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Tailored mental health awareness-raising, training and health promotion are needed to enhance psychological support for gender and sexually diverse people experiencing a high prevalence of depression, self-harm or suicide ideation.
Depression, self-inflicted injuries and suicide are leading causes of Australian disease burden, ranking fourth and sixth, respectively, for disability-adjusted life years in 2023. Although mental illness prevalence between metropolitan and regional areas is reported as similar, incidences of suicide or deliberate self-harm occur more frequently in regional Australian areas.
It is widely acknowledged that gender and sexually diverse (GSD) people face significantly higher rates of depression, self-harm and suicide compared to their cisgender and heteronormative counterparts (or those conforming to gender binary and heteronormative standards). However, there are limited data regarding these experiences of regional GSD-identifying people compared to metropolitan areas, which hampers prevention, treatment and health promotion efforts.
Obtaining research data from GSD-identifying people remains challenging due to societal stigma and discrimination leading to hesitancy and fear in disclosing sexuality or gender. Similarly, GSD people often experience invisibility or erasure in mainstream research due to assumptions of heteronormativity and gender-binary norms leading to methodological challenges in identification and representation. These concerns create significant barriers to obtaining representative samples, meaningful results or informed recommendations. Furthermore, regional areas have limited access to GSD-specific resources (community groups, health care, counselling), which restricts the ability of researchers and clinicians to engage with GSD people.
Alarming mental health disparities
Our research team developed the Safe Connections Toowoomba: connecting and supporting LGBTQIA+ communities project and report as part of a larger health and wellbeing research project with Lifeline Darling Downs and south-west Queensland. Our current study investigated a subset of survey data evaluating levels of depression and thoughts of self-harm or suicide among GSD people within a regional south-west Queensland community. One measure used within the survey was the patient health questionnaire (a diagnostic measure of major depressive disorder as per Diagnostic and statistical manual of mental disorders, 5th edition). We worked closely with local GSD community groups in study development and recruitment. Eligible participants self-identified as gender or sexually diverse, with 91 GSD people taking part in the study.
In our study, we were interested in the prevalence of depression and thoughts of self-harm or suicide and possible differences within subgroups regarding gender (trans, non-binary, cisgender) and sexuality (bisexual, pansexual, queer, lesbian, gay). Overall, 80.2% of our GSD sample revealed a high prevalence of depression (mild to severe). Across gender subgroups, trans and non-binary people reported experiencing 95.0% and 90.9% depression respectively, whereas 70.2% of sexually diverse cisgender people reported experiencing depression. Levels of clinically relevant severe depression were approximately 45% for both trans and non-binary people. Among sexuality subgroups, bisexual, pansexual and queer people reported experiencing 93.7%, 92.2% and 82.6% depression respectively (severe depression ranged from 34.8% to 42.9%). Whereas, 68.8% of gay people and 45.5% of lesbian people reported experiencing depression (severe depression 18.8% and 36.4% respectively).
Reported thoughts of self-harm or suicide in a two-week period across the sample was relatively high at 41.8%. Thirty-five per cent of trans people reported having self-harm or suicidal thoughts nearly every day, which was 3.8 and 8.1 times respectively more than non-binary and cisgender participants. Concerningly, nearly 29% of pansexual people reported having self-harm or suicidal thoughts nearly every day.
Our study aimed to highlight the vast and alarming mental health disparities experienced by GSD people who live within a regional Australian setting. These findings are particularly valuable as limited data exist for this underserved population. Although the study provided valuable insights, the sample size was modest, and care should be taken when generalising. Also, the cross-sectional research design limits the inference of causality of depression and may be susceptible to self-selection bias.
Greater support urgently needed
Our findings demonstrate disproportionately high rates and severity of depression and thoughts of self-harm and suicide. These findings signal an urgent call to action to ensure relevant human rights legislation, including the United Nations sustainable development goals, are upheld to “leave no one behind”. It is, therefore, critical to identify and address enablers and barriers to optimising mental health and wellbeing among GSD people at individual, GSD community and wider societal levels per Bronfenbrenner’s ecological model. As our study suggests, mental ill health was more pronounced for members of minority subgroups, with those identifying as non-binary, trans, pansexual and bisexual faring the poorest in terms of psychological wellbeing (ie, depression and thoughts of self-harm or suicide). This would suggest further marginalisation experienced by members of these subgroups within an already highly stigmatised GSD community. Parallel to this, it is important to highlight that being part of the GSD community in terms of community connectedness and pride, can serve as both protective and risk factors, and are not mutually exclusive. These negative experiences put a heightened demand on coping mechanisms among those who experience repeated discrimination and division within and outside the GSD community, with bisexual and pansexual people notably standing out in our data, who also often experience rejection and exclusion from within the GSD community, in turn contributing to heightened mental ill health risks and disparities.
Further work is urgently needed regarding prevention, health promotion, dedicated funding for specialised service provision, and awareness-raising for the broader community to promote affirming and inclusive values and practices, including enhancing training, capacity and competence for those in helping and health professions. Addressing and reducing structural barriers to health care is also essential for optimising mental health (eg, publicly available funding for gender-affirming surgery). Systemic efforts are needed in reducing stigma, discrimination and implicit bias within society, and would likely yield significant positive benefit for members of GSD communities and ameliorate salient risk factors that contribute to marginalisation and poorer mental health, especially those affected by intersectional forms of oppression. The minority stress theory and the psychological mediation framework provide useful direction to inform future health promotion and mental health supports. There also remains a strong need to focus on supporting those affected by intersectional forms of oppression, including those living in regional and rural areas, where stigma and discrimination are heightened with less available and affirming health promotion and community services to promote optimal mental health for all.
Tania Phillips is a research assistant at the University of Southern Queensland (UniSQ), with a background in psychology and a special interest in health behaviour change, priority and marginalised groups, chronic health conditions, and human immunodeficiency virus.
Dr Amy Mullens is a clinical and health psychologist and professor within the School of Psychology and Wellbeing at UniSQ. Amy is also the research team leader for Health and Equity within the Centre for Health Research at UniSQ.
Dr Annette Brömdal is an associate professor at UniSQ and leads the Sexuality and Gender Research Program team housed in the UniSQ Centre for Health Research. Their health promotion and rights research focuses on bodies, gender and sexuality through co-designing and working in partnership with LGBTQIA+ Sistergirl and Brotherboy community stakeholders.
The statements or opinions expressed in this article reflect the views of the authors and do not necessarily represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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