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Mental Wellbeing and LGBT*QIA Identities

Nazariya is a queer feminist resource group.

Not ‘queer and feminist’ but ‘queer feminist.’ By doing away with that and, we try to queer our feminism and our organisation’s politics. Part of the process of queering our work is trying to critically understand gender and sexuality outside of established patterns, whether that be in the form of questioning binaries (man/woman, masculine/feminine), questioning the dichotomy of sex being biology and gender being a social construct, or challenging the conformity to a strictly legal lens that may paint the LGBT*QIA+[1] community as an entirely oppressed minority.

It is with this approach that we began,in 2017, to explore what mental wellbeing means for queer persons.

The field of mental health in India offers up a great number of statistics: roughly 60 million people in India are estimated to suffer from some form of mental illness,[2] and the World Health organization (WHO) estimates that for every 100,000 people in India, there are only 0.3 psychiatrists, 0.12 nurses, 0.07 psychologists, and 0.07 social workers.[3] Factors of mental health includenot only individual attributes such as the ability to manage one’s thoughts, emotions, behaviours and interactions with others, but also social, cultural, economic, political and environmental factors such as national policies, social protection, living standards, working conditions, and community social supports.”[4] Mental health care therefore requires efforts to create a healthy, supportive environment in addition to adequate resources to tackle mental illness and stress such as clinical care, therapeutic services, support groups, etc.

Unfortunately, mental health care is not addressed in the comprehensive manner that it needs to be in India, and the system suffers from a paucity of resources as well as unequal access to what little resources do exist. Not only is there an extreme treatment gap where psychiatric and psychological services and access are limited by prohibitive costs, but also existing services, particularly in terms of regular psychotherapy, are heavily bound by heteronormative assumptions and expectations. Therefore, in addition to self-selecting for an urban, upper-middle class clientele, mental health care and mental health care practitioners in India are largely unaware that mental wellbeing is acutely and intensely impacted by the intersection of gender, sexuality, caste, socio-economic status, and other identities. This is where the majority of people who don’t fit the “normalor typical framework of society get pushed out even further.

Members of the queer community face significant familial, societal, and legal discrimination on the basis of their identity in addition to the stresses brought on by everyday life such as work, relationships, and peer pressure. This additional, unique stress is known as minority stress, which is defined as the additional stress individual experience as a result of their status as a minority.[5] According to Meyer’s 2003 minority stress model, LGBT*QIA+ individuals are more vulnerable to and have a higher prevalence of mental illnesses because of the additional stress in addition to everyday stressors, with coming out, staying in the closet, gender dysphoria, homophobia, and transphobia being just a few examples of minority stressors.[6] Common examples of minority stressors that take a toll on mental health for the queer community are concealment stress, i.e., staying in the closet, coming out, familial rejection or pressure to engage in a heterosexual relationship, homophobia (societal and internalised), gender dysphoria, and legal discrimination, to name a few.

There exists a substantial body of research conducted in the United States that corroborates Meyer’s findings on minority stress and his model. Gay, lesbian, and bisexual (GLB) individuals who report experiencing higher amount of “gay-related stress” also report higher depressive symptoms, with gay-related stress and consciousness of stigma being interdependent predictors of depressive symptoms.[7]Davison found American gay, lesbian, and bisexual individuals to experience not only the same psychological problems and patterns of ‘non-gays’ or heterosexual people but to struggle with concerns unique to their identities.[8] Examining the psychotherapy histories of 600 American GLB individuals, Jones & Gabriel found lesbians and gay men to be the most enthusiastic but least acknowledged consumers of psychotherapy for numerous reasons including coming out concerns, relationship issues, and work-related problems.[9]The oppressive social conditions that they are surrounded by also often leave GLB individuals vulnerable to anxiety, mood, and substance abuse disorders.[10] Furthermore, social oppression may increase risk of substance abuse, including tobacco use, and suicidal behaviour.[11] Depression and suicidal ideation in GLB youth has been linked to certain minority stressors, such as coming out and feeling like a burden.[12]Stigmatised LGBT youth suffer internalised homophobia and concealment stress, which were shown to have a direct effect on major depression.[13]

Similar results are seen in the Indian context. The MSM (Men who have Sex with Men) population in Chennai experienced psychological distress and feelings of low self-worth in relation to lack of familial acceptance and pressure to conceal their sexual identity.[14] 29% of MSM in Mumbai had symptoms of major depression and 45% of them admitted to suicidal ideation.[15]

