This article has been clinically reviewed by Melissa, LMHC.
TL;DR
- Gender-affirming mental health care is evidence-based, though it has not yet become mainstream for non-LGBTQIA specialist clinicians.
- Cognitive Behavioral Therapy (CBT), Mindfulness-Based Stress Reduction (MBSR), and Trauma-Informed Care (TIC) are evidence-based types of therapy helpful for trans and queer folks.
- Best practices stem from the Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC) Competencies for Counseling Transgender Clients and WPATH, among other guidelines.
- Gender-affirming mental health care can lead to gender euphoria and overall improvement in your well-being.
Mental health care for LGBTQIA+ folks is all about validating our identities and acknowledging our struggles. Finding a therapist who understands the nuances of the LGBTQIA+ community is key. LGBTQIA-oriented therapy aims to help you feel empowered in your body, feel gender euphoria, and revel in the joy of being queer!
Mental health care has a long track record of discriminating against and adding to the stigma around transgender and LGB identities. For example, at one time, psychoanalysis treated gender dysphoria and non-heterosexual identities or practices as something wrong. Thankfully, homosexuality is no longer listed as a mental illness.
Nevertheless, the label "gender dysphoria" is still listed as a mental disorder. This has led people to believe that gender minorities are not typical or that these differences in gender expression indicate mental illness.
Of course, this isn't true. However, it lays a unique foundation for mental health care for LGBTQ people.
Evidence-based mental health care includes addressing mental health disparities and ensuring the care supports and affirms the individual. For transgender individuals especially, therapists should incorporate social advocacy into their practice. This means therapists should be involved in the LGBTQIA+ community and be aware of the legal and social implications that come with being trans.
What is evidence-based mental health care?
Several types of therapy are considered evidence-based practices for intersectional and gender-affirming health care. Evidence-based is often considered the "gold standard" for clinical interventions.
Several types of therapy are considered evidence-based practices for intersectional and gender-affirming health care. Evidence-based is often considered the "gold standard" for clinical interventions.
Evidence-based means there is science-backed research that supports an intervention. It is based on "scientific evidence, clinical expertise, and individual patient needs and choices."
Conversion therapy, for example, should never be used in trans or LGBQ therapy settings. Rejection of gender (non-affirmation) can negatively impact mental health.
For queer, nonbinary, and trans people, WPATH (World Professional Association of Transgender Health) and ALGBTIC (Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling) have published guidelines on evidence-based LGBT mental health care.
The main types of therapy that have been shown to help LGBTQ people include:
- CBT (Cognitive-Behavioral Therapy)
- MBSR (Mindfulness-Based Stress Reduction)
- Trauma-informed care
Evidence-based LGBT mental health care
What are the key points to trans-affirming therapy, and what types of therapy work best for trans and LGBQ people? For gender and sexual minorities, an approach to counseling must be affirming. The best approach to therapy must address health inequities experienced by LGBTQ people (according to ALGBTIC).
It's essential to highlight individuals' strengths. The resilience of transgender and queer people in the face of oppression should be acknowledged in therapy settings. Therapists should affirm that trans and nonbinary people live fully functioning and emotionally healthy lives. It doesn't matter where they fall along the spectrum of gender identity and gender expression.
This kind of affirmative counseling framework helps promote LGBTQ well-being.
Evidence-based frameworks come from a strength-based approach to counseling. This framework is based on several factors, including an understanding of "minority stress" and a recognition that gender expression isn't something that needs to be fixed or seen as a problem. It's also important to understand that transgender people face discrimination or mistreatment because of their gender identity, which can negatively impact their daily lives.
Additionally, therapists must acknowledge potential biases they may have. Approaches should be multicultural, feminist, and social-justice oriented.
Stigma and minority stress
LGBT people and LGBT youth are more likely to have experienced trauma. Daily microaggressions and even violence contribute to minority stress. It's not uncommon to lose social support or experience family rejection. For gender-nonconforming young people, including trans people of color, there are higher rates of well-being with family support. These stressors are significant to LGBTQ identity in mental health care settings.
We know, as affirmed by WPATH, that gender identity is not a mental illness. It's important to note two things.
- One, is that suicide rates are higher among trans people wanting affirming surgeries.
- Two, that this is mainly due to societal stigma–not gender expression in and of itself.
Additionally, the prevalence of homelessness, substance use disorders, and anxiety disorders are more common among trans and gender-diverse folks than cisgender people.
The experience of mental health issues and substance use is important to address. Still, these symptoms should not create barriers to GAC (gender-affirming care). In fact, psychiatric symptoms lessen with gender-affirming procedures or medical care.
Language and health equity
Transgender affirmative language is another component of evidence-based mental health care. LGBTQIA+ terminology varies and is constantly evolving. One critical key point is to use the client's affirming pronouns. This type of affirmation is the building block of a therapeutic client-therapist relationship.
It's essential to use the least-restrictive language to include all ways of being gender-diverse. Therapists should also support sexual and gender fluidity.
Working with an affirmative therapist can help you unlock gender euphoria and queer joy.
