Mental Health and Well-Being of LGBTQI+ Persons

Abstract

Lesbian, gay, bisexual, transgender, queer and intersex (LGBTQI) persons often experience violations of their human rights. Due to persistent social barriers, severe discrimination and human rights violations, social isolation and loneliness, as well as mental health conditions, are reported to be experienced widely among LGBTQI persons globally. Studies have shown that symptoms and diagnoses of depression, anxiety, post-traumatic stress disorder, substance abuse, and self-harm and suicidal attempts are reported higher among LGBTQI persons. Risk factors include factual and perceived discrimination, internalized phobia, violence, unsuccessful coping strategies, lack of sense of belonging, self-stigma, concealment-openness of their sexual orientation and gender identity, rejection by family members and friends, and lack of LGBTQI communities nearby. Further research with special attention to marginalized LGBTQI persons is warranted, together with enhancing awareness, data collection, policy and legal systems and the capacity of key stakeholders to promote and protect the human rights and mental health of LGBTQI persons.

1. Introduction

Many lesbian, gay, bisexual, transgender, queer and intersex (LGBTQI) person experience violations of their human rights based on their actual or perceived sexual orientation, gender identity and expression, and sex characteristics (various terms are used for a range of spectrum of sexual orientation and gender identity including same-sex behaviors, identities or relationships, transgender identities, non-binary gender identities, those who identify as queer, questioning their sexual orientation and gender identity, asexual, pansexual, and two-sprit, intersex persons, and other persons. In this chapter, “LGBTQI” is used consistently with the United Nations (UN) website. See [1] and Appendix 1. for details).

This is often due to a lack of awareness and education, homophobic and transphobic attitudes, the existence of discriminatory laws, lack of adequate protection against discrimination, impunity of perpetrators, and a combination of these and beyond. These human rights violations are pervasive in society worldwide, including schools, the labour market, medical settings, legal systems, and national and municipal systems, communities, and sometimes in their own families. Human rights violations against LGBTQI include discrimination, exclusion, denial of their rights, verbal abuse, humiliation, harassment, bullying including cyberbullying, hate speech, hate crime, physical assault, sexual and gender-based violence, forced medical examinations, “conversion therapy,” sterilization, arbitrary arrest and detention, torture, death threats, death sentence, and murder. According to the UN, 77 countries among 193 UN member states, i.e., about 40% of the countries, have laws to criminalize consensual same-sex conduct, exposing millions of LGBTQI persons to the risks of arrest, prosecution, and imprisonment, and, in five countries, the death penalty [2].

Against these situations, LGBTQI organizations and their allies have continued various efforts at the grassroots level, as well as at the national and international levels. At the UN, based on the Universal Declaration of Human Rights in 1948, which states, “All human beings are born free and equal in dignity and rights” [3], concerns about human rights violations of LGBTQI persons started to be discussed in the 1990s. After years of persistent efforts by various stakeholders including member states, UN agencies, funds and programmes, and civil society organizations including organizations of LGBTQI persons, the 1st UN resolution on human rights, sexual orientation, and gender identity was adopted in 2011. In 2012, a landmark publication, “Born Free and Equal: Sexual Orientation and Gender Identity in International Human Rights Law,” was published by the Office of the High Commissioner for Human Rights (OHCHR) (The second edition was published in 2019) [4, 5]. In 2015, 12 UN system entities issued a joint statement to eradicate violence and discrimination against LGBTI persons [6]. The UN Independent Expert on protection against violence and discrimination based on sexual orientation and gender identity was established by the Human Rights Council in 2016 to assess the implementation of international human rights law, raise awareness, engage in dialog with all relevant stakeholders, and provide advisory services, technical assistance, capacity-building to help address violence and discrimination against persons based on sexual orientation or gender identity: Currently, Mr. Graeme Reid serves as the Independent Expert since November 2023. In 2018, 14 UN entities got together and released “The Role of the United Nations in Combatting Discrimination and Violence against Lesbian, Gay, Bisexual, Transgender and Intersex People: A Programmatic Overview” [7]. An increased number of multi-pronged efforts are going on globally, nationally, and on the ground [1].

