1. Bibliographic Information

1.1. Title

The title of the paper is: "The lesbian, gay, bisexual and transgender communities' mental health care needs and experiences of mental health services: An integrative review of qualitative studies". It clearly indicates the central topic: an examination of mental health care for the lesbian, gay, bisexual, and transgender (LGBT) communities, specifically focusing on their needs and service experiences through an integrative review of qualitative research.

1.2. Authors

The authors of this paper are:

• Samuel N. Rees

• Marie Crowe

• Shirley Harris

  All three authors are affiliated with the Centre for Postgraduate Nursing Studies, University of Otago, Christchurch, New Zealand. Marie Crowe is also listed as the corresponding author. Their affiliation suggests a background in nursing, mental health, and academic research, particularly within a postgraduate nursing studies context.

1.3. Journal/Conference

The paper was published in J Psychiatr Ment Health Nurs. (Journal of Psychiatric and Mental Health Nursing). This journal is a peer-reviewed publication dedicated to advancing knowledge and practice in psychiatric and mental health nursing. Its focus aligns perfectly with the paper's subject matter, indicating it is a reputable venue for research in this specific field.

1.4. Publication Year

The paper was published in 2021. The submission and revision dates (Received: 11 February 2020, Revised: 19 June 2020, Accepted: 25 June 2020) indicate it was a relatively recent publication at the time of its release, suggesting its findings reflect contemporary understanding and research in the field.

1.5. Abstract

The paper's abstract outlines its primary objective, methodology, key findings, and implications. Research Objective: To identify the mental health needs of the LGBT communities and their experiences when accessing mental health care. Core Methodology: An integrative review of qualitative studies was conducted. An integrative review is a method that synthesizes findings from diverse research designs to generate new knowledge and perspectives on a phenomenon of concern. Qualitative studies focus on understanding experiences, perspectives, and meanings, making them suitable for exploring the nuanced experiences of the LGBT communities. Main Results: Fourteen studies were selected. Participants' experiences were categorized into: (a) experiencing stigma and (b) staff's lack of knowledge and understanding of LGBT people's needs. The identified need was for mental health care that promotes principles of equity, inclusion, and respect for diversity. Key Conclusions: The LGBT communities, despite not being homogenous (meaning composed of similar parts), face unique challenges with their mental health needs. Services promoting health equity and self-acceptance are crucial for this group. Implications: Mental health nursing education must incorporate models promoting equity, inclusion, and respect for diversity for LGBT individuals.

1.6. Original Source Link

The original source link provided is /files/papers/69056cd20b2d130ab3e0481c/paper.pdf. This indicates the paper is an officially published work, as it is hosted on a domain that typically archives published academic articles. The DOI: $10.1111/jpm.12720$ further confirms its official publication status.

2. Executive Summary

2.1. Background & Motivation

The paper addresses a critical issue: the mental health care needs and experiences of the lesbian, gay, bisexual, and transgender (LGBT) communities.

• Core Problem: Despite evidence of greater health disparities (differences in health outcomes and access to care) within LGBT communities, particularly concerning mental health, their specific mental health needs and experiences with services have been largely overlooked or misunderstood. Historically, the focus has been narrow, primarily on sexual health issues like HIV/AIDS.
• Why this problem is important:
  • LGBT individuals are a minority population and are vulnerable to poorer health outcomes, including higher rates of mental illness compared to the general population.
  • Past heterosexism (a system of attitudes, bias, and discrimination in favor of opposite-sex sexuality and relationships) and homophobic bias (prejudice or aversion toward homosexual people) have limited research and appropriate care.
  • LGBT individuals often face stigma (a mark of disgrace associated with a particular circumstance, quality, or person) and discrimination (unjust or prejudicial treatment of different categories of people) within mental health services, leading to marginalization (treatment of a person, group, or concept as insignificant or peripheral).
  • The DSM (Diagnostic and Statistical Manual of Mental Disorders) previously classified homosexuality and gender identity disorder as mental illnesses, contributing to pathologization (treating a normal human variation as a disease). While these classifications have been removed, their historical impact lingers.
• Paper's Entry Point / Innovative Idea: The paper seeks to give voice to the experiences of LGBT individuals by specifically conducting an integrative review of qualitative studies. This approach allows for a deeper understanding of the lived realities, perspectives, and specific needs of LGBT people, moving beyond statistical prevalence to understand the why and how of their mental health challenges and interactions with services.

