Special Report: What You Should Know to Care for LGBTQ Patients
Abstract
The recognition that sexual orientations and gender identities are expanding has presented new treatment challenges to psychiatrists.
In 2004, I started seeing a therapist. He was not an LGBTQ specialist—none existed that I could find in Alabama at that time. Without knowing his stance on gay people, I told him my one and only goal was to develop enough courage to leave a place I had lived my entire life. It was the only place I had ever known, and everyone I knew, with the exception of a few close friends, was trying to convince me not to move elsewhere for residency. I did not come out until age 22 because the idea of being gay was buried somewhere deep in my mind, covered with years of negative attitudes about gay people instilled in me—the same attitudes and hostilities that existed in my everyday life even as an adult.
My own medical school had discouraged me and a few other gay students from starting an LGBT medical organization. We were told it would be in our best interest to keep “these things” secret. I told the therapist I had to leave to find a more supportive environment. It was clear to me that if I did not, my destiny there would have been to end up as another statistic—probably ending my own life. Fate fortunately provided me an escape route, and it took me to New York.
The specialty of LGBTQ psychiatry is a continuously growing field. The view of human sexuality has historically been very narrow. People were typically thought of as “normal” or something else—that something else was ultimately labeled as gay. It has largely been in the past 100 years, with research dedicated to sexual behavior, that our understanding of the range of human sexuality has expanded. More and more people have begun to identify as bisexual, and the “sexuals” haven’t stopped there, further expanding into asexual, pansexual, demisexual, polysexual, and omnisexual, among many others.
Psychiatrists who identify and/or work with the LGBTQ community often become overwhelmed as new research findings are published and the cultural landscape constantly changes with words and phrases about the community coming in and going out of fashion. Making matters more complicated, traditionally held views of gender and sexual identity are also becoming increasingly questioned and challenged. What were believed to be the foundational corners of human civilization, such as what it means to be a man or a woman, are being questioned and debated.
What we know is that both gender and sexuality appear to exist on a spectrum. Given that most human traits are also on a spectrum, this isn’t a surprise. Hair color, skin color, eye color, extroversion, energy level, temperament, mood, and a whole host of other human conditions are never questioned in their unending variations present in humans. Why, then, do many people react negatively when a person’s sexual orientation doesn’t align with strict heterosexuality? What is so troubling about a person who is female acting in masculine ways or vice versa? People are complicated, and if history has taught us any lesson, particularly recently, it is that trying to put people into specific boxes doesn’t go well.
A major part of the healing work that can be done with LGBTQ people in a therapeutic setting focuses on identity and their acceptance of not who they wish to be but of who they are. This internal struggle over identity—gender and sexuality—is painfully obvious in many who are given a chance to tell the story of their lives in a psychiatric interview. In addition, a therapist can play a major supportive role by providing emotional relief. Even those who are lucky enough to have an extremely accepting support system can still struggle with the process because of what they read and hear about from the larger world.
The internal burden carried by the LGBTQ community can easily explain why so many have a difficult time accepting their identities. The process of “coming out” is a phenomenon unique to LGBTQ experience in which LGBTQ individuals, either internally in their mind or externally to those around them, come to realize their sexual orientation and/or gender identity. Mood swings, irritability, angry outbursts, isolation, depression, panic attacks, and suicide attempts are all commonly associated with the experience of coming out—this being greatly dependent on the individual’s environment and mental health status. Many of these symptoms are largely caused by society systematically teaching them that they are deviant. In short, LGBTQ people are taught to hate themselves. Those who are surrounded by supportive family and friends may have a much easier experience.
In addition to reactions of family and friends, LGBTQ individuals face the potential for negative repercussions in their work environment. In many places, LGBTQ people can be fired from their job simply because of their sexual or gender identity. Only certain states have protections to prevent discrimination based on sexual orientation or gender identity. Because of this, coming out can have serious financial and long-term career implications. While overall, the world might be moving toward acceptance of diversity, LGBTQ people still need to be concerned with the individual beliefs of those who can keep them or fire them.
Like other people, LGBTQ individuals are impacted by social determinants of health—aspects of a person’s social environment or situation that contribute to their mental and physical health in positive or negative ways. Common negative ones for LGBTQ people are higher rates of homelessness, poorer access to health care, lack of accepting and affirming physicians, and social isolation. One example of social isolation is living in a rural area where it can be difficult to identify others who also might be part of the queer community, and doing so incorrectly can create a dangerous situation because of stigma.
Case Examples of LGBTQ-Affirming Care
Case 1
Edward was a 55-year-old man who came to see me for help with depression. He had been married for the past 30 years and had an adult son. He and his wife lived together but had developed into strangers over the years. Edward disclosed to me he had been keeping a secret from both his wife and his son all these years. He would take “business trips” as an excuse to go to other towns to be the identity he felt most comfortable as—female. It was only in the safety of anonymity that he could dress in the clothing in which he felt most appropriate. He could wear makeup and a wig, and he could be seen by everyone else as female—something he had known himself to be for decades.
