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Meaningful engagement with LGBTQI+ lived expertise can reduce inequity in mental healthcare. Healthcare must be rebuilt to embed lived experience in design and delivery to tackle the structural homophobia and transphobia that contribute to poorer outcomes among gay and trans people, writes Matthew Jackman

I identify as a white settler in Australia, living on the lands of the Wurunjeri people of the Kulin Nation in Melbourne. I identify as queer and non-binary (pronouns they/them), having come out through a “bipolar” manic episode; as well as neurodivergent; and mad (a politicised term to reclaim and resist oppressive uses of the word “madness” and highlighting the history, context, and politics of mental health). I was placed in institutional systems such as child welfare, foster care, and psychiatric hospitals as a response to experiences of child abuse, neglect, family violence, and the complex grief and loss from my mother’s suicide when I was 9 years old. These were compounded by poverty, homophobia, bullying, and isolation resulting from sanism (prejudice against, discrimination towards, and oppression of people experiencing madness).10 My father told me that “gay people” were diseased, a rhetoric rooted in religion and psychiatry as institutions of oppression. At school, queer students were physically assaulted and verbally abused by other students. Direct and indirect homophobia led me to overwhelming distress and shame. I was referred to psychiatrists and received diagnoses and “treatments” for anxiety, mood swings, trauma, and attentional related “disorders.” The healthcare response felt stigmatising, discriminatory, and unresponsive to the structural root causes of my distress. I felt blamed by family, peers, and the psychiatric system and workforce, which influences societies’ perception of queerness as illness and deviance.

s, trauma, and attentional related “disorders.” The healthcare response felt stigmatising, discriminatory, and unresponsive to the structural root causes of my distress. I felt blamed by family, peers, and the psychiatric system and workforce, which influences societies’ perception of queerness as illness and deviance. I needed instead to feel that healthcare providers were partnering with, and empowering, me to navigate the pain, trauma, grief, and social isolation I experienced related to broader structural determinants. Queer affirming care that recognises that trauma and oppression have structural determinants is crucial.11 12 These trauma informed practices respect, validate, and centre queer identities and lived experiences.13 11 In my experience, this has often been limited to clinicians and peer workers who identify as LGBTQI+. But the whole healthcare system and every professional and should champion cultural humility by listening to individuals and learning what matters to them. I felt that my first suicide attempt was medicalised. I received a diagnosis, drug treatment, and hospital admission, with limited acknowledgement of the structural causes of my distress—representative of culturally unresponsive healthcare. There is no drug for social injustice and oppression. I felt that systems and professionals responded with the wrong, reductionist tools, language, attitude, and care.

Partnering with LGBTQI+ people in the design and delivery of healthcare is essential for diversity, equity, and inclusion: to increase access to healthcare and improve health outcomes in an increasingly politically violent climate. Lived experience leadership and peer support ensures care emphasises social, cultural, spiritual, and structural determinants alongside clinical determinants of mental health specific to LGBTQI+ people.14 The World Health Organization’s framework for meaningful engagement offers pragmatic guidance for involving people with lived experience in co-designing and implementing care aligned with community needs.15 The importance of having people with lived experience leading in healthcare policy making and service delivery is increasingly recognised.16 Having people with lived experience in leadership improves access to healthcare for everyone—including LGBTQI+ people10—increases LGBTQI+ affirming care,17 and improves culturally competent interactions.18 Peer educators can train clinical staff to provide care that is more sensitive to patients’ values, beliefs, and behaviours.18 19 Peer navigators can help LGBTQI+ people to access and navigate care, improving outcomes.20 For example, peer led interventions among gay and bisexual men have shown positive outcomes and effectiveness, including in reducing HIV transmission14 and addressing structural issues related to internalised stigma and stress from stigma.21 Peer support has demonstrated improved mental health outcomes for trans and non-binary youth.22

led interventions among gay and bisexual men have shown positive outcomes and effectiveness, including in reducing HIV transmission14 and addressing structural issues related to internalised stigma and stress from stigma.21 Peer support has demonstrated improved mental health outcomes for trans and non-binary youth.22 Inclusive, anti-oppressive, and responsive healthcare systems require structural reforms to promote queer affirming care, including models of care that reflect the needs and wishes of LGBTQI+ people.1 Healthcare professionals need training in culturally competent care that acknowledges structural as well as clinical determinants of health.18 Embracing lived experience in leadership and peer support is key.