Week 8 Assignment

Rural Lesbians: Unique Challenges and Implications for Mental Health Providers

K. Nikki Barefoot, Amanda Rickard, and K. Bryant Smalley Georgia Southern University

Jacob C. Warren Mercer University

Although the majority of lesbians reside in urban areas, lesbian couples significantly outnumber partnered gay men in rural communities and are an important part of the rural demographic landscape. However, being present does not mean lesbians are fully embraced within rural culture. Rural culture is often associated with traditional gender roles, conservatism, patriarchy, fundamental religiosity, hetero-normative family struc- tures, and conformity—all of which can have significant effects upon mental and social wellbeing. Furthermore, rural residents frequently report negative perceptions of les- bian, gay, bisexual, and transgender (LGBT) people. These aspects of rural living can create challenges and vulnerabilities for lesbians who make their home there, creating unique considerations for mental health providers practicing in rural areas. The current article is a comprehensive review of the existing literature regarding the mental health of rural lesbians, summarizing current findings of the literature, highlighting areas of additional research need, and providing recommendations for mental health practitioners.

Keywords: rural, lesbians, mental health, LGBT, review

According to the most recent U.S. census, approximately 12% of same-sex couples live in rural areas (Bishop, 2011). Although the major- ity of lesbians continue to reside in urban areas, lesbian couples significantly outnumber part- nered gay men in rural communities (Bishop, 2011). Although, historically, lesbians may have been drawn to rural areas by the lure of agricultural feminist communes beginning in the 1960s and lasting through the early 1980s, they may still be tempted to reside in rural areas because of affordable housing and property, beautiful landscapes, privacy, and the slower

and quieter pace of life (Bell & Valentine, 1995; Leedy & Connolly, 2007). Additionally, lesbian couples may live in rural areas at higher rates than gay male couples because women typically earn less than men and are more likely to have children, which could make the less costly rural lifestyle more appealing than urban living (Bishop, 2011). Therefore, although lesbians may be more readily associated with urban dwelling because of their concentrations in ma- jor cities, they are highly present in the fabric of rural living as well.

However, being present does not mean lesbi- ans are fully embraced within rural culture. Ru- ral culture is synonymous with traditional gen- der roles, conservatism, patriarchy, fundamental religiosity, hetero-normative family structures, and conformity (Miller & Luloff, 1980). Fur- thermore, rural residents report negative percep- tions of sexual minorities, which appear to be related to fundamentalist religiosity, lack of in- terpersonal contact with sexual minorities, fear of AIDS, and conservative political orientation (Eldridge, Mack, & Swank, 2006; Herek, 2002; Hopwood & Connors, 2002; Snively, Kreuger, Stretch, Watt, & Chadha, 2004). These aspects

This article was published Online First May 26, 2014. K. Nikki Barefoot and Amanda Rickard, Department of

Psychology, Georgia Southern University; K. Bryant Smal- ley, Department of Psychology and Center of Excellence for Rural and Minority Health, Georgia Southern University; Jacob C. Warren, Center for Rural Health and Health Dis- parities and Department of Community Medicine, Mercer University.

Correspondence concerning this article should be ad- dressed to Jacob C. Warren, Mercer University–Community Medicine, 1550 College Street, Macon, GA 31207. E-mail: [email protected]

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Journal of Rural Mental Health © 2014 American Psychological Association 2015, Vol. 39, No. 1, 22–33 1935-942X/15/$12.00 http://dx.doi.org/10.1037/rmh0000014

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of rural living can create challenges and vulner- abilities for lesbians who make their home there, creating unique considerations for mental health providers practicing in rural areas.

Vulnerabilities and Risk Factors

The increased negative perceptions of sexual minorities (used herein to refer to the entire spectrum of sexual orientation and gender iden- tity other than heterosexual, cis-gendered indi- viduals) by rural residents create a number of vulnerabilities and risk factors for rural lesbians that can impact their mental health. Lesbians and other sexual minorities in rural areas and small communities report frequent experiences of discrimination and victimization (Edwards, 2005; Leedy & Connolly, 2007; Oswald, Geb- bie, & Culton, 2003; Palmer, Kosciw, & Bart- kiewicz, 2012). For example, some have expe- rienced discrimination in regard to credit and banking decisions, tax benefits, entry into com- munity groups, employment benefits, and even termination of employment (Leedy & Connolly, 2007). Victimization experienced by sexual mi- norities residing in rural areas includes verbal harassment, property damage, and physical as- sault (Boulden, 2001; Cody & Welch, 1997; Leedy & Connolly, 2007).

