Studies have reported that sexual minorities have a 1.5 times higher risk of experiencing common mental health disorders (e.g., anxiety, depression), substance dependence, and suicidality (King et al., 2008; Ploderl & Tremblay, 2015). And yet, this population has also been found to have less favourable experiences of mental health services (Blosnich, 2017; Elliott et al., 2015) and poorer treatment outcomes (Rimes et al., 2019).

Experiences commonly reported by sexual minority adults when accessing mental health services include discrimination, difficulties in discussing sexual orientation, and a lack of awareness and understanding from their practitioner (Ferlatte et al., 2019).

Morris and colleagues (2022) expanded on previous research by exploring the experiences of sexual minority service users in the UK, with a focus on:

• How participants’ identities as sexual minorities relate to barriers to treatment and optimal outcomes;
• How these barriers may affect therapeutic relationships;
• How services may be developed to improve the experiences and outcomes for sexual minorities struggling with their mental health.

Methods

Participants were recruited through social media, mental health websites, and sexual minority community groups. 26 participants who met the inclusion criteria were selected, all of whom had experience with Improving Access to Psychological Therapies (IAPT, now referred to as Talking Therapies) or primary care counselling services.

Of the 26 participants, 7 identified as gay, 9 as lesbian, 6 as bisexual, 3 as queer, and 1 as pansexual. 35% of participants identified as men, 62% identified as women, and 1 participant identified as a genderqueer man (4%).

Semi-structured interviews took place over the telephone and were recorded. Interviews covered topics such as expected and experienced discrimination or stigma, the impact of their sexuality on treatment experience, and how services could improve to better address their needs. Data was analysed using thematic analysis (Braun & Clarke, 2006).

Results

Thematic analysis generated three main themes:

Theme 1: Service user-centred barriers: Fears surrounding disclosure

• Rejection sensitivity as a barrier to sexual orientation disclosure
  Fear of discrimination, even when there was no apparent evidence of prejudice, often prevented participants from disclosing their sexuality to clinicians. Participants raised concerns about whether worries about discrimination might prevent those who need support from seeking it, or from fully engaging in the therapeutic process.
• Apprehension towards addressing uncomfortable topics
  In cases where participants did disclose their sexuality, some reported a reluctance to discuss sensitive topics concerning romantic relationships and physical intimacy, for fear of a lack of understanding.

…it’s a little bit uncomfortable to be that vulnerable with somebody when you don’t really know whether or not they’re going to be accepting of you.

Theme 2: Practitioner-centred barriers: Neglecting sexual orientation and lack of understanding

• Lack of knowledge about sexual minority experiences
  Participants noted that non-sexual minority clinicians often lacked knowledge of common terminology, nuances of sexual identities, and common problems or stressors. Participants stated feeling misunderstood, resulting in them feeling “more guarded”. Participants also reported spending a great deal of time explaining themselves, yet still feeling as if they weren’t believed or understood.
• Pathologisation of sexual minority identity
  Participants noted a discomfort with the generalised assumption that their presenting problems stemmed from issues relating to their sexuality. While this wasn’t always an incorrect assumption, some participants felt like their sexuality was being pathologised, while other potential factors were ignored.
• Neglecting discussions about sexual orientation
  Contrastingly, some participants reported experiences where clinicians appeared reluctant to acknowledge their sexual minority identity and its relevance to their mental health. While some stated that they didn’t find this detrimental to their therapeutic relationship, others reported feeling deprived of the opportunity to openly discuss topics related to their sexuality.
• Heteronormative assumptions and stereotyping
  Participants reported that clinicians often assumed they were heterosexual. Following disclosure of their sexual identity, participants reported facing stereotyping from the clinician.

because they were … wanting to be politically correct, or not wanting to ask the wrong question, they also didn’t ask the right question…

Theme 3: Service development: Improving the experiences of sexual minorities in psychological services

• Healthcare professionals with shared identifies and experiences
  Thoughts varied on this matter, with some participants preferring clinicians with lived experience of discrimination, whereas others just needed clinicians to be able to understand and empathise with their struggles.
• Visible signs of inclusivity
  Participants wanted clear indications that their clinician is well-versed in sexual minority issues, is confidently able to provide support, and welcomes sexual minority service users. They suggested that this messaging could help ease concerns regarding discrimination, stigma, and stereotyping.
• Sexual minority training
  Participants highlighted a need for specialised training that considered the varied experiences of all sexual minority identities, and how these may impact mental wellbeing. For any training to be beneficial, there must be an emphasis on avoiding sweeping generalisations, and acknowledgement of individual differences.
• Tailored support
  Participants stated that having staff and services specialised in sexual minorities’ mental health may reduce anxiety around discrimination, and potentially encourage more help-seeking.
• Technological adjuncts
  Technology could also play a part in supporting the mental health of sexual minority service users, such as online support groups to increase accessibility and self-help mobile apps. It was emphasised that online services should be in support and not in replacement of in-person services.

Conclusions

This study explored the experiences of sexual minority service users accessing mental health support services for common mental health disorders, and the subsequent effects of these experiences on the therapeutic relationship. Participants highlighted several barriers to productive therapeutic relationships, including fears of disclosure due to discrimination, and practitioners’ lack of understanding of issues relating to sexual minority identities and mental health.

