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LGBTQ-Affirming Care in Teen Inpatient Mental Health Treatment

Written by Evolve's Behavioral Health Content Team​:

Alyson Orcena, LMFT, Melissa Vallas, MD, Shikha Verma, MD, Ellen Bloch, LCSW, Lianne Tendler, LMFT, Megan Johnston, LMFT
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Why Gender and Cultural Competence is Critical in Mental Health Support

In 2004, experts in adolescent mental health published an influential paper that identified nine components common to the most respected and highly regarded adolescent treatment programs in the country. Since then, researchers have re-examined these components and made small additions and changes. But for the most part, the components recognized as essential to top-quality treatment of adolescents for mental health, behavioral, or addiction disorders are the same now as they were in 2004, when researchers published that first paper.

These components help parents find the best residential and inpatient treatment centers for teens and set the benchmark for a new standard of care in mental health treatment for adolescents. In this article, we focus on one specific element of the top treatment programs that’s essential for offering LGBTQ+ teens seeking inpatient mental health treatment the support they need: gender and cultural competence.

Here’s a broad definition of gender and cultural competence in the context of adolescent mental health treatment.

Cultural, Spiritual, and Gender/Sexuality Competence:

The staff at adolescent treatment centers should understand and serve the needs of their entire population. All clinicians should be trained in treatment practices specific to females, males, and teens from gender/sexual and cultural/ethnic minorities.

With regards to LGBTQI+ teens who need inpatient mental health treatment, cultural competence – and make no mistake, the LGBTQI+ community is definitely its own culture within our culture – means that clinicians and staff at any treatment center should know and understand not only the challenges that LGBTQI+ teens face, but the strength it takes to live the truth of their identity in a world that too often excludes, rather than includes, that identity.

Let’s take a look at the challenges LGBTQI+ teens face, so that we may better understand the need for LGBTQI+ affirming care in mental health treatment spaces.

The Challenges LGBTQI+ Teens Face Every Day

Teens in the gender and/or sexual minority experience daily difficulty in different ways. General challenges include:


  • When an LGBTQI+ teen comes out, their friends, family, teachers, and people out in the world may not treat them well: they may experience exclusion, judgment, and ridicule.

Social isolation

  • When an LGBTQI+ teen comes out, the reactions they experience from others may cause them to withdraw – or be excluded from – from friends, family, and social situations.


  • Teens in the gender/sexual minority experience increased risk of verbal or physical online or in-person bullying and abuse from peers, teachers, or strangers on the street. LGBTQI+ teens are also at increased risk of experiencing violence and interpersonal aggression.

In addition to these challenges, which are external, LGBTQI+ teens also experienced increased rates of internal emotional, behavioral, or psychological issues. These include:

Emotional Issues

  • LGBTQI+ are at increased risk of developing depressive disorders and anxiety disorders

Substance Use and Addiction Problems

  • 20-30% of LGBTQI+ individuals experience drug addiction problems
  • 25% of LGBTQI individuals experience alcohol addiction problems

Suicidal Ideation and Suicidal Behavior

  • Suicide is a leading cause of death for LGBTQI individuals age 10-24.
  • LGBTQI youth are four times more likely to attempt suicide
  • Teens in process of questioning their gender or sexual identity are at increased risk of engaging in self-harming behaviors or suicidal behavior
  • 50% of transgender individuals report they’ve seriously considered suicide

If you’re an adult in the sexual and gender majority reading this article, we want you to look back over those two lists and put yourself in the position of an LGBTQI+ teen. This is crucial if you’re the parent of an LGBTQI+ teen.

Think back to adolescence and remember the challenges you faced. Now imagine how adolescence would have been if you had the additional challenges of facing all these impediments to daily life just because of who you were: bullying, harassment, exclusion, stigmatization, mental health issues – you get the idea.

Now you can understand exactly what we mean, and what our LGBTQI+ teens mean, when you hear this:

Being a queer kid isn’t easy, even in the 21st century.

And no: they can’t simply decide not to be queer. Living the truth of their identity is the goal – and there’s an important way we can support that goal, especially teens who need inpatient treatment for mental health, behavioral, or addiction issues: LGBTQI+ affirming care.

What is LGBTQI+ Affirming Care?

LGBTQI+ affirming care is mental health treatment and support that meets well-established criteria for gender and culture competency.

For LGBTQI+ adolescents, that means providers must understand how to tailor treatment plans that meet both those sets of needs: adolescent needs and LGBTQI+ needs.

We work with a lot of LGBTQI+ teens in our residential treatment centers, and one way we maintain a high level of cultural competency is by reading the latest research on mental health treatment in the LGBTQI+ community. We found an insightful article published by the American Psychiatric Association (APA) called Special Report: What You Should Know to Care for LGBTQ Patients by Dr. Eric Yarborough, who is himself both a member of the LGBTQI+ community and a psychiatrist.

His article mixes personal and clinical experience to make the case for creating an affirming treatment environment for LGBTQI+ people. First, he discusses the fact that many queer people have to create a false self in order to live a world where their true self would face stigma and discrimination. Living this false self can create emotional confusion, because the default situation is illogical.


