1 Background

Compelling evidence demonstrates that Lesbian, Gay, and Bisexual (LGB) populations have a higher prevalence of mental disorders compared to their heterosexual peers (Meyer 2003), as they are 1.5 times more at risk for depression, anxiety and substance abuse and are twice as likely to attempt suicide (King et al. 2008; Fulginiti et al. 2020). Meyer’s model previously excluded the transgender population (Meyer 2003), although more recent research shows that they also have a disproportionate degree of mental health conditions compared to their cisgendered peers (Connolly et al. 2016)including suicide (Adams et al. 2017), anxiety (Reisner et al. 2016), depression, self-harm and eating disorders (Hughes et al. 2021).

Meyer’s model theoriss that stressors are generated from having a minority status which overlaps with the circumstances of their environment, leading to negative mental health outcomes (Meyer 2003) (Fig. 1).

Fig. 1
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Meyers (2003) original model

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Since establishing this model in 2003, there have been significant socio-political events that discriminate against SGM individuals, suggesting that a revision of the model is necessary. Since Putin’s return in 2012–2013 there has been a ban on “propaganda for non-traditional sexual relations” (Edenborg 2020). Currently, Scottish changes regarding laws for transexuals has been met with controversial responses, with Ministers fearing it will lead to “gender tourism” (Sky.com 2023).

During Donald Trump’s presidency of the United States (2016–2021), he refused to sign statements in support of marriage equality and transgender rights, as well as putting anti-LGBT agendas into extremely influential and lifetime positions. For example, he appointed federal judges including Jeff Mateer to the U.S District Court, (who openly supports conversion therapy), and supreme court roles (who now have the power to block progressive law for the next decade (Brownworth 2021)) including Neil Gorsuch (who opposes same sex marriage and crucial medical treatment to transgenders) (Brownworth 2021).

Since the election there has been significant reversal of transgender accommodation and healthcare (Bockting et al. 2020) and civil rights and diverse family erasure has intensified (Lebow 2018). Aligning these events with the Minority Stress Model, the increase of socio-political discrimination (which would be distal stressor), through several processes, could lead to negative mental health outcomes.

1.1 Current research

Meyer’s model received criticism from rival hypotheses about SGM mental health disparities, namely Feinstein (2020) and Bailey (2019).

Feinstein (2020) extended Meyer’s model by including “Rejection Sensitivity” theorising that SGM individuals with negative mental health have a cognitive-affective processing disposition in which they anxiously (or angrily) expect rejection. This leads to readily perceiving rejection in the presence of minimal or ambiguous cues, intensely reacting to perceived rejection, and finally, due to the anticipatory emotions, eliciting the stigma they expected (Feinstein 2020). Feinstein (2020) did not mention gender minorities in this extension.

Other theories, such as psychoanalytic, have traditionally pathologized homosexuality as either biological or developmental mistakes (Condorelli 2015). Bailey (2019) states that biological causes could be directly linked to SGM mental health disparities, specifically ‘neuroticism’ in gay men. Bailey (2019) opposed the directionality of the model (discrimination causes mental health issues) instead suggesting that non-heterosexuals, through the lens of having mental health problems, “merely perceive more experiences of stigmatization”. Bailey doesn’t discuss the transgender population as a whole but does theorize with colleagues that people with gender dysmorphia might be “more likely to misperceive neutral events as stigmatization” (Bailey 2019). In both examples, suspicions about the reported experiences of stigma have been raised.

While there have been a notable number of systematic reviews about minority stress and its impact on mental health and wellbeing (which include gender minorities), they have been predominantly quantitative reviews researching prevalence and associations (Livingston et al. 2020; Ferlatte et al. 2018). Bostwick et al. (2014) noted that his findings indicated the “complexity of the relationship between discrimination experiences and mental health”. Therefore, statistics alone might not cover all we need to understand minority stress, and full, rich context of these experiences is needed. Even though qualitative reviews have explored some health needs and coping strategies of minorities (i.e., McCann and Brown (2019; Smith et al. 2022) there is no current qualitative systematic review exploring the Minority Stress Model and its impact on mental health.

Furthermore, although Meyer’s model has been built upon by researchers to explore new and extended models for gender minority stress and resilience (Testa et al. 2015; Toomey 2021), no review has explored how well gender minorities—such as transgender and non-binary individuals—experiences fit into the original model. Therefore, this review will aim to include gender minorities into Meyers original model for the first time since it was first posed in 2003, exploring whether these experiences align with Meyer’s minority stress model (2003). Having more conceptual and explanatory frameworks to understand the mental health experiences of gender minority people is crucial as we learn about mental health disparities with this group. For example, Fulginiti et al. (2020) state that there is a 1.5 increased risk of suicide, depression, anxiety and substance abuse in sexual and gender minority youth.

