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Objective: Lesbian, bisexual and queer (LBQ) women experience substantial unmet alcohol and mental health treatment needs. This paper explores the way in which sexual identity shapes experience, and needs, in relation to alcohol and mental health treatment, and presents key messages for improving treatment.Methods: Twenty-five in-depth interviews were undertaken with same-sex attracted Australian women, aged 19–71. Interview transcripts were analysed thematically.Results: Key messages offered by participants focused on language, disclosure and practitioner training. Variation in sexual identity did not alter treatment expectations or needs; however, we noted an important difference with respect to identity salience, with high LBQ identity salience linked with preference for disclosure and acknowledgement of sexual identity in treatment interactions, and low identity salience linked with a preference not to disclose and for sexual identity not to require acknowledgement in treatment.Conclusions: Treatment providers may find it useful to gather information about the centrality of sexual identity to LBQ women as a means of overcoming treatment barriers related to heteronormative conventions and discrimination, language and disclosure.Implications for public health: Treatment providers should adopt more inclusive language, seek information about identity salience and the importance of sexual identity to the current treatment, and regularly pursue LBQ-related professional development upskilling.