Worlds Behind Words 10: LGBTQ Identity, Internalized Stigma, and Gender-Affirming Care

Author(s): Scott Douglas Jacobsen

Publication (Outlet/Website): The Good Men Project

Publication Date (yyyy/mm/dd): 2026/04/01

 William Dempsey, LICSW, is a Boston-based clinical social worker and LGBTQ+ mental-health advocate. He founded Heads Held High Counselling, a virtual, gender-affirming group practice serving Massachusetts and Illinois, where he and his team support clients navigating anxiety, depression, trauma, ADHD, and gender dysphoria. Clinically, Dempsey integrates EMDR, CBT, IFS, and expressive modalities, with a focus on accessible, equity-minded care. Beyond the clinic, he serves on the board of Drag Story Hour, helping expand inclusive literacy programming and resisting censorship pressures. His public scholarship and media appearances foreground compassionate, evidence-based practice and the lived realities of queer communities across North America.

In this interview, Scott Douglas Jacobsen speaks with William Dempsey about the rise in LGBTQ self-identification in the United States, linking it to generational change, safer social climates, internet-driven language, and expanding mental-health access. Dempsey explains how internalized stigma emerges from social messaging and why its emotional effects are real, even when the stigma itself lacks legitimacy. The conversation also examines anti-trans legislation, gender-affirming care, abortion policy, public funding debates, and information control. Together, Jacobsen and Dempsey frame bodily autonomy, healthcare access, and queer resilience as central issues in contemporary democratic life and global human rights worldwide.

Scott Douglas Jacobsen: LGBTQ people have been cataloged again in the United States, probably the most surveyed nation on earth. Gallup, a reliable polling organization, has found that about 9.3% of U.S. adults identified as lesbian, gay, bisexual, transgender, or something other than heterosexual in 2024. Gallup first measured this in 2012, when 3.5% of adults identified that way, so the share has increased substantially over the past decade.

A reasonable explanation is that people feel safer identifying as such, or that people who previously lacked the language to describe their experiences now have ways to articulate them.

It is similar to people going through psychotherapy when they lacked strong family or community support earlier in life. They begin to process their experiences and put them into words. They can articulate emotions and recognize them as feelings. Something similar may be happening with identity: people now have a more fine-grained vocabulary for describing themselves. That suggests a cultural shift.

As a footnote, I am not an expert. I am not a psychotherapist or a licensed social worker. From the perspective of a licensed social worker, how do you interpret this finding of such a large increase over roughly a decade? Those who self-identify as LGBTQ+. Gallup measured about 3.5% in 2012, and by 2024 the estimate reached about 9.3%.

Dempsey: I think it is likely a combination of factors. One is the broader societal movement toward greater acceptance of LGBTQ people, even though significant challenges remain.

Another factor involves generational change. Younger adults are far more likely than older adults to identify as LGBTQ. Recent Gallup data suggest that roughly 23% of adults under 30 identify as LGBTQ, compared with much lower percentages in older generations.

There is also the role of the internet. Platforms such as TikTok and other online communities expose people to terms and ideas they might never encounter in their local environment, particularly in rural or low-population areas. People can see experiences and identities described that resonate with them.

Access to language matters. When people learn vocabulary that describes their experiences, they may recognize themselves in those descriptions.

Another factor may be the gradual destigmatization of mental health care over the past few decades. If more people engage in therapy or counseling, they may have opportunities to explore identity and internal experiences in ways that were less common in the past. Clinicians can also help individuals address internalized stigma related to identity. That is another reason one might hypothesize why these numbers have increased.

Jacobsen: A broader question arises: which internalized stigmas or phobias are well supported by evidence, and which claims are exaggerated? That nuance often disappears when the issue becomes politicized. Some people argue that internalized stigma does not exist at all, which seems implausible. People can have low self-esteem or self-hatred, and that can become connected to identity.

Dempsey: I am not certain about the full research literature, but concepts such as internalized homophobia or internalized transphobia are commonly discussed in psychological research. In general, internalized stigma around identity is considered a real phenomenon in mental health discussions. 

What you are thinking about is that internalization comes from societal value systems. Any societal negative view of an identity—whether racial, gender-based, sexual orientation, religion, or something similar—is where that internal messaging originates.

What we have to remember is that we are not born with these views. When someone hates themselves for being gay, or for being Black, or for being Muslim, or for any other identity, it usually reflects messaging they have absorbed from society that tells them those traits are bad, wrong, or unacceptable.

Any form of identity can be associated with internalized stigma. The stigma itself is not inherently valid because it is based on social messaging. However, the feelings people experience are valid because they arise from pressures imposed by society. That distinction is important. When I say the experiences are valid, I mean that people’s emotional responses to social stigma are real. At the same time, it is a reminder not to give weight to those stigmatizing messages, because we should question the legitimacy of the opinions behind them—who determines them and who gives them authority.