2 Research question

What are the experiences of minority stress amongst SGM, LGBT individuals, and to what extent do these align with Meyer’s minority stress model (2003)?

3 Methodology

A systematic review was conducted using Meyer’s model (Meyers 2003) as a deductive framework however original themes can still generate organically through thematic analysis (Braun and Clarke 2006), creating a ‘hybrid approach’.

3.1 Search strategy

The following databases (see Fig. 2) were searched between April and July 2021: (see Fig. 2).

Fig. 2
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PRISMA diagram

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Search terms entered were: ((LGBT*) AND (Minority Stress*) AND (Perceptions*) AND (Qualitative*)).

The following exclusion criteria was applied manually:

  • English language only

  • Papers with participants under the age of 16 were excluded as it is assumed that parental consent wasn’t needed, decreasing the risk of being ‘outed’ to family members (Paceley et al. 2020). 16 is also the age of (medical and sexual) consent in the UK (NHS 2021).

  • Papers published before 2016 were excluded. The criterion only specifies the year to incorporate multiple socio-political events.

  • Studies were not excluded based on geographical location to ensure the maximum retrieval of literature as LGBT research is an under researched area (Arnull et al. 2021; Gorcczynski and Fasoli 2020), where exclusion based on location may impact this work's engagement with published research. Although this could create a heterogeneous socio-political context across analysed data, the limited range of research to draw upon to begin with is a wider scholarly issue and makes full inclusion of geographical areas a pragmatic decision. To contextualise the social climates for SGM individuals in the various countries, the ‘Social Acceptance of LGBT Ranking’ (Flores 2021) has been included for each country in the study characteristics (Appendix 4) (Table 1 and 2).

Table 1 Search terms
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Table 2 Criteria (SPIDER)
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3.2 Quality assessment

Quality assessment was done using a qualitative papers checklist (CASP 2020). The researcher devised a scoring system for evaluation (1 = Yes, 0.5 = Unsure, 0 = No). The scores ranged from: Low (0–5); medium (6–7); and high quality (8–10). Results can be found in “Appendix 1”.

3.3 Data extraction

Extraction sheets, created by the researcher, captured sample characteristics including age, race, and sexual orientation/gender minority. Study characteristics including aim, geographical location and design were also extracted. Both templates can be found in the “Appendix 2”.

3.4 Data analysis

A narrative approach was used to synthesize the data, with thematic analysis translating the data in the final stage (Braun and Clarke 2006).

The data set was read three times then free coded; all were recorded. Several themes were generated which didn’t match any individual paper’s research aims.

3.5 Author’s positionality

Multiple theoretical perspectives require the positionality of the researcher/author to be specifically stated to increase the trustworthiness of their work (Hackman et al. 2020). Therefore, I, the principal researcher (BM), recognize that the interpretations of the findings are informed by experiences generated by several variables, including being a White British, cis-gender female, and bisexual. The researcher recognizes that the overall narrative presented in this review has, undoubtedly been influenced by the researchers position to a degree, and has equally enriched the emergent thematic analysis. The author is confident that the deduction of data to Meyer’s model and specifically the core themes of discrimination and circumstantial stress would have been generated to a non-SGM researcher, as the model defines them so clearly. The author considers that her position afforded a conceptualization of new emerging sub-themes including conditional support, vigilance, and minority identity socialization.

4 Results

All sixteen eligible papers passed quality assessment using the CASP tool (2020; see Appendix). There were 305 number of participants across studies, of which 169 identified as transgender (Appendix 3).

4.1 Qualitative analysis

4.1.1 Key

L = Lesbian; G = Gay; B = Bisexual; T = Transgendered; NB = non-Binary/ Gender fluid; LGB = Broad term was used

Categories from Meyer’s model

Superordinate theme

Sub-themes

Examples

(A) Circumstances in the environment

And

(D) Minority Stress Processes (Distal): Prejudice Events

(1) Discrimination

1.1 Discrimination in Healthcare

‘Doctors act confused and ask if the father was still involved in [our child’s] life’(P1[L])

Doctor repeatedly ignored my partner and asked invasive questions about “the father,” even though we used a donor and had ensured that this was clearly indicated in our kids’ files (P1[L])

[Therapists] ‘pathologize my trans as being neglected at home [and] abandonment issues’ (P8[T])

‘[University] Health staff are ignorant of queer issues’(P12[LGB])

[counselling services] ‘were terrible, and pretty much only take you if you’re suicidal’ (P12[LGB])

1.2 Discrimination in Politics

‘It’s already scary to go outside…. It now just feels like the government is keeping you down and telling you that you don’t have rights, you shouldn’t exist… How can you possibly feel safe in that?’ (P5[NB])

‘To me, if your own country's not going recognise your relationship, then that's a country that doesn't see you as being equal to other people…’ (P2[G])

