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The recent reported suicides of gay teens including Asher Brown (13), Seth Walsh (13), Billy Lucas (15), and Tyler Clementi (18) have sparked a national debate over the problem of bullying and harassment directed at lesbian, gay, bisexual, and transgender youth. A 2009 survey of middle and high school students found that 85 percent of LGBT teens experienced being verbally harassed at school because of their sexual orientation. Nearly two-thirds experienced being harassed because of their gender expression.

Bullying is one of several factors that put immense strain on LGBT teens’ mental health. Fear of rejection from family members, anti-LGBT messages heard in places of worship and in the media, and the chronic stress associated with having a stigmatized and often hidden identity all serve to exacerbate the mental health problems affecting LGBT youth in America.

Research has demonstrated the connection between anti-LGBT messages and actions, and a young person’s mental health. Studies have established a clear link between a family’s rejection or acceptance of an LGBT young adult and that person’s long-term mental and physical health. LGBT youth as a whole are significantly more likely than their non-LGBT counterparts to experience depression, anxiety, suicidal thoughts, and substance abuse. Research has demonstrated that gay and lesbian youth are significantly more likely than heterosexuals to attempt to commit suicide—up to 40 percent more likely, according to some reports. And a recent survey found that 41 percent of transgender and gender-nonconforming respondents in the United States report having attempted suicide at some point in their lives, compared to 2 percent of the general population.

A discussion of the difficulties experienced by America’s youth in accessing effective mental health services was largely absent from the recent national debate over health care reform. Passage of the Patient Protection and Affordable Care Act of 2010 was an important victory for progressives, but few have fully recognized the law’s potential to help the thousands of young adults with mental health concerns—LGBT or not—that are struggling to find appropriate treatment.

When LGBT youth do receive treatment, it is usually through primary care providers. Age restrictions, an inability to pay for treatment, and transportation problems prevent many teenagers from being able to reach out to secondary mental health service providers. Young adults struggling with their sexual orientation or gender identity in particular may be hesitant to contact a mental health provider, fearing that their search for help may reveal their LGBT status to unsupportive parents or other family members.

Primary care providers cannot always rely on patients to reveal the nature or severity of their mental health concerns. Young adults experiencing mood disorders wait seven and a half years before seeking treatment, on average. General practitioners trained in noticing and responding to the first signs of mental health issues in LGBT youth are therefore an invaluable asset in the effort to mitigate the damaging effects of severe depression and other mental health problems that LGBT youth often experience.

There are several large structural problems that prevent the primary care system from being able to adequately meet the mental health needs of LGBT youth. These include lack of LGBT-specific training for health care providers, the limited accessibility of services, lack of financial incentives to treat LGBT youth, a failure to deal with the intersection between mental health and substance abuse issues, and a general lack of information about LGBT health needs.

This brief describes these problems and offers potential solutions that the United States Department of Health and Human Services can implement, especially in relation to the recently passed health care reform law. Many of the recommendations, if implemented, could benefit the entire LGBT population. This brief supports the findings of a previous Center for American Progress brief, “Mental Health Services in Primary Care,” which advocated for bringing mental health and primary care services together for the general public.

Health care providers are unprepared to treat LGBT youth

Many health care professionals are not trained or equipped to effectively treat vulnerable LGBT youth. A majority of medical school curricula include no information about LGBT issues, and most public health school programs only mention population diversity in sexual orientation and gender identity when discussing HIV/ AIDS. This lack of training and awareness may cause care providers to misdiagnose or underestimate the extent of emerging disorders in the LGBT population.

Poorly trained medical practitioners may even make the mistake of viewing homosexuality and gender nonconformity as illnesses that can be overcome with appropriate “reparative” therapy, further magnifying the psychological damage and personal trauma already experienced by LGBT youth and young people who experience discrimination because of their perceived gender identity or sexual orientation.

LGBT people are unlikely to fully disclose the severity of their mental health problems to medical professionals they do not perceive to be LGBT-friendly. In fact, the possibility of being discriminated against or misunderstood is enough to deter many LGBT youth and adults from seeking treatment for their mental health concerns in the first place. Establishing rigorous, LGBT-supportive cultural competency training programs for primary care providers is essential to improving provider-patient relationships so that LGBT youth can feel comfortable seeking out the help they need.

Recommendations for the U.S. Department of Health and Human Services

• Develop and disseminate a cultural-competency curricula to medical training programs that explicitly includes materials concerning LGBT patients.
• Acquire congressional funds to support medical education or continuing education programs that teach LGBT cultural competency, especially for providers who participate in public health programs such as Medicaid.
• Develop LGBT cultural competency goals, policies, training modules, and other tools in close consultation with LGBT community stakeholders, including consumer representatives, policy and research organizations, and direct service providers such as community health centers serving the LGBT community.
• Prioritize cultural competency training for mental health students and other relevant professionals and require that educational programs receiving funding from HHS begin incorporating mandatory LGBT cultural competency into their curricula.
• Issue guidance that requires any medical facility receiving federal dollars to implement an LGBT cultural-competency training program for all staff members.
• Provide additional financial support to National Health Service Corps scholarship recipients who participate in cultural competency training around serving diverse populations, including the LGBT population.
• Require all members of the U.S. Public Health Service Commissioned Corps to undergo cultural competency training in serving diverse populations, including the LGBT community.
• Direct the Substance Abuse and Mental Health Services Administration to credential and recognize mental health training and LGBT culturalcompetency programs.

