Prevalence and associated factors of post-traumatic stress disorders among LGBTQI+ adults: a systematic literature review

Abstract

Background

LGBTQI+ individuals appear to be particularly at-risk of exposure to interpersonal violence. This leads to an increased risk of developing symptoms of Post-Traumatic Stress Disorder (PTSD) or Complex Post-Traumatic Stress Disorder (C-PTSD). The objectives of this systematic review is to: (1) Compile the prevalences of PTSD/C-PTSD among LGBTQI+ individuals; (2) Compare the symptomatology of PTSD/C-PTSD according to sexual orientation and gender identity; (3) Identify the factors involved in the symptomatology of PTSD/C-PTSD among LGBTQI+ individuals.

Methods

A systematic literature review was conducted on PTSD/C-PTSD among LGBTQI+ individuals. Psychinfo, Psycharticle, Psychology and Behavioral Sciences Collection, Embase, and LGBTHealth databases were queried. Only quantitative, observational studies based on data collected after 2010 and involving LGBTQI+ adults were included. The risk of bias was assessed using the Control Guidelines Critical Appraisal Toolkit developed by the Public Health Agency of Canada.

Results

Out of the 7446 articles identified, 60 were included. Eighteen provided data on prevalence, and 57 on associated factors. The majority of studies were conducted in the United States. The vast majority of studies assessed PTSD using self-administered scales. Only one evaluated symptoms of C-PTSD. All included studies reported extremely high PTSD prevalence rates, with certain populations appearing particularly at risk, such as bisexual (10.3–35.7% PTSD) and transgender individuals (36.8–64.3% PTSD). Individual (e.g., financial precarity, transition, internalized stigma), interpersonal (e.g., outness, social support), organizational (e.g. health barriers), community (e.g. anti-trans discourse), and political variables (anti-trans laws project) associated with PTSD/C-PTSD symptoms have been identified.

Conclusions

The results show the importance of considering PTSD/C-PTSD among LGBTQI+ individuals in clinical practice and research. Higher quality studies are needed to quantify the extent of the problem. Healthcare professionals must be trained in the specific factors that may contribute to PTSD/C-PTSD symptoms in LGBTQI+ individuals. This cannot be achieved without public policies aimed at preventing all forms of violence against the LGBTQI+ population and ensuring access to equal rights.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-025-24843-1.

Background

Lesbian, Gay, Bisexual,1 Transgender,2 Queer,3 and Intersex4 (LGBTQI+5) individuals constitute a significant portion of the population. According to a recent IPSOS survey conducted across 30 countries in 2023, 9% of respondents identified as LGBTQI+ [1]. The exact proportions are expected to vary based on several factors, including geographical and generational considerations. While individuals within the LGBTQI+ community share the commonality of not conforming to heterosexual and cisgender6 norms, they represent a diverse range of identities and experiences. The LGBTQI+ acronym encompasses matters related to sexual orientation (homosexuality, bisexuality, asexuality,7 etc.), romantic orientation (distinct from sexual orientation, e.g., aromantic8), gender identity (cisgender, transgender, non-binary9), bodily characteristics (intersexuality), and gender expression.10 Paradoxically, psychological research must navigate the challenge of grouping these identities to draw general conclusions while studying a population with profoundly diverse and specific lived experiences.

Due to their sexual orientation and/or gender identity, LGBTQI+ individuals may face specific challenges, particularly in terms of violence. These experiences can manifest in various forms and span a wide spectrum of violence, including remarks or behaviors, often unintentional, that demonstrate a lack of understanding (e.g., misgendering,11 making assumptions about the person’s sexual orientation); discrimination; rejection behaviors; verbal, physical, and sexual violence; and hate crimes. These forms of violence can occur in various contexts, including within the family (e.g., parental non-acceptance) [2], education (e.g., school bullying) [3], employment (e.g., discrimination in job access) [4], and daily life (e.g., insults, physical and sexual violence) [5]).

This context renders this population particularly vulnerable on a social level (isolation [6], precarity [7], barriers to accessing healthcare [8] or social support [9]), as well as on the physical and mental health fronts [10–12]. This lived experience has been conceptualized under the term minority stress [13]. However, not all these challenges are of the same nature within the LGBTQI+ community, and certain groups, such as gender minorities, appear to be particularly vulnerable today [14]. To date, scientific literature shows the overexposure of this population to violence [5, 15] and the consequences it can have on their lives [3, 16]. Yet, the literature still remains sparse on one of the key factors involved in post-traumatic symptomatology.

Exposure to a potentially traumatic event, specifically exposure to death or a life-threatening situation (e.g. natural or human-made disaster, accident, assault…) constitutes the gateway to the development of PTSD [17]. Certain forms of exposure, such as chronic exposure to interpersonal violence during childhood, which may involve attachment figures, significantly increase the risk of developing post-traumatic stress symptoms and their severity [18–20]. In a study involving a sample of 34 000 people in the USA, homosexual and bisexual individuals were more than twice as likely to report exposure to childhood maltreatment compared to heterosexual individuals [21]. Nevertheless, some authors support the idea that certain events, which do not involve life-threatening or potentially life-threatening situations but involve psychological threats (e.g., bullying, cisheterosexism, racism), could also lead to traumatic symptomatology [22, 23].

To date, several conceptualizations of PTSD exist. DSM-5 considers the existence of a single disorder (PTSD), encompassing four symptom clusters: (1) Intrusions (i.e., intrusive memories, nightmares, dissociative reactions related to the event, psychological distress and physiological reactions upon exposure to reminders of the event); (2) Avoidance (i.e., avoidance of memories, thoughts, feelings, places, people, situations that could remind one of the event); (3) Negative alterations in cognitions and mood (i.e., amnesia, negative beliefs and emotions, cognitive distortions, detachment, loss of interest, and inability to experience positive emotions); (4) Alterations in arousal and reactivity (i.e., irritability, self-destructive behaviors, hypervigilance, exaggerated startle response, concentration problems, sleep disturbances) [17]. The ICD-11, on the other hand, proposes two distinct disorders: PTSD and C-PTSD. C-PTSD consists of three symptom clusters comprising ICD-11 PTSD (re-experiencing, avoidance, and a constant sense of threat), along with three symptom clusters constituting Disturbances in Self-Organization (DSO; emotional dysregulation, negative self-concept, interpersonal difficulties) [18]. Independently of the classification, post-traumatic stress symptoms can lead to significant and persistent difficulties in one or more areas of life (relational, professional, personal). Identifying and addressing individuals suffering from these disorders is therefore a significant health concern.

The results of a single recent meta-analysis show a notably higher risk of LGBTQI+ individuals reporting PTSD compared to cisgender and heterosexual individuals [24]. However, this meta-analysis is limited to studies including a control group consisting of heterosexual and cisgender individuals, thus excluding a considerable number of existing studies to date and does not delve into factors that could explain the symptomatology. The objectives of this systematic review were as follows:

1. Compile the prevalences of PTSD/C-PTSD among LGBTQI+ individuals reported in the scientific literature.

2. Compare the symptomatology of PTSD/C-PTSD according to sexual orientation and gender identity.

3. Identify the factors associated in the symptomatology of PTSD/C-PTSD among LGBTQI+ individuals.

Based on the existing literature, we hypothesized that LGBTQIA + individuals would report higher PTSD/C-PTSD prevalence rates in the included studies compared to those typically observed in the general population. We also hypothesized that certain subgroups, such as gender minorities, would show particularly elevated prevalence rates. Finally, we expected that the factors contributing to PTSD/C-PTSD symptoms would operate at multiple levels, both individual and societal.

