TYPE Opinion

PUBLISHED 22 June 2023

DOI 10.3389/fpsyt.2023.1189231

Gender in mental health: toward

OPEN ACCESS an LGBTQ+ inclusive and
affirming psychiatry and mental
EDITED BY
Julia Knopes,
Case Western Reserve University, United States

REVIEWED BY
Lexi White,
healthcare in the Philippines
WellStar Health System, United States
Sérgio A. Carvalho,
University of Coimbra, Portugal Rowalt Alibudbud*
*CORRESPONDENCE
Department of Sociology and Behavioral Sciences, De La Salle University, Manila, Philippines
Rowalt Alibudbud
[email protected]

RECEIVED 18 March 2023 KEYWORDS

ACCEPTED 09 June 2023
PUBLISHED 22 June 2023
sexual and gender minorities, LGBT persons, gender affirmation, Mental Health Act,
gender equality, Philippines, SOGIE Equality Bill, mental health
CITATION
Alibudbud R (2023) Gender in mental health:
toward an LGBTQ+ inclusive and affirming
psychiatry and mental healthcare in the 1. Introduction
Philippines. Front. Psychiatry 14:1189231.
doi: 10.3389/fpsyt.2023.1189231
The Philippines enshrined in its constitution the commitment to uphold the rights of
COPYRIGHT
all people regardless of gender (1–3). Toward this commitment, it has been considered the
© 2023 Alibudbud. This is an open-access
article distributed under the terms of the most gender-equal country in Asia in the Gender Gap index (4). However, discrimination
Creative Commons Attribution License (CC BY). against lesbians, gay men, bisexuals, transgenders, queers, and other individuals with diverse
The use, distribution or reproduction in other
genders and sexual identities (LGBTQ+) remained persistent (1–3). In addition, negative
forums is permitted, provided the original
author(s) and the copyright owner(s) are attitudes toward gay men and lesbians have been reported by about a quarter of the
credited and that the original publication in this Filipino population over the years (5–7). Moreover, a study involving Filipino students
journal is cited, in accordance with accepted
found that non-gender-variant participants reported more genderism and transphobia than
academic practice. No use, distribution or
reproduction is permitted which does not their gender-variant peers (8). Furthermore, another study found that these negative societal
comply with these terms. attitudes may translate to high self-stigma among LGBTQ+ individuals (9).
The continued negative attitudes against LGBTQ+ Filipinos and their self-stigma
can lead to higher rates of mental disorders (1, 9–21). Therefore, there is a need for
mental healthcare that is responsive to the needs of LGBTQ+ Filipinos. However, these
negative attitudes toward LGBTQ+ Filipinos have also been reported among mental health
professionals. For instance, a Filipino psychologist on a national television show advised
parents with LGBTQ+ children to consider conversion therapy to achieve a “happy family
life” despite evidence of its deeply damaging consequences (10). These negative attitudes
are further complicated by the limited number of trained counselors who can address their
depression, suicidal tendencies, self-acceptance, anger, and family relationship issues, as
highlighted by a UNDP and USAID report (2). Thus, in accordance with the Philippine
Mental Health Act’s guaranteed rights and protection from sexual orientation, gender
identity, and expression (SOGIE)-based discrimination of service users (22), this opinion
paper discusses several steps that can be undertaken to achieve inclusive and affirming
mental healthcare for LGBTQ+ people in the country.

2. Negative attitudes and discrimination against

LGBTQ+ Filipinos
Negative attitudes and discrimination against LGBTQ+ Filipinos may stem from
Philippine heteronormative norms that promote a gender binary perspective (1, 2, 5–7). In
this perspective, only men and women are acknowledged, disregarding the spectrum and
diversity of SOGIE (1, 2, 5–7). These norms are rooted in colonial, religious, and cultural
factors. Furthermore, they are reflected in Philippine societal positions, laws, and attitudes

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Alibudbud 10.3389/fpsyt.2023.1189231

toward LGBTQ+ individuals (1–3, 5–8). For instance, the proposed the advancement of LGBTQ+ rights and welfare” (10). Similarly,
SOGIE Equality Bill, which seeks to penalize SOGIE-based other Philippine professional organizations, such as the Philippine
discrimination, institute redress mechanisms for discrimination, Psychiatric Association (PPA) and the Philippine Guidance and
and establish programs that promote non-discrimination and Counseling Association (PGCA), should also call on their members
diversity, has languished in the Philippine Senate for about 20 years to uphold the commitment to advance LGBTQ+ inclusion,
(1, 2, 23). The most common argument against this bill is religious affirmation, and rights in their professional practice.
immorality, including some politicians who consider LGBTQ+
Filipinos ’worse than animals’ (1–3, 5).