It's offensive…to debate whether I should be allowed to take part in something that's so central to being human (P2[G])

'It's about losing rights, to change names, change genders.' (P5[T])

1.3 Racial Discrimination

‘… we’re rejected because of two things, Latino, and lesbian. It’s double … It’s even harder.’ (P14[L])

‘It’s harder to come out as transgender if you’re black’ (P11[T])

[Client blacklists for sex workers] “because of racism trans women of colour are not included in those groups, so they don’t get to have access to those safety mechanisms” (P6 [T])

1.4 Discrimination in Consumerism

I’ve been in restaurants where the service that I’ve received was completely different from what other people received. Gruff and hostile … Clothing or perfume stores, there’s always the “Why should I give you any kind of help? This is my store, it’s not a joke.” Well, that’s saying that I’m a joke.” (P11[NB])

‘The landlord wanted me gone and people are living with their wives and children, and we had no right to stain their privacy with our dirty sexual orientation’ (P10[G])

‘My father kicked me out for being trans …spent several months homeless’ (P8[T])

‘Expelled from my dorm for being gay’ (P6[G])

‘I got fired…manager told me they hadn’t needed a man with lipstick.” (P10[T])

‘One job I had in a group home for HIV-positive folks, I was not allowed to collect urine samples’ (P11[T])

(2) Lack of representation

2.1 In the legal System

‘If we’re left out of laws, or demonized in them, we can’t expect people at home would think any different’ (P9[LGB])

‘If the Affordable Care Act gets repealed then a lot of people are gonna die….’ (P5[T])

[Azadi stadium, that banned women]

I was beaten so hard that I saw death in front of my eyes… he had no right but when there is no law {related to transsexuals}, anyone does whatever they think is right. (P10[T])

I’m a female, I’m gay, and I’m Latina, and he’s [Trump] in power. And I felt so scared…(P14[L])

2.2 In the media

‘…we don’t say he’s gay. We don’t talk about his boyfriend…. He’s there for comedic support, like [a] token Black guy kind of deal’ (P14[G])

[transgender characters] ‘disgusted reaction…or comic relief roles’ (P11[T])

A young Black trans woman was killed, …they mis-gendered her… consistent reminders that she was homeless and a prostitute, and it was like, “These are all the list of reasons why it doesn’t really matter that this woman is dead” (P11[T])

2.3 In education

There was a lot of educating [that we had to do] … It’s not really the burden that it used to be when I was a kid, because we’re educating each other all the time. Whether it’s like, “Okay we’re gonna do a presentation on being Asian or being transgender…” (P11[T])

‘Teachers said AIDS was caused by gay men’ (P4[T])

‘No Trans sex ed,’ (P4[T])

‘Trump’s attack on trans youth and education’ (P5[T])

I wrote a speech for class about … transitioning or about bathroom policies—but [the professor] said that it was not an appropriate topic …. He was like,’It’s too emotionally involved …. People can have too many reactions to it,’ and he docked my grade. (P8[T])

a. Minority status

(3) Navigation of (Multiple) Minority Status

3.1 In public Spaces

My experience of college has become a lot about... navigating “Who do my friends know is a good professor?” and being very selective about classes. (P8[T])

People look at me strangely. Until I change clothes, and they see, ‘Oh, it was a girl,’ But, if I go into the guys’ changing room, it’s the same thing, but in the other direction (P7[T])

‘Felt safer when I was pregnant…more easily identifiable as female’ (P1[T])

[Bathroom bill]: Everyone was debating whether or not trans people were dangerous…just kind of like a weird, sexual being that shouldn't be allowed in public spaces with other people. It was just a huge debate about, pretty much, whether trans people should be allowed to exist in public or not. (P4[T])”

‘Find a closed family bathroom’ (P4[T])

‘So much resistance calling me by my name” (P4[T])

‘Reported to campus police for using “the wrong bathroom”’ (P8[T])

You can universally make a joke about a Trans person and the general public will think it’s hysterical- because we’re viewed as freaks’ (P11[T])

‘Got kicked out of church ‘(P4[T])

‘Learned not to be sporty’ (P16[T])

‘We’ve never been socialized in those changing rooms’ (P16[T])

‘I jumped off a very tall wall. Even other men were surprised and warned me it was dangerous. I wanted to prove my manliness’ (P10[T])

‘I was trying hard to look charming–-friends said I had been trying to attract men’s attention like prostitutes’ (P10[T])

Our kids call us ‘mom’ and ‘ma’ wherever we are -and we get outed by our kids. Strangers will stare …I don’t have the opportunity to control the disclosure and I have started to talk to our kids about this potential risk (P1[L])

3.2 In LGBT Spaces

“they’re so over the top [Other gay fathers] …. scoring this well on tests… got her an iPad…” (P3[G])