Although not specific to rural lesbians, Os- wald and Culton (2003) found that, of a sample of 527 sexual minorities from nonmetropolitan and rural communities, 92% reported a history of overhearing antigay slurs and 51% reported being bullied (i.e., teasing or name calling) or being rejected by others because of their sexual orientation. Furthermore, approximately 22% of individuals indicated experiences of physical violence or harm related to their sexual orien- tation. More recently, a national survey (Palmer et al., 2012) of lesbian, gay, bisexual, and trans- gender (LGBT) adolescents found that in com- parison to their urban counterparts, rural sexual and gender minority youth reported higher rates of both hearing homophobic and derogatory comments at school as well as experiences of harassment and victimization by their peers. These experiences of heterosexism and ho- mophobia can be a major stressor and have psychological, physical, and financial conse- quences for rural lesbians.

Another possible vulnerability for lesbians residing in rural areas is the likelihood of being

exposed to fundamental religious beliefs, which can create internalized homophobia. Rural cul- ture tends to place greater emphasis on religi- osity with an adherence to evangelistic beliefs and traditional codes of moral behavior (e.g., Aten, Mangis, & Campbell, 2010). Internalized homophobia occurs when an individual identi- fying as a sexual minority harbors negative ste- reotypes and feelings about being a sexual mi- nority. Gay men residing in rural areas frequently report feeling guilt and shame about themselves and their sexual orientation as well as having low self-esteem as a result of experi- ences of homophobia and condemnation from others related to fundamental religious beliefs (Boulden, 2001; Cody & Welch, 1997; Ken- nedy, 2010). The only research pertaining to the experience of rural lesbians with fundamental religiosity involved qualitative interviews with four lesbians, who reported themes of grief and loss related to their own religious beliefs and a lack of acceptance within the religion they orig- inally practiced (Hansen & Lambert, 2011). Further research is needed to ascertain if rural lesbians experience the same negative effects as gay men on their identity development, self- esteem, and psychological well-being when ex- posed to fundamental religiosity.

Isolation creates further vulnerability and risk for rural lesbians. There is geographic isolation and a lack of opportunity to socialize with other lesbians in rural areas (Leedy & Connolly, 2007; McCarthy, 2000). Whereas LGBT com- munity support has been demonstrated to re- lieve psychological distress (Waldo, Hesson- McInnis, & D’Augelli, 1998), a lack of community-based LGBT resources heightens feelings of social isolation among rural lesbians (McCarthy, 2000). Rural lesbians sometimes form small groups of lesbian friends and allies, yet some report that this is not a suitable sub- stitute for a LGBT community (McCarthy, 2000). Feelings of isolation may be com- pounded by the perceived need to conceal their sexual orientation because of fear of victimiza- tion and discrimination (Bell & Valentine, 1995; McCarthy, 2000). The need to remain invisible as a lesbian in the rural environment also impedes social networking with other les- bians and allies. Additionally, concealment and invisibility lead to negative effects on health, identity development, self-esteem, and overall emotional well-being (Edwards, 2005). As a

23MENTAL HEALTH OF RURAL LESBIANS

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result, rural lesbians likely feel the stress and negative impact of being a sexual minority even more acutely than their nonrural counterparts.

Feelings of isolation can be exacerbated by a lack of social support. Beyond limited opportu- nity to socialize with other lesbians and allies, some rural lesbians also struggle with a lack of familial support (Comerford, Henson-Stroud, Sionainn, & Wheeler, 2004). If combined with a low level of social support, rural lesbians may face the fear of not having anyone to rely on in times of need (King & Dabelko-Schoeny, 2009). This need drives some rural lesbians to create informal and formal social support net- works; however, balancing the need to avoid isolation with the danger of exposing their sex- ual orientation is a cost–benefit analysis they have to weigh (Comerford et al., 2004). This lack of adequate social support further endan- gers the health and emotional well-being of rural lesbians.

