Searching for a therapist from the community and in-network: A qualitative exploration of gay and bisexual men’s mental healthcare navigation

Abstract

Gay and bisexual men experience disproportionate rates mental health challenges including for depression, suicidality and substance use disorders. At the same time, they may face unique barriers to seeking mental health care that is LGBTQ-affirming. In this study, we describe and analyze gay and bisexual men’s mental healthcare navigation, with a focus on identifying challenges that arose when seeking care. Between July and September of 2023, 24 individuals participated in in-depth interviews via video-conferencing software. Interviews were transcribed and analyzed using a reflexive thematic approach. Participants reported challenges navigating insurance networks, which often engendered frustration and emotional upset. Participants desired mental health providers that could provide affirming and culturally-tailored care, with a preference for providers from the LGBTQ+ community and from their racial or ethnic background. Such needs were complicated by narrow provider networks, limited resources and provider directories replete with inaccuracies and unavailable providers. Participants also highlighted cost-related challenges, including high out-of-pocket costs associated with care and treatment limitations that restricted access to care. Finally, participants reported programming and resources that helped bridge the payment gap or made accessing care more convenient, including community and employer-offered mental health programming, primary care provider-delivered care and telehealth utilization. Our findings support that gay and bisexual men experience challenges when seeking mental health care that also affect the broader population, but may be magnified for this population, particularly for men of color seeking care from a smaller sub-set of providers prepared to be deliver culturally-tailored and affirming and care to LGBTQ+ individuals.

INTRODUCTION

Mental health disparities among LGBTQ+ communities have remained persistent for decades and are magnified for marginalized racial and ethnic groups. One meta-analysis reviewing the literature from the past 20 years reported that sexual minority individuals experience higher rates of mental health challenges across diagnostic categories, including for depression and suicidality, when compared to their heterosexual counterparts—disparities that have held over time (Wittgens et al., 2022). In the U.S., a report from the Substance Abuse and Mental Health Services Administration (SAMHSA) revealed that lesbian, gay and bisexual individuals experience higher rates of major depressive episodes and suicidal ideation (Substance Abuse and Mental Health Services Administration, 2022). Additionally, the prevalence of having experienced a “serious mental health illness” within the past year was two and three times that of heterosexual men, for gay and bisexual men, respectively (Substance Abuse and Mental Health Services Administration, 2022). Likewise, gay and bisexual men experience higher rates of substance use disorders, with 32% of gay and bisexual men having experienced a substance use disorder in the past year compared to 21% of heterosexual men (Substance Abuse and Mental Health Services Administration, 2022).

The causal mechanisms driving mental health and substance use disorders among gay and bisexual men have been well documented in the literature and largely expressed within the constructs of The Minority Stress Model (Hoy-Ellis, 2023); first coined by Ilan H. Meyer in 1995 (Meyer, 1995). Meyer’s Minority Stress Model (2003) suggests that health disparities, including mental health disparities, among lesbian, gay and bisexual individuals are the result of distal and proximal stressors that are specific to sexual minority individuals. These stressors include external experiences of prejudice, discrimination and violence, interactive stressors, defined as expectations of experiencing distal stressors and subsequent, accompanying vigilance, as well as the internalization of external stressors in the form of internalized homophobia (Meyer, 2003). The model also proposes that negative health outcomes may be mediated by community connectedness, resilience and social support—suggesting critical pathways for improving the mental health of LGBTQ+ individuals, including through thoughtful and culturally-tailored mental health care (Meyer, 2003).

To address mental health disparities among gay and bisexual men, reliable access to LGBTQ+-affirming mental healthcare is imperative. The existing literature on mental health care seeking and navigation for men has focused broadly on cisgender men, rarely disentangling differences in care navigation for gay and bisexual men, who both experience higher rates of mental health challenges than their heterosexual peers and may experience unique barriers to mental health care. This body of evidence has often underscored how mental health stigma and heteronormative masculine norms influence and discourage care seeking among men (Seidler et al., 2016; Vickery, 2021; Whitley, 2021). Yet, gay and bisexual men may face additional barriers to mental health care, including a smaller pool of mental health providers prepared to deliver LGBTQ+-affirming care, and expectations of prejudice, stigma or discrimination by mental health providers (interactive stressors within Minority Stress Model). Indeed, one qualitative study of gay men’s mental healthcare navigation underscored how participants’ expectation of homophobic provider interactions led to their selectively disclosing their sexual orientation and seeking providers who were perceived as safe; facets of care seeking unique to sexual minority individuals (Cosh et al., 2024).

One potential pathway for expanding gay and bisexual men’s access to LGBTQ+-affirming mental healthcare may be via primary care and integrated care models. Indeed, between 2012 and 2014, 32% of mental health-related appointments were delivered by primary care providers in the U.S., with a higher proportion of mental health appointments delivered within primary care settings in rural versus urban areas (The Centers for Disease Control and Prevention, 2018). Likewise, integrated care models may offer a particularly promising model for delivering mental healthcare to LGBTQ+ individuals, by integrating behavioral healthcare within settings providing primary care, and/or care specializing in sexual wellness, social services and other programming to support the socioeconomic needs of individuals. In their work on the importance of integrated care models for LGBTQ+ individuals, Heredia et al. (2021) outlined three critical criteria for affirming care, “(1) systematic identification of LGBTQ patients, (2) application of LGBTQ-affirmative assessment and treatment of behavioral health conditions, and (3) availability of affirming behavioral health specialists to accept referrals.” However, limited LGBTQ+ competency within primary care/integrated care settings and knowledge of patients’ sexual minority status may undermine these critical pathways to mental healthcare for gay and bisexual men. For example, one U.S. national study of providers revealed that only 34% of primary care practices provided LGBTQ+ training to their clinicians (Akre et al., 2025).

