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59
Matej Vajda1
Družbeni in strokovni izzivi pri varovanju
duševnega zdravja LGBT+ oseb
Social and professional challenges in protection
of LGBT+ people's mental health
Povzetek
Raziskave, izvedene v Sloveniji in tujini, kažejo na večjo ogroženost duševnega
zdravja LGBT+ oseb. Zato predstavlja varovanje njihovega duševnega zdravja
zahteven izziv za strokovnjake, med ostalimi tudi za psihoterapevte, ki ponujajo
raznovrstne oblike psihosocialne pomoči. Da bi dosegli boljšo kvaliteto strokovne
pomoči posameznim LGBT+ osebam, je namreč potrebno spremeniti mnogo
tudi na institucionalni in širši družbeni ravni. Pomemben pozitivni premik na
svetovni ravni je umik vseh kategorij, povezanih s transspolnimi identitetami iz
MKB-11, ter uvedba nove kategorije spolne inkongruence, v Sloveniji pa Resolu-
cija o nacionalnem programu duševnega zdravja 2018−2028, ki naj bi posredno
vplivala na LGBT+ osebe s težavami v duševnem zdravju (kot pripadnike ranlji-
vejše in pogosto socialno izključene družbene skupine), npr. s povečanjem
dostopnosti do storitev medicinske in psihosocialne pomoči ter z zakonsko
ureditvijo storitev na področju duševnega zdravja. Pri nas je podpore nevla-
dnih organizacij glede na potrebe uporabnikov znatno premalo. Legebitra in
TransAkcija sta glavni organizaciji, ki ponujata psihosocialno svetovanje LGBT+
populaciji, slednja pa je hkrati tudi edina, ki se v naši državi osredotoča izključno
na delo s transspolnimi osebami. Na ravni posamezne LGBT+ osebe, ki išče
pomoč oz. podporo, se kažejo izzivi, povezani s psihiatrično obravnavo pri
medicinskem procesu potrditve spola (medicinski tranziciji), ter predvsem
pomanjkanje ustreznega znanja strokovnjakov, ki ponujajo raznorazne oblike
psihosocialne pomoči. Na družbeni ravni predstavlja veliko težavo v vsakda-
njem življenju LGBT+ oseb (še vedno) diskriminacija, ki slabo vpliva tudi na
njihovo duševno zdravje. Eden izmed potencialno (naj)bolj stresnih dogodkov
1 Matej Vajda, mag. soc., specializant sistemske psihoterapije na Univerzi Sigmunda Freuda Dunaj - podružnica
Ljubljana, doktorski študent socialnega dela na Univerzi v Ljubljani, mvajda@gmail.com
Kairos Leto - Year
2022
Letnik - Volume
16
Številka - Number
1–2
Znanstveni prispevki - Scientific papers
6160 Družbeni in strokovni izzivi pri varovanju duševnega zdravja LGBT+ oseb Matej Vajda
Extended abstract
1. Introduction
This article aims to present some of the mental health problems experienced by
LGBT+ people and the challenges in finding strategies to solve them, especially
sources of information and various forms of psychosocial support. We focus on
this issue at the macro (socio-political or systemic), meso (organizational) and
micro (individual, personal) levels. We give special emphasis to the impact of
social discrimination regarding mental health problems and mental disorders
of LGBT+ people, the issue of appropriate professionalism in the field of psycho-
social support for LGBT+ people and the impact of the process of disclosing
sexual orientation or gender identity on the mental health of LGBT+ people.
2. Legal and systemic regulations impacting LGBT+
people – globally, in Europe and in Slovenia
2.1. Globally
The World Health Organization's 2013-2020 Mental Health Action Plan
(WHO, 2013) mentions LGBT people (among others) as more at risk of mental
health problems.
In 2018, in ICD-11 (WHO, 2019b), the WHO removed all the categories that
related to transgender identities from the chapter on mental and behavioural
disorders, and introduced new categories of sexual incongruence. This does
not mean the end of discrimination from the point of view of the majority
of society, but it is at least an official recognition that transgenderism is not
a pathology, thus abolishing the automatic responses that too often followed
an official diagnosis (e.g. institutionalization, conversion programmes, etc.)
(Transtube, 2018). The Diagnostic and Statistical Manual of Mental Disorders in
Version 5 (DSM-5; American Psychiatric Association, 2013) talks about sexual
dysphoria. For transgender people with mental disorders, any diagnosis in
medical records can reinforce stereotypes and promote pathologization (Trans-
Tube, 2018).
2.2. Europe
The European Union Agency for Fundamental Rights published a study in
2009 linking the mental health of LGBT+ people to homophobia and discri-
mination (especially by the health system) and mentioning the impact of
v življenju LGBT+ osebe pa je vsekakor razkritje spolne identitete oz. spolne
usmerjenosti svojim bližnjim ter najbližjim, še posebej staršem.
Ključne besede: LGBT+, spolna usmerjenost, spolna identiteta, transspolnost,
duševno zdravje, psihosocialna pomoč in podpora, diskriminacija,
stigmatizacija, nasilje
Abstract
Research in Slovenia and abroad shows an increased threat to the mental health
of LGBT+ people. Protecting their mental health is a challenge for various
psychosocial care professionals, including psychotherapists. In order to achieve
a better quality of professional assistance to LGBT+ individuals, a lot needs to
be changed at the institutional and wider societal level. An important positive
step in this direction is the withdrawal of all categories related to transgender
identities from ICD-11 and the introduction of a new category of sexual incon-
gruence. In Slovenia, the Resolution on the National Mental Health Programme
2018-2028 is expected to indirectly improve the lives of LGBT+ people with
mental health challenges (as a more vulnerable and often socially excluded
social group), by for instance increasing access to medical and psychosocial
care services. Also important is the legal regulation of private mental health
care. Support of the LGBT+ population by non-governmental organizations is
insufficient due to increasing needs. Legebitra and TransAkcija are the main
organizations that offer psychosocial counselling to the LGBT+ population, the
latter being the only one that focuses exclusively on working with transgender
people. At the level of a LGBT+ individual seeking help or support there are chal-
lenges associated with psychiatric treatment in the medical process of gender
confirmation (medical transition). There is also a lack of relevant knowledge
among professionals who offer various forms of psychosocial care. At the
societal level, a major problem in the daily lives of LGBT+ people is (still) discri-
mination, which also has a negative effect on their mental health. One of the
potentially more stressful events in the life of an LGBT+ person is the disclosure
of sexual identity or sexual orientation to loved ones, especially parents.
Keywords: LGBT+, sexual orientation, sexual identity, transgender, mental health,
psychosocial assistance and support, discrimination, stigmatization, violence
6160 Družbeni in strokovni izzivi pri varovanju duševnega zdravja LGBT+ oseb Matej Vajda
Extended abstract
1. Introduction
This article aims to present some of the mental health problems experienced by
LGBT+ people and the challenges in finding strategies to solve them, especially
sources of information and various forms of psychosocial support. We focus on
this issue at the macro (socio-political or systemic), meso (organizational) and
micro (individual, personal) levels. We give special emphasis to the impact of
social discrimination regarding mental health problems and mental disorders
of LGBT+ people, the issue of appropriate professionalism in the field of psycho-
social support for LGBT+ people and the impact of the process of disclosing
sexual orientation or gender identity on the mental health of LGBT+ people.
2. Legal and systemic regulations impacting LGBT+
people – globally, in Europe and in Slovenia
2.1. Globally
The World Health Organization's 2013-2020 Mental Health Action Plan
(WHO, 2013) mentions LGBT people (among others) as more at risk of mental
health problems.
In 2018, in ICD-11 (WHO, 2019b), the WHO removed all the categories that
related to transgender identities from the chapter on mental and behavioural
disorders, and introduced new categories of sexual incongruence. This does
not mean the end of discrimination from the point of view of the majority
of society, but it is at least an official recognition that transgenderism is not
a pathology, thus abolishing the automatic responses that too often followed
an official diagnosis (e.g. institutionalization, conversion programmes, etc.)
(Transtube, 2018). The Diagnostic and Statistical Manual of Mental Disorders in
Version 5 (DSM-5; American Psychiatric Association, 2013) talks about sexual
dysphoria. For transgender people with mental disorders, any diagnosis in
medical records can reinforce stereotypes and promote pathologization (Trans-
Tube, 2018).
2.2. Europe
The European Union Agency for Fundamental Rights published a study in
2009 linking the mental health of LGBT+ people to homophobia and discri-
mination (especially by the health system) and mentioning the impact of
v življenju LGBT+ osebe pa je vsekakor razkritje spolne identitete oz. spolne
usmerjenosti svojim bližnjim ter najbližjim, še posebej staršem.
Ključne besede: LGBT+, spolna usmerjenost, spolna identiteta, transspolnost,
duševno zdravje, psihosocialna pomoč in podpora, diskriminacija,
stigmatizacija, nasilje
Abstract
Research in Slovenia and abroad shows an increased threat to the mental health
of LGBT+ people. Protecting their mental health is a challenge for various
psychosocial care professionals, including psychotherapists. In order to achieve
a better quality of professional assistance to LGBT+ individuals, a lot needs to
be changed at the institutional and wider societal level. An important positive
step in this direction is the withdrawal of all categories related to transgender
identities from ICD-11 and the introduction of a new category of sexual incon-
gruence. In Slovenia, the Resolution on the National Mental Health Programme
2018-2028 is expected to indirectly improve the lives of LGBT+ people with
mental health challenges (as a more vulnerable and often socially excluded
social group), by for instance increasing access to medical and psychosocial
care services. Also important is the legal regulation of private mental health
care. Support of the LGBT+ population by non-governmental organizations is
insufficient due to increasing needs. Legebitra and TransAkcija are the main
organizations that offer psychosocial counselling to the LGBT+ population, the
latter being the only one that focuses exclusively on working with transgender
people. At the level of a LGBT+ individual seeking help or support there are chal-
lenges associated with psychiatric treatment in the medical process of gender
confirmation (medical transition). There is also a lack of relevant knowledge
among professionals who offer various forms of psychosocial care. At the
societal level, a major problem in the daily lives of LGBT+ people is (still) discri-
mination, which also has a negative effect on their mental health. One of the
potentially more stressful events in the life of an LGBT+ person is the disclosure
of sexual identity or sexual orientation to loved ones, especially parents.
Keywords: LGBT+, sexual orientation, sexual identity, transgender, mental health,
psychosocial assistance and support, discrimination, stigmatization, violence
6362 Družbeni in strokovni izzivi pri varovanju duševnega zdravja LGBT+ oseb Matej Vajda
3. Mental health of LGBT+ people -
research from abroad
LGBT+ people experience elevated levels of anxiety, depression, mood disor-
ders, suicide, behavioural disorders, self-harm, and substance abuse (e.g., McCabe
et al., 2010; Lewis, 2009; King et al., 2008; Johnson, 2007; Cochran et al., 2007;
Cochran et al., 2004; Mays and Cochran, 2001; Sandfort et al., 2001; Cochran
and Mays, 2000; Mayock et al., 2009; Skerrett, Kölves and De Leo, 2015; Sker-
rett, Kölves and De Leo, 2016). These problems are especially pronounced in
young people (Takács, 2009; Scott et al., 2004; Almeida et al., 2009; Higgins
et al., 2016).
Mental health problems are more common in LGBT+ people compared to
the general population, which may be related to their experiences of social
exclusion (Scott et al., 2004; Burgess et al., 2007; Meyer, 2003), This may also
take the form of inadequate and insufficient representation in the media, and
institutional discrimination (Pizer et al., 2012). LGBT+ people themselves believe
that they experience more psychological distress compared to the heterosexual
population (D'Augelli, 2002), they seek help from mental health professionals
more often (Sing and Shleton, 2011), despite similar levels of social support
and quality of physical health (King in McKeown, 2003). Higgins et al. (2016)
identified poorer coping strategies in LGBTI people, where mostly avoidance
is used, which can lead to poorer mental health.
According to research, one of the main sources of resilience is the support
of loved ones. Mayock et al. (2009) find that resilience and LGBT-specific
support, especially inclusive mental health services, are positive factors for
the mental health of LGBT people.
