Understanding mental health and psychosocial support needs among marginalised communities in Uganda

Abstract

Background

Sexual and gender minority (SGM) populations in Uganda experience significant mental health challenges, exacerbated by widespread stigma, discrimination, and hostile legal frameworks. Despite increasing mental health needs, access to appropriate and affirming services remains limited within the existing health systems. This study explored the psychosocial and mental health needs of SGM individuals and the barriers they face in accessing care.

Methods

We conducted a qualitative study using focus group discussions (n = 3 groups) and in-depth interviews (n = 11) with SGM individuals across sexual and reproductive health clinics and community-based organizations in Uganda. Overall, thirty-eight participants were purposively sampled to reflect a diversity of sexual and gender identities (N = 38). Thematic analysis was used to identify patterns and insights from the data.

Results

Participants reported a high burden of mental health concerns, including depression, anxiety, trauma, and substance use, often linked to structural violence, familial rejection, and internalized stigma. Key barriers to care included fear of discrimination, lack of trained and affirming providers, and limited access to safe, confidential mental health services. Participants emphasized the need for community-based interventions, peer-led support structures, economic empowerment initiatives, and the integration of mental health care into HIV services. Structural reforms—particularly decriminalization and health worker training—were also viewed as critical to improving access and outcomes.

Conclusion

Addressing the mental health needs of SGM populations in Uganda requires a multifaceted, rights-based approach that strengthens health systems, promotes inclusive service delivery, and amplifies community voices. Integrating mental health support into existing health services and scaling up peer-based models may offer effective and sustainable pathways to care.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-026-26797-4.

Background

The mental health needs of sexual and gender minorities (SGM) represent a critical area of inquiry within healthcare, as these populations often face unique challenges that contribute to significant disparities in health outcomes. The term “sexual and gender minorities” encompasses a diverse range of identities, including but not limited to lesbian, gay, bisexual, transgender, and queer individuals. This diversity necessitates a nuanced understanding of the various factors that influence mental health within these groups, including societal stigma, discrimination, and the internalization of negative societal attitudes. A systematic review highlighted that stigma-related stressors are linked to adverse mental health outcomes, emphasizing the pervasive impact of discrimination on emotional well-being [1].

Uganda’s socio-political landscape, characterized by significant stigma and discrimination against SGM individuals, poses unique challenges to mental health service accessibility and utilization [2–4]. Globally, research indicates that SGM individuals experience higher rates of mental health disorders, such as depression, anxiety, and suicidal ideation, largely attributable to minority stress—a concept that encapsulates the chronic stress experienced by individuals due to their marginalized identities [5–7]. In sub-Saharan Africa, emerging evidence illustrates that mental health challenges among SGM populations are shaped by intersecting structural and social stressors, including stigma, discrimination, economic marginalisation, and constrained access to supportive services, as documented in Kenya [8, 9], Zambia [10] and Nigeria [11]. Furthermore, the COVID-19 pandemic highlighted and intensified existing disparities, revealing that SGM communities reported higher levels of anxiety and depression during this period compared to the general population [12–15]. In Uganda, the intersection of cultural norms and legal frameworks that criminalize homosexuality creates an environment where individuals may be reluctant to seek help, fearing further ostracization or legal repercussions [16, 17]. This restrictive context is mirrored in the limited empirical literature examining the mental health needs and priorities of these populations. Such gaps present a challenge for the co-design of tailored interventions, as these approaches depend on a well-established understanding of community-defined concerns. Without this evidence base, interventions risk being insufficiently aligned with the lived experiences and specific mental health burdens encountered by these groups.

Despite the challenges SGM individuals face, it is essential to recognize the resilience and coping strategies many individuals within these communities employ. Research has shown that social support, community engagement, and positive identity affirmation can serve as protective factors against mental health issues [18, 19]. The intersectionality of sexual orientation and other identity factors further complicates the landscape of mental health needs, necessitating a comprehensive approach that considers the diverse experiences of individuals within these populations [20, 21]. The implications of these mental health disparities extend beyond individual well-being; they also impact broader public health outcomes and healthcare systems. Addressing the mental health needs of SGM populations requires a multifaceted approach that includes policy changes, increased access to culturally competent mental health services, and community-based interventions aimed at reducing stigma and discrimination [5, 6, 22, 23]. Furthermore, healthcare providers must have the knowledge and skills to effectively support SGM individuals, recognizing their unique challenges and the importance of creating safe and inclusive environments [24].

This qualitative exploration will provide a comprehensive understanding of the mental health needs of sexual and gender minorities in Uganda, highlighting the barriers they face and the community perspectives that can inform more effective mental health interventions. While recognizing the importance of broader stakeholder involvement, this paper specifically focuses on the voices of SGM individuals to ensure their experiences and unique challenges are at the forefront of the discussion. By centering the voices of those directly affected, this research aims to advocate for improved mental health services and support systems that are inclusive and responsive to the unique challenges faced by sexual and gender minorities in Uganda.