Participants also outlined a number of improvements that could be made to services to address the needs of sexual minority service users. The authors state that these findings offer insight into potential contributory factors to treatment inequalities for this population, as well as suggestions for service improvement.

Strengths and limitations

Strengths

• The study sample included a range of minority sexual identities, capturing a breadth of experience within this community from a potentially representative sample.
• The authors completed a reflexivity statement prior to and following interviews and analysis. This process involved reflection on how their own sexual identities and experiences may have influenced the study. This critical examination of the researchers’ own potential biases suggests that measures were taken to ensure the themes presented were accurately representative of the data gathered from participants.
• The authors frame the need for further training of clinicians as a matter of cultural sensitivity, avoiding pathologisation of minority sexual identities.
• The authors make achievable and attainable suggestions for service improvement using direct feedback from the population that stands to benefit from them.

Limitations

• There is a loss of nuance due to grouping together a range of sexual identities under one sample.
  While there is certainly an overlap of experiences within this population, there are important differences, too. For example, Rimes et al. (2019) found that bisexual participants reported higher final-session severity scores for depression and anxiety, as well as a higher risk of not reaching reliable recovery following treatment, when compared to participants identifying as gay or heterosexual. It is important to understand how the specific and varied experiences of those within the sexual minority population impact the therapeutic relationship and subsequent treatment outcomes for the subgroups within this community.
• This study also lacked consideration of other potential contributing factors, such as ethnicity and socioeconomic background.  These may interact with sexual identity to impact the therapeutic process and mental health outcomes. However, the authors do identify this limitation and state that future research should explore these relationships.

Implications for practice

Practitioners:

• The authors suggest that therapeutic approaches targeting minority stress processes could be beneficial, as has been found in previous research (Pachankis et al., 2020). However, the authors do note that this would only be effective in cases where service users’ minority sexual identities were indicated as playing a role in their presenting problems. As such, practitioners should, as a matter of routine, include discussion of their clients’ own perception of their mental health difficulties in relation to their identity as a minority.

• Practices should take care to make clear their intentions to provide non-discriminatory, inclusive and informed care. As suggested by participants in this study, this can be achieved through things like posters, leaflets, and signposting to sexual minority-specific mental health support resources.

Services:

• There is a need for additional cultural sensitivity training for clinicians in order improve recognition, acknowledgement, and confidence discussing common issues that arise within sexual minority communities. Knowledge of how these issues might impact mental health, and how best to navigate these issues with their clients, would also be beneficial.

Education:

• In addition to continued professional development, sexual minority mental health awareness and understanding should be introduced and addressed at university level. This approach is likely to reach a much wider audience of future practitioners than requiring them to sign on for further training post-qualification.
• Additionally, including knowledge and understanding of sexual minority mental health in core course material early on in training may allow future practitioners to more easily integrate this knowledge into their routine, making it common practice.

Statement of interests

None declared.

Links

Primary paper

Morris, D. D., Fernandes, V., & Rimes, K. A. (2022). Sexual minority service user perspectives on mental health treatment barriers to care and service improvements. International Review of Psychiatry, 34(3-4), 230-239

Other references

Blosnich, J. R. (2017). Sexual orientation differences in satisfaction with healthcare: Findings from the behavioral risk factor surveillance system, 2014. LGBT Health, 4(3), 227–231.

Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology, 3(2), 77–101.

Elliott, M. N., Kanouse, D. E., Burkhart, Q., Abel, G. A., Lyratzopoulos, G., Beckett, M. K., Schuster, M. A., & Roland, M. (2015). Sexual minorities in england have poorer health and worse health care experiences: A national survey. Journal of General Internal Medicine, 30(1), 9–16.

Ferlatte, O., Salway, T., Rice, S., Oliffe, J. L., Rich, A. J., Knight, R., Morgan, J., & Ogrodniczuk, J. S. (2019). Perceived barriers to mental health services among Canadian sexual and gender minorities with depression and at risk of suicide. Community Mental Health Journal, 55(8), 1313–1321.

King, M., Semlyen, J., Tai, S. S., Killaspy, H., Osborn, D., Popelyuk, D., & Nazareth, I. (2008). A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC Psychiatry, 8, 70.

Pachankis, J. E., McConocha, E. M., Clark, K. A., Wang, K., Behari, K., Fetzner, B. K., Brisbin, C. D., Scheer, J. R., & Lehavot, K. (2020). A transdiagnostic minority stress intervention for gender diverse sexual minority women’s depression, anxiety, and unhealthy alcohol use: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 88(7), 613–630.

Plöderl, M., & Tremblay, P. (2015). Mental health of sexual minorities. A systematic review. International Review of Psychiatry, 27(5), 367-385.

Rimes, K. A., Ion, D., Wingrove, J., & Carter, B. (2019). Sexual Orientation Differences in Psychological Treatment Outcomes for Depression and Anxiety: National Cohort Study. Journal of Consulting and Clinical Psychology, 87(7), 577–589.

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