Although no research targeting the experi- ences of rural racial/ethnic minority lesbians was available for review, some themes from the qualitative research with racial/ethnic minority lesbians in general can be helpful in understand- ing unique challenges they may face in rural environments. Concealment and invisibility may be further reinforced by certain race/ ethnicity groups such as African American fam- ilies, and lesbians may have to contend with added pressure from within their own families to remain invisible (Miller, 2011). Triple op- pression, resulting from racism, sexism, and heterosexism, can have negative consequences for lesbians searching for an affirming commu- nity and attempting to integrate their race/ ethnicity, gender, and sexual identities in a con- text of limited support. Experiences of triple oppression or encouragement to remain invisi- ble by family may increase the likelihood of developing self-hatred and internalized ho- mophobia (Miller, 2011). Religious teachings, which are particularly salient for certain racial/ ethnic groups, also may play a factor in the experience of some racial/ethnic minority lesbi- ans. Bates (2010) found that African American lesbians and bisexuals from a large metropoli- tan area in the South reported experiencing early religious teachings that forbade homosex- ual relationships, and some reported feeling they had to leave their religious affiliation in order to pursue their same-sex relationships.

Themes of guilt and feelings of internalized homophobia pertaining to religiosity were re- vealed (Bates, 2010). Other women indicated that gays and lesbians were particularly segre- gated and ostracized from the African American community, resulting in concealment by lesbian African Americans to avoid such isolation from their racial community (Bates, 2010). This ex- perience is echoed in research involving African American and Latino adolescents who come out: adolescents who reported being religious were more likely to experience a negative reac- tion from their parents (Potoczniak, Crosbie- Burnett, & Saltzburg, 2009). Because of the close connection between rurality and religios- ity, it is likely that this effect creates even more burden among rural lesbian adolescents.

Developmental Issues: Youth

Lesbian youth face challenges to developing their sexual identity in the rural environment. As previously mentioned, rural cultures gener- ally value traditional and heteronormative gen- der roles. Therefore, Cohn and Hastings (2010) proposed that rural lesbian adolescents may struggle with balancing gender role expecta- tions and their sexual orientation. Within the rural community, there may be a sense of se- crecy and coercion to conform to social norms in order for adolescent girls to fit in (e.g., dating boys). In addition, because of isolation and lack of visibility of other sexual minority women, rural lesbian youth often lack visible role mod- els (Edwards, 2005; Mathy, Carol, & Schillace, 2003). As such, lesbians raised in rural areas disclose their sexual orientation to others at later ages than their nonrural counterparts (Mathy et al., 2003). According to research by Gray (2007, 2009), rural lesbians may rely more heavily on the Internet and various forms of social media to find coming-out related re- sources and social support from other sexual minority youth. However, although the Internet may be a viable source of support for rural lesbian youth, Palmer and colleagues (2012) found that rural sexual minority youth also were more likely to report experiences of cyberbul- lying compared to their nonrural counterparts, suggesting that the Internet may equally be a source of support and increased vulnerability for rural lesbians.

24 BAREFOOT, RICKARD, SMALLEY, AND WARREN

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In general, lesbian youth are at higher risk for emotional distress, substance use, and suicide attempts than their heterosexual counterparts (Bagley & Tremblay, 2000; Marshall et al., 2008). A large-scale study by Saewyc et al. (2007) highlighted many risk factors for rural lesbian and bisexual female youth. In compari- son to their urban counterparts, rural respon- dents were more likely to have experienced verbal harassment or teasing, suffered social exclusion from peer groups, gambled, tried al- cohol, used marijuana and other illicit sub- stances, engaged in binge drinking, previously driven under the influence of a substance, and had sexual intercourse. They also were less likely to use a seatbelt, use a condom, or report being religious than urban female sexual minor- ities. These rural sexual minority females were twice as likely as their urban counterparts to become sexually active before the age of 14 and contract a sexually transmitted disease. In addi- tion, they were more likely to report having contact with a stranger on the Internet that made them feel unsafe. These results suggest rural lesbian youth engage in certain risk-taking be- havior at higher rates than their urban counter- parts, with particular risks (e.g., being more likely to have contact with a stranger online) potentially linked back to the isolating effect of living in a rural setting. Furthermore, a recent report by the Gay, Lesbian, and Straight Edu- cation Network surveying a national sample of sexual and gender minorities found that, com- pared to their urban peers, rural LGBT youth reported greater levels of harassment and as- sault, as well as lower levels of overall LGBT- related school resources and support (Palmer et al., 2012). These increased vulnerabilities trans- lated into lower levels of school engagement, higher rates of absenteeism related to victimiza- tion concerns, and, for rural youth reporting the highest levels of harassment, lower grade point averages and lower college aspirations (Palmer et al., 2012).