Methods

Eligibility criteria (PICOTS)

Prisma [25] and INESS [26] guidelines were followed throughout the present review. The review were not registered in Prospero.

Population: Studies involving adults (≥ 18 years old) identifying as sexual and/or gender minorities were considered. Studies specifically focusing on populations exposed to trauma due to their profession (e.g., war veterans), physical condition (e.g., HIV), or life experiences (e.g., migratory history) were excluded. For prevalence data, only studies involving a general LGBTQI+ population, were included.

Intervention: Only observational studies were considered. All interventional studies were excluded.

Group comparison: All studies, with or without a control group, were included. This included studies comparing LGBTQI+ subgroups with each other or with groups consisting of cisgender or heterosexual individuals.

Outcome: Only studies using validated measurement tools to assess PTSD or C-PTSD, based on full DSM or ICD symptom criteria, were considered. Results were considered if they provided insights into:

1. The prevalence of PTSD/C-PTSD within the LGBTQI+ population.

2. The symptomatology of PTSD according to sexual orientation and/or gender identity.

3. Factors associated with PTSD/C-PTSD symptoms within the LGBTQI+ population.

For prevalence, studies were included if the diagnosis was based on full symptoms criteria or a cut-off criterion.

Temporality: This criterion is not restrictive. Cross-sectional and longitudinal studies were considered with equal interest.

Settings: Only quantitative studies were considered. Qualitative studies were excluded, and in the case of mixed-methods studies, only the quantitative results were considered. This review was limited to peer-reviewed articles in English and French due to the languages spoken by the authors, published in indexed scientific journals. Due to the evolving living conditions of LGBTQI+ individuals over recent decades and changes in PTSD classifications, studies based on data collected before 2010 were not considered in order to focus solely on the most current publications. Conference abstracts, literature reviews, academic dissertations, and case studies were excluded.

Sources of information

The following databases were queried: Psychinfo, Psycharticle, Psychology and Behavioral Sciences Collection, Embase, and LGBTHealth. The search was initiated on October 28, 2021, and the last update was conducted on January 16, 2023. The first author (WP) conducted all database searches.

Search algorithm

The keywords related to sexual orientation or gender identity used in this review are those proposed in a systematic review identifying various terminologies used in LGBTQI+ research [27]. The table summarizing the keywords used is available in the supplementary material.

Study selection

All articles were recorded on Zotero [28]. Duplicate articles were removed using the software. The title and abstract of each article were assessed, and those that did not meet the eligibility criteria were excluded. WP was responsible for the initial screening. In case of uncertainty, articles were retained for a full read. A second screening based on full articles was independently conducted by WP and HF on 30 common references. WP was then responsible for the entire initial screening (n = 138). In cases of doubt or disagreement, meetings were held involving WP, HF, MH, and BQ. Studies were excluded if they did not meet the defined criteria in terms of population (e.g., age below 18 years, not focused on LGBTQI+ individuals, or data did not allow distinguishing LGBTQI+ individuals from the rest of the sample), study design (e.g., academic dissertation, qualitative study), or outcome (e.g., lack of a measurement scale for PTSD/C-PTSD) (Fig. 1).

Fig. 1.

Prisma flow diagram

Data items and collection process

The extraction of information from the selected studies was based on the recommendations of INESSS [26]. For each article, information about participant characteristics (sample size, age range, gender identity, sexual orientation), location, design, methods used (measurement tool, data analysis), outcomes, and strengths and limitations were systematically noted. These data were manually identified in each study and noted on a spreadsheet. All articles in which the researchers had doubts about their inclusion were discussed in a committee approach with BQ until a consensus was reached.

Summary strategy

As the selected studies showed clinical heterogeneity in terms of settings (sample size, participants characteristics), study design, methods (measurement tools, data analysis), it was impractical to run a quantitative analysis for meta-review. However, we have synthesized the main data from each study in tables constructed from those proposed by the Public Health Agency of Canada [29] and the INESS Guidelines [26].

Risk of bias

The Control Guidelines Critical Appraisal Toolkit (developed by the Public Health Agency of Canada [29]) was utilized to assess the quality of each quantitative study and assign a specific grade. The first author (WP) was responsible for the evaluation of study quality. The quality of a study was considered high if it received high ratings on most criteria (sample, data collection method, measurement tools, ethics, statistics), and no elements were rated as low. The quality of a study was considered moderate if the data collection method or statistics used were considered moderate, and other items rated as weak or moderate were insufficient to compromise ability to draw conclusions regarding a possible association. The quality of a study was considered low if the data collection method or statistics used were considered low independently of other aspects (e.g., wide confidence interval, inadequate statistical power), or if all criteria compromised the internal validity of the study.

Results

Study selection and description

The final selection of studies for this review included 60 studies. The results are summarized in supplementary material. The review included only quantitative studies, mostly retrospective (n = 53), while seven were of a longitudinal nature. The vast majority of studies took place in the United States (n = 51), Canada (n = 4), or on the North American continent (n = 2). Two studies were conducted in Europe, in Ireland and Spain specifically. One was carried out in Kenya.

Most studies used a variant of the PCL (PCL C, PCL S, PCL 5; n = 33) [30, 31], while others used the PC-PTSD (n = 11) [32, 33]. Occasionally, some other tools were used, such as AUDADIS (n = 2) [34, 35], DTS (n = 2) [36], IES-R (n = 3) [37], PDS (n = 3) [38], SCID-IV (n = 2) [39], TSC-40 (n = 2) [40], Short Screening Scale for DSM IV (n = 1) [41], or ITQ (n = 1) [42].

In total, 31,943 LGBTQI+ participants were included in all studies. From articles providing age information (n = 43), the average age of participants was 29.18 years.

The populations recruited in different studies were highly diverse, illustrating the complexity of research on sexual and gender minorities. Some focused on individuals with a specific sexual orientation or gender identity (e.g., bisexual individuals, transgender individuals), others concentrated on a specific gender within the spectrum of sexual orientation or gender identity (e.g., gay men, transgender women), and others grouped individuals based on their sexual orientation (LGB individuals; gay individuals), gender identity (transgender individuals), or more broadly, their affiliation with the LGBTQI+ community. This information is systematically presented in the descriptive table (see supplementary material).

Some heterogeneity in terms of quality was observed in the included studies. Eleven were considered to be of high quality, 42 of moderate quality, and 7 of low quality (see supplementary material).

Prevalence of PTSD/C-PTSD

Prevalence according to sexual orientation

Among the 18 included studies presenting prevalence rates, 9 reported PTSD prevalence among sexual minorities, with one reporting PTSD/C-PTSD (ICD-11) prevalence. Three studies reported prevalence among gay and bisexual men. The reported prevalences among gay men were 6.2% for PTSD [43], 5.3% for PTSD, and 10.7% for C-PTSD (16% cumulative PTSD and C-PTSD; [44]). The only prevalence reported specifically among bisexual men was 10.3% for PTSD [43]. However, a study conducted in Western Kenya among gay and bisexual men showed a significantly higher prevalence of PTSD (52.4%; [45]). Contextual and cultural factors likely explain this higher prevalence and they will be discussed further.