In addition to limited LGBTQ+ affirming care, there is a need to assess other systemic, structural, and financial access issues as they affect gay and bisexual men’s mental health care navigation. These may include insurance coverage for LGBTQ+-affirming care, financial challenges that bar or complicate access to care, and geographic healthcare access issues. For example, in 2021, the U.S. Department of Health and Human Services reported that despite improvements in insurance coverage for sexual minority individuals since the passage of the Affordable Care Act, cost challenges continue to bar access to care (Bosworth et al., 2021). For example, lesbian, gay and bisexual individuals were significantly more likely to report delaying therapy or counseling due to cost in the past 12 months when compared their heterosexual counterparts (Bosworth et al., 2021). Moreover, employment and economic disparities may undermine health insurance and financial stability, and by extension, mental health care access and engagement over time. Findings from a 2022 survey found that 57% of LGBTQ+ individuals had incomes of $50,000 or less, compared to 36% of U.S. adults (Center for LGBTQ Economic Advancement & Research & Movement Advancement Project, 2023). Finally, there is evidence that LGBTQ+ individuals are more likely to have insurance coverage via state Medicaid programs, less likely to have employer-sponsored health insurance and are more likely to be enrolled in a high-deductible health insurance plans (Gonzales et al., 2021; Mann et al., 2023; Nguyen et al., 2024; Tran et al., 2023); differences that may impact navigation of mental healthcare and financing for care, for better or worse. Note, these findings do not disentangle economic, health insurance or mental healthcare access outcomes by sexual and gender minority group, leaving critical gaps in our understanding of between group differences for LGBTQ+ individuals, including for gay and bisexual men.

Insurance coverage gaps, cost-burden and mental health provider network challenges have been documented in the broader public health literature for their impact on mental healthcare access in the general population (Mongelli et al., 2020). However, assessing these topics as they impact mental health equity for gay and bisexual men, and specifically gay and bisexual men of color, is warranted and can provide critical insights for improving mental health among these key populations. Furthermore, identifying policy and insurance practice-level challenges that perpetuate mental health disparities among gay and bisexual men may provide specific avenues for policy, programmatic and regulatory compliance intervention aimed at improving mental health disparities among this population. In this qualitative study, we sought to describe and analyze gay and bisexual men’s mental healthcare navigation, with a specific focus on identifying challenges that arose when seeking care. We discuss our findings within a policy-analysis of persisting mental healthcare barriers, and how they operate as unique barriers for this population.

METHODS

Participants and Procedures

This study uses data collected in the Together 5,000 (T5K) study, a US national internet-based cohort study of cisgender men, transgender women and transgender men who are vulnerable to HIV. The goal of T5K was to identify missed opportunities for HIV prevention and PrEP use (see Grov et al., 2019; Nash et al., 2019 for detailed description). Enrollment began in October 2017 and concluded in June 2018, with recruitment using ads on men-for-men geosocial networking phone applications. Eligibility criteria specified that participants were cisgender men, transgender men, or transgender women; aged 16 to 49 years; and at risk for HIV (see Nash et al., 2019 for full criteria).

Participants completed at-home annual surveys and at-home HIV testing for five years. For the present study, participants were eligible if they were cisgender men enrolled in the T5K cohort and completed their 48-month assessment and reported having sought mental healthcare in the past year. Participants were invited via email to a one-on-one qualitative interview—a total of 144 invitations were sent. We chose to utilize qualitative interviewing to answer our research question, with the intention of offering nuanced data on the lived experiences of gay and bisexual men navigating the mental healthcare system across the U.S. Moreover, we employed a gender-specific approach that aimed to specifically enroll gay and bisexual men, in an effort to contribute to a scant body of research exploring gay and bisexual men’s navigation of mental healthcare (Restar et al., 2021). Extant research suggests that (broadly) cisgender men face specific challenges when seeking or requiring mental healthcare, while research on LGBTQ+ populations offers insights into the unique barriers to care for these diverse populations. Thus, our sampling approach seeks to understand the experiences of those at the intersection of these two groups. To ensure diversity among gay and bisexual men by race, ethnicity and socioeconomic status, we oversampled for Black and Latine individuals, as well as those enrolled in Medicaid and without insurance. Thus, our sampling efforts prioritized a diverse group of gay and bisexual men, with the goal of offering robust qualitative insights for this particular population, though we acknowledge the limitations of this approach (see Limitations section).

Between July and September of 2023, 24 individuals participated in in-depth interviews via video-conferencing software. We concluded data collection upon reaching saturation with regard to our core research foci, namely, experiences navigating insurance network and cost-related barriers to care. Participants were compensated with a $40 digital gift card. All study procedures were approved by the Institutional Review Board for the City University of New York. Participants provided informed consent via email.

Measures

All interviews were conducted by the first author (AD), who is trained in qualitative interview methods. AD took detailed field notes which discussed emerging ideas, methodological considerations and reflexive personal notes when appropriate. Interviews followed a semi-structured guide and lasted from 30 to 60 minutes. Interviews covered topics pertaining to mental health care and STI prevention strategies—this study used data only from discussions regarding mental healthcare (see Appendix A, for relevant interview questions). In brief, participants were asked to share their experiences navigating mental health care, whether they encountered any challenges paying for care, finding a provider or attending appointments, along with any specific characteristics they sought in a mental health provider. Interviews were audio-recorded and transcribed verbatim. Transcripts were reviewed for quality assurance by two research staff members. Demographic data were taken from participants’ 48-month assessment and analyzed using SPSS version 28.