Methods

Positionality and reflexivity

The research team comprised healthcare providers and health researchers, and the study was informed through close collaboration with members of diverse sexual and gender minority (SGM) communities. Through reflexive practice, the team critically examined how their professional roles, social positions, and assumptions shaped the research questions, data collection, analysis, and interpretation.

Healthcare providers on the team contributed practical insights from clinical and community-based work, particularly regarding disparities in mental health outcomes and barriers to culturally competent care experienced by SGM populations. Reflexivity was embedded throughout the research process, with ongoing reflection on how individual and collective positionality influenced decision-making and interpretation.

Although none of the authors identify as members of sexual and gender minority communities, the study relied heavily on the expertise, perspectives, and guidance of SGM community members and SGM-led organisations. This engagement was central to ensuring that the research was conducted ethically, respectfully, and in a manner responsive to the diverse lived experiences of these populations. Acknowledging positionality in this way strengthened the team’s commitment to amplifying marginalised voices and supporting inclusive approaches to mental health research and care.

Design and setting of the study

This was an exploratory, descriptive qualitative study conducted in two settings.

Sexual and reproductive health clinics

Four clinics located in different regions of Uganda were selected for their experience providing HIV prevention, care, and treatment services to key populations, including men who have sex with men (MSM), women who have sex with women (WSW), transgender individuals, and other SGM groups. These clinics operate within both urban and peri-urban contexts and serve as critical entry points for SGM individuals seeking healthcare in a relatively supportive environment. The clinics’ existing peer structures and history of engagement with key populations made them strategic sites for recruitment and data collection.

SGM-led community-based organizations (CBOs).

The study collaborated with a network of SGM-led CBOs that provide psychosocial, legal, and healthcare referral services to SGM communities across Uganda. These organizations were identified through existing partnerships, snowball sampling, and outreach via community networks, social media, and advocacy platforms [25]. The CBOs served not only as key recruitment sites but also as safe spaces where focus group discussions (FGDs) and interviews could be conducted with minimal risk to participant safety and confidentiality.

Study participants

Participants were individuals who self-identified as sexual or gender minorities or held other non-heteronormative identities. Eligibility required availability for face-to-face, virtual, or phone interviews and the provision of informed consent. Participants were purposively sampled to reflect a diversity of sexual and gender identities [26].

Data collection

We used guides to conduct focus group discussions (FGDs) with participants from SGM-led community organizations and in-depth interviews (IDIs) (Supplementary file 1). All the guides included questions about understanding mental health, conditions, access to mental health services, and priority mental health needs. Additionally, we inquired about the strategies or support required to address the mental health needs of SGM populations in Uganda.

Focus group discussions

CBOs played a central role in engaging community members in a trusted and affirming environment. Organizations were selected based on their history of advocacy, service delivery, and representation of different SGM subgroups. Recruitment was initiated through formal partnerships with leadership teams, who provided administrative approval and guidance on safe engagement practices.

Participants were recruited via direct contact, community events, and online platforms such as WhatsApp groups, social media pages, and internal mailing lists managed by the CBOs. Flyers and digital posters were circulated with brief study information, eligibility criteria, and contact details for peer mobilizers or the study team. Snowball sampling was also employed, whereby participants referred others within their networks who met inclusion criteria and expressed interest.

Focus group discussions (FGDs) were conducted at safe community spaces managed by the CBOs. Participants were grouped according to shared characteristics (e.g., transgender individuals, MSM, WSW, peer educators) to facilitate comfort and peer solidarity during discussions. The CBO setting allowed for open, peer-led recruitment, increasing reach and inclusivity, especially among individuals who may not access formal health services. Three focus group discussions (FGDs) were conducted in a safe space provided by a community-based organization (CBO), each comprising approximately ten participants, for a total of twenty-seven (N = 27). One team member took notes and observed non-verbal cues. Each FGD lasted 2–3 hours.

In-depth interviews

Participants (N=11) were purposefully selected based on their declared sexual and gender identities. Recruitment at SRH clinics was facilitated through established peer structures within each facility. Peer educators—who themselves identified as members of sexual and gender minority (SGM) communities—were engaged as liaisons to support participant identification and outreach. These peers had pre-existing relationships with clinic clients and were trusted members of the community, which enhanced rapport and minimized participant discomfort.

Clinic staff were oriented to the study's objectives and eligibility criteria, and they assisted in identifying individuals who had accessed HIV prevention or treatment services and who self-identified as part of the SGM population. To preserve anonymity and reduce risk, researchers did not access medical records; instead, clinic teams conducted initial screening and introduced the study to potential participants using a standardized recruitment script. Participants were then referred to the study team, who provided detailed information and obtained informed consent.Recruitment at clinics prioritized diversity in participant backgrounds and experiences. Individuals of different sexual orientations, gender identities, HIV statuses, and levels of service engagement were approached to ensure varied perspectives. Participants had the option to be interviewed on-site during scheduled visits or later, depending on their preferences and safety considerations. Interviews, conducted by one peer and a research team member, lasted 1-2 hours.

