Pride 2018 is well underway, and as we celebrate the achievements and strides made by LGBTQ people, we must recognize that many gay men, lesbians, and transgender individuals continue to face the negative impact of societal bigotry and discrimination. This places lesbians, gay men and transgender individuals at a higher risk for mental health conditions and Substance Use Disorders (SUDs) than non-LGBTQ people. Some LGBTQ individuals experience additional discrimination and prejudice based on their race. Given the existing social stigmas around mental health conditions and SUD, LGBTQ people who seek mental health or SUD treatment may need extra support in navigating these stigmas.
The Affordable Care Act (ACA) extended protections to ensure access to mental health and SUD treatment by amending the 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) to include individual as well as group insurance coverage. Behavioral health parity requires that most health insurers, including many Medicaid and CHIP plans, cover behavioral health treatment (the term “behavioral health” generally includes both mental health and SUD treatment) at equal levels to physical health treatment. Previously, health insurance companies covered behavioral health services at lower rates (or not at all) compared to physical health coverage. Now, all plans subject to the federal parity law must cover inpatient and outpatient in-network and out-of-network services, emergency care, prescription drugs and other behavioral health services, equally to physical health services.
Behavioral health parity is vital for LGBTQ individuals. Studies show that they face disproportionately higher rates of behavioral health conditions. For example:
- An estimated 20 – 30 percent of LGBTQ people have a substance use disorder and 25 percent have an alcohol use disorder, compared to approximately 10 percent of the general population;
- The risk of depression and anxiety is 1.5 times higherfor lesbian, gay men, and bisexual individuals than their non-LGB peers;
- The risk of experiencing any mental health condition is 3 times higher for LGBTQ individuals than their non-LGBTQ peers;
- Lesbian, gay men, and bisexual individuals of all ages are more than 2 times more likely to have attempted suicide than their non-LGB peers; and
- Transgender individuals are more than 2.5 times more likely to have attempted suicide than their non-transgender peers.
For many LGBTQ individuals, the damaging effects of discrimination and rejection start young. Family rejection of adolescents’ sexual orientation and gender expression, including punitive and traumatic reactions from parents and caregivers, is closely correlated with youth being more likely to attempt suicide, report high levels of depression, and higher incidence of illicit drug use, compared to peers from families with no or low levels of family rejection. Other risk factors, including victimization and harassment in and out of the home, such as feeling unsafe at school, further contribute to the high rates of mental health conditions among LGBTQ youth. It is therefore critical that insurers provide behavioral health parity for all ages, gender identities, and sexual orientations.
Inequities in the behavioral health of the LGBTQ people are exacerbated by disparities in, and limited access to, health care that remain despite advances made by the ACA. Lingering trauma from anti-LGBTQ discrimination, including misdiagnoses by providers who thought that being LGBTQ was a mental illness, has continued to influence hesitancies among LGBTQ community members who fear facing ignorance, discrimination, and hostility (including abuse) from providers. Consequently, LGBTQ individuals, and especially transgender people, are more likely to avoid or postpone necessary medical care out of fear of discrimination.
Even though LGBTQ people continue to face bigotry and discrimination that puts them at risk of developing mental health conditions and substance use disorders, community members continue to self-advocate and build partnerships to improve their health and the health of their community members. As the movement for LGBTQ behavioral and overall health equity continues, our society as a whole will grow stronger if our health care and political systems, at the local, state, and federal levels, advance policies supporting the specific health needs of the LGBTQ community. National Health Law Program and others are working to help create inclusive health care environments and health coverage, including our work defending transgender patients’ health rights in Wisconsin and people living with HIV/AIDS’ rights to medication in Florida, but further work on the enforcement of behavioral health parity is needed. Only when our health care and health insurance systems are affirming of everyone’s sexual orientation and gender identity, responsive to the wide variety of behavioral health needs, and sensitive to the intersectionality of people’s identities and health needs will we provide the high quality care that all people deserve.