Data Analysis

Our analytic approach can best be described as a codebook approach to thematic analysis, while drawing heavily from the methodological processes of a reflexive thematic approach, as outlined by Braun and Clarke (Braun & Clarke, 2006, 2019; Byrne, 2022). The first author (AD) was raised by a single-parent, licensed clinical social worker, which has shaped her critical perspective on insurance challenges in the context of mental healthcare. The second author (RE) was raised as a first-generation immigrant in a South Asian household where mental health was often stigmatized; however, this has motivated her to further recognize the importance of access and acceptability of mental health care.

AD led the thematic analysis, first by reviewing detailed qualitative notes from each interview, alongside a brief review of the relevant policies dictating mental health coverage at the federal level—both in pursuit of re-familiarizing herself with the relevant data in keeping with an RTA approach (stages indicated in italics). Next, AD did a close review of each interview transcript, assigning preliminary codes and memos across all transcripts (code generation). The initial coding and memo-ing process resulted in an initial draft of a codebook, which was iteratively reviewed and adjusted against the data by both AD and RE (generating and reviewing themes). This process of researcher triangulation, involved both authors coding the same six transcripts and convening several times throughout this axial coding process to discuss reflexive reactions to the data, code applications and definitions, and the organization of codes into broader thematic categories (defining and naming themes). After several iterations of edits, the codebook was applied to the remaining transcripts by both coders. Finally, the Results (report writing) were written by the first author, during which time final minor analytic adjustments were made to the names and organization of themes and categories. Despite being informed by the first authors’ understanding of relevant health policies, including the Affordable Care Act and Mental Health Parity and Addiction Equity Act (a deductive, policy-driven approach), our analysis ultimately leaned toward an inductive and experiential orientation. This data-driven approach prioritized participants thoughts and feelings with regard to which challenges were deemed most salient when seeking mental health care, and elevated those categories through rich detail and analytic focus.

RESULTS

In total, twenty-four participants were included in our analytic sample, with a mean age of 34.58 years old. Most reported being cisgender male, (91.7%, n = 22) and identified as gay (79.2%, n = 19), with three individuals identifying as bisexual (12.5%). By race and ethnicity, 25.0% of participants were White, 33.3% were Black, and 16.7% were Latine, and over 20% (n = 5) were uninsured at the time of their 48-month assessment (see Table 1 for a complete overview of demographic characteristics of the sample).

Table 1.

Participant demographic characteristics, N = 24

Characteristics	M ± SD or n (%)
Age	34.58 ± 7.33
Race/ Ethnicity
White	6 (25.0%)
Black	8 (33.3%)
Latine	4 (16.7%)
Asian or Pacific Islander (API)	2 (8.3%)
All Other Multi	4 (16.7%)
Sexual Orientation
Gay, Queer, Homosexual	19 (79.2%)
Bisexual	3 (12.5%)
Heterosexual, Straight	1 (4.2%)
Other (Pansexual)	1 (4.2%)
Gender
Cisgender Male	22 (91.7%)
Non-binary	1 (4.2%)
Genderqueer	1 (4.2%)
Health Insurance
No	5 (20.8%)
Yes	19 (79.2%)
Employment
Full-time	12 (50.0%)
Part-time	5 (20.8%)
Part-time work – Full time student	1 (4.2%)
Permanent or temporary disabled and not working	1 (4.2%)
Unemployed	5 (20.8%)
Income
Less than $10,000	4 (16.7%)
$10,000 – $19,999	3 (12.5%)
$20,000 – $29,999	4 (16.7%)
$30,000 – $39,999	3 (12.5%)
$40,000 – $49,999	1 (4.2%)
$50,000 – $74,999	6 (25.0%)
$75,000 – $99,999	2 (8.3%)
$100,000 – $149,999	1 (4.2%)
Region
Northeast	2 (8.3%)
Midwest	3 (12.5%)
South	11 (45.8%)
West	8 (33.3%)

Our results were organized into three overarching thematic categories; 1.) Navigating the Networks, a theme that explores participants’ experiences navigating insurance networks to find an appropriate mental health provider. 2.) Cost and Coverage Challenges, which describes financial challenges that insured and uninsured participants face when seeking and maintaining access to care and 3.) Bridging the Chasm, a theme that encompasses a variety of programs and resources that helped bridge the mental health care gap. These broader thematic categories house several sub-themes, which seek to describe the variation and nuance within each theme.

Navigating the Networks

Complexity of care navigation

Participants often described the process of navigating our mental healthcare system as challenging and/or confusing; both when seeking outpatient talk therapy, counseling or psychiatric medication management. Some began by reaching out to their insurance provider for a list of in-network mental health providers, who offered provider directory lists that varied in accuracy, number of providers, and background information for each provider. Although some were able to easily navigate this information, others were overwhelmed by the complexity and burdensome nature of the process, as one participant explained:

I went on my portal through my insurance because I called and they were like, ‘Well, you need to go here, you need to do this. You need to click on your portal’…They weren’t helpful on the phone at all. They just kept pushing me to go online. I finally got irritated…it shouldn’t be that hard. You shouldn’t have to fight people to get information from your insurance plan. (White, 31years old, South)

Of note, several participants reported a lack of awareness of their mental health coverage at some point in time, with one individual reflecting that insurers are often “not proactive about letting the insured know what they have or what’s available to them,” (Black, 34 years old, West) and another describing uncertainty regarding their coverage, saying “I don’t know what the mental health portion of my insurance actually is. I’ve never looked at it” (Asian, 41 years old, West).

