = 1.68, and competence t(65) = 3.56, p < .001, d = .73 to work with transgender clients compared to LGB clients (see Table 6).

Table 6. Descriptive statistics and paired samples T-test results when comparing cultural competency for gender minorities (T) and sexual minorities (LGB).

	LGB Mean (SD)	T Mean (SD)	Mean Change (SD)	t	df	p	Cohen’s d
Training & Supervision	2.94 (1.98)	2.74 (2.03)	0.2 (.75)	2.14	65	.036	0.75
Experience	3.26 (2.13)	2.5 (2.01)	0.76 (1.68)	3.66	65	<.001	1.68
Competence	4 (1.99)	3.68 (1.96)	0.32 (.73)	3.56	65	<.003	0.73

Finally, an independent samples t-test was conducted to examine whether cultural competency was higher for those who had clinical experience. The results showed that there was a significant difference in cultural competency between people who had clinical experience and those who did not t(64) = 2.35, p = .02, d = .85. Students who had completed clinical practice (M = 5.2, SD = .91) on average were more culturally competent than those who had not completed clinical practice (M = 4.69, SD = .66).

The discrepancies across subscales were also emphasized by analyzing the open-answer questions. This further highlights the expression of full respect and acceptance compared to the low rates of efficacy found within the sample. The guidelines for an informed, affirmative approach to working with LGBTQ+ clients and patients, laid out by the majority of health care organizations, were referenced to support this analysis (American Psychological Association, 2021; British Psychological Society, 2019; World Professional Association for Transgender Health, 2012).

Affirmative but uninformed

An affirmative approach to mental health requires practitioners to encourage, accept, and support their LGBTQ+ patients, rather than pathologize (Chavez-Korell & Johnson, 2010). To practice affirmative care, practitioners are required to understand the relevant LGBTQ+ psychosocial and health issues (Bidell, 2017). Although majority of participants expressed high rates of acceptance and affirmation, participants’ responses indicated lower rates of efficacy and knowledge, with many believing that their client’s LGBTQ+ identity was not relevant to their care:

I don’t think anyone should be discriminated upon based on their sexual orientation. We are all humans. … These are social issues, I’m studying clinical psychology so my modules are focused on mental diagnosis and intervention. If I was studying social psychology maybe I would have been trained in these constructs.

—Participant 2, Male, Heterosexual

Haven’t had education on this, typically, I’m not sure how it would be relevant to treating a patient. Unless this was at forefront of the patients life/personality We are thought to treat everybody with respect and as equals, gender, race, sexual orientation, shouldn’t impact treatment

—Participant number 23, Female, Heterosexual

Similarly, in a US study across 18 different healthcare organizations, researchers found that majority of clinicians reported comfort and preparedness in providing care to LGBTQ+ people. However, participants rarely or never talked to their patients about their LGBTQ+ identity, mostly due to a belief that the topic was not relevant to care (Goldhammer et al., 2018). When mental health practitioners disregard their client’s identity, LGBTQ+ clients are solely responsible for initiating discussions of identity and disclosure (Daley, 2010; Harbin et al., 2012). To avoid making assumptions or judgements, many health care practitioners avoid talking to their patients about gender and sexual identity, instead drawing on positions of neutrality and professionalism (McNair & Hegarty, 2010). Positions of neutrality can carry implicit assumptions of heterosexuality, ultimately contributing to the reinforcement hetero and gender normativity in healthcare (Rees et al., 2021). Even though participants emphasized the significance of treating their clients impartially, mental health professionals must recognize that this approach cannot adequately address the varied and distinct needs of all patients.

Although an individual’s LGBTQ+ identity is relevant to their care, having an LGBTQ+ identity is also not the cause of mental health issues. Clinicians are recommended to acknowledge the changing socio-political context and how that may affect their LGBTQ+ clients (British Psychological Society, 2019). Most importantly, understanding minority stress and how this can impact gender and sexual minorities. Although some participants highlighted the connection between social stigmatization and their client’s mental health, others did not make this distinction clear in their responses:

I think that while there are higher rates of mental distress in the LGBTQIA community I do not think it’s due to their orientation, rather due to the cultural context where they are often still discriminated against

—Participant 64, Female, Prefer not to say

There needs to be more education in the area because of the strong link between LGBTQ+ members and mental health struggles

—Participant 9, Female, Questioning

Without a clear understanding of minority stress and its implications, clinicians are at risk of pathologizing their client’s identity. This has been highlighted as a major fear for LGBTQ+ individuals when accessing mental health care (Delaney & McCann, 2021; Higgins et al., 2021; McCann & Sharek, 2014a, 2014b; Rees et al., 2021).