All data collection activities were carried out in secure, private environments conducive to open dialogue. In cases where participants preferred virtual or phone-based interviews due to safety concerns or logistical constraints, appropriate digital safeguards were employed. Throughout the study, efforts were made to ensure that the research process was inclusive, participatory, and sensitive to the risks faced by SGM individuals in Uganda’s legal and socio-political climate.

Data collection stopped when saturation was achieved. We assessed thematic saturation following Hennink and Kaiser, using their distinction between code saturation (no new codes emerging) and meaning saturation (no new insights into existing themes) [27]. Interviews were analysed iteratively, and saturation was judged to be reached when additional interviews produced neither new codes nor substantive new understanding of the themes. At this point, further data collection was considered unlikely to yield additional conceptual insights.

Data management and analysis

All study documents were securely stored in a password-protected, fireproof safe accessible only to the Principal Investigator, with no identifying information linked to participant data. Unique identification numbers were assigned to maintain anonymity. To ensure participant safety, data was not shared electronically; instead, electronic files were securely transported and stored off-site, with all documents password protected.

All interviews and focus group discussions were conducted in English, Luganda, or a mix of both, depending on participant preference. Audio recordings conducted in Luganda were first transcribed verbatim in the original language and then translated into English by trained research assistants familiar with SGM terminology and context. Transcripts were checked by a bilingual team member for accuracy and cultural meaning. Data were coded manually without qualitative analysis software. Two independent coders reviewed the transcripts, discussed discrepancies, and developed a unified coding framework to enhance reliability.

Data were analyzed using deductive thematic analysis [28]. In line with Braun and Clarke’s reflexive thematic analysis, the deductive codebook was developed from the study objectives and key concepts identified in the existing literature on mental health and wellbeing among marginalised communities [29]. These initial codes served as sensitising concepts rather than rigid categories and were refined through an iterative, reflexive reading of the transcripts as familiarity with the data deepened. Findings were shared with members of the sexual and gender minority (SGM) communities for validation to ensure accurate representation of their mental health needs. Direct quotes from participants are included to contextualize the findings and inform recommendations for future interventions.

Trustworthiness and quality control

The study ensured credibility through triangulation, collecting data from multiple sources, including in-depth interviews and focus groups with SGM individuals, community leaders, and mental health professionals. Preliminary findings were shared with participants for member checking to ensure an accurate representation of their perspectives. Dependability was achieved through thorough research process documentation, including an audit trail and regular peer debriefing to address potential biases. Confirmability was maintained by keeping a reflexive journal and recording all decisions to trace the study’s conclusions. Transferability was enhanced by providing detailed descriptions of the study setting, participant demographics, and the socio-cultural context of Uganda, allowing others to assess the applicability of the findings.

Results

Participant characteristics

Participation in this study was conditional upon the maintenance of strict confidentiality and the non-disclosure of individually identifiable characteristics. Identification as non-cisgender or non-heterosexual is criminalised, which exposes individuals to potential legal and social harms. In accordance with participants expressed preferences and to mitigate these risks, only a high-level summary of participant characteristics is presented (Tab. 1). This table was reviewed and approved by participants prior to publication.

Table 1.

High level summary of participants characteristics

	Frequency (n)
Gender Identity
Transgender	15
Cisgender	14
Other non-Cisgender identity	3
Prefer not to say	6
Sexual orientation identity
Gay	18
Lesbian	8
Queer	6
Prefer not to say	6
Role
Peer educator	5
SGM-CBO leadership team member	6
Health worker	2
SGM community member	16
Prefer not to say	9

Mental health and psychosocial support needs of SGM populations in Uganda

Seven themes emerged for the mental health and psychosocial support needs of sexual and gender minority populations in Uganda (Tab. 2).

Table 2.

Coding tree for mental health needs for SGM populations in Uganda

Themes	Categories
1. Limited Awareness and the Need for Community-Wide Understanding of SGM Mental Health Challenges	Sensitization of SGM individuals
	Sensitization of peer supporters
	Family awareness
	Community awareness
2. Critical Need for Accessible and Affirming Mental Health and Psychosocial Support Services	Proactive Approaches to Mental Health: Early Identification and Prevention
	Non-facility-based Mental Health and Psychosocial support
	Online access to Healthcare Professionals for SGM Individuals
	Self-management and coping strategies
3. Comprehensive Substance Use reduction, recovery and Reintegration Programs	Individualized Support for Substance Use Recovery
	Community-Based Group Rehabilitation and Support
	Community Reintegration Programs for Rehabilitated People
	Peer-based support networks
4. Integrated Mental Health and Psychosocial Support with SGM-focused health services	Integration with HIV prevention and care
	Leveraging peer-based supportive care
5. Improved Community mental Health	SGM Community empowerment
	Leverage existing community-based health organizations
	Peer mentorship programs
6. Inclusive and Supportive Mental Health Care	Employ mental health specialists who identify as SGM or allies
	Safe spaces
	Access to emergency mental health or crisis intervention services
	Trustworthy and professional mental health service providers
	SGM community support groups
7. Need for Mitigation of structural barriers to anti SGM-stigma	Legal and social advocacy
	Sensitivity training for Law Enforcement and Judicial personnel
	Change in criminalizing policies
	Stigma and discrimination-reduction programs
	Dialogue with key stakeholders

Limited awareness and the need for community-wide understanding of SGM mental health challenges

Sensitization of SGM individuals

Participants agreed on the need to raise awareness about mental health within the LGBTQ community. They suggested various approaches for healthcare providers to engage and educate the community about mental health, such as organizing health dialogues and disseminating educational literature on mental health.

