• 60% of LGBTQ individuals have had depression, compared to 20% of the general population. 45% have had post-traumatic stress disorder (PTSD), compared to 3.5% general. 36% have had an anxiety disorder, compared to 18% general

• LBGQ youth experience greater risk for mental health conditions and suicidality and are 2 times as likely as heterosexual peers to feel sadness or hopelessness

• Transgender youth are 2 times as likely as cisgender LGBQ youth to experience depression and consider or attempt suicide. 40% of all trans individuals have attempted suicide, compared to 13% of the general population 

Risk factors

Accessing Healthcare

• One study found members of the LGBTQ+ community were 2.5 times more likely than peers to use mental health services
• 10% of LGBTQ and 23% of trans individuals postponed or did not get care due to disrespect, discrimination or fear of mistreatment from healthcare providers

Coming out: While there are positive changes in societal acceptance, it remains difficult or even traumatic to cope with rejection. 

• 40% of LGBT adults experienced rejection from family or close friends
• 86% of LGBTQ youth were harassed or assaulted at school

Trauma from discrimination, including from labeling, stereotyping and denial of opportunities or access, as well as verbal, mental and physical abuse. The LGBTQ+ community:

• Is at significantly heightened risk for PTSD due to homophobia and bullying 
• Is one of the most targeted in the U.S. by hate crime perpetrators

Substance misuse or overuse

• 2 times as many LGB as heterosexual adults—and 4 times as many transgender as cisgender adults—have a substance use disorder
• Much higher Illicit drug use in LGB high school youth compared to heterosexual peers

Homelessness

• LGBTQ+ youth and young adults have 120% higher risk of homelessness—often due to family rejection or discrimination. Especially high among Black LGBTQ+ youth
• LGBTQ+ individuals are less accepted at homeless shelters, or experience harassment and abuse there
• This is especially true for trans individuals, who would either be rejected from the many “gendered” shelters or targets of assault if staying at a shelter that doesn’t match their gender identity 

Reasons to seek professional mental healthcare

Most LGBTQ+ individuals are resilient and can do well in the face of adversity, especially with the help of supportive families, communities and peers. Still, there is greater risk for experiencing shame, fear, trauma and discrimination. LGBTQ+ individuals should have appropriate support and, when needed, seek therapeutic care, no matter what choices and decisions lie ahead. 

Coming out—Some of the most difficult and important decisions in life for LGBTQ+ youth and young adults relate to coming out to parents, family, colleagues and friends. Yet feeling safe to come out is different for everyone and can be difficult and intimidating to guess how people are going to react. 

Sexual and gender identity—can be considered on a spectrum, with individuals identifying at any point on or outside this spectrum. Seeking professional help can help individuals deal with troubling issues or with anxiety or depression before they become aggravated conditions and simply help open pathways toward a rich and fulfilling life.

Stigma, bullying, trauma and discrimination—Social pressures and more specifically targeted abuse against the LGBTQ+ community is associated with suicide attempts, eating disorders, substance-use disorders, panic attacks, depression and anxiety disorders. Individual and group therapy not only helps alleviate symptoms, but fosters supportive community.

Gender dysphoria and transitioning, pre- and post-therapy—Some youth may feel at odds with their gender identity and sex assigned at birth and can be risk for developing a gender identity disorder (GID). When a strong desire to be a different gender causes significant distress and makes it difficult to enjoy life or do normal activities, trans people might be interested in exploring hormone blockers, hormone replacement therapy and/or surgical options.

Behavioral Health Evaluation

Conducted by a therapist with expertise in the transgender and intersex population, a behavioral health evaluation explores gender nonconformity and how stigma and discrimination affect mental health—toward making it easier to ease gender dysphoria and/or alleviate the symptoms of gender identity disorder (GID). It assesses:

• • Gender identity and dysphoria
  • Impact of gender identity in work, school, home and social environments, including issues related to discrimination, abuse and minority stress
  • Mood or other mental health concerns, such as depression or anxiety
  • Risk-taking behaviors, substance abuse and self-harm
  • Sexual health concerns
  • Social support from family, friends and peers—protecting against depression, suicidal ideation or attempts, anxiety or high-risk behaviors
  • Goals, risks and expectations of treatment and trajectory of care

Behavioral Health Treatment 

Therapeutic treatment always starts by providing a safe space for LGBTQ+ youth, adolescents and young adults, so they can be secure and comfortable in exploring their sexual and gender identities and in better understanding and dealing with stressors and the challenges they face. 

Therapy is not aimed at altering gender identity or behavior, but at improving psychological wellbeing, quality of life and self-fulfillment. It can help LGBTQ+ individuals explore gender concerns and lessen gender dysphoria. Transgender and gender-nonconforming individuals can become more comfortable with their gender expression and learn skills to enable success in relationships, education and work. 

Specifically, therapy can help LGBTQ+ individuals:

• • Explore, integrate and accept gender identity and expression
  • Build confidence, self-esteem and coping skills 
  • Address the mental and emotional impact of minority stress 
  • Develop a plan to address social and legal issues related to coming out or transitioning to loved ones, friends, colleagues and other close contacts
  • Explore healthy sexuality in the context of gender transition
  • Make decisions about medical treatment options 
  • Treat other mental health concerns
  • Build a support network
  • Increase wellbeing and quality of life

Behavioral health services can be paired to help LGBTQ+ adolescents and young adults excel in school, work and life, including:

• • Cognitive behavioral therapy (CBT) groups for social anxiety and social skills
  • Neuropsychological assessment and educational advocacy
  • Parent training 
  • Medical/health psychology 
  • Nutritional counseling 
  • Speech therapy 
  • Occupational therapy

For LGBTQ+ youth in great distress for 6 months or more, treatment can help them explore their gender identity and find the gender role that feels comfortable for them, easing distress. Treatment may or may not involve a change in gender expression or body modifications. Options include changes in gender expression and role, behavioral therapy, hormone therapy and surgery. 