“The LGBT community can sometimes be very exclusionary, which almost makes no sense given that their whole sort of message and ideology is openness and celebration of diversity… they’re the ones who are like ‘No fats, no femmes, no Blacks, no Asians.’” (P14[LBG])

‘You can’t really cut alcohol out and still go to gay bars. It’s not compatible’ (P15[G])

‘Felt pressure to identify as pansexual rather than bisexual, implying bisexuality was not enough’ (P13[B])

‘The stereotype that “bisexual people are more promiscuous” is prevalent within the LGBTQ + community and people might dismiss an assault in saying that the survivor “obviously wanted it”’ (P12[B])

… had no business being an activist unless [they were] actively dating another woman… take an ally position instead. (P13[B])

3.3 Vigilance

‘I’m hearing stories of increased hate crime…with the election of Trump’ (P5[T]),

‘We’re always thinking about safety’(P1[L])

‘Feeling hypervigilant’ (P9[LGB]),

‘I’ve lived through this before, which is where my [grave] concern of people who haven’t been exposed to this [homophobia]’ (P2[G])

‘It’s so normalised in me that it becomes second nature to think about stuff like that’ (P7[T])

(f) Minority Stress Processes (Distal):

(4) Harassment

4.1 Verbal harassment

‘Too pretty to be a lesbian’(P6)

‘Stop playing hard to get, you’re not even really a woman’ (P6),

‘they’re gonna rape you, hit you, cut you, throw you into the river’ (P10)

‘All trans people are perverted’ (P11[T]),

“you people are just trying to escape military service”’ (P10[T])

You look so ugly… like a voodoo doll’ (P6[T])

‘Walk and speak like a man’ (P14[G])

4.2 Objectification

‘let’s have a threesome!’(P13[B])

‘loosing agency’ (P6[T])

Someone stood in front of me in the restroom at school, and he said, “Are you gay?” And I said “yes,” and took out his [penis] and said “oh, suck it.” (P14[G])

‘People treat us as a doll … they can remove clothes; dress us… see us as inanimate object... you don’t have any control over what’s being done to you. You don’t ask a doll what kind of dress she wants.’(P6[T])

4.3 Physical harassment

‘groped’ (P6[T])

‘Spat on my heels’ (P6[T]),

‘I was quite violently sexually and physically assaulted … three blocks who had been harassing me…they were waiting when I got back from the reception.’ (P6[T])

(Proximal)

(5) Depersonalisation

 

You don’t wanna disappoint your mom, or you don’t wanna make your dad so angry that they don’t talk to you’ (P14[G])

‘I have to tone down the gayness’ (P14[G])

‘I keep my personal life, if I’m dating a guy, separate from the life that I have with activism’ (P13[B])

‘If a guy hits on me and finds out later…he’ll be mad. I try to avoid that’ (P6[T])

[During marriage debate] ‘I need to stay away from Facebook’ (P2[LGB])

‘I was dating a guy and had to lie to everyone’ (P15[G])

‘[being a minority] becomes stressful and requires time for recovery. I need to rest and just be with safe people or be alone’ (P7[T])

‘Survivors may believe they “deserved” assault because of their identity’ (P12[LGB])

‘You think no one else is going to be with you…. you tolerate so much of the abuse’ (P6[T])

(I) Mental health outcomes

AND

(h) Coping and social supports

(6) Mental health outcomes

6.1 Depression and low mood

‘[I’m] not normally a teary person’ (P2[LGB])

‘wouldn’t leave home for months’ (P10[T]),

‘[I] didn’t feel like eating and even when I’m thirsty I won’t get up to drink some water’ (P10[T])

‘I have no motivation to live. I have no love, no hope, no future” (P10[T])

‘… it comes to the point where my depression gets so bad, I go … I could take my life’(P5[T])

“Every time the groom’s family found out about my sex change surgery, everything ended sadly … now I’m not considering marriage anymore because I get depressed for a year after every relationship.’ (P10[T])

6.2 Stress and anxiety

‘It’s stressing me out, and I’m smoking more’ (P15[LGB])

‘Too stressed to sleep’ (P5[NB])

‘[being a minority] becomes stressful and requires time for recovery. I need to rest and just be with safe people or be alone’ (P7[T])

6.3 Body image and appearance concerns

‘People who pass [as cis-gendered individuals] get treated better’ (P6[T])

I had a much better senior year, because … I could pass as a dude all the time (P8[T])

‘I felt a disconnect with my body and loathed it’ (P15[T])

‘I don’t take my clothes off to shower’ (P10[T])

‘The way that we advertise to women is that everybody wants to be a white woman. We don’t show any kind of variety, which directly impacts what kind of beauty ideals you might be going for in your own transition’ (P11[T])

You look so ugly… like a voodoo doll’ (P6[T])

Too pretty to be a lesbian’(P6)