However, due to the persistent social barriers, severe discrimination and human rights violations that still exist daily and worldwide, mental health disparities among LGBTQI persons are a significant concern. Those social barriers and mental health disparities are associated with intersections with other factors, including discrimination on the grounds of race, color, descent, age, national or ethnic origin, religion, age, disability, poverty, environment, disasters, and conflicts, too.

2. Mental health and well-being of LGBTQI persons

There has been an increasing number of research conducted on the mental health and well-being of LGBTQI persons. Though pioneering review articles and publications are available and provide useful inputs, the number of studies is still limited, partly due to traditions to ask about gender in a dichotomous way (male or female) without reflecting the diversity of sexual orientation and gender identity.

In general, studies have shown that symptoms and diagnosis of depression, anxiety, post-traumatic stress disorder, substance abuse, and self-harm, suicidal ideation, attempt and death are reported higher among LGBTQI persons [8, 9, 10]. While risk and protective factors for mental health conditions among LGBTQI persons are similar to those among other marginalized populations, factors unique to LGBTQI persons are also reported: In addition to factual and perceived discrimination and disrespect, internalized phobia, violence, coping strategies, and sense of belonging, self-stigma, openness/concealment of their sexual orientation and gender identity, rejection by family members and friends, and lack of LGBTQI communities nearby have been reported to be associated [8, 9]. These factors interact with each other in a complicated manner. For example, concealment can be both a risk and a protective factor since it can lead to positive and negative reactions from their surroundings and impacts on themselves [8]. There were increased reports on mental health among LGBTQI during COVID-19, too.

Loneliness has also been increasingly recognized as a pressing health threat. The World Health Organization (WHO) states that people of all ages are affected by loneliness and social isolation globally. In particular, one in four older adults experience social isolation, and between 5 and 15% of adolescents experience loneliness [11]. Loneliness is linked to depression, suicide, and dementia by up to 50% and can increase the risk of cardiovascular disease and stroke by up to 30% and the risk of premature death by 25%. It affects not only individuals but communities and societies. Based on these, WHO has recently established a new Commission on Social Connection to address loneliness as a physical and mental health threat and promote social connection. According to a meta-analysis on LGBTQI persons conducted by Gorczynski P and Fasoli F [12], sexual minorities report higher ratings of loneliness than those who are heterosexual regardless of their age groups, while the number of studies is limited.

As for intervention to protect and promote the mental health and well-being of LGBTQI persons, while research is increasing, the number of randomized control trials is still limited [13, 14]. In addition, existing research indicates that LGBTQI persons face barriers to accessing mental health services, partly due to widespread stigma and ignorance related to LGBTQI among health professionals [8]. The integration of a clinical perspective is crucial, yet it is also vital to foster an interdisciplinary and multi-sectoral approach. This approach should prioritize awareness-raising initiatives through education, training, social networking services (SNS), and mass media. Policy development should aim to integrate LGBTQI perspectives and explicitly safeguard their human rights as well as mental health and well-being in all settings including the health system. This necessitates a twin-track approach: mainstreaming LGBTQI issues while providing specific services tailored to LGBTQI persons. Furthermore, establishing physical and virtual safe spaces is essential to cultivate social connections and support networks. Complementary to these efforts, a comprehensive range of mental health and well-being services, along with social services, based on the local resources and gaps, are imperative to address the unique needs of the LGBTQI community. It is important to involve LGBTQI organizations in all the processes, including planning, implementation, monitoring, and evaluation, based on the principle of “nothing about us, without us.” For this, capacity development and empowerment of LGBTQI persons will be useful. This includes the capacity to provide social support including peer support to other LGBTQI persons, and the knowledge and skill to change the systems to promote the rights and the mental health of LGBTQI persons. It is also important to make sure civil society, faith-based organizations and young people are in the scope of the solutions since they play critical roles in the protection and promotion of human rights and mental health of LGBTQI persons. Empowering service providers such as primary health workers, mental health professionals, teachers, law enforcement stakeholders, lawyers, social/welfare service providers, and others to strengthen their awareness of the needs and rights of LGBTQI persons is another priority, too, together with capacity development of those who oversee budget and policy stakeholders. In addition, the arts and music have the power to address barriers, and promote empathy, understanding, mental well-being and societal change.