Within sexual minorities, the LBT*FAB[16] community has the added layer of gender intersecting their experiences of minority stress. Researchers found lesbians and bisexual women more likely than heterosexual women to have poor health related behaviour and access to health care.[17]Many Transgender/Gender Nonconforming (TGNC) people are isolated and must cope with the stigma of gender nonconformity without guidance or support, worsening the negative effect of stigma on mental health.[18]TGNC people also experience stressors from constant barriers, inequitable treatment, and forced release of sensitive and private information about their bodies and their lives.[19]

Therefore, as intersectional identities overlap and exist simultaneously, the various forms of prejudice associated with each of the identities are also compounded, but this is seldom anticipated or recognized.[20] In India, empirical and quantitative studies on LGBTQ issues tend to focus on HIV related risks amongst men and/or individuals assigned male at birth.[21] A 2015 report brought out by the National Consultative Meet of LBT Collectives and Practitioners highlighted the lack of conversation around the gender identity of lesbians and bisexual women. The report stressed the importance of examining the intersectionality of identities and examining how mental illness, gender, and sexual orientation are factors in multiple levels of discrimination faced by individuals and exacerbate the stress of a heteronormative society. Questions of identity and internalised homophobia arise as individuals struggle with self-acceptance, the concealment stress of staying in the closet, and the dissonance of reconciling their identity and orientation with a heteronormative society. Individuals also fear losing status and privileges that are associated with a heteronormative lifestyle once they come out. Issues that arise out of the need to find a partner, the fear of never finding a meaningful relationship, and loneliness because of the desire to talk to someone about problems, especially in the event of a break up, are also significant within the Indian LBT* community, as highlighted by the report.[22]

In an attempt to increase the discourse on and access to mental health for queer people outside of a solely medicalised model, to shift the conversation away from pathology, while respecting individual choice and multiple treatment options, we focused our efforts on the premise that mental health is so much more than the absence of an illness, or a diagnosis, or a prescription. Acute and chronic stress and their accompanying symptoms of tension headaches, stomach aches, fatigue, increased heart rate, anxiety, and burnout, take a toll on mental wellbeing, particularly when the triggers for such stress might be related to an individual’s gender and sexual identity.

During the need-mapping conducted for our project on mental health, members of the Nazariya research team spoke to individuals from the LBT*FAB community, gathering information on the needs of the queer community with respect to mental healthcare. Across individuals, a non-judgmental attitude was seen as one of the important qualities of a counsellor/therapist. The more general qualities that the interviewees listed were those of patience, being willing to listen, addressing the stigma around counselling, understanding that medication may not be the best option for everyone, and a feminist outlook, especially regarding topics of marriage, gender roles, and sexuality. Specific to their gender and sexual identities, interviewees expressed a desire for counsellors and therapists to actively devote time and energy into creating a safe space for them to talk, to see them as individuals, be understanding of existing stigmas and taboos, and have an increased knowledge of the LGBTQ spectrum instead of expecting clients to explain everything to them. Interviewees also recommended that counsellors understand the importance of a Gender Identity Disorder (GID) certificate for trans* persons to be able to begin the legal name and gender marker change process,[23] have some knowledge about the transition process, know and explain alternative identities and options available, and understand the pressures from the transman community to conform the body to certain standards to ‘prove’ manliness. Finally, interviewees also note that counsellors and therapists had to be mindful of the high cost of mental healthcare, understand that many LGBTQ individuals may not be able to afford such services, and duly inform their clients of the costs involved beforehand. Such information could be imparted to counsellors and therapists through trainings on gender and sexuality, and for the short term, lists of queer-friendly counsellors and therapists could be widely circulated amongst the LGBTQ communities.

Keeping all of this in mind and taking into consideration the gaps in the current health care system, Nazariya worked with TARSHI to hold a series of free, bilingual workshops on stress management and burnout prevention for LGBT*QIA+ individuals in New Delhi in September and December 2017. The workshops emphasized self-care as a feminist issue and functioned on a non-medical model with an emphasis on simple stress management techniques that can be practiced individually without any additional equipment or resources.

Overwhelmingly, participants spoke about the stress of expectations. Some participants spoke about being expected to and being pressured to conform to heterosexual norms, to get married, have children, and settle down”, while others spoke about LGBTQ+ stereotypes that they were expected to adhere to. The stereotypes of the ‘effeminate’, cisgender gay man, the butch lesbian, and the bisexual whocannot make up their mindhave heteronormative bases and are sources of stress for individuals.

