Black Sexual Minority Adults’ Avoidance of Professional Mental Health Care

Black sexual minority people experience simultaneous race- and sexuality-based biases and discriminations (1) in addition to unique forms of oppression, such as racism within lesbian, gay, bisexual, transgender, and queer (LGBTQ) communities (2–5) and heterosexism within Black spaces (6, 7). These unique identity-based stressors (i.e., minority stress [16]) have deleterious effects on the mental health of Black sexual minority people. For example, compared with their Black heterosexual and White sexual minority counterparts, Black sexual minority persons report higher levels of psychological distress, a construct that reflects nonspecific symptoms of conditions such as anxiety and depression (8). In one study, Black and Hispanic sexual minority adults who reported experiences of discrimination based on their sexual orientation had 4.5 times higher odds of a suicide attempt in the past 5 years, relative to Black and Hispanic sexual minority adults who had not had these experiences (17).

These identity-based experiences create a need for PMHC. However, access to PMHC varies greatly across sociodemographic groups. Andersen and Newman’s model of health services use (18) helps conceptualize the factors that influence use of mental health care. Demographic characteristics such as sexual and racial identities serve as individual characteristics predisposing individuals to mental health care use (19); these facets of one’s lived experience can facilitate or impede access to mental health services. Emerging research about PMHC utilization by Black sexual minority individuals suggests that this population may be less likely than White sexual minority persons to seek services. Findings from studies that examined a community sample of sexual minority women and a sample of college students suggest that, compared with their White sexual minority counterparts, Black sexual minority people are less or only equally likely to use mental health care (10, 14). Furthermore, Meyer et al. (15) found that Black sexual minority adults were nearly five times less likely than White sexual minority adults to seek mental health or medical treatment before a suicide attempt. Thus, additional research is needed to clarify potential racial disparities in PMHC utilization within sexual minority samples.

Growing evidence suggests that Black sexual minority individuals may differ from their White sexual minority counterparts with regard to another predisposing individual characteristic: beliefs about mental health care. Qualitative data indicate general skepticism about using PMHC among Black sexual minority persons. Moore and colleagues’ (20) investigation of mental health service engagement among Black and Hispanic sexual minority persons has provided several insights into beliefs about mental health care seeking. Themes included a reluctance to engage with services or premature termination of services due to personal factors (e.g., beliefs that treatment would not help or that mental health problems should be handled on one’s own and shame about symptoms and sexual minority identity), social influences (e.g., family members discouraging the use of traditional mental health services), accessibility factors (e.g., difficulty paying for care), and provider characteristics (e.g., a patient may withhold information from providers who do not share the patient’s racial-ethnic or LGBTQ identity).

Given that PMHC is an important tool for supporting the mental health of Black sexual minority people, it is important to understand whether, and why, Black sexual minority adults may avoid care. Limited research has investigated potential racial disparities in PMHC utilization among sexual minority populations. Additionally, quantitative studies have yet to examine why Black sexual minority people might postpone or avoid mental health care. This study used survey data from an online sample of sexual minority adults to explore racial differences in postponement or avoidance of PMHC. With the analyses that follow, we sought to answer the following questions: Are Black sexual minority people more likely than White sexual minority people to postpone or avoid mental health care? If so, do Black sexual minority people and their White peers show differences in the reasons for postponing or avoiding mental health care?

Table 1 presents the characteristics of the sample. The proportion of male and female respondents varied by race, with a larger proportion of the Black sexual minority subsample identifying as male (67%) than in the White sexual minority subsample (51%). The subsamples also varied in education, with Black sexual minority participants (78%) being more likely than White sexual minority participants (64%) to hold a college degree or more. We observed no other statistically significant differences between the two subsamples.