Research on young LGBTQI persons [15, 16, 17] and older LGBTQI persons [18, 19] is increasing. While stigma and discrimination against LGBTQI persons have been gradually decreasing except for certain areas, it is important to conduct further research on the mental health and well-being of LGBTQI persons. In particular, research on marginalized LGBTQI, such as LGBTQI persons with disabilities or chronic conditions, and LGBTQI persons in humanitarian settings, is warranted with attention to their intersection. Based on these, it is urgently needed to accelerate the development of rights-based strategies, policies, programmes, and systems to pursue the mental health and well-being of LGBTQI persons.

3. Way forward

Following up on the Yogyakarta Principles developed and unanimously adopted by human rights experts, including a former UN High Commissioner for Human Rights, members of human rights treaty bodies, NGOs and academia in 2006, and its supplement, the Yogyakarta Principles plus 10 in 2017, as well as various efforts worldwide, there are emerging guidelines on protection and promotion of human rights and mental health of LGBTQI persons including “Advancing the Human Rights and Inclusion of LGBTI People: A Handbook for Parliamentarians” issued by UNDP and Parliamentarians for Global Action (PGA) issued since 2017 and the newest version in 2022 [20]. In the same year, OHCHR’s “Minding the Corporate Gap: How Human Rights Defenders and Companies Can Work Together to Tackle Discrimination against Lesbian, Gay, Bisexual, Transgender and Intersex Persons” was also published [21]. WHO recently announced the development of a guideline on the health of trans and gender-diverse people. In addition, existing tools related to the rights of women and girls, as well as the rights of persons with disabilities, can be used as practical tools just like the Convention on the Rights of Persons with Disabilities (CRPD) [22] was developed based on good practices and lessons learned from the Convention on the Elimination of Discrimination against Women (CEDAW) [23]. Particularly, the concept of the social model in CRPD might be a strategically useful concept for promoting human rights and the mental health of LGBTQI. The social model sees disability as socially constructed: Disability results from the interaction between the person and the environmental (including informational), institutional and attitudinal barriers in societies. Thus, the model finds solutions for removing societal barriers rather than forcing the person to change. In addition, the concept of meaningful participation based on the principle of “nothing about us, without us”, the twin-track approach to push forward mainstreaming together with strengthening specialized services to fill existing gaps, and the disaggregated data derive from CEDAW and CRPD discussions in the international community are important and useful [24]. In data collection, systems to protect information security must be constructed with ensuring confidentiality.

Together with disaggregated data, it is useful to quantify their situation related to protection and promotion of their rights so that longitudinal and horizontal comparison is possible. For this purpose, the Human Rights-based Well-being Checklist (HRWC) (Appendix 2) was developed based on CRPD, one of the latest internationally-agreed human rights instruments, through a collaborative action among the University of Tokyo, the UN, disability and human rights experts, organizations of persons with disabilities and youths. HRWC can quantify states of human rights among individuals and groups. The HRWC consists of 39 questions that assess the degree to which people have experienced specific human rights violations in the last year. The validity and reliability were confirmed. Respondents answer each question on a scale of 0 to 4, while some questions are scored in reverse. The higher the score, the higher the human rights-based well-being [25]. HRWC has been used in various settings including the UN, Bangladesh, Indonesia, and the Philippines.