Even if clinicians are open minded and non-judgmental, a lack of knowledge can lead to non-affirmative experiences, hindering the clinician’s therapeutic alliance with their LGBTQ patients (Delaney & McCann, 2021). For example, this participant expressed positive views toward LGBTQ+ people in their open answers, however they contend that they did not know how many LGBTQ+ clients they had worked with as they had only worked with children.

I don’t know as I worked with children. … I have received no formal training on transgender identities. I rely on students to inform me of the different terminologies that are present today. I would have preferred to receive formal training. I think this is very important so that I can respect others going into the workforce.

—Participant number 4, Female, Heterosexual

This comment suggests that the participant does not believe a child’s gender or sexual orientation is relevant to their care. This is a common problem that young people face when discussing their LGBTQ+ identity health care practitioners. Service providers can be dismissive of young people who identify as transgender, believing them to be too young to know their identity (Lefkowitz & Mannell, 2017). However, research shows the average age that people know they are LGBTQ+ is 12 (Higgins et al., 2016). Further, the hierarchy of risk identified in the LGBT Ireland Report was also evident across different age groups, with those under the age of 25 experiencing poorer mental health outcomes (Higgins et al., 2016). Thus, informed, affirmative care for LGBTQ+ youth is imperative to ameliorate these disparities in mental health outcomes. Despite the high rates of acceptance, participants responses indicated lower levels of knowledge. A lack of knowledge can lead to issues of trust and hinder the therapeutic alliance. On the other hand, through an understanding of the LGBTQ+ experience, clients feel affirmed by their mental health care providers (Delaney & McCann, 2021).

Experiential predictors of cultural competency scores

A hierarchical linear regression was conducted to examine if LGBTQ+ patient experience significantly predicted LGBTQ+ cultural competency, when controlling for demographic variables. Preliminary analyses were conducted to ensure assumptions were not violated. Age and LGBTQ+ identity were entered in the first step of the model, followed by political orientation, SES, and religion in the second step. LGBTQ+ patient contact and overall LGBTQ+ education were entered in the third step of the model. The Enter method was used in all three blocks.

The first block, with age and LGBTQ+ identity as predictors was significant, F(2,63) = 3.72, p = .03, adjusted R² = .106. As can be seen in Table 7, only age significantly predicted LGBTQ+ cultural competency, and explained 10.6% of the variance in competency. The addition of SES, religion and, political orientation in the second step of the model did not lead to a significant change in the model (p = .489).

Table 7. First block, second block (controls), and third block (predictors) hierarchical multiple regression of experiential variables and LGBTQ+ cultural competency.

Predictors	Step F (df)	B (SE)	β	Step R^2
Block 1*	3.72 (2, 63)			0.106
LGBTQ+Identity		0.24 (.22)	0.13
Age in years		0.02 (.01)	0.33*
Block 2	1.97 (5, 60)			0.035
LGBTQ+Identity		0.19 (.24)	0.12
Age in years		0.03 (.01)	0.35*
Political Orientation		−0.04 (.07)	−0.07
Religion		0.2 (.024)	0.11
SES		0.06 (.06)	0.12
Block 3**	2.97 (7, 58)			0.123
LGBTQ+Identity		0.18 (.23)	0.1
Age in years		0.02 (.01)	0.22*
Political Orientation		−0.05 (.07)	−0.09
Religion		0.1 (.23)	0.06
SES		0.09 (.06)	0.18
LGBTQ+Patient Education		0.01 (.01)	0.28*
LGBTQ+Patient Exposure		0.01 (.01)	0.2

*p < 0.05.