2.2. Main Contributions / Findings

The paper makes several significant contributions by synthesizing existing qualitative research:

• Identification of Specific Barriers to Care: It explicitly identifies stigma and lack of knowledge/understanding among mental health staff as primary barriers LGBT individuals face. This includes heteronormative language, cis-normative expectations (expectations that align with the assumption that gender identity matches sex assigned at birth), homophobia, biphobia (prejudice against bisexuality), and transphobia (prejudice against transgender people), leading to feelings of being ignored or mistreated.
• Articulation of Key Mental Health Needs: The review highlights a clear demand for:
  • LGBT-friendly services or spaces.
  • Informed care that does not pathologize sexuality or assume mental health symptoms are solely due to sexual identity.
  • Services that actively promote self-acceptance.
  • Access to culturally sensitive and LGBT-friendly therapists and talking therapies (psychotherapy).
• Call for Systemic Change: The findings underscore the need to challenge the existing heteronormative and cis-normative culture in mental health nursing practice.
• Implications for Education and Practice: It strongly advocates for the integration of health equity promotion models into mental health nursing education and practice. These models emphasize equity (fairness in health outcomes), inclusion (making all individuals feel welcome and valued), and respect for diversity.
• Confirmation of Minority Stress Theory: The review indirectly supports minority stress theory, which suggests that chronic stress arising from social stigmatization contributes to mental health disparities in marginalized groups.

3. Prerequisite Knowledge & Related Work

3.1. Foundational Concepts

To fully understand this paper, a beginner should be familiar with several core concepts:

• LGBT Communities: This acronym stands for Lesbian, Gay, Bisexual, and Transgender.
  • Lesbian: A woman whose primary romantic and sexual attractions are to other women.
  • Gay: Typically refers to a man whose primary romantic and sexual attractions are to other men, though it can also be used as an umbrella term for homosexual individuals.
  • Bisexual: A person whose primary romantic and sexual attractions are to both men and women, or to people of more than one gender.
  • Transgender: An umbrella term for people whose gender identity (their internal sense of being a man, woman, neither, or both) differs from the sex they were assigned at birth. This is distinct from sexual orientation.
  • The paper also mentions GLBTI (including Intersex) and LGBTQ (including Queer or Questioning). The term communities emphasizes the diverse, non-homogenous nature of these groups.
• Mental Health: Refers to a person's emotional, psychological, and social well-being. It affects how we think, feel, and act. Good mental health is essential for living a full and productive life.
• Health Disparities: Differences in health outcomes and their determinants (such as social, economic, and environmental conditions) that are closely linked to social, economic, and/or environmental disadvantage. In the context of LGBT communities, this means they often experience worse health outcomes (e.g., higher rates of mental illness) compared to the general population.
• Stigma and Discrimination:
  • Stigma: A negative societal perception or attitude associated with a particular characteristic (e.g., being LGBT, having a mental illness). It can lead to prejudice and exclusion.
  • Discrimination: Unfair or prejudicial treatment of a person or group based on characteristics like sexual orientation or gender identity. This can manifest in healthcare settings as unequal access, substandard care, or disrespectful interactions.
• Heteronormativity: The assumption that heterosexuality is the default, normal, or preferred sexual orientation. In healthcare, this can lead to staff making assumptions about patients' relationships, partners, or family structures, causing LGBT individuals to feel invisible or misunderstood.
• Cis-normativity: The assumption that cisgender (gender identity aligns with sex assigned at birth) is the default or normal gender identity. This can lead to similar issues as heteronormativity for transgender individuals, where their gender identity is not recognized or respected.
• Integrative Review: A research method that systematically synthesizes findings from diverse research designs (e.g., quantitative, qualitative, and mixed-methods studies) to generate new knowledge and provide a comprehensive understanding of a particular topic. Unlike a systematic review which often focuses on a narrower question and stricter inclusion criteria (e.g., only randomized controlled trials), an integrative review allows for a broader scope and a synthesis of different types of evidence.
• Qualitative Studies: Research that explores attitudes, experiences, behaviors, and opinions through non-numerical data collection methods like interviews, focus groups, and observations. The goal is to gain an in-depth understanding of a phenomenon from the perspective of those experiencing it, providing rich, descriptive insights rather than statistical generalizations.

3.2. Previous Works

The paper acknowledges that the mental health needs of LGBT communities have been largely overlooked, with a historical focus on sexual health issues, particularly HIV/AIDS. It explicitly references the historical pathologization of LGBT identities within psychology and psychiatry:

• Diagnostic and Statistical Manual of Mental Disorders (DSM):

  • The American Psychiatric Association (APA) removed homosexuality as a mental disorder from its DSM (third edition) in December 1973. This was a significant turning point, influenced by gay and lesbian activist and civil rights movements.
  • Gender identity disorder was removed from DSM-5 (2013) and replaced with gender dysphoria. Gender dysphoria refers to the distress a person feels due to a mismatch between their gender identity and their sex assigned at birth, rather than the identity itself being a disorder. This evolution reflects a shift from viewing LGBT identities as inherently pathological to recognizing the distress that can arise from societal non-acceptance or the incongruence between identity and physical characteristics.

• Prior Reviews: The authors note that previous reviews in the area were limited:

  • King et al. (2008): Identified a higher risk of mental health problems in the LGBT community but did not capture their specific needs. This highlights the gap the current paper aims to fill by focusing on the qualitative experiences and specific needs.

  • Mason et al. (2018): Was specific to disordered eating and body image concerns among sexual minority women, a narrower focus than the current paper's broader scope.