Due to widespread stereotypes embedded in many cultures and outdated systems in countries, discrimination and lack of protection are still pervasive. LGBTQI persons are not vulnerable but marginalized and violated their human rights. Making sure inclusion of protection and promotion of human rights and the mental health of LGBTQI persons as a priority in all the relevant policies and programmes, meaningful participation of LGBTQI persons including those with mental health conditions or psychosocial disabilities in decision making with ensuring accessibility and reasonable accommodation, and empowerment of LGBTQI persons with enough resources, options and safe spaces, our world will be transformed.

4. Conclusion

The world has changed dramatically and drastically in the past decade around LGBTQI persons: Diversity in sexual orientation and gender identity has been widely recognized and understood as a continuum and spectrum, and various aspects of society have started to include and remove barriers to and respond to the needs of LGBTQI persons. For example, more options exist in various social systems, services and facilities, including marriage equality in 30 countries, more benefits and entitlements to a same-sex partner, including leaving properties to a partner, gender-neutral restrooms, various peer support systems, and beyond. However, at the same time, despite these enormous social advancements, many LGBTQI persons still experience discrimination and violations of their human rights in their daily lives. In some countries, their situation is extremely alarming.

These affect the mental health and well-being of LGBTQI persons critically. Therefore, all the efforts to protect and promote the rights of LGBTQI persons need to integrate perspectives of the mental health and well-being by looking into environmental, institutional, and attitudinal barriers in various aspects of their lives as risk factors. Social support plays a critical role in protecting our mental health and well-being. In that sense, addressing social isolation and loneliness is an important entry point for the mental health and well-being of LGBTQI persons. Ultimately, mental health and well-being should be key indicators of their human rights and well-being.

All of us are unique and different. However, we tend to categorize people by focusing on one aspect and labelling them based on stereotypes. It is high time to return to the foundational principle of the Universal Declaration of Human Rights adopted right after World War II and reiterate that “All human beings are born free and equal in dignity and rights” and respect and embrace multiple differences of all of us. As UNDP and PGA described, “Inclusive societies promise more sustainable human development outcomes. This is because every member of such societies understands that they have a contribution to make, their contribution is valued, and no one should be left behind. Inclusiveness is thus a key precondition for building and sustaining peace, harmony and societal cohesion” [20].

Acknowledgments

This chapter utilized KAKENHI 22 K02060, 22H00925, 22 K18551 (https://www.jsps.go.jp/english/e-grants/).

Conflict of interest

The authors declare no conflict of interest.

Appendix 1. Glossary

(Edited from UNDP, PGA (2022). Advancing the Human Rights and Inclusion of LGBTI People: A Handbook for Parliamentarians.) [21].

Aromantic: Someone who does not experience romantic attraction to anyone.

Asexual: Someone who does not experience sexual attraction towards anyone.

Bisexual: A person who is emotionally and/or sexually attracted to persons of more than one sex.

Cisgender: A term referring to persons whose gender identity and gender expression match the sex they were assigned at birth and the social expectations related to their gender.

Gender expression: The way a person communicates their gender identity externally through their appearance, e.g. clothing, hair style, use of cosmetics, mannerisms, way of speaking and demeanor and how these presentations are interpreted based on gender norms.

Gender identity: A person’s internal, deeply felt sense of their gender or a combination of genders. A person’s gender identity may or may not correspond with her or his sex assigned at birth and their sex characteristics.

Intersex: Intersex people are born with physical or biological sex characteristics, such as sexual anatomy, reproductive organs, hormonal patterns and/or chromosomal patterns, that do not fit the typical definitions or social expectations for male or female bodies. These characteristics may be apparent at birth or emerge later in life, often at puberty.

Queer: “Originally an offensive term used to degrade sexual and gender minorities, this term has intentionally been re-appropriated (taken back) and now refers to a political, sexual and/or gender identity that is intentionally and visibly different from the norm. ‘Queer’ is often used as a broad term for all people who are not strictly heterosexual or CIS gendered.”

Sex characteristics: The characteristics that compose a person’s physio-anatomical sex, including genitals, gonads, hormones, internal organs and chromosome patterns. These characteristics may be apparent from conception or at birth, or emerge later in life, often at puberty.

