by Katherine Von Wald
One of the great remaining silences within the healthcare community is mental illness, and those who live with it suffer from and in such silence. The conceptions surrounding mental health are intricately tied to cultural baggage and create challenges for those seeking quality care. This is further complicated for those in queer communities where disparities in access to adequate mental health support are exacerbated along lines of gender and sexuality. There is a severe disparity between the mental health of queer and non-queer individuals. Understanding that these glaring differences come from complex histories of structural oppression begins dismantling the negative silence surrounding queer mental health care.
The stigmatization and pathologization of non-normative bodies and behaviors continues to haunt current iterations of mental healthcare. Queer individuals face systematic discrimination that manifests in material ways to create barriers to accessing and receiving care. The implications of heterosexist patriarchy and structural inequities place queer individuals in a precarious position not often addressed by mainstream health professionals. If such disparities are to be addressed, we must first investigate the deeply entrenched formations which precede an individual and code their journey through medical institutions.
I define mental illness as a mental health condition that significantly impacts quality of life and contributes to overall health problems. This includes but is not limited to depression, anxiety, affective disorders, schizophrenia, and eating and personality disorders. Mental illness affects perception and cognition; motivation and behavior; and interpersonal relationships . Mental health care refers to the treatments individuals require in order to alleviate the disruption that mental illness can cause.
Queer is used as a self-referential term for sex, gender, and sexuality minorities. This includes but is not limited to lesbian, gay, bisexual, transgender, pansexual, intersex, and asexual individuals. In a broader sense, queer can refer to any individual who is distinctly non-normative, non-binary, ambiguous, and/or fluid in their various representations or self expressions. Queer is a reclaimed slur that attempts to celebrate non-normativity rather than punish it and aims for inclusion of the multiplicity of those who do not conform to traditional social notions of gender, sex, and sexuality . For the remainder of my writing, I will use queer to refer only to those who self-identify as within this category of marginalized, non-normative individuals.
Today, queer individuals report higher instances of mental illness than their heterosexual (those who desire the opposite gender), cisgender (those whose biological sex aligns with their gender identity), or otherwise normative counterparts but receive disproportionally inadequate services once in care. According to a study conducted in 2014, queer individuals “have shown rates of depressive, anxiety, and substance abuse disorders [that] are 1.5 to 3.0 times higher” than other populations . These numbers are further exaggerated when intersections of race and class are considered and point to a systemic social problem. The effects of marginalization, violence, and discrimination are embodied as much as they are mentally and physically taxing. Queer individuals face stressors associated with living in a heteronormative patriarchal society that others do not.  This constant conflict with societal standards and oppressive institutions significantly impacts the mental health of sex/gender minority populations. The nuanced nature of lived experiences is not often taken into account by mental health care professionals, so queer individuals do not always seek medical care.
Mental Illness as a Social Disease
According to the 2015 survey conducted by the National Institute of Mental Health, roughly 43.4 million individuals aged 18 or older suffered from mental health concerns in the U.S. This number represents about 18% of all adults. Despite the prevalence of mental illness, the number of individuals who receive mental health services is starkly low. Many studies show that the stigma associated with mental illness not only keeps people from seeking care but contributes to discrimination of individuals with mental health concerns. People with mental health concerns are regarded as dangerous, unpredictable, flawed, and/or weak .
These types of perceptions come out of years of enculturation. Throughout Western history, there exists a tenuous relationship between stigma and social order whereby social norms surrounding behavior have at times collapsed into understanding of reasonability, normality, and even health.
In his book Madness in Civilization: A History of Insanity in the Age of Reason, Michel Foucault traces the often-changing criteria for and perception of mental health. According to Foucault, a drastic change occurred sometime in the early 17th century that coded mental illnesses through standards of morality. In this age of scientific advancement and intensified medical categorization, any version of unacceptability had to be uprooted. This more frequently referred to people who were viewed as outside the social imaginary and who threatened social decorum than to those suffering from health concerns.