Five studies reported prevalences among lesbian and bisexual women. The reported prevalences among lesbian women were 7.4% for PTSD [43], 11.4% for PTSD, and 25.7% for C-PTSD (37.1% cumulative PTSD and C-PTSD; [44]). The only reported prevalence among bisexual women was 21% for PTSD [43]. Three studies focused on samples composed of lesbian and bisexual women and mentioned prevalences ranging from 15.43% [46] and 22.9% [47] to 50.4% for PTSD [45]. However, the latter study is distinct due to its sample recruited in Western Kenya. Lastly, one study, using a similar database to Evans-Polce et al. [43], reported prevalences for individuals questioning their sexual orientation or engaging in non-heterosexual practices, even if they identified as heterosexual. The reported PTSD prevalences were 4.2% and 8.9% for discordant heterosexual men and women, and 11.5% and 15.3% for men and women questioning their sexual orientation [48].

Five studies reported prevalences among lesbian, gay, and bisexual individuals regardless of gender. The majority focused on samples of bisexual individuals. The reported prevalences of PTSD varied between 15.5% (population aged over 25 years; [49]), 35.7% [50], and 47.62% (including transgender individuals; [51]). One study, based on ICD-11 criteria, reported a prevalence of 3.4% for PTSD and 23.9% for C-PTSD (27.3% cumulative; [44]). This same study also reported prevalences in a group of pansexual, asexual, and other sexual minority individuals of 7.1% for PTSD and 30.8% for C-PTSD (37.9% cumulative; [44]). Finally, a study focusing on South Asian American LGB + individuals reported a significantly higher prevalence of PTSD (61.3%; [52]). This result will be discussed further.

Figure 2 synthesizes the reported prevalences in each study according to sexual orientation.

Fig. 2.

Prevalences of PTSD reported in included studies according to sexual orientation

Prevalence according to gender identity

Among the 14 included studies, 9 reported prevalences of PTSD among gender minorities, with only one assessing PTSD/C-PTSD (ICD-11; [44]). Most studies grouped gender minorities without distinguishing their gender identity in the analyses (n = 8) [44, 45, 53–58], while one focused on a population of transgender or non-binary individuals assigned male at birth [59]. Reported prevalences ranged between 36.8% and 64.3%, with the majority falling between 36.8% and 46.6% for PTSD (6/9) [44, 54–58]. One study using the diagnostic criteria of ICD-11 reported a prevalence of 9.6% for PTSD and 31.9% for C-PTSD (41.5% combined) [44]. The study that reported the highest prevalence focused on a sample recruited in Western Kenya (64% PTSD) [45], while the second one involved a sample of 155 transgender individuals, mostly assigned female at birth (62.6% PTSD) [53].

Figure 3 summarizes the reported prevalences in each study, according to gender identity.

Fig. 3.

Prevalence of PTSD reported in included studies according to gender identity

Comparisons of traumatic symptomatology based on sexual orientation or gender identity

Twenty-six studies explored whether traumatic symptomatology can vary based on reported sexual orientation or gender identity within samples exposed to potentially traumatic events [43, 45, 46, 52, 56, 57, 59–78].

Comparison between sexual minorities and heterosexual individuals

Fourteen studies compared a sample of sexual minorities with heterosexual individuals. Eight of them showed that lesbian, gay, and bisexual individuals reported more PTSD symptoms than heterosexual individuals [52, 62, 64, 72, 74, 76, 77, 79]. One study showed stronger symptomatology among lesbian, gay, and bisexual individuals in the sample but without observing differences in terms of prevalence [70]. Three studies showed results that varied depending on sexual orientation or gender. For example, the study by Evans-Polce et al. [43] showed that sexual minorities (gay and bisexual men, bisexual women) reported higher PTSD symptoms than heterosexuals, except for lesbian women. In contrast, Kammer-Kerwick et al. [66] showed that gay and lesbian individuals reported more PTSD symptoms than heterosexual individuals, but these results did not appear in bisexual or pansexual individuals, or asexual and other sexual orientations in the sample. In the study by Warren et al. [78], the difference in symptomatology was significant only for lesbian and bisexual women, not gay and bisexual men. Finally, two studies showed no differences between LGBTQ + individuals and heterosexual individuals [60, 67].

Comparison between gender minorities and cisgender individuals

Four studies compared a sample of gender minorities with cisgender individuals. Three showed that gender minorities reported more symptoms of PTSD than cisgender individuals [61, 71, 73]. Two of them focused on an undifferentiated sample of transgender and non-binary individuals [71, 73], and the third distinguished between non-binary individuals, transgender women, transgender men, and individuals reporting another gender identity, all of whom reported more PTSD symptoms than cisgender men [61]. Only one study did not demonstrate differences in terms of PTSD symptoms in transgender and gender diverse individuals compared to a group of cisgender and heterosexual men [66].

Factors associated with PTSD symptoms

Figure 4 summarizes all of the factors identified in the literature.

Fig. 4.

Factors identified in the literature. + = positive association; - = negative association; * = mixed results; ns = not significant. At the center of the figure are shown the main categories of identified variables, which become more specific as one moves outward

Individual level

Sociodemographic variables

Age

Many studies (n = 15) took the age of LGBTQI+ individuals recruited in their analyses into account. The majority (n = 10) did not show significant associations between participants’ age and traumatic symptomatology [46, 50, 56, 59, 63, 80–84], whereas some studies found that young adults represented a vulnerable population within the community (n = 5) [49, 57, 61, 65, 85]. One study among men who have sex with men (MSM) found the opposite trend, with young adults being less likely to report PTSD than their older counterparts. However, this difference was not observed in terms of lifetime prevalence [86].

Education

Among studies that considered participants’ education levels (n = 9), five studies, mainly focusing on transgender populations, did not show a significant association with PTSD symptoms [56, 57, 59, 61, 66]. The results of the remaining studies (n = 4) among sexual and gender minorities indicated a negative association between a higher level of education and PTSD symptoms [46, 50, 65, 87].

Race & Ethnicity

Ten studies considered race and ethnicity in their analyses. The majority (n = 6) did not show a significant association between race or ethnicity and PTSD symptoms [50, 56, 57, 65, 82, 88]. The other four studies, all among sexual minorities, did show associations, but they involved different races or ethnicities. One, focusing on an MSM sample, found that Hispanic or Latino individuals reported more PTSD symptoms than non-Hispanic Black individuals [89]. The second, in a sample of bisexual women, showed that Black bisexual women reported more symptoms than other bisexual women [74]. The third study showed a tendency where, compared to non-White individuals, White individuals reported fewer PTSD symptoms only in the intrusion cluster, not in terms of overall symptomatology [68]. Finally, the fourth study, with an sexual minority women sample, showed that Asian-American individuals reported fewer PTSD symptoms than White individuals. However, it did not find differences between White, African American, and Latino American sexual minority women [90].

Financial stability

With financial security being a particular concern in the LGBTQI+ community, many studies (n = 10) considered the level of financial precarity in their analyses. The conceptualization of financial precarity varied across studies (poverty threshold, annual income, access to social assistance, perceived financial situation, food insecurity, etc.). Most studies (n = 7) showed a positive association between precarity and PTSD symptoms [50, 56, 59, 65, 82, 85, 91].

Three additional studies considered housing stability in their analyses. Two studies among transgender individuals showed that housing instability was associated with increased PTSD symptoms [56, 57]. Finally, a study among MSM did not find a link between housing instability and PTSD symptoms [82].

