Therapists are in short supply in Wisconsin. That's especially true for trans patients and LGBTQ youths.

Note: A previous version of this article misstated the status of conversion therapy in Wisconsin. It has been corrected to reflect the current statute.   

When he first started seeing a new therapist years ago, Theo Lallaman knew from the décor alone he wouldn’t be able to come out to her as a trans man.

Crosses, religious texts and similar iconography adorning the office felt too close to home for Lallaman, who felt silenced by the church growing up in Green Bay.

A religious therapist conjured fears from his youth: being an outsider, a sinner and, worse, someone in need of conversion therapy, the practice of attempting to remove homosexuality, transgender or gender-nonconforming identity from a person's psyche.

As of this year, 20 states have passed bills prohibiting the practice of conversion therapy, but 15 states more recently have restricted gender-affirming care, a type of intervention designed to support and affirm someone's identity when it conflicts with the gender they were assigned at birth.

Wisconsin hasn't outright banned the practice of conversion therapy, but the Evers administration signed an Executive Order ordering the Wisconsin Department of Health Services, the state Department of Children and Families and the state Department of Corrections to disallow payment of state and federal funds for youth conversion therapy.

Lallaman, 25, has been in and out of therapy since middle school, vacillating between school-based therapists and social workers to better understand his depression, anxiety and self-harm.

"It's hard enough coming out as is with people who you're comfortable around. A lot of times in the medical field, they fixate on whether you were born male or female," Lallaman, who works at the Barnes & Noble in Ashwaubenon, said. "Sometimes doctors and therapists will tell me they know what's better for me, which is definitely tricky."

The high prevalence of mental health disparities in the LGBTQ community is the result of a few circular issues: the centuries-old school of thought that misdiagnosed mental illnesses in LGBTQ patients; the shortage of therapists in Wisconsin; and the trans population, considered the highest risk group for mental health conditions, who often don't seek treatment, citing mistrust and a lack of culturally appropriate services.

Statistics show only about half of the people with mental health symptoms seek treatment. That proportion is even lower for the LGBTQ community, which suffers from higher rates of anxiety, depression and suicide than other groups.

In states like Wisconsin, which has an acute shortage of mental health providers, finding a therapist trained to work with LGBTQ patients is even more difficult.

"We wish there were more LGBTQ therapists available for people to see," said Kathy Flores, director of Diverse + Resilient Appleton, a Wisconsin support and advocacy organization. "It's extremely important because when you're in an emotional crisis, you need emotional support. The last thing you want to have to do is educate somebody about your identity."

Changes come to therapy profession slowly

Historically, the medical community misdiagnosed LGBTQ identity as a mental disorder. It was only nine years ago the American Psychiatric Association stopped pathologizing homosexuality and gender identity.

The APA's fifth volume of the Diagnostic and Statistical Manual of Mental Disorders removed the conflation of mental disorders with being LGBTQ and introduced gender dysphoria — when a person experiences discomfort or distress between their biological sex and gender identity — into the profession.

Gender dysphoria was previously classified as gender-identity disorder, which the association reframed after recognizing the stigma and prejudice that came from framing gender identity as a "disorder."

Still, shifting language is only the first step, said Kathleen Schiltz, a licensed marriage and family therapist who runs the LGBTQ consult at Prevea Health, where she provides trainings on LGBTQ-affirming practices at Prevea University, a professional development program established for employees.

"As we challenge the community, we challenge our providers to do better," Schiltz said. "There's a lot of better training now, but the question I always pose to folks is whether we would have such a high prevalence of these disparities if the culture were different or if our environment supported us?"

Therapists are in short supply in Wisconsin. According to the Wisconsin Department of Safety and Professional Services, between in- and out-of-state professionals, there are 5,540 licensed professional counselors, 4,383 licensed clinical social workers, 2,055 psychologists and 926 licensed marriage and family therapists.

Put into context, and considering that licensed psychologists occupy a range of academic and not necessarily clinical positions, 68,324 Wisconsinites used mental health services in 2020, the last year of comprehensive data. Nearly half of all clients sought crisis intervention, the No. 1 need for services.