Rural Lesbian Adulthood: Partnering and Parenting

Unlike their urban counterparts, because of issues related to isolation and lack of visibility, concealment related to fears of discrimination or victimization, and a lack of safe places to congregate (e.g., gay bars, book stores, LGBT

community centers), rural lesbian adults often face unique obstacles to finding lesbian peers and potential partners (Bell & Valentine, 1995; King & Dabelko-Schoeny, 2009; McCarthy, 2000). When these lesbians are able to meet other women and enter into romantic relation- ships or partnerships within a rural community, they face numerous vulnerabilities to not only their own well-being, but also a variety of unique stressors on the relationship. For exam- ple, in a qualitative study interviewing sexual minority women in rural communities, Edwards (2005) illustrated themes suggestive of con- scious attempts to maintain invisibility of same- sex relationships within rural communities, such as refraining from public displays of af- fection (e.g., holding hands) or concealment of sexual orientation within the community for fear of victimization or relational aggression. Further, subsequent psychological distress and threats to an individual’s well-being and the integrity of intimate relationships are described as a direct result of concealment and invisibility (Edwards, 2005). These types of behaviors may have a propensity to not only threaten a person’s identity and sense of self-worth and further fa- cilitate internalized homophobia, but also de- value or minimize the commitment and status of the same-sex relationship of rural lesbians.

Other qualitative studies have revealed addi- tional aspects of same-sex intimate relation- ships that may be unique among rural lesbians. For example, being partnered may be protective for rural lesbians, as this may buffer some of the negative impacts of feelings of isolation, a lack of belongingness, and rejection (e.g., Comer- ford et al., 2004). Further, depending on the severity of isolation and rejection from their family of origin or the community, rural lesbi- ans may rely almost exclusively on their partner for social and familial support (e.g., Butler & Hope, 1999). In addition, within rural commu- nities where connections with other lesbians and sexual minorities may be difficult, rural lesbians may be more likely to rely on ex- partners as part of their social support network (Butler & Hope, 1999; Comerford et al., 2004; D’Augelli, Collins, & Hart, 1987), potentially complicating current romantic relationships. Fi- nally, other issues related to partnerships and legal rights (e.g., same-sex marriage, partner benefits, property ownership, tax issues, and health care decision and visitation rights) that

25MENTAL HEALTH OF RURAL LESBIANS

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the majority of sexual minorities face regardless of geographic location may be more difficult for rural lesbians. For example, research findings by Leedy and Connolly (2007) suggest that rural sexual minority partners may face discrim- ination at the societal- and institutional-level when attempting to attain housing, credit/ banking assistance, and employee benefits for their partners. With the rapidly evolving nature of same-sex marriage laws, it will be important to see how the implications of changes in such laws filter down (or fail to filter down) to rural areas.

According to census data, approximately 33% of lesbian couples are raising children to- gether (Simmons & O’Connell, 2003). Al- though exact estimates of lesbian families in rural areas are not available, among rural lesbi- ans parenthood comes in many forms, and fam- ilies may consist of offspring from a variety of family planning methods. Women in same-sex relationships face obvious obstacles to family planning, and often have to rely on nontradi- tional means of conception as a result. In addi- tion to difficulties related to conception, rural lesbians may face other challenges such as ob- jections from family members, fear of being ostracized from the community, and unavail- ability of affirming obstetricians and gynecolo- gists.

