By Nora Dennis via Blue Cross NC
In discussing LGBTQ+ behavioral health, centering the voices of LGBTQ+ behavioral health specialists is essential.
We reached out to Hayden Dawes LCSW, LCAS to clarify the role of health plans in supporting whole health for our LGBTQ+ members. Here’s what he had to say.
This interview focuses on mental health at the intersection of gender, sexuality and race. If you are currently in a place to engage with this content, here are some terms to know.
BIPOC: Black, Indigenous and people of color.
LGBTQ+: lesbian, gay, bisexual, transgender, and queer (or sometimes questioning). The “plus” represents other sexual identities not covered by the other initials.
Cisgender (cis): relating to a person whose sexual identity matches their sex assigned at birth.
Behavioral health: broadly refers to mental health, substance use, and related health care services.
As a researcher, I think about community and identity a lot. Thinking about populations is difficult. How do we capture shared experience, but also capture the nuance within communities? The LGBTQ+ population is diverse. However, there is a shared experience of being a sexual/gender minority.
One of the shared experiences related to health care include experiences of stigma when seeing a physician. This often leads to worry about being judged for who they are as a person. For trans people, health care providers may judge them for their bodies and their gender presentation.
One concern I have when communities are spoken of collectively is that we don’t do a good job at highlighting the most marginalized of the marginalized. Trans women of color are the most marginalized in terms of unemployment and homicide deaths, and they are ridiculed because of their race and because of their gender. One critical focus in recent years is to shine a light on the experiences of trans women of color. If we highlight their experiences, the experiences of everyone else should get better.
Yes. My freedom and liberation are tied to theirs. When you think of trans women losing opportunities—in terms of employment, stable wages, finding partners willing to walk in public with them—this range of stigmatizing situations impacts their well-being and self-esteem. If things get better for them, it will be better for me as a gay Black man because people will then have enough space for the true diversity of our human experience.
Health care is where we go when we are suffering and have experienced wounds – to alleviate the suffering we are feeling. Every patient should be treated equally, but we know from the literature on health care outcomes that that is not the case. We have so many health disparities determined by our social identity. How healthy we are often comes down to whether we are cis or trans, straight or gay, White or a person of color.
Drivers of health are about what goes on between the person and society. How are we constructing a health care system that acknowledges that? How are we mediating harm at the intersection of person and environment that occurs for all of us, but particularly for those who are the most marginalized of the marginalized?
There is a higher suicide rate due to discrimination and internalized stigma. As a gay Black man, I have had plenty of experiences of discrimination in public schools and the workplace. Discrimination in terms of words spoken to me, but also as to how legally codified my relationship is. I have not experienced bad suicidal ideation because of the love that I experienced from my family, but that is not the case for everyone else. People are dying because of the stigma that they experience. This manifests as high rates of depression, anxiety, substance use disorders, and high-risk behavior leading to STDs and HIV. Poor behavioral health is in some ways a symptom of what it means to be a person with discriminated identities in our current society.
Marginalized identity is a risk factor for discrimination, not a risk factor for behavioral health conditions themselves. The problem is not the identity. The problem is what is done to you when you hold that identity.
Whether you identify with this community or not, everyone experiences some adversity. The environment we live in is sicker than any one individual patient. The patient is not the toxin; it’s the environment that is toxic.
For me, being a compassion warrior emerges from the idea of the Boddhisattva. I am using my own suffering to awaken. And whatever I learn along the way, I hope to pass on, to teach, to show other people that it is possible. As a gay Black man, I want to elevate the most marginalized among us, as well as alleviate my own suffering. I want to get out of the experience of my own internalized stigma of what it means to be gay or Black or feminine. I am no longer interested in continuing to believe myths that the larger environment would have me believe about myself. I want to help others stop believing the myths about themselves that society tries to tell them.
Most folks would talk about access to insurance as well as access to care. Once you have insurance, it is difficult to find providers who are prepared and trained in the LGBTQ+ community, of the community or allied with the community. The other issue is tailored treatment. Trans youth need access to integrated physical and behavioral health care. Substance use treatment programs are another issue – people need access to addiction treatment centers that can affirm and be responsive to all their identities, not just their identity as a substance user. Finding medication providers who are well-trained is another challenge.
Administrative staff are critical. People in the front office who might or might not understand the nuances of the LGBTQ+ community are the ones who set the tone as to what treatment someone will receive. They are the ones who establish whether the environment will be welcoming or stigmatizing. The billing staff, the front office—everyone plays a part in creating a welcoming care environment.
The biggest thing is continuing to support telehealth. Telehealth mitigates potential barriers, such as transportation and location. There are some rural queer folks who can’t find a local provider with whom they feel comfortable. They won’t have access to transportation or know people who can get them to the people who can provide competent services.
At the same time, there may also be rural providers who are knowledgeable about these issues. They might not be as full and could give treatment to someone who lives in a more populous area. We have to assure that there is capacity for LGBTQ+ adolescents. Their suicide risk far exceeds the risk for people who are cisgender or straight. Adolescents are the most vulnerable. And if you add the challenges faced by Black youth who are sexual/gender minorities, these youth have a 40% increase in suicidal ideation.
Lastly, as much as we can, it’s important to match LGBTQ+ providers with patients who have that preference.
First, the W-PATH standards of care are a good starting point for physicians and therapists with trans and gender diverse populations. Fenway Health is an education and research institute for sexual and gender minorities. I’m all about looking at local options – providers need to make sure that they are reaching out to the community. I will tout the importance of a local LGBTQ+ center and finding providers who provide consultation. Queer folks will show up for other queer folks – there are innovations in providing material resources, donating money or clothing. Lastly, providers seeing LGBTQ+ patients should consult with providers who are of the community. When I take on trans clients, I pay for consultation with trans therapists because it is my due diligence to make sure that I’m not missing things, and also a way to receive education and provide monetary support for the community itself.
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