Specializing in gender-affirming therapy is even rarer, and it isn't an intervention method that the state licenses. This type of therapy comes from internal education and training, much the way, for example, some licensed architects specialize in commercial buildings while others focus on landscaping.

A 2019 report from the University of Wisconsin Population Health Institute that examined gaps in the state's behavioral health system found that, of the conditions that contribute to behavioral health gaps, 57% of mental health respondents said providers are not culturally matched.

'I didn't even feel like the same species'

Growing up on a farm in Oostburg, a village in Sheboygan County, Jasmine Lammers didn't meet her first openly queer person until she was 20 years old. It would take another decade for her to realize herself as a transgender person.

"By the time I met a gay person, my identity formation had already occurred and I didn't really understand myself," Lammers said. "I didn't even feel like the same species as the people around me."

What began as a lifetime of trauma worked its way into an object lesson for Lammers. She went from struggling to understand what she wanted to do with her life to obtaining a counseling degree to specialize in gender diversity and sexuality affirming therapy. She started practicing therapy in 2016.

After years of hiding, she made it her mission "to be visible on purpose" when she opened her Manitowoc-based LGBTQ counseling clinic, Transformative Services LLC, a year and a half ago.

Lammers is one of three therapists in northern Wisconsin whose experiences as a trans person inform her counseling services. That background allows her to speak to her clients with a true-to-life comprehension of baseline societal discrimination, from the most blatant displays of hate to the more subtle forms of harm.

Suicide among LGBTQ youths, Lammers said, decreases by 90% when adolescents have support structures in place, and the addition of a counselor who is both educated in therapy and gender diversity goes a long way for patients consumed by rejection and discrimination.

Sarah Bassing-Sutton, community suicide prevention coordinator at N.E.W. Mental Health Connection, said recent surveys conducted in partnership with the Medical College of Wisconsin demonstrated that people who identified as LGBTQ in Outagamie, Calumet and Winnebago counties are less likely to seek help from a health care provider or family members and friends when they're experiencing mental health concerns.

People in the LGBTQ community also have a higher propensity for engaging in self-harm practices such as cutting and other self-injurious behaviors, contemplating suicide and suffering from anxiety and depression compared with cisgender heterosexual individuals, Bassing-Sutton said.

"They are a group of individuals who really don't know where to reach out for help and who a safe, helping professional might be, compared to those who don't identify as LGBTQ," Bassing-Sutton said.

LGBTQ patients discouraged by gap in culturally aware providers

A report from the nonprofit Mental Health America found that, in 2019, 20% of adults who reported having a mental illness weren't able to seek treatment. The most recent report, published in October 2021, reveals that half of all adults didn't receive treatment.

Those numbers look bleaker for LGBTQ individuals, where 86% of LGBTQ youths ages 11 to 17 screened positive for a mental health condition.

Only 17% of LGBTQ individuals who screened positive for a mental health condition find treatment.

Schiltz, from Prevea, said many things can go wrong if trans and gender non-conforming patients aren't seeing culturally competent providers. More traditional therapists might fail to understand their patients' life experiences, use the wrong pronouns, inadvertently pathologize their identity or their experience of pain within that identity — the list goes on.

"A really important aspect of affirming care is to understand that many LGBTQ folks have had experiences with discrimination prior to walking into our offices. We face minority stress as a community," Schiltz said. "That means bullying and street harassment, rejection by loved ones, hate speech, negative representation in the media."

According to Schiltz, Prevea has about 12 behavioral clinicians who are currently providing LGBTQ-affirming care to patients.

Flores, from Diverse + Resilient, said in northeast Wisconsin, about 100 cognitive behavioral therapists who specialize in LGBTQ-affirming services are licensed to practice, but that doesn't always mean patients will have a positive experience, nor does it suggest those therapists know the difference between, say, gender identity and gender expression.

In fact, she's worked with many patients who go to a health care provider that advertises as LGBTQ-affirming only to discover there are ulterior motives, with conversion therapy chief among them.

"We know that conversion therapy is actually abuse and harmful," Flores said. "You cannot change somebody's sexual orientation or gender identity."