Outside of insurance network navigation, some participants described their process of seeking care independently using online search engines, via referral from primary care providers or through word-of-mouth referrals via social networks. Uninsured individuals often navigated a distinct set of low-cost or sliding-scale mental health resources and community programming (see Bridging the Chasm: Community programs); likewise, some insured individuals sought these resources when they were unable to find a provider via insurance networks. Participants often described several experiences attempting to access care, recalling different periods when they needed support for their mental health. Thus, participants’ mental health care narratives were often inclusive of both positive and negative experiences, multiple modalities of care (telehealth, in-person), and experiences with several providers.

Finding an available and accessible provider

Participants outlined challenges finding an in-network therapist with open availability and who was accessible to them, or with less frequency, a psychiatrist without a long waitlist. As mentioned, some participants were presented with a list of in-network mental health providers from their insurance company only to find that many were not in-network or were not available to take new patients. One participant illustrated a particularly challenging example of searching for a therapist, stating “I printed out 93 different therapists, and I’ve called across 21 pages. I’m eight pages into the printout and I still haven’t found a therapist in-network who is taking a new patient” (Latine, 33 years old, West). Participants also highlighted challenges with geographic accessibility, with some providers located too far away to be accessible, or providers with limited scheduling availability (i.e., after work hours). Although the shift to telehealth opened new provider options by removing geographic hurdles (see Bridging the Chasm: Telehealth), for some, telehealth was not their preferred modality of care, further complicating access issues for those with a preference for in-person care.

“Finding the right fit”

Participants frequently expressed the need to find a provider prepared to deliver LGBTQ+-affirming care. For most, this meant finding a provider who was from the LGBTQ+ community or had familiarity working with the community. Participants explained that it was important to find a therapist who understood their experiences as gay or bisexual men, and had an easier time connecting with therapists from their community, as one participant explained:

So that was another big thing I was looking for; someone that was part of the community. It took me a while to find the right fit, because I went through a couple of interviews or chatting with people that were therapists…they weren’t part of the community. And that didn’t make me feel very comfortable (Latine, 30 years old, South).

Participants reported experiences with providers unprepared to deliver LGBTQ+ affirming care, ranging from unhelpful to harmful and homophobic experiences, as one participant described, “I’ve had a male therapist as well that was very judgmental regarding me being gay. There were things brought up about how that’s against the Bible” (White, 31 years old, South). Moreover, some reported that providers were unprepared for conversations about non-monogamy and “kink” (often characterized by sexual practices that incorporate role play and power dynamics), or expressed “shock” at what participants shared with them; experiences that were interpreted as resulting from a lack of LGBTQ+ competency.

Some participants had specific requisites for a provider by demographic characteristics, including gender, race, ethnicity, or class background. For example, some expressed a preference for a gay, male-identified therapist, while others specified a preference for a female-identified provider, or specifically did not want a male provider. Preferences based on gender were sometimes attributed to having had traumatic experiences with a given gender outside of the therapeutic context. Several participants expressed the desire to find a provider from their racial or ethnic background, underscoring the importance of cultural concordance for connecting with their provider, and/or for working through familial challenges in therapy. One participant, who was able to find a culturally appropriate provider, described their experience, saying, “I managed to find somebody that was super specific to me somehow. My first therapist I found was LGBT. He was Puerto Rican. I was able to connect with him on multiple aspects, not just LGBT problems, but Hispanic family problems and stuff like that” (Latine, 31 years old, South). As illustrated in this quote, participants’ desire for racial or ethnic cultural concordance often coincided with a preference for an LGBTQ+ therapist, highlighting the intersectional nature of individuals’ lived experiences and mental health care needs. However, some were unable to find a provider who met these overlapping needs:

I was really hoping for someone who identified the same way as I do Black and gay…And I wanted to come to them and be like, ‘Hi, I’m a Black, gay dude, and I feel like I’m doing this whole living in this world thing all wrong, help me’… but I just didn’t get matched with exactly what I was looking for. It makes me wonder if there are really a lot of Black, gay therapists down here in [city in Texas]. But I’m not going to give up on that (Black, 23 years old, South).

The challenge of finding a culturally concordant provider was interconnected with finding an available provider through one’s insurance network, as one participant illustrated: “It’s been my experience that a lot of the people that are taking new patients tend to be older, white-presenting individuals, and not being white-presenting [myself]…that’s not always helpful” (Latine, 33 years old, West). Another participant reflected on the confines of narrower networks when searching for an appropriate provider, saying, “It would always be a benefit if there was a larger network, so there’s a greater chance of being matched with someone who’s able to tailor to my needs” (Black, 26 years old, West).

Finally, finding a culturally concordant provider did not always guarantee a successful therapeutic match between client and provider, often referred to as a “therapeutic alliance” (Ackerman & Hilsenroth, 2003; Bordin, 1979). Other qualities that participants highlighted as important were providers’ ability to provide safety, comfort and reciprocity in the therapeutic space, as well as a style and therapeutic approach that aligned with participants’ specific needs.

