CHAPTER 37
Treatment of Lesbian, Gay, Bisexual, and Transgender Patients
This chapter addresses issues to be considered in the psychiatric treatment of lesbian, gay, bisexual, and transgender (LGBT) patients. Following the removal of homosexuality as a psychiatric disorder from DSM-II by the American Psychiatric Association (APA) in 1973 (American Psychiatric Association 1968; Bayer 1987; Drescher and Merlino 2007), psychiatry gradually shifted its therapeutic efforts away from trying to change an individual's homosexual identity to a heterosexual one. Also, adding the diagnosis of transsexualism to DSM-III (American Psychiatric Association 1980) led to growing psychiatric recognition of a patient population that could benefit from sex or gender reassignment rather than futile attempts to change gender identities (Drescher 2010). In accepting patients' homosexual or transgender identities, today's psychiatric focus is treating other diagnoses in LGBT patients (depression, anxiety, etc.) as well as addressing problems encountered in living as a lesbian, gay, bisexual, or transgender person (Levounis et al. 2012).
Psychiatry's shift in clinical focus parallels the cultural normalization of homosexuality (and, to a lesser degree, of transgenderism) in many societies. For example, the last edition of this textbook (Hales et al. 2008) noted that marriage equality (same-sex or gay marriage) was only possible in Belgium, Canada, the Netherlands, Spain, and the state of Massachusetts. At the time of this writing, gay marriage is legal in ten European countries; Argentina, Brazil, Canada, New Zealand, South Africa, and Uruguay; and thirteen U.S. states and the District of Columbia. In 2013, the U.S. Supreme Court upheld the overturning of California's gay marriage ban. The Court also overturned the 1996 Defense of Marriage Act, requiring for the first time that the federal government recognize same-sex marriages performed both in the United States and elsewhere (Liptak 2013). In 2011, the United States repealed its "don't ask, don't tell" military policy and allowed its lesbian, gay, and bisexual (LGB) citizens to serve openly in the military (Bumiller 2011), joining 25 other countries that already allowed openly gay people to serve (Palm Center 2009). Increasingly, international groups define LGBT rights as human rights (Council of Europe 2011; United Nations High Commissioner for Human Rights 2011). In medicine and psychiatry, there is a growing literature of anecdotal treatment and small sample studies of LGBT patients, prompting a report by the Institute of Medicine (2011) calling for increased research into the health and mental health needs of these populations.
In addition to a lack of much-needed research, many if not most psychiatrists (as well as physicians in other specialties) have little formal training in human sexuality despite the important role sexuality and gender play in human development, psychology, and relationships. Furthermore, the biopsychosocial model of psychiatry presumes that the meanings of an individual's sexual orientation or gender identity are shaped by cultural factors. Clinicians hoping to understand the lives and mental health issues of LGBT patients must embark on a cross-cultural exploration (Drescher 2007). It is the aim of this chapter to introduce clinicians to both general and specific issues encountered when a patient grows up as a member of a sexual or gender minority, to address some of the mental health concerns of LGBT individuals, and to provide resources and references for further study. The Appendix at the end of this chapter defines a number of colloquial and professional terms that are used in this chapter and that can assist mental health practitioners in their clinical practice with LGBT patients.
In the nineteenth century, Western scientists, lawyers, philosophers, and physicians sought to replace traditional religious explanations of human behavior with scientific and medical understanding. These efforts were applied to homosexuality and gender expression. In 1864, Karl Heinrich Ulrichs published a political treatise arguing against German laws criminalizing male homosexuality (sodomy laws). He put forward a third sex theory of male homosexuality, that some men were born with a woman's spirit trapped in their bodies (Ulrichs 1864/1994). By the beginning of the twentieth century, Magnus Hirschfeld (1914/2000), an openly homosexual German psychiatrist, was the leading proponent of third sex theory. Hirschfeld was also credited with being the first person to distinguish the desires of homosexuality (to have partners of the same sex) from those of transsexualism (to live as the other sex), a distinction that would not gain broader currency until decades later.
In his 1886 Psychopathia Sexualis, psychiatrist Richard von Krafft-Ebing (1886/1965) classified homosexuality as a "degenerative" disorder. He believed its origins were biological but thought of it as a congenital disease. He also viewed transgenderism as psychopathology, documenting both cases of gender dysphoria and cases of gender-variant individuals born to one sex yet living as members of the other.