Possible solutions in the health reform law

• Section 5301 provides primary care training programs and can prioritize programs that provide LGBT-inclusive cultural competency training.
• Section 5306 authorizes grants to support mental and behavioral health education and training for institutions that demonstrate that they prioritize cultural competency. These grants can target institutions that focus on developing LGBT-inclusive programs.
• Section 5307 expands the cultural competency of mental health workforces through research and demonstration projects; LGBT-specific components can be part of this work.

Lack of access to mental health services and workers

Access to mental health specialists and experts is a critical first step in treating people with mental health issues; increased numbers of psychiatrists, psychologists, and social workers per capita in a state typically result in lowered rates of suicide. Yet the United States is currently facing a shortage of primary care and mental health professionals, forcing many patients with mental health concerns to go without adequate treatment. This is especially true in rural areas, where mental health services are chronically in short supply.

The lack of fully integrated, multidisciplinary mental health primary care teams can also lead to patients getting caught up in a complicated system of referrals and delayed appointments. Primary care providers’ inability to adequately treat mental health problems is evidenced by a trend of “carving out” mental health services from primary care and putting them under the control of secondary mental health management organizations.

The fragmentation of health services poses a major problem for LGBT youth, who often lack opportunities to contact mental health service providers and may fear that reaching out to a mental health provider will risk revealing their LGBT status to unsupportive or hostile family members. Equipping primary care providers with the tools and resources to adopt a holistic, “one-stop shop” approach to the physical and mental health of young LGBT patients is essential to ensuring that all youth are comfortable seeking professional help.

There is also a need to increase the number of LGBT medical professionals in the health care workforce. Developing an LGBT-inclusive workforce would help patients feel more comfortable discussing mental health issues related to their sexual orientation or gender identity, and allow them to more readily access necessary treatment.

Recommendations for the U.S. Department of Health and Human Services

• Expand the use of telecommunication tools in order to deliver vital mental health services to LGBT youth living in rural and underserved areas.
• Include LGBT populations in health care workforce recruiting and training initiatives focused on diversifying the workforce, including the National Health Services Corps and the U.S. Public Health Service. 6 Center for American Progress | How to Improve Mental Health Care for LGBT Youth
• Encourage states to amend age-of-consent laws in order to allow minors to receive outpatient mental health treatment without having to inform their parents.
• Direct the Bureau of Primary Health Care to fund the establishment of youthspecific health centers that are equipped to deal with a wide range of mental and physical health issues affecting young adults, as well as multidisciplinary mental health teams in primary care clinics in order to provide rapid diagnosis and treatment.

Possible solutions in the health reform law

• Section 5604 authorizes $50 million in grants to bring together primary and specialty care in community-based mental health settings. These grants can support the establishment of multipurpose mental health teams in primary care centers.
• Section 4101 requires school-based health centers to provide mental health services and allows the centers to prioritize populations that have historically faced barriers in accessing these services. LGBT youth can be considered a priority population.
• Section 5101 creates the National Health Care Workforce Commission to make recommendations on national health care workforce priorities, including workforce issues affecting special populations. These recommendations can explicitly take into account health care services of particular importance to the LGBT population, including mental health services.
• Section 5102 creates a health care workforce development grant program to support efforts to improve the diversity of regional health care workforces. These grants can target diversity programs that include LGBT professionals.
• Section 5306 provides funds for mental and behavioral health education and training grants across a broad range of professions. These can be used to implement LGBT training programs for mental health professionals.
• Section 5403 allows the federal government to use training dollars to prepare health professionals for placement in underserved areas. Preparing NHSC members to work with young LGBT people should can a component of this training.
• Section 5602 directs the secretary of HHS to establish a comprehensive methodology and criteria for designating medically underserved populations and health professional shortage areas. The LGBT population can be designated as a medically underserved population through this process.
• Section 5404, the Primary Care Extension Program, is meant to provide assistance and education to primary care providers about effective therapies, health promotion techniques, and mental health treatments. It can be utilized to prepare primary care providers to effectively serve young LGBT people.

