CLINICAL REFLECTIONS
In 1970, a group of gay and lesbian activists made history when they disrupted the annual meeting of the American Psychiatric Association (APA) in San Francisco. Outside the convention center, they formed a human chain to prevent visiting psychiatrists from entering. Inside, they interrupted sessions on transsexualism, laughed at a purported expert on homosexuality, and were so disruptive that a panel titled “Issues of Sexuality” it had to be adjourned.
A year later, they returned with the same demand: delist homosexuality from APA’s Diagnostic and Statistical Manual—where it had been classified as a sexual deviation.
In 1972, the APA allowed a panel of gay activists to make their case. Among them was John E. Fryer, MD, a psychiatrist who appeared in disguise, worried he might lose his license because he was gay.
In 1973, the APA put the issue to a vote, with the majority of attending psychiatrists agreeing to remove homosexuality as a mental disorder from DSM-III. However, the APA compromised by replacing the term homosexuality with sexual orientation disturbance. This, they argued, would allow homosexuality to be considered an illness if an individual distressed with being gay sought psychiatric help to reverse it.
The APA took the final step in 1987 and dropped this reference completely. They officially adopted what is considered a normal variant view on sexual identity. Individuals could, they acknowledged, be born gay.
Sidebar. Resources for Treating LGBTQI Patients
APA Resources and Publications: A collection of educational content for mental health providers treating LGBTQI patients.
Glossary of Terms: The terminology used within the LGBTQI community is as diverse as its individuals and is always evolving. The Human Rights Campaign, the largest LGBTQI advocacy group and political lobbying organization in the US, has a helpful glossary of terms.
Transgender Standards of Care: The World Professional Association for Transgender Health provides clinical guidance for health professionals to assist transgender, transsexual, and gender-nonconforming people.
The Association of LGBTQ Psychiatrists: A community of psychiatrists that educates and advocates on LGBTQI mental health issues.
It is against this backdrop that the uneasy relationship between psychiatry and the lesbian, gay, bisexual, transgender, queer, and intersex community (LGBTQI) continues to evolve. While there are far more protections than there were in the 1950s, this is a group that still struggles to find acceptance, especially its transgender members.
The ideal model of health care is that patients receive unbiased care regardless of gender identity or sexuality. In reality, however, clinicians may both consciously and subconsciously discriminate against members of the LGBTQI community, causing many to forego needed care.
Members of the LGBTQI community are at increased risk for mental health issues associated with minority stress, or the unique experiences associated with homophobic victimization.1 Many grapple with feelings of shame, rejection, and depression. They are the target of abuse, trauma, and bullying. As a result, they experience higher rates of homelessness, substance abuse, and suicide.2
As mental health professionals, it is our ethical responsibility to identify our biases as clinicians. We need to educate ourselves about the needs of this unique and ever-evolving population, to provide the best care possible, and to do so in a way that does not perpetuate the stigma and trauma many sexual minorities contend with daily.
Health Disparities in the LGBTQI Community
As of 2017, there were 9 million adults in the United States, about 3.8% of the country’s population, who identified as lesbian, gay, bisexual, or transgender.2
It takes incredible courage to come out in front of family, friends, school, work, and society at large. It can be an extremely vulnerable experience that can elicit reactions of anger, rejection, and even violence from others. Additionally, there are many subpopulations within the LGBTQI community that have their own unique risk factors that must be considered in the context of care.
According to a 2013 survey of LGBTQI Americans, 39% said they had been rejected by a family member or friend because of their sexual orientation. About 30% said they had been attacked or threatened because of it, and 58% said they were the target of jokes or slurs.3
LGBTQI individuals are more than twice as likely to experience a mental disorder compared to heterosexual men and women. They are also 2.5 times more likely to experience depression, anxiety, and substance misuse.3
Almost 12% of gays, lesbians, and bisexuals have considered attempting suicide, compared to 2.3% of heterosexual individuals. With transgender individuals, this number jumps significantly to 30.8%.3
Another big challenge facing the LGBTQI community is substance abuse and homelessness. A 2015 national survey on drug use and health revealed that 39.1% of sexual minorities used illicit drugs, compared to 17.1% among sexual majorities.4
LGBTQI youth were twice as likely to be homeless than non-LGBTQI youth. And black LGBTQI youth were even more at risk for homelessness. While 7% of black non-LGBTQI youth were homeless in the United States, that number jumped to 16% for black LGBTQI youth.5
These statistics for youth are particularly troubling. More youth are coming out as gay or transgender at younger ages, perhaps due to the growing social acceptance for LGBTQI communities. The average age of coming out was around 14 years old, according to data collected between 2000 and 2010. A decade earlier, this age was 16. In the 1970s, it was 20. Despite this trend, concerns about the rising prevalence of adolescent LGBTQI mental health issues are increasing.6
Perhaps because they are already grappling with identity development, adolescents are already at increased risk for suicide; it is a leading cause of death for youths aged 10 to 19.7 LGBTQI youth, however, tend to have higher rates of mental health issues, with 18% meeting the criteria for depression, 11.3% experiencing posttraumatic stress disorder, and 31% reporting suicidal behavior at some point during their lives. This compared to national youth rates of 8.2%, 3.9%, and 4.1%, respectively.6
The reason behind these rates may have to do with increased peer pressure experienced during these ages. One 2012 study pointed to stronger prejudicial attitudes and homophobic behaviors among youth 12 to 18 years old, especially among boys.8
A 2019 school climate survey revealed that 86% of LGBTQI students experienced harassment or assault at school, according to the Gay, Lesbian, & Straight Education Network (GLSEN), a national organization that supports the LGBTQI community in K-12 schools.9
When LGBTQI people turn to mental health providers for help, they are often let down. Almost one-sixth of LGBTQI adults have felt discriminated against at a doctor’s office, while one-fifth say they avoid medical care altogether due to their fear of discrimination, according to a poll conducted by Harvard University, National Public Radio, and the Robert Wood Johnson Foundation.10
A 2018 Harvard panel said health care providers were woefully unprepared to address the needs of the LGBTQI community. Panelists said providers needed to do a better job gathering data about these patients, even if it meant asking them direct questions about their sexual health.10 For many providers, improvements in mental health care must be based on increased education and understanding of how different people experience and express gender identity.