6.4 Positive coping mechanisms

‘[Black lesbian support group] that was a specific place to release my stress’ (P14[L])

“[Support groups] It's really good. I've got to meet a lot of kids that I relate to, and it's nice to see that I'm not alone, … It feels like home.” (P4[T])

‘I often say that the queer bubble has saved my life”’(P7[T])

It’s both fucking depressing but also very sustaining to be able to recognize yourself in each other’s stories (P7[T])

It’s a catch 22 … I want to stand up for myself and my people, but at the same time it’s not great for my own well-being to be privy to some of the hateful speech that’s come through (P2[G])

‘a great sense of hope … there’s people who think like I do… and I know that’s increasing … so I still feel hopeful’ (P2[L])

I have been more empowered to express my anger, to stand up for myself and to say I don’t deserve to be treated like this. So, I feel like if more people are empowered to stand up for themselves, that can affect wider social change (P5[T])

6.5 Negative coping mechanisms

It’s stressing me out, and I’m smoking more’ (P15[LGB])

‘The idea of having to come out drove me to drink.’ (P15[T])

don't meet new people anymore, … Cause I just don't wanna get hurt …. I start on a more intense level of distance …(P2[L])

‘I have been using sanitary pads since I was 13. I try to make the pad bloody even by wounding my genitals with a razorblade.’ (P10[T])

4.2 Thematic analysis

Thematic analysis generated five superordinate themes (Discrimination, Lack of Representation, Navigating Multiple Minority Statuses, Harassment, and Mental Health Outcomes) and 20 sub-themes. Each superordinate theme and the corresponding sub-themes were then situated within the relevant category or categories from Meyer’s original model.

4.2.1 Discrimination

The first superordinate theme was Discrimination, which was felt to fit within Meyer’s categories of (A) Circumstances in the environment, and (D) Minority Stress Processes (Distal): Prejudice Events.

Four sub-themes emerged, including: discrimination in healthcare, legal systems, consumerism, and racial discrimination. For example, participants across the studies reported discrimination in health care systems. They were constantly compared to a heterosexual norm (‘asked about the dad’), were ‘pathologized,’ or services were poor if available at all. These interactions and assumptions continue to normalize cis-gendered and heterosexual narratives whilst othering SGM experiences.

Participants also described discrimination in the legal system where they are ‘losing rights’ and not being seen as ‘equal’. Laws that discriminate against them ‘taking part in something that is so central to being human’ continuously sends the message that their government is against them telling them ‘They shouldn’t exist,’ which leads to them feeling unsafe. They also discussed how a right that is given to a heterosexual, cisgendered citizen automatically, being debated when it applies to your identified group, is itself an ‘offensive’ distal event.

Racial discrimination was also examined throughout the data set. Exploring the ‘double rejection’ of Latino lesbians and black transgendered people, highlighting multiple minority status. Already belonging to one minority ‘black’ makes ‘coming out’ as another minority ‘transgender’ ‘even harder.’ The most disturbing example being transgender sex workers left out of blacklists and safety mechanisms. The concept of multiple minority identities compiling also appear in later themes of media representation and body ideals.

Participants experienced various social exclusions, including employment exclusion such as being fired, or their job being altered due to their LGBT identity. This can be referred to as discrimination in consumerism, as participants described receiving a different experience from the norm when at restaurants, stores, and housing. Participants described being evicted by prejudice landlords and family members. Many of these examples were unmistakably due to the participants minority status ‘gay men could collect samples, but I couldn’t,’ ‘didn’t need a man with lipstick,’ ‘had no right to stain their privacy with our dirty sexual orientation.’

4.2.2 Lack of representation

Lack of representation was highlighted throughout the data set. which also was felt to fit within Meyer’s categories of (A) Circumstances in the environment, and (D) Minority Stress Processes (Distal): Prejudice Events.

Three sub-themes emerged, including lack of representation in the legal system, in the media, and in education.

A lack of representation in the legal system doesn’t refer to legal issues being debated, as found in the above theme, but participants not having legal representation at all. Participants showed concern over but ‘being left out of laws,’ laws being ‘repealed’ and the consequences this will have for the LGBT community: ‘people are going to die,’ ‘[there will be] demonization’ and generation of ‘fear.’ The most violent example is a transgendered participant who was ‘beaten’ in an Azadi stadium and had no legal backing.

LBGT characters also have a lack of representation in the media, with LGBT protagonist being rare, and often appearing as ‘the token gay guy,’ ‘comic relief’ side characters, or someone the protagonist has a ‘disgusted reaction’ to. In non-fiction media, such as the news, reports about LGBT victims contains ‘lists of reasons why it doesn’t matter their dead.’ Therefore, underrepresentation in the media and law means SGM individuals aren’t ‘normalized’ in any of these categories.