Jacobsen: It is a little like the journalistic axiom: consider the source. At the same time, the opposite extreme is not particularly helpful either. I have interviewed several experts on personality disorders, particularly Cluster B personality disorders. Those cases sound extremely difficult for clinicians to manage. I believe one of them once joked that “Cluster B” sometimes becomes shorthand for “difficult patients.” Going too far in the opposite direction—relying only on yourself and having no external calibration—is also unhealthy.

Dempsey: I personally stay away from that area, especially Cluster B. Clinically, I would not choose to work with it. However, some clinicians specialize in it and thrive in that niche.

Jacobsen: For them, that becomes their bread and butter.

Dempsey: Exactly.

Jacobsen: Let me shift topics slightly. In the United States there has been discussion around the SAVE Act. Some political actors have suggested refusing to sign legislation unless Congress passes that act. In effect, that functions as coercive pressure tied to other policy goals. The messaging around it sometimes overlaps with broader debates about gender-affirming care and transgender policy.

I am interested in your view on the use of legislative coercion as a strategy to push agenda-driven bills. Historically, what kinds of outcomes tend to follow when legislation targeting gender-affirming care is proposed or passed? What is the impact of that on the community?

Dempsey: I think legislation targeting the community is nothing new. As we discussed earlier, if you look historically in the United States, laws criminalizing same-sex relations remained in place in many states until relatively recently. In fact, consensual same-sex conduct was not fully decriminalized nationwide until the U.S. Supreme Court’s Lawrence v. Texas decision in 2003. So in the broader scope of history, these legal changes are quite recent.

Because of that history, the LGBTQ community has spent decades responding to legislation that affects the basic ability to live openly. There is also a generational divide within the community. Some people lived through periods when being openly queer carried clear legal and social risks, while others were born into a period where, at least in some places, the law is less punitive.

When I refer to privilege in this context, I mean the relative privilege of living in a time and place where it is not criminal to be queer. That does not mean there are no legal or social challenges. Legislative battles still exist, and those can create fear and uncertainty—particularly for transgender people, who are currently the focus of many political debates and policy proposals.

At the same time, it is important to remember how much progress has occurred. Looking back at the history of LGBTQ rights can help people recognize the resilience of the community and build confidence for the future.

I also try to acknowledge my own position. I am queer, but I am cisgender, which means I do not face many of the same concerns that transgender people currently face. Much of the recent legislation focuses specifically on transgender issues rather than on sexual orientation more broadly.

Another factor is the political environment. Many people in the community believe that some of the current political messaging around gender identity serves broader political strategies. That does not mean the policies are unimportant. However, there is often debate about how much of the rhetoric will translate into lasting law versus how much is intended to mobilize political support or shift public attention.

Jacobsen: This one appears to involve more intimidation and policy signaling rather than settled legal decisions or adjudication.

For example, there have been recent legal developments involving gender-affirming care. Courts have been reviewing state laws related to medical treatment for transgender individuals. One example involves litigation over a Tennessee law restricting gender-affirming medical care for minors. That case reached the U.S. Supreme Court in United States v. Skrmetti, which concerns whether such restrictions violate constitutional protections.

There have also been cases involving other states, such as West Virginia, where courts have considered the legality of similar laws. In some instances, appellate courts have issued divided rulings or dissents reflecting differing judicial interpretations.

One judge summarized the reasoning behind certain legislative approaches by arguing that legislatures may believe they are encouraging citizens to accept their biological sex and may choose not to fund medical treatments they consider experimental.

That raises an important question about how courts and legislatures interpret medical evidence, individual autonomy, and the role of the state in regulating medical care.

Perhaps that argument holds for some people, but I do not think terms such as “unproven,” “invalid,” or “no evidence” are especially helpful, or empirically accurate, in describing the current state of research on gender-affirming care. What is your perspective on this decision, and others like it?  

Another item in the news this week involves spending controversies within the Pentagon. Reports indicate that the Department of Defense spent large amounts of money in a short period on items such as lobster, steak, luxury furnishings, and even a grand piano during an end-of-year spending surge. Some commentators contrasted that spending with debates about funding for gender-affirming care.

So you can see individual policy commitments and ideological commitments appearing simultaneously in different areas of the news.

Dempsey: I am just skimming through the material. My general thought is that people should be able to make decisions about their own bodies. Much of the debate involves the government attempting to regulate those decisions. The justification often involves public funding—for example, arguments that taxpayer money should not be used for certain medical services, whether abortion or gender-affirming care.

