It was not till June this year that trans identities were de-pathologized and removed from the World Health Organization’s (WHO) classification of mental health disorders, despite stating that “sexual orientation by itself is not to be classified as a mental disorder” in 1992, when it removed homosexuality from the same. WHO’s move away from labeling ‘gender congruence’ as a mental disorder was primarily in attempt to reduce associated stigmas and meet the prevalent health care needs of LGBT individuals. In Pakistan, society has recently seen a shift towards a more tolerant approach to gender diversity, at least from a legislative standpoint; however, sexual diversity is still considered taboo (or even illegal depending on one’s interpretation of the law).

Gender and sexual identities have been consistently pathologized all over the world, which has inadvertently contributed to enormous stigma, discrimination, harassment, abuse and even criminalization on the basis of gender and sexual expression. In comparison to the general population, non-heterosexual and transgender subpopulations have higher rates of mental health problems such as depression, anxiety and substance abuse. Risk ratios show that members of the lesbian, gay, bisexual and transgender (LGBT) community are twice as likely to experience depression, have elevated risks for alcohol and drug abuse, heightened rates for anxiety, lower self-esteem, and almost 3 times higher risk for suicide ideation and suicide attempts. Gender and sexual minorities face distinct social challenges, struggling with reconciling their sexual behaviour and identities with the norms prevalent in their families and communities, and being marginalized by (or in conflict with) society. There is therefore a general consensus that the social stressors faced by members of these subpopulations account for the disparity found in mental health outcomes.

The psychological effects of discrimination vary from the lack of legal recognition and protection, to discrimination in social services, and societal backlash – the third being the least quantifiable (but also the most damaging) form of discrimination. Stigma may greatly affect the choices made by LGBT community members to either disclose or conceal their sexual orientation, with hesitance stemming from their need to protect themselves from abuse, violence or social isolation. Concealing one’s identity, whether gender-based, sexual or otherwise, can have significant and adverse impacts on an individual’s psychological well-being; given that a large part of mental health is the ability to have meaningful relationships with those around you, and being able express one’s emotions and sharing important aspects of one’s life – especially when a core identity is involved.

Given the difficulty in self-identification, reaching out for assistance whilst battling mental health issues is not always seen as an option. In cases where the option has been taken, it is not uncommon for LGBT individuals to find themselves subject to covert or overt biases from their confidants, friends, families, and at times from therapists and mental health professionals too. In the latter case, these biases may destructively impact course of treatment.

In Pakistan, there is a significant level of distress between faith-based values and sexual and gender diversity. Societal and legal codes prescribed on faith-based understandings of what is lawful or not has damaging effects on those who do not conform to heterosexual expectations. At times, members of the LGBT community are forced to seek psychological treatment if they present unfavourable ‘symptoms,’ assuming that their sexual orientation is a product of disease and therefore ‘curable.’ A person is not mentally unstable, psychologically ill, developmentally delayed or a substance abuse addict simply because they experience same-sex attraction or feel more comfortable in non-traditional gender roles. Nor can we assume that those identifying with unconventional sexual orientation are making ‘incorrect choices.’ The only choice members of the LGBT community have to make is the most difficult one: to either be themselves, or to conform to someone else’s definition and expectation of ‘normality’. Yet, therapeutic terminologies routinely adopted emphasize ‘reparative,’ ‘conversion’ and ‘affirmative’ therapies, instead of favoring language which focuses on reducing distress and societal acceptance.

All sexual orientations and gender identities, as well as faith-based or culturally-motivated ideological values have the potential to be lived in healthy or unhealthy ways. Our focus should be on changing unhealthy expressions, and providing safe spaces for individuals to explore, define and articulate their own identities – to ultimately find their true self. The same way that we, as a society, advocate for exercising respect and understanding of religious, cultural, or other values of individuals and communities, we must extend the same advocacy to understanding sexuality and gender as a spectrum of diverse identities.

The association between sexual orientation, gender and mental health is very strong. In countries like Pakistan, where identifying as LGBT is in and of itself a risk factor for mental health, understanding these risks will allow us to, quite literally, save lives.

Published in the Daily Times on 24 September 2018.