“There is a need to raise awareness and foster dialogue among peer educators, clients, and other key populations (KPs) about the availability of these services. Educating the broader KP community on mental health and the services offered will encourage them to seek and utilize these resources.” -P17, FGD1.

“I am a reader, so you can publish for us books, books for mental health, so that we can get enough information.” -P7, FGD1.

Sensitization of peer supporters

Peer education emerged as a powerful tool for raising mental health awareness within the community. Participants emphasized that peers, with their deeper understanding of the community, offer more relatable and effective engagement.

“When a fellow student explained a topic in my school days, it became clearer. The best solution is to train peers to reach a basic qualification, ensuring every health facility has peers trained in mental health.” -P14, FGD 1.

“Mental health doesn’t require injections or specialized skills; we can learn and gain knowledge. They don’t understand our community.” -P1, FGD1.

Family awareness

Participants highlighted the need to raise awareness about sexual orientation and gender identity issues among their families to foster acceptance and improve treatment.

“Offering education on sexual orientation at home could help improve understanding. When my family discovered I was part of the community, it became difficult because my parents couldn’t accept it. If parents were better informed, they might learn how to support their children, which could prevent issues like alcohol and drug use.” P18, FGD2.

Community awareness

The respondents reported that negative comments and violence from the community are harmful to their mental health. They felt that educating the community on sexual orientation and gender identity could reduce stigma and discrimination.

“I believe the mental health awareness package should include a topic on sociology since many mental health issues arise from social relationships. Stigma, discrimination, and violence can greatly harm our mental well-being. It’s hard to thrive in a society that treats us this way.” -P5, IDI.

Critical need for accessible and affirming mental health and psychosocial support services

Proactive approaches to mental health: early identification and prevention

Participants emphasized that early identification of identity-related mental health struggles was vital in preventing more severe issues.

“Inform key populations about mental health, as they may not recognize the signs. They might say they’re stressed, have headaches, feel disturbed, hate themselves, struggle with sleep, or lack appetite without realizing these are symptoms of mental illness.” -P13, FGD2.

Non-facility-based Mental Health and Psychosocial support

Alternatives to hospital visits for mental health support were identified as valuable for improving access. These options enable individuals to engage with empathetic providers in familiar settings, avoiding the stigma often associated with healthcare facilities.

“If someone has a mental health issue, having the doctor’s contact is helpful. Let me decide whether to reach out, explain my situation, and allow the doctor to determine if a meeting or phone consultation is appropriate. I prefer options, not a hospital visit.” P13, FGD2.

Online access to healthcare professionals for SGM individuals

Participants mentioned that using online platforms like WhatsApp to talk to mental health providers is convenient and feels safe. They suggested setting up support networks for people managing mental health issues outside of formal healthcare.

“I suggest creating a WhatsApp group without labeling it as queer. We can add three doctors and include individuals with mental health challenges. I’ll explain the doctors’ roles, and they can reach out directly, make appointments, and handle issues over the phone if needed. The group should allow new members and serve as a space to share mental health information and updates on ongoing projects to raise awareness.” P13, FGD2.

Self-management and coping strategies

Participants identified various coping strategies for maintaining mental health, stressing that it is a personal, individual effort. They emphasized self-awareness as key to managing well-being, enabling individuals to recognize their emotions and triggers.

“Mental health is a personal effort. The more you understand your emotions and learn about yourself— whether quick-tempered or emotional— the better you can manage it. It’s about being aware of your mental state and knowing how to handle it and who to contact for help.” -P05, IDI.

“I think they can get us something to do, like practical skills. If someone gets something to do, it will help.” -P7, FGD1.

Addressing substance use through comprehensive, community-based recovery and reintegration programs

Individualized support for substance use recovery

Participants stressed the need for culturally competent healthcare workers who understand the unique mental health needs of SGM individuals.

“Most of us face challenges unless a healthcare worker understands us—someone we can call to schedule appointments during quiet times, meet at a safe location, or even visit where we’re staying. Other healthcare workers often speak poorly, don’t give us time, and seem indifferent, leaving us feeling neglected.” -P6, FGD1.

Community-based group rehabilitation and support

Rehabilitation for alcohol and drug addiction was identified as a critical mental health need. Participants suggested that group-based rehabilitation could be more effective and accessible, particularly in shelters and drop-in-centers (DICs) where SGM individuals feel safe.