Researching the mental health of Australian LGBT population, Leonard, Lyons
and Bariola (2015) found that mental health and resilience improve with
age (for most subgroups) and that lower socio-economic status, including
unemployment, has a significant impact on mental health problems, especi-
ally for transgender people. Most of the research respondents were exposed to
harassment or abuse in the previous year because of their gender identity or
orientation, which has also been a factor in poorer mental health. The latest in
a series of Private Lives research (Hill et al., 2020) reports a significant increase in
depression and anxiety, stress, suicidal thoughts and suicide attempts compared
to the general population.
Skerrett, Kölves, and De Leo (2016; 2015) find that the main factor leading
to suicide in LGBT individuals is a lack of family support (see also Bauer et
al., 2015; Trujillo et al., 2017; Moody and Smith, 2013). Other additional factors
negative experiences on mental health and increased risk of self-harm and
suicide (FRA, 2009). In 2014, FRA ranked Slovenia among European countries
with the fewest violent incidents against LGBTI+2 people per 1,000 inhabi-
tants, while data from 2019 show an increase and a shift to the middle of the
scale (FRA, 2014; FRA, 2020).
In 2017, the European Parliament voted to adopt a report with several
recommendations for gender equality in clinical treatment and rese-
arch, including specific provisions on the mental health and well-being of
LGBTI people, in particular on tailored support and services. The report also
mentions the problem of intersectional discrimination (ILGA-Europe, 2017c).
2.3. Slovenia
In the Resolution on the National Mental Health Programme 2018−2028
(ReNPDZ18–28, 2018), there is no explicit mention of LGBT+ people, but only
of “all residents”. There is however mention of more vulnerable groups and
"... socially excluded groups, such as people with mental disorders ..." (ibid.)
– and this can be interpreted as including LGBT+ people, whether with or
without mental health problems. For them, we also find relevant the principle
of reducing inequalities in mental health. Article 7 of the Implementation of
the Principle of Equal Treatment Act (2007) states that all state bodies "... within
their competences should create conditions for equal treatment of a person
regardless of any personal circumstances."
The problem of access to mental health services is multifaceted (financial and
time aspects), and an additional specific problem of LGBT+ people in need of
psychosocial counselling is vulnerability, especially of minors under the age of
18. Longer waiting times for clinical psychologists and other sources of support
within the health care system are often also a challenge for adults, which is
why many people seek help in the private sector, which can be uncertain and
unreliable or even a risky choice due to the lack of legal regulation (Možina et
al., 2018). ReNPDZ18–28 (2018) envisages the legal regulation of psychothera-
peutic, psychological and psychosocial counselling services, but as of the recent
Action Plan 2022-2023 for the implementation of ReNPDZ18–28 (2022) this has
not yet occurred.
The Action Plan 2022-2023 for the implementation of ReNPDZ18–28 (2022)
emphasizes the need for destigmatization of children and adolescents with
mental health problems.
2 In general, in this article we use the abbreviation LGBT+, except where we follow the original and adopt the
abbreviation as it is used in the cited source (e.g. LGB, LGBT, LGBTI, LGBTIQ+ etc.)
6362 Družbeni in strokovni izzivi pri varovanju duševnega zdravja LGBT+ oseb Matej Vajda
3. Mental health of LGBT+ people -
research from abroad
LGBT+ people experience elevated levels of anxiety, depression, mood disor-
ders, suicide, behavioural disorders, self-harm, and substance abuse (e.g., McCabe
et al., 2010; Lewis, 2009; King et al., 2008; Johnson, 2007; Cochran et al., 2007;
Cochran et al., 2004; Mays and Cochran, 2001; Sandfort et al., 2001; Cochran
and Mays, 2000; Mayock et al., 2009; Skerrett, Kölves and De Leo, 2015; Sker-
rett, Kölves and De Leo, 2016). These problems are especially pronounced in
young people (Takács, 2009; Scott et al., 2004; Almeida et al., 2009; Higgins
et al., 2016).
Mental health problems are more common in LGBT+ people compared to
the general population, which may be related to their experiences of social
exclusion (Scott et al., 2004; Burgess et al., 2007; Meyer, 2003), This may also
take the form of inadequate and insufficient representation in the media, and
institutional discrimination (Pizer et al., 2012). LGBT+ people themselves believe
that they experience more psychological distress compared to the heterosexual
population (D'Augelli, 2002), they seek help from mental health professionals
more often (Sing and Shleton, 2011), despite similar levels of social support
and quality of physical health (King in McKeown, 2003). Higgins et al. (2016)
identified poorer coping strategies in LGBTI people, where mostly avoidance
is used, which can lead to poorer mental health.
According to research, one of the main sources of resilience is the support
of loved ones. Mayock et al. (2009) find that resilience and LGBT-specific
support, especially inclusive mental health services, are positive factors for
the mental health of LGBT people.
Researching the mental health of Australian LGBT population, Leonard, Lyons
and Bariola (2015) found that mental health and resilience improve with
age (for most subgroups) and that lower socio-economic status, including
unemployment, has a significant impact on mental health problems, especi-
ally for transgender people. Most of the research respondents were exposed to
harassment or abuse in the previous year because of their gender identity or
orientation, which has also been a factor in poorer mental health. The latest in
a series of Private Lives research (Hill et al., 2020) reports a significant increase in
depression and anxiety, stress, suicidal thoughts and suicide attempts compared
to the general population.
Skerrett, Kölves, and De Leo (2016; 2015) find that the main factor leading
to suicide in LGBT individuals is a lack of family support (see also Bauer et
al., 2015; Trujillo et al., 2017; Moody and Smith, 2013). Other additional factors
negative experiences on mental health and increased risk of self-harm and
suicide (FRA, 2009). In 2014, FRA ranked Slovenia among European countries
with the fewest violent incidents against LGBTI+2 people per 1,000 inhabi-
tants, while data from 2019 show an increase and a shift to the middle of the
scale (FRA, 2014; FRA, 2020).
In 2017, the European Parliament voted to adopt a report with several
recommendations for gender equality in clinical treatment and rese-
arch, including specific provisions on the mental health and well-being of
LGBTI people, in particular on tailored support and services. The report also
mentions the problem of intersectional discrimination (ILGA-Europe, 2017c).
2.3. Slovenia
In the Resolution on the National Mental Health Programme 2018−2028
(ReNPDZ18–28, 2018), there is no explicit mention of LGBT+ people, but only
of “all residents”. There is however mention of more vulnerable groups and
"... socially excluded groups, such as people with mental disorders ..." (ibid.)
– and this can be interpreted as including LGBT+ people, whether with or
without mental health problems. For them, we also find relevant the principle
of reducing inequalities in mental health. Article 7 of the Implementation of
the Principle of Equal Treatment Act (2007) states that all state bodies "... within
their competences should create conditions for equal treatment of a person
regardless of any personal circumstances."
The problem of access to mental health services is multifaceted (financial and
time aspects), and an additional specific problem of LGBT+ people in need of
psychosocial counselling is vulnerability, especially of minors under the age of
18. Longer waiting times for clinical psychologists and other sources of support
within the health care system are often also a challenge for adults, which is
why many people seek help in the private sector, which can be uncertain and
unreliable or even a risky choice due to the lack of legal regulation (Možina et
al., 2018). ReNPDZ18–28 (2018) envisages the legal regulation of psychothera-
peutic, psychological and psychosocial counselling services, but as of the recent
Action Plan 2022-2023 for the implementation of ReNPDZ18–28 (2022) this has
not yet occurred.
The Action Plan 2022-2023 for the implementation of ReNPDZ18–28 (2022)
emphasizes the need for destigmatization of children and adolescents with
mental health problems.
2 In general, in this article we use the abbreviation LGBT+, except where we follow the original and adopt the
abbreviation as it is used in the cited source (e.g. LGB, LGBT, LGBTI, LGBTIQ+ etc.)
6564 Družbeni in strokovni izzivi pri varovanju duševnega zdravja LGBT+ oseb Matej Vajda
5. LGBT+ organizations that offer psychosocial
support in Slovenia
In Slovenia, Legebitra and TransAkcija mainly offer psychosocial support to
LGBT+ people. TransAkcija is currently the only organization in Slovenia that
focuses exclusively on working with transgender people. LGBT+ organizations
use press releases and media appearances, events and various publications for
the lay and professional public to ensure the visibility and recognition of LGBT+
people in society (e.g. Grm and Markovčić, 2019; TransTube, 2018; Koletnik, Grm
and Gramc, 2016; Plahutnik Baloh, 2015; Magić in Swierszcz, 2018).
The specific challenges of working with LGBT+ people and implementing
psychosocial counselling is, according to LGBT+ organizations, mostly the need
for holistic treatment. In Slovenia there are not enough LGBT-friendly mental
health professionals (TransTube, 2018). Deficiency and inadequacy are at least
partly related to the still common cases of discrimination and inappropriate
treatment, but partly also to the consequences of the lack of legal regulation
of mental health services in Slovenia, especially non-transparency (absence of
quality criteria) and unavailability of services (prices and waiting times). Lege-
bitra has therefore published a list of (self-assessed) LGBT-friendly psychothe-
rapists (Legebitra, n.d.) on its website.
6. Psychosocial support for LGBT+ people -
lack of relevant expertise
Legebitra (TransTube, 2018) highlights a lack of LGBT-specific knowledge
among all psychosocial professionals, both clinical psychologists and psychi-
atrists, as well as in schools and centres for social work, which can lead to
additional discrimination and trauma. A common complaint of LGBT+ people
is that they first need to educate psychotherapists, even if they themselves have
come for advice (ibid.; similar to Schulman and Erickson-Schroth, 2017). There is
a lack of information about working with the LGBT+ population in the existing
curricula for mental health professionals (e.g. Perger et al., 2018).
Also in Koletnik (2019), almost 80% of the participating transgender people
expressed that mandatory participation of social workers, psychologists, social
pedagogues, etc. in transgender education would have a very positive impact
on their lives. In this study, 31% of people reported disrespectful and ineffective
treatment by a clinical psychologist, and 25% reported such treatment by
a psychiatrist. They expressed more satisfaction with the treatment by their
GP's, where more than half reported fast, respectful and effective treatment
include abuse of psychoactive substances, minority stress and related repression
and discrimination (Mereish, O’Cleirigh and Bradford, 2014; Hatzenbuehler et
al., 2015). According to a study by Mustanski, Garofal, and Emerson (2010), about
one-third of LGBT youth meet the criteria for at least one mental disorder.
The COVID-19 pandemic has also emphasized the previously underac-
knowledged problem of LGBT+ people's mental health (Salerno et al., 2020a;
Gorczynski and Fasoli, 2020): in particular their problems with coping, more
suicidal thoughts, self-harm, substance abuse (Slemon et al., 2022; Brennan et
al., 2020; Moore et al., 2021; Philips et al., 2020; Salerno et al., 2020b; Duarte
and Pereira, 2021; Fish et al., 2021; Suen, Chan and Wong, 2020), with the mental
health of young LGBT+ people particularly at risk (Salerno et al., 2020a; Salerno
et al., 2020c).
4. Research on the mental health of LGBT+
people in Slovenia
According to the survey on transsexuality in Slovenia (Koletnik, 2019), two thirds
of transgender people see their mental health as poor and very poor. More than
half of them have experience with (self-)diagnosis of depression (65%), and more
than half also have suicidal thoughts and anxiety. Self-harm is unfortunately
quite common (43%). One in three transgender people in the study reports that
they seldom have anyone to turn to for support regarding their mental health.
In a study that focused on violence against LGBTI+ children, the usual expe-
rience of an LGBTI+ child or adolescent within the national health care system
is a sense of misunderstanding; health workers lack knowledge from both
a medical and a social point of view (Urek, Jurček and Poglajen, 2020).
The educational environment is extremely dangerous for LGBT+ people, as it
is here that they experience most discrimination and violence (Koletnik, 2019;
Kuhar and Švab, 2019; Magić and Maljevac, 2016; Perger et al., 2018; Sešek and
Margon, 2021). Only one-third feel safe at school which means increasingly
frequent feelings of depression and lower levels of self-confidence (Sešek and
Margon, 2021).