**p < 0.01.

LGBTQ+ patient contact and overall LGBTQ+ patient education was added in the third step of the model. This model, with age, gender identity, sexual identity, SES, religion, and political orientation was significant, F(7,58) = 2.97, p = .01, adjusted R² = .264. Adding the LGBTQ+ experiential variables to the model lead to a further 12.3% of the variance in LGBTQ+ cultural competency. As can be seen in Table 7, Age and LGBTQ+ patient education were significant predictors in the final model, with the entire model explaining 26.4% of the variance in LGBTQ+ cultural competency. Examination of Table 7 confirmed that when controlling for demographics, LGBTQ+ patient education was positively associated with LGBTQ+ cultural competency.

Discussion

This study explored the LGBTQ+ cultural competency of Irish student mental health workers while also examining the relationship between LGBTQ+ patient contact, education, and cultural competency. Although students report high attitudinal awareness toward LGBTQ+ patients and clients, their basic knowledge and clinical competency were significantly lower. In addition, when comparing sexual and gender minorities, students reported significantly lower cultural competency for transgender clients and patients. Analyses of the open answers further substantiated both findings. Finally, the study demonstrates that while LGBTQ+ patient contact was not a significant predictor, LGBTQ+ patient education does significantly predict cultural competency when controlling for demographic variables. Students also offered a set of recommendations for the implementation of cultural competency training in mental health programmes.

A large majority of the participants received no curricular or extra-curricular LGBTQ+ cultural competency training. Considering the low levels of basic knowledge and clinical competency in the sample, this is to be expected. Analysis of the open answers reveal that even when training was offered, participants often felt it was insufficient. These results are also consistent with findings from similar studies looking at health care practitioners outside of Ireland (Nowaskie, 2020; Nowaskie et al., 2020; Nowaskie & Patel, 2020, 2021; Parameshwaran et al., 2017). Although many students had sought training outside of their course, studies show these classes are often attended by students who are already sympathetic to the LGBTQ+ community (Ellis, 2009). Therefore, mandatory LGBTQ+ training is recommended (Higgins et al., 2021).

For those who had completed clinical practice, they reported seeing low levels of LGBTQ+ patients and clients. It is common for mental health professional to report low LGBTQ+ patient contact (Nowaskie, 2020). This may be explained by the participant’s limited understanding of the importance of collecting sexual orientation and gender identity data in health care settings. Surprisingly, it was more common for participants to ask about gender identity compared to sexual identity. Nonetheless, the frequency of requestion information about gender and sexual identity was relatively low. Enquiring about sexual and gender identity allows practitioners to offer more individualized care and improves patient-provider relationships (Maragh-Bass et al., 2017). Despite widespread acceptance from service users (Cahill et al., 2014) avoiding discussions of sexual orientation or gender identity is common among health care providers (Goldhammer et al., 2018).

Participants reported low LGBTQ+ basic knowledge and clinical competency, analysis of the open answers allowed for a deeper understanding of these findings. Although participants possessed positive and affirming attitudes toward their LGBTQ+ patients, many commented that training would not be necessary as their clients’ LGBTQ+ identity was not relevant to their care. It is common for health care providers to overlook the importance of training as they “treat everyone the same” (Carabez et al., 2015). This practice frames health care settings as heteronormative environments and perpetuates heterosexist attitudes within mental health care (Higgins et al., 2021; McCann & Sharek, 2014a; Morrison & Dinkel, 2012). Positive attitudes and “treating everyone the same” are not sufficient for the provision of culturally competent care. This indicates a need for cultural competency training to focus on improving basic knowledge and clinical competence rather than just improving attitudes (Bettergarcia et al., 2021).

Previous research has demonstrated that increasing amounts of contact with LGBT individuals leads to lower levels of implicit bias (Nowaskie, 2020; Nowaskie & Patel, 2020, 2021). Contrary to this, contact with LGBTQ+ patients and clients was not a significant predictor of cultural competency in this sample. This variable may have been affected by the over-representation of LGBTQ+ people in the sample. For students who are LGBTQ+, it is unlikely that patient contact would increase their cultural competency. Previous research has highlighted that even some LGBTQ+ people may struggle when working with different LGBTQ+ groups. For example, in a study involving nurses, a gay man highlighted that he sought additional training to enhance his proficiency in providing care to transgender and lesbian patients (Carabez et al., 2015). Future research may benefit from collecting data from a larger more representative sample size.