Understanding Gender Identity and Expression
Today, there are increasing efforts being made to explore what, exactly, gender is and how it should be defined. In Eurocentric models rooted in colonialism, gender has been identified as a binary model that distinctly categorizes individuals as either male or female based on their sex.11 It operates on the idea that gender can be visually seen as a bodily characteristic, with males having penises and females having vaginas. Gender-identity research is shifting away from this binary approach and acknowledging that the idea of gender exists on a spectrum. It is not defined by simplistic biological characteristics and is very individualized.12
While our understanding of the concept of gender is evolving, gender has been postulated to encompass 4 parts: anatomical sex, gender identity, legal gender, and gender expression. Anatomical sex generally refers to genitalia, chromosomes, and bodily attributes. Gender identity refers to one’s sense of self, which can be fluid and change over time and within context. Legal gender is tied to an individual’s assigned gender at birth and is used as a way to measure differences between genders, such as health and wage disparities. Gender expression is how a particular individual presents their gender identity to society, usually through appearance, dress, and behavior. Cisgender refers to those whose self-defined gender identity matches their assigned gender at birth. Transgender refers to others whose assigned gender at birth does not match their self-identified gender.
The problem with a simple binary description of gender identity tends to be with its limitations. In research studies, for example, most demographics include gender responses with very little reflection on why it is included or how it is relevant.13 This standard fails to consider findings related to other gender identities, which can provide results that are inaccurate or misrepresented. Additionally, by only giving male or female as gender options, it immediately discriminates against anyone who does not identify as either.
This discrimination continues in other areas. Even though APA’s recognition of gender dysphoria as a diagnosis is not necessarily stigmatizing, it is the gatekeeping of care that perpetuates the stigma. In addition to a gender dysphoria diagnosis, transgender individuals, for example, need to jump through significant hoops to access gender-affirming care—including psychological evaluations, letters of support, and therapy.14
These are just some examples of how the mental health community needs to shift awareness to treat a population desperately in need of treatment and acceptance.
Nurturing A Vulnerable Community
For decades, psychiatry viewed being gay as a degenerative disorder. It created a deep scar that the mental health industry must now work to mend by setting aside biases, broadening our understanding, and earning the trust of LGBTQI patients. To do so, it is vitally important to refrain from making assumptions about a patient’s gender, sexuality, or sexual identity. It is always necessary to ask about an individual’s pronouns. Do not refer to them as preferred pronouns; they are simply pronouns.
Clinicians are obligated to be aware of their own biases, both conscious and subconscious, that can potentially negatively influence the care provided to their clients. This will help avoid any countertransference of opinion from provider to client.
Creating a therapeutic container is essential for holding patients in a safe place that allows them to express any feelings of pain and shame.15 This is based on Carl Jung’s concept that compares the therapeutic container to an alchemical container that safely holds the feelings and thoughts of patient and analyst alike.
In their book, Becoming a Kink Aware Therapist,16 authors Caroline Shahbaz, BBSc(Hons), MPsych, MA; and Peter Chirinos, MA, LPC, NCC, DCC; offer the following guidelines to create a therapeutic container:
- Validate the sociopolitical issues confronting a patient’s marginalized community
- Do not assume their psychological problems are a function of their sexuality
- Affirm individual life choices
- Help clarify one’s needs and desires
- Validate and work on self-esteem
- Connect patients with appropriate communities and networks
LGBTQI patients may engage in sexual activities that a provider may find disturbing and uncomfortable, which is indicative of a clinician’s own conscious and unconscious biases that can impede a patient’s progress in care. As with any patient population, when treating sexual minorities, competent care as it relates to this population must be the standard of practice and directly translates into making patients feel accepted and validated.