    The paper also cites substantial literature identifying higher rates of specific mental health conditions within LGBT communities:

• Depression (e.g., Bailey, 1999; Bockting et al., 2020)

• Anxiety (e.g., Adams et al., 2012; Mays & Cochran, 2001)

• Substance and alcohol misuse (e.g., Adams et al., 2012; King et al., 2003)

• Body image and eating disorders (e.g., Duggan & McCreary, 2004)

• Borderline personality disorder (Paris et al., 1995)

  These previous works establish the existence of mental health disparities but leave a gap in understanding the qualitative experiences and specific care needs from the perspective of LGBT individuals themselves.

3.3. Technological Evolution

The evolution of understanding LGBT mental health has shifted from pathologization to a minority stress framework and health equity.

• Phase 1: Pathologization (pre-1970s): Homosexuality and transgender identity were considered mental disorders. Healthcare's role was often to "cure" or "correct" these identities, leading to harmful and unethical practices.
• Phase 2: Depathologization & Risk Identification (1970s-early 2000s): The removal of homosexuality from the DSM marked a pivotal shift. Research then began to identify LGBT individuals as a vulnerable population experiencing higher rates of mental illness, but often without deeply exploring the underlying social causes or specific care needs. The focus on HIV/AIDS during this period, while critical, also tended to overshadow broader mental health concerns.
• Phase 3: Minority Stress & Health Equity (2000s-present): Current understanding emphasizes minority stress theory, which posits that LGBT individuals experience unique stressors due to stigma, prejudice, and discrimination. These stressors contribute to mental health disparities. This phase advocates for affirmative care and health equity, recognizing that LGBT individuals have specific needs that require culturally competent and inclusive services, not just treatment for symptoms. This paper fits squarely within this third phase, seeking to inform practice based on the lived experiences of LGBT individuals.

3.4. Differentiation Analysis

Compared to the main methods in related work, this paper's approach stands out in several ways:

• Focus on Qualitative Data: Unlike quantitative studies that measure prevalence rates or correlations, this integrative review specifically synthesizes qualitative studies. This allows for a rich, in-depth understanding of the lived experiences, perceptions, and specific needs from the perspective of LGBT individuals, which quantitative data often cannot capture. The authors explicitly state they wanted to "give voice to the experiences of those with direct mental health service experiences."
• Integrative Review Methodology: By using an integrative review, the authors are able to synthesize diverse qualitative findings from various contexts, providing a broader and more comprehensive picture than a single qualitative study or a systematic review limited to a very narrow question. This methodology is particularly suited for emerging fields or topics where a full theoretical understanding is still developing.
• Comprehensive Scope: While previous reviews were either too broad (identifying risk but not specific needs) or too narrow (focused on specific conditions), this paper aims for a comprehensive understanding of both mental health care needs and experiences of mental health services across the diverse LGBT communities.
• Emphasis on Service Improvement: The direct implication for mental health nursing education and practice is a strong differentiator, positioning the review as a direct input for improving healthcare delivery rather than just a summary of health status.

4. Methodology

4.1. Principles

The core idea of the method used is to conduct an integrative review of qualitative studies. The theoretical basis or intuition behind this approach is to synthesize diverse qualitative findings to provide a comprehensive and nuanced understanding of a complex phenomenon – in this case, the mental health needs and service experiences of LGBT individuals. By focusing on qualitative data, the researchers aim to capture the lived experiences and perspectives of the LGBT community members themselves, giving voice to their specific challenges and desires for care. This approach aligns with the understanding that LGBT experiences are shaped by social and cultural contexts, which qualitative research is uniquely suited to explore.

The review explicitly followed the framework for conducting an integrative review described by Whittemore and Knafl (2005). This framework typically involves five stages: problem identification, literature search, data evaluation, data reduction, and data extraction/synthesis.

4.2. Core Methodology In-depth (Layer by Layer)

The methodology involved a systematic five-step process:

4.2.1. Problem Identification

The authors identified a gap in existing research. While LGBT communities experience higher rates of mental disorder, there was a lack of understanding regarding how to best address their mental health needs. They found only two previous reviews:

• King et al. (2008) identified higher risk but not specific needs.
• Mason et al. (2018) was specific to disordered eating and body image concerns among sexual minority women. This highlighted a clear need for a review focusing on the specific mental health needs and experiences of LGBT individuals across the board, particularly from a qualitative perspective to capture their voices.

4.2.2. Literature Search

A comprehensive literature search was conducted across four major electronic databases:

• Ovid Medline

• Embase

• CINAHL

• PsycINFO

  Assistance from a research librarian was utilized to ensure the use of appropriate MeSH (Medical Subject Headings) search terms, enhancing the rigor and comprehensiveness of the search.

