Since the Stonewall Inn demonstrations of 1969 helped catalyze the LGBTQ+ rights movement, the U.S. has made many social and legal strides to treat LGBTQ+ individuals more fairly. Still, as the nation celebrates Pride Month more than 50 years later, many people continue to face stigma related to their sexual orientation, creating a unique set of behavioral health challenges.
Members of the LGBTQ+ community are more than twice as likely to have behavioral health disorders, according to the Substance Abuse and Mental Health Administration (SAMHSA). And for transgender adults, that likelihood is even higher, data published in the journal Transgender Health indicates.
As such, it’s critical for behavioral health providers to have the cultural competencies to meet the unique needs of LGBTQ+ patients. That means hiring diverse staff, developing specialized programs and avoiding one-size-fits-all approaches.
LGBTQ+ staffing, programming
One clinic that prides itself in its specialized LGBTQ+ approach is Central Outreach Wellness Center, a Pittsburgh-based intensive outpatient clinic that provides medical, mental health and substance use disorder (SUD) treatment services, primarily to LGBTQ+ individuals.
Serving those patients well starts with staffing, according to Tamar Carmel, the medical director of mental health services for Central Outreach.
“When people feel connected to their psychiatrist [or] to their therapist, they’re more likely to stay engaged in care and have better outcomes,” Carmel — who identifies as queer and transgender — told Behavioral Health Business, noting that his own orientation makes LGBTQ+ patients feel “inherently more safe.”
Operating a total of four clinics in western Pennsylvania, Central Outreach was founded in 2015 to address what its founder perceived as a lack of culturally competent services for the LGBTQ+ community.
When it opened, a particular focus of the clinic was providing services to HIV-positive LGBTQ+ individuals who did not feel comfortable going to traditional doctors in the Pittsburgh area. Before founding Central Outreach, Stacy Lane — who currently serves as CEO — worked as a physician at the Allegheny County, Pennsylvania public health department, where she provided care to HIV patients.
That experience helped inspire Lane to launch Central Outreach, after seeing the unique struggles her patients were facing and the lack of options that existed for them.
Central Outreach’s services are built around the minority stress model, which asserts that people in certain minority groups are more prone to prejudice-related incidents, while they’re also more likely to receive sub-par care.
“Because of … an invalidation of our identities and political attacks, … we come in with more trauma-based mental health needs,” Carmel said.
For LGBTQ+ individuals, prejudice and discrimination can have serious negative behavioral health ramifications, which doctors frequently miss.
“I often find myself diagnosing and re-diagnosing [patients] because they didn’t feel comfortable or were not heard [by other doctors],” Carmel said. “Trauma is a great mimicker of other mental health problems.”
Central Outreach provides care for a variety of co-occurring behavioral health conditions, which are especially common in the LGBTQ+ community and can be complex to treat.
According to SAMHSA, 1.9 million lesbian, gay and bisexual (LGB) adults have co-occurring mental illnesses and SUDs. To help them, Central Outreach uses a multi-pronged approach, with primary care physicians and nurse practitioners providing care to individuals with mild to moderate depression, anxiety and attention deficit hyperactivity disorder (ADHD).
Additionally, the provider offers medication-assisted treatment (MAT) for SUD with the help of its peer support specialists and case managers, who can also link individuals to more intensive rehab and detox centers. Plus, for patients seeking gender affirming surgeries, Central Outreach can provide mental health assessments and operation referrals.
Although Central Outreach’s business model is specifically built with a focus on the LGBTQ+ population, Carmel believes traditional health care providers have an opportunity to do the same, at least to a degree.
“There should be mandatory LGBTQ+ cultural competency in all health care [with] providers and clinicians and staff, but unfortunately, that’s not the case,” he said. “It disproportionately impacts communities that experience societal discrimination and associated negative mental health outcomes. I don’t think that health care is necessarily seen as a safe space for the LGBTQ+ communities, but it should be.”
Personalized treatment, peer support
The Gateway Foundation has also stepped up to the plate to improve services for LGBTQ+ patients.
Founded in 1968, the Chicago-based Gateway operates mental health and SUD treatment centers in Illinois, Delaware, Florida, Michigan, Missouri, New Jersey, Texas and Wyoming, serving over 9,000 people a day.
For the LGBTQ+ communities, Gateway has specialized treatment programs to take into account patients’ unique traumas.
“They face a lot more challenges than … people who identify as heterosexual, and there’s also a greater risk of harassment and violence,” Jim Scarpace, an executive director with the Gateway Foundation, told BHB. “Because of that, we see an increased risk for behavioral health issues.”
Like Central Outreach, Gateway’s LGBTQ+-specific services are designed to address not just SUDs, but other co-occurring behavioral health conditions as well. It also prioritizes personalized care plans.
“Even in the LGBTQ+ population, everyone’s story is different,” Scarpace said. “Creating customized care plans is important to us, because we need to set up a unique treatment plan that’s going to really help that person have the best chance of achieving and sustaining recovery.”
One client who has benefited from Gateway’s LGBTQ+ approach is Gimel Tillman, the daughter of Dorothy Tillman, a civil rights activist and a politician who for more than two decades was a Chicago alderman.
The younger Tillman said she knew she was a lesbian at a very early age and never struggled with her sexuality. Still, during her teenage years she started experimenting with substances.
Tillman would continue to wrestle with SUD into her adult years before reaching out to Gateway in the summer of 2019.
Initially at Gateway, Tillman was in a women’s group, which she felt was geared more toward heterosexual women, impeding her success. Tillman credits Gateway with being flexible enough to change her treatment plan and place her with a one-on-one counselor to better address her unique needs.
“By the third week, I was able to insert my relationships into the conversation, because I became more comfortable,” she said. “[Before] I could have … [been in the women’s group] for 30 days and never talked about my issues, because I felt like they wouldn’t have been taken seriously [since] I was the only lesbian in the group.”
Two years into her recovery, Tillman now is helping others like herself at Gateway, as she recently became a certified recovery support specialist. Tillman believes her story illustrates why behavioral health providers need to be better attuned to serving LGBTQ+ individuals.
“There’s room for improvement, because [LGBTQ+ issues are] always evolving,” she said. “We can do a better job of our community being more honest with our issues, and I believe the treatment facilities can be a bit more welcoming as far as transparency.”
At the end of the day, she hopes that the behavioral health industry can one day become skilled enough at providing care to LGBTQ+ individuals that there would be no need for programs geared specifically toward one’s sexual orientation.
“When you make a situation a ‘specialty situation,’ sometimes our community will shy away from it more than identify with it, because it still makes us stand out in the way that we’re trying to overcome,” she said. “There’s a little nuance in there that we’re happy to have. But at the same time, we don’t want to seem like a fish in a fishbowl.”