Minority stress

Psychiatric residency training could integrate the minority stress model into its programmes.^{Reference Fisher, Hirschtritt and Haller12} The minority stress model provides a framework for understanding the mental health disparities experienced by LGBT+ individuals.^{Reference Meyer10} Within this model, it is posited that unique social experiences account for the higher prevalence of mental disorders among LGBT+ individuals.^{Reference Meyer10} These stressors are categorised into distal stressors, representing adverse social experiences rooted in one's sexuality and gender (e.g. discrimination and prejudice), and proximal stressors, encompassing cognitive processes that uniquely affect LGBT+ individuals (e.g. internalised homophobia).^{Reference Meyer10} This model is applicable in the Philippine context, where research consistently highlights the negative impact of discrimination on the mental health of LGBT+ Filipinos.^{Reference Alibudbud3,Reference Alibudbud4,Reference Tan and Saw8} Therefore, incorporating the minority stress model into psychiatric residency training could provide trainees with essential insights into a pivotal factor perpetuating mental health disparities within the LGBT+ population. Notably, previous training models for psychiatric trainees exemplify the feasibility of incorporating this concept through modular training, mentorship and clinical experiences.^{Reference Fisher, Hirschtritt and Haller12–Reference Pachankis, Soulliard, Seager van Dyk, Layland, Clark and Levine14}

Intersectionality

Another concept that could be included in psychiatric residency training is the theory of intersectionality, an analytical framework developed by Crenshaw. Intersectionality considers different social positions, such as race, gender and sexuality, in elucidating the dynamics of privilege and discrimination within society.^{Reference Ng15} It has been applied to LGBT+ mental health in understanding how the confluence of different marginalised and privileged social positions affects mental health.^{Reference Ng15} Intersectionality is an important factor influencing LGBT+ mental health in the Philippines. For instance, variables such as age and romantic relationships have positively and negatively influenced the mental health of LGBT+ Filipinos.^{Reference Alibudbud3,Reference Alibudbud4} Therefore, the incorporation of intersectionality into psychiatric residency training could provide a deeper understanding of the intricacies and factors that underlie the mental health of LGBT+ Filipinos. In practice, this inclusion could serve as a framework for understanding the social factors involved in psychiatric case formulations and patient presentations.

Identity concealment

The Philippines has not enacted the Sexual Orientation and Gender Identity or Expression (SOGIE) equality bill, a legislative endeavour designed to protect Filipinos from violence, abuse and discrimination arising from their SOGIE.^{Reference Alibudbud3} Therefore, LGBT+ Filipinos may hide their SOGIE-based identities to avoid societal marginalisation and discrimination.^{Reference Alibudbud3,Reference Thoreson7,9} In this regard, psychiatrists and other mental health professionals should understand the effects of SOGIE-based identity concealment on the mental health of LGBT+ Filipinos. For instance, a review conducted by Pachankis et al^{Reference Pachankis, Mahon, Jackson, Fetzner and Bränström16} shows a positive association between sexual orientation concealment and mental health problems, including depression, anxiety and distress. Therefore, the inclusion of identity concealment in existing training programmes could sensitise future Filipino psychiatrists to the need to assess SOGIE and its added complexities associated with the mental health of LGBT+ Filipinos. Consistent with prior initiatives in the field of LGBT+ mental health training, the relationship between identity-related concerns and mental health could be incorporated into didactic and clinical experiences (e.g. journal clubs or patient case presentations) of psychiatric trainees.^{Reference Fisher, Hirschtritt and Haller12}

LGBT+-affirming practices

The interaction between mental health clinicians and their patients serves a dual purpose, encompassing clinical assessment and management.^{Reference Morgan and Bhugra17} Beyond the explicit objectives, this relationship is a therapeutic encounter that can benefit mental health.^{Reference Morgan and Bhugra17} Therefore, it is necessary to foster affirmation and inclusivity, as well as avoid prejudice and discrimination, in psychiatric and mental health services, particularly among LGBT+ people. This could be done by integrating the biological and psychosocial aspects of LGBT+-affirming practices.

Emerging evidence of gender-affirming biologically based interventions and their effects on mental health could be incorporated into existing training topics, such as gender dysphoria.^{Reference Abesamis2} For instance, the large prospective study conducted by Chen et al^{Reference Chen, Berona, Chan, Ehrensaft, Garofalo and Hidalgo18} revealed that gender-affirming hormones improved appearance congruence and psychosocial functioning and decreased depression and anxiety symptoms.

Discussions within training programmes should also encompass the psychosocial dimensions of gender-affirming practices. For instance, international guidelines on gender-affirming mental healthcare, such as the utilisation of preferred names and pronouns to foster comfort and ease among LGBT+ individuals,¹⁹ could be adapted and culturally validated in the Philippine setting.

By incorporating the biological and psychosocial aspects of LGBT+-affirming practices into existing psychiatric residency and training, future generations of psychiatrists could be better equipped to assess, address and analyse the multifaceted needs of LGBT+ Filipinos. As a start, training programmes could culturally adapt and incorporate evidence-based training methods, such as in LGBTQ-affirmative cognitive–behavioural therapy.^{Reference Pachankis, Soulliard, Seager van Dyk, Layland, Clark and Levine14} This training encompasses discussions of socially relevant factors, such as minority stress, and the practical implementation of LGBT+-affirmative practices, including behavioural skills training. This approach could significantly enhance the competence of future psychiatrists in providing affirming care to LGBT+ individuals in the Philippines.