Sigmund Freud saw adult homosexuality as neither normal nor pathological and put forward a third view in "Three Essays on the Theory of Sexuality" (Freud 1905/1953). He saw homosexuality, part of an innate human bisexuality, as a normal phase in heterosexual development and believed that its expressions in adults could be attributed to an "arrested" psychosexual development. Freud's writing did not directly address transgenderism, in part because, like many in his time, he conflated what are now thought of as distinctions between sexual orientation and gender identity.
Later psychoanalytic practitioners of the mid-twentieth century based their clinical approaches on the work of Sandor Rado (1940), who, rejecting Freud's views, saw homosexuality as a phobic avoidance of heterosexuality caused by inadequate early parenting. His theories had a significant impact on mid-twentieth-century psychiatric thought and were a contributing factor in including "homosexuality" as a disorder in the first (American Psychiatric Association 1952) and second (1968) editions of DSM. However, as previously noted, homosexuality was removed as a disorder in 1973 from DSM-II (Bayer 1987; Drescher and Merlino 2007). This action followed reviews of both the psychoanalytic literature and the sexology (sex research) literature; the latter, unlike the former, supported a normal-variant view of homosexuality. Notable among sexology studies were Kinsey's reports on human sexuality (Kinsey et al. 1948, 1953), which found homosexuality to be more common than was generally believed. Hooker (1957) later published a study showing that, contrary to psychiatric beliefs of the time, nonpatient homosexual men demonstrated no more psychopathology than heterosexual control subjects.
In reviewing the sexology literature, the APA concluded that there was greater scientific evidence supporting a normal-variant view of homosexuality than a pathologizing one. When homosexuality was removed as a disorder from DSM-II, it was replaced with "sexual orientation disturbance" (SOD), which applied to anyone distressed about their sexual attractions who wanted to change them. In addition to treating homosexuality as an illness if an individual with same-sex attractions found them distressing, this new diagnosis allowed for the rare possibility that a person unhappy with a heterosexual orientation might seek psychiatric treatment to become gay. In DSM-III, the SOD diagnosis was replaced with "ego-dystonic homosexuality"; however, this new diagnosis was inconsistent with the growing evidence-based approach of the new diagnostic system and so was removed from DSM-III-R (American Psychiatric Association 1987).
Since 1973, the APA has issued numerous position statements supporting civil rights for lesbians and gay men, opposing discrimination on the basis of sexual orientation, and supporting marriage equality (American Psychiatric Association 2005; Drescher 2010).
By the middle of the twentieth century, scientific and clinical views of gender identity began to diverge from those of homosexuality. Although physicians in Europe experimented with sex reassignment surgery (SRS) in the 1920s, transsexualism and SRS entered the popular imagination when an American, George Jørgensen, went to Denmark as a natal man and returned to the United States in 1952 as trans woman Christine Jørgensen (1967). Sexologists at the time were increasingly doing research on gender identity in intersexual (hermaphroditic) children born with ambiguous genitalia as well as transsexual adults. Subsequently, the work of Benjamin (1966), Money (1994), Stoller (1964), and Green (1974) led to increased clinical recognition of the phenomena of gender identity and gender dysphoria.
The work on gender identity and gender dysphoria took place mainly in specialized gender clinics, and many physicians and psychiatrists of that time criticized using surgery and hormones to irreversibly treat people suffering from what they perceived to be either a severe neurotic or psychotic, delusional condition in need of psychotherapy and reality testing. In a 1960s survey of 400 psychiatrists, urologists, gynecologists, and general medical practitioners who were asked to give their professional opinions about what to do in a case of an individual seeking SRS, "the majority of the responding physicians were opposed to the transsexual's request for sex reassignment even when the patient was judged nonpsychotic by a psychiatrist, had undergone two years of psychotherapy, had convinced the treating psychiatrist of the indications for surgery, and would probably commit suicide if denied sex reassignment. Physicians were opposed to the procedure because of legal, professional, and moral and/or religious reasons" (Green 1969, p. 241).
The diagnosis of transsexualism first appeared in the International Classification of Diseases, 9th Revision (ICD-9; World Health Organization 1977). In 1980, DSM-III adopted a neo-Kraepelinian, descriptive, symptom-based framework drawing on contemporary research findings. Its authors felt that there was a large enough database to support transsexualism's inclusion (Zucker and Spitzer 2005). In recent years transgender activists have appealed to the APA to reduce the stigma they face and to remove the diagnosis from DSM-5 (American Psychiatric Association 2013; Drescher 2010), and they have also initiated petitions to the World Health Organization asking to remove the diagnosis from the mental disorders section of ICD-11 (European Parliament 2011). In 2012, the APA issued two position statements, one supporting access to care for transgender individuals and the other opposing discrimination against them (American Psychiatric Association 2012a, 2012b). That same year, an APA Task Force found "current evidence ... sufficient to support recommendations for adults in the form of an evidence-based APA Practice Guideline with gaps in the empirical data supplemented by clinical consensus" (Byne et al. 2012, p.759).