Search Terms: The search terms were categorized and combined using Boolean operators:

• Terms for LGBT Communities (combined with OR): 'GLBT', 'gay', 'LGBTQ', 'gay lesbian and bisexual', 'lesbian gay and bisexual', 'lesbian gay bisexual and trans', 'gay lesbian bisexual and trans', 'gay lesbian bisexual and transgender', 'lesbian gay bisexual and transgender', 'homosexual', 'rainbow', 'queer', 'rainbow community', 'lesbian', 'bisexual', and 'Fa'afafine'.
• Terms for Mental Health (combined with OR): 'mental health', 'mental health needs', 'experience of mental health services', 'psychiatric patients'.
• Terms for Experiences (combined with OR): 'lived experience', 'perception', 'perceived'.

These three sets of terms were then combined using the Boolean operator AND.

Inclusion Criteria:

• Studies examining LGBT communities' mental health needs and experiences of seeking help.
• Publication date: January 1996 to January 2020. This timeframe was chosen after an initial search failed to locate relevant studies prior to 1996.
• Participants: Between 18-65 years of age.
• Language: English language.
• Publication type: Peer-reviewed journal articles.
• Study design: Qualitative and mixed-method design. For mixed-method studies, only the qualitative data was considered.

Exclusion Criteria:

• Quantitative studies (unless part of a mixed-method design where only the qualitative component was extracted).

• Mental health needs exclusively in the context of HIV/AIDS diagnosis, as this was identified as a historically over-focused area.

  The initial search yielded 470,912 articles from the combination of terms. The search terms relating to mental health were applied, and then experiences, resulting in 533 articles after combining all three search term categories with AND.

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2009 flow diagram was used to document the selection process.

The following figure (FIGURE 1) from the original paper illustrates the PRISMA flow diagram of the search process:

该图像是一个PRISMA流程图，展示了文献检索过程。图中显示，数据库检索识别出528条记录，经过去重后剩余380条，筛选后获得39篇全文文章，其中14篇被纳入定性综合分析。

FIGURE 1 PRISMA flow diagram of search process

As shown in FIGURE 1, 528 records were identified through database searching. After removing duplicates, 380 records remained. These 380 records were screened, leading to 39 full-text articles being assessed for eligibility. Out of these, 14 studies were ultimately included in the qualitative synthesis.

4.2.3. Data Evaluation

The methodological quality of the selected studies was assessed using the JBI critical appraisal checklist for qualitative research (Lockwood et al., 2015). The JBI (Joanna Briggs Institute) provides standardized critical appraisal tools to assess the methodological quality of different types of research studies, which helps to determine the extent to which a study has addressed the possibility of bias in its design, conduct, and analysis. This step ensures that only studies meeting certain quality standards are included in the synthesis.

4.2.4. Data Reduction

After initial identification, 533 articles were found. Duplicates were removed, leaving 380 papers. These papers were organized by publication date. For mixed-method studies, only the qualitative data component was extracted for the review. The process is further detailed in the PRISMA flow diagram (FIGURE 1).

4.2.5. Data Extraction

Findings relevant to the mental health needs and participants' experiences of accessing treatment were systematically extracted from each included study. This information was then organized into a table format (Table 1), which included the following details for each study:

• Author

• Country of study

• Sample size and demographic details (gender and sexual orientation)

• Methodology used in the original study

• Aim of the original study

• Mental health needs identified

• Experiences of seeking help

• Conclusion of the original study

  After extraction, the data were examined to identify emerging themes, patterns, or relationships across the different studies.

4.3. Quality Appraisal

All included papers underwent a rigorous quality appraisal process using the JBI critical appraisal checklist for qualitative studies. This process aimed to assess the methodological quality and trustworthiness of each study. The appraisal was conducted independently by the three authors, and a consensus was reached after discussion to ensure consistency and reliability of the appraisal. All fourteen included articles were found to meet the required quality standards, indicating their methodological soundness for inclusion in the review.

4.4. Findings (Synthesis of Extracted Data)

The synthesis of findings from the 14 individual studies led to the identification of overarching themes related to experiences of mental health services and mental health needs.

4.4.1. Experiences of Mental Health Services

Participants' experiences were categorized into two main areas:

• Experiencing Stigma: Twelve of the fourteen studies highlighted stigma and discrimination. This was often described as being positioned as "different" or "not normal" by mental health staff, through the use of heteronormative language and cis-normative expectations. Homophobia, biphobia, transphobia, monosexism (the belief that people are only attracted to one gender), and heterosexist bias (bias in favor of heterosexual people) were frequently reported. Participants often felt they faced dual barriers: having a mental health problem and being a member of a minority group, leading to feelings of being ignored or mistreated. Many reported being silenced out of fear when using services.
• Lack of Knowledge and Understanding of LGBT People's Needs: Seven studies found that health professionals often had limited knowledge of the specific needs of LGBT communities. Participants felt pathologized for their sexuality or gender identity, leading to under-treatment for their primary mental health issues. This lack of knowledge resulted in feelings of vulnerability and hopelessness due to culturally insensitive practice. Some clinicians were perceived as over-intrusive with questions unrelated to the main intervention, making participants feel they had to educate the staff. This underscored a need for more time and resources to improve care.