When they do decide to become parents, rural lesbians and their children face additional chal- lenges that may significantly impact the well- being of the entire family. For example, in ad- dition to typical parenting stress, other potential challenges and risk factors include heightened sexism, heterosexism, discrimination and ho- mophobia, lack of family and community sup- port, and difficulties interacting within tradi- tional institutions (e.g., school systems, physical and mental health care systems, churches) within the rural community (Fried- man, 1997; Oswald & Lazarevic, 2011; Puckett, Horne, Levitt, & Reeves, 2011). In addition, when rural lesbian partners are parenting within step- or blended families, other challenges are often present that may be exacerbated by the conservative climate, such as custody arrange- ments and legal complications, issues related to coparenting with previous male partners, paren- tal role conflicts for the nonbiological “step- mother,” and relational stress (e.g., Friedman, 1997; Puckett et al., 2011). Puckett and col-

leagues (2011) surveyed a sample of urban and rural women with at least one child under the age of 18 that was planned within their current same-sex partnership. Rural–urban compari- sons revealed that rural women reported greater likelihood of prejudice and discrimination when seeking services within the community, inter- acting with individuals in helping professions, and encountering strangers. In terms of chil- dren’s level of outness to others, although rural and urban mothers did not differ in terms of the degree to which they discouraged disclosure of their sexual orientation to others by their chil- dren, the status of rural families (i.e., having same-sex parents) was less likely to be known by neighbors and the parents of classmates.

Furthermore, although artificial insemination proved to be the most common method of con- ception for both groups, rural lesbians were more likely to report sexual intercourse as a means of conception (Puckett et al., 2011). Al- though the reason for relying on sexual inter- course to conceive is unknown and may vary depending on the unique circumstances of the couple, one possible explanation for this type of method is that rural lesbians may lack adequate access to lesbian-friendly providers for family planning and fertility treatment (e.g., Friedman, 1997) and therefore rely more on sexual inter- course with men as a means of conception. Although the implications of this are unclear, it could lead to increased vulnerability to identity development issues and minority stress result- ing from the potential perception of a require- ment to engage in heterosexual intercourse as a means to secure their desired family structure.

Aging Rural Lesbians

Sexual minority women who are aging in a rural community may experience vulnerabilities and risk factors related to triple oppression from multiple minority statuses in the form of het- erosexism, sexism, and ageism that threaten their well-being. Comerford and colleagues (2004) pointed out that within rural communi- ties, if there is a notion that older women in general are “out of sight and out of mind,” then aging sexual minority women are likely to be “truly invisible.” These women may actively avoid routine mental and physical health care because of a history of systematic oppression and stigma experienced in their lifetime and

26 BAREFOOT, RICKARD, SMALLEY, AND WARREN

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instead rely more heavily on informal networks and alternative sources of health care (Butler & Hope, 1999). For example, these women grew up at a time when homosexuality was still a formally diagnosable mental illness (Silver- stein, 2009), resulting in stigma and skepticism by the traditional rural health care system. Al- though the research specifically examining the unique characteristics or experiences that aging rural lesbians face are scarce, there are a few recently published qualitative studies that offer some insight for rural mental health providers on their distinctive lives (Butler & Hope, 1999; Comerford et al., 2004; King & Dabelko- Schoeny, 2009).

In a qualitative study of a small sample of older lesbian-identified women residing in rural Vermont (N � 15), Comerford and colleagues (2004) identified themes such as self-reliance, interdependence, and informal sources of social support among the participants’ narratives. These narratives illustrate that aging rural women engage in a variety of cross-gendered and life sustaining activities such as car and home repairs. Because of their sexual orienta- tion, they may not readily fit within the soci- ety’s norms and expectations, resulting in a mutual unwillingness to seek help from others, in addition to less available help from conser- vative individuals within the rural community. These authors also point out that although rural elderly women in general tend to rely heavily on church and the religious community for support, rural aging lesbians rely more heavily on “friend-as-family” or “chosen family” support systems. However, these women reported few local venues and opportunities to socialize with other aging lesbians, which they regard as very important to their vitality. Therefore, in order to seek out these interactions, these findings sug- gested that rural lesbian elders have to drive to nearby cities or rely heavily on telephone calls and email in order to interact with aging lesbian peers (Comerford et al., 2004). In another qual- itative study examining the health and well- being of aging rural lesbians, Butler and Hope (1999) identified and explored themes such as issues related to access to care, health and health care, importance of family and commu- nity, and expectations and fears related to the future. In terms of access to care, 30% of the sample of aging rural lesbians lacked health insurance. Further, the majority of the sample