4.2. Professional organizations, higher

3. Minority stress, negative attitudes, education institutions, and hospitals in the
discrimination, and mental health Philippines can abolish the practice of
Meyer’s minority stress model identifies distal and proximal
conversion therapy and integrate
stressors as risk factors that can contribute to the higher rates LGBTQ-affirmative therapy in psychiatric
of mental disorders among LGBTQ+ individuals (17). Internal and mental health training programs
processes, such as self-stigma and internalized homophobia,
are considered proximal stressors (17). On the other hand, Organizational commitment to LGBTQ+ inclusivity and
negative attitudes and discrimination, such as those experienced affirmation in mental healthcare should be paralleled with actions
by LGBTQ+ Filipinos, are considered distal stressors or external among individual members. As a first step, Philippine professional
objective stressful events (9–21). In the Philippines, evidence organizations involved in mental healthcare need to abolish
suggests that self-stigma, negative attitudes, and discrimination and oppose the practice of conversion therapy. Conversion
against LGBTQ+ Filipinos contribute to poor mental health, therapy rejects an individual’s inherent identity (24–27). Moreover,
including their higher rates of suicidal ideations, depression, conversion therapy not only leads to poor mental health but may
anxiety, and stress than the general population (1, 9–16, 18–21). also violate a constitutionally guaranteed human right (24–27).
Therefore, there is a need for measures that promote inclusive and Thus, psychiatrists and other mental health professionals must
affirming mental health for LGBTQ +. This is in keeping with the commit themselves to end this practice.
country’s recent pledge to respond to the gendered needs of people To further advance action at the individual level, psychiatrists
with mental health concerns in its recently enacted Mental Health and other mental health professionals should have the competency
Act (22). Herewith, this opinion paper proposes several steps that and understanding of gender affirmation and inclusivity in
can be undertaken to promote LGBTQ+ inclusive and affirming their practice (24, 25). However, in the Philippines, LGBTQ+
mental healthcare in the Philippines. organizations have highlighted that few people are trained
to address their mental health concerns (2). For instance,
psychiatrists and other mental health professionals can train
4. Discussion on and practice affirmative therapy, defined as “a type of
psychotherapy used to validate and advocate for the needs of
4.1. Philippine professional organizations sexual and gender minority clients” (28). Likewise, promising
involved in mental healthcare can commit sexual and gender-affirmative mental healthcare practices, such
to LGBTQ+ inclusive and affirming mental as affirmative psychotherapy principles and affirmative Cognitive
healthcare practices Behavioral Therapy, can be studied, adapted, and expanded in
the Philippines (29, 30). Affirmative Cognitive Behavioral Therapy,
The past role of mental health professionals, particularly which validates stigmatized identities by acknowledging the impact
psychiatrists, in spreading the enduring stigma against LGBTQ+ of their sexual and gender identity-based stigma and targeting their
people gives them a responsibility to affirm the diversity of SOGIE cognitive, affective, and behavioral processes, has shown promise
and oppose attempts to change it (24, 25). In recent years, the in combatting the increased rates of distress among LGBTQ+
Philippine mental health professions also participated in this individuals (29). Similarly, practicing affirmative psychotherapy
LGBTQ+ stigma promulgation (i.e., the promotion of Conversion principles, such as normalizing the impact of minority stress,
therapy) (7, 10). Thus, there is a need for Philippine professional decreasing avoidance, restructuring minority stress cognitions, and
organizations involved in mental healthcare to uphold the rights empowering and validating the unique strengths of LGBTQ+
and affirmation of LGBTQ+ identities and the diversity of SOGIE. individuals, may help them cope with minority stress, including
By doing so, distal stressors that stem from mental health care internalized homophobia (30). These affirmative mental healthcare
can be avoided and reduced (1, 9–21). Furthermore, this assurance practices can be supplemented by studying and incorporating
from professional organizations involved in mental healthcare is the effects of promising medical interventions, such as gender-
a welcome signal to LGBTQ+ Filipinos that their identities are affirmative hormone therapy (e.g., testosterone or estrogen), which
respected in psychiatric and mental healthcare practices. have shown promising results in improving the psychosocial
The Philippine Psychological Association (PAP) recently functioning of gender-diverse people (31). Thus, universities
instituted its commitment to gender-affirming mental healthcare and colleges with mental health-related degree programs (i.e.,
through its policy statement calling on psychologists “to ensure counseling and psychology), as well as hospitals with psychiatric