Table 2 outlines results from unadjusted and adjusted regression models. Black sexual minority individuals had significantly higher odds than their White counterparts of having postponed or avoided PMHC for any reason (OR=1.96; adjusted OR [AOR]=2.69). Furthermore, compared with White sexual minority people, Black sexual minority people had higher odds of reporting that they had postponed or avoided mental health care because they thought people should work out their mental health problems by themselves (OR=1.87; AOR=1.83) or with friends and family (OR=2.32; AOR=2.46). Black sexual minority individuals also had higher odds than their White peers of postponing or avoiding care because a provider refused to see them (OR=4.21; AOR=4.20). The two racial groups did not significantly differ in the other reasons for postponing or avoiding care.

Figure 1 shows the predicted probabilities of postponing or avoiding mental health care for Black and White sexual minority people. Overall, the individuals in our sample had high probabilities of avoiding or postponing care, with 71% of White individuals and 85% of Black individuals endorsing this behavior for any reason (average marginal effect [AME]=13.7 percentage points, 95% CI=5.4–21.9). Predicted probabilities illustrated the proportional differences between Black and White sexual minority persons who were more likely to postpone or avoid care because they thought that persons should work out mental health problems on their own (40% vs. 27%, respectively; AME=13.1 percentage points, 95% CI=1.2–24.9) or with friends and family (38% vs. 20%; AME=17.5 percentage points, 95% CI=6.0–29.1) or because a provider refused to treat them (26% vs. 8%; AME=17.4 percentage points, 95% CI=7.6–27.1). We also noted that nearly 50% of the overall sample stated that they had postponed or avoided care because they could not afford it.

In this study, we used an online sample to document differences in postponing or avoiding PMHC between Black and White sexual minority adults. Black sexual minority persons were nearly twice as likely as White sexual minority persons to postpone or avoid PMHC for any reason. They were also more likely to postpone or avoid care because they thought they should work out their mental health problems by themselves or with friends and family or because a provider refused to treat them. Our finding that Black sexual minority persons were more likely than their White peers to postpone or avoid care aligned with the research literature about general racial-ethnic differences in PMHC utilization. Although little work has been done to explore PMHC utilization at the intersection of race-ethnicity and sexual orientation, results with samples from general populations show that Black adults are reluctant to engage with traditional mental health care (25, 26). Although Andersen and Newman’s model of health services use (18) regards race as a predisposing individual characteristic of the level of engagement with such services, it may be more useful to consider how identity-related beliefs (e.g., a distrust of the medical establishment among Black adults and doubts in the effectiveness of services) influence service utilization (26).

The reluctance to engage in care was further explained by our findings about differences between Black and White sexual minority individuals in the reasons for postponing or avoiding PMHC. Black sexual minority individuals were more than three times as likely as their White counterparts to report postponing or avoiding care because a provider refused to treat them. Although these data did not assess individuals’ perceptions about why some providers refused to work with them, this disparity indicates that institutional racism or unique intersectional experiences of bias may play a role in Black sexual minority people postponing or avoiding mental health care. We note evidence for racism in the mental health care system, including not only refusal to treat Black clients but also microaggressions from providers against such clients, a general lack of competence in attuning to the specific cultural needs of Black clients, and lack of sensitivity to their experiences of discrimination (27). These experiences with the mental health care system likely reinforce distrust of formal systems of care that is rooted in historical medical exploitation of Black bodies (26). Furthermore, research suggests that mistrust of the system and community mores about self-sufficiency contribute to Black persons’ preference to work out their issues on their own or with their family and friends (28, 29). This preference was also evident in the present analysis. Although friends and family can be an important source of support regarding mental health, the expectation that they should preclude PMHC systems can do more harm than good in instances where PMHC is clinically indicated (i.e., when symptoms are too severe to self-manage). These findings support the importance of prioritizing cultural humility (i.e., ongoing self-evaluation and critique, addressing power imbalances in clinical relationships, and removing paternalism from these relationships) (30) when mental health providers deliver care to Black sexual minority individuals. Such efforts for cultural humility require an intersectional framework to effectively understand and meet the mental health needs of Black sexual minority people.