Employment

Two studies explored employment status and its associations with PTSD symptoms among LGBTQI+ individuals. The first study, which focused on a sample of transgender individuals, showed that unemployed individuals reported more PTSD symptoms than those who were employed [56]. However, these findings are contrasted by the study conducted by Landes et al. [46] among lesbian and bisexual women, which stands out due to its longitudinal design. This study demonstrated that the time spent employed in the last 24 months was not associated with PTSD symptoms.

Transition

Three studies, specifically focusing on transgender populations, explored issues related to the transition process in their analyses. These analyses mostly covered different aspects of the transition process. One study showed that transgender individuals who had undergone medical transition (hormones or surgery) reported fewer PTSD symptoms than those who had not undergone a medical transition [57]. However, these findings are contradicted by the study conducted by Peitzmeier et al. [59], which did not observe differences in symptomatology between transgender women with access to hormone therapy and transgender women who had not undergone hormone therapy. Another study found that individuals who had experienced interactions where their gender identity was not respected due to their appearance reported more PTSD symptoms [54]. These results align with those observed by Reisner et al. [57], where transgender individuals who reported that their transgender identity was visible to others also reported more PTSD symptoms. Surprisingly, these same authors found that undergoing social transition (living full-time in one’s gender identity) was associated with an increase in PTSD symptoms. These results are discussed further ahead.

Adversities

Characteristics of violence

Three studies investigated the characteristics of traumatic events. One study among LGBTQ individuals emphasized that, for lesbian and bisexual women in the sample, being sexually assaulted by one or more women was associated with increased symptoms compared to those assaulted only by men. This finding was not demonstrated among heterosexual women in the sample [69]. Another study among LGBTQ individuals showed that the time elapsed since the last experience of interpersonal violence was associated with a reduction in PTSD symptoms [87]. Finally, a study among racialized MSM who were sexually abused during childhood did not demonstrate a link between the age of first abuse and PTSD symptoms [89].

Prejudice, stigmatization, discrimination

Nine studies explored the consequences of experiences of prejudices, stigmatization, and discrimination in terms of traumatic symptomatology. These experiences varied in nature depending on the measurement tools used, ranging from stigmatizing remarks to violent behaviors, but were all related to the victim’s sexual orientation or gender identity. All studies (n = 9) showed a link between experiencing anti-LGBTQI+ behaviors and an increase in traumatic symptomatology [50, 51, 56, 57, 92–96]. Some studies showed interesting nuances. For example, for bisexual individuals recruited in the study by Arnett et al. [92], experiencing anti-bisexual attitudes had an impact on PTSD symptoms only if it came from heterosexual individuals, not from lesbian or gay individuals.

Perceptions and cognitions

Internalized Stigma

The internalization of stigmatizing remarks and behaviors regarding sexual orientation or gender identity in the LGBTQI+ community has been well-identified in the literature. Several studies explored the link between this internalized stigma and traumatic symptomatology (n = 9). The studies are heterogeneous, both in their populations and the measurement tools used (internalized homophobia/biphobia/transphobia, internalized heterosexism, non-acceptance of one’s sexual orientation or gender identity, fear of being negatively perceived). Five studies showed that reporting signs of internalized stigma was associated with an increase in PTSD symptoms. This observation was found in the bisexual population [92], sexual minority women [85, 94], transgender individuals [54], and the broader LGBTQI+ population [71]. A study by Stenersen et al. [87] showed more nuanced results. The authors emphasized that expecting not to be accepted because of sexual orientation or gender identity was associated with an increase in PTSD symptoms. At the same time, if the authors did not observe an association between PTSD symptoms and the desire not to be LGBTQI+, experiencing a difficult acceptance process of one’s sexual orientation or gender identity could be associated with more PTSD symptoms. Another study showed a link between internalized homophobia and PTSD in a sample of sexual and gender minority individuals who were victims of sexual abuse, but not in another sample of individuals who were victims of intimate partner violence [75]. Two additional studies did not demonstrate a link between self-acceptance and PTSD [56, 95]. Finally, some studies explored the mediating role that internalized stigma can play in certain associations with PTSD. In Barr and colleagues’ study [54], for example, internalized transphobia explained the relationship between experiencing discrimination or transmisogyny and an increase in PTSD symptoms. However, this mediating role was not found in the longitudinal study by Dworkin et al. [94], where internalized heterosexism did not mediate the relationship between experiencing heterosexist behaviors and PTSD symptoms.

Shame

One study investigated the link between feelings of shame and traumatic symptomatology. It is noteworthy that in this study involving sexual minority women, the authors examined the general sense of shame rather than specifically in connection with trauma. While the authors did not observe a link between shame-related cognitions (i.e., thinking one is bad or worthless) and PTSD, they found that behaviors in response to feelings of shame (i.e., avoiding people or situations) explained the relationship between internalized heterosexism and PTSD symptoms [85].

Post-traumatic perceptions and cognitions

A few studies examined individuals’ perceptions of the trauma they had experienced (n = 2). One study, focusing on a sample of 245 bisexual individuals reporting events constituting rape, showed that individuals who were aware that it was rape reported more PTSD symptoms than those who did not define what they experienced as rape [97]. The second study found that individuals who connected their trauma to discrimination reported more PTSD symptoms than those who did not link this event to their sexual orientation or gender identity [95].

Other studies examined post-traumatic cognitions (n = 2), which are certain negative beliefs or feelings that individuals who have been exposed to violence may report. Both studies focused solely on sexual minorities. A study by Newins et al. [67] showed a positive relationship between feeling distressed when others are in control and PTSD symptoms, which appeared stronger in LGBTQ individuals than in heterosexual individuals. The second longitudinal study found a significant link between post-traumatic cognitions and PTSD symptoms reported one year later. Additionally, the authors highlighted that experiencing heterosexist events seemed to be temporally linked to the severity of PTSD symptoms through the negative beliefs about oneself it engenders [94].

Behaviors

Adaptation strategies

Coping strategies

Several studies have examined the link between coping strategies and symptoms of PTSD (n = 6). Results varied depending on the panel of coping strategies evaluated. Two studies, both focusing on sexual minorities, demonstrated that individuals who consumed substances to cope with their thoughts or feelings reported more PTSD symptoms [81, 93]. One of these studies delved into this association and showed that experiences of heterosexist events led to the deployment of coping strategies oriented towards substance use, which exacerbated PTSD symptoms [93]. These authors made the same observation with other coping strategies in the face of heterosexist discrimination, such as internalization behaviors (i.e., wondering if it’s their fault) or detachment (i.e., avoiding talking about it with others). Stenersen et al. [87] observed that LGBTQI+ individuals with help-seeking behaviors tended to report lower traumatic symptomatology, thus constituting a protective factor. They also noted a positive association between behaviors of concealing one’s sexual orientation or gender identity and the presence of PTSD symptoms. Other authors considered coping strategies oriented towards anger regulation and observed nuanced results [98]. While the repression of anger was positively associated with PTSD symptoms in gay men and lesbian women, the expression of anger was positively associated with PTSD symptoms only in gay men. Having to conceal one’s sexual orientation led gay men and lesbian women to suppress their anger, thereby exacerbating their PTSD symptoms. Finally, three studies did not demonstrate a link between coping strategies and traumatic symptomatology. The coping strategies involved were problem-solving strategies [82], religion-focused strategies [98], and strategies focused on vigilance towards heterosexual individuals [44].

Hypervigilance

One study investigated hypervigilance behaviors. Note that while hypervigilance is a symptom of PTSD, the authors here focused on the contexts in which this hypervigilance could form, as well as the hypervigilance behaviors employed. They observed that only hypervigilance towards strangers predicted an increase in PTSD symptoms, which was not the case for hypervigilance towards religious individuals or in the workplace. Among the measured hypervigilance behaviors, social withdrawal and scanning predicted an increase in PTSD symptoms, but not concealing one’s LGBTQ + identity [71].