reported living outside of mainstream society and relying more heavily on small, close-knit networks for social support and health care. Although the majority of the sample reported good health currently, there was evidence of fears related to accessing lesbian-friendly health care and/or assisted living accommodations in the future (Butler & Hope, 1999). The one large-scale, quantitative study exploring the ex- periences of rural and urban aging sexual mi- norities found that, as expected, older LGBT- identified individuals residing in rural areas reported greater guardedness and lower levels of outness and lower annual household incomes compared to their urban counterparts (Lee & Quam, 2013). These results highlight the unique vulnerabilities aging rural lesbians may face with regard to inadequate social and financial support.

Finally, in a sample of aging LGB individuals residing in rural areas, King and Dabelko- Schoeny (2009) examined participants’ percep- tions of the feasibility of aging-in-place as a sexual minority in a rural community. Qualita- tive analysis of participant interviews revealed issues related to barriers to adequate health care including transportation difficulties, lack of health care options and gay-affirming providers, as well as isolation and inadequate social con- nections and a lack of belongingness as an aging sexual minority within a rural community. These qualitative results highlight unique chal- lenges that rural lesbians may face as they age and require increased support and health care. Moreover, it is important for rural mental health care providers to be aware of the unique sources of social support and/or health care that aging rural lesbians may rely on and helping foster these connections and sources of coping and support.

More recently, service providers and re- searchers have begun to recognize the unique challenges and barriers to care that sexual mi- norities aging in rural communities face. For example, Moore (2002) outlined the implemen- tation of a telephone-based support group de- signed for rural lesbian and gay elders who are caring for a partner who is suffering from de- mentia or Alzheimer’s disease. These types of lesbian and gay-affirming, innovative initiatives are needed to meet the unique mental and phys- ical health care needs of this population while also utilizing strength-based approaches and

27MENTAL HEALTH OF RURAL LESBIANS

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technology to reduce barriers related to overall geographic isolation.

Mental Health

There is a substantial need for research in the area of mental health disparities faced by rural lesbians, as there are no published empirical research studies focused on this issue. In addi- tion, in order to practice in a culturally compe- tent and affirming manner, there is also a high need for mental health providers to recognize that rural lesbians have unique barriers to men- tal health and to learn about these issues. Al- though there is a paucity of research focusing specifically on rural lesbian mental health, re- search indicates sexual minorities overall are at higher risk for psychological distress and men- tal health disorders than heterosexual individu- als. For example, sexual minorities have con- sistently been found to be at higher risk for anxiety, depression, and other mood disorders than heterosexual individuals (Bostwick, Boyd, Hughes, & McCabe, 2010; Cochran, Mays, Alegria, Ortega, & Takeuchi, 2007; Cochran, Sullivan, & Mays, 2003; Gilman et al., 2001; King et al., 2008). In addition, sexual minorities have been found to have an increased risk for substance use and dependence disorders (e.g., King et al., 2008). More specifically, lesbians seek treatment significantly more often than heterosexual women for depression and sub- stance use-related services, suggesting a vulner- ability to mood and substance use issues (Koh & Ross, 2006; Razzano, Matthews, & Hughes, 2002). Although not specifically related to rural lesbians, results from a recent study involving Southern lesbians demonstrate that these women are more likely to report frequent binge drinking and recent experiences of depression in addition to facing several barriers to receiving adequate mental health care including low so- cioeconomic status and/or inadequate health in- surance and a lack of a regular mental and physical health provider (Austin & Irwin, 2010).

Additionally, sexual minorities appear to be at higher risk for suicidal thoughts and attempts than heterosexual individuals. Sexual minorities have an increased risk for suicidal ideation, suicide attempts, and self-injurious behavior (Balsam, Beauchaine, Mickey, & Rothblum, 2005). In fact, Bradford, Ryan, and Rothblum

(1994) found that 50% of a sample of lesbians had experienced thoughts of suicide over their lifetime. Of particular note, lesbians and bisex- ual women who do not openly disclose their sexual orientation to others are significantly more likely to have experienced suicide ide- ation or attempted suicide than heterosexual women (Koh & Ross, 2006). This may be par- ticularly relevant for rural lesbians who are more likely to conceal their sexual orientation because of fears of rejection, discrimination, and victimization. These specific mental health concerns may be further exacerbated by expe- riences of stigma, minority stress, discrimina- tion and victimization, and isolation and rejec- tion that are likely to be experienced with increased frequency among rural lesbians who may lack adequate support and community re- sources while living in a community that may be characterized as more conservative and reli- gious (Butler & Hope, 1999; Edwards, 2005; Hopwood & Connors, 2002; Leedy & Con- nolly, 2007).