4.4.2. Mental Health Needs

Two primary themes emerged regarding the identified mental health needs:

• Need for LGBT-Friendly Services or Spaces: Seven studies indicated a strong need for providers to be open, comforting, and non-judgmental, and to ask open-ended questions without assuming heterosexuality. This points to a desire for spaces where their identities are acknowledged and respected. The transgender community specifically sought transgender affirmative therapy and treatment that recognized gender dysphoria (distress due to the incongruence between one's gender identity and sex assigned at birth), particularly in light of treatment delays or denial.
• Need for Informed Care that Promotes Self-Acceptance: All studies found that participants desired informed care that did not pathologize sexuality or incorrectly attribute mental health symptoms solely to sexual identity. However, they acknowledged that their social and cultural experiences related to their identity could contribute to mental health problems. Needs included:

  • Addressing internalized norms and promoting self-acceptance to combat self-blame, loneliness of being an outsider, and leading a double life.

  • Addressing the impact of past harassment, abuse, violence, and other adversities.

  • Acknowledging the specific struggles associated with heteronormativity, complex relationship dynamics, and processes within gay culture.

  • Access to affordable and timely talking therapies that are culturally sensitive and LGBT-friendly.

    The following are the results from Table 1 of the original paper:

    Author	Country	Sample size and Sexual and gender orientation	Method	Aim	Mental Health needs identified	Experiences of seeking help	Conclusion
    Adams et al. (2013)	New Zealand	Gay men n = 44 Lesbian n = 28 Transgender n = 14 Bisexual man n = 2 Bisexual woman n = 13 Other n = 23	Email Survey Interviews Online qualitative survey	To identify the current mental health promotion initiatives focused on the GLBTI population, as well as mental health service specifically for the GLBTI people	Dedicated LGBTI- focused mental health services Public health services for mild to moderate mental	Impact of Stigma, Homophobia and Transphobia.	Increased inclusion in policy Limited services for GLBTI people
    Aggarwal and Gerrets (2014)	Netherlands	Gay men n = 12	Ethnographic method: Observation, Interviews	How can one understand this Dutch paradox of high rates of mental health problems among gay men in a country with marked sociocultural, economic and legal equality?	Struggle with internalized norms	Stigma	Absence of symbolic equality. Heteronormative behaviours
    Benson (2013)	United States of America	Transgender n = 7	Phenomenological: Feminist-informed	The study aim is to give voice to self- identified transgender people and provide therapist an opportunity to learn from the experiences of this marginalized population	Emotional health Process of gender identity	Misunderstood Prejudice Stigma Lack of educated and informed therapist on transgender health needs	Affirmative practice Affirmative training
    Eady et al. (2011)	Canada	Bisexual n = 55	Qualitative community-based study	To understand the experiences of bisexual people who have sought mental health service, their perception of providers' attitudes towards bisexuality, and whether they felt their overall needs were met by the mental health care system		Judgmental Dismissal of bisexuality Pathologizing sexuality Intrusiveness Non-judgemental	The mental health services experiences described by the participants in this study suggest that some providers may be expressing common social beliefs about bisexuality through their practices.
    Ellis et al. (2015)	United Kingdom	Trans people n = 621	Mixed-method design, quantitative scales and fixed response questions, as well as open response qualitative questions	The purpose of this study was to gain a better understanding of the experiences of trans people as a whole and to evaluate the above services in relation to trans clients.	Gate-keepers to gender identity treatment Symptoms perceived as being related to being trans	Dissatisfaction Intrusive Lack of knowledge and lack of experience Requirement to conform to gender binary Ill-informed clinicians	Adopting a flexible patient-centred approach, policy and practice changes to improve the health outcomes of the specific group.
    Matthews et al. (2005)	United States of America	Lesbian n = 20	Qualitative grounded theory	The purpose of this study is to examine, in an in-depth and narrative fashion, the factors that woman who self-identify as lesbian and in recovery from addiction have found helpful in their recovery from addiction.	Self-acceptance Learning to recover Interpersonal relations	Addressing both Substance use and internalized homophobia through a lesbian-based Alcohol Anonymous or Narcotic Anonymous lead to a greater	Lesbians in recovery must overcome stigma and discrimination, which is vital that the complexities are incorporated in treatment.
    McAndrew and Warne (2010)	United Kingdom	Gay men n = 4	Qualitative psychoanalytically informed methodology	To facilitate the exploration of the early biographical experiences of adult gay men who have engaged in suicidality	Self-blame Loneliness of being outsider Leading a double life	self-acceptance	Need to challenge professional normative hetrosexism Need for recognition and acknowledgment of gendered
    McCann et al. (2013)	Ireland	Gay n = 22 Lesbian n = 13 Bisexual n = 1	Qualitative data coding using N-Vivo	To investigate mental health needs of LGBT over the age of 55 years (Under 65 years n = 21)	33% experienced lifetime mental health problem Associated with past experiences		Need for standards of care that support the principles of equity, inclusion and respect for diversity
    McCann and Sharek (2014)	Ireland	Gay n = 22 Lesbian n = 13 Bisexual n = 1	Qualitative categorical coding using N-Vivo	To examine the experiences of LGBT people of mental health services in Ireland		Services not knowledgeable or responsive to needs Stigma and discrimination Lack of treatment choices	Mental health nurses need to develop responsive to needs of LGBT people including fear of coming out, homophobia, violence and harassment.
    Pettinato (2008)	United States of America	Lesbian n = 12 Bisexual woman n = 1	Qualitative - Grounded theory	Disconnecting from authentic self: Drinking to keep closet door shut	Alcohol misuse Past sexual abuse Childhood adversity Suicide attempts Positive experiences with therapy Recovery from alcohol use		Multiple issues when addressing alcohol misuse in lesbian Lack of lesbian focused health education
    Robertson (1998)	United Kingdom - Scotland	Gay men n = 37	Qualitative - grounded theory Focus groups (n = 20) then individual interviews (n = 17)	The aim of the study is to explore gay men's experiences and views of health and health care	Treatment for homosexuality	Reluctant to discuss sexuality Treatment for being gay versus underlying MH issue Deep distrust of mental health services	Social stigma Gay men have multiple mental health needs Health organizations neglecting health issues
    Ross et al. (2010)	Canada	Bisexual n = 55	Qualitative - Grounded theory	To describe the perceived determinants of mental health for bisexual people	Understanding and acceptance of bisexuality Interpersonal relationships Struggle with identity, self- acceptance and	Bisexuality is dismissed or disallowed by health services Biphobia Homophobia Monosexism stigmatized for sexual promiscuity	Like other marginalized populations, bisexual people perceive discrimination as impacting on mental health
    Ross et al. (2016)	Canada	Bisexual n = 41	Mixed methodology Qualitative data was obtained using Charmaz's grounded theory approach	To enhance understanding of the relationship between bisexuality, poverty and mental health	self-care Intersection of poverty and bisexualism impacts on mental health	Poor access to quality mental health services	A significant proportion of the bisexual population live in poverty that effects their mental health. Early life events effect financial stabiliy
    Rounds et al. (2013)	United States of America	Gay n = 2 Lesbian n = 4 Bisexual n = 1 Queer n = 4	Qualitative - Focus groups	To obtain this information via focus groups with LGBTQ people regarding behaviours of health care providers that improve or impede quality of care and then to summarize those behaviours		Barriers to good care based on knowledge and communication skills	Poverty impacts mental health Lack of competency when working with this population Health care providers need educating Need for empowering LGBTQ people to access appropriate health care