Emotional toll of care navigation

Participants described and experienced a range of emotions when discussing challenges navigating mental health care. These emotions ranged from frustration and annoyance to hopelessness, bitterness, stress and anxiety, as one participant expressed, “Oh my god, I get the worst anxiety when I’m trying to do stuff like that and it’s not working out… trying to help my mental health is making my mental health worse to an extent because they make it so hard” (White, 31 years old, South). Meanwhile, some individuals articulated feeling “alone” in the process of finding a provider; underscoring the isolation that some may feel navigating a challenging system, while simultaneously experiencing mental health challenges:

It’s just been really hard. It’s been emotionally draining doing the search alone… and going through the process of mutual interviewing [with a new therapist] … I’ve had bad experiences within the first phone call consultation... So, it makes me really sad. I think that’s why in-between therapists, I’ve taken such a big break. I was like, ‘Okay, I know that I’m struggling, but I need to heal, process what just happened with this therapist before I can move on’ (Black, 30 years old, Midwest).

As illustrated in the preceding quotation, poor early experiences navigating care or with a specific provider discouraged participants from seeking further care, undermining their therapeutic journey. These negative care experiences were often emotionally charged, deflating, and even dangerous for participants who were vulnerable and in urgent need of support. In a similar vein, some individuals’ navigational journeys were characterized by disruptions in care—either due to a change in insurance provider or status, employment, or the relocation of a participant or their provider. These life changes created disruptions in psychiatric medication management and/or came with the burden of starting talk therapy “all over again.” Disruptions in care were a source of upset, as participants grappled with losing their provider, finding a new provider, maintaining psychiatric medications, and re-engaging in their therapeutic journey.

Cost and Coverage Challenges

In addition to—and overlapping with—network navigational challenges, participants reported several cost and coverage-related challenges when seeking mental health care, including being uninsured or having inadequate mental health coverage, high out-of-pocket expenses associated with care, and experiencing treatment limitations, which limited access to care or the type of care one could access via insurers or other programming.

Uninsured or inadequate coverage

Participants spoke of instances in which they went without health insurance. As previously mentioned, these periods were often due to job changes, being “laid off” or unemployed, or changing their state residence. However, some were able to quickly regain coverage either via Medicaid, the Marketplaces, or through extending coverage via the Consolidated Omnibus Budget Reconciliation Act (COBRA). Moreover, one insured participant described having health insurance via a small employer that lacked mental health coverage through their plan.

Out-of-pocket expenses associated with care

Some participants faced nominal or no cost-sharing for care or were able to cover associated costs without issue. However, others experienced out-of-pocket expenses, including in the form of copays, deductible payments, and provider fees via self-pay that were often deemed burdensome, prohibitive, or unsustainable for maintaining care. In some cases, expenses resulted when insured participants were unable to find an in-network provider, consequently moving to self-pay for their mental health care.

Participants paying out-of-pocket for care were sensitive to price increases and reported adjusting their frequency of care or care avoidance in response. As one participant described, “To see a psychiatrist, my copay is $100, so I can’t go as much as I want. I can go every three months or so… And therapy. I’ve been struggling to get into a therapist because, again, it’s $100 copay for a specialist” (White, 31 years old, South). This participant was not able to expediently address medication challenges, because of spacing out appointments for cost-related reasons.

Out-of-pocket expenses associated with care were often discussed relative to other medical and non-medical bills, as well as recreational activities like getting “a nice meal,” or taking a trip, as participants weighed their need for mental healthcare against other life expenses. One participant highlighted the importance of prioritizing their mental health care, despite the cost, saying, “If I’m paying for my health, it’s worth the debt. If I was to be in debt for it…I need to feel better. I can’t function if I can’t go to work. I can’t do what I need to do to make the money if I don’t pay for it now” (Multiracial, 35 years old, West).

Treatment limitations

Some out-of-pocket expenses occurred because of “treatment limitations,” wherein coverage was qualified to a number of therapy sessions, or specified mental health services were excluded from participants’ plans. One participant recalled that their therapist left their insurance network as a result of newly imposed limits, stating:

When I first started in 2015, it paid for my sessions all the way up until last year, which was 2022. It was unlimited…And last year…they said you’ll only be able to have a certain amount of sessions based on whatever life changes or based on the mental health assessment. That’s when my therapist was like, ‘Okay, I’m not doing insurance anymore.’ And thankfully, when she did switch over and go completely private, I was able to afford her because she kept it at the same rate the insurance company paid and not like, her private rate (Black, 34 years old, West).

Visit limits were not isolated to insured participants, but also affected those accessing therapy via community programming and school-based counseling centers. In one instance, a participant associated such limits with care provided specifically to lower-income populations, saying, “For people who are accessing it from low-income, there’s time limits or visit limits…and there’s almost a pressure to say, ‘okay, your time is up, and everything is fine’” (Multiracial, 40 years old, South).

Bridging the Chasm

Community programs & employer resources

Participants described several programmatic and employer-sponsored resources that helped connect them with mental health care. Free and low-cost therapy, including via on-campus counseling services, LGBTQ+ centers and other community-based programming facilitated access to mental health care, particularly for those uninsured or without mental health coverage. Of note, experiences in higher education, including with on-campus counseling, were often referenced as both beginning individuals’ mental healthcare journey and as pivotal periods wherein individuals took stock of their mental health needs, sometimes for the first time. Other programs mentioned included The Okra Project (a non-profit organization that funds Black queer and trans individuals’ mental healthcare), coupon cards (for prescription medications), and mental health hotlines. Finally, several participants mentioned employer-delivered resources, including Employee Assistance Programs (EAP) programs and navigational services for mental health care. Taken together, these resources were generally discussed as bridging the payment gap but not closing it.

Primary care provider-delivered care

Several participants reported receiving psychiatric medication management through their primary care provider (PCP), or utilizing PCPs as a resource for referral to therapy. However, PCP training qualified their ability to deliver mental health care, with certain medications or treatments falling outside of their comfort or purview.