This study had several other notable findings. First, a large proportion (74%) of the total sample reported postponing or avoiding care for any reason. This finding likely reflects the barriers that sexual minority persons of any race face when seeking mental health care, which may include limited availability of affirming providers, transportation challenges, and inability to afford health care, particularly related to a lack of health insurance (9, 31–33). Additionally, Black and White sexual minority individuals did not differ in several reasons for postponing or avoiding care, even though, on the basis of previous research, we might have expected such differences to exist. For example, extensive literature has explored the stigma surrounding mental health issues and PMHC utilization in Black communities (26, 34). However, Black individuals in this sample were as likely as their White counterparts to postpone or avoid care because they were embarrassed about their mental health concerns. This finding suggests that medical distrust among Black individuals is a strong and distinct factor in avoiding or postponing care and does not play a significant role in care avoidance due to personal embarrassment. Thus, both the broader issues about health care access and the specific intersectional challenges Black sexual minority individuals contend with must be addressed to promote uptake of mental health services by Black sexual minority individuals.

This analysis had several limitations. The survey did not include a direct measure of need for PMHC; items about postponing or avoiding mental health care were presented to all respondents, not only those who reported a need for care. Thus, our conclusions might have been stronger if this analysis had been conducted among only individuals who reported needing mental health care. Future studies should assess self-reported need for mental health care and include this factor in analyses. We also note a lack of specificity in the items used in this analysis. Use of PMHC was assessed with a question about ever having “talked with a mental health provider because you were concerned about your mental health.” It is possible, for example, that someone spoke with their pastor about mental health issues and was unsure about how to answer the question as it was worded. Items asked about lifetime behaviors, which limited our ability to make strong temporal inferences. Future studies should utilize items that are more specific about when and from whom individuals sought mental health care and support and about the type of treatment. Furthermore, given the disproportionate numbers of Black individuals with HIV and the mental health services available to these individuals, future studies may also explore how HIV status might alter mental health care engagement. Last, given that the availability of PMHC, especially services tailored to meet the needs of sexual minority people, varies greatly by location (31), future studies may include indicators of participants’ geography and urbanicity.

Although the sampling for the larger study used a stratified quota approach to ensure representation across different sexual orientations and gender identities, no quotas were imposed for many other demographic characteristics, including race-ethnicity. One consequence of this approach was inclusion of relatively few Black sexual minority individuals and even fewer Black sexual minority individuals who had not postponed PMHC. This sampling approach likely limits the generalizability of this analysis. By using a larger sample, future analyses could increase statistical power to detect significant differences among demographic subgroups. Future research should also consider additional comparison groups (e.g., how PMHC utilization by Black sexual minority individuals compares with that of Black individuals overall) to identify drivers of the observed inequities. Additionally, the use of MTurk for data collection limited our pool of potential study respondents to those with Internet literacy who were seeking to complete online tasks for pay. Last, data were collected during the early months of the COVID-19 pandemic. This period was characterized by heightened levels of stress and anxiety for many people, including those who were already receiving PMHC or in need of it. It is possible that some MTurk workers had COVID-19–related factors in mind when responding to items about postponing or avoiding care.

Finally, we note that PMHC use is one of many mental health management strategies. Health services researchers and public health surveillance efforts typically assume that PMHC utilization is the principal measure of mental health care. However, Black sexual minority people and members of other marginalized communities often embrace less traditional mental health management strategies that are not captured in these measures (e.g., community-based supports, less formal conversations with faith leaders or barbers) (35, 36). Not all PMHC meets the needs of members of marginalized communities, and less traditional strategies for managing mental health may be sufficient alternatives to professional care. Future studies should use both qualitative and quantitative approaches to examine how Black sexual minority individuals choose to manage their mental health, the benefits and challenges of informal systems of support, what makes traditional service utilization more appealing or less appealing, and the effectiveness of less traditional strategies.

These findings highlight the rates at which and reasons why Black sexual minority adults postpone or avoid PMHC. Each of the reasons identified presents opportunities for professional development among providers and creation of systemic policies to make PMHC more equitably available to all persons, regardless of race or sexual orientation.