Experiences of Seeking Health/Mental Health by Southern Minority Transgender and Gender Nonconforming People

Overview: This qualitative, case-study research explores the experiences of TGNC people with minority intersectional identities in the southern U.S. Results show providers had minimal awareness of actions that were detrimental to treatment; intersecting minority identities increased barriers through misunderstanding and providers' lack of acknowledgement of the importance of identities.Proposal text: Background and Purpose
Sexual and gender minority (SGM) people experience substantial mental health disparities, such as anxiety, depression, and suicide attempts and completions (SAMHSA, 2019). These disparities are more substantial in states in the southern U.S., which is likely related to the more pronounced social stigma of the SGM identity in the south (Harless et al., 2019). Although psychotherapy can be a useful tool to reduce mental health disparities for SGM people, not all therapeutic experiences are beneficial (Leitch, 2021XX). This may be more often the case in southern states due to the regionally-specific stigma (GLAAD, 2020; Hasenbush et al., 2014). This study describes perspectives of SGM people seeking mental health services in the south. The process of selecting a therapist, building trust in the therapeutic alliance, and harmful and helpful experiences are described. The purpose of this work is to make recommendations for social work practitioners and educators on best practices with SGM people, particularly in the south.

Method
This project uses a thematic, qualitative methodology and analysis aimed at creating rich and detailed data reflecting participant’s experiences. Participants (Nf15) were interviewed for an approximately one hour recorded session using a semi-structured interview guide. Questions focused on how participants chose a therapist, expectations for the therapist, positive and negative therapeutic relationship experiences, and recommendations for future therapist education. Data were analyzed into themes using three rounds of coding, moving from open coding, to clustering, then to theme-building. The lenses of both Phenomenology and Symbolic Interactionism were used as sensitizing theories.

Results
Data demonstrate a wide variety of perceptions of therapy, including positive and negative experiences. Themes center on perceptions of SGM identity in a community context, revising hopes and expectations of the therapeutic process, the symbolic meaning of religion, questions about the value of the SGM identity to self, marginalized experiences within the SGM community (particularly those of intersex and first generation U.S. citizens), and signs of hope. Of note was the consistent belief of participants that they would provide some level of SGM-specific education about their identity, and the underlying fear of hatred by the therapist.
Discussion & Implications
Findings show that many therapists engage in behaviors that are harmful to SGM people in a clinical context, such as unprofessional behavior, exoticization, misgendering, and making assumptions based on gender presentation. Therapists who were seen as “safe” were those endorsed by individual members of the SGM community, but were often not those who self-identified as SGM-affirming or members of the SGM community. Barriers of cost and availability of practitioners led many participants to repeatedly engage with therapists who were somewhat harmful. Effects of negative practices led to mistrust of therapists and failure to seek mental health care. This study acts as a call to improve services for SGM people, particularly those with salient intersectional identities such as intersex or first-generation. Increased awareness of SGM experiences and a willingness to listen to and believe clients were fundamental to positive therapeutic relationships.