Finally, two participants discussed their experiences in integrated care programs; wherein they received primary care (including STI and HIV prevention), or treatment alongside mental health care, case management and other programming aimed at supporting their overall well-being. These participants reported the most comprehensive care described throughout the study, with both reporting easy access to care and no burdensome cost-sharing. Notably, these participants discussed their physical and mental health care interchangeably, illuminating the comprehensive nature of their care. One uninsured participant described their care with Ryan White (an integrated care program for those living with HIV) as “easy peasy,” and illustrated their experience getting connected with a therapist, saying:

It was a screening for mental health… And then I unravel. I started to fall apart. I started to cry. All my trauma for my family and this and that. I think I said I wanted to die…So that was very concerning for them. They were like, “okay, so we’ll start therapy right away.” And it was actually right away. And then that’s when I met my first therapist. Oh, my God. That woman saved my life in many ways, many different occasions. I love her dearly…I’m still amazed by it. I’m very thankful. And all the services that have been provided because of this situation are the upside of this entire situation, where it all started with HIV (Latine, 32 years old, South).

Telehealth

Participants spoke both of their experiences with telehealth platforms (i.e. BetterHelp) as well as telehealth delivered mental healthcare from independent providers. Participants underscored that “matching” features offered by platforms helped connect them with providers who were a good fit, though not all reported success. Participants also highlighted lower out-of-pocket expenses associated with platform-delivered care when compared to paying the full out-of-pocket fee for therapy; sometimes these costs were perceived as affordable, though not always.

Participants also spoke broadly about the switch to telehealth for mental health care (resulting from COVID-19). For many, telehealth-delivered care was convenient, made scheduling and commuting easier, and provided more options due to expanded geographic access to more providers. However, as previously mentioned, telehealth-delivered care was not preferred by all participants.

DISCUSSION

Gay and bisexual men in this study described a range of challenges when attempting to access mental health care, echoing those experienced broadly by U.S. healthcare consumers, while underscoring resource constraints more prevalent in this population. These challenges were often described as complex and overwhelming, and sometimes created emotional upset in the process of seeking care. Notably, participants sought mental health providers who could provide culturally tailored care, with a preference for providers from the LGBTQ+ community, and/or who shared their racial or ethnic background. Such needs were complicated by narrow provider networks, limited resources, and provider directories replete with inaccuracies and unavailable providers.

Narrow and inaccurate network directories have been described in the public health literature as they qualify and undermine access to mental healthcare (Cummings, 2015; Williams et al., 2017). Regarding provider directories, several consumer studies have revealed widespread patterns of directory inaccuracies, including with regard to provider location, contact information, and whether providers were accepting new patients (Burman, 2020; Office of the New York State Attorney General Letitia James, 2023; Tenner et al., 2023; The Centers for Medicare & Medicaid Services, 2018). One analysis of Blue Cross Blue Shield’s Medicaid Managed Care plans in California revealed a disparity in inaccuracies by specialty—with a 15% error rate for non-psychiatrist providers and a 45% error rate for psychiatrists (Burman, 2020). Yet some states have reported even higher inaccuracy rates for mental health provider directories. For example, an analysis conducted by the New York Attorney General’s Office (OAG) in 2023 revealed that of 400 mental health providers, OAG staff members were able to book appointments with only 56 providers; suggesting that 86% of listed providers were unavailable to members (Office of the New York State Attorney General Letitia James, 2023). Furthermore, some participants were presented with a limited number of in-network mental health providers to begin with—many of whom may ultimately have been inaccurately listed. Indeed, studies support that mental health networks are more likely to be “narrow,” defined by some researchers as inclusive of less than 25% of local providers (Rae et al., 2024). One study estimates ACA marketplace plans include only 11.3% of practicing mental health care providers in their market (Zhu et al., 2017).

Taken together, the proliferation of narrow networks and inaccurate directories for mental health providers leave many gay and bisexual men with limited (or no) options for mental health care by further restricting access to the limited number of providers prepared to deliver LGBTQ+ affirming care. According to the American Psychological Association (APA), as of 2021, 5% and 6% of psychologists identified as gay or lesbian, or bisexual, respectively (APA, 2022). Moreover, participants seeking concordance by LGBTQ+, racial and/or ethnic community membership are likely to face exponentially fewer options, underscoring the intersectional challenge of finding appropriate mental health care.

Participants reported challenges with out-of-pocket expenses associated with mental health care, including high copays, deductibles and self-pay fees for talk therapy. At the federal-level, coverage regulations for mental health care in the United States are dictated in large part by the Mental Health Parity and Addiction Equity Act (MHPAEA) and the Affordable Care Act (ACA) (Kocher et al., 2010; Peterson & Busch, 2018). Broadly, MHPAEA requires that coverage and cost-sharing practices for mental health match that of medical and surgical care (Peterson & Busch, 2018). The ACA expanded the regulations of MHPAEA by designating behavioral and substance use treatment as an essential benefit and extending parity provisions to the individual insurance market (amongst other stipulations) (Peterson & Busch, 2018). Despite these improvements in coverage, many continue to face burdensome out-of-pocket expenses when seeking mental healthcare (Schwartz et al., 2023). Participants receiving weekly or bi-weekly mental health care may find cost-sharing practices that are in parity with medical/surgical care prohibitive or unsustainable when compared to less frequently sought medical or surgical care.