“What we know is that both gender and sexuality appear to exist on a spectrum,” Dr. Yarborough says. He goes on to point out that many other human traits exist on a spectrum, as well, such as:

  • Hair color
  • Skin color
  • Eye color
  • Energy level
  • Temperament

That’s one reason coming out involves conflicting emotions. It makes no sense to have to build a false self to cover for a basic human personality trait. It also makes no sense that you have to unravel that false self to live your real self, or further, that your real self may be the object of judgment and create real world problems.

Balancing the Dominant Paradigm With Affirming Care

For instance, in some states in the U.S., you can be fired from your job for being gay. That’s not a major issue with adolescents, but it’s an example of how the gender and sexual majority can create serious, long-term problems for people not in the gender/sexual majority. In areas of the country – or in families – where there is low acceptance and tolerance for coming out, the coming out process can often involve:

  • Mood swings
  • Irritability
  • Angry outbursts
  • Isolation
  • Depression
  • Panic attacks
  • Suicide attempts

These emotions and behaviors are common to LGBTQI+ teens during their formative, exploratory, and coming-out years. In some cases, these teens develop depressive disorders, anxiety disorders, or alcohol/substance use disorders as a result of this unique combination of internal and external stressors. Some teens may need outpatient treatment, some teens may intensive outpatient or partial hospitalization, and some teens may need inpatient or residential treatment.

In all cases LGBTQI+ teens who need treatment need treatment that’s LGBTQI+ affirming.

Dr. Yarborough reiterates that the foundation of affirming care is the knowledge that “gender identity and sexual orientation fall on a spectrum.” Therefore, he says, “…it’s essential to treat each individual as just that – an individual.”

Here’s how he advises therapist to approach LGBTQI+ people who need support.

Tips: How to Offer Affirming Therapy

Mental Health First

  • Address the mental health concerns that bring the individual to treatment first:
    • Depression
    • Anxiety
    • Alcohol use
    • Substance use

Recognize the Impact of Social Norms

  • Understand that influence of our culture on our thinking, and be aware that LGBTQI+ people often feel in conflict with our cultural constructs around:
      • What it means to be a boy or a girl
      • What it means to be a man or a woman
      • How marriage is supposed to look and work
      • How relationships are supposed to look and work
      • What skills men should display at home and in the workplace
      • What skills women should display at home and in the workplace

Not Every Trans Person Want the Same Thing

  • With transgender people, follow their lead. Not every trans person wants surgery, hormones, or a name change. They need to be aware of those options, but therapists should deal with mental health issues first.

Normalize LGBTQI+ Relationships

  • With full knowledge of all of the above, it’s critical not to pathologize the LGBTQI+ experience, but rather to normalize it. This means that all issues and difficulties – especially in relationships – are not a result of LGBTQI+ identity. Everyone has problems, and everyone has issues. The simple act of normalizing queer relationships with this reframing tool can offer relief. This is critical because the dominant paradigm offers no model for LGBTQI+ relationships to follow.

LGBTQI+ Identity

  • Allow a lesbian, gay, bisexual, trans, queer, intersex, non-binary, or seeking person to be who they are on their own terms and in their own way. There’s no one way to be any of the letters – L,G,B,T,Q, or I – and once a person is secure in their version of their real self, they’ll be able to participate and fully celebrate the vast diversity of the LGBTQI+ experience.

Those are valuable insight from a person in a position to know whereof he speaks. Dr. Yarborough has been on both sides of the equation. He faced stigma when he came out as a young man, and now he helps people work through similar issues in his professional capacity as a psychiatrist.

Treatment for LGBTQI+ Teens Works

We welcome LGBTQI+ adolescents with open arms. And, as Dr. Yarborough advises, we take them as they are, one individual at a time. The integrated treatment model, which evidence indicates is the most effective approach to mental health treatment, includes support for people with:

  • Depression
  • Anxiety
  • Alcohol/Substance Use Disorder
  • Bipolar Disorder
  • Behavioral Disorders

Typical modes of therapy for an LGBTQI+ teen in an integrated treatment program include:

  • Cognitive behavioral therapy (CBT)
  • Dialectical behavior therapy (CBT)
  • Mindfulness-based cognitive behavioral therapy (MBCBT)
  • Motivational Interviewing
  • Expressive therapies (music, art, writing)
  • Experiential therapies (yoga, exercise, meditation)

When an LGBTQI+ teen experiences symptoms of a mental health disorder, it’s important for parents to arrange a full psychiatric assessment administered by a qualified mental health professional. For an LGBTQI+ teen, it’s best to find a therapist who is culturally competent and creates an affirming and accepting environment. During an evaluation, they’ll be able to diagnose the presence of any emotional, behavioral, or addiction-related disorder. In some cases, teens will need an entry level of support, such as outpatient care. In others, teens will need immersive support at the residential or inpatient level.

As Dr. Yarborough says, it’s essential to see and treat each LGBTQI+ teen not only through the lens of their gender or sexual identity, but as an individual: that’s validating, affirming, and leads to the best possible outcomes.

Our Behavioral Health Content Team

We are an expert team of behavioral health professionals who are united in our commitment to adolescent recovery and well-being.

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