Health behaviors

Physical Activity

Only one study explored the link between sports participation and PTSD symptoms among sexual minorities, and it showed contrasting results. While engaging in sports was positively associated with PTSD symptoms in lesbian women, no such link was demonstrated in gay men [98].

Substance Use

Substance use is a behavior frequently reported among individuals exposed to violence. While it can sometimes be a coping strategy, we have chosen to distinguish the following studies due to their methodology, which did not allow for an evaluation of whether this behavior was perceived by individuals as a response to the difficulties they faced. Methodologies varied among studies, with some covering a range of drugs, while others were more specific (alcohol, tobacco, methamphetamines).

For studies that did not specify the type of drug, results seem mixed. Two studies showed a positive association between polydrug use and PTSD symptoms, whether in a sample of young MSM [88] or transgender individuals [57]. In contrast, two other studies did not show associations with traumatic symptomatology [89, 99].

Regarding studies targeting specific substances, the majority focused on alcohol consumption (n = 9). Operationalization varied, ranging from the number of drinks reported to signs of an alcohol use disorder. Most studies (n = 5) showed a link between high alcohol consumption and PTSD symptoms [43, 63, 80, 96, 100]. One study particularly emphasized that sexual minorities reported more alcohol use disorders comorbid with PTSD symptoms over the past year than heterosexual individuals [43]. In contrast, four studies did not demonstrate a link between alcohol consumption and traumatic symptomatology [47, 81, 89, 98].

Two studies explored tobacco use in relation to PTSD symptoms. One of them did not show a link between tobacco consumption and traumatic symptomatology in homosexual individuals [98]. The other, in a sample of lesbian, bisexual, and gay individuals, showed that compared to heterosexual individuals, only bisexual individuals more frequently reported a tobacco use disorder comorbid with PTSD [43].

Finally, only one study explored crystal methamphetamine use in relation to traumatic symptomatology and did not demonstrate a correlation in a sample of MSM who experienced childhood sexual abuse [82].

Sexual Practices

Some studies have focused on risky sexual behaviors in relation to PTSD symptoms (n = 5). Most did not show an association with traumatic symptomatology, whether in terms of unprotected sex in racialized MSM [89] and transgender individuals [82], or in terms of sex work in transgender women [59]. One study demonstrated more nuanced results in a transgender population, with no link between seroadaptive behaviors (i.e., discussing less risky sexual behavior with a partner) but a negative association between PrEP12 use and PTSD symptoms in the past week [82]. Finally, a study of gay and bisexual men showed, in a network analysis, that specific PTSD symptoms (avoidance of thoughts and feelings) were associated with risky sexual behaviors. The authors noted that the group least prone to risky sexual behaviors reported the greatest association with hypervigilance symptoms. The authors hypothesized that, in the absence of avoidance symptoms, this hypervigilance could be protective against risky behaviors [102].

Health status

Somatic Health

Three studies considered indicators of somatic health in their analyses. One examined the relationship between Body Mass Index and symptoms of PTSD in young lesbian and bisexual women and found no association [80]. A second study looked at self-reported sleep duration over the past week and demonstrated a negative association with PTSD symptoms only in lesbian women and not in gay men [98]. Finally, a study focused on physical health in bisexual individuals and found a negative association between physical health status and PTSD symptoms. Poor health status (physical functioning, health-related relational limitations, pain) was associated with higher traumatic symptomatology [92].

Mental Health

Fifteen studies explored the association between mental health variables and the presence of PTSD symptoms. The majority of these studies focused on the relationship between depression and PTSD (n = 15). Almost all of them (n = 14) showed a positive link between depression and PTSD [46, 47, 57, 63, 71, 82–84, 88, 89, 92, 96, 99, 102]. Only one study, focusing on a sample of 19 Black transgender women, did not find a significant link between lifetime PTSD and depression [103]. The methodology of a study on MSM who experienced childhood sexual abuse stands out by exploring the link between depression and PTSD through network analyses. The authors highlighted that depression and PTSD symptoms clustered well in their respective diagnoses, but their symptoms were connected through key nodes involving sleep disturbances, concentration difficulties, and limited life outlook [102].

Three studies considered anxiety in their analyses [47, 89, 99]. All of them focused on samples of sexual minorities and showed a positive association between anxiety and PTSD symptoms.

Only one study addressed distress tolerance and demonstrated that MSM who had experienced childhood sexual abuse and reported greater difficulty tolerating distress tended to report more PTSD symptoms in the past week [82].

Some studies explored variables expected to be protective against PTSD symptoms (n = 3). One, focusing on racial minority MSM, showed that feeling in control of one’s mental health, reporting positive effects, and resilience were associated with lower traumatic symptomatology [89]. This result seems supported by another study among transgender individuals, which also found that resilience was associated with a reduction in PTSD symptoms [56]. Finally, one study examined the relationship between life satisfaction and PTSD symptoms in an LGBTQ + sample, observing that higher life satisfaction was associated with fewer PTSD symptoms [71].

Interpersonal level

In an ecosystemic perspective, the interpersonal level includes interactions with the immediate environment, such as parents, friends, romantic relationships, or more broadly, the world around us.

Partner

Only one study, focusing on transgender individuals, considered having a life partner in its analyses related to PTSD. The authors observed that individuals who reported having a partner had fewer PTSD symptoms [56].

Parents with Mental Health Disorders

A study on young MSM explored their perception of their parents’ mental health. When these young individuals perceived psychiatric disorders in their parents (depression, manic depression, schizophrenia), they were also more likely to report PTSD symptoms [88].

Outness

Few studies have included being open about one’s LGBTQI+ identity in their analyses (n = 2). One of them, involving LGBTQ + individuals, focused on two samples: one exposed to sexual violence and the other exposed to domestic violence. Their results tend to suggest no link between openness about sexual orientation and traumatic symptomatology. Indeed, a link was demonstrated only in the sample exposed to sexual violence [75]. Other authors also observed no association in their sample of bisexual individuals. However, they did note an indirect effect, that being open about sexual orientation increased the risk of experiencing discrimination, which, in turn, heightened the risk of developing PTSD symptoms [51].

Perceived Social Support

Seven studies considered perceived social support in their analyses. In these studies, perceived social support is conceptualized differently, sometimes referring to family, friends, or a significant other, and sometimes as a global construct. Four studies assessed perceived overall social support. Three of them showed a negative association between perceived overall social support and traumatic symptomatology in transgender [56, 100] and bisexual individuals [50], while one did not find a link in LGBQA students [63].

Four studies considered perceived family support. For three of them, bisexual [50], LGB [76], and transgender individuals [83] who perceived good support from their families reported fewer PTSD symptoms. Only one study, involving 89 transgender women, did not demonstrate a link [100].

Four studies considered perceived friend support, with most showing a negative association with traumatic symptomatology [50, 83, 100], and only one not demonstrating any link [76].

Four studies considered perceived support from a significant other, with two observing a negative association with traumatic symptomatology in bisexual [50] and transgender individuals [83], and two others not finding a link in LGB [76] and transgender individuals [100].

Two additional studies did not specifically assess social support but rather rejection and acceptance. One study in an LGBT sample showed an increase in PTSD and DSO symptoms in individuals reporting feelings of isolation or experiencing rejection from their family of origin [44]. Another study, involving transgender individuals, showed a decrease in PTSD symptoms for those reporting feeling accepted by other transgender individuals [56].