5. Experimental Setup

This paper is an integrative review of qualitative studies, not an empirical study involving traditional experimental setups. Therefore, the "experimental setup" section must be reframed to describe the characteristics of the studies included in the review and the methods used to evaluate those studies.

5.1. Datasets

The "datasets" in this context refer to the individual qualitative studies that were identified and included in the integrative review.

• Source: The studies were sourced from major electronic databases: Ovid Medline, Embase, CINAHL, and PsycINFO.

• Scale: A total of 14 qualitative studies were selected and synthesized for the review.

• Characteristics and Domain:

  • Geographic Distribution: The studies originated from various countries, including the $USA (n=4)$, $Canada (n=3)$, $Ireland (n=2)$, $United Kingdom (n=3)$, $New Zealand (n=1)$, and $Netherlands (n=1)$. This geographical diversity suggests a breadth of experiences from different cultural and healthcare contexts.
  • Sample Size of Included Studies: The number of participants in the original studies ranged from four to 621. The study with 621 participants was a national mixed-methods survey, where only the qualitative components were extracted.
  • Participant Demographics: Across all included studies, there were 1,111 participants who identified as:
    • $Gay (n=162)$
    • $Lesbian (n=109)$
    • $Transgender (n=642)$
    • $Bisexual (n=171)$
    • $Other or more than one (n=27)$ This diverse representation covers the breadth of the LGBT acronym, with a notable number of transgender participants, highlighting their experiences.
  • Methods of Included Studies: Most studies utilized interviews for data collection, which is a common method in qualitative research to gather in-depth narratives. Two studies incorporated qualitative questions attached to surveys, indicating a mixed approach within those particular studies. The table of extracted data further details methods like ethnographic method, phenomenological, qualitative community-based study, mixed-method design, grounded theory, and psychoanalytically informed methodology.

• Why these studies were chosen: These studies were chosen because they met the inclusion criteria of examining the LGBT communities' mental health needs and experiences of seeking help, were peer-reviewed qualitative or mixed-method articles published between January 1996 and January 2020, and involved adult participants (18-65 years) in English. Their qualitative nature was crucial to fulfill the review's aim of "giving voice" to LGBT individuals.

5.2. Evaluation Metrics

For an integrative review, the primary "evaluation metric" is the quality appraisal tool used to assess the methodological rigor and trustworthiness of the included studies.