Finally, data showed a lack of representation in education for LGBT participants. A lack of information about minorities, leads to a role of ‘educator’ for members of minority groups, which was described as ‘a burden’ and lifelong by one participant, as they describe having this role as a child, even if they got more used to it throughout their life. Participants also found that typical systemic sources of knowledge didn’t offer education in return, explaining that there is ‘no Trans sex ed’ or they received misinformed education such as ‘AIDS were caused by gay men.’ Participants were also told that Trans issues had no place in educational settings because ‘people can have too many reactions to it’ and had their grades docked. Participants described ‘Trumps attack on trans education’.

4.2.3 Navigation of (multiple) minority status

Aligning with Meyer’s category a) Minority Status, this theme explores the realities of navigating a minority status, and sometimes more than one, in a cis-heteronormative society.

Navigating these statuses in public spaces, in LGBT spaces, and the vigilance needed in both were the three sub-themes.

Participants described navigating through several scenarios in public spaces, such as having to be ‘very selective’ about classes in college due to the professors and finding ‘closed family bathrooms’ to avoid being ‘reported for using the wrong bathroom’ or ‘being looked at strangely.’ One participant explained how this was an issue no matter which changing room they picked ‘same thing, other direction,’ and another described how she ‘felt safer when she was pregnant’ as she was more identifiable as a woman. These participants are made to feel that they are breaking ‘a secret societal rule: gender must be readable at a glance’ (Bockting et al. 2020).

Navigation through society became more difficult for participants during times of debate. Legal inclusion has been touched upon in the above theme ‘lack of representation,’ however one participant describes how during the debate ‘everyone’ was debating about Transgendered people and talking about them as ‘weird, sexual being that shouldn’t be allowed in public spaces with other people.’ Discussions in public spaces, outside of the courtrooms, escalated into debates about ‘whether trans people should be allowed to exist in public or not.’

Other public places made participants feel unwelcomed such as sports and getting ‘kicked out of church.’ Generic public interactions that participants described navigating included constant mockery ‘universally viewed as freaks’ and experience a ‘huge resistance to being called my name.’ Another navigation required was adaptive concealment, which one parent described being ‘outed’ by her kids ‘they call us mom and ma’ and they must talk to their kids about ‘this potential risk.’ This quote highlights the difference between discretion and concealment.

Another navigational issue that emerged pertained to LGBT spaces. Having a minority status is the concept of minority identity socialisation, which refers to learning how the sub-group that you identify with conducts themselves within society. For example, participants described that they ‘learned not to be sporty’ in large part due to ‘never being socialised in those changing rooms.’ The idea of not knowing how to act at first, has been identified in this data set by Transgender participants as an early pit fall to minority socialisation. Two participants described moments of over-compensating, where they ‘flirted like a prostitute’ or ‘jumped off a high wall’ to prove their manliness.

Participants described difficulty navigating LGBT spaces as an LGBT minority. This includes being competitive with other LGBT parents, an ‘exclusionary’ atmosphere with LGBT dating, and the main social events being based on alcohol, making it difficult for recovering alcoholic LGBT individuals to socialise. Bisexuals specifically reported struggles within the LGBT community, stating they ‘felt pressure’ to identify differently as ‘bisexuality wasn’t enough’ or being told they had ‘no business being an activist’ unless they were dating a woman, despite activism being a prominent coping mechanism [see ‘coping’ theme below]. The most disturbing example referred to the ‘stereotype that bisexuals are more promiscuous’ which can lead to assault being dismissed as ‘obviously wanting it.’ Overall, this section proves that there are still navigational issues within LGBT ‘safe spaces.’

Several studies illustrated the need for vigilance when you have a minority identity. The idea of being ‘hyper vigilant’ and ‘always thinking about safety’ has been ‘normalised’ into being ‘second nature.’ This intensifies during socio-political shifts including, Trumps election and marriage equality debate in Australia where participants heard ‘stories of increased hate crimes.’ Another older participant points out that he has been through this before and has ‘grave concerns’ for those who haven’t been exposed to this before. Proving that homophobia has been normalised through generations, which could further explain the need to be vigilant.

4.2.4 Harassment

The theme of Harassment also aligned with Meyers category (D) Minority stress processes (distal).

The sub-themes that emerged included; verbal harassment, objectification, and physical harassment.

Experiences of verbal harassment include catcalls such as ‘too pretty to be a lesbian’ or ‘stop playing hard to get’ the implications being that lesbians are ‘ugly’ and trans women should be grateful for the attention. The concept of ‘ugliness’ is joined to the idea of LGBT in other quotes such as ‘you look so ugly…like a voodoo doll’, as well as the concept of ‘manliness’ with LGBT members being told to ‘walk and speak like a man’ or being accused of trying to ‘escape military service’. Verbal harassment can escalate into threats of violence ‘rape, hit, cut you, throw you into the river.’

