Policy and Mental Health among LGBTQ

I am currently a hospitalist nurse practitioner working in Hamilton, Montana (MT). I returned to school last fall to further my training in the specialty of psychiatric and mental health, to address a significant need here among hospitalized and non-hospitalized patients alike. Issues pertaining to lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) youth have taken center-stage in my community lately. Recently a rally was held in support of a church organization that withdrew their help from the Food Bank because they had distributed some flyers on LGBTQ equality. MT Senator Theresa Manzella, from Hamilton, was quoted as saying “Now, they (gay people) like to play the protected class card and they’re the minority and they’re discriminated against, and they’re scared to walk down the street hand in hand. I’ve got to tell you, I think those are normal consequences associated with the choices they made. We can’t prevent them from doing that” (Rispens, 2021, para. 21). She stated, “my right to live a righteous lifestyle based on my sincerely held beliefs does not end where their choice to live a perverse lifestyle begins” (Rispens, 2021, para. 18). While Theresa Manzella is correct that the church acted within their rights per their recently passed senate bill (S.B.) 215 (interestingly, Manzella was one of the sponsors of said bill), her words were also particularly damaging to a community already struggling with major health disparities and discrimination, especially among youth and adolescents.  

According to the MT Department of Public Health and Human Services (DPHHS, 2021), suicide is the second major cause of death in children, adolescents, and young adults ages 10-24 nationally. As of 2019, MT ranked number 3 for highest suicide rates in the U.S. Suicide occurs more often in Native Americans, followed by Caucasians, and is overwhelmingly completed via lethal means such as firearms (60%). MT adolescents ages 11-17 have more than twice the rate of suicide, when compared to the national average. Some possible contributing factors include MT’s concurrently high rate of alcohol abuse, social isolation, high poverty levels, lack of mental health care, and the frequently stigmatizing views of mental health issues held by many Montanans. LGBTQ children and young adults are 4 times more likely to attempt suicide than cis-gendered (identifies with gender assigned at birth), straight individuals. LGBTQ youth who have families who do not approve of their sexual orientation or gender identity are more than 8 times as likely to attempt suicide. For each incidence of verbal or physical abuse related to being LGBTQ, the incidence of self-harm more than doubles (DPHHS, 2021).  

The year 2021 will go down in history for its anti-LGBTQ legislation in MT, as well as around the country. MT S.B. 215 (freedom and restoration act) was signed into law April 22 and allows for remediation of situations where the government makes policies or people demand services or treatment that directly conflicts with an individual’s or entity’s ability to practice their religion or faith (S.B. 215, 2021). An example of this bill in action would be the blocking of a requirement for churches to hire LGBTQ staff, business owners to serve LGBTQ customers, and even the medical care of a patient who lives any lifestyle that directly conflicts with the “sincerely-held religious belief” of those caring for them (S.B. 215, 2021, p.2). This bill will impact an LGBTQ population in MT that already has a high rate of attempted suicide and self-harm by allowing direct discrimination towards both adults and children.