Pandemic and anti-LGBTQ bills accelerate mental health needs

In the pandemic's first wave of lockdowns, statistics emerged about upticks in domestic violence across the world. While this affected intimate partners, Flores said LGBTQ youths suffered too in lockdown, a result of unaccepting family members and a lack of access to school-based social workers and counselors.

That quickly created a crisis in young people who are LGBTQ, Flores said, which compelled Diverse + Resilient to apply for emergency funding and hire a youth advocate.

"We could not handle the volume of youths we were seeing," Flores said. "There were so many college students who had come out for the first time at school where it's safe, only to come home to unsupportive parents. The mental health crisis was real for us immediately."

Three years ago, 110 LGBTQ clients came to both the Appleton and Milwaukee offices of Diverse + Resilient. Between October 2020 and October 2021, Flores said, that number in northeast Wisconsin alone is closer to 150 people in need of mental health support.

According to a suicide report on impact and prevention from the Wisconsin Department of Health Services released in September 2020, half of LGBTQ youths in the state reported having depression. For young people who identify as cisgender heterosexual, depression affects one in four adolescents.

LGBTQ youths are three times likelier than heterosexual peers to consider suicide. From 2013 to 2017, the average age of people who died by suicide in Wisconsin was 32 for those known to be lesbian, gay or bisexual, while the average was 46 for those identified as heterosexual. The state's report did not track those known to be transgender.

Compounding this, a record-breaking surge in anti-LGBTQ bills in state legislatures nationwide specifically targeting transgender and gender nonconforming youths have further rattled mental well-being in the LGBTQ community.

One of those bills, from Alabama, makes it illegal to provide LGBTQ-affirming care, Schiltz said.

"We're basically telling professionals how to practice based on someone's religious or political views, as opposed to meeting the very specific health care needs of the population. It's definitely going to impact access to care," Schiltz said.

The psychological turbulence this inspires is not lost on Lammers, who said it's created heavy burdens that make it impossible for her clients to "put the shield down and take the armor off."

Lammers uses a term with her patients called "delusions of life," the idea being that people operate under the false assumption that they are safe and secure, that one can establish stability by working hard and finding the right support systems.

People in the trans community, especially youths, can't live under the same assumption of safety as cisgender people, Lammers said.

Lammers compared the everyday traumas faced by trans people to a person who suffers injuries from a car accident. A crash victim might have reservations about sitting in a car. Memories of the crash may flare up, inciting nerves, anxiety, distress.

Of course, Lammers points out a a key difference between these two situations.

"Can you imagine that person who is traumatized by the car accident never being able to get out of the car?"

The right therapist can help trans folks feel more grounded, sooner

Lammers said there's still a temptation for some health care professionals to assume being trans is a catalyst to suicidality when, in reality, it's the result of society's discrimination.

"Anybody who is in that much stress needs an outlet. They need support and they need somebody who understands the base details of how society is putting pressures on these individuals that most people can't even see," Lammers said.

For Lallaman, those pressures lightened when he started seeing his current therapist. The therapist's active listening and support-driven questions helped Lallaman ultimately feel comfortable with a doctor for the first time in his life. Besides his family pediatrician, it's the longest relationship with a doctor he's ever had.

In January, Lallaman underwent top surgery, a common gender-confirmation procedure that changes the look of a trans person's chest. His therapist not only supported him, but ultimately wrote the diagnostic letter required by the surgeon that confirmed he dealt with gender dysphoria.

"Having somebody I could talk to about this stuff and feel comfortable being open to, no matter what, was a really big thing," Lallaman said. "It's definitely helped me put the puzzle pieces together faster. It's really helped me be myself."

Natalie Eilbert covers mental health issues. She welcomes story tips and feedback. You can reach her at [email protected] or view her Twitter profile at @natalie_eilbert. If you or someone you know is dealing with suicidal thoughts, call the National Suicide Prevention Lifeline at 800-273-8255 or text "Hopeline" to the National Crisis Text Line at 741-741.

This article originally appeared on Green Bay Press-Gazette: Wisconsin LGBTQ people struggle to find culturally competent therapist