“Rehabilitation for alcohol and drug addiction is needed. Group programs might work better and be easier to access. Offering these services in shelters and drop-in centers, where SGM individuals feel safe, could help.”-P7, FGD 2.

Community reintegration programs for rehabilitated people

Participants suggested that economic empowerment projects could benefit rehabilitated SGM individuals by providing income-generating skills and knowledge. These opportunities help keep them focused on maintaining sobriety and avoiding setbacks.

“Providing immediate job opportunities for those struggling with addiction can be helpful. Having a job that requires your time, and focus will reduce alcohol or drug intake. Over time, it can assist in withdrawing from substance abuse. Staying at home can lead to depression, but working allows for socializing and connecting with others, which can further support recovery.” -P9, FGD2.

Peer-based support networks

Creating support networks, including a sponsor system where individuals who have overcome addictions mentor others, was suggested to improve mental health. Mentors with personal experience can provide valuable guidance and encouragement, helping SGM individuals in recovery gain insights into overcoming addictions and managing mental health challenges.

“…. a system where, after seeing a therapist for addiction, once you’re ready to quit, they assign you a sponsor. The peer- sponsor could be a previous client who has just overcome addiction. This way, you get help from the therapist and someone who has been through it, and you might even become friends.” P1, IDI.

Participants reported that supportive friends and role models provide crucial encouragement and practical guidance.

“Most of the things that have helped me overcome my addiction have been the support of my friends.” P3, IDI.

Need for integrated mental health and psychosocial support with SGM-focused health services

Integration with HIV prevention and care

Participants suggested that the HIV prevention and care services they already receive at specific clinics should be expanded to include mental health care.

“Over time, I’ve seen our HIV prevention and care system working well. We have peer supporters who visit us in the community and special clinics where we receive care without stigma or discrimination. I believe everyone in our community knows about HIV prevention and how to take their medication. I propose that doctors who treat mental health and HIV should work together so we can receive all our care in one place. Things are already working well, and we’re happy with the care provided to our community.” P8, IDI.

Leveraging peer-based supportive care

Participants strongly agreed on the need for peers to receive formal training and qualifications to serve as frontline mental health supporters, including in health facilities. They believed this would create a more inclusive environment where peers act as trusted resources, reducing dependence on healthcare workers.

“Peers [peer supporters] need opportunities to grow and be more effective. They should be supported by taking courses like mental health. This way, they can provide all the care and support to the people they help, especially by addressing both HIV and mental health needs.” -P2, FGD1.

“The healthcare providers are overloaded with malaria, HIV, and PrEP. Let peers be trained in mental health.” -P16, FGD1.

Need for building and strengthening community mental health

SGM community empowerment

Participants recognized that economic empowerment initiatives are vital for building a sense of agency and self-worth in the LGBTQ+ community.

“An economic empowerment project would be beneficial. Many of our problems, aside from the law and family pressure, stem from poverty. Money is a big issue, so this intervention could be a great goal.” P20, FGD2.

Leverage existing community-based health organizations

Participants suggested incorporating mental health services and specialists into existing community-based health organizations that support them. They felt that these organizations already had established relationships with minority populations and that adding mental health services could improve access and care.

“You could recommend organizations with many projects in Kampala, like [….], which has a strong team. With [……] large population, they could benefit. The organization should think about opening branches here. We would get things like PrEP, condoms, and HIV self-testing kits on time, and they could also offer mental health services.” P3, FGD2.

Peer mentorship programs

Peer mentorship programs were seen as a valuable way to support mental health. Participants noted that these programs are helpful because they connect individuals with mentors who have faced similar challenges.

“Teaching peers about mental health is important so we can go to them for support instead of facing healthcare workers who might be hostile or discriminatory. Training peers builds a trusted network of people who understand our struggles.” -P18, FGD2.

Need for inclusive and supportive mental health care

Employ mental health specialists who identify as SGM or allies

Participants emphasized the urgent need for SGM mental health specialists, noting they would be more likely to seek help from professionals who understand their unique challenges.

“Ideally, we need counselors who understand us and our identity from our community. Straight healthcare providers don’t get us, and I’d feel more comfortable with someone who is part of our community.” -P9, FGD1 “…psychiatric nurses and medical officers are scarce.” - P7, FGD2.

Safe spaces

Safe spaces are crucial for supporting mental health and recovery. Participants stressed that these environments offer security and acceptance, allowing individuals to discuss their challenges openly. Many expressed insecurities, especially when dealing with authority figures.

“I once went to [a safe space organization] for counseling, and the care was much better than at the health facility. At the main hospital, people stare at me because of who I am, which makes me feel scared and insecure. If I see a policeman there for treatment, I’d probably turn and run because of the law.” -PA, FGD1.

Access to emergency mental health or crisis intervention services

Participants highlighted several barriers to accessing crisis intervention services, particularly fear of stigma and discrimination when disclosing mental health issues. Concerns about being judged, misunderstood, or mistreated due to their sexual orientation or gender identity often deterred them from seeking help, leading to missed opportunities for timely support.

