The Social Anxiety LGBTQ People Carry

Reading through some of the scientific literature, it becomes clear that a great many LGBTQ (Lesbian, Gay, Bisexual, Transgender, Queer/questioning) people carry a disproportionate burden of mental-health difficulties. Within the LGBTQ population, many people experience depression at some stage of their lives. The risk of depression among LGBTQ people is several times higher than among heterosexual people. Beyond depression, even more LGBTQ people experience social anxiety disorder (SAD), and they may be in a state of heightened risk for it. People troubled by social anxiety disorder experience a range of physical symptoms, including sweating, a racing heartbeat, palpitations and a frequent urge to use the toilet. The condition often comes with other co-occurring conditions, such as depression, and so it can have a major negative impact on everyday life. Through this article, I hope to talk through the relationship between LGBTQ people and social anxiety disorder.

The Social Context That Gives Rise to SAD in LGBTQ People

We know that heterosexual people can develop SAD too. So what exactly is it that leaves LGBTQ people at greater risk of developing social anxiety disorder? Beyond social anxiety disorder, LGBTQ people also face higher risks of depression, suicidal behaviour and suicidal thoughts than heterosexual people. The thing that triggers and worsens social anxiety is, in fact, the very social context in which LGBTQ people live. For LGBTQ people, monitoring their own words and conduct in social settings — together with environmental or hereditary factors — can be enough to set their social anxiety disorder in motion.

LGBTQ people belong to a minority group, and their social context often includes minority stress. Minority stress refers to the long-term, elevated stress a group endures. Heterosexual people tend to grow up in an environment that accepts their identity. For LGBTQ people, however, that is usually not the case. If LGBTQ people reveal their identity, they may face discrimination. The reason is that, growing up, heterosexual people may have seen few examples of LGBTQ people in their own culture, and so they do not understand the concept of being LGBTQ. As a result, many heterosexual people view LGBTQ people as "strange", and may even develop transphobia or homophobia, leading LGBTQ people to be humiliated, as if they were living in a world that does not welcome them at all. This lack of understanding can lead to even more serious consequences, such as hate crimes and other malicious acts.

LGBTQ people therefore become overly sensitive, learning to read every situation in excessive detail to make sure they are safe. They keep silent and hide their LGBTQ identity. Although these are natural responses to enduring ongoing discrimination and prejudice, they can lead to anxiety and shame, which in turn intensify the anxiety. As a result, every time before joining any social setting they care about, they feel intensely tense. They also keep imagining, in vivid detail, all the situations that could leave them awkward or embarrassed. On top of this, they may feel humiliated over things that others take for granted, such as holding hands or expressing affection. Some individuals even become afraid to enter shops or restaurants, or worry about eating and drinking in public.

As time goes on, this negative external messaging gradually becomes internalised, shaping how LGBTQ people see themselves. If the outside world is full of negative messages about their identity, they may ultimately come to believe that they are deeply flawed. LGBTQ people may hold a negative core belief that they are worthless. This experience can have a powerful and long-lasting negative effect on their mental health. The most serious consequence is the emergence of suicidal thoughts and self-harming behaviour.

It is worth adding that SAD tends to develop in adolescence — which is also the time when LGBTQ people are first mocked and humiliated because of their identity.

LGBTQ People Seeking Help to Address SAD

For an LGBTQ person with social anxiety, admitting that they need help is no easy thing, because their social anxiety makes it hard for them to talk to others, and on top of that they believe they may face discrimination for being LGBTQ. This can make it difficult for others to offer support.

Below, I would like to share two actions that LGBTQ people can take on their own to address SAD.

Self-help

If conversation feels too difficult for an LGBTQ person, they should consider first doing small activities that can build their confidence — such as joining some support groups, trying self-help books or taking online courses — because an LGBTQ person with a healthy self-image cannot be affected by minority stress. The key to building confidence lies in being able to remove one's own negative core beliefs, and in whether one can recognise the idea that one is powerless in social situations for what it is. Strengthening self-confidence is the first step in addressing SAD.

Treatment

When severe social anxiety appears, LGBTQ people are advised to seek consultation as soon as possible. A doctor may prescribe medication, such as a selective serotonin reuptake inhibitor (SSRI). Taking the medication within the prescribed schedule can help LGBTQ people reduce their anxiety. Comparing medication with cognitive work, where the therapies include Cognitive Behavioural Therapy (CBT) or Acceptance and Commitment Therapy (ACT) to treat social anxiety, medication is generally regarded as the more effective option.

As for cognitive work, CBT is a talking therapy that uses goal-oriented and systematic procedures to address dysfunctional emotional, behavioural and cognitive problems. ACT is another therapy that, through processes such as mindfulness, acceptance, cognitive defusion, taking the self as context, clarifying values and committed action, helps LGBTQ people strengthen their psychological flexibility and commit to a life of value. LGBTQ people should try to let their therapist understand their living environment, and talk through their own experience of anxiety with the therapist, because everyone's experience is different.

LGBTQ people with SAD may develop certain bad habits to deal with the problems they currently face, such as misusing drugs and engaging in high-risk sexual activity. An LGBTQ person with SAD should seek help as early as possible, to avoid developing bad habits.

Helping LGBTQ People with SAD

We may have friends, or even family members, who are LGBTQ and may have SAD. At one time or another, we may all feel distressed because we do not know how to handle the situations described above. Since most of us are not professionals, I would like to share a few actions you can take.

If you want to help an LGBTQ person with SAD in an effective way, and want to try some forms of intervention, then there are a few key points you must keep in mind. The first is that you should treat an LGBTQ person with SAD just like anyone else with social anxiety disorder, and tell that person that you will support them. For an LGBTQ person with SAD, their identity is an especially sensitive yet hard-to-avoid topic. So when talking with LGBTQ people, keep your questions as open as possible — for example, "How would you describe your sexual orientation?" rather than asking, "Are you straight, gay or bisexual?" In addition, never use clinical jargon to refer to transgender people. Also, communicate in a way that is as gender-neutral and relationship-neutral as possible. Finally, likewise do not mind requests to be called by a particular name or to be referred to in a particular way. Beyond conversation, try to find resources — such as support groups, group therapy or self-help resources — to seek more professional help for an LGBTQ person with SAD. If possible, the ideal approach is to enable this person to receive support from a psychologist or psychiatrist, improving the individual's mental health. Things that look insignificant may be of great help to them.

Also, because LGBTQ people become anxious from hiding their identity, one way to boost an LGBTQ person's confidence is to help that person reveal their identity to their own friends or family — in other words, to "come out". As you might imagine, this act can give rise to a fair amount of anxiety, especially when that LGBTQ person is already living with SAD. When an LGBTQ person wants to "come out" publicly, but does not know how others will react, you can discuss with them some strategies that help reduce other people's negative reactions. This might include identifying who would be the best person to first receive the individual's "coming out". And you should use inclusive language, showing support with an open and friendly attitude, so they know there is someone they can trust by their side.

Practical Resources

References

The Mental Health Association of Hong Kong (2018). Mental Health First Aid Manual (Hong Kong Fourth Edition). Hong Kong: Advanced Commercial Printing.