Strengths and Resiliency in Rural Communities

Although there are apparent challenges to living in rural areas for lesbians and other sex- ual minorities, there also are potential strengths and positive aspects of rural living that mental health providers can encourage and foster in treatment and within the rural community. For example, in their interviews with rural lesbians, Comerford and colleagues (2004) found that many of the women described an appreciation of the unique aspects of rural living and geo- graphic isolation, such as privacy and security, allowing them to have more freedom. Further- more, in a large sample of sexual minorities living in rural and nonmetropolitan areas, par- ticipants were asked to describe the “best as- pects” of living in a small community (Oswald & Culton, 2003). Qualitative analyses of the participants’ narratives revealed that sexual mi- norities living in small communities reported positive aspects of having intimate and support- ive relationships with partners, friends, and neighbors, involvement with small networks or communities of LGBT individuals, experienc- ing a good quality of life, and having high levels of acceptance for oneself. More specific to rural lesbians, Oswald and Lazarevic (2011) sur-

28 BAREFOOT, RICKARD, SMALLEY, AND WARREN

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veyed a sample of lesbian mothers living in rural and small communities and found that a combination of having regular contact with par- ents and extended family, at least one LGBT community organization in the area, and fre- quent interactions with other LGBT friends and social networks was predictive of a stronger attachment to the community.

Although there appear to be obvious limita- tions on visibility within the rural community to protect a person’s safety and security, coming out and being visible may be beneficial and actually serve as a potential protective factor. For example, D’Augelli (2006) argued that coming out within rural and small town com- munities can foster support and role models for other sexual minorities, particularly youth. In this way, visibility can reduce feelings of isola- tion by forming connections as well as giving rural lesbians a sense of empowerment as ad- vocates. This type of tactful visibility can also help rural sexual minorities foster small alli- ances and a sense of community. Furthermore, Eldridge and colleagues (2006) demonstrated that when rural inhabitants knew of or were friends with a lesbian or gay person, they were more likely to report increased comfort with homosexuality. In addition, at a more personal level, as described earlier, invisibility can threaten the identity development and overall well-being of rural lesbians (Edwards, 2005; Koh & Ross, 2006). Therefore, becoming visi- ble within the rural community may foster a greater sense of community among sexual mi- norities, while at the same time promoting ac- ceptance and appreciation.

Limitations of the Literature and Recommendations for Researchers

While this article has focused on the exist- ing literature surrounding the mental health of rural lesbians, the overall state of the litera- ture is very preliminary and in need of sig- nificant future research. Most studies are small-scale, qualitative, and highly regionally bound. Although these studies are very im- portant in beginning to develop the literature surrounding rural lesbians, it is vital for fu- ture researchers to include larger samples, which will allow for conclusions to be drawn from quantitative data to supplement existing qualitative studies. In addition, because of the

distinct variations in overall culture across geographic regions, the lack of a national (or even regional) examination of rural lesbian mental health creates an opportunity for fu- ture research that engages more than a single community’s residents in research in this area.

When considering specific research areas, investigations of barriers to and facilitators of mental health are needed. As was discussed previously, there are many factors that may be impacting rural lesbians’ mental health (e.g., double minority status, lack of access to care) but the current literature has not adequately explored specific outcomes, much less the factors leading to those outcomes. In addition, it will be important to focus on the specific factors of rural living that may serve a pro- tective role or that allow for rural-specific mental health promotion or intervention pos- sibilities. For example, the frequent availabil- ity of outdoor recreational opportunities may serve as a buffer against some of the stresses encountered in more urban-based living, but the aspects of rurality that may enhance men- tal health for lesbians are essentially unstud- ied. Further, it will be essential for future research to address the complete lack of ex- amination of rural lesbians of racial or ethnic minority backgrounds, including if there are racial/ethnic disparities within the rural les- bian population and if so, what could be done to address them.