“How do I start telling the healthcare workers that this is my issue?” -P5, FGD2.

“When sharing my story, I hold back because I know straight people are the ones helping me.” -P1, FGD1.

Trustworthy and professional mental health service providers

Participants emphasized the importance of trust and professionalism among health providers. One participant shared negative past experiences with unprofessional providers, highlighting the impact on their care.

“We share our personal stories with healthcare workers at the [……] for counseling, but then we hear others discussing what we said. This breaks our trust, and instead of getting help, we end up more stressed, sometimes leading to depression.” -P1, FGD1.

SGM community support groups

Participants stressed the value of support groups in providing emotional and practical assistance to those facing similar challenges. They suggested that existing groups, already focused on other issues, could be used for mental health interventions, allowing members to support each other’s recovery.

“Many of us have supported each other emotionally through the various stresses we face as a community. Since most of our issues are related to mental health and we share similar challenges, we could use these groups to support each other. If I know there’s a treatment I need to follow and my peers are doing the same, it motivates me to stay on track because we are in this together.” -P18, FGD2.

Need for mitigation of structural barriers

Legal and social advocacy

Community-based organizations (CBOs) and Civil Society Organizations (CSOs) supported participants’ mental health. However, they noted that recent legislation has hindered their ability to operate effectively. Participants suggested providing resources and training to strengthen their capacity to advocate for mental health support.

“Our organization used to hold health and wellness events and invite people, but the current laws no longer allow us to do advocacy openly.” -P13, FGD2.

“Giving CSOs mental health resources can help them better reach and support the communities they serve.” -P1, FGD1.

Sensitivity training for law enforcement and judicial personnel

Several participants proposed specialized training for police officers, lawyers, and judges, among others, to address the unique challenges and concerns of SGM individuals. They stressed the need for more knowledge and sensitivity within law enforcement.

“Police officers need training to understand the specific challenges SGM individuals face.” -P15, FGD2.

“If someone is caught using drugs, they should be treated as a patient, not a criminal. People must understand that prison doesn’t help, and the person will probably do it again. Instead, they need rehab, support to quit, and education about the risks of drug use.” -P10, IDI.

“Also, when they handle us with force, we get more depressed and hence more need to use the drugs. Show me a reason to stop; don’t give me a reason to continue.” - P19, FGD 2.

Change in criminalizing policies

Participants unanimously expressed concern over criminalizing policies that harm the mental health of SGM individuals by limiting access to essential services.

“I want to emphasize that the Minister of Health should push the government to remove the AHA [Anti-Homosexuality Act] from the Ugandan constitution. This law is the primary source of trauma for the SGM community, and its repeal would greatly alleviate our distress.” - P1, FGD 1.

Stigma and discrimination-reduction programs

Stigma within healthcare settings and society was identified as a significant barrier to accessing mental health services for SGM individuals. They believed that educating the population would lead to better understanding and more effective support for their needs.

“Healthcare workers need a deeper understanding of SGM populations through personality studies. By learning about their behaviors and backgrounds, medical professionals can better understand the factors influencing their actions that may prevent them from seeking healthcare, especially stigma.” - P7, FGD2.

“Stop making us feel uncomfortable. One has come to you, and you are asking many unnecessary questions.” -P2, FGD1.

Dialogue with key stakeholders

It was suggested that meetings be organized between SGM community members and stakeholders to rebuild trust and foster collaboration. Participants emphasized that open, honest dialogue could reassure them that mental health challenges will be addressed.

“A meeting between health workers and a small group of queer individuals is needed to rebuild trust. This would reassure the queer community that supportive doctors are still allies. Feeling safe enough to return to the hospital is essential, as fear—not a lack of services—keeps us away. By encouraging open dialogue, the meeting could help bridge the gap between doctors, health workers, and the community, reducing fear on both sides.” - P13, FGD2.

Discussion

This study provides critical insights into the mental health needs and strategies for sexual and gender minority individuals in Uganda, highlighting the multifaceted challenges and potential solutions within the community. The findings are organized around several key themes, reflecting the voices and perspectives of SGM individuals, healthcare providers, community leaders, and other stakeholders.

The need for increased awareness and education on SGM health issues and mental health was a recurrent theme. Participants emphasized the importance of sensitization across multiple levels—individuals, peers, families, communities, healthcare providers, and security organisations. Workshops and sensitization programs targeting SGM individuals, and their peers were seen as crucial in fostering understanding and reducing stigma. This has shown success in several countries, including Uganda [30, 31], the United States [32], and Ghana [33]. For families and the broader community, including health workers and law enforcement, sexual and gender minority awareness initiatives were deemed essential for creating a supportive environment [34]. The participants' experiences highlighted that interactions with healthcare providers often lacked sensitivity, exacerbating mental health challenges, which resonates with findings from the UK [35]. For example, one participant noted the stress caused by rude healthcare providers, leading to reliance on drugs as a coping mechanism. This highlights the urgent need to train healthcare professionals to interact respectfully and empathetically with SGM individuals. However, a study suggests that diversity training alone is not enough to address heteronormative microaggressions in hospital settings [36]. It is also essential to consider other factors, such as the internal and external environments, that may contribute to the mental health challenges faced by sexual and gender minorities in healthcare facilities.