For many participants, the expectation and pressure to conform to a heteronormative ideal was also intrinsically connected to family, and the necessity for deception and lying to one’s family. Participants described the process of having to lie as stressful and suffocating because such self-censorship takes a lot of effort. One participant in particular said, I hate lying, but I would rather lie than have a panic attack thinking about my mother’s reaction to my identity.”

The participants who were out to their families spoke of the difficulty of maintaining boundaries. Even when families were supportive of their identities, many participants revealed that they were often subjected to invasive questions, many of which are about sex. One participant said, It’s a struggle to find a balance and draw boundaries. I don’t want my queer identity to be denied, but I also don’t want it to be the only thing that is talked about me.” Another participant said, “It feels like I always have something to prove or compensate for with my family because I’m queer.”

Several participants emphasised that they considered the personal to be political; while doing so allowed them to take greater ownership of their identities and their politics, it also constantly highlighted ways in which their surroundings were in conflict with them, whether that be having to stay in the closet, keeping a queer relationship a secret, or the pressure to ‘pass’ as someone conforming to heteronormative standards. Participants stressed that politicising one’s identity made it extremely hard to find a safe space to just ‘be’ or to disengage. Participants said that while knowledge and awareness of patriarchal and heteronormative structures and finding like-minded people to discuss such topics with makes understanding societal frameworks and exploring identities much easier, the ‘bubble’ of such like-minded people remains small and hard to find for most people and does not negate the negative experiences outside of the bubble.

Further tangled with wellbeing and sexuality is gender. Participants who were assigned female gender at birth pointed out that their voices and identities tend to remain unheard and invisiblised because of their gender identity, with individuals assigned male gender at birth dominating even queer social and online spaces. These participants talked about how the intersections of gender and sexual identity bring about unique lived experiences that are not faced by individuals assigned male at birth, even if they identify as a sexual minority. They spoke about facing misogyny within the sexual minority community, the literary community, and the political sphere in terms of their thoughts and contributions not being respected or acknowledged.On the other hand, male-identifying participants spoke at length about the expectations the patriarchy thrust upon them to be the ‘right’ kind of ‘man’ and the resulting anxiety on not being able to meet these standards. The standards of toxic masculinity made one male-identifying participant very scared to live in a hostel while in college because he did not conform to masculine norms.

It became evident over the course of the workshops that the participants were experiencing several stressors tied specifically to their identities, including but not limited to sexual identity, gender identity, caste, and class. These identities intersect in different ways for each individual, but each of them struggles with the stereotypes and expectations tied to each identity.

At the end of all the workshops, while most participants reported positive experiences with a range of stress management techniques, including meridian energy tapping,[24] art based therapy, and breathing techniques, one of our biggest takeaways was a more nuanced understanding of how different queer individuals connected their mental wellbeing to their sexuality and the intersectionality of the two with other identities and facets of their lives.

To us, these sessions illustrated a few of the ways in which wellbeing is tied to sexuality; experiencing or being a part of queer/LGBT*QIA+ spaces by itself leads to reflection, healing, catharsis, and empathy. One of the participants even admitted to viewing the workshop they attended as a support group” Being able to relate experiences and share difficulties in a non-judgmental and open environment was very important to the participants and made us realize the need for such spaces where individuals are able to talk about their messy, fun, delightful, complex lives and their accompanying challenges.

***

[1]Trans* is an umbrella term for transgender people, gender queer people or people who do not conform to notions of the gender assigned to them at birth.

[2]http://www.indiaspend.com/cover-story/nearly-60-million-indians-suffer-from-mental-disorders-68507

[3]http://www.searo.who.int/india/topics/mental_health/about_mentalhealth/en/

[4]ibid.

[5]Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129, 674-697.

[6]Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129, 674-697. http://dx.doi.org/10.1037/0033- 2909.129.5.674

[7]Lewis, R. J., Derlega, V. J., Griffin, J. L., & Krowinski, A. C. (2003). Stressors for gay men and lesbians: Life stress, gay-related stress, stigma consciousness, and depressive symptoms. Journal of Social and Clinical Psychology, 22(6), 716-729.

[8]Davison, G. C. (2005). Issues and Non issues in the Gay‐Affirmative Treatment of Patients Who Are Gay, Lesbian, or Bisexual. Clinical psychology: science and practice, 12(1), 25-28.