Being deviant from the societal sexual norm means being seen as sexually deviant. Inappropriate advancements were directed at bisexuals including ‘let’s have a threesome! This can lead to objectification. Participants reported that due to their sexual identity they were ‘expected to satisfy needs’ and ‘losing agency’ in sexual activity or they only existed for sexual pleasure ‘you have to suck [my penis].

Transgender participants were objectified down to being ‘dolls’ that get undressed and dressed without having ‘any control.’

Experiences of physical harassment included being ‘groped’ and ‘spat on,’ as well as more extreme physical violence, as one participant shared that they were ‘beaten within an inch of my life.’ Another disturbing example includes one participant being ‘violently sexually and physically assaulted.’

4.2.5 Depersonalisation continuum

Across the dataset, participants referred to depersonalising experiences that could be conceptualised as sitting on a spectrum of identity concealment to internalised stigma—this continuum as depersonalisation can be situated within Meyer’s category (F) Minority Stress Processes (Proximal).

Participants talked about concealing their identity from their family, so they don’t ‘disappoint’ or ‘anger’ family members. Other participants discussed compartmentalising parts of their identity whether they ‘tone down’ their identity or ‘keep dating separate from their activism’ or ‘lying to everyone’ about someone they are dating.

More extreme examples are participants who avoided certain things in their life entirely, including avoiding the internet because of online debates, or avoided being hit on so no one can ‘get mad’ at them, or avoiding everything due to the stress of being a minority needing time to ‘rest and just be alone’ or with people they deem safe.

Internalized homophobia is defined as ‘the gay person’s direction of negative social attitudes toward the self,’ (Meyer and Dean 1998. P. 161). The results expand this definition, renaming the concept internalized stigma. The most graphic examples involved participants who felt their sexual assault experiences were ‘deserved’ because of their sexual identity or lead participants to ‘tolerate abuse… you think no one else is going to be with you.’

4.2.6 Mental health outcomes

Aligning with categories (i) and (h) from Meyer’s model (mental health outcomes; coping and social support), the superordinate theme of ‘Mental Health Outcomes’ was generated from this dataset, with the following subordinate themes therein: depression and low mood, stress and anxiety, body image, negative coping mechanisms and positive coping mechanisms.

For example, many participants across studies referenced feelings of Depression and Low Mood such as crying, self-isolation, lack of motivation leading to self-neglect, hopelessness, and suicidal ideation. In addition, some participants alluded to experiences of Stress and Anxiety due to being “too stressed” to look after themselves, leading to risk-taking habits (i.e., smoking) and insomnia.

Furthermore, Body Image and Appearance Concerns were also a prominent sub-theme across the dataset. Many participants placed an emphasis on the impact that their appearance had on their mental health, which was mostly associated with the degree of ‘passing’ or their gender congruence. Disconnection from and avoidance of one’s body was also discussed, as well as the prominence of unwelcomed comments on appearance from others.

To manage these aspects of their mental health, participants shared both Positive Coping Mechanisms and Negative Coping Mechanisms. Whilst some utilised peer support groups which instilled hope and empowerment, others turned to substance misuse, isolation, and self-harm.

5 Discussion

This systematic review thematically analysed 16 eligible studies, which generated 6 superordinate themes (Discrimination, Lack of representation, Navigation, Harassment, Depersonalization and Mental Health Outcomes) and 18 sub-themes (Discrimination in healthcare, politics, consumerism and racial discrimination, Lack of representation in the legal system, media and education, Navigation in public spaces, LGBT spaces and vigilance, verbal harassment, objectification and physical harassment, depression, anxiety, body image, positive coping mechanisms and negative coping mechanisms.). These themes were then situated in categories from Meyer’s Minority Stress Model (2003) (Circumstances, Minority Status, Distal stressors, Proximal stressors, and Mental health outcomes).

All sixteen papers in the final stage of screening passed quality assessment with scores of 8 and above on the CASP tool. There was an over-representation of transgender participants in the overall sample (however, this is a strength as this group was previously omitted). Papers covered a variety of locations, but the majority were conducted in the USA.

5.1 Meyers model

This qualitative systematic review explored SGM experiences of minority stress and the impact on health and wellbeing and for the first-time included transgender participants into the original model from 20 years ago.

The results were integrated into Meyers model, which now included transgender experiences also integrated into these themes without any specific deviations. No biological or cognitive trends were found in the data, nor did any ‘neurotic,’ or ‘imagined’ experiences arise, as proposed by Bailey (2019, 2020) or seemed ‘imagined’, as all the stressors were rooted in tangible, evidence-based concerns. This suggests that the Minority Stress Model is the superior evidence base for understanding minority stress. These results provide validity to the original model due to using qualitative data. Real-world experiences were applied to the framework; therefore, logically, the framework can be applied to the real world. This makes a compelling argument for the model’s efficacy.