Another significant theme was the necessity of improving access to mental health services and support for SGM individuals. Even when mental health services are available, they are often not tailored to the specific needs of the SGM community. The quality of services is inconsistent, with participants reporting limited access to trained mental health professionals and inadequate support systems. Many services are not welcoming or inclusive, leading to feelings of insecurity and further alienation. Experiences of anti-LGBT stigma and discrimination increase distress and reduce effective coping, which harms development, health, and well-being [37, 38]. Proactive steps, like preventing and treating factors such as minority stress, can help reduce mental health challenges before they escalate [39]. Participants also suggested non-facility-based approaches for managing diagnosed mental health conditions, such as community-based care models [40] that are more accessible to SGM communities in rural areas. This agrees with recommendations from the World Health Organization to promote a person-centered and rights approach [41]. However, other studies suggest that deinstitutionalization models can sometimes be uncoordinated and underfunded, leading to gaps in care [42], while others have demonstrated success in similar contexts [43]. Therefore, innovative approaches are needed to effectively reach the SGM community, particularly in regions where stigma and discrimination are prevalent. Criminalization in many countries makes SGM populations more vulnerable to human rights violations, harassment, and violence, highlighting the need for safe and confidential access to mental health care [9]. Strategies could include digital platforms [44, 45], discreet community outreach [46], and collaboration with local organizations familiar with the unique challenges faced by these groups. Participants in this study suggested using online platforms and phone services for easier access, especially in remote areas but emphasized the need for transparency about who provides care. They recommended involving peer supporters to build trust and engagement, aligning with Barnett and colleagues' suggestion that lay health workers (LHWs) can enhance access to evidence-based treatments (EBTs) by conducting outreach or, with training, serving as primary treatment providers [47]. Participants also called for SGM specialists, such as counselors, psychiatric nurses, and psychologists. However, this may be challenging in settings like Uganda, where criminalization discourages disclosure of sexual and gender identity, and there is a shortage of mental health specialists [48]. Such an approach could stigmatize healthcare providers and isolate their practices [49]. A more practical strategy may involve integrating mental health care into existing services or training healthcare workers on SGM-specific issues.

The study also revealed the necessity of comprehensive support systems for SGM individuals recovering from alcohol and substance use. The mental health needs, particularly regarding alcohol and substance use, were complex and deeply intertwined with the social, legal, and economic challenges these populations face. Our findings suggest that alcohol and substance use are widespread within SGM communities, and this has been reported elsewhere [50, 51]. These were utilized as a coping mechanism to deal with the stigma, discrimination, stress, fear of violence, economic hardships, and the pressure of living in environments that criminalize their identities. Some studies have reported an association between minority stressors and substance abuse among SGM individuals [52, 53]. The participants in our study explained that alcohol and substance use often serve as a temporary escape from these harsh realities, providing moments of relief from anxiety, depression, and the constant fear of persecution. However, this reliance on substances poses significant risks to both physical and mental health. Continuous use can lead to dependency [54], worsening mental health conditions, and increased vulnerability to health problems such as the risk of acquiring HIV through shared needles or unprotected sex and ART nonadherence [55, 56]. They proposed strategies such as individualized support from health workers, group rehabilitation to address peer influence, and SGM community support networks, including sponsors who have overcome addiction. They also suggested reintegration programs like economic empowerment initiatives to tackle underlying factors such as unemployment and poverty. This aligns with findings from Supriyanto and colleagues, who emphasize that effective reintegration programs must account for the social dynamics surrounding individuals after rehabilitation [57]. Integrating mental health services with broader social support systems is essential for a holistic approach that addresses both the psychological and socioeconomic challenges faced by SGM individuals, such as racism, family rejection, and unstable housing [58-60].

Integrating mental health support into existing SGM programs, such as HIV prevention and care, is crucial. A recent scoping review indicates that combining mental health management with other healthcare services improves outcomes like adherence to antiretroviral therapy (ART) and reduces stigma among healthcare providers [61]. Participants in our study suggested that this holistic approach addresses both physical and psychological needs by offering mental health services alongside HIV testing, counseling, and treatment. However, barriers such as a shortage of trained mental health professionals, criminalizing laws, and low preparedness to manage both conditions continue to limit access to care [38, 62]. For instance, a South African study highlighted significant gaps in provider awareness and readiness to deliver both HIV and mental health services [63]. Peer-based service delivery could play a vital role in overcoming these challenges. Participants expressed a strong preference for receiving mental health support from peers who understand their unique experiences, considering them more approachable and trustworthy. This fosters rapport and reduces stigma, as demonstrated by a systematic review in Canada showing that youth view peer support as an accessible and safe resource, encouraging open discussions about mental health [64]. Ultimately, creating accessible, peer-driven support systems is essential for promoting recovery, self-efficacy and reducing stigma among vulnerable populations [65]. Healthcare providers should prioritize building partnerships with peer supporters to enhance accessibility and trust in mental health services. Additionally, increasing training and resources for healthcare professionals to address both mental health and HIV-related needs is critical.