Negative and stereotyped media representations of transgender people also
have a frequently cited negative impact on the mental health of transgender
people (Koletnik, 2019; Perger, Muršec and Štefanec, 2018).
6564 Družbeni in strokovni izzivi pri varovanju duševnega zdravja LGBT+ oseb Matej Vajda
5. LGBT+ organizations that offer psychosocial
support in Slovenia
In Slovenia, Legebitra and TransAkcija mainly offer psychosocial support to
LGBT+ people. TransAkcija is currently the only organization in Slovenia that
focuses exclusively on working with transgender people. LGBT+ organizations
use press releases and media appearances, events and various publications for
the lay and professional public to ensure the visibility and recognition of LGBT+
people in society (e.g. Grm and Markovčić, 2019; TransTube, 2018; Koletnik, Grm
and Gramc, 2016; Plahutnik Baloh, 2015; Magić in Swierszcz, 2018).
The specific challenges of working with LGBT+ people and implementing
psychosocial counselling is, according to LGBT+ organizations, mostly the need
for holistic treatment. In Slovenia there are not enough LGBT-friendly mental
health professionals (TransTube, 2018). Deficiency and inadequacy are at least
partly related to the still common cases of discrimination and inappropriate
treatment, but partly also to the consequences of the lack of legal regulation
of mental health services in Slovenia, especially non-transparency (absence of
quality criteria) and unavailability of services (prices and waiting times). Lege-
bitra has therefore published a list of (self-assessed) LGBT-friendly psychothe-
rapists (Legebitra, n.d.) on its website.
6. Psychosocial support for LGBT+ people -
lack of relevant expertise
Legebitra (TransTube, 2018) highlights a lack of LGBT-specific knowledge
among all psychosocial professionals, both clinical psychologists and psychi-
atrists, as well as in schools and centres for social work, which can lead to
additional discrimination and trauma. A common complaint of LGBT+ people
is that they first need to educate psychotherapists, even if they themselves have
come for advice (ibid.; similar to Schulman and Erickson-Schroth, 2017). There is
a lack of information about working with the LGBT+ population in the existing
curricula for mental health professionals (e.g. Perger et al., 2018).
Also in Koletnik (2019), almost 80% of the participating transgender people
expressed that mandatory participation of social workers, psychologists, social
pedagogues, etc. in transgender education would have a very positive impact
on their lives. In this study, 31% of people reported disrespectful and ineffective
treatment by a clinical psychologist, and 25% reported such treatment by
a psychiatrist. They expressed more satisfaction with the treatment by their
GP's, where more than half reported fast, respectful and effective treatment
include abuse of psychoactive substances, minority stress and related repression
and discrimination (Mereish, O’Cleirigh and Bradford, 2014; Hatzenbuehler et
al., 2015). According to a study by Mustanski, Garofal, and Emerson (2010), about
one-third of LGBT youth meet the criteria for at least one mental disorder.
The COVID-19 pandemic has also emphasized the previously underac-
knowledged problem of LGBT+ people's mental health (Salerno et al., 2020a;
Gorczynski and Fasoli, 2020): in particular their problems with coping, more
suicidal thoughts, self-harm, substance abuse (Slemon et al., 2022; Brennan et
al., 2020; Moore et al., 2021; Philips et al., 2020; Salerno et al., 2020b; Duarte
and Pereira, 2021; Fish et al., 2021; Suen, Chan and Wong, 2020), with the mental
health of young LGBT+ people particularly at risk (Salerno et al., 2020a; Salerno
et al., 2020c).
4. Research on the mental health of LGBT+
people in Slovenia
According to the survey on transsexuality in Slovenia (Koletnik, 2019), two thirds
of transgender people see their mental health as poor and very poor. More than
half of them have experience with (self-)diagnosis of depression (65%), and more
than half also have suicidal thoughts and anxiety. Self-harm is unfortunately
quite common (43%). One in three transgender people in the study reports that
they seldom have anyone to turn to for support regarding their mental health.
In a study that focused on violence against LGBTI+ children, the usual expe-
rience of an LGBTI+ child or adolescent within the national health care system
is a sense of misunderstanding; health workers lack knowledge from both
a medical and a social point of view (Urek, Jurček and Poglajen, 2020).
The educational environment is extremely dangerous for LGBT+ people, as it
is here that they experience most discrimination and violence (Koletnik, 2019;
Kuhar and Švab, 2019; Magić and Maljevac, 2016; Perger et al., 2018; Sešek and
Margon, 2021). Only one-third feel safe at school which means increasingly
frequent feelings of depression and lower levels of self-confidence (Sešek and
Margon, 2021).
Negative and stereotyped media representations of transgender people also
have a frequently cited negative impact on the mental health of transgender
people (Koletnik, 2019; Perger, Muršec and Štefanec, 2018).
6766 Družbeni in strokovni izzivi pri varovanju duševnega zdravja LGBT+ oseb Matej Vajda
According to the model, negative experiences - the most common being
violence, abuse, torture, harassment, contempt, exclusion, ignoring one's gender
identity and unfair treatment, discrimination and rejection (e.g. Barnett et
al., 2018; Willging, Green and Ramos, 2016) - lead to chronic stress, and this affects
the mental health of LGBT+ people (Poteat, German, and Kerrigan, 2013). Stressful
situations and hardships experienced by LGBT+ people increase the risks of
suicidal behaviour (Grossman, Park and Russell, 2016). Experiences of discri-
mination, rejection, victimization and non-recognition of an individual's sexual
identity indirectly affect the higher risk of suicidal thoughts in transgender
individuals (Testa et al., 2017; Schulman and Erickson-Schroth, 2017).
In an exclusionary environment, self-stigmatization and internalized
homophobia may develop in the long run, which can have detrimental
consequences for mental health (Walch et al., 2016; Flanders, Dobinson, and
Logie, 2015). Ryan et al. (2017) in their study found that higher levels of depression
and anxiety in people with more internalized homophobia can be reduced under
conditions of appropriately extensive support from family, friends, peers, or co-wor-
kers (see also Schulman and Erickson-Schroth, 2017). The key role of the support
of loved ones - in addition to wider social acceptance - are also emphasized by
Tebbe and Moradi (2016); Barr, Budge and Adelson (2016); Foster and Scherrer
(2014). Regarding the daily confrontation with stigma and discrimination, Kole-
tnik (2019) notes that in general health treatment, transgender people were
addressed with incorrect pronouns (50%), were asked invasive and inapprop-
riate personal questions (37%) due to their gender identity and/or sexual
expression, were called by the wrong name (35%) and received inappropriate
comments about their body or body parts (27%). Overall, 41% of transgender
people reported experiences of discrimination, violence or unequal treatment
due to gender identity and/or gender expression. The research from other
countries show similar results (e.g. Johns et al., 2019; Eisenberg et al., 2017).
Research by the American organization GLSEN (2014; 2016) shows that 55%
of LGBTIQ+ students do not feel safe at school because of their gender iden-
tity, and 38% because of their sexual expression; 74% have already experienced
verbal harassment due to their sexual orientation, and 36% have experienced
physical harassment due to their sexual identity (2014). In Slovenia, according
to Kuhar and Švab (2014), almost 30% of respondents experienced discrimina-
tion or harassment due to their sexual orientation during primary or secondary
school. Also according to research by Perger et al. (2018) 40% of respondents
have already experienced violence based on gender identity or sexual orienta-
tion in the school environment.
– although this is certainly influenced by the fact that we usually choose our own
doctors (ibid.). The Urek, Jurček and Poglajen (2020) survey highlights the need
for young people (especially transgender people) to receive more sex education
and relevant information from a medical point of view, as well as the problem
of long waiting times and a lack of specialists. With regard to the latter, the
report points out that a so-called universalist approach - apparent acceptance
(“we treat everyone the same”) - does not necessarily mean inclusive treatment.
7. The intertwining of discrimination and
mental health of LGBT+ people
To understand the personal experiences of LGBT+ people with mental health
problems, the concept of the multidimensionality of discrimination or inter-
sectional discrimination seems useful. This concept refers to the interaction of
several personal circumstances - and, as researchers point out, some stigmatized
identities may prevail over others (Kuhar, 2009). Discrimination is related to
this as a reason for the development of a mental disorder, which then leads to
new discrimination. The problem of stigma is also highlighted in research on
the daily lives of gays and lesbians (Kuhar and Švab, 2014), and the intersection
of discrimination and violence with other personal circumstances is also menti-
oned by Koletnik (2019).
The connection between discrimination and damaging the mental health
of LGBT+ people also stems from the fact that "belonging to a so-called vulne-
rable group (e.g. homosexuals, non-cissexual gender identity ...) can pose
a constant risk to such a person" (Vernik Šetinc, 2016, p. 18). Such discrimina-
tion is structural and has arisen during the historical process as a result of the
influence of prejudices and stereotypes (ibid.), which makes such discrimina-
tion also systemic - a collective decision for inequality and unwillingness to
deal with it. There is a "vicious circle in which the causes and consequences
of discrimination (e.g. low self-esteem, feelings of inferiority, mental health
problems, stress, low ambitions ...) are so intertwined that they can no longer
be separated" (ibid., p. 19).
When talking about the mental health of LGBT+ people, the so-called
minority stress is also a relevant concept: members of a stigmatized social
group, e.g. LGBT+ people, are exposed to unique and chronic additional stressors
precisely because of their minority position in society, e.g. discrimination, hara-
ssment and violence (Meyer, 2013; Lewis, 2009).
Meyer’s model of sexual minority stress (Meyer, 2003) attempts to explain
the impact of discrimination on the increased risk of suicidal behaviour.
6766 Družbeni in strokovni izzivi pri varovanju duševnega zdravja LGBT+ oseb Matej Vajda
According to the model, negative experiences - the most common being
violence, abuse, torture, harassment, contempt, exclusion, ignoring one's gender
identity and unfair treatment, discrimination and rejection (e.g. Barnett et
al., 2018; Willging, Green and Ramos, 2016) - lead to chronic stress, and this affects
the mental health of LGBT+ people (Poteat, German, and Kerrigan, 2013). Stressful
situations and hardships experienced by LGBT+ people increase the risks of
suicidal behaviour (Grossman, Park and Russell, 2016). Experiences of discri-
mination, rejection, victimization and non-recognition of an individual's sexual
identity indirectly affect the higher risk of suicidal thoughts in transgender
individuals (Testa et al., 2017; Schulman and Erickson-Schroth, 2017).
In an exclusionary environment, self-stigmatization and internalized
homophobia may develop in the long run, which can have detrimental
consequences for mental health (Walch et al., 2016; Flanders, Dobinson, and
Logie, 2015). Ryan et al. (2017) in their study found that higher levels of depression
and anxiety in people with more internalized homophobia can be reduced under
conditions of appropriately extensive support from family, friends, peers, or co-wor-
kers (see also Schulman and Erickson-Schroth, 2017). The key role of the support
of loved ones - in addition to wider social acceptance - are also emphasized by
Tebbe and Moradi (2016); Barr, Budge and Adelson (2016); Foster and Scherrer
(2014). Regarding the daily confrontation with stigma and discrimination, Kole-
tnik (2019) notes that in general health treatment, transgender people were
addressed with incorrect pronouns (50%), were asked invasive and inapprop-
riate personal questions (37%) due to their gender identity and/or sexual
expression, were called by the wrong name (35%) and received inappropriate
comments about their body or body parts (27%). Overall, 41% of transgender
people reported experiences of discrimination, violence or unequal treatment
due to gender identity and/or gender expression. The research from other
countries show similar results (e.g. Johns et al., 2019; Eisenberg et al., 2017).
Research by the American organization GLSEN (2014; 2016) shows that 55%
of LGBTIQ+ students do not feel safe at school because of their gender iden-
tity, and 38% because of their sexual expression; 74% have already experienced
verbal harassment due to their sexual orientation, and 36% have experienced
physical harassment due to their sexual identity (2014). In Slovenia, according
to Kuhar and Švab (2014), almost 30% of respondents experienced discrimina-
tion or harassment due to their sexual orientation during primary or secondary
school. Also according to research by Perger et al. (2018) 40% of respondents
have already experienced violence based on gender identity or sexual orienta-
tion in the school environment.