As illustrated in these data, out-of-pocket expenses may result from copay and deductibles fees deemed burdensome, or self-pay fees, wherein individuals pay for care outside of insurance provider networks. The latter may occur when individuals are uninsured, under-insured (lack mental health coverage), or fail to find a provider through their insurance provider networks. Indeed, the extant research reveals both a high prevalence of exclusively self-pay psychotherapy practices, and upward trends in psychiatric practices that are predominantly self-pay (Benjenk & Chen, 2020; Zhu et al., 2024). The trend toward self-pay in mental healthcare may increasingly leave patients with access to care contingent on their ability to pay out-of-pocket. Such practices can disproportionately bar access for those from marginalized communities, with lower incomes, and facing higher unemployment or precarious employment.

Gay and bisexual men in this study reported experiencing “treatment limitations,” which qualified their access to care via limitations on the number of talk therapy sessions covered by their insurers. The MHPAEA includes provisions which allow for insurers to impose both Quantitative Treatment Limitations, which are numeric limits on sessions or days covered for in- and out-patient care, and Non-Quantitative Treatment Limitations, which include medical necessity reviews, tiered formulary lists for psychiatric medications, and coverage restrictions by location, facility, and provider specialty, amongst other limitations (Peterson & Busch, 2018). Treatment limitations have been the subject of policy debate and compliance challenges (The Centers for Medicare & Medicaid Services), as they may undermine access to, and continuity in mental health care. Participants in this study likewise reported treatment limitations when receiving care via programmatic resources like school counseling programs and via LGBTQ+ centers, suggesting that such practices are also used to ration care outside of insurance networks. Treatment limitations may also be considered for their role in undermining health equity, as gay and bisexual men, and particularly those from other marginalized racial and ethnic communities, navigate the added challenge of losing access to care after successfully going through the process of finding it.

Treatment limitations and insurance changes sometimes resulted in growing out-of-pocket expenses for participants. Participants were sensitive to out-of-pocket cost changes, and reported reducing, forgoing or terminating care due to cost. Within the extant health economics literature, healthcare demand is generally considered “inelastic,” with demand largely stable even when the price for services changes (Ringel et al., 2002). However, some studies have found that mental health and substance use treatment have slightly higher elasticities, with demand more sensitive to increases in price than for other medical care (Ringel et al., 2002). Moreover, one study estimated that psychotherapy may have an even higher demand elasticity (greater than −1, which would classify psychotherapy as a truly elastic service) (Ringel et al., 2002). However, this body of literature are largely derived from the RAND Health Insurance Experiment and other studies from the 1980s and1990s. More recent data have reported reductions in mental health and substance use treatment elasticity (Ellis et al., 2017; Meyerhoefer & Zuvekas, 2010). Some researchers propose that advancements in treatment and expanded coverage for mental healthcare are responsible for reduced elasticity, but this updated body of evidence makes it difficult to disentangle demand changes for newer therapeutic approaches (i.e. cognitive behavioral therapy, CBT) from psychopharmacological treatments (Cronin et al., 2024; Meyerhoefer & Zuvekas, 2010). Further research is needed to better understand demand elasticity for talk therapy in the age of newer therapeutic approaches like CBT and increased access to telehealth counseling. Moreover, understanding the role of demand elasticity within the context of health equity may provide additional insights into the role of mental healthcare cost and its impact on utilization among those disproportionately impacted by mental health conditions, including gay and bisexual men.

Participants receiving care via integrated medical systems reported the most comprehensive care experiences. Integrated care services may be particularly well suited to addressing the healthcare needs of gay and bisexual men by providing culturally tailored mental health care alongside HIV and STI prevention, chronic disease treatment, and case management (Brown, 2023; Hughes et al., 2017). Indeed, several examples of integrated care facilities exist with a specific focus on addressing LGBTQ+ health, including Howard Brown Health Center (Chicago), Fenway Health (Boston), and Callen-Lorde Community Health Center (New York), to name a few. Although integrated care models offer promise in supporting the health needs of LGBTQ+ individuals in the U.S., there is a dearth of literature exploring their effectiveness (Hudson, 2018; Hughes et al., 2017; Mayer et al., 2016). Such gaps represent a critical need for further study, both to better understand the impact of existing facilities, as well as to inform best practices for scaling up integrated care models for addressing health disparities among LGBTQ+ communities across the U.S. Additionally, participants reported that PCP-delivered care, employer resources, telehealth, community- and school-based counseling programs also helped facilitate access to mental health care, albeit with varying success and sustainability.

In summary, addressing these mental healthcare barriers and supporting factors that facilitate access to care for gay and bisexual men may aid in addressing persisting mental health disparities (outlined in our Introduction). Informed by these qualitative data, and in pursuit of evidence-based solutions, policymakers and practitioners should consider addressing the following systemic challenges, as well as provider and insurer-level practices, when building policy solutions to improve mental healthcare access for this population:

1. Address inadequate mental healthcare provider directories. Improving both the quality of information shared via provider directories (e.g. accuracy), and the breadth of mental health provider options offered via provider networks can help increase access to culturally competent providers for all, including gay and bisexual, and particularly men of color who exist at the intersections of marginalization by sexual orientation, race and ethnicity.

2. Fund and support LGBTQ+ affirming training for mental health providers. Increasing resources for training mental healthcare providers to deliver LGBTQ+ affirming care can help increase access to culturally tailored and affirming care— though trainings should also be assessed for their efficacy in improving quality of care for LGBTQ+ individuals, representing another critical area of needed work (Yu et al., 2023).

3. Expand use of online matching features that allow patients to search for LGBTQ+ affirming providers, and filter by demographic characteristics. Expanding the implementation of online matching tools by both insurers, telehealth platforms and other mental health programming can help gay and bisexual men connect with providers’ prepared to deliver culturally-tailored and affirming care.