We recognize that conducting research with rural sexual minorities can be difficult because of challenges in recruiting individu- als who are less likely to be public with their sexual orientation/gender identity than their urban counterparts. For this reason, we rec- ommend that researchers pursue innovative recruitment strategies such as online method- ologies and respondent-driven sampling methods that previously have been used very successfully to increase the representation of urban sexual minorities in research. Although there is a lingering perception that rural areas of the United States are cut off from advances in technology, there are still high rates of technology uptake in even the most under- served of rural residents (Warren, Smalley, Klibert, & Denmark, 2011) and this remains an underutilized method of engaging rural sexual minorities in research.

29MENTAL HEALTH OF RURAL LESBIANS

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Recommendations for Clinicians

Mental health practitioners can positively im- pact the lives of rural lesbians on several levels. The clinician can begin by examining his or her own beliefs and biases related to sexual orien- tation (Hastings & Hoover-Thompson, 2011; Leedy & Connolly, 2007). Environmental con- siderations, such as including lesbian magazines in the waiting area to provide a more affirming environment, in addition to intake paperwork being worded in a manner that is culturally sensitive to lesbians and their families (Oswald & Culton, 2003). Within the therapeutic rela- tionship, the clinician can attend to minority stress, sexual identity development, and inter- nalized homophobia. Therapy also may entail interventions related to planning and network- ing because the therapist can help rural lesbians recognize the importance of visibility, while at the same time recognizing safety issues. For example, processing and planning different lev- els of disclosures as outlined in Tiemann, Ken- nedy, and Haga (1998), through decision- making skills and role playing, may prove beneficial. Furthermore, a positive psychology approach may be productive through fostering a sense of empowerment and advocacy, focusing on strengths of the LGBT and overall commu- nity, and identifying positive coping and resil- iency of the individual (Cohn & Hastings, 2010). Hastings and Hoover-Thompson (2011) recommended that the practitioner can support lesbian families and other social groups/ organizations serving lesbians; this may be pos- sible by establishing support or therapy groups to address issues of isolation and normalize experiences of being a rural lesbian by utilizing technological innovations to make connections and combat barriers related to access and avail- ability (e.g., Facebook, Youtube, Skype, tele- conferencing).

Mental health practitioners can act on a com- munity level to improve the lives of rural les- bians. Snively (2004) proposed creating non- clinical-based gay/straight community-based groups for adolescents and young adults in rural areas, because young people need a nonschool, nonclinical acceptance-based group alternative that is not bound by bureaucracy. Rural lesbian adults can serve as mentors, volunteers, and board members for these groups, which may be a method of strengthening LGBT-affirming

communities in rural areas for adult lesbians. Oswald and Culton (2003) proposed many ways practitioners could help improve life for lesbi- ans living in rural areas: strengthen LGBT- affirmative resources; improve public support for lesbians; collaborate with the LGBT com- munity to develop programs to meet needs such as parenting classes, relationship enhancement groups, drug- and alcohol-free social events, retirement workshops, and legal rights classes; offer community workshops to school, law en- forcement, health care workers, and other com- munity service providers on LGBT issues; and encourage local positive media portrayals of lesbians.

Oswald and Culton (2003) also suggested practitioners consider becoming allies and ad- vocates for LGBT issues at local, state, and national levels. State governments can require mandates, similar to other minority training mandates, to require mental health providers to obtain training about LGBT issues (Willging, Salvador, & Kano, 2006). By being required to seek LGBT-affirming continuing education re- quirements, practitioners in rural areas who are generally seasoned professionals have the op- portunity to hone new skills that will increase their cultural competency with this population. Additionally, this can be a stop-gap measure for the current lack of concentrated training related to LGBT issues in professional psychology and counseling graduate programs. Practitioners are cautioned to treat homosexuality not as the problem, but rather collaborate with the rural lesbian community to be allies in order to ad- vocate for an end to the oppression, discrimina- tion, and victimization of rural lesbians (Boul- den, 2001; Cody & Welch, 1997). By implementing any of these suggestions, mental health practitioners could actively improve rural life for lesbians.

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Received October 8, 2013 Revision received April 18, 2014

Accepted April 23, 2014 �

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