Social trauma response

Two studies have explored how the social environment reacts after individuals disclose a trauma and its connection to traumatic symptomatology. Both studies showed nuanced results.

The study by Salim et al. [96] notes that bisexual women who have experienced rejection after disclosing their sexual assault reported more PTSD symptoms than those who did not face rejection. However, further analyses showed that these results were observed only when the victim lived in a negative context for bisexual individuals. The authors also observed that recognition accompanied by a clumsy reaction could be associated with an increase in PTSD symptoms, but this association did not persist in multiple regression analyses.

In the second study [75], the authors also observed that individuals who felt they were treated differently after disclosing their trauma reported more PTSD symptoms. Most other forms of reactions (egocentrism, assistance in procedures, distraction, or taking over) were also associated with an increase in PTSD symptoms, but this association did not persist in multiple regression analyses. The authors also noted that being believed was associated with more PTSD symptoms, primarily among victims of domestic violence. Other forms of reactions, such as being listened to or being blamed, did not seem to have an impact on symptomatology.

Organizational level

The organizational level reflects the broader environment in which an individual operates. This can encompass both the work environment and educational institutions, healthcare structures, as well as LGBTQI+ centers.

Barriers in access to care

Only two studies have considered aspects related to the organizational level in connection with symptoms of PTSD, both focusing on barriers in access to care for transgender individuals. Sherman et al. [84] observed that experiencing barriers in access to care was associated with an increase in traumatic symptomatology. In their analyses, the authors emphasized that experiencing barriers in access to care also magnified the relationship between exposure to multiple forms of violence and PTSD symptoms. The second study was more nuanced, noting that experiencing difficulties in accessing gender affirmation care in previous months was associated with more PTSD symptoms, but this association did not persist when controlled for other variables [56].

Community level

The community level reflects the interactions between the individual and the wider world. It encompasses environments in which the individual is not directly involved but can still be influenced by the norms and values they may convey.

Four studies have considered these factors in their analyses related to PTSD. For example, one study examined neighbourhood crime rates among MSM who experienced childhood sexual abuse but did not show an association [82]. Another study, involving a small sample of Black transgender women, explored the relationship between their sense of connection with the transgender community and PTSD symptoms, and also did not show any association [84]. A third study investigated the link between exposure to pandemic-related information during the COVID-19 health crisis and found that sexual and gender minority individuals who were the most exposed to pandemic-related news reported more PTSD symptoms [61]. Finally, a study wich considered exposure to anti-transgender media discourse found that the more transgender individuals were exposed to negative discourse about their community in the media, the more PTSD symptoms they reported [65].

Political level

The political level includes cultural and political elements that can affect individuals, such as societal attitudes towards LGBTQI+ individuals or the legal system.

A study conducted among transgender individuals living in the United States specifically considered the political context in its analyses. The authors observed that compared to individuals who did not live in states where politicians aimed to pass laws reducing the rights of transgender individuals, those living in affected states reported more symptoms of PTSD [55].

Discussion

The main objectives of this systematic literature review were (a) to explore the prevalence of PTSD and C-PTSD among LGBTQI+ individuals as reported in articles published since 2010; (b) to compare the symptomatology of PTSD/C-PTSD according to sexual orientation and gender identity and (c) to identify factors associated with PTSD and C-PTSD symptoms among LGBTQI+ individuals. Of the 7446 articles identified in the literature, 60 were selected for analysis: 18 for prevalence analyses, and 57 for analyses of associated factors.

Clinical elements

Prevalence rates of PTSD/C-PTSD and disparities across groups

Our first hypothesis was that LGBTQIA + individuals would report higher prevalence rates of PTSD/C-PTSD compared to those typically observed in the general population. The findings of this systematic literature review underscore that PTSD prevalences reported in studies are significantly higher than those typically observed in the general population: around 4.7% for PTSD in the past year (DSM-5) [104] and 7.3% for PTSD/C-PTSD over a lifetime (ICD-11) [105].

The observation of a higher prevalence holds true for the entire LGBTQI+ community, but certain populations seem particularly more at risk, as expected in our second hypothesis. This is notably the case for bisexual individuals, already identified as more at risk than others for other mental health issues such as anxiety, depression, or suicidal ideation [12, 106]. This disparity is partly explained by chronic exposure to different stereotypes specific to bisexuality (e.g., questioning their sexuality, potential infidelity, etc.), even within the LGBTQI+ community, see the review by Chan et al., [107]. The PTSD prevalences gathered in this systematic review are even higher among transgender individuals, where multiple factors (e.g., precarity, barriers to healthcare access, overexposure to interpersonal violence) combine with certain stressors common to LGBTQI+ individuals. Transgender individuals are confronted with various forms of stigmatization [108] and seem less accepted by the general population than homosexual individuals [109]. The meta-analysis conducted by Marchi et al. [24] on PTSD prevalences in LGBTQI+ individuals further supports our results. The study by Marcha and colleagues is based on 27 studies, the vast majority different from those included in this systematic review (only two studies are common: [43, 45]).

Certain studies included in this systematic review have showed particularly high prevalences of PTSD. This is notably the case in the study by Ali et al. [52], which reported a PTSD prevalence of 61.3% among Asian American LGB + individuals, and the study by Harper et al. [45] conducted in Western Kenya, which reported a PTSD prevalence of 52.3% across their LGBTQI+ sample and 64.3% among transgender individuals within the sample. The heterogeneity in prevalences reported in these last two studies likely stems from the specific characteristics of their samples. Individuals recruited by Ali et al. [52] experienced a combination of stigmatized identities, involving sexual orientation and racial background. This intersection of different stigmas can make individuals particularly vulnerable to experiencing violence [110] or encountering barriers in accessing healthcare [111]. Harper and et al. [45] also emphasize that cultural and political contexts can influence the exposure to violence among LGBTQI+ individuals, whereas the results of our systematic review may have been smoothed by a large majority of studies conducted in North America.

Several international studies showed the impact of cultural and political context on the experiences of this population. In Europe, for instance, in a sample of 86,000 sexual minority adults recruited from 28 different countries, Bränström et al. [112] underline a direct link between structural stigmatization13 in the country and victimization. Other studies emphasize that the political context sometimes leads LGBTQ+ individuals to flee their countries due to the violence they face, exposing them to other forms of violence throughout their journey [113].

Factors associated with trauma-related symptomatology

Our third hypothesis was that the factors contributing to PTSD/C-PTSD symptoms would operate at multiple levels, encompassing both individual and societal factors. Consistent with this hypothesis, this systematic review reveals a wide range of factors associated with PTSD/C-PTSD symptoms, acting across multiple levels. Several of these factors are examined in greater detail in the following sections.

Violence exposure

The experience of violence, particularly anti-LGBTQI+ violence, has been consistently identified as a factor associated with increased symptoms of PTSD. This observation aligns with the scientific literature on ICD-11 PTSD and C-PTSD, highlighting that the primary factors identified in the development of C-PTSD include repeated exposure to interpersonal violence from an early age, which is difficult to escape or avoid [114].