It is difficult, if not impossible, to delineate a developmental line for all LGBT or heterosexual patients. First, knowledge of how one acquires either a sexual orientation or a gender identity remains a subject of theoretical speculation. No definitive research yet explains the origins of homosexuality, heterosexuality, bisexuality, a cisgender identity, or a transgender one. Second, it is unlikely that there is a developmental line that can be applied to all LGBT patients—even within each of the subgroups. Some individuals become aware of their sexual or gender identity in childhood, others in adolescence, still others as young adults, and some in midlife or later. There are differing ages at onset in individuals experiencing gender dysphoria. Third, since identities are socially constructed and can be understood as a way to make meaning of one's feelings of sexual attraction or one's sense of gender, a variety of experiences lead individuals to call themselves "gay," "lesbian," "bisexual," or "transgender." In other words, there are a myriad of psychological frames of mind, interpersonal experiences, and cultural beliefs from which the diversity of modern LGBT identities are constructed.
While it is impossible to delineate a single maturational line leading to LGBT identities, there are developmental themes that recur in the retrospective accounts of LGBT adults. For example, many of them look back at their lives and say they "knew" that they were lesbian, gay, bisexual, or transgender since childhood. In one retrospective study, a significant number of adult gay men and women recalled engaging in gender-atypical behavior (Bell et al. 1981). In one prospective study of 66 boys with the DSM-III diagnosis gender identity disorder of childhood (GIDC), 75% of the subjects grew up identifying as gay men, not as transgender (Green 1987). However, not all LGBT adults report atypical gender behavior in childhood, and the majority of gay men were not diagnosed with GIDC. Consequently, it is difficult to predict what leads a child to grow up and adopt a lesbian, gay, bisexual, or transgender identity.
This section's focus is on developmental themes in LGBT patients. For additional information about transgender developmental issues, see Chapter 21 in this volume, "Gender Dysphoria."
A common theme in the lives of those who, in adulthood or adolescence, come to define themselves as lesbian, gay, or bisexual is an early memory of a same-sex attraction—a feeling they believed set them apart from others. These "children who grow up to be gay" can remember same-sex attractions or interest in members of the same sex as early as 4 years of age. Because most children are taught, either implicitly or explicitly, that they are only supposed to be attracted to the other sex, children who grow up to be LGB must come to terms with heterosexual models of relatedness. The other-sex interests of future heterosexual children are naturalized as normal, although acting on those feelings may be discouraged until a certain age or until they marry. In contrast, children who grow up to be LGB often lack explanations for same-sex feelings other than disparaging or stigmatizing ones. Although what they felt as children may not have necessarily been an attraction of a sexual nature, many LGB individuals retrospectively connect adult sexual feelings to childhood curiosity about or a desire for intimacy with members of their own sex.
In children who grow up to be LGB, early same-sex attractions may cause some to question the authenticity of their assigned gender. For example, a common though erroneous cultural belief is that a child grows up to be gay because of gender confusion. Yet most children with gender dysphoria grow up to be adults who do not identify as transgender but as LGB, and even these individuals constitute a relatively small proportion of the LGB population (Drescher and Byne 2013). More commonly, awareness of feelings for other children of the same sex may lead a young child to question the veracity of an assigned gender. In a boy, for example, this could make it difficult for him to believe in his masculine identity, because he possesses a trait (attraction to boys) that belongs, he has been told or comes to understand, to girls.
Some gay and bisexual men report a sense of childhood "otherness" that they associate with an inability to engage in "rough-and-tumble" play with other boys. It is unclear whether a feeling of otherness can lead to an inhibition of rough-and-tumble play, or vice versa, or even whether dislike of rough-and-tumble play is in any way related to feelings of same-sex attraction. Some boys who grew up to be gay or bisexual report that they found rough-and-tumble play too sexually stimulating and evocative of shameful sexual feelings—leading them to avoid it altogether.
The number of transgender children in the general population is small, although the number presenting to gender clinics has been increasing since the beginning of the century. Also increasing is the popular media attention they receive. Children as young as age 2 years may present with gender-variant or atypical gender behavior, although most of these children do not experience incongruence between their experienced gender and assigned sex. Follow-up studies show that a majority of gender-variant children who fulfilled DSM-III or DSM-IV (American Psychiatric Association 1994) criteria of gender identity disorder become less variant as they approach puberty (de Vries and Cohen-Kettenis 2012). Referred to as desisters, a majority of these children develop a homosexual orientation and LGB identities as adolescents and adults. The minority of these children whose gender dysphoria continues into adolescence and adulthood are referred to as persisters (see the next section).
