The mental health experiences of LGBTIQA+ people, kink-oriented people, and sex workers in rural and remote Tasmania

From penitentials to the medical model, sex, sexual, gender, and erotic difference has long been pathologised resulting in scientific righteousness, criminalisation, and pervasive systemic stigma and discrimination. Over the last two decades, society has become increasingly mutable as people and lexicon evolve. As a result, research into mental health includes lesbian, gay, bisexual, transgender, intersex, queer/questioning, and asexual (LGBTIQA) people, and people with other sexual orientations and gender identities (+). The inclusion of kink-oriented people and sex workers in research into mental health, however, has been a little slower. The foci on whether or not kink is a psychopathology and if sex work is a public health concern were a bit more entrenched, thus, scholarship has been slower to progress. Current research into the mental health of people who are LGBTIQA+, sex workers, and/or kink-oriented is more comprehensive, yet no research could be found that examines these populations in combination, despite their shared, compromised access to the human right of bodily autonomy. Furthermore, no research could be found that examines these populations‚ÄövÑv¥ mental health or service use in rural or remote areas. Investigations into the mental health status and related service experiences of LGBTIQA+ people, sex workers, and/or kink-oriented people in rural or remote Australia is absent from national health research and policy. In light of the well-documented impacts of minority stress, social exclusion, stigma, and discrimination, and the health disparities of rural populations, this gap is glaring. The aim of this research was to investigate the mental health of LGBTIQA+ people, kink-oriented people, and sex workers with preexisting mental health issues in rural or remote Tasmania as it pertains to psychological support. The aim was explored via five research questions relating to the target populations: 1) mental health status; 2) risk and protective factors; 3) mental health service uptake; 4) barriers to help seeking; and 5) factors that facilitate uptake. Inclusion criteria required that participants be current or former sex workers, and/or LGBTIQA+, and/or kink-oriented; be 18 years of age or older; be current or past residents of rural or remote Tasmania; have experiences with mental health issues; have used related formal or xix informal support; have functional English literacy; and have access to a telephone, and/or smart device or computer. A mixed-methods research approach consisting of a triangulation design-convergence model was used. Two systematic literature reviews were conducted to identify existing research. Semi-structured interviews and a survey were conducted concurrently. Recruitment was multipronged, consisted of purposive, convenience, and snowball sampling, and was conducted via emails, Facebook, a poster, telephone calls, in-person discussions, third-parties, and self-selection. Interviews (N = 33) were held in person or via telephone and consisted of 26 questions. The online survey (N = 78) contained 174 questions, including 10 for the Kessler Psychological Distress Scale (K10) and 6 for the Brief Resilience Scale (BRS). Due to technical error, n = 65 survey participants completed the K10 and the BRS. Three papers resulted from the dataset: a qualitative sex worker paper and mixed methods LGBTIQA+ and kink papers. NVivo software was used to transcribe and manage all interview data. Qualitative data was analysed thematically via line-by-line coding, code refinement, collation, aggregation, and revision to produce a descriptive narrative summary. For the LGBTIQA+ paper, quantitative survey data were analysed via descriptive statistics to establish demographic and psychosocial profiles, help-seeking experiences, and factors associated with psychological distress and resilience. Bivariate correlations were performed for all variables against K10 and BRS scores to determine those significantly associated with each measure. Descriptive statistics were used to analyse quantitative data in the kink paper, which facilitated pattern and trend identification. Across both measures, mental health status was gauged via issues reported, comorbidity, and suicidality. K10 and BRS survey findings also informed mental health status. Of the 23 total reported diagnoses, anxiety and depression were the most prevalent: anxiety was highest in heterosexual participants (n = 17; 88.2%) and depression was highest in transgender participants (n = 29; 93.1%). Comorbidities were rampant among all participants, with sex workers (n = 12) reporting the most (100%). Suicidality was highest in transgender participants (72.4%) and lowest in sex workers (25.0%). With a mean score of 31.9/50 or very high, distress was highest in transgender, kink-oriented (n = 52), gay (n = 11), and asexual (n = 11) xx participants. Distress was associated with lacking social support, younger age, outsiderness, and violence. With an average BRS score of 2.96/5.00 (SD = 1.02), our participants had low resilience overall. Low resilience was associated with outsiderness and lacking social support. Normal resilience, which 52.3% scored, was correlated with social support, self-pride, community belonging, and having a kink orientation. Across both measures, risk factors included social exclusion, stigma, isolation, forced secrecy, identity concealment, and discrimination. Resilience, self-awareness, self-care, and social inclusion were protective factors for both interview and survey participants and encouraged help seeking. Almost all (98.7%) survey participants and N = 33 interviewees consulted a mental health professional (MHP) at some point. Six interviewees reported not having seen an MHP in rural or remote Tasmania. Interviewees had more negative than positive formal help seeking experiences. A negative formative experience with an MHP, ineffective or ignorant MHP, a lack of tailored or culturally competent support, faith-based services, stigma, cost, an absence of services, waitlists, or too few MHP were barriers to care cited across both measures. Self-awareness, duty to others, social acceptance, culturally competent MHP, less-than-full-fare services, and proximal services facilitated help seeking for interviewees and survey participants. Although having a preexisting mental health issue was an inclusion requirement, our participants‚ÄövÑv¥ mental health existed on a continuum. Results from this research suggests that sex work, a kink orientation, and being LGBTIQA+ generally improved our participants‚ÄövÑv¥ mental health, but exogenous oppressions worsened it. Specialised curricula and services could help reduce disparities, but could also be minoritising in that they could indicate that knowledge about sexual orientation, gender identity, and/or sexual difference in mental health services is only important for some. Universalising curricula, services, and public education campaigns and decriminalising sex work could start to ameliorate harmful stigma against and treatment of people with sex, sexual, gender, and erotic difference. Endemic rural constraints such as reduced proximity to services, social conservatism, discrimination, stigma, and identity concealment can isolate people who are marginalised from vital social support and communities, worsen mental health, and breed help-seeking avoidance. Acceptance, access and proximity to care, and MHP xxi cultural competence would greatly benefit rural and remote Tasmanian LGBTIQA+ peoples‚ÄövÑv¥, sex workers‚ÄövÑv¥, and kink-oriented peoples‚ÄövÑv¥ mental health.