By providing competent care as clinicians, we can continue to bridge the gap of trust and open new appropriately informed ways to treat and support the LGBTQI community. In a sign of hope for the future, the American Psychoanalytic Association issued what it called an “overdue apology” in 2019 to members of the LGBTQI community for its “role in the discrimination and trauma caused by our profession.”17 Moving past apologies, the mental health community needs to focus on restorative justice on both the macro and micro levels. This can include educating themselves and their peers, centering learning from LGBTQI individuals, using cultural safety and trauma-informed frameworks for care, and reducing gatekeeping to gender-affirming care.
Additionally, it is vitally important to advocate for policy changes both in the mental health field and with broader causes that disproportionately impact LGBTQI individuals, such as fair housing, harm reduction, and antidiscrimination legislation. Only a multi-pronged approach will ensure members of the LGBTQI community receive the mental health services many of them so desperately need.
Summer R. Thompson is an Adolescent and Adult Psychiatric Mental Health Nurse Practitioner with Community Psychiatry.
References
1. Poteat VP, Scheer JR, Mereish EH. Factors affecting academic achievement among sexual minority and gender-variant youth. Adv Child Dev Behav. 2014;47:261-300
2. National Alliance on Mental Illness. LGBTQI. Accessed June 3, 2021. https://www.nami.org/Your-Journey/Identity-and-Cultural-Dimensions/LGBTQI
3. A Survey of LGBT Americans. Pew Research Center. June 13, 2013. https://www.pewresearch.org/social-trends/2013/06/13/a-survey-of-lgbt-americans
4. Medley G, Lipari RN, Bose J, et al. Sexual orientation and estimates of adult substance use and mental health: results from the 2015 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration. October 2016. https://www.samhsa.gov/data/sites/default/files/NSDUH-SexualOrientation-2015/NSDUH-SexualOrientation-2015/NSDUH-SexualOrientation-2015.htm
5. Chapin Hall at the University of Chicago, Voices of Youth Count. Missed opportunities: LGBTQ youth homelessness in America. April 2018. https://voicesofyouthcount.org/wp-content/uploads/2018/05/VoYC-LGBTQ-Brief-Chapin-Hall-2018.pdf
6. Russell ST, Fish JN. Mental health in lesbian, gay, bisexual, and transgender (LGBT) youth. Annu Rev Clin Psychol. 2016;12:465-87.
7. Centers for Disease Control and Prevention. Adolescent health. Updated April 14, 2021. Accessed June 3, 2021. https://www.cdc.gov/nchs/fastats/adolescent-health.htm
8. Poteat VP, Anderson CJ. Developmental changes in sexual prejudice from early to late adolescence: the effects of gender, race, and ideology on different patterns of change. Dev Psychol. 2012;48(5):1403-15.
9. GLSEN. The 2019 National School Climate Survey. 2019. Accessed June 3, 2021. https://www.glsen.org/sites/default/files/2020-10/NSCS-2019-Executive-Summary-English_1.pdf
10. Powell A. The problems with LGBTQ health care. The Harvard Gazette. March 23, 2018. https://news.harvard.edu/gazette/story/2018/03/health-care-providers-need-better-understanding-of-lgbtq-patients-harvard-forum-says/
11. Lugones M. The Coloniality of gender. Worlds & Knowledges Otherwise. 2008. Accessed June 3, 2021. https://globalstudies.trinity.duke.edu/sites/globalstudies.trinity.duke.edu/files/file-attachments/v2d2_Lugones.pdf
12. Ainsworth C. Sex redefined: the idea of 2 sexes is overly simplistic. Nature. October 22, 2018. https://www.scientificamerican.com/article/sex-redefined-the-idea-of-2-sexes-is-overly-simplistic1/
13. Lindqvist A, Sendén MG, Renström EA. What is gender, anyway: a review of the options for operationalising gender.Psychology & Sexuality. February 18, 2020. https://www.tandfonline.com/doi/full/10.1080/19419899.2020.1729844?scroll=top&needAccess=true
14. White Hughto JM, Reisner SL, Pachankis JE. Transgender stigma and health: A critical review of stigma determinants, mechanisms, and interventions. Soc Sci Med. 2015;147:222-31
15. Finlay L. Holding, containing and boundarying. In: Relational Integrative Psychotherapy: Engaging Process and Theory in Practice. Wiley; 2016.
16. Shahbaz C, Chirinos P. Becoming a Kink Aware Therapist. Routledge; 2016.
17. American Psychoanalytic Association. American Psychoanalytic Association issues overdue apology to LGBTQ community. June 21, 2019. https://apsa.org/content/news-apsaa-issues-overdue-apology-lgbtq-community