My response is that many of the people affected by those policies are also taxpayers. Individuals who rely on programs such as Medicaid still contribute taxes in many forms. When policymakers say that taxpayers do not want certain services funded, they are sometimes overlooking the fact that the people seeking those services are also part of the taxpaying public.

As a result, the policy debate can create significant stress for people who depend on those services. In the United States right now, some families feel compelled to move from one state to another to access gender-affirming medical care. That is a major decision. Families have to choose between remaining in a place where they feel unwelcome or where care is unavailable, and uprooting their lives in order to obtain medical services elsewhere.

This kind of legislation does not necessarily resolve the issue it aims to address. Instead, it often shifts where people live or seek care. One effect is that the country can become increasingly divided along political and cultural lines. Some states become associated with more liberal policies and others with more conservative ones, and people gravitate toward places that align with their needs or beliefs.

I do not think the division will become as stark as historical examples like the North–South divide during the Civil War. However, it can still lead to a pattern where different regions of the country develop very different policy environments and populations.

Jacobsen: This report comes from The Independent. It concerns a new abortion-related policy associated with the Trump administration that critics argue could threaten certain United Nations programs related to women’s and LGBTQ rights.

The policy would extend U.S. rules that bar foreign aid recipients from using those funds to provide or promote abortion services. Critics argue that this approach can weaken international programs designed to protect women’s health and support LGBTQ communities around the world.

A footnote to that issue is that the effect is not only a reduction in funding. Some observers argue that it also involves ideological influence through international networks. Certain religious organizations—both conservative Protestant and Catholic groups—have funded advocacy efforts abroad that support more restrictive social policies in different countries.

So there are two dynamics: domestic policy exported internationally through foreign aid restrictions, and the broader spread of ideological positions that do not prioritize individual autonomy in personal decision-making.

Pregnancy decisions illustrate the tension clearly. Discussions about population dynamics occur at the level of policy and development programs, but pregnancy itself involves deeply personal decisions. People face choices that can shape their lives for decades.

This raises a broader question. Regardless of cultural differences, what are some universal human challenges when people lack accurate information and then face situations such as unintended pregnancy? People must make decisions that can affect them and their families for many years.

There is a Human Rights Watch statement that I often cite. It describes safe and equitable access to abortion as a human rights issue and as part of healthcare. In that sense, restrictions on access can be framed as restrictions on healthcare.

Critics argue that such policies reflect a broader approach that limits healthcare access domestically and can also influence international health programs through U.S. policy.

How do you think this affects people in practice?

Dempsey: A similar argument can be made about transgender healthcare. In many ways, the issue revolves around access to healthcare services.

Historically, the United States has often attempted to project its political or ideological views internationally. That has occurred in many contexts, from Cold War efforts to contain communism to the spread of religious or cultural perspectives. Without getting too deep into global politics, that tendency forms part of the broader background of these debates.

As we have discussed today, restrictions on services can function as a form of suppression of healthcare access. Limiting information is another related issue. Some governments around the world tightly control access to information.

For example, countries such as China maintain extensive internet filtering systems and operate domestic versions of major online platforms. Those systems regulate the flow of information available to citizens.

Jacobsen: Yes. Many American companies operating in social media or digital services do not operate freely in China, so domestic equivalents developed instead. China also maintains systems that monitor social behavior through various administrative mechanisms. The internet filtering system is often referred to as the “Great Firewall.”

Many countries regulate internet access to some degree, although the openness of the internet varies significantly from place to place. Those information environments can shape what people know and how they make decisions about their lives.

They will sometimes amplify particular stories that make their state rivals look bad. There was an example a few months ago involving a remark by J.D. Vance that was widely criticized as dismissive toward Chinese people. Chinese social media platforms allowed that story to circulate widely and trend through their algorithms.

In that sense, information environments can be manipulated. We are increasingly recognizing similar dynamics within Western social media, particularly among platforms operated by American technology companies. In the American case, the influence is often corporate and market-driven. Companies control platforms, and economic incentives shape what content spreads.

China operates differently. It has a market-oriented economy, but political authority remains dominant. In China, no one ultimately stands above the authority of the Communist Party leadership. Even extremely wealthy entrepreneurs have been compelled to comply with state direction in prominent cases.

That highlights an important structural difference. In the United States, capital often drives political influence through markets and corporate power. In China, political ideology and party authority guide the system, even within a market-oriented economy.

So the broader point is that the filtering of knowledge can become a tool of power and control. When access to information is limited or curated, it can push people in particular directions.

At the same time, the internet has created new opportunities for global communication. In the United States, people increasingly connect with individuals around the world. I have noticed conversations between Americans, Canadians, and Europeans comparing what information they are hearing about events.

Thank you very much for the opportunity and your time, Will.

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