*This blog summarizes key points discussed during Myriad Neuroscience’s June 23, 2021 Webinar: Coming Out as Hate Awaits: The Impact on LGBTQ+ Mental Health

	Brandon Wolf – a nationally recognized advocate for LGBTQ+ issues and gun violence prevention; and survivor of the Pulse Nightclub mass shooting in 2016
	Debbie Thomas, EdD, APRN, PMHCNS-BC, PMHNP-BC, CMP – emeritus professor at University of Louisville School of Nursing; owner and medical director of Here & Now Psychiatric Services in Louisville, Ken.
	Antar T. Bush, LCSW, MPH – director of health communications at OUTPour Productions, LLC in Atlanta, Ga.

For Brandon Wolf, the challenges of living as LGBTQ+ individual, particularly as a person of color, were experienced well before surviving a mass shooting that targeted a well-known LGBTQ+ safe space in 2016.

What happened at Pulse is what we’ve been afraid of since before the time we came out,” said Wolf. “The reason that we carve out safe spaces, the reason that we have special bars, the reason that we look for restaurants with the rainbow flag in the window is because we’re afraid that in spaces where other people are, there’s going to be someone waiting around the corner to throw a fist, to throw a glass or worse.”

Physical violence is just one example of the hate directed toward people who identify or are perceived as being lesbian, gay, bisexual, transgender, queer or questioning (LGBTQ+). Fear as an LGBTQ+ person can stem from the threat of homophobic slurs, rejection from family members, exclusion from certain social groups and traditions, discrimination in health care and housing, and other forms of hate directed toward people perceived as living outside of traditional gender norms.

With so much hate awaiting LGBTQ+ individuals, many struggle if, and to who, they should reveal their true selves.

This makes coming out a pivotal moment in the mental health journey of many LGBTQ+ individuals, Wolf explained.

“It is both a relief and a stressor at the same time,” he said.

Wolf explained that often LGBTQ+ people are exhausted by living as if they are acting out a character at work, school and social activities, only able to be themselves once alone.

For Antar Bush, having an initial support system from a grandparent at the time he came out was vital to his entire mental health journey. Bush explained that while coming out introduces new challenges from society around gender expression and policing, having that foundation of support helped him to know he would be okay.

However, not having the support of loved ones or the community may contribute to anxiety for individuals wanting to come out. Bush explained that people of color, especially those who grow up in communities of faith, experience another layer of cultural pressures around acceptance of LGBTQ+ people.

The Cyclical Relationship Between Trauma and Risky Behavior

Dr. Debbie Thomas shared “snapshots” of the trauma experienced by her patients, and how a lack of support from parents can compound the shame among young LGBTQ+ persons. First, these adolescents may not be able to “take off their mask” at home and fear what they can express among family. In other cases, when parents force their children to go through reparative therapy, Dr. Thomas said these adolescents may carry additional shame about their inherent feelings, plus the shame of being forced to attend appointments.

Lack of support and trauma can lead to behaviors that are detrimental to one’s overall health, according to Bush. While he had a support system to help “fill him up,” Bush saw others who came out without a support system turn to risky behaviors such as drug use or sex in search of validation.

The relationship between shame, trauma and risky behavior can be cyclical.

“There’s so much shame in sex as an LGBTQ person. There’s shame in the way we view our own bodies,” said Wolf. “I simply assumed that to be gay and to have sex meant to eventually become HIV positive, and that itself would be a death sentence, one that was deserved because that’s the community that I had chosen to be a part of.”

The Importance of Safe Spaces Along the LGBTQ+ Mental Health Journey

One element of support involves providing safe spaces where LGBTQ+ individuals can freely express themselves without fear of ridicule or harm.

“Safe spaces are lifelines,” said Wolf.

The threat of violence against LGBTQ+ people is why many in the community seek physical locations like local LGBTQ+ centers and bars where they can be their authentic selves.

Safe spaces can exist in the relationships built within the LGBTQ+ community. When a person’s family of origin does not provide support, those LGBTQ+ individuals often find their “family of choice” through others in the LGBTQ+ community who help them feel welcome and accepted for who they are.

Dr. Thomas added that it is equally important for healthcare providers to treat, educate and advocate for their LGBTQ+ patients.

“It’s always important to respect in other people what we cannot see,” said Thomas. “I don’t know what you’re bringing into the room…I don’t know what’s there until I ask. I think it’s important to never assume that because someone looks put together and talks well that they’re not really suffering.”

Safe spaces can be especially important for transgender individuals because they may experience additional layers of trauma. Transgender people can go through the coming out process twice, or even three times, according to Bush. Often, transgender people may first come out as lesbian, gay or bisexual in their journey, then later come out as transgender.

Bush explained that transgender patients may struggle to find healthcare providers who affirm their transgender identity when seeking treatment. This underscores the need for clinicians to show understanding and empathy for their transgender patients.

How Healthcare Providers can Create Safe Spaces for LGBTQ+ Patients

Dr. Thomas suggested two areas where healthcare providers can better provide support and build safe spaces for LGBTQ+ patients: setting and behaviors.

“Setting” describes the physical spaces where a clinician provides care and interacts with a patient. Dr. Thomas noted that having a Pride flag in her waiting room and a notice on her clinic’s website that acknowledges her treatment and involvement in the LGBTQ+ community has helped reassure patients that they can feel comfortable seeking care.

“Behavior” describes how Dr. Thomas interacts with patients in inclusive ways. For example, introducing herself with preferred pronouns during a patient’s first appointment and empowering patients to share their story, but only if they are comfortable doing so.

Bush noted for healthcare providers unsure about how to treat patients in the LGBTQ+ community to simply ask for help.

“Even if you’re expected to know it, because there’s been a lot of things in this world I’ve been expected to know and I didn’t know, so you know you can ask,” said Bush.

Wolf offered advice for healthcare providers and others on how to support LGBTQ+ youth by empowering their  voices. “I have found the most success in allowing young people space to be themselves, and not trying to be their voice,” said Wolf. “When young people have space to live authentically and explore and have rich, robust dialogue with one another, and find the power in their identity, they are unstoppable.”

For more conversation about mental health and treatment in the LGBTQ+ community, view the full webinar.