“How are you doing?” The psychosocial health and well-being of LGBTIQ* people

Social-framework conditions represent an important factor that can influence the living situation and well-being of all LGBTIQ* people.¹ In recent years, Germany has observed positive developments towards legal and medical recognition, yet equal rights for LGBTIQ* people still cannot be assumed (cf. Pöge et al., 2020). To persuade decision-makers to create LGBTIQ*-friendly conditions, one must usually point out the discrimination that still exists. The minority stress model (see Meyer, 2003) is often used in this context to explain the increased vulnerability of LGBTIQ* people stemming from experienced, anticipated and internalised social stigmatisation.

Compared to the population as a whole, LGBTIQ* people are more frequently affected by depression and suffer more frequently from heart disease, migraines and chronic back pain (cf. Kasprowski et al., 2021). A more closer look at the individual subgroups revealed that trans* and inter* people in particular are exposed to greater psychological stress. Their avoidance of health services because of discrimination is a real problem (cf. Saalfeld, 2021).

According to the syndemic production approach (Stall et al., 2008), health restrictions in one area usually also lead to restrictions in other areas, e.g., sexual health. Discrimination in the healthcare system, in particular, as a place where LGBTIQ* people experience specific health issues and problems, only exacerbates the already precarious health situation of queer people.

In addition to looking at the social conditions and experiences of discrimination that influence well-being and health, this contribution focusses further on resources. The availability of appropriate resources – such as social contacts and support services – can help LGBTIQ* people to better cope with the stress of being in a minority and its negative consequences. However, the fact that people with proper resources sometimes learn to live with discrimination does not absolve society of its responsibility to deal with discrimination and its consequences. It is imperative that resources be made accessible, and that discrimination be reduced (cf. Colpitts & Gahagan, 2016; Oldemeier & Timmermanns, 2023).

The WGE study was an openly accessible, anonymous online survey of people who self-identify as LGBTIQ*. Recruitment took place via various social media channels, mailing lists, dating platforms and partner organisations (see the info box at the end of this text). This resulted in a convenience sample of 8,700 LGBTIQ* people living in Germany. Such a sample is not representative; however, based on the high number of participants, we think we can make relatively reliable statements about the living situation of queer people in Germany. To date, the data have been analysed mainly using descriptive analysis methods.

The average age of the participants was 38.3 years, significantly lower than that of the general population (44.5 years). Regarding their gender identity, there were 1,207 cis-females, 6,608 cis-males, 266 trans-males, 133 trans-females, 259 trans* persons and 160 gender*diverse persons (a subsequently created collective category to encompass the large number of self-designations used); 45 respondents were inter*. Sexual orientation was distributed as follows: gay (5,735), lesbian (812), bisexual (1,210), heterosexual (86), asexual (54), orientation*diverse (387; a subsequently created collective category to encompass the large number of self-designations used), pansexual (391), unspecified (25). The very small number of cases of asexual and inter* people in the study prevents us from making reliable statements about these subgroups but does indicate tendencies. The proportion of people who have experienced immigration lay at around 20% and was therefore 6% lower than in the general population. The sociodemographics also deviated from the population average in other areas. For example, people with a low level of formal education, a low net income and from towns with fewer than 100,000 inhabitants were underrepresented in the study. This pattern presumably emerges because of the chosen approach of an online survey, as online surveys tend to reach people who are better off (Wagner-Schelewsky & Hering, 2022).

When asked about their experiences of discrimination and violence, more than half of respondents reported discrimination in a public place, just under half in educational settings, 37 % in the family, and around one in five in healthcare settings and in the queer community. Trans* and gender*diverse people were more likely than the other queer subgroups to report experiencing discrimination in the healthcare system (40 % of trans* and 43 % of gender*diverse people).

The respondents perceived discrimination in the family or community as a greater psychological burden than in other areas of life. 30 % of respondents had experienced physical and/or sexual violence. Gender*diverse, pansexual, inter* and trans* people as well as bisexual cis-women are more affected by this than the other subgroups in the study.

Regarding services that would be personally helpful for LGBTIQ* people, counselling services (e.g., on coming out, dealing with discrimination and general psychological counselling) received the highest ratings. The respondents rated health-related services for LGBTIQ* people as the most personally helpful.

The LGBTIQ* community represents a resource for coping with difficult life situations. Feelings of loneliness are particularly common among bisexual cis-men, asexual, trans*, gender* and orientation*diverse, inter* people, under 20-year-olds and people in rural areas or small towns. But that is not the only reason why the queer community and its services represent an important resource: It also serves as a place to exchange ideas with like-minded people, discuss problems, make friends, start relationships, find hope and courage. Queer centres, groups and organisations tend to be visited more often by asexual, pansexual, trans* and younger people than by other subgroups or age groups. Chat forums and dating portals, on the other hand, are used significantly more by gay and bisexual cis-men than by other subgroups. Almost half of those surveyed had taken part in leisure activities such as sport, theatre, dance, etc., in the last 12 months, just under a third were involved in voluntary work, and a quarter were politically active. Regarding social contacts, it was striking that just under a fifth of LGBTIQ* persons do not turn to their own family when problems arise. Among oriented*, gender*diverse and trans* people, the figure is as high as 30 %. This fact could be related to the relatively high number of people who state that they experience discrimination in the family, and it confirms the finding that queer people have a more ambivalent perception of family than do heterosexual, cisgender and endosexual people.

