by Vanessa Ip

Graphic design by Geneviève Groulx

Two-spirit, lesbian, gay, bisexual, trans, and queer (2SLGBTQ+) individuals experience greater risk of mental health challenges compared to their heterosexual and cisgender counterparts.¹ This includes increased general anxiety, depressive symptoms, substance misuse and suicide risk, compared to the national average.² Research suggests that these effects have been worsened amidst the COVID-19 pandemic.^2,3 Prior to the pandemic, the Canadian Mental Health Association (CHMA) disclosed that one-third of 2SLGBT+ Canadians experience poor mental health.³ This ratio increased drastically over the pandemic, with over three-fourths of 2SLGBTQ+ respondents reporting poor mental health. 

This marginalized community continues to face barriers while accessing appropriate healthcare including service delivery gaps, access to resources, and knowledgeable providers.³ 2SLGBTQ+ individuals struggle to find gender affirming care and healthcare providers often lack the training to treat this diverse and intersectional group.^2,3 Notably, 2SLGBTQ+ individuals who face such barriers varied significantly in socioeconomic brackets, including income and education level.² The top barriers faced are finances and not knowing where to get help.⁴ In fact, many prefer to manage their substance use themselves simply because it is more convenient than going through the healthcare system. 2SLGBTQ+ youth who also identify with other marginalized groups (i.e. lower socio-economic status, homelessness) are further disadvantaged from accessing telehealth services due to lack of a reliable and private internet connection.² These results are in line with previous findings that low socio-economics status, regardless of their identity, is associated with decreased mental health services access.²  A greater percentage of 2LSBGTQ+ respondents accessed virtual mental health services during the pandemic, while only 7% accessing both virtual and in-person substance-use services.⁴ This lack of use is thought to be caused by stigma, living in unsupportive home environments, and nature of care through virtual platforms (e.g., gender affirming care).^2,3  

For those experiencing difficulty in attaining housing, 2SLGBTQ+ adults experience discrimination from landlords, lack of safety, and lack of awareness of services.⁵ 2SLGBTQ+ couples reported being targeted by landlords, as they may unconsciously choose a heteronormative couple. Some may feel a need to hide their identity to increase their chance of attaining housing. This ties into interpersonal challenges with accepting one’s identity. A “one-size-fits-all” model would not be helpful in these cases and for 2SLGBTQ+ adults experiencing homelessness, it is important to develop housing models and services that attend to their needs.⁵ Perhaps a “whole person” concept of care would help create a holistic point of view.^1,5

Aside from sociodemographic variables, differences in gender identity, sexual orientation, and education significantly impacted whether individuals expressed a need for care or not.² Those who identify as gender non-binary, gender non-conforming/Two-Spirit and women are more likely to express a need for care. This is because those who identify as men may be pressured to conform to gender norms traditionally associated with masculinity. For instance, expressing a need for mental health care or expressing feelings would go against these norms. Due to heteronormative counterparts not experiencing the same barriers, they do not have as high a need of care. In addition, individuals who identified with non-monosexual labels (i.e. bisexual or pansexual) are more likely to express a need for care. This may lead to isolation and difficulty assimilating with a group.² This further emphasizes the separation and comfort level between patients and physicians. The complications of these barriers to mental health care further stresses the need for proper training of health professionals and providers with lived experience. Pasanan⁶ emphasizes on the need to create an inclusive and safe environment for learning about LGBT issues. Policies should be put in place for healthcare providers to be informed about how to best serve the community and combat heteronormative, heterosexist, and homophobic thinking.^1,6 

Heterosexist, cis-normative, trans-negative and homonegative attitudes in formal and informal practice are barriers to promoting healthy 2SLGBTQ+ communities.⁶ These barriers are deeply rooted in health policy history, discrimination, and stigmatization⁷. Progress has been made, as shown by the Canadian Human Rights Act in 1966 that included sexual orientation as one of the prohibited grounds of discrimination.⁸ However, there continues to be stigma attached to queer identities and prejudice against 2SLGBTQ+ groups, as they experience twice as much public violence and harassment as heterosexual Canadians.⁴ A 2019 forum identified emerging themes and future action items.¹ Creating safe spaces for 2SLGBTQ+ in healthcare should aim to be trauma-informed, use a harm-reduction lens, provide anti-racist and anti-oppressive frameworks, and assure respect for confidentiality and informed consent.^1,6 A patient’s previous experience with providers may have been negative and it is important to work towards building trust and rapport through acknowledging these barriers.² Building cultural competency and gender-affirming care⁷ is urgently required for providers, so “we can let the client be the client”.³ Current examples of care that implement these recommendations include LGBTQ cultural competency training,⁷ family intervention approach, trans lived experience programs, and sexual-health-focused programs.⁹ 