– although this is certainly influenced by the fact that we usually choose our own
doctors (ibid.). The Urek, Jurček and Poglajen (2020) survey highlights the need
for young people (especially transgender people) to receive more sex education
and relevant information from a medical point of view, as well as the problem
of long waiting times and a lack of specialists. With regard to the latter, the
report points out that a so-called universalist approach - apparent acceptance
(“we treat everyone the same”) - does not necessarily mean inclusive treatment.
7. The intertwining of discrimination and
mental health of LGBT+ people
To understand the personal experiences of LGBT+ people with mental health
problems, the concept of the multidimensionality of discrimination or inter-
sectional discrimination seems useful. This concept refers to the interaction of
several personal circumstances - and, as researchers point out, some stigmatized
identities may prevail over others (Kuhar, 2009). Discrimination is related to
this as a reason for the development of a mental disorder, which then leads to
new discrimination. The problem of stigma is also highlighted in research on
the daily lives of gays and lesbians (Kuhar and Švab, 2014), and the intersection
of discrimination and violence with other personal circumstances is also menti-
oned by Koletnik (2019).
The connection between discrimination and damaging the mental health
of LGBT+ people also stems from the fact that "belonging to a so-called vulne-
rable group (e.g. homosexuals, non-cissexual gender identity ...) can pose
a constant risk to such a person" (Vernik Šetinc, 2016, p. 18). Such discrimina-
tion is structural and has arisen during the historical process as a result of the
influence of prejudices and stereotypes (ibid.), which makes such discrimina-
tion also systemic - a collective decision for inequality and unwillingness to
deal with it. There is a "vicious circle in which the causes and consequences
of discrimination (e.g. low self-esteem, feelings of inferiority, mental health
problems, stress, low ambitions ...) are so intertwined that they can no longer
be separated" (ibid., p. 19).
When talking about the mental health of LGBT+ people, the so-called
minority stress is also a relevant concept: members of a stigmatized social
group, e.g. LGBT+ people, are exposed to unique and chronic additional stressors
precisely because of their minority position in society, e.g. discrimination, hara-
ssment and violence (Meyer, 2013; Lewis, 2009).
Meyer’s model of sexual minority stress (Meyer, 2003) attempts to explain
the impact of discrimination on the increased risk of suicidal behaviour.
6968 Družbeni in strokovni izzivi pri varovanju duševnega zdravja LGBT+ oseb Matej Vajda
identity, and 33% were rejected by their parents.
50% of transgender people in Slovenia are disclosed to their mothers, 42%
to their fathers (Koletnik, 2019), among gays and lesbians the figures are 75% to
mothers and 53% to fathers. Research by Perger et al. (2018) shows that 46% of
LGBTIQ+ people aged 16 to 30 are disclosed to parents or guardians. Green (2000)
reports that fathers are usually the last to find out; disclosure to the father is
also said to be the most difficult (Švab and Kuhar, 2005; similar to Pirnar, 2006).
Kuhar and Švab (2014) find that the number of positive responses to the
disclosure of sexual orientation is increasing, which may be related to careful
planning. A survey in the U.S. on the importance of parental support in disclosure
found that two-thirds of respondents experienced a positive parental response
(Rothman, 2012). The incidence of mental health problems and the rate of misuse
of various substances in this group was lower compared to respondents who
were not supported by their parents. For these, the risk of developing major
depression and the risk of alcoholism and drug abuse were much higher.
We cautiously join Kuhar (2017) in speaking about “gradual destigmatization
of homosexuality, at least in the immediate family circle” (ibid., p. 92), but the
importance of parental support in disclosure should be kept in mind, and better
education should be provided to the professional public in the field of mental
health, as well as educational institutions. The beginning of the disclosure
process in increasingly younger LGBT+ people (e.g. Koletnik, 2019) is a key phase
in the consolidation of sexual and thus personal identity, which is associated
with self-acceptance and self-esteem - and these are some of the foundations
for good mental health and the ability to cope with life challenges. Research
on the daily lives of transgender people also confirms this, as about a third of
respondents see rejection by parents or guardians as a negative factor affecting
their mental health (ibid.).
9. Using professionalism and systemic regulation
against discrimination
As elsewhere, when talking about the mental health of LGBT+ people, personal
problems of an individual are very much related to - or even originate from -
the wider society. Stigma, discrimination and trauma are always directly or
indirectly impacted by the context (Cohn, Casazza and Cottrell, 2018) in which
a person lives, is being educated or works.
The social context for LGBT+ people in Slovenia's neighbouring countries
and in Europe in general is far from friendly (examples in Italy, Hungary, Poland
and Russia). In several countries, the LGBT+ community is seen as a convenient
In the study by TransAkcija and Legebitra (2015), 69% of transgender people
reported discrimination – but, as they cautioned, we need to take into account
that “the percentage of people who have experienced discrimination is always
higher than actually reported. Many people, for example, do not label micro-
-aggression, insulting comments, whispers, ugly looks, etc. as discrimination, but
do report that they receive such treatment." (Koletnik, 2019, p. 38). Perger et
al. (2018) describe this as normalization of everyday violence.
In the Pirnar (2006) survey, 17% of respondents were victims of physical
violence, and 72% experienced verbal attacks. The research of Velikonja and
Greif (2001) and Velikonja (2004) confirms this. In the Švab and Kuhar (2005)
survey, 53% of respondents confirmed that they had been victims of violence due
to their sexual orientation, most often psychological violence (91%), physical
violence (24%) and sexual violence (6%). Women most often experienced
psychological violence, and men physical violence. The results were similar
9 years later (Kuhar and Švab, 2014).
8. The impact of coming out on the mental health
of an LGBT+ person
According to a study by Švab and Kuhar (2005), LGBT+ people most often (77%)
reveal their sexual orientation to a close circle of friends (because it is the least
stressful; Doty, 2010), followed by disclosure to the family. A similar picture is
shown by the results of the Pew Research Center (2013), where 77% of gays and
71% of lesbians came out to people close to them (a similar picture was also
shown 6 years later; Pew Research Center, 2019).
Younger LGBT+ people reveal their sexual orientation earlier and live it
more openly, while the older turn more to private circles, because it is only
there that they can live their lives in a genuine way. Most have been preparing
for disclosure for a relatively long time (Švab and Kuhar, 2005).
The pre-disclosure phase represents high psychological pressure and effort
for a LGBT+ person, which is further increased by living a double life. They feel
tense, are afraid of rejection, exclusion, humiliation, and ridicule. Coming out
means mental relief and thus improves mental health (Švab and Kuhar, 2005;
Lutes, 2007; Škorjanc, 2008; Greif, 2006).
Young LGBTIQ+ people are most often fully disclosed inside the LGBT+
community (58%), to partners (55%) and among friends (54%) – i.e. in those
types of relationships that they can choose themselves and therefore perceive as
safer (Perger et al., 2018). Koletnik (2019) finds that 36% of transgender people
experienced the ending of a friendship due to the disclosure of their sexual
6968 Družbeni in strokovni izzivi pri varovanju duševnega zdravja LGBT+ oseb Matej Vajda
identity, and 33% were rejected by their parents.
50% of transgender people in Slovenia are disclosed to their mothers, 42%
to their fathers (Koletnik, 2019), among gays and lesbians the figures are 75% to
mothers and 53% to fathers. Research by Perger et al. (2018) shows that 46% of
LGBTIQ+ people aged 16 to 30 are disclosed to parents or guardians. Green (2000)
reports that fathers are usually the last to find out; disclosure to the father is
also said to be the most difficult (Švab and Kuhar, 2005; similar to Pirnar, 2006).
Kuhar and Švab (2014) find that the number of positive responses to the
disclosure of sexual orientation is increasing, which may be related to careful
planning. A survey in the U.S. on the importance of parental support in disclosure
found that two-thirds of respondents experienced a positive parental response
(Rothman, 2012). The incidence of mental health problems and the rate of misuse
of various substances in this group was lower compared to respondents who
were not supported by their parents. For these, the risk of developing major
depression and the risk of alcoholism and drug abuse were much higher.
We cautiously join Kuhar (2017) in speaking about “gradual destigmatization
of homosexuality, at least in the immediate family circle” (ibid., p. 92), but the
importance of parental support in disclosure should be kept in mind, and better
education should be provided to the professional public in the field of mental
health, as well as educational institutions. The beginning of the disclosure
process in increasingly younger LGBT+ people (e.g. Koletnik, 2019) is a key phase
in the consolidation of sexual and thus personal identity, which is associated
with self-acceptance and self-esteem - and these are some of the foundations
for good mental health and the ability to cope with life challenges. Research
on the daily lives of transgender people also confirms this, as about a third of
respondents see rejection by parents or guardians as a negative factor affecting
their mental health (ibid.).
9. Using professionalism and systemic regulation
against discrimination
As elsewhere, when talking about the mental health of LGBT+ people, personal
problems of an individual are very much related to - or even originate from -
the wider society. Stigma, discrimination and trauma are always directly or
indirectly impacted by the context (Cohn, Casazza and Cottrell, 2018) in which
a person lives, is being educated or works.
The social context for LGBT+ people in Slovenia's neighbouring countries
and in Europe in general is far from friendly (examples in Italy, Hungary, Poland
and Russia). In several countries, the LGBT+ community is seen as a convenient
In the study by TransAkcija and Legebitra (2015), 69% of transgender people
reported discrimination – but, as they cautioned, we need to take into account
that “the percentage of people who have experienced discrimination is always
higher than actually reported. Many people, for example, do not label micro-
-aggression, insulting comments, whispers, ugly looks, etc. as discrimination, but
do report that they receive such treatment." (Koletnik, 2019, p. 38). Perger et
al. (2018) describe this as normalization of everyday violence.
In the Pirnar (2006) survey, 17% of respondents were victims of physical
violence, and 72% experienced verbal attacks. The research of Velikonja and
Greif (2001) and Velikonja (2004) confirms this. In the Švab and Kuhar (2005)
survey, 53% of respondents confirmed that they had been victims of violence due
to their sexual orientation, most often psychological violence (91%), physical
violence (24%) and sexual violence (6%). Women most often experienced
psychological violence, and men physical violence. The results were similar
9 years later (Kuhar and Švab, 2014).
8. The impact of coming out on the mental health
of an LGBT+ person
According to a study by Švab and Kuhar (2005), LGBT+ people most often (77%)
reveal their sexual orientation to a close circle of friends (because it is the least
stressful; Doty, 2010), followed by disclosure to the family. A similar picture is
shown by the results of the Pew Research Center (2013), where 77% of gays and
71% of lesbians came out to people close to them (a similar picture was also
shown 6 years later; Pew Research Center, 2019).
Younger LGBT+ people reveal their sexual orientation earlier and live it
more openly, while the older turn more to private circles, because it is only
there that they can live their lives in a genuine way. Most have been preparing
for disclosure for a relatively long time (Švab and Kuhar, 2005).
The pre-disclosure phase represents high psychological pressure and effort
for a LGBT+ person, which is further increased by living a double life. They feel
tense, are afraid of rejection, exclusion, humiliation, and ridicule. Coming out
means mental relief and thus improves mental health (Švab and Kuhar, 2005;
Lutes, 2007; Škorjanc, 2008; Greif, 2006).
Young LGBTIQ+ people are most often fully disclosed inside the LGBT+
community (58%), to partners (55%) and among friends (54%) – i.e. in those
types of relationships that they can choose themselves and therefore perceive as
safer (Perger et al., 2018). Koletnik (2019) finds that 36% of transgender people
experienced the ending of a friendship due to the disclosure of their sexual
7170 Družbeni in strokovni izzivi pri varovanju duševnega zdravja LGBT+ oseb Matej Vajda
The common and ultimate goal should be to eradicate (or, if we are more
realistic, continue reducing as much as possible) the stigma and discrimination
that are still present not only in mental health services, but in the health system
and society at large. Psychotherapists can and also should contribute to this
goal through social engagement. One of the ways is to be heard advocating the
rights of social minorities and vulnerable groups, and continuously addressing
social injustices, whether we encounter them in professional contexts or in
everyday life.
scapegoat or as the symbol of ''modern society's depravity" and thus the reason
for introducing conservative measures to strengthen "true family values". These
are also strongly linked to the Roman Catholic Church, whose attempts to
dominate the rights of gender and sexual minorities are not unfamiliar to us
in Slovenia (see Kuhar, 2015).