Beyond the overexposure to interpersonal violence, the characteristics of these events also seem to influence the development of PTSD symptoms. This is suggested by some studies, such as that of Keating and Muller [95], which noted an increase in PTSD symptoms when the reported trauma was identified as related to LGBTQI+ identity. Another study by Paquette et al. [69] noted an increase in symptomatology when lesbian and bisexual women reported being sexually assaulted by other women, compared to those assaulted only by men. These specific characteristics of violence likely involve several factors, such as the risk of revealing one’s sexual orientation or gender identity by talking about the assault, the risk of reinforcing negative stigmas toward the LGBTQI+ community when the perpetrator is part of it, or the construction of a global perception of an insecure world where violence can come from both outside and inside the LGBTQI+ community.

Psychiatric comorbidities

The presence of comorbid disorders, typically psychiatric (anxiety disorders [47, 89, 99], depressive disorders [71, 82, 103]), and sometimes somatic [92], has frequently been associated with the existence of traumatic symptomatology. This finding is consistent with existing literature on the mental health challenges faced by LGBTQI+ individuals, who are overexposed to various negative mental health outcomes compared to the general population [115]. This observation is not surprising considering that overexposure to violence, starting in childhood, is a major factor in the development of psychopathology [3, 116, 117].

Surprisingly, no included study explored the link between PTSD and other relevant variables such as dissociative symptoms or suicidal ideation. Once again, this review couldn’t clarify if having other disorders makes LGBTQI+ individuals more vulnerable to traumatic symptomatology or if these disorders occur after untreated traumatic symptomatology, which is frequently found in patients reporting chronic C-PTSD [118]. It is highly likely that both scenarios exist, emphasizing the importance of identifying symptoms reported by LGBTQI+ individuals in clinical practice, both to prevent the development of other disorders and for therapeutic purposes in addressing identified disorders.

Coping strategies

In the context of exposure to violence, LGBTQI+ individuals may adopt a variety of coping strategies or coping behaviors. However, the design of the included studies and, consequently, the results of our systematic review do not allow us to determine whether the use of these strategies explains the onset of PTSD symptoms or if traumatic symptomatology is responsible for the use of such strategies. For example, several studies showed a link between substance use and PTSD [63, 96], and a meta-analysis shows higher comorbidity in sexual minority women than in heterosexual women [119]. The hypothesis that alcohol consumption could be a self-medication strategy in the case of PTSD is supported in the literature [120]. Other authors emphasize that beyond being a coping strategy, substance use disorders and PTSD might share common neurobiological mechanisms [121].

Furthermore, one study explored the adoption of hypervigilance behaviors in relation to traumatic symptomatology [71]. It is noteworthy that hypervigilance was conceptualized as an adaptive strategy rather than solely in terms of PTSD dimensions, even though it did not appear to be protective, but the contrary. The hypothesis of adaptive hypervigilance behavior in the context of chronic violence has also found support in other studies, such as among young, racialized men in the United States [122].

While hypervigilance is often described as a particularly costly strategy, it is frequently reported by LGBTQI+ individuals to cope with various contexts in their lives [123]. It seems challenging to consider hypervigilance solely in terms of an adaptive strategy or, conversely, solely in terms of traumatic symptomatology, although it constitutes a central dimension [124]. These symptoms likely play a role in a complex system of chronic exposure to violence and a lack of efficient coping strategies.

Gender transition-related issues

Specific issues related to gender transition have been identified in gender minorities, although further studies would be necessary for specification. The protective aspect of access to medical transition on PTSD symptoms appears unclear, with one study observing a decrease in PTSD symptoms in individuals who underwent a medical transition [57], and another not finding a link [59]. Several methodological issues intersect and certainly limit interpretations. For example, the two cited studies compared individuals who had or had not medically transitioned and lacked clarity in conceptualizing medical transition, as some transgender individuals may not feel the need to medically transition. Therefore, the experiences are necessarily different between a person wanting to transition medically but not having the opportunity, and a person who has the opportunity but may not feel the need. Moreover, other variables likely influence the relationship between transition and PTSD symptoms. This is particularly evident in the included articles, which, contrary to expectations in terms of psychopathology [125], show an increase in PTSD symptoms in individuals who have socially transitioned [57]. Several studies suggest that social transition itself is not responsible for this increase in symptoms. Indeed, the experience of social transition, especially when passing does not allow concealing one’s transgender identity, increases the risk of exposure to adversities ranging from microaggressions to hate crimes [54, 57, 126], thereby increasing the risk of traumatic symptomatology. This finding is more generally applicable within the LGBTQI+ community, where being open about one’s sexual orientation or gender identity seems to be associated with an increased risk of exposure to violence [127].

Methodological elements

Conceptual challenges of sexual orientation and gender identity

Certain conceptual and methodological challenges need to be highlighted in the context of this systematic literature review. Firstly, it should be noted that the very definition of sexual orientation and gender identity varies across studies. For instance, some studies conceptualize sexual orientation based on behaviors (e.g., “Have you had sex or engaged in sexual activity with someone of the same gender as you?“) [102], while others conceptualize it based on self-reported identity (e.g., “You identify yourself as…”) [49]. Some studies include both options in their sociodemographic questionnaires, supplemented by the possibility of having an attraction to people of the same gender without necessarily having had sexual intercourse (e.g., “Within the past year, have you felt physically attracted to people of the same gender as you?“) [75]. Regarding gender identity, various operationalizations of gender are also observed, from self-reporting (e.g., “What is your current gender identity?“) [66] to a two-step methodology asking about assigned sex at birth first (e.g., “What was the sex you were assigned at birth?“) and then current gender identity (e.g., “I identify as…”) [49]. This variability in operationalizing sexual orientation or gender identity necessarily leads to variability in the recruited profiles. For example, some individuals engaging in homosexual behaviors might identify as heterosexual if sexual orientation is operationalized solely in terms of identity. This variability in profiles likely leads to variability in results; individuals recruited based on homosexual behaviors may be more at risk of exposure to various forms of violence compared to individuals self-identifying as homosexual without having engaged in homosexual activity.

Statistical and methodological challenges in research on sexual orientation and gender identity

Another methodological challenge in research involving LGBTQI+ individuals relates to the methodological and statistical treatment of the results. The vast majority of included studies were retrospective, with some choosing to group different profiles of sexual orientations or gender identities together, thus diluting the existing specificities of each group. This practice is more broadly reflected in the scientific literature concerning LGBTQI+ individuals [128] and may indicate difficulties in recruitment or obtaining financial means to deploy more robust methodologies. This often comes at the expense of the most vulnerable and hard-to-reach populations. In this regard, it is noteworthy to mention profiles that do not appear in the results of this systematic review: no included study provided results regarding intersex individuals. This observation is likely explained by the design of the included studies, necessarily quantitative, which is a minority research format in intersex populations [129], probably due to the challenges of obtaining a significant sample. It is worth noting that one study, not included due to our inclusion criteria, showed that in a sample of 198 intersex adults, 40.9% reported having been diagnosed with PTSD [130]. These results suggest that intersex individuals constitute a particularly vulnerable population that needs to be acknowledged and supported.

Conceptual and methodological challenges of PTSD

Beyond the specific challenges related to research methodologies involving LGBTQI+ individuals, it is also important to highlight the limitations encountered in this systematic review in the conceptualization of PTSD. While the included studies had to assess traumatic symptomatology by referring to a recognized classification (DSM, ICD) and use validated tools, there is heterogeneity in the quality of the tools used, with some studies opting for short versions of self-questionnaires. It is worth mentioning that only a minority of studies have assessed PTSD using clinician-administered diagnostic interviews. Moreover, studies could rely on different classifications (e.g., DSM-IV, DSM 5, ICD-11), leading to different conceptualizations of PTSD in terms of dimensions, and even in terms of diagnoses with the introduction of the diagnosis of C-PTSD in the ICD-11. While LGBTQI+ individuals are massively exposed to the risk factors identified in the development of C-PTSD and some authors advocate for considering this symptomatology more specifically in the LGBTQI+ population [131, 132], only one included study assessed C-PTSD [44].