Lack of financial incentive for treating mental health concerns

Payment mechanisms currently discourage primary care providers from spending time diagnosing and treating mental health problems—even in cases where medical professionals are adequately trained to treat LGBT patients. Visits to primary care facilities are usually very brief and involve screening for a wide variety of physical medical problems, monitoring preexisting conditions, and engaging in preventive health measures. This forces doctors to engage in a quick and cursory search for signs of mental health issues. Primary care physicians often end up treating the physical symptoms of mental illnesses while failing to deal with their underlying causes. Providing primary care physicians with adequate financial incentives for thoroughly identifying and treating mental health problems would streamline the provision of health services and minimize the need for patients to visit secondary mental health service providers.

Recommendations for the U.S. Department of Health and Human Services

• Provide financial reimbursement for mental health prevention and screening services with a focus on reaching at-risk LGBT youth.
• Review and streamline widely varying interpretations of reimbursement policies and allowable services, and publicize any clarifications to all service providers.
• Encourage states to implement policies for adequate reimbursement of telemedicine mental health services. 8 Center for American Progress | How to Improve Mental Health Care for LGBT Youth
• Improve public-sector contract and private-sector reimbursement systems for the adoption of quality standards and quality improvement programs.

Possible solutions in the health reform law

• Section 5606 provides state grants to care providers that serve high percentages of medically underserved populations. HHS can provide guidance to states that these grants should focus on care centers that deliver mental health services to LGBT youth.
• Section 10322 establishes a quality-measure reporting program for inpatient psychiatric hospitals. This can be used to link payment to quality outcomes and to provide inpatient and outpatient mental health professionals with incentives for delivering quality mental health care.
• Section 10322 establishes a quality measure reporting system for inpatient psychiatric hospitals. This and other PPACA requirements for public performance reporting provide the basis for requiring additional financial reimbursement for high-quality mental health services. Performance and standards related to LGBT youth services can be prioritized.

Need to integrate mental health services and substance abuse treatment

Some LGBT youth turn to tobacco, alcohol, and drug use to cope with the social stigma and stress. Substance abuse in the LGBT population is reported at disproportionately higher numbers than in the non-LGBT population. Primary care providers must recognize the link between mental health problems and substance abuse for LGBT youth and tailor their treatment to deal with the interrelated nature of physical and mental health problems.

Recommendations for the U.S. Department of Health and Human Services

• Adopt a “no wrong door” approach to dual-diagnosis programs. Effective dual-diagnosis programs combine mental health and substance abuse (including alcohol abuse) interventions that are tailored for the complex needs of LGBT clients with co-morbid disorders.
• Provide federal funding to support mental health and substance abuse disorder prevention services that prioritize the provision of these services to the LGBT community.

Possible solutions in the health reform law

• A number of provisions improve access to mental health and substance abuse services. These provisions should explicitly target programs that recognize the link between substance abuse and mental health problems in the LGBT community.
• Section 5306 authorizes mental and behavioral health education and training grants and requires applicants to demonstrate participation by individuals of different gender identities and diverse sexual orientations. Expansion of these grants would help encourage care providers to approach mental health and substance abuse problems among LGBT people holistically and effectively.

Lack of information about LGBT mental health needs

No major federal funding exists to support research on LGBT mental health issues, and there is a paucity of accurate and comprehensive data on the mental health needs of LGBT people. This information is needed to fully understand and overcome the obstacles that currently prevent at-risk LGBT youth from getting the help they need.

Recommendations for the U.S. Department of Health and Human Services

• Proactively engage researchers working in the field of LGBT health, both through formal application processes and via demonstrated interest in supporting LGBT health research.
• Require routine and consistent data collection on sexual orientation and gender identity on federally supported health surveys, including the National Health Interview Survey, the National Survey on Drug Use and Health, the Youth Risk Behavioral Surveillance System, and the Behavioral Risk Factor Surveillance System.
• Support appropriate and anonymous collection of information on the sexual orientation and gender identity of participants in federally funded mental health and substance use programs.

Possible solutions in the health reform law

• Ensure that PPACA funding for health research supports services and programs that focus on the LGBT population.
• Ensure that the Patient-Centered Outcomes Research Institute considers the mental health needs of LGBT people in its recommendations.
• Explicitly include LGBT stakeholders in advisory groups and processes that influence the future of mental health services research.
• Section 4302 allows the Secretary of HHS to designate health disparity populations as “priority populations” for improved data collection. The LGBT population can be included as a priority population for enhanced data collection on health disparities under this section.

Conclusion

The recent string of highly publicized suicides by gay teenagers highlights the importance of improving the quality and accessibility of mental health services for LGBT youth. It is not indicative of a new trend in the LGBT community, however. Disproportionately high rates of suicide have been an underreported reality for LGBT youth for decades.

A tremendous amount of work remains to be done to combat the daunting and unacceptable rates of depression, anxiety, and substance abuse that LGBT teens experience. Focusing on enhancing the effectiveness of primary care and related services is the most effective way of improving mental health services for at-risk LGBT youth in the near term.

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Carlos Maza is an intern with LGBT Progress and Jeff Krehely is the Director of the LGBT Research and Communications Project at American Progress.

See also:

• Providing a Lifeline for LGBT Youth by Carlos Maza