My therapy with Edward was focused only on affirming interventions. I asked him what name he would prefer I use and if she/her pronouns were appropriate. Edward, now Samantha, had thought I would give her a diagnosis and try to change her views of herself as a female. She was surprised that I validated her identity and encouraged her to do what she felt to be best. Over a series of sessions, Samantha started to present as female at all times, outed herself to her wife and son, and discussed with me the option of starting estrogen.
Although the road was initially rocky, her wife and son accepted Samantha’s saying that it explained her secretive behavior for so many years. She told me she had never been so happy in her life, and now that she could fully express herself for who she was, she could never see her life any other way.
Case 2
Madison was a young woman just turning 20 years old. She initially started seeing me because of frequent panic attacks. After starting her on a medication to help decrease her anxiety, we explored her life in weekly sessions.
Much of her anxiety had started after her best friend moved away. She described the two of them as very close. They were so close, in fact, that they would spend most days together, sleep in beds together, and often cuddle. While Madison had dated men in the past, she had never had romantic feelings for them. She did, however, have those feelings for her friend. These feelings surfaced when her friend moved away, breaking Madison’s heart.
In therapy, Madison was given the space to talk about her feelings and desires. She was able to express what she fantasized about in a nonjudgmental environment. The more we spoke, the less anxiety she had, ultimately stopping the medication she had been on since our first visit. By the end of treatment, Madison identified as gay and was dating women in the hopes of establishing a new romantic relationship.
Case 3
Timothy and Charles were both men in their 30s who had a difficult time with their sexualities early in life. They both had grown up in very religious settings, and only one of their families was accepting of their relationship. They had been dating for three years and were discussing getting married. As plans for a wedding were unfolding, Timothy and Charles found themselves fighting more and more. When Timothy suggested that marriage might not be right for them, they opted to try couples therapy first.
When talking to the couple, it became apparent very quickly that they both secretly held views about their own sexualities that they did not often disclose. Charles had grown up Mormon, and although he openly supported LGBTQ rights, he had a lingering feeling that his being gay was immoral and he was going against the values he had been raised to believe. While Timothy did not hold these same negative views to the same extent, he did have questions about whether two men could be in a relationship and married like a “normal couple.” His using those words provided a gateway to start to dismantle both Timothy and Charles’s views on homosexuality and relationships.
Through couples treatment, they were both able to express fears they had kept hidden for many years. The main goal of treatment was to affirm not that they conform to the idea of marriage they had been taught growing up, but what marriage would look like for them. They were provided the space to create their own fantasies about their life and the way it would look going forward. New skills of communication were encouraged, and they learned the process of verbalizing their worries. By being more vulnerable with each other, their relationship strengthened.
LGBTQ people also remain the target of socially conservative politics that can put them in an unwanted spotlight at election time. Some candidates can drive their base to the voting booth by using the existence of LGBTQ people as an example of how the world is headed in an immoral and deadly direction.
The fear of diversity and change create a strong resistance away from self-acceptance. For young people to hear their identity used in such a hateful way further contributes to the painful internal experience they face each day as they move about the world. For some, the hate toward them turns into violence and even results in their death.
Because LGBTQ people are often taught to see themselves as deviant, it is not surprising that many choose to remain in the closet and not disclose their sexual orientation or gender identity to anyone. To fit into the larger society, they learn to hide certain aspects about themselves to avoid being found out. Over time, they can develop what is colloquially known in mental health circles as a “false self.” A false self is a version of a person that is shown to the outside world in an effort to mask what lies underneath. This is done usually as a way to protect the person from negative or traumatic experiences. LGBTQ people may spend years working on and developing this false self, with some remaining in this state for their entire life.
Importance of Providing Affirming Care
A significant part of therapy with LGBTQ people is often working with undoing this false self. It can become such a common state for people that it is often difficult for them to tell the difference between who they have pretended to be for so many years and who they really are. Helping LGBTQ individuals discover and express their real self, outside of the fear of judgment and in a place of safety provides a firm foundation in what can be called “gay-affirming” or “gender-affirming” therapies. Regardless of the symptom or concern that brings a person in to see a therapist, affirming care should always be given. It resides in the way a therapist approaches a patient’s treatment, asks questions, and responds to difficulties the patient is experiencing.
Fundamental to providing affirming care is understanding, as mentioned earlier, that gender identity and sexual orientation fall on a spectrum. Given that knowledge, it is necessary to approach each individual just as that—an individual. All of us are subject to the collective influence that culture has on our thinking. As mentioned before, we are taught from an early age what it means to be a boy or girl, man or woman. Marriage is supposed to look like this, and relationships are supposed to look like that. Men should have a particular set of skills and work, and women should behave in certain ways. Sex is supposed to mean particular behaviors.