The results added context and expansions to the original Minority Stress Model (2003). ‘Circumstances’ were shown to include discrimination and lack of representation (P10) and extends to multiple minority identities. Participants navigated their minority identity through public and LGBT social spaces, and navigational issues such as ‘the role of the educator’ were identified in the results. Conditional support was highlighted by bisexual participants, leading to bisexual activism burnout.

Many distal events were identified in the data (verbal harassment, objectification, and physical violence). These distal events directly produced proximal stressors and vigilance, e.g., a need for hypervigilance after hearing stories of increased hate crimes during anti-LGBT social-political climates. Therefore, vigilance might be a better term than “imagined or elicited stress” (Feinstein 2020). Meyers’ model acknowledges that experience of antigay violence is likely to increase vigilance (Meyer 2003).

Queer theory underlines that speaking of homosexuality as a ‘disorder’ may be ‘nonsensical’ and may add up to create a ‘false problem’ (Condorelli 2015). Hence, it may serve the LGBT community better to view these stressors as non-distorted realities that individuals that contribute to poor mental health and wellbeing outcomes such as hypervigilance, low mood, and body image disturbance.

Figure 3 shows the fully integrated model. The original model is black, and the expansions are red.

Fig. 3
figure 3

Minority stress processes in sexual and gender minority populations

Full size image

5.2 Gender research

Various theories have been utilized to frame gender minority research; Queer theory argues that every expression of gender is political (Penney 2014) and is overall performative (Salih 2023). This purely social perspective doesn’t account for biological realities, for example the participant whose gender was perceived differently once pregnant (P1). Gender identity, as theorised by Romani, states that gender is an internal sense and is purely psychological (Romani et al. 2021). Which does not account for the social roles, such as the role of the educator (P11) that stems from having a minority status. Even anti-oppressive theories such as feminism defines it subjects based on sex (Mohammadi 2017) which struggles to adjust for transgender existence (Mohammadi 2017).

The DSM5 defines “gender dysphoria” as “a marked difference between assigned and expressed gender” (American Psychiatric Association 2013). However, participants in the data set felt overly policed on mannerisms and expressions, such as “walk and talk like a man” and cutting their hair short but “still feel like a woman” (P14). This highlights that the DSM5’s gender dysphoria definition is incomplete because it ignores these social circumstances that dictate ‘gender expression’. These circumstances can also change based on geographical locations e.g., women who are banned from football matches or from walking alone in (place) (P10). Would breaking these local rules be classed as expressing a different gender?

To get a holistic view, this review proposes utilising the biopsychosocial model. This model compounds biological realities (pregnancy; P1), social and political circumstances (all papers) and psychological outcomes (body dysmorphia, depression, suicidal thoughts; P10, P5, P15).

‘Contrary to general belief, even sex reassignment surgery is not purely biological, but requires emotional and social training appropriate to their reassigned sex to help them adjust to their society’ (Mohammadi 2017). This links to ‘minority identity socialisation’ where participants felt ‘unsocialised’ in their minority status. Further hypothesis of this concept is that it’s prevalent during times of development, including puberty or transitioning genders. This term could help individuals discuss vulnerable periods in their lives.

If biological factors as suggested by Bailey (2019) (although not found in data) or biological realities (as found in data) are presenting in any LGBT individual, the societal circumstances, and psychological outcomes, (that operate within Meyers framework) can’t be ignored.

5.3 Limitations

The qualitative data was secondary, which has limitations of possible misinterpretation and locating quotes out of their socio-political contexts (Walters 2009). However, this specific weakness has been addressed as the socio-political context of the quotes was one of the main research aims of the paper.

Self-selection bias should be considered as most participants self-selected to participate in the included studies, with limited transferability based on participant selection being an inherent function of qualitative research (Patton 1999). Grey literature databases were searched but no appropriate data was found, which leaves this paper open to publication bias. All papers were in English so language bias should be considered. Screening was conducted by one researcher (BM) as this project contributed to their MSc thesis, increasing the risk of selection bias. However, transparency of the method and analysis has been assured because the positionality of the researcher is clearly stated. A strength of this study is the inclusion of transgender participants, which adds originality to the model. This research, even with this inclusion, acknowledges the limitations in unequal representation of LGBT population groups within the drawn upon literature; there is need for further research to remedy this and sets limits on this work’s ability to engage with the spectrum of LGBT orientations, identities, and expression. Research challenging collapsed SGM orientations and identities within studies is of immediate concern (Zeeman et al. 2018), to untangle potential homogenous narratives, alongside attaining greater diverse population group sampling.

5.4 Future research

Whilst this review was a good starting point in highlighting experiences of minority stress, further research is required to achieve a deeper understanding of minority stress in different contexts, specifically, ‘education’, ‘minority identity socialization’ and ‘multiple’ minority stressors.