Treatment approaches are based on personal goals, as well as an evaluation of the risks and benefits of medication use, presence of other conditions and consideration of social and economic issues. Individuals might want to experience living for a time in another gender role consistent with their gender identity before taking further steps.

Treatment criteria for hormonal and/or surgical treatment includes:

• • Persistent, well-documented gender dysphoria
  • Capacity to make a fully informed decision and consent to treatment
  • Age of majority in the U.S. or, if younger, following the standard of care for children and adolescents
  • Reasonably well-controlled medical or mental health concerns, if significant 

Additional criteria for surgical procedures:

• • Pretreatment medical evaluation by a doctor experienced in transgender and intersex care 
  • Addressing medical conditions that could affect treatments or make them inadvisable, including:
    • Identify and manage tobacco, drug and alcohol abuse
    • Identify and manage HIV and other sexually transmitted infections
    • Assess desire for fertility preservation 
    • Assess history of potentially harmful, prior treatments, such as unprescribed hormone use, silicone injections or self-surgeries

Individual or one-on-one psychotherapy: The goal is to provide structure and support for individuals to better navigate the stressors and stigma they may experience. Evidence-based treatments can be tailored to specific mental health challenges, including depression, behavior problems, school or social anxiety, trauma and thoughts about suicide. 

Couples or family therapy: The goal is to reduce stress and build understanding in a relationship or family out of respect and acceptance for one another’s perspectives and experiences. It is often difficult and confusing for those with loved ones questioning their sexuality and/or gender, identifying as LGBTQ+ or transitioning. Participating in therapy together can help prepare couples or family members to be more supportive and helpful of one another.

Group therapy: The goal is for LGBTQ+ youth and young adults to feel less isolated and alone by meeting with peers in their age group. Evidence-based techniques foster goal-oriented, productive environments where members gain a sense of community and inclusion, while reducing social anxiety and eliminating stigma and other pressures. For many, group therapy in combination with individual and family therapy can be particularly helpful.

For LGBTQ+ youth, adolescents and young adults

Support and acceptance of an LGBTQ+ individual might not come easily, but that is not always a bad sign. Many family members or friends need more time to adjust or react. Those from older generations probably may be less comfortable discussing complex topics of sexual and gender identity and different life choices—they fear what they do not understand. 

Parents and family members may have questions and concerns about a young person’s health and wellbeing, especially if life-changing decisions are being discussed. For this reason, it is important for anyone considering a physical or medical change to ask their families and/or other nominated support people to join their journey. This requires patience, education and open, honest communications. 

However, it is also possible that loved ones or family members can be disrespectful, discriminatory or bullying. If LGBTQ+ individuals feel unsafe around anyone, at any time, they need to find an alternative safe network for vital support. 

For those caring for someone else

It can be difficult seeing a loved one experience a mental health issue or struggle with daily life. If someone is going through a transition, experiencing gender dysphoria or just needs someone to talk to while they figure out what’s going on, there are things to do to help. One of these is listening without judgement, asking what is happening for them and helping them access professional support. Many caretakers are confused and worried at first, but educating themselves is a way to better understand what their loved one might be going through. 

It is equally important for caretakers not to forget their own wellbeing. Caring for someone can be rewarding, but also emotionally and physically challenging.

Being respectful of LGBTQ+ people

Everyone has a right to privacy. Whether LGBTQ+ or cisgender or straight, no one should be expected to share intimate details of their sexual life or body. In addition, everyone is responsible for their own education. It is not up to the LGBTQ+ community to educate the general population. 

Good rules of the road:

• • Be genuine and curious about someone’s life without being invasive
  • Ask open-ended questions
  • Reflect the person’s language on terms, partners and preferred pronouns 
  • Be willing to make mistakes and try again without being defensive
  • Do not ask transgender individuals about birth names or transitions

Ways to help someone who might be struggling

• • Give support as you would to anyone
  • Educate yourself on how to be a good ally
  • Start with active listening and asking how to help
  • Show respect and acceptance through words and actions
  • Encourage them to seek counseling

CONNECT TO CARE

References

Anxiety & Depression Association or America 

FBI—Victims

“Health Disparities Among LGBTQ Youth,” Adolescent and School Health,  CDC

The GLSEN 2019 National School Climate Survey: The Experiences of Lesbian, Gay, Bisexual, Transgender, and Queer Youth in Our Nation’s Schools

LGBT Foundation

Mayo Clinic

Mental health challenges in the LGBTQ community, Health Partners  

Mental Health America

“Mental Health in Lesbian, Gay, Bisexual, and Transgender (LGBT) Youth,” National Institute of Health

“Missed Opportunities: LGBTQ Youth Homelessness in America,” Voice of Youth Count

National LGBT Health Education Center

Rainbow Health (formerly Just Us Health) 

Standards of care for transgender health, the leading framework for clinicians to follow when considering writing a letter of readiness for transition 

A Survey of LGBT Americans, Pew Research Center

“Understanding the Mental Health of Transgender and Nonbinary Youth,” Journal of Adolescent Health

Youth Risk Behavior Survey, CDC

U.S. Trans Survey