4. Reduce use of treatment limitations for talk therapy. Policymakers should reduce the use of quantitative treatment limitations on talk therapy, or provide pathways for overriding treatment limitations when care is still needed, in pursuit of continuity of care and mental health equity.

5. Scale-up models of care that deliver mental healthcare alongside primary care, social services and higher education. Scaling up integrated care models that offer mental healthcare alongside primary care (and other social programming) may offer a particularly promising pathway for addressing mental healthcare equity issues among gay and bisexual men. Moreover, higher education institutions offer a unique pathway to mental healthcare for students, and should thus be prepared to deliver culturally appropriate care to all students seeking counseling, including LGBTQ+ students via affirming care practices.

Ensuring access to mental healthcare for LGBTQ+ individuals takes on urgency in today’s sociopolitical context, with rising homophobia (and notably transphobia) reflected in public policies at the state-level (Jones, 2023), as well as in national data reporting increases in hate crimes against LGBTQ+ individuals (Community Relations Service, 2024). Following the presidential election in 2024, LGBTQ+ youth crisis hotlines saw a 700% increase in calls, reflecting urgent mental health needs in a time of heightened antagonism toward the LGBTQ+ community (The Trevor Project, 2024). Ensuring reliable, consistent, and affordable access to mental health care is central to reducing mental health disparities and achieving health equity for LGBTQ+ individuals and communities in the U.S.

Limitations

Our findings should be interpreted with consideration for their limitations. First, our study theoretically sampled for gay and bisexual men with experience seeking mental health care, with a focus on racial and ethnic diversity. This decision allowed us to offer in-depth contributions on the specific needs of gay and bisexual men seeking care, but did not allow us to assess the variation in said challenges for different demographic groups. In a similar vein, our data were not saturated across insurance status and type. Thus, our data on care navigation of programs or providers offering free, low-cost or sliding scale mental healthcare was limited to those currently or formerly uninsured, comprising a smaller group within our sample of participants. Likewise, differences in care navigation between those on private, employer-sponsored insurance, Medicaid, and those purchasing through the insurance Marketplaces could not be assessed with these data but represent a key area of research for future assessment. These limitations underscore the need for future quantitative methodologies to assess the prevalence of challenges outlined in this work across demographic groups, as well as additional qualitative work aimed at oversampling those with experience navigating mental healthcare resources outside of health insurance networks. Moreover, we note that these qualitative insights are, by design, specific to gay and bisexual men, and may not be easily transferred to other populations under the LGBTQ+ community umbrella. Thus, further research is needed to explore how women, gender-nonconforming individuals, and transgender populations experience navigating mental healthcare across the U.S.

Finally, we acknowledge that some themes are described with greater richness, detail, and supporting qualitative evidence. These intentional decisions reflect the saturation (and perceived importance) of different themes, which ranged from fully saturated and deeply explored (i.e., “Navigating the Networks”) to less saturated sub-themes, wherein nuanced exploration is lacking (for example, Telehealth). Thus, despite reaching saturation for our core research focus, future qualitative research may benefit from reproducing this work while attending to saturation across a broader array of salient theoretical concepts, building thick description across constructs in keeping with Lincoln and Guba’s approach to establishing transferability in qualitative research (Guba, 1981; Stalmeijer et al., 2024).

Conclusions

Gay and bisexual men in the U.S. face barriers and complexity when seeking mental healthcare, including both those seeking care through their insurer and those searching outside of insurance networks. Though not universal, many experienced high or burdensome costs associated with care and some reported that treatment limitations interfered with continuity or access to care. These barriers also affect the broader population seeking mental healthcare, but may be magnified for gay and bisexual men, particularly men of color, seeking care from a smaller subset of providers prepared to be delivered culturally appropriate care to LGBTQ+ individuals.

PUBLIC SIGNIFICANCE:

Gay and bisexual men experience a variety of network-level challenges when seeking mental health care. These include finding a provider who is prepared to provide LGBTQ+ affirming care and from one’s own racial or ethnic background. The challenge of finding a provider who is the right fit, is made increasingly difficult when individuals are offered limited in-network options and inaccurate mental health care directories from insurers—potentially contributing to persisting mental health disparities among this population.

APPENDIX A: Relevant interview questions regarding mental healthcare access.

1. Thanks for sharing a little about yourself. Now I want to start by asking whether you have ever sought mental health care? If so, can you start by walking me through the steps you took to access care?  a. Clarifying questions: What type of care were you seeking? Ie. In-patience treatment, therapy, psychiatric care, other specialty treatment etc.  b. What type of health insurance did you have (if any) at the time of seeking care?

2. Can you speak about any challenges you experienced during this process?  a. [Probe: For insurance network challenges, provider availability, accessibility etc.]  b. What, if anything, would have made it easier to access care?

3. How did you feel about the process of seeking care?

4. After the steps you took, were you able to access care?  a. Did it take more than one try?

5. [For folks who were able to access care] Can you speak a little bit about your experiences in care?  a. Have you experienced any financial challenges throughout your treatment/therapy/care?  b. Have you experienced any other challenges maintaining care? If so, can you describe those?

6. [For folks who were not able to access care] If you are willing, can you speak about how these challenges seeking care or being unable to access care affected your mental health experience?  a. In lieu of traditional mental healthcare, did you use any other strategies to manage your mental health? If so, can you tell about those?

7. Before I move on to our next topic, is there anything else you would like to share on the topic of accessing and engaging in mental health care?