All these programmed beliefs are slowly teased apart in affirming therapy. People get to decide individually what it means to be a man or a woman. People get to decide individually who they are attracted to and what they like to do in and outside the bedroom. Providing patients with the freedom and space to make these decisions can be very therapeutic. With this information at hand, it becomes more obvious why affirming therapists are necessary and should be easily found. Given that in the past 50 years homosexuality was labeled a mental illness (and in many ways gender diversity still is), it makes sense that LGBTQ people might be hesitant to seek mental health care out of fear of judgment. There are still therapists who practice conversion therapy and attempt to “correct” a person’s sexual orientation or gender diversity. Conversion therapy is rightfully being banned in many parts of the country due to the psychological harm it can cause.
Issues Related to Transgender Care
Approaching people as individuals and not as part of a larger group can be at odds with how health care professionals are taught to practice. Psychiatrists and mental health professionals are taught to group people into categories. Making a diagnosis requires that patients fit a certain number of criteria as listed in the Diagnostic and Statistical Manual (DSM). For instance, recent data have shown that about half of transgender people have attempted suicide. This shocking information should lead many mental health professionals to take extra care regarding suicide assessment when working with transgender individuals. While this statistic can be used to direct clinical care, the same extrapolation should not be applied to aspects of an individual person’s transgender identity. After all, what does it mean to be transgender?
Transgender people have been typically thought of as people who transition (medically) from male to female or vice versa. While this may be true for some, there is no set way in which a person should be expected to transition. Clinicians who rarely work with transgender people might assume that all transgender people want the same set of needs met—a name change, a gender marker change on documents, access to hormones, and access to surgery. While all of these may be important, it is necessary to first address the mental health concerns that have brought the individual into treatment—be that depression, anxiety, substance abuse, or whatever else might be burdening them. If a transgender person comes to treatment seeking gender-affirming care, validation, and acceptance of their real gender identity, gender-affirming treatments should be made available to them. It falls upon transgender individuals to decide which options are best for them and their lives. Some psychiatric symptoms might be due to the dysphoria that some people experience with their body. These can improve with gender-affirming treatments. Therapists can be most helpful by making space for the transgender individuals to discover what is best for them and then help them along the path.
Navigating LGBTQ Relationships: No Model to Follow
Affirming care can be useful in other ways such as in the realm of dating and relationships. LGBTQ people, while approaching treatment either individually or as a couple, will likely have many of the same concerns as heterosexual couples. The main difference is the extra layer of judgment and pressure—the “minority stress” mentioned earlier—that comes from the outside world. Young people learn about relationships through modeling from their family, friends, community, television, and movies. These modeled relationships have been exclusively heterosexual until the recent past. When straight people run into relationship problems, they often have these models to turn to as a way to validate and normalize their experience. LGBTQ people have had no normalizing presence available to them by which to examine their own relationships. When LGBTQ people run into the same relationship problems as straight people, instead of accepting the issue as commonly experienced by couples, they sometimes blame their LGBTQ identity status—that is to say, they believe their relationship problems would not exist had they been straight, further invalidating and pathologizing their experience. Therapists can help reframe these views to normalize LGBTQ relationships and provide a significant amount of relief through that action alone.
As the world slowly evolves to accept other sexual orientations and gender identities, traditional views on what relationships are and expectations attached to them are also under examination. Because the right to marry has only recently become possible for same-sex couples, the expectations associated with marriage were not completely present. Ideas about monogamy and being together “until death do you part” have not historically been part of LGBTQ romantic relationships. While many LGBTQ people do choose the path of monogamy, many do not—relationships can be non-monogamous or “open.” Some relationships involve more than two people—polyamory. These nontraditional relationships are becoming more common among heterosexuals as well. Therapists need to challenge their own views of traditional relationships to provide affirming treatments for their patients. What works well for one person isn’t necessarily going to work well for another. Taking an individual approach and examining a person’s values and desires will likely lead to the most affirming care.
What Does It Mean to Be Part of the LGBTQ Community?
Another source of stress for LGBTQ individuals resides within the community itself. While the LGBTQ community prides itself on diversity, many rifts and tensions occur not only between L, G, B, T, and Q people but also within the letters. Gay people often disagree about what it means to be gay. Sometimes it is defined as completely sexual while others believe there is a large cultural component. Some men might be labeled as “too gay” or “not gay enough.” Bisexual people find themselves facing stigma from the community as being confused or wanting the best of both worlds. They often hide their bisexual status to prevent judgment from the communities that surround them—gay or straight. Within the transgender world, there are strong beliefs about who is transgender and if someone is transgender enough. Some people see their transgender status as complete once they have had gender-affirming surgeries, while others hold tight to their transgender identity as a significant part of who they are regardless of whether they have had surgery. Views about what it means to be bigender, agender, and nonbinary are as plentiful as there are people who associate with those identities. Q for queer or questioning also is subject to scrutiny. The word “queer” was previously used in hateful ways.