• Conceptual Definition: The JBI critical appraisal checklist for qualitative research (Lockwood et al., 2015) is a tool developed by the Joanna Briggs Institute for systematic reviews. Its purpose is to assess the methodological quality of qualitative research studies by evaluating the extent to which the researchers have minimized bias and the methods are appropriate to the research question. It helps reviewers determine if the study's findings are credible, transferable, dependable, confirmable, and relevant.

• Mathematical Formula: The JBI critical appraisal checklist is a set of criteria, not a single mathematical formula. It typically involves a series of questions (e.g., "Is there congruence between the philosophical perspective and the research methodology?," "Is the ethical standing of the research clear?") for which reviewers respond "Yes," "No," "Unclear," or "Not Applicable." These responses are then used to inform a judgment about the overall quality of the study, rather than producing a numerical score. The specific checklist for qualitative studies usually includes 10 criteria.

• Symbol Explanation: Since it is a checklist rather than a formula, there are no specific symbols to explain. Each item on the checklist represents a methodological aspect to be evaluated (e.g., congruence, ethical standing, representation of participants' voices).

  All included articles were independently appraised by the three authors and met the required quality standards according to the JBI checklist, indicating their suitability for synthesis.

5.3. Baselines

In the context of an integrative review, there are no "baseline models" in the traditional experimental sense. Instead, the current review positions itself against the existing body of literature and previous review efforts.

• Implicit Baselines: The paper implicitly compares its approach to:
  • Purely quantitative reviews: These might report rates of mental illness but fail to capture the nuanced experiences and specific needs that qualitative research provides.
  • Reviews with a narrow focus: For instance, the Mason et al. (2018) review on eating disorders, or broader reviews like King et al. (2008) that identified higher risk but not specific needs.
• Differentiation: The strength of this review lies in its qualitative focus and integrative methodology, which allows for a deeper, more comprehensive understanding of LGBT individuals' perspectives on mental health services. It aims to fill the gap left by these implicit baselines by providing the "voice" that was previously missing or understated.

6. Results & Analysis

6.1. Core Results Analysis

The synthesis of the fourteen qualitative studies provided robust findings validating the unique challenges and needs of the LGBT communities regarding mental health care. The results strongly validate the paper's core assertion that LGBT individuals face significant barriers and have specific, often unmet, mental health care needs.

Experiences of Mental Health Services: The review identified two primary adverse experiences:

1. Experiencing Stigma: A predominant finding was the pervasive stigma and discrimination encountered by LGBT individuals. This stigma was not only societal but also deeply embedded within mental health services. Participants felt othered and abnormal, often facing heteronormative language and cis-normative expectations that invalidated their identities. This included direct manifestations of homophobia, biphobia, and transphobia. This reinforces the idea that LGBT individuals face dual barriers – both having a mental health concern and being a member of a stigmatized minority group. The fear of such treatment often led to silence and reluctance to engage fully with services.
2. Staff's Lack of Knowledge and Understanding: A critical disadvantage of the current system is the widespread lack of knowledge among mental health staff regarding LGBT specific needs. This often resulted in pathologizing LGBT identities or misattributing mental health symptoms solely to their sexual orientation or gender identity, leading to under-treatment or inappropriate care. Participants often felt compelled to educate their clinicians, highlighting a significant burden placed on them and demonstrating a lack of cultural competence within the services. This indicates that current services are not adequately equipped to provide culturally sensitive care.

Mental Health Needs: The studies consistently highlighted a demand for specific types of care:

1. LGBT-Friendly Services/Spaces: There is a clear need for environments where LGBT individuals feel safe, openly accepted, and not judged. Providers should actively avoid assumptions about heterosexuality and proactively demonstrate comfort and non-judgment. For the transgender community specifically, transgender affirmative therapy and recognition of gender dysphoria as distinct from mental illness, with appropriate and timely treatment, were paramount. This directly addresses the stigma and lack of understanding identified in their experiences.
2. Informed Care Promoting Self-Acceptance: LGBT individuals seek care that acknowledges the complex interplay between their sexual/gender identity and mental health. While they reject pathologization of their identity, they recognize that minority stress (e.g., from heteronormativity, discrimination, harassment, abuse, violence) can significantly impact their mental well-being. Services should help individuals navigate internalized norms, self-blame, and develop self-acceptance. The demand for affordable, timely, culturally sensitive, and LGBT-friendly talking therapies underscores the need for specialized and accessible support that understands their unique social and cultural experiences.

Comparison with Baselines (Implicit): The findings directly contrast with a healthcare system that operates under heteronormative or cis-normative assumptions. Where baseline services might offer generic mental health care, the reviewed studies highlight the inadequacy of such an approach for LGBT individuals. The advantages of the proposed LGBT-friendly and informed care models are that they would likely reduce the stigma, improve trust, and lead to more effective and patient-centered outcomes. The current system's disadvantages are its reinforcing of stigma, mistreatment, and failure to meet specific LGBT needs, leading to unmet mental health needs.

