“Mental health is not a lack of willpower. Mental health is not being inflicted by the Devil. Mental health isn’t about not being strong enough to cope with life.” This is the opinion of psychiatrist Dr. Z. (She has requested that her name remain anonymous).
Dr. Z is a Hillsborough National Alliance on Mental Illness board member and has both clinical knowledge as well as the mental health delivery system. Untreated mental health, as she views it, is a serious public health issue; “Not in the contagious sense of the word. I can’t catch depression from someone else. I can’t catch schizophrenia from someone else. I can’t catch bipolar [disorder] from someone else. But how I’m feeling does impact others. For example, social ails like homelessness, like prison populations, where a lot of that has to do with untreated mental illness; society at large is impacted by the way we that we approach the treatment of mental health.”
Mental health and its treatment are often neglected, sometimes unwittingly, by millions of Americans. Those percentages become increasingly alarming as you further refine the subset; for instance, gay women. However, when that subset is divided into a subset – gay women of color – the rates, severity, and adverse outcomes of mental health-neglect intensify. Now imagine, a subset of a subset of a subset, trans women of color, and the already distressing percentages only get bigger.
At the risk of coming across as pessimistic, the fact remains that mental healthcare in the LGBTQ ethnic minority communities could be better. But that is not for a lack of input by a diverse group of healthcare professionals and facilities. They are on the frontlines of a mental health access battle in the Black and Latinx LGBTQ communities. And the good news is that they’re winning.
The National Institute of Mental Health (NIMH) reveals that of all the adults in the U.S. with a mental health-related condition (roughly 1 in 5), a mere 41 percent received treatment in 2015. Statistical numbers tell a tale of disparity in regards to LGBTQ mental health diagnosis and treatment. The NIMH estimates that those in the LGBTQ community are twice as likely to have a mental health condition as their straight counterparts. In an article published by The Substance Abuse and Mental Health Services Administration (SAMHSA), it states that LGBTQ individuals are more likely than straight individuals to have substance abuse as well as mental health issues. The suicide rate is also higher among the LGBTQ community than the straight community. LGBTQ youth are somewhere between two and three times more likely to attempt suicide as the sexual majority youth, according to the NIMH.
The Agency for Healthcare Research and Quality (AHRQ), calculated that African-American and Latinxs utilize mental health services 50 percent less often than white Americans. The observation is echoed by several other governmental organizations, like the Centers for Disease Control and the National Institutes of Health.
So, a few questions emerge from the avalanche of data. First, what is mental health? Second, what are the barriers, if any, that are keeping LGBTQ people of color from receiving mental health services? Next, what is being done to counteract the trend? Lastly, what to do about the mental health concerns of the hidden population within the LGBTQ ethnic minorities?
Cary Coll is a licensed clinical social worker, and has been for 11 years. She is currently the Behavioral Health Program Manager at Metro Health and Wellness Community Center in St. Petersburg. For the past three years, she has specialized in services catered to the LGBTQ community. She says that mental health is a health issue when a patient “(has) experienced behaviors that are disrupting their lives. Within that, it’s a wide range, because you could be suffering from a diagnosable mental health disorder. And the outline for treatment for that is would be found in the Diagnostic Statistical Manual.”
This can be regarded as a mental illness which implies a chemical imbalance. Therefore, it’s often treated with drugs, sometimes for the rest of the patient’s life. Coll emphasizes that is not the only indicator of a need for mental health treatment.
“For others there is, maybe, a certain behavior that they don’t know the root foundation of how it started. But they know they keep on repeating the same mistake over and over again. So, they feel their mental health is suffering.”
In general terms, for both the Black and Latinx communities, strong traditional gender roles tend to dictate what is acceptable to do and how to act within African-American and Latinx communities, Coll says. She explains that, in psychology, this type of constrained behavior in minority communities is called ‘enmeshed behavior.’
“When a person does identify as part of the LGBTQ community and has mental health concerns, (the family) says, ‘We have to keep it in the family; we have to keep it a secret.’ That means the person can’t go out and get help because (then) there’s something wrong with the rest of the family,” Coll says. This sentiment is also affirmed in studies conducted by the CDC.
Robert Baker-Hargrove is Co-CEO of Two Spirit Health Services, an LGBTQ centered holistic healthcare facility in Orlando. He quipped that they service the LGBTQ community from “the womb to the tomb.” Baker-Hargrove identifies religion as playing a pivotal role in whether or not people of color acknowledge or seek treatment for mental health issues. “(The) instant label of being crazy and going to see a therapist; then there is this sense of, ‘I need to pray deeply about it or really connect with whatever spiritual guidance, or whatever you believe in.”