Society's attitude towards vulnerable groups has always been a litmus test
of democracy and freedom. Reducing discrimination in society could have
significant consequences for the mental health of LGBT+ people (e.g. Bauer
et al., 2015).
Protective and risk factors for mental health can be identified in a social
context, not only in the personal life of an LGBT+ person. The social reco-
gnition of an LGBT+ person, which is reflected in concrete social and legal
changes, enables them to feel more accepted and equal.
An LGBT+ person who seeks help due to mental health problems, but does
not receive it, due, at least in part, to their sexual orientation or gender iden-
tity (or the support provided is inappropriate, unprofessional or discrimina-
tory), experiences shock, feelings of inferiority, lower self-confidence. This
can lead to a deterioration in their mental state, which can lead to problems at
work, school, family or partnership. They usually blame themselves (e.g. Walch
et al., 2016). The spiral can lead to feelings of hopelessness and anxiety, which
often develops into depression. The consequences can be an increased risk of
alcohol and drug abuse, self-harm and suicide attempts. The prevailing medical
model in mental health systems (McIntyre et al., 2011) poses specific barriers
to LGBT+ people's access to psychosocial support and help, which they despe-
rately need and seek due to being at greater risk (e.g. Cochran, Björkenstam
and Mays, 2017).
In order to improve the current situation in the field of the overlooked social
problems of the mental health of LGBT+ people, changes are needed, especi-
ally in terms of legal and systemic solutions (see e.g. Sešek and Margon, 2021;
McIntyre et al. 2015; Leonard, Lyons and Bariola, 2015; Lewis, 2009; Bauer et
al., 2015), for example:
• introduction of identity documents with a properly identified gender;
•
systematization of education on LGBT+ topics at all levels, especially profe-
ssional staff in the field of health and social care;
•
adoption of new, more appropriate legislation, including the normative regu-
lation of psychotherapy (Možina and Bohak, 2008; Možina and Kosovel, 2017;
Možina et al., 2018ab), which would increase access (for all) to psychotherape-
utic and counselling services in the field of mental health and thus improve
acute problems with waiting times.
7170 Družbeni in strokovni izzivi pri varovanju duševnega zdravja LGBT+ oseb Matej Vajda
The common and ultimate goal should be to eradicate (or, if we are more
realistic, continue reducing as much as possible) the stigma and discrimination
that are still present not only in mental health services, but in the health system
and society at large. Psychotherapists can and also should contribute to this
goal through social engagement. One of the ways is to be heard advocating the
rights of social minorities and vulnerable groups, and continuously addressing
social injustices, whether we encounter them in professional contexts or in
everyday life.
scapegoat or as the symbol of ''modern society's depravity" and thus the reason
for introducing conservative measures to strengthen "true family values". These
are also strongly linked to the Roman Catholic Church, whose attempts to
dominate the rights of gender and sexual minorities are not unfamiliar to us
in Slovenia (see Kuhar, 2015).
Society's attitude towards vulnerable groups has always been a litmus test
of democracy and freedom. Reducing discrimination in society could have
significant consequences for the mental health of LGBT+ people (e.g. Bauer
et al., 2015).
Protective and risk factors for mental health can be identified in a social
context, not only in the personal life of an LGBT+ person. The social reco-
gnition of an LGBT+ person, which is reflected in concrete social and legal
changes, enables them to feel more accepted and equal.
An LGBT+ person who seeks help due to mental health problems, but does
not receive it, due, at least in part, to their sexual orientation or gender iden-
tity (or the support provided is inappropriate, unprofessional or discrimina-
tory), experiences shock, feelings of inferiority, lower self-confidence. This
can lead to a deterioration in their mental state, which can lead to problems at
work, school, family or partnership. They usually blame themselves (e.g. Walch
et al., 2016). The spiral can lead to feelings of hopelessness and anxiety, which
often develops into depression. The consequences can be an increased risk of
alcohol and drug abuse, self-harm and suicide attempts. The prevailing medical
model in mental health systems (McIntyre et al., 2011) poses specific barriers
to LGBT+ people's access to psychosocial support and help, which they despe-
rately need and seek due to being at greater risk (e.g. Cochran, Björkenstam
and Mays, 2017).
In order to improve the current situation in the field of the overlooked social
problems of the mental health of LGBT+ people, changes are needed, especi-
ally in terms of legal and systemic solutions (see e.g. Sešek and Margon, 2021;
McIntyre et al. 2015; Leonard, Lyons and Bariola, 2015; Lewis, 2009; Bauer et
al., 2015), for example:
• introduction of identity documents with a properly identified gender;
•
systematization of education on LGBT+ topics at all levels, especially profe-
ssional staff in the field of health and social care;
•
adoption of new, more appropriate legislation, including the normative regu-
lation of psychotherapy (Možina and Bohak, 2008; Možina and Kosovel, 2017;
Možina et al., 2018ab), which would increase access (for all) to psychotherape-
utic and counselling services in the field of mental health and thus improve
acute problems with waiting times.
7372 Družbeni in strokovni izzivi pri varovanju duševnega zdravja LGBT+ oseb Matej Vajda
podpori LGBT+ osebam ter vprašanje o vplivu procesa razkritja spolne usmer-
jenosti oz. spolne identitete na duševno zdravje LGBT+ oseb.
Članek je nastal ob naraščajočem osebnem in družbenem interesu glede
vprašanja spola in spolnosti v kontekstu duševnega zdravja, udeležbe na temat-
skih dogodkih ter pogovorih z LGBT+ osebami o temah spolne identitete, spolne
usmerjenosti in duševnega zdravja. Dodatna spodbuda pisanju pa je bilo tudi
nekaj ključnih premikov na omenjenih področjih v letu 2018: v Sloveniji
sprejetje Resolucije o nacionalnem programu duševnega zdravja 2018−2028
(v nadaljevanju ReNPDZ18–28), v svetu pa umik transspolnosti kot duševne
motnje iz 11. različice Mednarodne klasifikacije bolezni in sorodnih zdravstvenih
problemov za statistične namene (v nadaljevanju MKB-11) (WHO, 2019b).
2. Zakonske in sistemske ureditve področja LGBT+
v svetu, Evropi in Sloveniji
2.1. Svet
Akcijski načrt za duševno zdravje 2013-2020 Svetovne zdravstvene organi-
zacije (SZO; World Health Organisation – WHO, 2013) omenja, da so dolo-
čene_i posamezniki_ce4 in družbene skupine bolj izpostavljene tveganju
za težave v duševnem zdravju, in vanje prišteva tudi LGBT
5
osebe. Obenem
omenja, da morajo biti za zagotavljanje celostnih, integrativnih in odzivnih
storitev duševnega zdravja in socialne oskrbe v skupnostih tovrstne storitve
ustrezne glede na potrebe ranljivih in marginaliziranih skupin, tudi LGBT
oseb. Za implementacijo strategij promocije in preventive duševnega zdravja SZO
državam članicam predlaga ukrepe na področju preprečevanja samomorov, med
drugim z razvojem in implementacijo obširnih nacionalnih strategij s posebno
pozornostjo, namenjeno skupinam z večjim tveganjem, kamor uvrščajo tudi
LGBT osebe (WHO, 2013). V novejši, izčrpnejši različici akcijskega načrta, podalj-
šanega do leta 2030 (WHO, 2019a), SZO duševno zdravje LGBT+ oseb dodatno
naslovi kot eno od neskladij. Priporoča proaktivno identifikacijo ter ponudbo
podpore skupinam s posebnim tveganjem za duševne motnje, ki imajo slab
dostop do storitev ter naslavljanje ovir, s katerimi se soočajo pri dostopu do
obravnav, nege in podpore.
4 V članku v duhu tematike uporabljamo vključevalen, spolno nevtralen zapis sicer spolno zaznamovanih besed;
z uporabo podčrtaja med oblikama za moški in ženski spol namreč nakažemo zajem celotnega spektra različnih,
torej nebinarnih spolnih identitet (Kern in Dobrovoljc, 2017).
5 V članku načeloma uporabljamo kratico LGBT+, razen kjer sledeč izvirniku navajamo kratico, kot je uporabljena v
citiranem viru (npr. LGB, LGBT, LGBTI, LGBTIQ+ ipd.)
1. Uvod
Ob pisanju članka je bilo in je še vedno najaktualnejše družbenopolitično doga-
janje vojna v Ukrajini, ki med drugim nazorno prikazuje, kako ranljiva družbena
skupina so LGBT+ osebe. Poleg siceršnjih grozot se tudi LGBT+ osebe zaradi
ruske invazije posledično bojijo, da bodo izgubile že pred vojno priborjene
pravice (pri čemer jim je pomagala ukrajinska aspiracija po pridružitvi Evropski
uniji), še posebej v vzhodnih pro-ruskih regijah (Wareham, 2022). Obenem pa
je zaradi neenake obravnave za LGBT+ osebe oteženo tudi čezmejno gibanje
v sosednje države: Rusija, Poljska, Madžarska, Romunija ne slovijo kot LGBT+
osebam prijazna območja (Gallagher, 2022). Kakšne bodo posledice za duševno
zdravje teh ljudi, bodo pokazale raziskave v prihodnjih letih – obeti pa zagotovo
niso dobri. Ker bomo v članku veliko govorili o pomenu družbenega konte-
ksta, diskriminaciji in pravicah, se nam je zdelo smiselno in odgovorno uvod
v temo duševnega zdravja LGBT+ oseb pričeti s tem poudarkom.
Ob omenjanju duševnega zdravja in kratice LGBT+3 spomin h itro seže v (pol)
preteklo zgodovino, ko so bile istospolne usmeritve in odstopanja od hetero-
normativnosti - tako v splošni kot medicinski javnosti - razumljene kot duševne
motnje. Tudi stigmatizacija, izključevanje in nesprejemanje oseb z duševnimi
težavami še zdaleč niso izginili iz vsakdanjega življenja – niti v Sloveniji niti
drugod po svetu. Diskriminatorna stališča in predsodki so še vedno močno
prisotni v vseh življenjskih in družbenih sferah, tako o LGBT+ osebah kot
o osebah s težavami v duševnem zdravju, še posebej pa o osebah, ki se uvrščajo
v obe skupini.
Namen članka je predstaviti izzive, s katerimi se strokovnjaki na področju
duševnega zdravja pri preventivnem in kurativnem delu z LGBT+ osebami
soočamo. Zanima nas vidik pojavnosti težav v duševnem zdravju in izzivi pri
iskanju strategij za reševanje le-teh, predvsem virov informacij in raznovr-
stnih oblik psihosocialne pomoči. V ta namen se posvečamo tej problematiki
na makro (družbeno-politični oz. sistemski), mezo (organizacijski) in mikro
(individualni, osebni) ravni. Poseben poudarek namenjamo vplivu družbene
diskriminacije na duševne težave in motnje LGBT+ oseb. Dodatno izpostavljamo
še dve pomembni vprašanji: vprašanje ustrezne strokovnosti pri psihosocialni
3 S kratico LGBT+ označujemo lezbijke (L), geje (G), biseksualne (B), transspolne in transseksualne (T) osebe; plus na koncu
kratice nakazuje dodatne prve črke ostalih spolnih manjšin oz. oznak, npr. queer (Q), interseksualne (I), aseksualne
(A), panseksualne (P) itd. Gre za enotno oznako, ki pa vključuje zelo heterogeno skupino, in v zvezi z njo večinoma
govorimo o istospolnih osebah (L in G v kratici) – nanje se nanaša tudi največ raziskav. Kljub različnim pomislekom
jo zaradi enostavnosti konsistentno uporabljamo tudi v tem članku (razen na mestih, kjer drugačna uporaba izhaja
iz navajanja drugih virov), s posebnim poudarkom, da naš namen ni izključevanje ali zanemarjanje drugih spolnih
skupin ali manjšin, temveč da gre za krovni pojem (ang. umbrella term), ki označuje celotno skupnost in torej ne more
biti popolnoma brez poenostavitev ter vsaj delnega posploševanja (U niversity of California, Davis , b.d.).