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Alibudbud 10.3389/fpsyt.2023.1189231

residency training programs, in the Philippines need to upscale gender-affirming society conducive to the mental health of all
and integrate gender-affirmative therapy into their training and individuals, such as supporting the proposed SOGIE Equality Bill.
research programs. Doing so can foster and nurture future By supporting this bill and the societal effort to decrease SOGIE-
generations of LGBTQ+ supportive psychiatrists and mental based discrimination and negative attitudes, psychiatrists and other
health professionals. mental health professionals take part in the systemic reduction of
minority stress that may contribute to mental health disparities
among LGBTQ+ Filipinos (1, 2, 8, 11–16, 18–21).
4.3. The Philippine government can include
LGBTQ+ mental health as a national
research agenda
5. Conclusion
In general, Filipino psychiatrists and other mental health
While previous studies suggest that distal stressors contribute
professionals should affirm and advocate the plurality of SOGIE at
to poor mental health among LGBTQ+ Filipinos, they also
both the individual and the social levels. Among others, inclusive
highlighted that the determinants of mental health problems
and affirming mental health and psychiatric services for LGBTQ
among LGBTQ+ Filipinos might vary from the general population
+ can be achieved in the Philippines by committing to gender
(1, 8, 11–13, 18). This variation is accounted for by the unique
inclusivity, opposing conversion therapy, integrating affirmative
cultural features of Philippine society, such as its colonial
therapy for LGBTQ in training programs, including LGBTQ +
patriarchal norms (1–3, 8, 11–13). For example, a romantic
mental health in the Philippine research agenda, and advocating
relationship was found to be protective among heterosexual
for the rights and freedoms of these marginalized individuals
cisgender Filipinos but not among LGBTQ+ individuals (1).
in Philippine society. In doing so, the Philippines can be the
Thus, previous studies emphasized the need for further research
country with the most gender equality in Asia, which is inclusive
to understand and address the mental health disparities among
of the spectrum and diversity of sexualities and genders as well as
LGBTQ+ Filipinos (1, 11–16). This need is echoed by local
conducive to mental health.
LGBTQ+ organizations in a national dialogue with the UNDP
and USAID, where they emphasized that there is poor information
on their mental health (2). This limited information on LGBTQ+ Author contributions
mental health may reflect the apparent invisibility of LGBTQ+
Filipinos in the local mental health literature. Thus, moving RA had substantial contributions to the design, drafting,
their mental health agenda from the margins to the center is revision, acquisition, interpretation, and final approval of the data
necessary to address their invisibility and mental health needs. and work.
As a start, the Philippine Department of Science and Technology,
the government agency mandated to provide the direction and
leadership of scientific and technological efforts in the country, can Conflict of interest
include LGBTQ+ research in the Philippines’ National Research
and Development Agenda under its mental health section. The author declares that the research was conducted in the
absence of any commercial or financial relationships that could be
construed as a potential conflict of interest.
4.4. Psychiatrists and other mental health
professionals can advocate for LGBTQ+ Publisher’s note
rights and welfare
All claims expressed in this article are solely those
The Philippine society itself, with its heteronormative norms, of the authors and do not necessarily represent those of
negative attitudes, and continuous discrimination, can be a fertile their affiliated organizations, or those of the publisher,
ground for minority stress that accounts for the high rates of the editors and the reviewers. Any product that may be
mental disorders among Filipinos with LGBTQ + (1–3, 5, 23). evaluated in this article, or claim that may be made by
Hence, as patient advocates, psychiatrists and other mental health its manufacturer, is not guaranteed or endorsed by the
professionals in the Philippines need to advocate for a more publisher.

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