Using inclusive language contributes to the mental health equity of LGBTQIA+ people. Additionally, interactions that decrease the effects of minority stress improve mental health outcomes. Therapists must also act as social change agents and allies for transgender (and LGBQ) clients.
MBSR and CBT for trans and queer folks
The experience of mental health distress is a universal human experience. Cognitive Behavioral Therapy (CBT) and Mindfulness-Based Stress Reduction (MBSR) are beneficial because they help reduce stress and build ways to cope. These powerful evidence-based interventions have a myriad of benefits, all of which you can experience when working with a therapist who genuinely cares about your lived experience.
Affirmative Cognitive Behavioral Therapy (CBT)
What is CBT? CBT aims to empower people to understand how their thoughts impact their feelings and actions, thus helping build more insight and healthier coping methods.
- Be mindful that there really are no good or bad coping skills--it's the impact that skill has on your life that is good or bad!
- One main component of CBT is not avoiding but tackling problems directly. Confronting avoidance builds resilience and self-confidence.
Affirmative therapists understand that our identities shape our experiences. Affirmative CBT highlights your identity expression or sexual orientation as a strength. Highlighting your identity as a strength helps you strategize for optimal well-being.
Feeling aligned with your gender identity is one benefit of affirmative CBT. When you feel comfortable and empowered in your identity, your mind is often calmer, making it easier to cope with stress or other symptoms like anxiety or depression.
Affirmative therapists respect and validate trans and queer people's sexual orientation and gender identity. Validation by a therapist can go a long way to improve your mental health and help you feel joy again in being yourself.
Mindfulness-based stress reduction (MBSR)
What is MBSR? MBSR, or mindfulness-based stress reduction, involves simple activities like mindful meditation. Often, an instructor guides participants in weekly practices like meditation and yoga. These are also skills people can learn to do independently to manage stress and build distress tolerance skills.
MBSR is an effective nonpharmacological approach to chronic illness. It also:
- Improved depression for gay men with HIV, who reported more positive feelings after MBSR.
- Reduced minority stress for lesbian, gay, and bisexual people in rural Tennessee.
- Decreased panic and anxiety in group mindfulness meditations.
Culturally competent and trauma-informed mental health care
Evidence-based mental health for the LGBTQIA+ community must be culturally competent and trauma-informed. LGBTQ folks are at risk of being put in situations where trauma results, whether from social stigma or even violence.
What does Trauma-Informed Care (TIC) look like?
TIC looks like a therapist working collaboratively with you as a client. Trauma-informed therapists will:
- Ensure you feel emotionally safe.
- Establish trust through transparency, which means being direct and honest about the counseling process.
- Act as a collaborator and not an expert on your life.
- Take extra precautions not to induce triggering or re-traumatizing impacts.
- Be trained to identify signs and symptoms of trauma and work directly with you to establish de-escalation and safety practices.
Trauma-informed care is culturally-informed care. SAMHSA's (Substance Abuse and Mental Health Services Administration) guidelines for trauma-informed care guide mental health practitioners to create a safe space for clients. Creating a safe space using a TIC approach allows for trust, collaboration, and empowerment.
Addressing real external stressors like discrimination from homophobia and transphobia is LGBTQ-specific. Minority stress is why it's so crucial for therapists to validate the community. For LGBTQ folks, a biopsychosocial approach to mental health care is incredibly empowering. Studies show that LGBTQ-affirmative and trauma-informed therapy is the best practice.
More LGBTQ-oriented research is needed
We need more research on behavioral health interventions and services for trans folks. In addition, more research is necessary to account for the entire LGBTQ community-i.e., each letter. It's also essential to differentiate how mental health conditions may manifest for LGBTQ folks. For example, anxiety disorders and depressive symptoms frequently stem from societal stigma.
Fortunately, there is more data on LGBTQ youth mental health. Clinicians may be able to scale these findings to support affirming mental health interventions for LGBTQ adults.
There's not a mainstream framework for LGBTQIA+-competent mental health care–yet. However, mental health providers can apply evidence-based findings into practice to serve queer and transgender clients.
Finding a therapist who understands mental health for the queer community takes effort. Fortunately, FOLX offers mental health counseling with practitioners who understand and are LGBTQIA-identifying themselves. FOLX also offers peer-led support groups. We want you to feel safe, validated, and empowered in your therapy journey.
It actually does get better with LGBTQIA-affirming mental health care.
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FOLX Health is the first digital healthcare company designed by and for the LGBTQIA+ community. Our services include virtual primary care, gender-affirming hormone therapy including estrogen and testosterone (HRT), mental health care, sexual and reproductive health care, preventive care, and fertility consultations. FOLX memberships give you access to LGBTQIA+ expert clinicians, peer support, thousands of LGBTQIA+ resources, and more. Whether you’re lesbian, gay, bisexual, transgender, queer, gender non-conforming, or nonbinary, you can find LGBTQIA+-specialized health care that helps you meet your wellness goals. FOLX Health is health care that's queer all year. Get all the benefits of becoming a FOLX member and sign up today!