The steadfast reliance on faith and the church for treating mental health may work for some LGBTQ ethnic minorities, but not all. Mrs. D is a licensed clinical social worker for over 25 years. She has experience with mental health and substance abuse. Like the psychiatrist Dr. Z, Mrs. D is a board member of the Hillsborough Chapter of NAMI, who has also requested that her name remain anonymous. She touches on what many others have also mentioned: That there is a stigma associated with mental healthcare in the African-American community. “(They say) ‘I’m not crazy.’ Or, ‘We are going to take care of the problem in our own house. Or we’re going to see the pastor.’ But with the type of mental illnesses and conditions we are seeing, they can’t be taken care of by not talking about them. They can’t be taken care of by their own. And some of them can’t be taken care of by the pastor.”
Another aspect in the reluctance of LGBTQ people of color to seek mental health diagnosis and treatment, is a perceived gap in cultural competency. Baker-Hargrove of Two Spirit Health Services says that too many in the Black and Latinx LGBTQ communities don’t want to go for intimate treatments if they feel they aren’t understood. A more prosaic way to look at it is; if you don’t look like me, then you can’t possibly understand me. The fact that ethnic minorities are mistrustful of healthcare institutions isn’t lost on Dr. Z.
“There are historical issues of abuse by the mental health field against those communities of color,” she says.
Everyone interviewed for this article has serious concerns about the repeal of Obamacare and the possible implementation of Trumpcare. The Congressional Budget Office determined, in their review, that somewhere around 20 million Americans could lose insurance by 2018, with nearly 30 million losing coverage by 2026, if the current iteration of the Obamacare repeal is passed. No one knows how it will ultimately affect the LGBTQ community, because no data is collected with respect to sexual orientation nor gender identity. It is felt, however, that many in LGBTQ community, and likewise LGBTQ ethnic minorities, have been helped by the Affordable Care Act. If nothing else, it has meant that many people have access to affordable mental healthcare. As of now, we will have to read the tea leaves in order to guess what a repeal will mean for mental healthcare.
Despite the uncertainty of the repeal and replacement of the ACA, there are several organizations in Florida which are providing mental healthcare to LGBTQ people of color. The measures they are taking, or have taken, resemble a Venn diagram. There is overlap on key issues and more focus on other issues, which all chip away at the disparity in mental healthcare of LGBTQ ethnic minorities.
Two Spirit Health Services is committed to ensuring that their clinical staff reflects the communities to which they serve. For Baker-Hargrove it starts with cultural competency.
“Where there is a heavily Latino population, you’re going to want to have some Spanish-speaking therapists. If you’re going to go into a heavily urban community, you’re going to want to have more African-American therapists on your staff. It’s about understanding where you are locally, and understanding your demographics and trying to mirror that,” he says.
Bliss Healthcare Services, located in Orlando, is another one-stop shopping organization when it comes to LGBTQ healthcare. Kim Murphy is a licensed mental health counselor at Bliss since April. She is adamant that if holistic healthcare was not a core component of the organization, then many people may never seek mental healthcare. “They’re people referred to me, and they may not be culturally open to it. Were they not told that, hey, we offer these services; if you really need to talk with somebody…it all seems to flow together and work really well.”
An unnamed Latinx transgender client in her thirties confirms the power of Bliss.
“Being able to vent is not something I get to do regularly,” she says. “I don’t like talking about my issues. I feel like they’re going to be made fun of. Coming to Bliss Cares (the nonprofit wing of Bliss, which refuses no clients) I found a non-judgmental environment where it was easy to open up.”
Metro Health and Wellness uses a broad pallet of partnerships and outreach to help remove barriers to LGBTQ ethnic minority mental healthcare. The list includes churches, community organizations, and social services to name a few.
“For the minority community it is very important to try to get into the neighborhoods and work from advocating from within the community and partner up with a face that is trusted and known by the community; we take advantage of it,” Coll says.
And because of patient-doctor confidentiality – along with HIPPA laws – there isn’t an objective way to get into the issue of mental health in the community from the outside.
Gary Howell, Psy.D., PC, operates out of Ybor in Tampa. His practice ranges from free youth LGBTQ group meetings to private counseling with adult LGBTQ people.
