LGBTI+ communities are one of the most underrepresented communities in the Balkan’s health, social, political and legal framework. This has also been confirmed by the latest Rainbow Europe report, an annual tool which ranks LGBTI+ equality laws and policies where Macedonia has been ranked 43rd out of 49 countries (ILGA-Europe, 2018).
Why, even after years-long advocacy efforts and community organizing activities, are we still fighting for basic human rights?
Even though there is a number of non-governmental organizations (NGOs) providing services to LGBTI+ community members, the homophobic and transphobic portrayal still persists in the everyday lives of these people. Overall, these NGOs offer help and support to LGBTI+ individuals mostly in the field of advocacy, legal framework analyses, sexual health services and community organizing. The research of LGBTI+ needs assessment in Croatia claims that over 40% of LGBT individuals would like to see psychological counseling as a service provided by the LGBTI-serving NGOs (Juretic, Bozic, Birta, Lacovich, Almesberger, Balenovic, 2007). Also, mental health needs appeared to be one of the major needs of the LGBTI+ community members in Macedonia (Stojanovski, 2017).
Despite all these findings, psychological health remains on the edge of priorities of the decision-making institutions such as the Ministry of Health and LGBTI-serving NGOs in Macedonia, as mental health is not recognized in the national documents for public health, and only two out of ten NGOs offer free mental health services to LGBTI+ help-seekers (National Annual Program of Public Health of the Republic of Macedonia for 2018; Ministry of Health, 2018).
In the patients’ rights law as part of the ethical code for health professionals in Macedonia it is stated that the patients must not be discriminated based on their sexual orientation (Law on protection of patients’ rights; Ministry of Health, 2012). More, in the ethical code of psychologists it is stated that the psychologists must be aware of the individual differences including sexual orientation and must not engage in any discriminatory or prejudicial behavior based on sexual orientation (Ethical code of psychologists in the Republic of Macedonia, 2006).
So, why do we urgently need to advocate for improved mental health of LGBTI+ people?
The studies conducted in the Balkan region demonstrate that LGBT victims of violence face higher levels of anxiety, depression and lower self-esteem compared to LGBT non-victims of violence (Pikic & Jugovic, 2006). Studies on the LGBT mental health in Croatia show poorer mental health outcomes compared to individuals who do not identify as LGBT (Kamenov, Jelic, & Huic, 2016). Another study shows that 59 out of 101 LGBT victims of violence sought help from a friend and more than 70 individuals did not seek help from a professional source, such as mental health service provider, social worker, police, or medical staff (Pikic & Jugovic, 2006). More, 67% of LGBTI individuals in Bosnia did not seek professional help for meeting their mental health needs mostly because of fears of revealing LGBTI identity (26%) and beliefs that the service will not help (20%). However, in 60% of the cases, revealing of sexual identity was positively accepted by psychologists and therapists, and a in bit lower number of cases by psychiatrists (40%) (Numanović, 2017). In Macedonia, several studies show that 34% of the LGBTI individuals experienced bullying, and high 60% experienced LGBTI-based physical violence. Moreover, young non-heterosexual students in Macedonian elementary schools face higher levels of psychosomatic and psychosocial difficulties compared to their heterosexual peers (Kjostarova-Unkovska, 2017).
When it comes to the needs and priorities of LGBT persons living in Macedonia, it has been found that LGBT community members express higher needs for mental health services, however they are facing specific barriers to seeking services which include negative experiences with the service providers in the past. These experiences vary from lack of knowledge about the mental health system, to unethical treatments and pathologizing homosexuality by the service providers (Stojanovski, 2017). Similar structural concerns have been noted in Croatia as there were still psychiatrists claiming to “cure” homosexuality (Juras & Grđan, 2006, 2007 according to Vučković Juroš, 2014). The reports in Bosnia show that LGBTI+ individuals rarely seek professional psychological help due to socio-cultural beliefs that “seeking help is sign of weakness”, structural insensibility of service providers for issues related to sexual orientation, gender identity and sex characteristics (Cvjetkovic & Vasic, 2017).
So, how should we address LGBTI+ mental health as a structural barrier to achieving equal access to healthcare?
Having the previous findings in mind, I believe that we are facing crisis in LGBTI+ rights activism as there is a broader neglect of an important aspect in the LGBTI+ health – mental health and psychosocial support. There should be a structural reform in terms of changing the priorities of the key actors operating in the field of LGBTI+ activism – services of the NGOs, project proposals of the donor organizations, mental health professionals and the state institutions. For example, how many service providers are LGBTI-friendly? How many psychologists received LGBTI-specific education on how to deliver adequate support to LGBTI clients? How many mental health centers offer LGBTI-focused training programs for future service providers? By ignoring these questions, the LGBTI activism will be drowning in a magical circle – donor organizations will not open application calls that prioritize mental health in context of LGBTI, NGOs will be lacking resources to provide quality mental health services to LGBTI people, the LGBTI community members will experience high mental health needs which are not met and they will not be satisfied with the work of NGOs, nor they will be interested to participate in the LGBTI+ rights activism. We have to re-think the social factors which contribute to the poorer mental health of LGBTI+ people, see how they are related and develop strategic ways for creating interventions that will meet their mental health needs.