MT House Bill (H.B.) 112, also known as the Save Women’s Sports Act, was enacted into law on 05/07/21 and specifically bars youth and young adults from playing on sports teams according to anything but their gender at birth in public elementary, high school, or higher educational institutions, regardless of whether they have entered puberty or are taking testosterone blockers (H.B. 112, 2021). The original unamended bill used sexist language based on popular media sources (some outdated from the 1980s) rather than science, to point out inferiority of female athletic performance when compared to males and used this information to advance the bill as a way of addressing gender disparities (H.B. 112, 2021). Katz and Luckinbill (2017) described the current literature regarding gender and athletic performance as generally showing a higher proportion of high-performing males when compared to females, in areas of speed, endurance, and strength, but also that females with similar body weight, height, and training were capable of outperforming males.  They pointed out that rigorous scientific studies showing testosterone confers a definite and measurable performance benefit are non-existent.  They also noted historical context and treatment differences for females based on stereotypes could make it appear as if males were outperforming females. Females were classically viewed as the weaker sex.  For most of American history, sports were presumed to cause difficulties with fertility and seen as unbecoming.  Title IX was enacted in the 1970s, giving females the right to play on sports teams, but continued to advance stereotypes by not allowing females on teams engaging in full-contact sports or on men’s teams because of their perceived fragility, despite there being no data in support of this view (Katz and Luckinbill, 2017).  Research was not even required by law to include females until the 1990s, and often didn’t for fear of unpredictable effects of the menstrual cycle and the view of women as needing protection (National Institutes of Health: Office on Research on Women’s Health, n.d.). Women were not allowed to participate in all games of the Olympics until 2012 (Katz & Luckinbill, 2017). Most of the testosterone research is related to an over-representation of intersex (having differences in hormone levels or chromosomes not matching gender anatomy or ambiguous anatomy) and other conditions leading to naturally higher testosterone levels in female athletes competing in the Olympics (Handelsman et al., 2018).  I would posit we have no way of knowing if it is an overrepresentation, due to lack of testing for these things in non-athletes.  I would also point out that having medal-winners that are also intersex is not proof that testosterone levels lead to increased performance.  All these studies show is that gender is not binary and there are normal variations to testosterone levels and sensitivity (which cannot even be tested for) even among females (Tannenbaum & Bekker, 2019). Assuming there was a definite link between higher testosterone and athleticism, this point would be mute in pre-pubescent boys and transgender females taking testosterone blockers anyways (Handelsman et al., 2018).  H.B. 112 directly impacts the mental health of the LGBTQ population in MT. Participation in sports often creates mediating effects to mental health issues in youth, and the bill effectively bans transgender females from participating at a time when suicide, depression, and anxiety among transgendered individuals is at an all-time high (Schubert 2021a).

Another bill, S.B. 99, was signed into law on 04/30/21 and prohibits instruction in grade and elementary schools on human sexuality, sexual orientation, gender identity, sexual anatomy, sexually transmitted infections, reproduction, and contraception without first notifying guardians and allowing them to review the curriculum beforehand, with the option to opt-out, and also forbids any provider or entity from participating in these instructive activities, that currently provides any abortion services out in the community, such as Planned Parenthood (S.B. 99, 2021). While sexual education in the schools has always been an opt-out choice for MT parents, the new bill specifically adds sexual and gender minority (SGM) information, in response to schools teaching about SGM inclusiveness. This is particularly damaging. Research by Proulx et al. (2019) showed that schools with LGBTQ-inclusive sexual education had lower rates of LGBTQ student bullying, suicidal ideation, and depression symptoms. Pearson et al. (2021) found that state-level policies supporting LGBTQ inclusiveness resulted in lower rates of suicidality among high school students. 

S.B. 280 was passed on 04/30/21 and makes it so a transgender person may only amend their birth certificate with proof that they have undergone gender reassignment surgery, and the amended status, once approved, will show up on the birth certificate as amended, unless the gender assigned at birth was a mistake and not corrected by surgery (S.B. 280, 2021). Schubert (2021b) wrote that this new requirement would out transgender individuals every time they have to supply identification, to rent a home, to apply for a job, even purchasing alcohol in a bar, would increase bullying and suicidality, and would effectively punish poor people for not having the money to undergo surgical transition. Restar et al. (2020) indicated that transgender individuals are 2-3 times more likely to forgo necessary healthcare or medical interventions due to fear of discrimination. Over 65% of those surveyed had experienced discrimination within the community. The intersectionality of transgender and other minorities such as race made it even less likely that a transgender person was able to undergo sex reassignment surgery. Restar et al. (2020) completed a study that showed lower rates of depression, anxiety, somatization (development of physical complaints related to mental health issues), and emotional distress associated with the amendment of legal identification, regardless of the ability for surgery or hormone therapies. S.B. 280 simply puts these outcomes out of reach for the majority of transgender Montanans.  

The upstream issues related to MT policies on LGBTQ people include the size of the community (mostly rural), religion (high proportion of religions who view LGBTQ as a choice and a sin), education levels, and exposure. Stifling authentic living by LGBTQ youth results in internalization of shame and hiding sexual orientation and gender identity. The more hidden this becomes, the more likely a community is to see LGBTQ as other and according to stereotypes. One of the greatest successes in the fight for LGBTQ rights has been the visibility of this group within our communities, in our families, in the media, and as friends and loved ones. This creates cognitive dissonance with the stereotypes and leads to the view of LGBTQ as regular humans with differences and similarities, much like cis-gendered straight people. Visibility in the religious community is also important.  Gay people can be Christians. Transgender people can live a life helping others. LGBTQ people can be your doctor, dentist, psychiatrist, and nurse practitioner.  