7372 Družbeni in strokovni izzivi pri varovanju duševnega zdravja LGBT+ oseb Matej Vajda
podpori LGBT+ osebam ter vprašanje o vplivu procesa razkritja spolne usmer-
jenosti oz. spolne identitete na duševno zdravje LGBT+ oseb.
Članek je nastal ob naraščajočem osebnem in družbenem interesu glede
vprašanja spola in spolnosti v kontekstu duševnega zdravja, udeležbe na temat-
skih dogodkih ter pogovorih z LGBT+ osebami o temah spolne identitete, spolne
usmerjenosti in duševnega zdravja. Dodatna spodbuda pisanju pa je bilo tudi
nekaj ključnih premikov na omenjenih področjih v letu 2018: v Sloveniji
sprejetje Resolucije o nacionalnem programu duševnega zdravja 2018−2028
(v nadaljevanju ReNPDZ18–28), v svetu pa umik transspolnosti kot duševne
motnje iz 11. različice Mednarodne klasifikacije bolezni in sorodnih zdravstvenih
problemov za statistične namene (v nadaljevanju MKB-11) (WHO, 2019b).
2. Zakonske in sistemske ureditve področja LGBT+
v svetu, Evropi in Sloveniji
2.1. Svet
Akcijski načrt za duševno zdravje 2013-2020 Svetovne zdravstvene organi-
zacije (SZO; World Health Organisation – WHO, 2013) omenja, da so dolo-
čene_i posamezniki_ce4 in družbene skupine bolj izpostavljene tveganju
za težave v duševnem zdravju, in vanje prišteva tudi LGBT
5
osebe. Obenem
omenja, da morajo biti za zagotavljanje celostnih, integrativnih in odzivnih
storitev duševnega zdravja in socialne oskrbe v skupnostih tovrstne storitve
ustrezne glede na potrebe ranljivih in marginaliziranih skupin, tudi LGBT
oseb. Za implementacijo strategij promocije in preventive duševnega zdravja SZO
državam članicam predlaga ukrepe na področju preprečevanja samomorov, med
drugim z razvojem in implementacijo obširnih nacionalnih strategij s posebno
pozornostjo, namenjeno skupinam z večjim tveganjem, kamor uvrščajo tudi
LGBT osebe (WHO, 2013). V novejši, izčrpnejši različici akcijskega načrta, podalj-
šanega do leta 2030 (WHO, 2019a), SZO duševno zdravje LGBT+ oseb dodatno
naslovi kot eno od neskladij. Priporoča proaktivno identifikacijo ter ponudbo
podpore skupinam s posebnim tveganjem za duševne motnje, ki imajo slab
dostop do storitev ter naslavljanje ovir, s katerimi se soočajo pri dostopu do
obravnav, nege in podpore.
4 V članku v duhu tematike uporabljamo vključevalen, spolno nevtralen zapis sicer spolno zaznamovanih besed;
z uporabo podčrtaja med oblikama za moški in ženski spol namreč nakažemo zajem celotnega spektra različnih,
torej nebinarnih spolnih identitet (Kern in Dobrovoljc, 2017).
5 V članku načeloma uporabljamo kratico LGBT+, razen kjer sledeč izvirniku navajamo kratico, kot je uporabljena v
citiranem viru (npr. LGB, LGBT, LGBTI, LGBTIQ+ ipd.)
1. Uvod
Ob pisanju članka je bilo in je še vedno najaktualnejše družbenopolitično doga-
janje vojna v Ukrajini, ki med drugim nazorno prikazuje, kako ranljiva družbena
skupina so LGBT+ osebe. Poleg siceršnjih grozot se tudi LGBT+ osebe zaradi
ruske invazije posledično bojijo, da bodo izgubile že pred vojno priborjene
pravice (pri čemer jim je pomagala ukrajinska aspiracija po pridružitvi Evropski
uniji), še posebej v vzhodnih pro-ruskih regijah (Wareham, 2022). Obenem pa
je zaradi neenake obravnave za LGBT+ osebe oteženo tudi čezmejno gibanje
v sosednje države: Rusija, Poljska, Madžarska, Romunija ne slovijo kot LGBT+
osebam prijazna območja (Gallagher, 2022). Kakšne bodo posledice za duševno
zdravje teh ljudi, bodo pokazale raziskave v prihodnjih letih – obeti pa zagotovo
niso dobri. Ker bomo v članku veliko govorili o pomenu družbenega konte-
ksta, diskriminaciji in pravicah, se nam je zdelo smiselno in odgovorno uvod
v temo duševnega zdravja LGBT+ oseb pričeti s tem poudarkom.
Ob omenjanju duševnega zdravja in kratice LGBT+3 spomin h itro seže v (pol)
preteklo zgodovino, ko so bile istospolne usmeritve in odstopanja od hetero-
normativnosti - tako v splošni kot medicinski javnosti - razumljene kot duševne
motnje. Tudi stigmatizacija, izključevanje in nesprejemanje oseb z duševnimi
težavami še zdaleč niso izginili iz vsakdanjega življenja – niti v Sloveniji niti
drugod po svetu. Diskriminatorna stališča in predsodki so še vedno močno
prisotni v vseh življenjskih in družbenih sferah, tako o LGBT+ osebah kot
o osebah s težavami v duševnem zdravju, še posebej pa o osebah, ki se uvrščajo
v obe skupini.
Namen članka je predstaviti izzive, s katerimi se strokovnjaki na področju
duševnega zdravja pri preventivnem in kurativnem delu z LGBT+ osebami
soočamo. Zanima nas vidik pojavnosti težav v duševnem zdravju in izzivi pri
iskanju strategij za reševanje le-teh, predvsem virov informacij in raznovr-
stnih oblik psihosocialne pomoči. V ta namen se posvečamo tej problematiki
na makro (družbeno-politični oz. sistemski), mezo (organizacijski) in mikro
(individualni, osebni) ravni. Poseben poudarek namenjamo vplivu družbene
diskriminacije na duševne težave in motnje LGBT+ oseb. Dodatno izpostavljamo
še dve pomembni vprašanji: vprašanje ustrezne strokovnosti pri psihosocialni
3 S kratico LGBT+ označujemo lezbijke (L), geje (G), biseksualne (B), transspolne in transseksualne (T) osebe; plus na koncu
kratice nakazuje dodatne prve črke ostalih spolnih manjšin oz. oznak, npr. queer (Q), interseksualne (I), aseksualne
(A), panseksualne (P) itd. Gre za enotno oznako, ki pa vključuje zelo heterogeno skupino, in v zvezi z njo večinoma
govorimo o istospolnih osebah (L in G v kratici) – nanje se nanaša tudi največ raziskav. Kljub različnim pomislekom
jo zaradi enostavnosti konsistentno uporabljamo tudi v tem članku (razen na mestih, kjer drugačna uporaba izhaja
iz navajanja drugih virov), s posebnim poudarkom, da naš namen ni izključevanje ali zanemarjanje drugih spolnih
skupin ali manjšin, temveč da gre za krovni pojem (ang. umbrella term), ki označuje celotno skupnost in torej ne more
biti popolnoma brez poenostavitev ter vsaj delnega posploševanja (U niversity of California, Davis , b.d.).
7574 Družbeni in strokovni izzivi pri varovanju duševnega zdravja LGBT+ oseb Matej Vajda
•
diskriminacijo s strani zdravstvenega sistema ter označevanje spolne usmer-
jenosti za duševno motnjo oz. iskanje vzročnosti med obema pojmoma
(podobno v King in McKeown, 2003; Willging, Salvador in Kano, 2006);
•
diskriminacijo in neustrezen odnos s strani zdravstvenih delavcev,
kar lahko LGBT+ osebe "odvrne od tega, da poiščejo zdravstveno varstvo"
(FRA, 2009, str. 12) – kot primer navedejo "med strokovnjaki na področju
duševnega zdravja pogosta (hetero)seksistična stališča do spolne identitete"
(prav tam, str. 128) na Madžarskem;
•
vpliv negativnih izkušenj na duševno in telesno zdravje ter povečano tveganje
za poslabšanje duševnega zdravja, samopoškodovanja ter samomorilnosti ob
homofobiji, transfobiji, nadlegovanju ali marginalizacijam, kar vodi do višjih
stopenj "slabega duševnega zdravja, samomorov in uživanja psihoaktivnih
snovi" (prav tam), zaradi česar se LGBT+ osebe s težavami v duševnem zdravju
lahko "izogibajo iskanju zdravstvene oskrbe, tako obnašanje pa lahko samo
po sebi vodi k zdravstvenim tveganjem" (prav tam, str. 88).
Poleg tega v študiji navajajo poročila LGBT organizacij, npr. o višji stopnji depre-
sije med LGBT populacijo v Belgiji, o visokih stopnjah samopoškodovalnega
vedenja med lezbijkami in biseksualnimi ženskami v Združenem Kraljestvu
ter ugotovitve o slabšem duševnem zdravju LGBT oseb Nacionalnega inštituta
za javno zdravje na Švedskem. Študija navede tudi več deset primerov dobrih
praks iz praktično vseh v študiji sodelujočih evropskih držav, tudi slovenskih
(npr. Mirovni inštitut). FRA je izdala še več drugih poročil in študij o izzivih
LGBT oseb pri doseganju enakosti pravic, ki se vsaj posredno dotikajo tudi
teme duševnega zdravja LGBT populacije, predvsem težav z enakim dostopom
in obravnavo ter diskriminacijo. Slovenijo je FRA še leta 2014 uvrščala med
evropske države z najmanj primeri nasilnih incidentov nad LGBTI+ osebami
na 1000 prebivalcev, podatki iz leta 2019 pa kažejo povečanje ter premik na
sredino lestvice (FRA 2014; FRA 2020).
Na evropski ravni občasno prihaja do združevanja večih organizacij, ki imajo
skupen cilj. Primer tega je npr. skupna izjava 17 evropskih organizacij (med
drugim Evropskega združenja psihiatrov, Evropskega foruma pacientov, Evropske
federacije psiholoških združenj in tudi ILGA-Europe – evropske veje medna-
rodnega LGBT+ združenja), ki poziva EU in države članice k intenzivnejšemu
ukrepanju na področju duševnega zdravja v Evropi, med drugim tudi na področju
zagotavljanja enakega dostopa za ranljive skupine, vključno z LGBTI osebami
(Mental Health Europe in dr., 2017). Podobno so pri Equinet (2018), evropski mreži
teles za načelo enakosti (z organi iz osemindvajsetih držav članic), zaradi ugoto-
vitve nizke ozaveščenosti otrok in mladostnikov o njihovih pravicah, sprejeli
Na stičišču področij duševnega zdravja in transspolnosti je SZO leta 2018
v MKB-11 (ICD-11; WHO, 2019b) iz poglavja o duševnih in vedenjskih motnjah
umaknila vse kategorije, povezane s transspolnimi identitetami. Kot opozar-
jajo organizacije, aktivne na področju boja za pravice transspolnih oseb, to ne
pomeni konca diskriminacije z vidika večinske družbe, a gre vseeno vsaj za
uradno priznanje, da transspolnost ni patologija, s tem pa je ukinjen tudi avto-
matizem, ki je prepogosto sledil na podlagi te diagnoze (npr. institucionaliza-
cije, programi spreobrnitev ipd.) (Transtube, 2018). Transspolne osebe pa bodo še
vedno imele dostop do medicinskih postopkov in podpore, ki jo potrebujejo, saj
so v MKB-11 v poglavje o spolnem zdravju uvedene nove kategorije spolne
inkongruence6, kar naj bi po SZO zmanjšalo stigmo ob enaki ali celo boljši
dostopnosti do podpore (WHO, 2019b). Diagnostični in statistični priročnik
duševnih motenj v svoji 5. različici (v nadaljevanju DSM-5; American Psychiatric
Association, 2013) govori o spolni disforiji. Za transspolne osebe z duševnimi
motnjami kakršnakoli diagnoza v zdravstveni dokumentaciji lahko utrjuje
stereotipe in spodbuja patologizacijo (TransTube, 2018).
