The study adopted a qualitative, descriptive, phenomenological design. Because the study was aimed at exploring mental health challenges from the lived experiences of LGBTI+ community, the design was appropriate (Polit & Beck 2022:165).

The study was conducted in Gaborone, the capital city of Botswana, located in the southern part of Botswana. Gaborone has an extensive network of public and private health facilities that include a national referral hospital and three private hospitals as well as clinics. It has an estimated population of 289 703 (Statistics Botswana 2022:5). Gaborone is a cosmopolitan city and has people from diverse cultural groups with English and Setswana being the main languages.

The population for this study was people identifying themselves as LGBTI+. In selecting research participants, snowball sampling method was used. Snowball sampling is a method whereby research participants make referrals for others to be research participants and is often used with minority or hard to reach populations (Polit & Beck 2022:176). Initial participant was established through gatekeepers, LEGABIBO. The rest of the participants were identified by the participants themselves. The sample population was 15 participants who were arrived at after data saturation. Data saturation was achieved at 12 participants and 3 more participants were interviewed to confirm the same.

Inclusion criteria involved individuals self-identifying as LGBTI+, had attained 18 years of age and above, had disclosed their identity to the advocacy organisation, voluntarily participated in the process, communicated in English and/or Setswana, and resided in Gaborone. Individuals who were not self-identifying as LGBTI+ and were below 18 years were not included in the study. Furthermore, individuals who were not residing in Gaborone and were not citizens of Botswana were also excluded.

Data were collected from June 2021 to August 2021 through unstructured individual interviews with an interview guide. The interview guide was developed in English and Setswana. The interviews which lasted for approximately 60 min, started with the following open-ended question being posed to the participants: ‘Tell me about the mental health challenges if any, that you experience as an LGBTI+ individual?’ was asked. To further facilitate the discussion, communication techniques like clarifying, reflecting, and summarising were used by the researcher.

Data which were collected telephonically to minimise coronavirus disease 2019 (COVID-19) transmission were recorded by a voice recorder. Each interview was given a code and data were then safely kept in a computer which was password-protected. The data were transcribed verbatim by the researcher following the telephonic interviews that were audio-recorded.

Data were analysed by the researcher and an independent co-coder guided by a modified Collaizi’s data analysis method (Finlayson et al. 2018:3). The method is used to analyse phenomenological data, hence suitable for this study.

The data analysis process followed several procedural steps that include describing the phenomenon of the study, collecting participants’ descriptions of the phenomenon, reading all participants’ descriptions of the phenomenon, returning the original transcripts and extracting significant statements, spelling out the meaning of each significant statement, organising and then aggregating the formalised meanings into clusters of themes (Finlayson et al. 2018:3). Lastly, a comprehensive description of codes was written and sent to participants for validation of the description. There was no new data following validation which led to the researcher and independent co-coder cordially agreeing on the themes that were presented in narrative and descriptive format.

Trustworthiness is the gauge through which the research quality is measured (Bradshaw et al. 2017:5). Several strategies were enforced to ensure the quality using Lincoln and Guba’s framework (Polit & Beck 2022:277). In ensuring trustworthiness, several strategies were employed that include: credibility, transferability, dependability, confirmability, and transparency.

In ensuring transparency, the recruitment procedure for research participants and the data analysis process have been clearly outlined in the report. Direct quotations of research participants have been used in the report to enhance confirmability of the data. Raw data like field notes and verbatim transcriptions were availed to ensure confirmability. An audit trail of what happened in systematic data collection and data analysis process is available; a process that will highlight the dependability of the research.

In order to ensure transferability, data interpretation was supported by evidence-based literature. In ensuring credibility, the telephonic interviews were audio-recorded and then transcribed verbatim with participants given an opportunity to confirm the findings. Data saturation was reached after 10 interviews, with 5 more interviews conducted to guarantee rich data. There was prolonged engagement with the participants, and also involvement of an independent co-coder in data analysis to safeguard the veracity of findings.

The researcher kept a reflective journal which encompassed the researcher’s personal reflections. A reflexive journal was also kept to avoid the researcher being expressively immersed with the participants which could have contaminated the data (Polit & Beck 2022: 279).

