Building Bridges—Sharing What Works in LGBTQIA+ Mental Health Care

Here’s why affirming care matters: A landmark 2018 study in the Journal of Adolescent Health found that transgender youth who could use accurate names and pronouns experienced 71% fewer symptoms of severe depression, a 34% drop in reported suicidal thoughts, and a 65% decrease in suicide attempts.  

Inclusive care saves lives. In a world where hatred, discrimination, and violence threaten the physical, emotional, and mental well-being of LGBTQIA+ people, mental health providers can hold space for people to feel safe. 

This month, we held a Brown Bag talk to begin discussion on how to better serve LGBTQIA+ clients. Moderated by Emma Holland, a community activist, clinicians shared their experiences of what’s worked for them to provide affirming care. The panel included Caitlin Hughes, LPC (Staff clinician at Fairfield University), Victor Rivera, LPC (UpLift therapist), and Dr. Raj Sachdej, MD (UpLift psychiatrist). 

We gathered some overarching takeaways and resources for providers seeking to deepen their understanding, so clients can trust they’re getting the care they need and deserve. 

1. Affirming care is unique to each person.

Affirming care looks different for everyone, and that holds true for LGBTQIA+ clients. 

It’s okay to ask questions. “What does affirming care mean to you? How might I support that process?” suggested Dr. Sachdej. “That will show you are interested in both understanding where they’re coming from and learning how you might be helpful because… it’s going to be different from each individual as well as between providers.”

Affirming care can also change throughout a client’s life. Each clinician agreed that coming out isn’t something that only happens once. Someone may come out to people in one sphere of their life but not in another—or they may come out gradually, over time.

People’s identities change, too. Dr. Sachdej said, “You might come out once and then maybe you learn something new about yourself, you have new experiences, and then you have to come out again… It's not linear, it's not singular, it's not codified.” 

As people learn new things about themselves, Hughes suggested “making that space and saying, ‘Do we need to change anything on your forms? What do you want me to call you today? I like the idea of continuously checking in. of, finding ways to keep yourself accountable to the type of care that you are providing.”

Rivera also reminded providers to hold yourself accountable to your biases and understanding: “This job can be so consequential and so impactful, for better or worse, and approaching somebody in an inappropriate way could be life-altering.”

2. Someone's sexuality or gender may have nothing to do with why they're seeking care.

Just because someone identifies as LGBTQIA+ doesn’t mean that’s what they want to discuss in sessions. 

“They may not be coming to you because of anything related to their sexual identity, so don’t jump to that conclusion. Don’t assume anything,“ said Rivera. “It should be client-led all the way.”

Dr. Sachdej said, “There is a connotation that affirming care, especially with this population, refers to the transitioning process, but that's not necessarily how I view it. Affirming care doesn't really have to do anything with your sexual orientation or gender identity. It's just how can you make an inviting, trusting environment?”

As Holland summarized, “100 percent of the time, LGBTQ people—we just want to be treated like everybody else.”                                                                                                                     

3. Identity is intersectional.

Providers often seek answers for how to address the intersection of gender and race. After all, many LGBTQIA+ people hold multiple identities. 

“Making sure that you’re super supportive to the person and firmly,” said Rivera, drawing on his experience treating LGBTQIA+ people of color, before emphasizing the depth of this topic and encouraging providers to learn more. These identities can come with more stressors. "How did the experiences and stresses of the person layer up to where they have come today?” 

4. Don't be afraid to visually signal your support.

It doesn’t have to be big or loud. Small visual cues can signal to clients that their sessions are safe spaces where they can share their whole selves. 

Some suggestions included having Pride flags around your office or showing pins. For people who have less contact with the rest of the community, the colors of Pride may be one of the few things they recognize. 

If you’re setting up or editing a provider profile, consider including your pronouns. In turn, try asking clients about their own pronouns and if they have a name they prefer during intake sessions. These can hint at how you approach gender identity while giving clients an opportunity to self-define from the start. Clinicians can extend this practice to other areas of their office, such as paperwork that affirms someone’s identity or ensuring that other people in the office refer to clients by the correct name.