There is a “hierarchy of risk” evident in the research which indicates that transgender people have poorer mental health outcomes compared to other LGBTQ+ subpopulations (Higgins et al., 2016; McNeil et al., 2013; Su et al., 2016). Adding to this, there was a significant difference in participant’s knowledge, experience, and clinical preparedness to work with TGNC clients. Similar discrepancies in competence have been found in studies on different health care practitioners (Goldhammer et al., 2018; Nowaskie, 2020; Nowaskie & Patel, 2020, 2021). These findings are also in line with the research on LGBTQ+ service users, who report a lack of clinician knowledge when accessing mental health services in Ireland, especially concerning TGNC people (Delaney & McCann, 2021; Higgins et al., 2021). If cultural competency training is to be implemented into the course curriculum, there needs to be increased advocacy and training surrounding the diverse needs of each LGBTQ+ subpopulation (Bettergarcia et al., 2021).

Limitations

In terms of limitations, due to the quantitative nature of this study, cultural competency was measured using a self-assessment scale for clinical preparedness, attitudinal awareness, and basic knowledge. This measure can only offer quantitative insight into these discrete components of culturally competent care. Future research may benefit from a more in-depth qualitative study. This study design relies on voluntary participation. Those who are more likely to already hold more positive views of LGBTQ+ people may be more likely to take part in the study (Ellis, 2009). The over-representation of LGBTQ+ people in this sample further highlights this limitation. Results of this study may be subject to selection bias and may not be representative of the general population. Social desirability bias is also a common problem in self-reported cultural competency scales (Bettergarcia et al., 2021). However, analysis of the open answers offered a more nuanced view of the participant’s cultural competency.

Research suggests that LGBTQ+ cultural competency training does increase knowledge and attitudes for health care professional students (Kelley et al., 2008; Pratt-Chapman, 2021; Strong & Folse, 2015). However, studies that investigate this vary in training intervention, study design, and participants (Bettergarcia et al., 2021). This study only examined at the number of the number of hours of training, not the content of training. Therefore, it is difficult to reach a consensus on what competency training is most effective. Given that there is no standard for LBGTQ+cultural competency training in terms of content, modality, length, or students, this is a potential point of interest for future research.

Conclusion

Based on numerous accounts from LGBTQ+ people in Ireland, there is evidence to suggest they are not receiving adequate and affirmative care from mental health services (Higgins et al., 2021; McCann & Sharek, 2014a, 2014b). TGNC people report poorer mental health outcomes, while knowledge and competence on TGNC identities is even less pervasive (Delaney & McCann, 2021; Higgins et al., 2016). Mental health practitioners are responsible to provide affirmative care to LGBTQ+ individuals with cultural competency and humility and therefore, adequate and comprehensive training is required in all mental health programmes. Results of this study suggest that practitioners lack the competency needed to provide effective care for their LGBTQ+ clients and patients. Training programmes should focus on improving basic knowledge and skills for practitioners. There should be an emphasis placed on understanding the diverse needs of all members of the LGBTQ+ community. Based on recommendations from mental health practitioners, training should include, an intersectional approach, education for trainers, and most importantly, training should incorporate the voices of the LGBTQ+ community.

Ethics statement

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants included in the study.

Disclosure statement

The authors declare that there are no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

The data that support the findings of this study are available from the corresponding author, Dearbhla Moroney, upon reasonable request.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.

Notes

1 For the context of this research, the term LGBTQ+ is employed as an overarching label. This term is widely embraced and is more comprehensive in its scope, encompassing a variety of sexual and gender identities. It is used with the aim of inclusivity, welcoming anyone who identifies within the LGBTQ+ spectrum. The intent is not to exclude or prioritize specific identity labels. Nevertheless, it is acknowledged that this term might not fully encompass all individuals, particularly those who perceive their identities as fluid.

2 The Irish Psychological Society of Ireland does not have an updated set of guidelines for working with LGBTQ+ clients. In 2015, the PSI released a Guidelines for Good Practice with LGB Clients (Psychological Society of Ireland, 2015). However, to date there are no guidelines set out by the PSI for practitioners working with transgender clients.