The ethical clearance to conduct the study was granted by the Ministry of Health and Wellness through the Health Research and Development Division (HPDME 13/18/1) for the study to be conducted in Botswana. Goodwill permission was offered by the advocacy organisation, LEGABIBO. An independent person informed the participants on their right to self-determine their participation or withdrawal from the study. Identities of the participants were concealed and were only identified as Participant 1, 2, 3 and so on during the data selection process. The participants were not coerced to participate in the study, and they were informed about their rights to stop participating anytime when they feel so.

Three sub-themes identified under theme 1 were namely, suicide attempts, low self-esteem, and not being fully themselves.

‘Experiences of depression’ emerged as the first theme following data analysis. The participants self-reported depression that was validated by various emotions that included expressions of worry, frustration, stress and sadness, and below are some of their expressions:

Another participant echoed the same sentiment:

Another participant added by saying that:

Some participants expressed that COVID-19 was a factor that contributed to them experiencing depression. The discussion unfolded as follows:

The findings revealed that some of the participants identifying as LGBTI+ experience gender dysphoria (GD). The participants expressed having feelings of some incongruence with their bodies on several occasions. One of the participants stated:

Another participant expressed feelings of being trapped in the wrong body and said the following;

Another participant echoed similar views as follows:

Majority of the participants who were diagnosed with GD also had anxiety and depression. One of the participants had this to say:

The last theme that emerged was loneliness and isolation. Several of the participants expressed finding it difficult to interrelate with people because of the feelings of inadequacies in them as well as of not belonging. It was apparent from some of the research participants’ perceived frustration that this was a problem which led to their isolation.

Participant 1 had this to say:

Another participant who shared the same view added by saying that:

The following was echoed by another participant:

Another participant who accepted himself expressed as follows:

A participant who could not accept their gender echoed the following:

Experiences of depression was the first theme of the study as most of the participants expressed having feelings of depression. The findings of the study are consistent with a systematic review of studies which found that LGBTI+ community are increasingly vulnerable to depression and suicide (Mongelli et al. 2019:47; Harper et al. 2021:9). Furthermore, some studies conducted in Africa, notably in Kenya and South Africa, had participants highlighting to have experienced depression (Harper et al. 2021:9; Muller & Daskilewicz 2018:271).

Some research participants had depression compounded by COVID-19. Suen, Chan and Wong (2020) posit that the advent of COVID-19 resulted in a significant number of LGB individuals experiencing clinical depression and generalised anxiety disorder. The impact of COVID-19 was also observed in a study in Australia as gender and bisexual men had increased rates of depression and anxiety (Bavinton et al. 2022). Elsewhere in Canada during the pandemic, LGBTI+ individuals were diagnosed with moderate to severe symptoms of depression (Abramovich et al. 2021:8).

Suicide attempts was the first sub-theme in this study. In the current study, participants who identified as transgender reported having attempted suicide. Existing literature highlights that there is increased vulnerability to suicide among the LGBTI+ community, with the act of discriminating and victimising transgender individuals increasing their risk for suicide (Rood et al. 2015:272). Previous studies have also highlighted increased suicidal ideations, thoughts and attempts in South Africa, Kenya, and Botswana (Ehlers et al. 2001:848; Muller & Daskilewicz 2018:271).

Another sub-theme was the experience of low self-esteem among individuals identifying as LGBTI+. Most of the participants in the current study underlined that their self-esteem was dented by issues of homophobia and transphobia which is evident in other studies also (Taylor et al. 2019:19). There is however, contrasting findings as a study in Brazil found that high rates of self-esteem in a majority of the participants (Canali et al. 2014:4509). In the aforementioned study, the participants who were graded low in self-esteem also had additional adverse factors other than gender minority status (Canali et al. 2014:4509).