Strengths and limitations of the study

To date, and to our knowledge, this study is the first to conduct a systematic literature review on factors associated with PTSD symptoms in LGBTQI+ individuals. This work complements, from a different perspective, the recent meta-analysis on PTSD prevalence in LGBTQ+ individuals [133]. The main strength of our work lies in the rigor inherent to systematic reviews, providing a condensed summary of the literature on PTSD among LGBTQI+ individuals published in recent years. The contributions of this study are numerous and relevant for both clinical practice and research, emphasizing that PTSD is a public health concern among LGBTQI+ individuals.

We hope that this systematic review finds its place at various levels:

For clinicians, this work constitutes a major resource for updating their knowledge by highlighting the importance of a systematic assessment of exposure to violence and PTSD symptoms in LGBTQ+ patients. Identifying factors influencing traumatic symptomatology provides an important framework to consider in therapeutic work.

For researchers, this systematic review provides a condensed overview of factors evaluated in the PTSD literature among LGBTQI+ individuals to date. It serves as a foundation for exploring associations with PTSD that have not been extensively studied within the LGBTQI+ community (e.g., dissociation) or require further investigation (e.g., race and ethnicity, transition, barriers to accessing care). We also hope that this work can be utilized by LGBTQI+ individuals and associations in their interactions with public authorities to advocate for funding support for LGBTQI+ individuals exposed to violence.

Some limitations need to be acknowledged. One of the main limitations is that, through this work, we have aimed to offer a comprehensive synthesis of factors associated with PTSD in LGBTQI+ individuals. In this endeavor, we had to navigate a delicate balancing act between synthesis and precision. To remain accessible, we chose to group profiles with multiple characteristics, potentially smoothing over certain specificities. This is particularly true for gender minorities, where specific issues related to transition may have been observed that are not present in sexual minorities. It is certain that systematic reviews focusing specifically on PTSD in certain groups within the LGBTQI+ community are necessary. This is evident in the proposals made by Lépine et al. [134] in a systematic review on post-assault factors involved in PTSD among gay men, or Scheer et al. [119] in a meta-analysis on PTSD and alcohol consumption among sexual minority women. We hope that further research will complement these works. Additionally, due to the predominantly exploratory and retrospective designs of the included studies, this systematic review does not allow for inferring causality for the majority of identified variables. Furthermore, the heterogeneity of methods for assessing sexual orientation and gender identity in scientific literature makes it particularly challenging to conduct meta-analyses and systematic reviews in this field. Despite our vigilance, it is likely that some publications presented as solely addressing sexual minorities may also include gender minorities that were not identified in sociodemographic questions. Some heterogeneity was also observed in the methods used to assess PTSD across the studies. The vast majority of studies (n = 56) evaluated the presence of probable PTSD using self-report scales rather than clinician-administered diagnostic interviews (n = 4). This methodological bias may have led to an overestimation of the prevalence rates reported in the studies, and consequently in this systematic review. Finally, the systematic evaluation of exposure to one or more potentially traumatic events was not a criterion in the selection of studies. This choice reflects a bias in existing studies, which do not always assess the presence of PTSD criterion A. This may have influenced the results reported in this systematic review and highlights the need for more rigorous future studies.

Perspectives

It is important for researchers working in the field of PTSD to consider sexual and gender minorities more in their protocols, especially as this would only involve adding a few items to their research protocol. Recommendations already exist for inclusive collection of sexual orientation and gender identity information in studies [135, 136].

Our results also emphasize the importance of going beyond the assessment of PTSD and exploring C-PTSD symptoms. Some tools, such as the ITQ [42], make its assessment possible at a relatively low cost in terms of administration time. While some factors have already been extensively investigated, others still deserve exploration to identify their role in the traumatic symptomatology of LGBTQI+ individuals (e.g., dissociation). Furthermore, we encourage the use of more robust methodological designs to address the numerous biases identified in the included articles. At a lower cost, this involves considering sexual and gender minorities in the sociodemographic questions of existing epidemiological studies.

On a therapeutic level, it seems necessary for professionals supporting LGBTQI+ individuals to be trained in identifying and managing psycho-trauma. Likewise, professionals trained in psycho-trauma management should be sensitized to LGBTQI+ issues in order to feel competent in welcoming this population, given that a significant number of LGBTQ+ individuals are likely to seek therapy [137]. Access to care adapted to the specific needs of the LGBTQI+ community is a matter of access to human rights and public health. Some care options that meet the specific needs of the LGBTQI+ community do exist today and have proven to be relevant (e.g., support groups for affected individuals, parent-child support). However, it is certain that existing techniques for treating PTSD/C-PTSD are also suitable for LGBTQI+ individuals, although specific stressors for this population should be taken into account [138]. It is therefore necessary to facilitate the access of these populations to these care options at various levels (e.g., financial accessibility, public healthcare offerings, professional training, etc.).

Finally, it seems impossible to discuss the treatment of PTSD in LGBTQI+ individuals without addressing the urgency of protecting this population from the violence to which they are exposed. It seems difficult, if not ethically questionable, to imagine being able to treat PTSD symptoms such as hypervigilance, avoidance, or difficulties in connecting with others in an environment where, without these strategies, these individuals would risk being exposed to violence again. A public health policy aimed at improving the mental health of LGBTQI+ individuals urgently calls for a broader policy of inclusivity for this population in common law at all levels (e.g., education, employment, justice, family rights, access to healthcare, etc.).

Conclusions

This systematic review shows the importance of considering PTSD/C-PTSD among LGBTQI+ individuals in clinical practice and research. Higher quality studies are needed to quantify the extent of the problem. Healthcare professionals must be trained in the specific factors that may contribute to PTSD/C-PTSD symptoms in LGBTQI+ individuals. This cannot be achieved without public policies aimed at preventing all forms of violence against the LGBTQI+ population and ensuring access to equal rights. 

Abbreviations

C-PTSD

Complex Post-Traumatic Stress Disorder

DSM

Diagnostic and Statistical Manual of Mental Disorders

DSO

Disturbance in Self-Organization

ICD-11

International Classification of Diseases, 11th Revision

ITQ

International Trauma Questionnaire

LGB

Lesbian, Gay, Bisexual

LGBQA

Lesbian, Gay, Bisexual, Queer, Asexual

LGBTQ+

Lesbian, Gay, Bisexual, Transgender, Queer

LGBTQI+

Lesbian, Gay, Bisexual, Transgender, Queer, Intersex

MSM

Men who have Sex with Men

PREP

Oral Pre-Exposure Prophylaxis of HIV infection

PTSD

Post-Traumatic Stress Disorder

Authors’ contributions

W.P, H.F and B.Q have made substantial contributions to the conception or design of the work. W.P and H.F. have made substantial contributions to the acquisition analysis. W.P, H.F, M.H and B.Q have made substantial contributions to the interpretation of data. W.P have drafted the work; H.F, M.H and B.Q have substantively revised it. W.P, H.F, M.H and B.Q have approved the submitted version and have agreed both to be personnaly accountable for the author’s own contributions and to ensure that questions related to the accucary or integrity of any part of the work.

Funding

Not applicable.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.