“Depending on the culture, if one identifies as lesbian or gay, or even transgender, they’re dealing with the stigma. A lot of people don’t come out to their families. Between my work in Chicago and my work here, I’ve worked with several hundred gay men in straight relationships,” he says. “Most importantly, they’re able to get to a place where they’re happy with themselves once they’re able to address that without substances or body-image issues.”
Moreover, issues that arise in current events can be paralyzing for those in search of therapy.
“Especially with the Pulse anniversary just passed,” he says, noting that a number of his clients are persons of color. “When it first happened, I had an uptick in services. We had 10 or 15 intakes within the year. Each and every one of them was talking about Pulse. A lot of the issue with my patients after the 2016 election was that their rights were going to be taken away given the sociopolitical climate.”
Both Hillsborough NAMI board members Dr. Z and Mrs. D confirm the notion that even in the African-American churches, the zeitgeist is shifting toward openness, acceptance and mental healthcare promotion.
These actions are the cornerstone to dismantling a paradigm that has alienated LGBTQ people of color from mental healthcare. Yet, there is a segment of the LGBTQ ethnic minority community that is virtually hidden and statistically very fragile. This is the T of the LGBTQ: the transgender community. A National Institute of Mental Health study claims that just over 10 percent of transgender people have reported that they have been denied care at mental health clinics because of discrimination or bias.
According to the Gay and Lesbian Alliance against Defamation (GLAAD), transgender people are a severely marginalized subgroup of the LGBTQ community. The statistics are staggering: 30 percent have at some point been homeless, have three times the rate of unemployment compared to the U.S. average with 4 times the rate for transgender people of color; a high rate of workplace discrimination; high rates of abuse and violence. In general, transgender women of color are faced with high rates of homelessness, incarceration, and murder. The number of murders of transgender women of color might be greater, because so many transgender people are misgendered on death certificates, GLAAD reports. An article in the British news site, Pink News, says that every 3 days a transgender person is murdered somewhere in the world. Recent numbers from the National Coalition of Anti-Violence Programs reports that in 2017 alone, 13 transgender people of color have been killed.
The transgender community is lagging 20 years behind the gay, lesbian and bisexual communities, as far as exposure and public education are concerned, director of transgender equality at Equality Florida Gina Duncan says. In the past, coverage of mental healthcare and healthcare in general were lacking for transgender people. This was partly due to a residual effect of societal norms. Things are changing. However, Duncan points out, during a town hall meeting after the Pulse tragedy, the LGBTQ community wasn’t as aware of the T portion of the community as it should be.
“Two things that were overtly clear. One, that not everyone in the LGBTQ community had a seat at the table. Secondly, there was the lack of understanding in reference to the inclusion of those communities. Specifically, LGBTQ people of color were underrepresented,” she says. “These included transgender people of color, which includes Latinx people of color.”
Transgender women of color are facing more job discrimination, violence, and cultural bias than other members of the LGBTQ community. They are often seen as a hidden group; the subset of a subset of a subset. Coupled with a reluctance to go and seek out mental healthcare, they can go almost unnoticed. Two Spirit Health Services is reaching out to the Black and Latinx transgender community in an innovative way.
“If you feel you are in a marginalized group, in today’s society they will create a secret Facebook page. They will find ways to connect with one another through the internet,” Baker-Hargrove explains.
Bliss Cares, a division of Bliss Healthcare Services, is utilizing a Contigo Fund grant. The grants are disbursed to organizations aiding the LGBTQ community. The grants arose in the wake of the Pulse tragedy. Kim Murphy of Bliss Healthcare Services says they used their grant money to reach out to transgender women of color.
“We partnered with some agencies to bring in trans women of color,” she says. “They help them with dealing with stigma, and being in the workforce, getting their name changed and their gender marker changed, they get help with all of that.”
Gina Duncan of Equality Florida made a list of things that need to be done in order to generate better mental healthcare for the transgender community of color.
“There’s education and awareness needed with our major healthcare providers (and) to help them adopt transgender cultural competency policies and procedures, so that they will support the transgender community properly in providing healthcare,” she says.
On October 5 and 6, a major academic conference will be held on LGBTQ mental health in New York. It’s entitled In My Mind: LGBTQ Peoples of Color Mental Health Conference. The fight continues, and it’s working.
“I had one young gay male who had gone through shock therapy,” Howell says. “He had scars on his stomach. He was able to come out of it and not think of himself as some repulsive person.”