6.2. Data Presentation (Tables)

The following are the results from Table 1 of the original paper:

6.3. Ablation Studies / Parameter Analysis

Ablation studies or parameter analyses are typically conducted in empirical studies to evaluate the contribution of individual components of a model or the sensitivity of results to different parameter settings. As this paper is an integrative review of qualitative studies, such analyses are not applicable. The methodology focuses on synthesizing existing qualitative data and identifying overarching themes, rather than building or optimizing a model. The "parameters" in this context would be the inclusion/exclusion criteria or search terms, which were carefully defined and adhered to rather than varied for experimental purposes.

7. Conclusion & Reflections

7.1. Conclusion Summary

This integrative review compellingly concludes that LGBT communities, while diverse, share common experiences of stigma and lack of understanding when accessing mental health services. These negative experiences contribute to unmet mental health needs and highlight the inadequacy of current heteronormative and cis-normative mental health systems. The review identifies a critical need for services that prioritize equity, inclusion, respect for diversity, and actively promote self-acceptance. It underscores that mental health nurses, in particular, must integrate these principles into their practice, moving towards care that is destigmatizing and genuinely affirming.

7.2. Limitations & Future Work

The authors implicitly and explicitly point out several limitations and suggest future directions:

• Limitations of the Review:
  • The review is limited to qualitative studies published in English within a specific timeframe (1996-2020), potentially missing quantitative insights or studies in other languages.
  • The synthesis relies on the interpretations of the original qualitative researchers, and while quality appraisal was conducted, inherent biases in primary studies could still exist.
  • The LGBT communities are heterogenous, and while the review aims to capture broad themes, specific nuances within each sub-group might require further, more targeted research.
• Future Work:
  • The paper calls for further research that promotes affirmative care for gender and sexual minorities, suggesting a need for intervention development and evaluation specific to LGBT mental health.
  • It advocates for the incorporation of health equity promotion models into mental health nursing education, implying a need for curriculum development and evaluation of educational interventions.
  • At a policy level, the paper suggests that health promotion for LGBT communities needs to be driven by their voices and experiences, and public health campaigns are needed to combat phobias, heterosexism, and cisgenderism.

7.3. Personal Insights & Critique

This paper provides crucial insights by consolidating qualitative evidence, effectively giving a collective "voice" to LGBT individuals' experiences with mental health services. The emphasis on stigma and lack of knowledge as core barriers is a powerful finding that directly translates into actionable implications for practice and education. The detailed review of diverse qualitative studies from multiple countries strengthens the generalizability of these themes, even though qualitative research doesn't aim for statistical generalizability.

Inspirations and Transferability: The findings have broad applicability beyond LGBT communities. The principles of equity, inclusion, respect for diversity, informed care, and self-acceptance are fundamental to providing effective care for any marginalized or minority group. The Health Equity Promotion Model (Fredriksen-Goldsen et al., 2015), introduced in the discussion, is particularly inspiring. Its focus on heterogeneity, intersectionality (the interconnected nature of social categorizations such as race, class, and gender as they apply to a given individual or group, regarded as creating overlapping and interdependent systems of discrimination or disadvantage), structural context, and both health-promoting and adverse pathways could be adapted to understand health disparities in other populations (e.g., racial/ethnic minorities, people with disabilities, immigrants). The concept of challenging normative cultures (like heteronormative or cis-normative) within healthcare is a critical takeaway for fostering patient-centered care across the board.

Potential Issues, Unverified Assumptions, or Areas for Improvement:

• Specificity within LGBT: While the review highlights common themes, the heterogeneity of the LGBT community means that needs and experiences can differ significantly between lesbians, gays, bisexuals, and transgender individuals, and further, within these groups (e.g., transgender men vs. transgender women, LGBT people of color). While the paper acknowledges this, the synthesis necessarily generalizes. Future work could delve deeper into the unique experiences of specific subgroups.

• Intersectionality: The review touches upon minority stress and the impact of social factors. However, the discussion could further elaborate on intersectionality – how LGBT identities intersect with other social categories like race, class, disability, and age to create unique and compounded experiences of stigma and discrimination. The extracted data from Ross et al. (2016) mentions poverty and bisexualism impacting mental health, which is an example of such intersection.

• Nuance in "Lack of Knowledge": While "lack of knowledge" is a significant barrier, its manifestation can vary. Is it simply ignorance, or is it combined with implicit bias or even explicit prejudice? A deeper qualitative exploration of healthcare providers' perspectives could offer more targeted solutions for educational interventions.

• Positive Experiences: While the review effectively highlights negative experiences, a more explicit discussion (if the included studies allowed) of what constitutes truly positive and affirming mental health care experiences from the LGBT perspective could provide clearer blueprints for best practices. The extracted table does include "Positive experiences with therapy" in Pettinato (2008), but the synthesis largely focuses on the negative.

• Geographical Contexts: While studies from various countries were included, the specific socio-political and legal contexts of each country might influence the nature and intensity of stigma and discrimination. A comparative analysis of these contexts could enrich the understanding of how policy and societal attitudes shape experiences.

  Overall, this paper is a valuable contribution to the literature, providing a clear and actionable summary of qualitative insights that should inform mental health practice and education.