Handelsman, D. J., Hirschberg, A. L., & Bermon, S. (2018). Circulating testosterone as the hormonal basis of sex differences in athletic performance. Endocrine Reviews39(5), 803.

H.B. 112, 67th legislature, 2021 Reg. Sess.  (MT. 2021).  Retrieved Nov. 30, 2021, from https://legiscan.com/MT/text/HB112/2021

Katz, R. S., & Luckinbill, R. W. (2017). Changing sex/gender roles and sport. Stanford Law & Policy Review28(2), 215–244.

Meadows, E. (2018). Sexual health equity in schools: Inclusive sexuality and relationship education for gender and sexual minority students. American Journal of Sexuality Education13(3), 297–309. https://doi.org/10.1080/15546128.2018.1431988

Montana Department of Public Health and Human Services.  (2021, Jan).  Suicide in Montana: Facts, figures, and formulas for prevention.  Retrieved Nov 28, 2021, from https://dphhs.mt.gov/assets/suicideprevention/SuicideinMontana.pdf

National Institutes of Health: Office on Research on Women’s Health.  (n.d.).  History of women’s participation in clinical research.  Retrieved Dec. 1, 2021, from https://orwh.od.nih.gov/toolkit/recruitment/history

Pearson, J., Wilkinson, L., & Wooley-Snider, J.L.  (2021).  State-level policy, school victimization, and suicide risk among sexual minority youth.  Sexual and Gender Minority Health, 21, 65-101. https://doi.org/10.1108/S1057-629020210000021009

Proulx, C. N., Coulter, R. W. S., Egan, J. E., Matthews, D. D., & Mair, C. (2019). Associations of lesbian, gay, bisexual, transgender, and questioning: Inclusive sex education with mental health outcomes and school-based victimization in U.S. high school students. Journal of Adolescent Health64(5), 608–614. https://doi.org/10.1016/j.jadohealth.2018.11.012

Restar, A., Jin, H., Breslow, A., Reisner, S. L., Mimiaga, M., Cahill, S., & Hughto, J. M. W. (2020). Legal gender marker and name change is associated with lower negative emotional response to gender-based mistreatment and improve mental health outcomes among trans populations. SSM – Population Health, 11. https://doi.org/10.1016/j.ssmph.2020.100595

Rispens, S.  (2021, Nov. 18).  ‘God, Country, Family’ tour stops in Clinton to support pastor accused of hate speech.  Retrieved Nov. 29, 2021, from https://www.montanarightnow.com/news/state/god-country-family-tour-stops-in-clinton-to-support-pastor-accused-of-hate-speech/article_af9fbb65-3824-50d4-b8a7-43d97a1703da.html

S.B. 99, 67th legislature, 2021 Reg. Sess.  (MT 2021).  Retrieved Nov. 30, 2021, from https://legiscan.com/MT/text/SB99/2021

S.B. 215, 67th legislature, 2021 Reg. Sess. (MT. 2021).  Retrieved Nov. 29, 2021, from https://trackbill.com/bill/montana-senate-bill-215-establish-the-religious-freedom-restoration-act/2026371/

S.B. 280, 67th legislature, 2021 Reg. Sess.  (MT 2021).  Retrieved Nov 30, 2021, from https://legiscan.com/MT/text/SB280/2021

Schubert, K. (2021a, May 7).  Transgender sports bill signed into law: Opponents warn of bill’s economic and social impacts.  Daily Montanan.  Retrieved Nov. 30, 2021, from https://dailymontanan.com/2021/05/07/transgender-sports-bill-signed-into-law/

Schubert, K.  (2021b, June 17).  Opponents: This is a life or death matter.  Daily Montanan.  Retrieved Nov 30, 2021, from https://dailymontanan.com/2021/06/17/opponents-this-is-a-life-or-death-matter/

Tannenbaum, C. & Bekker, S.  Sex, gender, and sports.  BMJ, 364, l1120.  https://doi.org/10.1136/bmj.l1120