The last sub-theme is that of LGBTI+ individuals ‘not being fully themselves’. There is documented evidence that inability for LGBTI+ individuals to express who they are can lead to adverse mental health problems with generalised anxiety and depression being the notable disorders (Feinstein et al. 2020:8; Rood et al. 2017:710). The research participants concealed their identity and could not express themselves when interacting with the general community, mainly out of fear of being adjudged by members of the community. Transgender individuals often conceal their gender-identity in community and/or social circles as a way of evading stigma and discrimination (Rood et al. 2017:8). Moreover, concealment of status as transgender or gender suppression, has been documented to decrease sense of belonging as well as adverse mental health problems (Brady et al. 2022). Low self-esteem is aggravated by several minority stressors that include fear of being victimised and concealment of gender-identity (Bridge, Smith & Rimes 2019:4).

Experiences of GD emerged as another challenge experienced by some of those identifying as transgender and to some extent, intersex. Gender dysphoria is a term to describe the mismatch between the gender expressed and/or experienced by a person and the one assigned at birth (Spurlin 2019:11; Townsend & Morgan 2018:646). Furthermore, for a clear diagnosis of GD to be confirmed, individuals should present with distress regarding the incongruence in schools, occupation and in social circles for a period of 6 months or more. For a tentative diagnosis of GD to be determined, transgender individuals must experience substantial emotional discomfort (Hall, Mitchell & Sachdeva 2021:7).

Identifying as transgender is itself not a mental health challenge, but rather a problem arises when the gender identity causes the emotional distress or discomfort (Stroumsa 2014:e31). Not every research participant who identified as transgender experienced GD as it is not always that individuals identifying as transgender will have a diagnosis of GD (Byne et al. 2018:60).

Some participants mentioned having experiences of GD without a mental health professional validation, whilst others had the diagnosis following a mental health assessment by a psychiatrist. Gender dysphoria includes a number of aspects ranging from a feeling to a diagnosis which means that GD can be either a diagnosis or a symptom (Byne et al. 2018; Lindley & Galupo 2020:6).

Some participants mentioned having GD occurring concurrently with other mental disorders. Freitas et al. (2019:101) posit that there is a high risk of mental disorders like depression and anxiety among transgender individuals. Moreover, low self-esteem, dissatisfaction with body and poorer social functioning also occur concurrently with GD (Witcomb et al. 2017).

The last theme of this study was loneliness and isolation. Loneliness is the perception of lacking connection with others, whereas isolation is the nonexistence of a meaningful connection with other human beings (Gardiner et al. 2018:148). Loneliness is deemed as a health problem as most participants identified it as a challenge, which is consistent with a study by Gorczynski and Fasoli (2022:112). Participants expressed that they do isolate themselves because they do not belong and avoid being questioned. The findings are consistent with those from several studies which observed that those identifying as LGBTI+ are at a higher risk for social isolation when they conceal their identification as ‘LGBTI+’ and yield to societal prejudice which leads to internalisation of negative emotions (Perone, Ingersoll-Dayton & Watkins-Dukhie 2020:12). Andersen et al. (2020:4) further contend that individuals identifying as transgender had high incidences of loneliness in comparison to cisgender individuals.

A review by Zeeman and Aranda (2020:10) highlighted that people with intersex variations have increased feelings of social isolation and anxiety. Some participants identifying as intersex did isolate themselves on account of ‘not wanting to be discovered’. Individuals identifying as intersex do not reveal much about themselves and consequently often isolate themselves (Henningham & Jones 2021:600). Furthermore, social isolation may also be a ‘self-preservation’ tool to avoid hostile reactions from members of the public.

In order to mitigate risks of COVID-19 and to conform to the regulations at the time, during data collection, interviews were modified from qualitative face-to face interviews to telephonic interviews. It was difficult to observe non-verbal cues during telephonic interviews which limited the field notes. Given the nature of the phenomenon being investigated, observations of participants’ behaviour and emotional reactions would have helped generate rich results.

Despite the various members of the LGBTI+ groupings having universal commonalities, significant differences do exist also. This was another limitation of the study as the varied differences complicated the data analysis process. Consequently, an in-depth exploration of mental health challenges within particular groupings would have yielded rich data.

The study recommends further research on the strategies to deal with mental health among individuals identifying as LGBTI+. The sub-groupings of intersex and transgender appear to be more vulnerable to mental health challenges, hence a study particularly focused on the specific groupings is recommended.