The fact that, because of frequent experiences of discrimination and violence, LGBTIQ* people are exposed to greater psychological stress and limitations than the general population aligns with the findings of international studies (for an overview, see, e.g., Hoy-Ellis, 2023) and is one of the main findings of the study. This is confirmed not the least by the findings on the risk of suicide, which is between five and ten times higher among the participants than in the general German population. On the other hand, the WGE study did not find that the participants’ physical health was generally worse than the population average. However, bear in mind that this may stem from the composition of the dataset: In a sample with predominantly young, formally well-educated people who have a higher socioeconomic status than the average in society, physical and chronic illnesses may be represented less frequently than would be the case in a representative sample. One can therefore assume that both mental and physical illnesses are underestimated rather than overestimated in the WGE study.

Regarding trans* and gender*diverse people, we found they suffer comparatively more from mental and physical stress than other subgroups, presumably because these two subgroups continue to be confronted with greater discrimination (especially in the healthcare system) than all other subgroups (see above).

When asked how emotionally burdened they felt, 22 % of the participants responded that they had experienced stress, depressive moods or emotional problems on more than 14 days in the last month. For pansexual, trans*, inter* and gender*diverse people, the figure was almost twice as high.

In this context, it is not surprising that 43% of the respondents to the WGE study stated having sought some form of psychotherapeutic or psychiatric help at least once because of a mental health crisis. In line with the pattern of psychological distress, bisexual cis-women, pansexual and especially trans* and gender*diverse people state having sought professional help. On average, 8% stated that they had not found suitable help – for trans* and gender*diverse people the figure is twice as high. This indicates gaps and barriers in the mental healthcare of people who do not conform to the social norm of cisgender or bisexuality.

The questionnaire also addressed the topics of sexual satisfaction, the gender of sexual partners and sexual health. Pansexual people, lesbian and bisexual cis-women and gay cisgender men are predominantly satisfied with their sex life; bisexual cis-men, trans* and inter* people are satisfied or dissatisfied at almost equal proportions. We need further research into possible reasons and correlations for this, especially in the case of trans* and inter* people. Recent findings from the project “Sexuelle Gesundheit und HIV/STI in trans* und nicht-binären Communitys (2023; Sexual Health and HIV/STI in Trans* and Nonbinary Communities) by the Robert-Koch-Institut (RKI) and Deutsche Aidshilfe (DAH) suggest that experiences of discrimination in the sexual context are significant: Looking back on the 12 months prior to the survey, between two-fifths and three-fifths of the trans* and nonbinary people surveyed stated that they had not been recognised in their gender identity (40.1 %), had been reduced to physical characteristics (41.0 %), had been asked very intimate questions more quickly than cis-people (55.9 %) and had felt that they had to “prove” their gender identity with their behaviour (58.0 %) (cf. RKI & DAH, 2023, pp. 64-65). There are still no further studies on inter* people.

In the WGE study, trans* men, trans* women and nonbinary trans* people are characterised by a high degree of flexibility regarding the gender of their sexual partners. Gay cisgender men show the least flexibility. Gender diversity regarding sexual partners also means that different bodies can be important in the context of lived sexuality and must be addressed in sexual education (cf. Hahne, 2021). It can be a complex task to appropriately address bodies in a differentiated way in the design of sexual health programmes.

The situation of LGBTIQ* people in Germany has changed for the better over the last 40 to 50 years. However, this should not obscure the fact that there is still much to be done, both at a legal and social level (cf. Pöge et al., 2020). This is also reflected in the results of the WGE study: LGBTIQ* people of all ages continue to experience stigmatisation, discrimination and violence in all areas of life. Even the supposedly safe environment of the family is no exception. The queer community is an enormously important resource for most LGBTIQ* people, but it does not equally serve as a refuge for all queer people. The reported personal experiences of discrimination, the internalised social rejection, and the diversity and complexity found in society and queer communities lead to discrimination also occurring there.

However, we should not see queer people just as a vulnerable group that has to endure discrimination. The WGE study showed that LGBTIQ* people in Germany are active and capable of taking action as well as seeking appropriate support. Yet, different subgroups on the queer spectrum find suitable services with varying degrees of ease: Trans* and gender*diverse people most frequently reported a lack of mental healthcare, while also experiencing the most discrimination (especially in the healthcare system) as well as physical and sexual violence. The fact that trans* people are one of the subgroups with the lowest level of satisfaction regarding their own sexuality is not surprising – particularly given more recent results from RKI and DAH (2023).

Counselling centres and support services for LGBTIQ* people must adapt to the diverse needs of queer people. On the one hand, they can achieve this by sensitising existing regular structures such as school sexuality education, extracurricular sexuality education or youth services, and by including the topics of gender, sexual and romantic diversity as cross-cutting issues. On the other hand, there is also a need for explicitly queer programmes tailored precisely to LGBTIQ* and the various subgroups. Queer people are experts in their own situation and must be included in the development of specific services. The findings on the health situation of LGBTIQ* (not only from the study presented here) show the enormous urgency to listen to their expressed needs and take them seriously. It is now up to sexual health services to fulfil these needs.

The WGE study also (once again) highlighted several research desiderata: Given the limited state of research, particularly in the German-speaking countries, we urgently need both representative population data and further target-group-specific data to better substantiate the need for action. On the one hand, this can enable direct comparability with the population as a whole and, on the other hand, map the heterogeneity within the LGBTIQ* group (a good example in the area of sexual health is the RKI and DAH 2023 study). In addition to better examining the impact of resources regarding LGBTIQ*, we must give greater consideration to other dimensions of inequality, such as education, socioeconomic status and migration, in the sense of an intersectional analysis.

¹Unless otherwise stated, all study results listed are taken from Timmermanns et al. (2022).