This mingling of social anxieties and disease paradigms thus developed symptomologies inherently informed by dominating ideology. Moral obstacles could be “recast in a scientific-sounding vocabulary” and ultimately stand in as justification for the confinement of populations of the poverty-stricken, the working-class, and the oppressed. Modern Western mental health care practices rest upon a tradition that worked to uphold racial and class distinctions; the economically disadvantaged or socially cast out were imprisoned within hospitals as a means of purging cities of sex workers, the unemployed, and the homeless. Only 10% of those hospitalized during this time were considered “insane;” the rest were merely poor .
This points to a deeply imprinted cultural pathway that has had resounding impacts on the stigmatization of mental health. For centuries, perceptions of the undesirable (both people and communities) have been viewed through the lens of of mental illness, regardless of symptomologies, care, or treatment.
The effect of such social stigmatization of mental illness has ensured the continued conflation of social fears and health concerns. Mental illness, though often unseen, has become visibly coded onto certain populations based on economic class, race, gender, and sexual orientation. Individuals with mental illness are seen as dangerously outside normal functioning because of this cultural perspective. There has developed an intense binary between those with and those without mental illness, which ensures that an individual’s mental health status be concealed. Social stigma against mental illness is one of the largest obstacles to receiving care for those who could most benefit from it. This stigma does more than isolate individuals as outside of society; it functions as a means to ignore truly harmful symptomologies in favor of constructed social assumptions that uphold oppressive hierarchies.
Just as stigma against individuals with mental health concerns are informed by socio-cultural anxieties, bias against queer individuals is informed by a history of pathologizing their identities, behaviors, and desires. Pathology defines the boundaries of disease; when these definitions become invested with social ideologies, they can be used to target populations for their non-normativity.
Again, Foucault’s work provides an analysis of the workings of sexuality and medicine that contributed to the pathologization of sexual behaviors. Perceptions of certain sexual behaviors have always faced shifting cultural perspectives. In the 19th century, monogamous heterosexuality was determined to be the standard for healthy sexual activity. Sexuality was taken out of the bedroom, imbued with the hegemonic social standards of the time, and brought into the realm of medicine.
In a society structured around the privileging of man-woman reproductive coupling, this meant that any kind of non-normative, non-heterosexual, non-monogamous behavior beyond strictly defined sex/gender roles became distinctly pathological. It was considered a perversion. Thus, queerness, homosexuality, sado-masochism, intersexuality, etc. were considered to be acceptable symptoms of mental illness.
We can think of pathologization as a complex process by which social subjugation is justified by diagnosis. It transforms a social ordinance into a disease paradigm and crafts non-normative behavior as something in need of intervention and curing. In the United States, the pathologization of queerness, be it sexual orientation or gender presentation, has contributed to the violent treatment of queer individuals within mental institutions. Conversion therapy, the attempt to change individual’s sexual orientation through psychological intervention, is just one example of an attempt to cure queerness by attempting to rid an individual of their homosexual desire.
The legacies of both stigma and pathology continue to code how individuals from the queer community interact with mental health care. Though many institutions have attempted to dismantle the stigma associated with mental illness, this history still informs internalized bias among patients and providers. Similarly, homosexuality and more recently gender identity disorder are no longer used as diagnostic tools to measure mental disorders. While this points to the continued shifts that both pathology and medicine undergo, it is also an important moment to investigate how individuals continue to be affected by structural oppression long after institutions might change.
The seething presence that haunts the mental health community is this tangled relationship between sociality and medicine. Queers face unique layering of stigma and pathologization that create material barriers, both socially and institutionally, to accessing and receiving adequate mental health care. Understanding the context of such barriers is the first step toward crumbling their foundations.
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 Foucault, Michel. Madness and Civilization: A History of Insanity in the Age of Reason. Vintage Books Ed., Nov. 1988. New York: Random House, 1988.