2.2. Evropa
Evropski parlament je pozval Evropsko komisijo in države članice k številnim
ukrepom za zagotavljanje enakih pravic in odpravljanje diskriminacije. Pri tem
omenja tudi duševno zdravje LGBT+ oseb, in sicer "obžaluje dejstvo, da so tran-
sseksualci v več državah članicah še vedno obravnavani kot duševno moteni"
(Resolucija Evropskega parlamenta z dne 12. decembra 2012 o razmerah na
področju temeljnih pravic v Evropski uniji (2010-2011), splošno priporočilo
98) ter "poziva države članice, naj uvedejo ali pregledajo zakonske postopke
priznavanja spola po vzoru Argentine in pregledajo pogoje (vključno s prisilno
sterilizacijo), ki veljajo za pravno priznavanje spola; poziva Komisijo in SZO, naj
motnje spolne identitete umakneta s seznama duševnih in vedenjskih motenj
ter naj pri pogajanjih o MKB-11 zagotovita ponovno nepatološko klasifikacijo"
(prav tam) - torej umik transspolnosti s seznama duševnih motenj MKB-11, kar
se je leta 2018 dejansko tudi uresničilo.
FRA - Agencija Evropske unije za temeljne pravice je leta 2009 obja-
vila študijo z naslovom Homofobija in diskriminacija na podlagi spolne
usmerjenosti in spolne identitete v državah članicah EU - Del II: Družbeni
položaj, kjer duševno zdravje LGBT+ oseb povezujejo s homofobijo in diskri-
minacijo (FRA, 2009), v kateri naštejejo:
6 Spolna inkongruenca je znatno in vztrajno neujemanje med spolom, pripisanim ob rojstvu, in spolom, ki ga oseba
čuti/izkuša kot svojega (American Psychiatric Association, 2013).
7574 Družbeni in strokovni izzivi pri varovanju duševnega zdravja LGBT+ oseb Matej Vajda
•
diskriminacijo s strani zdravstvenega sistema ter označevanje spolne usmer-
jenosti za duševno motnjo oz. iskanje vzročnosti med obema pojmoma
(podobno v King in McKeown, 2003; Willging, Salvador in Kano, 2006);
•
diskriminacijo in neustrezen odnos s strani zdravstvenih delavcev,
kar lahko LGBT+ osebe "odvrne od tega, da poiščejo zdravstveno varstvo"
(FRA, 2009, str. 12) – kot primer navedejo "med strokovnjaki na področju
duševnega zdravja pogosta (hetero)seksistična stališča do spolne identitete"
(prav tam, str. 128) na Madžarskem;
•
vpliv negativnih izkušenj na duševno in telesno zdravje ter povečano tveganje
za poslabšanje duševnega zdravja, samopoškodovanja ter samomorilnosti ob
homofobiji, transfobiji, nadlegovanju ali marginalizacijam, kar vodi do višjih
stopenj "slabega duševnega zdravja, samomorov in uživanja psihoaktivnih
snovi" (prav tam), zaradi česar se LGBT+ osebe s težavami v duševnem zdravju
lahko "izogibajo iskanju zdravstvene oskrbe, tako obnašanje pa lahko samo
po sebi vodi k zdravstvenim tveganjem" (prav tam, str. 88).
Poleg tega v študiji navajajo poročila LGBT organizacij, npr. o višji stopnji depre-
sije med LGBT populacijo v Belgiji, o visokih stopnjah samopoškodovalnega
vedenja med lezbijkami in biseksualnimi ženskami v Združenem Kraljestvu
ter ugotovitve o slabšem duševnem zdravju LGBT oseb Nacionalnega inštituta
za javno zdravje na Švedskem. Študija navede tudi več deset primerov dobrih
praks iz praktično vseh v študiji sodelujočih evropskih držav, tudi slovenskih
(npr. Mirovni inštitut). FRA je izdala še več drugih poročil in študij o izzivih
LGBT oseb pri doseganju enakosti pravic, ki se vsaj posredno dotikajo tudi
teme duševnega zdravja LGBT populacije, predvsem težav z enakim dostopom
in obravnavo ter diskriminacijo. Slovenijo je FRA še leta 2014 uvrščala med
evropske države z najmanj primeri nasilnih incidentov nad LGBTI+ osebami
na 1000 prebivalcev, podatki iz leta 2019 pa kažejo povečanje ter premik na
sredino lestvice (FRA 2014; FRA 2020).
Na evropski ravni občasno prihaja do združevanja večih organizacij, ki imajo
skupen cilj. Primer tega je npr. skupna izjava 17 evropskih organizacij (med
drugim Evropskega združenja psihiatrov, Evropskega foruma pacientov, Evropske
federacije psiholoških združenj in tudi ILGA-Europe – evropske veje medna-
rodnega LGBT+ združenja), ki poziva EU in države članice k intenzivnejšemu
ukrepanju na področju duševnega zdravja v Evropi, med drugim tudi na področju
zagotavljanja enakega dostopa za ranljive skupine, vključno z LGBTI osebami
(Mental Health Europe in dr., 2017). Podobno so pri Equinet (2018), evropski mreži
teles za načelo enakosti (z organi iz osemindvajsetih držav članic), zaradi ugoto-
vitve nizke ozaveščenosti otrok in mladostnikov o njihovih pravicah, sprejeli
Na stičišču področij duševnega zdravja in transspolnosti je SZO leta 2018
v MKB-11 (ICD-11; WHO, 2019b) iz poglavja o duševnih in vedenjskih motnjah
umaknila vse kategorije, povezane s transspolnimi identitetami. Kot opozar-
jajo organizacije, aktivne na področju boja za pravice transspolnih oseb, to ne
pomeni konca diskriminacije z vidika večinske družbe, a gre vseeno vsaj za
uradno priznanje, da transspolnost ni patologija, s tem pa je ukinjen tudi avto-
matizem, ki je prepogosto sledil na podlagi te diagnoze (npr. institucionaliza-
cije, programi spreobrnitev ipd.) (Transtube, 2018). Transspolne osebe pa bodo še
vedno imele dostop do medicinskih postopkov in podpore, ki jo potrebujejo, saj
so v MKB-11 v poglavje o spolnem zdravju uvedene nove kategorije spolne
inkongruence6, kar naj bi po SZO zmanjšalo stigmo ob enaki ali celo boljši
dostopnosti do podpore (WHO, 2019b). Diagnostični in statistični priročnik
duševnih motenj v svoji 5. različici (v nadaljevanju DSM-5; American Psychiatric
Association, 2013) govori o spolni disforiji. Za transspolne osebe z duševnimi
motnjami kakršnakoli diagnoza v zdravstveni dokumentaciji lahko utrjuje
stereotipe in spodbuja patologizacijo (TransTube, 2018).
2.2. Evropa
Evropski parlament je pozval Evropsko komisijo in države članice k številnim
ukrepom za zagotavljanje enakih pravic in odpravljanje diskriminacije. Pri tem
omenja tudi duševno zdravje LGBT+ oseb, in sicer "obžaluje dejstvo, da so tran-
sseksualci v več državah članicah še vedno obravnavani kot duševno moteni"
(Resolucija Evropskega parlamenta z dne 12. decembra 2012 o razmerah na
področju temeljnih pravic v Evropski uniji (2010-2011), splošno priporočilo
98) ter "poziva države članice, naj uvedejo ali pregledajo zakonske postopke
priznavanja spola po vzoru Argentine in pregledajo pogoje (vključno s prisilno
sterilizacijo), ki veljajo za pravno priznavanje spola; poziva Komisijo in SZO, naj
motnje spolne identitete umakneta s seznama duševnih in vedenjskih motenj
ter naj pri pogajanjih o MKB-11 zagotovita ponovno nepatološko klasifikacijo"
(prav tam) - torej umik transspolnosti s seznama duševnih motenj MKB-11, kar
se je leta 2018 dejansko tudi uresničilo.
FRA - Agencija Evropske unije za temeljne pravice je leta 2009 obja-
vila študijo z naslovom Homofobija in diskriminacija na podlagi spolne
usmerjenosti in spolne identitete v državah članicah EU - Del II: Družbeni
položaj, kjer duševno zdravje LGBT+ oseb povezujejo s homofobijo in diskri-
minacijo (FRA, 2009), v kateri naštejejo:
6 Spolna inkongruenca je znatno in vztrajno neujemanje med spolom, pripisanim ob rojstvu, in spolom, ki ga oseba
čuti/izkuša kot svojega (American Psychiatric Association, 2013).
7776 Družbeni in strokovni izzivi pri varovanju duševnega zdravja LGBT+ oseb Matej Vajda
Problem dostopnosti storitev je večplasten (finančni in časovni vidik), dodatna
specifična težava LGBT+ oseb, ki potrebujejo psihosocialno svetovanje, pa je
ranljivost, še posebej mladoletnih oseb. Tudi za polnoletne so večkrat izziv
daljše čakalne dobe pri kliničnih psihologih oz. drugih virih pomoči v okviru
zdravstvenega sistema, zaradi česar se marsikdo obrne na prosti trg, ki pa je
zaradi zakonske neurejenosti lahko negotova in nezanesljiva oz. zna biti celo
tvegana izbira (Možina in dr., 2018). ReNPDZ18–28 (2018) sicer predvideva
zakonsko ureditev psihoterapevtske in psihološke dejavnosti ter psihosocial-
nega svetovanja, do česar pa do izida Akcijskega načrta 2022-2023 za izvajanje
ReNPDZ18–28 (2022) še ni prišlo.
Pri govoru o LGBT+ osebah kot spolni in seksualni manjšini7 je potrebno
upoštevati tudi dejavnik diskriminacije – ReNPDZ18–28 (2018) poudarja, da se
»… duševno zdravje oblikuje tudi v družinah, šolah in na delovnih mestih ter
je rezultat tega, kako obravnavamo sebe in kako nas obravnavajo drugi« (prav
tam, str. 10-11). Akcijski načrt 2022-2023 za izvajanje ReNPDZ18–28 (2022)
poudarja potrebo po destigmatizaciji pri otrocih in mladostnikih s težavami
v duševnem zdravju. Ukrepi za znižanje diskriminacije, izključevanja ter
stigmatiziranja bi bili torej lahko blagodejni tudi za duševno zdravje LGBT+
oseb, še posebej mladih.
3. Tuje raziskave o duševnem zdravju LGBT+ oseb
LGBT+ osebe v povezavi z diskriminatornimi praksami, ki vključujejo fizične
in verbalne zlorabe, doživljajo povišano stopnjo anksioznosti, motenj razpolo-
ženja, samomorilnosti, samopoškodovanja ter zlorabe substanc (npr. McCabe in
dr., 2010; Lewis, 2009; King in dr., 2008; Johnson, 2007; Cochran in dr., 2007;
Cochran in dr., 2004; Mays in Cochran, 2001; Sandfort in dr., 2001; Cochran in
Mays, 2000). Težave z duševnim zdravjem so pri LGBT+ osebah pogostejše kot
v splošni populaciji, kar je morda povezano z doživljanjem izključenosti iz družbe
(Scott in dr., 2004; Burgess in dr., 2007; Meyer, 2003), tudi v obliki neustreznih
in nedovoljšnjih medijskih reprezentacij ter institucionalne diskriminacije
(Pizer in dr., 2012). LGBT+ osebe same menijo, da doživljajo več psiholoških
7 Za seksualne manjšine (ang. sexual minorities) so značilne nenormativne spolne usmerjenosti, za spolne manjšine
(ang. gender minorities) pa nenormativne spolne identitete (Suen in dr., 2020). Kot tudi glede drugih izrazov in
definicij na področju LGBT+ oseb, tudi tu ni enotnih mnenj. Nekateri menijo, da bi bilo na splošno namesto vedno
širšega nabora kratic bolj smiselno uporabljati inkluzivnejši krovni izraz seksualne in spolne manjšine (npr. Ayhan
in dr., 2020; Morgan in dr., 2020), medtem ko drugi problematizirajo izraz "seksualna manjšina" (Ginicola, Smith
in Filmore, 2017), saj se osredotoča na spolno življenje osebe, ne upošteva pa drugih vidikov. Podobno je tudi z
izrazom "spolna usmerjenost", ki ga isti avtorji ravno tako uvrščajo na seznam izrazov, ki se jim je bolje izogibati
(za zanimiv premislek o uporabi terminologije, predvsem v raziskovalne, metodološke in statistične namene, glej
Morgan in dr., 2020).
priporočila na področju enakosti spolov v izobraževanju. Poudarjajo pomembnost
aktivnega spremljanja vsebine šolskih učnih načrtov ter rednih priporočil za
odpravo diskriminatornih praks, pa tudi redna usposabljanja, pripravo gradiv
za usmerjanje in ozaveščevalne kampanje ter okrepitev zbiranja podatkov in
izvajanja raziskav.