[9]Jones, M. A., & Gabriel, M. A. (1999). Utilization of psychotherapy by lesbians, gay men, and bisexuals: findings from a nationwide survey. American Journal of Orthopsychiatry, 69(2), 209.

[10]Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129, 674-697.

[11]Fergusson, D. M., Horwood, L. J., & Beautrais, A. L. (1999). Is sexual orientation related to mental health problems and suicidality in young people?. Archives of general psychiatry, 56(10), 876-880.; Lock, J., & Steiner, H. (1999). Relationships between sexual orientation and coping styles of gay, lesbian, and bisexual adolescents from a community high school. Journal of the Gay and Lesbian Medical Association, 3(3), 77-82.

[12]Baams, L., Grossman, A. W., & Russell, S. T. (2015). Minority stress and mechanisms of risk for depression and suicidal ideation among lesbian, gay, and bisexual youth. Developmental Psychology, 51(5), 688-696.

[13]Bruce, D., Harper, G. W., & Bauermeister, J. A. (2015). Minority stress, positive identity development, and depressive symptoms: Implications for resilience among sexual minority male youth. Psychology of Sexual Orientation and Gender Diversity, 2(3), 287-296.

[14]Mimiaga, M. J., Closson, E.F., Thomas, B., Mayer, K. H., Betancourt, T., Menon, S., & Safren, S. A. (2015). Garnering an in-depth understanding of men who have sex with men in Chennai, India: A qualitative analysis of sexual minority status and psychological distress. Archives of Sexual Behaviour, 44 (7), 2077-2086.

[15]Mimiaga, M. J., Biello, K. B., Sivasubramanian, M., Mayer, K. H., Anand, V. R., & Safren, S. A. (2013). Psychological risk factors for HIV sexual risk among Indian men who have sex with men. AIDS Care, 25, 1109-1113

[16]Nazariya uses the term T*FAB i.e. Trans* Female Assigned at Birth because it’s a broad category of people who were assigned female gender at birth. A term like trans masculine excludes people who are genderqueer and people who do not want to exclude the feminine aspect of their identity.

[17]Diamant, A. L., Wold, C., Spritzer, K., & Gelberg, L. (2000). Health behaviors, health status, and access to and use of health care: a population-based study of lesbian, bisexual, and heterosexual women. Archives of family medicine, 9(10), 1043.

[18]Fredriksen-Goldsen, K. I., Kim, H. J., Shiu, C., Goldsen, J., & Emlet, C. A. (2014). Successful aging among LGBT older adults: Physical and mental health-related quality of life by age group. The Gerontologist, 55(1), 154-168.

Singh, A. A., Hays, D. G., & Watson, L. S. (2011). Strength in the face of adversity: Resilience strategies of transgender individuals. Journal of Counseling & Development, 89(1), 20-27.

[19]Hendricks, M. L., & Testa, R. J. (2012). A conceptual framework for clinical work with transgender and gender nonconforming clients: An adaptation of the Minority Stress Model. Professional Psychology-Research and Practice, 43(5), 460.

[20]Makkonen, T. (2002). Multiple, compound and intersectional discrimination: Bringing the experiences of the most marginalized to the fore. Institute for Human Rights, Åbo Akademi University.

[21]Parekh, S. (2006). Researching LGB youths in India: Still a distant dream. Journal of Gay and Lesbian Issues in Education, 3, 147–150. http://dx .doi.org/10.1300/J367v03n02_17

[22]National Consultative Meet of LBT Collectives and Practitioners (2015, December 17).

[23]As the Indian legal process currently stands, a GID certificate from a professional psychiatrist or psychologist is necessary for an individual to begin the name and gender marker change process. There is also an ongoing movement to strike the GID diagnosis from the International Classification of Diseases (ICD) and replace it instead with Gender Dysphoria. Nazariya does not support or condone labelling trans* identities as a disorder but works with individuals who are seeking to change their name and gender marker within the current system by referring them to psychiatrists and psychologists.

[24]https://goe.ac/

Cover Image: Pixabay

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Nazariya is a Delhi-based group of queer feminist activists. They work towards sensitizing those working on issues of gender-based violence, livelihoods, education, and health from a queer perspective through research and evaluations, capacity building, and advocacy health in order to impact the discourse on pleasure, desire, rights, and entitlements. Nazariya uses the word queer for people who have diverse sexual orientations and gender identities. Nazariya’s special focus is on issues and concerns of lesbian, bisexual, intersex, queer, asexual, pansexual, genderqueer, non-binary people assigned gender female at birth, and transmen.

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