SOGIESC: This acronym derives from the terms sexual orientation, gender identity, gender expression and sex characteristics. These are not specific to LGBTI people: everyone has them.

Trans (or transgender): As used in this publication, transgender describes persons whose gender identity (their internal sense of their gender) is different from the sex they were assigned at birth. Trans is an umbrella term that describes a wide variety of crossgender behaviors and identities. It is not a diagnostic term and does not imply a medical or psychological condition. This term should be avoided as a noun: a person is not “a trans”; they may be a trans person. It is important to understand that not all people who are considered trans from an outsider’s perspective in fact identify as transgender, nor will they necessarily use this term to describe themselves.

Appendix 2. Human rights-based well-being checklist (HRWC)

The following questions ask how much you have experienced certain things in the last year [26].

Please read each question and circle the number on the scale that gives the best answer for you.

		Never	Seldom	Quite Often	Very Often	Always
1.	I am suffering from inequality & discrimination due to my sex/gender.	0	1	2	3	4
2.	I am suffering from inequality & discrimination due to my age.	0	1	2	3	4
3.	I am suffering from inequality & discrimination due to my disability.	0	1	2	3	4
4.	I am suffering from inequality & discrimination due to my race or ethnicity.	0	1	2	3	4
5,	I am respected as a capable person.	0	1	2	3	4
6.	I can move around in this city without many barriers.	0	1	2	3	4
7.	I can use necessary transportation to participate in social life.	0	1	2	3	4
8.	I can access necessary information to participate in social life.	0	1	2	3	4
9.	I can access the Internet and other new technologies.	0	1	2	3	4
10.	I can ask for support from others when needed.	0	1	2	3	4
11.	I can participate in decision-making related to my community and nation if I want.	0	1	2	3	4
12.	I feel threats to my life.	0	1	2	3	4
13.	I think I can protect my minimum safety when disasters happen in this city.	0	1	2	3	4
14.	My legal decision-making will be obstructed by others.	0	1	2	3	4
15.	I can protect my money and assets without interference from others.	0	1	2	3	4
16.	I can access legal services such as the court when needed.	0	1	2	3	4
17.	I can be detained unlawfully.	0	1	2	3	4
18.	I can be subject to physical or sexual violence.	0	1	2	3	4
19.	I can make decisions on my body and mind without interference from others.	0	1	2	3	4
20.	I can decide where to live.	0	1	2	3	4
21.	My place of living is OK.	0	1	2	3	4
22.	I can make my opinion heard when needed.	0	1	2	3	4
23.	I can keep my privacy when I wish to.	0	1	2	3	4
24.	I can participate in a fair election.	0	1	2	3	4
25.	I can marry and have a child without much interference from others, if I want.	0	1	2	3	4
26.	I can communicate with my family when I want to.	0	1	2	3	4
27.	I can communicate with my friends when I want to.	0	1	2	3	4
28.	I can have/had quality education.	0	1	2	3	4
29.	I can receive necessary health services when I have a physical health condition.	0	1	2	3	4
30.	I can receive necessary health services when I have a mental health condition.	0	1	2	3	4
31.	I think I can receive necessary social services to live in the community when needed.	0	1	2	3	4
32.	I can choose my work if I want to.	0	1	2	3	4
33.	My work environment is/would be OK (If I work).	0	1	2	3	4
34.	My standard of living (food, clothing, and housing) is adequate.	0	1	2	3	4
35.	I have access to clean water and toilets.	0	1	2	3	4
36.	I can access/enjoy culture and the arts (including music, films, theaters, museums, libraries, etc.).	0	1	2	3	4
37.	I can access/enjoy sports.	0	1	2	3	4
38.	I can enjoy tourism and leisure when I want to.	0	1	2	3	4
39.	I have freedom to keep my culture and religion.	0	1	2	3	4

© The University of Tokyo