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Working with LGBTQ Patients

Prepared by Robert Paul Cabaj, M.D.

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The LGBTQ Population

There really is no single LGBTQ community, rather a very diverse population that comes from all racial, ethnic, cultural, socioeconomic, and geographic backgrounds. People who are LGBTQ may move to urban areas, if they can, where there may be a sense of greater acceptance and personal safety. It is very difficult to know the percentage of people who identify as LGBTQ. Stigma and the fear of biases contribute to an underreporting of actual sexual orientation. Some people may also self-identify one way even if their internal desires or sexual behavior imply a different orientation. Identify issues may be especially pronounced for LBGTQ people from particular racial and ethnic minority groups.

Significant History – Events which influenced the community and contextualize assessment and treatment

Understanding the history of the LGBTQ community both in American society and within the profession of psychiatry is essential in bringing context to treatment. Some major milestones have contributed to the civil rights of LGBTQ people and to greater acceptance. First, the Stonewall riots of 1969 have become the historic launching point for gay rights. In 2003, the Supreme Court struck down sodomy laws across the county with their decision in Lawrence vs. Texas. In 2013, the Supreme Court decision on United States vs. Windsor led to the same sex couple being allowed to share the same federal benefits as opposite sex couples, ending the Defense of Marriage Act. And in June 2015, the Supreme Court’s decision on Obergefell vs. Hodges led to same-sex marriage becoming legal in all 50 states. In the context of Psychiatry, APA removed homosexuality from the DSM in 1973 based on the new scientific studies, opening the way for new understanding and treatment LGBTQ.

LGBT and the DSM

  • DSM-I (1952) – Homosexuality is listed as a sociopathic personality disturbance.
  • DSM-II (1968) – Homosexuality continues to be listed as a mental disorder
  • DSM-II (1974) – Homosexuality is no longer listed as a category of disorder. The diagnosis is replaced with the category of “sexual orientation disturbance”.
  • DSM-III (1980) – The diagnosis of ego-dystonic homosexuality replaces the DSM-II category of “sexual orientation disturbance.”Introduces gender identity disorder.
  • DSM-III-R (1987) – Ego-dystonic homosexuality is removed and replaced by “sexual disorder not otherwise specified,” which can include “persistent and marked distress about one’s sexual orientation.”
  • DSM-V – Includes a separate, non-mental disorder diagnoses of gender dysphoria to describer people who experience significant distress with the sex and gender they were assigned at birth.

Stigma and Risk Factors

Despite advances in LGBTQ rights and acceptance, stigma, both internal and external, continues to be the greatest problem facing sexual and gender minorities. Internally, Many LGBTQ people develop an internalized homophobia that can contribute to problems with self-acceptance, anxiety, depression, difficulty forming intimate relationships, and being open about what sexual orientation or gender identity one actually has. Externally, stigma may be exhibited by the surrounding society and even from within the LGBTQ community. For example, some gay and lesbian people have a difficult time accepting bisexuals. Transgender people have been excluded from some gay organizations, and are only recently received more notice and acceptance throughout the country.

Additionally, most LGBTQ people are not raised by people who identify as LGBTQ. Accordingly, they might not have the ability to seek support from parents or peers who may understand these struggles.

LGBTQ persons who struggle with higher rates of anxiety, affective disorder related conditions, and substance use disorders most likely have struggled with stigma and the coming out and self-acceptance process. Alarmingly, LGBTQ people also have a nearly three time higher risk of suicide or suicidal behavior. LGBTQ people also face disparities in the physical medical context, including increased tobacco use, HIV and AIDS, and weight-related problems.

LGBTQ people are also at greater risk for discrimination, verbal abuse, physical assaults and violence, and perhaps even childhood sexual abuse. Though legal protections have been increasing dramatically, many places do not protect sexual or gender minorities in the workplace, housing, or access to health care. Fears of potential discrimination contribute to some LGBTQ people not seeking the help they need—medically or psychiatrically—in a timely manner if at all. Studies have shown that many are afraid to be open about their sexual orientation or feelings with their mental health providers.

Gender and Sexuality Assessment Tool with two scales from 1-10, one for Male/Masculine and one for Female/Feminine
Four Realms of Assessment, 1 Gender Identification, 2 Gender Role and Expression, 3 Sexual Attraction, 4 Sexual Behavior, all filtered through the Male/Masculine and Female/Feminine Sexuality Assessment Tool to result in Consolidated Gender and Sexuality Identity

Best Practices

I recommend the following “best-practices” for your work with LGBTQ patients:

  1. With new patients, create an accepting and affirming environment by not assuming sexual orientation or gender identity. Ask, “Do you have sex with men, women or both?” and “How do you identify yourself?” We should be sensitive to patients in transition, and ask both how they’d like to be addressed as well as use the appropriate pronoun.
  2. Assess level of openness and self-acceptance; The figure to the left offers a simple visual scale to use in clinical encounters.
  3. Be aware that there is NO basis for so-called “conversion or reparative” therapy which are unscientific attempts to change sexual orientation through shame-based efforts that result in depression, anxiety, and increased suicidality. All major health groups condemn such attempts. Refer to the APA’s position statement on therapies focused on attempts to change sexual orientation for more information.
  4. Be aware that families can be helped to accept their gay or lesbian children and that in turn leads to greatly reduced suicidality and anxiety in such youth given the risk of suicide, be comfortable to ask about risk and resilience factors.

Guiding Principles

In addition to incorporating best practice, be aware of seven guiding principles for understanding gender and sexuality.

Seven Guiding Principles:

  1. Gender and sexuality exist in continuums with infinite possibilities.
  2. The gender and sexuality continuums are separate, yet interrelated realms.
  3. The gender continuum breaks down into separate, but not mutually exclusive masculine and feminine continuums.
  4. Sexuality is composed of three distinct realms: orientation and attraction, behavior, and identity. These three realms are interrelated but not always aligned.
  5. Gender may develop based upon biologic sex, but this is not always the case (i.e., transgendered, intersex, androgynous individuals).
  6. There are biological, psychological, social, and cultural influences at play in gender and sexual developmental trajectories. Social factors, such as family and peer relationships, robustly shape behavior during preschool and school age years.
  7. Each individual is unique and composed of multiple identities that exist within and interact with other sociocultural realms, such as socioeconomic status, geographic region, race and ethnicity, religious and spiritual affiliation, gender and sexuality among others.

Derived from The Massachusetts General Hospital Textbook on Diversity and Cultural Sensitivity in Mental Health.

Future Needs

Future research is needed to enhance our clinical care of the LGBTQ population and their families, including understanding if reduced societal bias actually leads to improved mental health outcomes and if the benefits of marriage as evidenced for opposite sex couples are also manifest in same sex couples. We hope to see a reduction in LGBTQ health disparities with increased societal acceptance.

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