V letu 2017 je Evropski parlament izglasoval sprejem poročila z več pripo ročili
za enakost spolov pri klinični obravnavi in raziskavah, vključno s specifičnimi
določili glede duševnega zdravja in dobrega počutja LGBTI oseb, predvsem
glede prilagojene podpore in storitev. Poročilo poziva Evropsko komisijo, države
članice ter lokalne oblasti k ustreznim ukrepom za duševno zdravje interspolnih
in transspolnih oseb, ter med drugim omenja tudi težavo intersekcijske diskri-
minacije (ILGA-Europe, 2017c).
2.3. Slovenija
V ReNPDZ18–28 (2018) avtorji sicer izrecno ne omenjajo LGBT+ oseb, govorijo
pa o "... zagotavljanju pogojev za najboljše možno duševno in telesno blagos-
tanje vseh prebivalcev ..." (prav tam, str. 4) – pri čemer verjetno lahko privza-
memo, da med "vse prebivalce" štejejo tudi LGBT+ osebe. Resolucija obenem
omenja ranljivejše skupine (kamor večinoma prištevajo otroke, mladostnike in
starejše – med katerimi seveda tudi najdemo LGBT+ osebe); ter "... socialno izklju-
čene skupine, kot so ljudje z duševnimi motnjami in drugi ..." (prav tam), kjer
tudi lahko prepoznamo vrzel, v kateri je prostor za LGBT+ osebe, bodisi s teža-
vami v duševnem zdravju ali brez njih. Akcijski načrt 2022-2023 za izvajanje
ReNPDZ18–28 (2022) prav tako eksplicitno ne omenja LGBT+ oseb.
Za LGBT+ osebe s težavami v duševnem zdravju se nam zdi relevantno
npr. načelo zmanjševanja neenakosti na področju duševnega zdravja, ki stremi
"... k zmanjševanju preprečljivih in nepravičnih razlik na področju duševnega
zdravja med različnimi skupinami prebivalstva" (prav tam, str. 11). Gre za prilož
-
nost izboljšanja kvalitete psihosocialne pomoči in oskrbe za LGBT+ popula-
cijo, že v samem smislu izboljšanja stanja splošne neenakosti. 7. člen Zakona
o uresničevanju načela enakega obravnavanja (2007) namreč pravi, da naj vsi
državni organi "... v okviru svojih pristojnosti ustvarjajo pogoje za enako obrav-
navanje osebe ne glede na katero koli osebno okoliščino".
Splošno pomembno, a še toliko bolj za LGBT+ osebe s težavami v duševnem
zdravju, je povečanje dostopnosti storitev na področju duševnega zdravja ter
zmanjšanje regionalnih razlik, saj je "... na potrebe posameznikov in skupnosti
glede duševnega zdravja mogoče kakovostno, pravočasno in vsestransko odgo-
voriti le s sestavljeno in povezano mrežo služb in storitev" (prav tam, str. 2).
7776 Družbeni in strokovni izzivi pri varovanju duševnega zdravja LGBT+ oseb Matej Vajda
Problem dostopnosti storitev je večplasten (finančni in časovni vidik), dodatna
specifična težava LGBT+ oseb, ki potrebujejo psihosocialno svetovanje, pa je
ranljivost, še posebej mladoletnih oseb. Tudi za polnoletne so večkrat izziv
daljše čakalne dobe pri kliničnih psihologih oz. drugih virih pomoči v okviru
zdravstvenega sistema, zaradi česar se marsikdo obrne na prosti trg, ki pa je
zaradi zakonske neurejenosti lahko negotova in nezanesljiva oz. zna biti celo
tvegana izbira (Možina in dr., 2018). ReNPDZ18–28 (2018) sicer predvideva
zakonsko ureditev psihoterapevtske in psihološke dejavnosti ter psihosocial-
nega svetovanja, do česar pa do izida Akcijskega načrta 2022-2023 za izvajanje
ReNPDZ18–28 (2022) še ni prišlo.
Pri govoru o LGBT+ osebah kot spolni in seksualni manjšini7 je potrebno
upoštevati tudi dejavnik diskriminacije – ReNPDZ18–28 (2018) poudarja, da se
»… duševno zdravje oblikuje tudi v družinah, šolah in na delovnih mestih ter
je rezultat tega, kako obravnavamo sebe in kako nas obravnavajo drugi« (prav
tam, str. 10-11). Akcijski načrt 2022-2023 za izvajanje ReNPDZ18–28 (2022)
poudarja potrebo po destigmatizaciji pri otrocih in mladostnikih s težavami
v duševnem zdravju. Ukrepi za znižanje diskriminacije, izključevanja ter
stigmatiziranja bi bili torej lahko blagodejni tudi za duševno zdravje LGBT+
oseb, še posebej mladih.
3. Tuje raziskave o duševnem zdravju LGBT+ oseb
LGBT+ osebe v povezavi z diskriminatornimi praksami, ki vključujejo fizične
in verbalne zlorabe, doživljajo povišano stopnjo anksioznosti, motenj razpolo-
ženja, samomorilnosti, samopoškodovanja ter zlorabe substanc (npr. McCabe in
dr., 2010; Lewis, 2009; King in dr., 2008; Johnson, 2007; Cochran in dr., 2007;
Cochran in dr., 2004; Mays in Cochran, 2001; Sandfort in dr., 2001; Cochran in
Mays, 2000). Težave z duševnim zdravjem so pri LGBT+ osebah pogostejše kot
v splošni populaciji, kar je morda povezano z doživljanjem izključenosti iz družbe
(Scott in dr., 2004; Burgess in dr., 2007; Meyer, 2003), tudi v obliki neustreznih
in nedovoljšnjih medijskih reprezentacij ter institucionalne diskriminacije
(Pizer in dr., 2012). LGBT+ osebe same menijo, da doživljajo več psiholoških
7 Za seksualne manjšine (ang. sexual minorities) so značilne nenormativne spolne usmerjenosti, za spolne manjšine
(ang. gender minorities) pa nenormativne spolne identitete (Suen in dr., 2020). Kot tudi glede drugih izrazov in
definicij na področju LGBT+ oseb, tudi tu ni enotnih mnenj. Nekateri menijo, da bi bilo na splošno namesto vedno
širšega nabora kratic bolj smiselno uporabljati inkluzivnejši krovni izraz seksualne in spolne manjšine (npr. Ayhan
in dr., 2020; Morgan in dr., 2020), medtem ko drugi problematizirajo izraz "seksualna manjšina" (Ginicola, Smith
in Filmore, 2017), saj se osredotoča na spolno življenje osebe, ne upošteva pa drugih vidikov. Podobno je tudi z
izrazom "spolna usmerjenost", ki ga isti avtorji ravno tako uvrščajo na seznam izrazov, ki se jim je bolje izogibati
(za zanimiv premislek o uporabi terminologije, predvsem v raziskovalne, metodološke in statistične namene, glej
Morgan in dr., 2020).
priporočila na področju enakosti spolov v izobraževanju. Poudarjajo pomembnost
aktivnega spremljanja vsebine šolskih učnih načrtov ter rednih priporočil za
odpravo diskriminatornih praks, pa tudi redna usposabljanja, pripravo gradiv
za usmerjanje in ozaveščevalne kampanje ter okrepitev zbiranja podatkov in
izvajanja raziskav.
V letu 2017 je Evropski parlament izglasoval sprejem poročila z več pripo ročili
za enakost spolov pri klinični obravnavi in raziskavah, vključno s specifičnimi
določili glede duševnega zdravja in dobrega počutja LGBTI oseb, predvsem
glede prilagojene podpore in storitev. Poročilo poziva Evropsko komisijo, države
članice ter lokalne oblasti k ustreznim ukrepom za duševno zdravje interspolnih
in transspolnih oseb, ter med drugim omenja tudi težavo intersekcijske diskri-
minacije (ILGA-Europe, 2017c).
2.3. Slovenija
V ReNPDZ18–28 (2018) avtorji sicer izrecno ne omenjajo LGBT+ oseb, govorijo
pa o "... zagotavljanju pogojev za najboljše možno duševno in telesno blagos-
tanje vseh prebivalcev ..." (prav tam, str. 4) – pri čemer verjetno lahko privza-
memo, da med "vse prebivalce" štejejo tudi LGBT+ osebe. Resolucija obenem
omenja ranljivejše skupine (kamor večinoma prištevajo otroke, mladostnike in
starejše – med katerimi seveda tudi najdemo LGBT+ osebe); ter "... socialno izklju-
čene skupine, kot so ljudje z duševnimi motnjami in drugi ..." (prav tam), kjer
tudi lahko prepoznamo vrzel, v kateri je prostor za LGBT+ osebe, bodisi s teža-
vami v duševnem zdravju ali brez njih. Akcijski načrt 2022-2023 za izvajanje
ReNPDZ18–28 (2022) prav tako eksplicitno ne omenja LGBT+ oseb.
Za LGBT+ osebe s težavami v duševnem zdravju se nam zdi relevantno
npr. načelo zmanjševanja neenakosti na področju duševnega zdravja, ki stremi
"... k zmanjševanju preprečljivih in nepravičnih razlik na področju duševnega
zdravja med različnimi skupinami prebivalstva" (prav tam, str. 11). Gre za prilož
-
nost izboljšanja kvalitete psihosocialne pomoči in oskrbe za LGBT+ popula-
cijo, že v samem smislu izboljšanja stanja splošne neenakosti. 7. člen Zakona
o uresničevanju načela enakega obravnavanja (2007) namreč pravi, da naj vsi
državni organi "... v okviru svojih pristojnosti ustvarjajo pogoje za enako obrav-
navanje osebe ne glede na katero koli osebno okoliščino".
Splošno pomembno, a še toliko bolj za LGBT+ osebe s težavami v duševnem
zdravju, je povečanje dostopnosti storitev na področju duševnega zdravja ter
zmanjšanje regionalnih razlik, saj je "... na potrebe posameznikov in skupnosti
glede duševnega zdravja mogoče kakovostno, pravočasno in vsestransko odgo-
voriti le s sestavljeno in povezano mrežo služb in storitev" (prav tam, str. 2).
7978 Družbeni in strokovni izzivi pri varovanju duševnega zdravja LGBT+ oseb Matej Vajda
LGBT identitete in samozavesti ter razvoj učinkovitih strategij za soočanje
s težavami), ter LGBT-specifična podpora, predvsem vključujoče storitve na
področju duševnega zdravja.
Irski LGBT organizaciji GLEN in BeLonG To sta v sodelovanju z tamkajšnjo
Nacionalno pisarno za preprečevanje samomora izvedli raziskavo o duševnem
zdravju in dobrem počutju LGBTI oseb (Higgins in dr., 2016), pri kateri je bil
poseben poudarek na kohorti najstnikov in mladih odraslih ter na učinkih manj-
šinskega stresa na duševno zdravje LGBTI oseb, vključno z izkušnjo razkritja in
diskriminacije. Glede na presenetljivo visok odziv LGBTI populaci</