Community empowerment and strengthening SGM networks are essential for sustaining mental health initiatives. Participants highlighted the importance of partnering with SGM-led or SGM-friendly community-based organizations (CBOs) and civil society organizations (CSOs) to provide localized mental health support, such as at drop-in centers (DICs). Ssekamatte and colleagues emphasize that SGM-friendly CSOs not only provide shelter and legal services but also facilitate access to psychosocial support, reinforcing the need for these partnerships to enhance mental health services in community settings [66]. Moreover, champions and role models within the SGM community serve as influential figures for inspiring and guiding others, with research showing that such influential figures can encourage community members to seek necessary support and improve mental health retention [67, 68]. For practice, these findings suggest that building solid partnerships with SGM-led organizations and leveraging community leaders can create more effective and inclusive mental health services.

Finally, the study underscores the critical need for comprehensive support and advocacy for social justice to improve mental health outcomes for sexual and gender minority (SGM) populations. Achieving meaningful change requires robust efforts that address both legal and social determinants of mental health. This includes advocating for the decriminalization of LGBTQ+ identities and the enactment of laws protecting against discrimination and violence [69]. Talley and colleagues provide a thorough analysis of the impact of policy and law on the health and well-being of LGBTQ+ populations in the United States, demonstrating the necessity for decriminalization and protective legislation. They emphasize the positive effects of anti-discrimination laws and the harmful consequences of structural stigma [70]. Public education campaigns are also essential to raise awareness about the mental health needs of SGM individuals and to reduce stigma and prejudice [71]. Keuroghlian et al. (2021) highlight the critical role of healthcare worker training in effectively addressing these needs, particularly in environments characterized by stigma and discrimination [31]. Furthermore, Pachankis discusses how evidence-based affirmative practices can enhance treatment efficacy for SGM populations while promoting broader societal acceptance, thus reducing stigma and improving access to mental health resources [72]. Fostering partnerships among SGM organizations, healthcare providers, policymakers, and community leaders is crucial for creating inclusive, affirming, and supportive mental health environments. A study in rural southern U.S. regions illustrates the importance of an intersectional approach that addresses the unique challenges posed by sociopolitical and cultural factors and advocates for systemic changes in healthcare delivery to ensure inclusivity [73]. Collaborative efforts to dismantle health disparities and promote supportive frameworks for SGM populations are essential. Addressing these broader structural issues is necessary to build a more just and supportive environment for mental health.

Study strengths and limitations

The study relied on a purposive sampling method, which may not fully capture the diversity of experiences within the SGM community in Uganda. Additionally, we might not have explored all relevant dimensions of mental health needs and strategies.

Despite these limitations, this study contributes essential knowledge to the field and is the first to highlight the urgent need for targeted mental health interventions for SGM communities in Uganda.

Conclusions

The findings from this study reveal a complex interplay of factors affecting the mental health of SGM individuals in Uganda. Addressing the mental health needs of the SGM community requires a multi-faceted approach that integrates comprehensive support services with strong advocacy for social justice.

Integrating these strategies into existing health and social frameworks, alongside continued advocacy for social justice, is essential for creating a supportive environment where sexual and gender minority individuals can thrive.

Abbreviations

ART

Antiretroviral Therapy

CBO

Community-Based Organization

CSO

Civil Society Organization

DIC

Drop-in center

EBT

Evidence-Based Treatment

FGD

Focus Group Discussion

IDI

In-depth interview

KII

Key informant interview

LHW

Lay Health Worker

MSM

Men who have sex with men

PrEP

Pre-Exposure Prophylaxis

SGM

Sexual and Gender Minority

WSW

Women who have sex with women

Authors’ contributions

PM, and RN Concept and design, acquisition, analysis, interpretation of the data, and manuscript drafting. HL, and JSN Manuscript design, data collection and analysis, and critical revision for important intellectual content.All the authors gave final approval for the work to be published. All authors agree to be accountable for all aspects of the work to ensure that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Funding

The research reported in this publication was supported by the Fogarty International Center, the National Institute of Mental Health, and the Office of AIDS Research of the National Institutes of Health under Award Number D43 TW010037. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Data availability

This paper presents all relevant data; the raw data is available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

The Makerere University School of Health Sciences Research Ethics Committee approved the study (Ref. Number: MAKSHSREC-2022-257). The executive directors of each clinic and community-based organization granted administrative approval. Before participation, each participant provided written informed consent. All procedures were carried out following the applicable guidelines and regulations and the Declaration of Helsinki.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.