For providers who work at organizations or on campus, Hughes—who works with emerging adults at a faith-based institution committed to the principles of social justice—shared that she strives to be visible on campus and in the LGBTQIA+ community. By showing that she is part of the community, students know they will be welcome and heard. 

5. "Authenticity and self-disclosure—a fine balance."

Mental health providers must often navigate where self-disclosure can build rapport with the client and where it blurs boundaries. For providers who identify as LGBTQIA+ themselves, disclosing their identity may show clients that they wouldn’t face judgment—especially if clients live somewhere that’s hostile to them. 

When it comes to building trust, the panel encouraged providers to show up as themselves. 

Hughes explained, “If you’re going into a situation where you’re working through your own biases or you’re aware of a difference from your client, there’s sometimes that urge to put on a [therapist] costume.” She added, “There’s no such thing as a queer therapist costume. You don’t have to be queer to serve queer people. You don’t have to dress differently or act differently. The costume can get in the way because it comes off as disingenuous and it comes off as faking it.” 

Rivera echoed that clients can always tell when someone is genuine and when they aren’t. 

“Authenticity and self-disclosure [are] a fine balance,” said Dr. Sachdej, who also reminded that providers must consider their own well-being with certain clients. 

6. Assess for risk.

As with any client, don’t forget to assess for risk and safety. “Something that I'm more aware of is safety assessing, exploring risks, and protective factors. The environment I work at is primarily residential schools, so students are coming from all over the country. They're leaving their family of origin. They're leaving their community,” said Hughes. 

She described how to help clients create safety through contingency plans. For students, she asks about reintegrating back into their hometowns after the work they do in sessions. She talks with them about finding networks, community, and medical providers who can prioritize clients’ safety. 

7. Familiarize yourself with the laws where you practice.

“If you are a provider who is either specializing in or focusing on serving the LGBTQ community, it's important to understand the political landscape, understand the laws that impact your practice, understand how documentation is used,” said Hughes. 

“The ACLU has an up-to-date and well-maintained map of various laws [and bills] in different states that can be a good jumping off point as to what am I… going to be protected in doing as a provider.”

Among the challenges providers may face include what to do if a minor has a different name and pronouns than what their parents say to use. 

It’s a complex question that includes different dimensions of safety: How do you balance making a child feel safe enough to be themselves with whether they will be unsafe if you affirm their identity in front of their parents? Other factors come into play, as well.

Be sure to research laws around consent and treating minors whose pronouns and names differ from what their caretakers “allow” them to use. Providers’ rights vary from state to state, and may also change with the client’s age.

Regardless of where you are, conversion therapy is an unethical practice. Don’t be afraid to set that boundary with parents or guardians who want therapists who will “convince” their children to change their gender or sexual orientation. 

8. Don't forget to address physical symptoms.

Engaging in therapy—whether about their gender or sexual identity or about a different topic—becomes difficult when also dealing with physical symptoms. 

Dr. Sachdej listed insomnia, trauma symptoms, and substance abuse as just a few examples of what may need to be addressed simultaneously or even before a client can engage and make progress in therapy.

Resources

• An introduction to LGBTQIA+ terminology
• National LGBTQ Task Force — Queering Faith
• The Trevor Project
• PFLAG
• The Association of LGBTQ+ Psychiatrists
• Mapping Attacks on LGBTQ Rights in U.S. State Legislatures in 2024
• Five Things Therapists Can Do When Working with LGBTQ+ Individuals
• McConnell EA, Janulis P, Phillips G 2nd, Truong R, Birkett M. Multiple Minority Stress and LGBT Community Resilience among Sexual Minority Men. Psychol Sex Orientat Gend Divers. 2018 Mar;5(1):1-12. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5846479/
• Russell, S. T., Pollitt, A. M., Li, G., & Grossman, A. H. (2018). Chosen Name Use Is Linked to Reduced Depressive Symptoms, Suicidal Ideation, and Suicidal Behavior Among Transgender Youth. The Journal of adolescent health : official publication of the Society for Adolescent Medicine, 63(4), 503–505. https://doi.org/10.1016/j.jadohealth.2018.02.003