Identity is just one part of the puzzle causing tension within the LGBTQ community. Because much of what is associated with LGBTQ is physical attraction to people of one or more specified genders, perceptions and judgment around bodies and body image are paramount. Because so many LGBTQ individuals have fought for a space to be present in the larger world, it may be difficult for them to associate with other LGBTQ people who do not look like them or believe as they do.
Once LGBTQ individuals are firmly secure in their identity, being open to the diversity of others naturally causes them to reexamine themselves. The anxiety around examining oneself, depending on how secure the person is, can be too triggering and result in the person’s shutting out others who are different. This leads to many forms of racism, ageism, and bodyisms. Part of therapy is helping individuals discover what it means for them to be LGBTQ. So many are taught that LGBTQ looks this way or behaves that way that those who seek out acceptance find themselves in a more constricting environment than before they came out.
The concept of pride can help combat some of these queer divergences. LGBTQ Pride Month, often celebrated in June, is a time for LGBTQ people to celebrate their identity and the identity of others in their community. It is also a time of discussion and appreciation. Pride parades provide an opportunity for LGBTQ people to see others who are like and not like themselves. It can be a transformative experience for some and lead to a consolidation and integration of a person’s identity.
The first pride parade consisting of gay men and women in 1970 has blossomed into a celebration of a more colorful and more diverse palate of individuals. LGBTQ is just the beginning of a community that now encompasses asexuals, pansexuals, intersexuals, and allied individuals. As people change, so will the LGBTQ community to embrace more identities. It will take ongoing vigilance and emotional readiness for the community to continue to evolve and stay together. ■
APA Resources
Dr. Yarbrough is the author of Transgender Mental Health from APA Publishing. APA members may purchase the book at a discount here.
The following resources can be accessed here:
Best Practice Highlights: Working with LGBTQ Patients. Learn more about working with LGBTQ patients, including demographics, significant history, best practices, and disparities.
Mental Health Facts for Bisexual Populations. Research shows that bisexual individuals are at increased risk of adverse health outcomes compared with monosexual individuals. A significant contributor is stress that is related to stigma and discrimination.
Mental Health Facts for Gay Populations. Gay men experience adverse mental health outcomes including mood disorders, substance use, and suicide more frequently than heterosexual men. They also face additional barriers to accessing mental health treatment.
Mental Health Facts on Questioning/Queer Populations. Like other minority groups, questioning and queer people are often misunderstood, overlooked, and underrepresented in the health care system and societal institutions.
Mental Health Facts for Lesbian, Gay, Bisexual, Transgender, Queer/Questioning (LGBTQ). LGBTQ individuals are more than twice as likely as heterosexual men and women to have a mental health disorder in their lifetime.
Stress & Trauma Toolkit for Treating LGBTQ in a Changing Political and Social Environment. Violence against the LGBTQ community has increased over recent years. In 2017, anti-LGBTQ hate crimes rose 86% from 2016. LGBTQ people of color—particularly transgender people—are disproportionately affected by these hate crimes.
A Guide for Working With Transgender and Gender-Nonconforming Patients. This introductory guide offers an array of topics that are essential to understanding how to work with transgender and gender-nonconforming patients. It provides basic information to raise awareness of their needs and how to incorporate gender-affirming care in psychiatric practices.
Intimate Partner Violence: A Guide for Psychiatrists Treating LGBTQ IPV Survivors. LGBTQ survivors of intimate partner violence face increased barriers to obtaining consistent access to culturally competent services. Without access to identity-affirming advocacy, intervention, and other critical services, LGBTQ IPV survivors will continue to suffer from violence and adverse consequences of victimization.
Learning Modules on APA’s Learning Center (CME credit available).
“Transgender Mental Health”: This course introduces core concepts of working with gender-variant patients and provides a roadmap to providing gender-affirming care.
“Transgender Mental Health Pulsed Learning”: This course discusses the medical spectrum of gender in caring for transgender patients, such as asking for gender pronoun preferences.
“Impact of Microaggression on Mental Health Outcomes”: This activity focuses on microaggressions and their relationship to mental health and physical illness.
“Cultural Formulation Interview”: This course focuses on the impact of culture on the practice of psychiatry and the foundational basics of the DSM-5 Cultural Formulation Interview.
“Engagement Interview Protocol”: This course teaches participants how to perform culturally sensitive psychiatric interviews to engage patients from different cultures to receive appropriate treatment.
“Gay Men’s Mental Health”: This course will educate clinicians on the various facets of gay mental health.
