Perspectives on the Psychiatric Care of Lesbian, Gay, Bisexual, and Transgender People

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Perspectives on the Psychiatric Care of Lesbian, Gay, Bisexual, and Transgender People
Perspectives on the Psychiatric Care of Lesbian, Gay, Bisexual, and Transgender People

Lesbians, gay men, bisexual and transgender (LGBT) people seeking mental health treatment are likely to present with problems common to many patients such as mood and anxiety disorders, psychological conflicts, and maladaptive behaviors. Many of our treatment interventions do not significantly vary by the sexual or gender identity of our patients. 

While evidence-based standards of psychopharmacology and psychological interventions apply to all patients, we can enrich the care of LGBT persons with updated knowledge about risk factors in LGBT mental health and a familiarity with family, social, community, and professional resources allied with our efforts.

The mental health of LGBT persons has become increasingly recognized as an important public health issue.1 This community has elevated rates of mood and anxiety disorders, alcohol misuse (in women), and suicidality, particularly in LGBT youth.2,3,4 Despite these increased risks, LGBT persons have concerns about whether mental health providers will be informed and non-judgmental about their lives and may avoid treatment because of worries about stigmatization or discrimination by providers. This is especially true of older LGBT persons.5

Mental health practitioners, however, are in much better position than their predecessors to be helpful to LGBT patients as the field of LGBT mental health matures. Current perspectives on the psychology of LGBT persons recognize homosexual and bisexual affinities as normal variants of human sexuality.6

We now regard homosexual and bisexual identity as rooted in a deeply felt sense of personhood that, when unencumbered by conflict, are essential to psychological well-being.  Transgender identity — identity as male or female that differs from gender identity based on birth sex — is currently viewed as a non-pathological variant of gender identity, although DSM-5 recognizes that some transgender people experience gender dysphoria reflecting the incongruence between their biological sex and gender experience.7

The overarching psychological experience of LGBT patients is that of living with a minority sexual or gender identity and, to varying degrees, having to conceal or sometimes denigrate important aspects of personal identity, being stigmatized or discriminated against because of sexual or gender identity, or facing violence or persecution because of these identities. From the perspective of stress theory, these adversities are thought to account for much of the increased risk of mental health disorders found among LGBT people, although it is important to keep in mind that most of them do not have a mental health diagnosis.

In addition to these stressors, several individual, family, and social considerations compound risk for mental health distress, all of which occur more frequently among the LGBT population. These include gender non-conformity, history of childhood sexual abuse, family rejection, and lack of social support or opportunities for community affiliation. Certain developmental and transitional periods in the lives of LGBT persons are themselves associated with mental health risk such as the voluntary or involuntary revelation of sexual or transgender identity. The influences of culture, religion, law, and politics, and health-related factors such as whether some one is living with HIV, further shape mental health risk among them.

Within the LGBT community, bisexual and transgender persons have greater mental health vulnerabilities. Bisexual men and women, for instance, sometimes experience stigmatization by lesbians and gay men who regard bisexuality as a non-committal identity. Transgender people are perhaps the most stigmatized of all in this population. They receive the least protection by law, policy, and other measures intended to protect against discrimination. And if interested in legitimate hormone or surgical treatment, transgender people must locate affordable, competent, and sensitive health care providers.

Mental health treatment of LGBT persons can do much to lessen the impact of the above risk factors, enhance coping, and promote well-being. Beyond a clinician's standard tools, our basic intervention to help patients make sense of their lives has special resonance in the lives of LGBT people who many times grow up feeling that their aspirations for love, intimacy, or gender expression are incomprehensible or too shameful to permit acknowledgment. Sometimes, psychoeducation is an explicit component of the therapeutic process in which patients and their families come to understand that homosexuality, bisexuality, or being transgender are part of the human experience and non-pathological.

The mental health care of LGBT patients and their families is often boosted by their participation in community groups, advocacy organizations, and social networks — a plethora of opportunities that continues to expand. Mental health practitioners can benefit from an expanding roster of web-based training resources and academic programs that seek to advance research, clinical care, training, and public policy in LGBT mental health. With the availability of these resources and greater familiarity with the lives of LGBT persons, mental health practitioners can exceed standards of care to deliver sensitive and effective treatment.

Robert M. Kertzner, MD, is an associate clinical professor of psychiatry at Columbia University and an investigator at the Columbia LGBT Health Initiative, the Division of Gender, Sexuality, and Health at the New York State Psychiatric Institute.  He is also in private practice in New York City.

References

  1. Institute of Medicine (US) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities. "The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding." Washington (DC): National Academies Press (US); 2011.
  2. Meyer IH. "Prejudice, social stress, and mental health in lesbian, gay,and bisexual populations: Conceptual issues and research evidence." Psychol Bull. 2003; 129: 674-697.
  3. Cochran SD, et al. "Estimates of alcohol use and clinical treatment needs among homosexually active men and women in the U.S. population. J Consult Clin Psychol. 2000; 68(6): 1062-71.
  4. Marshal P, et al. "Suicidality and depression disparities between sexual minority and heterosexual youth: a meta-analytic review." Journal Of Adolescent Health. 2011; 49 (2): 115-123.
  5. Out and Visible: The Experiences and Attitudes of Lesbian, Gay, Bisexual, and Transgender Older Adults 45 – 75. http://issuu.com/lgbtagingcenter/docs/lgbt_oamarketresearch_rpt/1?e=2766558/9533483. Accessed October 8, 2014.
  6. The History of Psychiatry and Homosexuality.  Association of Gay and Lesbian Psychiatrists website. http://www.aglp.org/gap/1_history/. Accessed October 6, 2014.
  7. Diagnostic and Statistical Manual of Mental Disorders (5th ed.), The American Psychiatric Association, Washington DC; 2013.
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