Long-term action items include raising awareness of the important of safe spaces for 2SLGBTQ+ persons, prioritizing intersectionality, and spreading change through policy makers, service providers, and other decision makers.^1,6 Notably, it is important to educate and connect with allies in healthcare, so that they can adequately listen to and support the voices of the 2SLGBTQ+ community.¹ A community approach would help reduce social isolation and exclusion for queer people and help create a voice for them.⁶ This includes hiring providers with lived experience and incorporating person-centred care.^3,5 Educating mental healthcare providers about the struggles of this marginalized population and taking this into consideration when tailoring treatment interventions, are the first steps towards improving accessibility to mental health care for 2SLGBTQ+ individuals. Specific interventions for 2SLGBTQ+ individuals have been proposed for not only promoting mental health care, but also self-affirmation practices.⁹ Future mental health care for 2SLGBTQ+ persons include creating a safe space, offering resources, and trauma- and cultural-informed treatment and interventions. 

Reference list

1. Mental Health Commission of Canada, Wisdom2Action. Creating Safer Spaces for 2SLGTBQ+ Emerging Adults in Health-care (Forum Report) [Internet]. 2019 Jul 11 [cited 2023 Dec 30]. Available from https://mentalhealthcommission.ca/resource/mhcc-w2a-rainbow-youth-health-forum-report/
2. Chaito M, Musani I, Pullman M, et al. Access to Mental Health and Substance Use Resources for 2SLGBTQ+ Youth during the COVID-19 Pandemic. Int J Environ Res Public Health. 2021 Oct 28; 18(21):11315. Available from: https://doi.org/10.3390/ijerph182111315
3. Canadian Mental Health Association, Sherbourne Health. 2SLGBTQ+ mental health and wellness [Internet]. Available from: https://ontario.cmha.ca/wp-content/uploads/2023/06/Amplifying-Voices-Recommendations-for-MH-Organizations.pdf 
4. Leger, Canadian Centre on Substance Use and Addiction, Mental Health Commission of Canada. Mental Health and Substance Use During COVID-19 – Summary Report 6: Spotlight On 2SLGBTQ+ Communities in Canada [Internet]. 2022 Aug 2 [cited 2023 Dec 30]. Available from: https://mentalhealthcommission.ca/resource/mental-health-and-substance-use-during-covid-19-spotlight-on-2slgbtq-communities-in-canada/
5. Ecker J. Facilitators and barriers to attaining housing among 2SLGBTQ+ adults with experiences of homelessness. J Gay Lesbian Soc Serv. 2023 Aug 28. Available from: https://doi.org/10.1080/10538720.2023.2251132
6. Pasanen PR. 2SLGBTQ+ Community Health Needs: An Advanced Practicum Report. [Internet]. 2022 [cited 2023 Dec 30]. Available from: https://zone.biblio.laurentian.ca/handle/10219/4008
7. Organek AJ, Weisdorf T. Supporting 2SLGBTQ+ patients in your practice. Can Fam Physician. 2023 June; 69(6):377. Available from: https://doi.org/10.46747/cfp.6906377 
8. Canadian Human Rights Commission. Human Rights Milestones [Internet]. [cited 2023 Dec 30]. Available from: https://www.chrc-ccdp.gc.ca/en/about-human-rights/milestones
9. Higgins R, Hansen B, Jackson BE, et al. At-a-glance – Programs and interventions promoting health equity in LGBTQ2+ populations in Canada through action on social determinants of health. Health Promot Chronic Dis Prev Can. 2021 Dec; 41(12):431-5. Available from: https://doi.org/10.24095/hpcdp.41.12.04