June marks the month-long observance of Pride, when individuals, institutions and organizations come together to celebrate through jubilant displays of the rainbow flag, by sharing personal experiences and memories, and by demonstrating support for lesbian, gay, bisexual, transgender, questioning/queer, intersex, asexual (LGBT+) communities and allies.
Pride events, locally and around the world, revolve around themes to shape community messaging and to pass on lessons and cultural wisdom to successive generations. With its roots in the Stonewall Uprising in June 1969, the oldest Pride celebration, held in New York City, commemorates the multiday rebellion of LGBT+ activists protesting police raids and brutality. Celebrating Pride serves as a way to honor the action, through civil disobedience and civic engagement, of people who were marginalized, whose sexuality was criminalized and pathologized and, for some, whose very existence went beyond the labels and norms of the time.
New York City’s Pride March theme for 2024 is ‘Reflect. Empower. Unite.’, which prompts an interesting set of reference points: a time to look back at the hardships and accomplishments of those who came before, and an opportunity to take perspective on how to reinvest, reinvigorate and refocus efforts toward lifting and empowering the LGBT+ community.
Woven throughout the many international Pride celebrations there is great emphasis on fostering solidarity and a collective goal of achieving equality. These are not simple platitudes. Despite decades of progress, many countries and regions have experienced setbacks and recent surges of bigotry and homophobia. The Rainbow Map, produced by the International Lesbian, Gay, Bisexual, Trans, and Intersex Association (ILGA-Europe) shows the considerable heterogeneity across European countries in domains such as equality and non-discrimination and the occurrence of hate crimes and hate speech. In the United States, 2023 saw a record number of anti-LGBT+ bills introduced in the US Congress. Uganda, Kenya and Ghana have also seen new proposed legislation that criminalizes same-sex activity. Against this backdrop, international solidarity marches, such as the first coordinated continental Africa Pride 2024, have been organized to include both public gatherings and private gatherings to create safe spaces and to provide outreach and community services, including mental health support.
Reflecting on the struggle for equality requires looking at societies broadly but also looking more closely at barriers and progress within social structures and institutions. While so many LGBT+ people working in medicine and health fields have left indelible but often quiet imprints, the history of LGBT+ mental health has also been shaped by other, more visible and vocal influences.
One of the most galvanizing targets for gay activists in the late 1960s and early 1970s was challenging the classification of homosexuality as a mental illness as it was designated in the first Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association (APA) in 1952. Homosexuality, referred to as a sociopathic personality disturbance, bore with it more than social stigma — it was a ‘diagnosis’ that could cost people their livelihoods and subject them to imprisonment and institutionalization. In 1972, during a panel on homosexuality and psychiatry at an APA conference, ‘Dr. H. Anonymous’, in a wig, oversized tuxedo and rubber mask, declared, “I am a homosexual. I am a psychiatrist.” The psychiatrist in disguise was John Fryer, and the moment was instrumental in shifting the discourse that would see homosexuality as a mental disorder removed from the DSM in the following year.
Saul Levin, former CEO and medical director of the APA, shared some reflections on the role of the APA as a forum for promoting social justice and human rights. “The events around Dr. Fryer and his protest as Dr. Anonymous are important to us, not just because the APA finally came to the right position, but because the association had an honest, fact-based reckoning with the misguided idea that homosexuality is an illness. Upon [the] de-listing [of] this disorder, opponents of LGBT+ rights could no longer point to the DSM as evidence to back their discriminatory claims.”
The meaningful evolution of the APA’s stance also highlights the crucial partnership of advocacy and science. Levin suggests that “As psychiatrists, our greatest value to these movements is by promoting evidence-based information on how discrimination, structural racism and other issues affect the mental health of the various racial, ethnic and cultural communities that make up the fabric of our country. We can use our positions as clinicians and researchers to shine a light on the truth of these issues.”
Pride celebrations are propitious for making connections and reinforcing representation and inclusivity within communities and organizations. As one of the first openly gay leaders of the APA, Levin’s perspective links the past and the present. “One of the biggest lessons I have learned in my career was directly inspired by Dr. Fryer. His life and legacy, as well as my own experiences working during the HIV/AIDS epidemic, have shown me that if you are fighting for an issue that you care about, it is essential that you have a seat at the table. I have always believed in LBGT+ rights and representation, but seeing how powerful my own voice could be in a situation where an important decision was being debated cemented my view that anyone can be an unsung hero if they stand up for what they believe in. To any LGBT+ psychiatrists just starting their professional journey, I want to offer my encouragement and support — you are not alone.”
Extending the spirit of community, connection and support to the domain of LGBT+ mental health calls for embracing inclusivity and acknowledging the impact of intersectionality. By identifying the drivers of disparities, we also find the resilience and resources that come from diversity. In this issue, we include several pieces that serve as calls to action to improve LGBT+ mental health.
In their Comment, Schneider et al. discuss the challenges in research that includes Black sexually minoritized men (BSMM). BSMM are disproportionately affected by HIV globally, probably because of the intersection of factors such as racism and limited access to and quality of care. Given the existing disparities and structural barriers, the authors highlight efforts to tailor preventative and treatment interventions for BSMM that are currently lacking.
Presenting a new model in their Perspective piece, Frost and Castro identify shared mechanisms that underpin the association between stigma and mental health across various stigmatized populations, including sexual and gender minorities. The authors propose the use of this model as a framework for designing studies that involve comparative and/or intersectional approaches to target stigma and mental health.
Clinical research, especially when it involves clinical trials, is often criticized for neglecting minority groups, which leads to under-representation of sexual, gender and ethnic communities. The field of psychedelic-assisted therapy is no exception to this criticism. Hanshaw et al. discuss in their Perspective how assessing minority stress may help to elucidate the therapeutic mechanisms of psychedelic-assisted therapy and propose a theoretical framework that describes how distal minority stressors, including identity-based violence, discrimination and interpersonal stigma, affect different psychological processes and mental health outcomes.
There is still much work to be done to reduce disparities and to improve lives. Pride 2024 is a reminder that the history and future of LGBT+ mental health is the history and future of LGBT+ equality: you are not alone.