For LGB youth, puberty can provoke the first public "coming out" of sexual feelings, for example, when an adolescent tells her parents about being attracted to other girls. At other times, parents learn about these feelings from other sources, perhaps by searching a child's Internet browser history, raising anxieties and leading to increased scrutiny of the adolescent or even coercive attempts to change his or her sexual orientation.
When children who grow up LGBT become teenagers, the difficulties they encounter may be compounded by the ordinary developmental challenges of adolescence. Adolescence in general is characterized by an increase in sexual feelings. In many cultures, there are socially sanctioned, sublimated outlets for adolescents that serve purposes of modeling or role-playing the part of future heterosexual adults. Teenage dating and supervised coeducational activities such as high school dances are useful in developing interpersonal skills required for later life and relationships. In these interactions, an adolescent's confidence may be reinforced through his or her ability to conform to conventional gender roles. However, while the rituals of conventional adolescence teach lessons about future adult heterosexual roles, those same rituals often generate confusion, shame, and anxiety in adolescents who grow up to be LGBT. They can become anxious, superficial, or detached at a time when their heterosexual peers are learning social skills needed for adulthood. For example, assuming all youth are heterosexual leads to separating boys and girls during public disrobing. Yet a gay male adolescent can be sexually overstimulated in this environment, much as a heterosexual boy would be if he were required to change in the girls' locker room. For some LGBT adolescents, these repeated experiences foster connections between sexual, shameful, and anxious feelings (Drescher 2001).
Historically, the invisibility of LGBT adolescents in the developmental literature stems, in part, from an erroneous assumption that adolescents are too young to have a fixed sexual identity (Drescher 2002). However, many teenagers can and do identify themselves as LGBT, and by many popular and scholarly accounts (Drescher and Byne 2013; Savin-Williams 2005), they are coming out at much younger ages than in past generations.
Transgender adolescents are a heterogeneous group. Some were gender dysphoric in childhood, referred to in the literature as persisters and representing only a minority of these children. Some adolescents first experience gender dysphoria after puberty. Since the beginning of this century, gender-dysphoric adolescents have been treated with puberty-suppressing drugs (gonadotropin-releasing hormone analogs or progestin) to prevent the development of secondary sex characteristics or to allay anxieties about developing them. This is done in cases where the onset of or anticipation of puberty evokes panic or even suicidal ideation (Drescher and Byne 2013; Edwards-Leeper and Spack 2012; Hembree et al. 2009). Also, in the event that these adolescents eventually medically and surgically transition when legally able to do so, puberty suppression makes this process easier. If and when gender dysphoria desists following puberty suppression, the drugs are discontinued and the adolescent enters puberty, albeit later than nature intended. Some transgender adolescents initially identify as LGB but later become more aware of gender incongruence and identify as transgender. Some adolescents may experience comfort with their bodies and do not meet diagnostic criteria for gender dysphoria but nevertheless engage in gender-variant behaviors and identify as transgender or "genderqueer."
Some communities are accepting of LGBT adolescents in their midst while others are not. One recent study of LGBT young adults who reported higher levels of family rejection during adolescence showed they were 8.4 times more likely to report having attempted suicide, 5.9 times more likely to report high levels of depression, 3.4 times more likely to use illegal drugs, and 3.4 times more likely to report having engaged in unprotected sexual intercourse compared with peers from families that reported no or low levels of family rejection (Ryan et al. 2009).
Those who hide their sexual or gender identities are often referred to as "closeted" or said to be "in the closet." LGBT children and adolescents develop techniques for hiding that persist into young adulthood, middle age (Olson 2011), and even senescence. They hide out of fear of being subjected to antihomosexual or transphobic attitudes that may include teasing, ridicule, or violent bullying.
Revealing one's LGBT identity to others is referred to as "coming out" or "coming out of the closet." For example, a closeted woman can isolate her homosexual feelings and activities from herself, her acquaintances, and her family. From an intrapsychic perspective, she may be closeted to herself (see the next section). It can be psychologically painful to hide significant aspects of the self or to vigilantly separate aspects of the self from each other. For this reason, despite the stigma that may accompany doing so, many individuals find that coming out reduces their anxiety.
The developmental histories of LGB individuals frequently include periods of difficulty in acknowledging their homosexuality, either to themselves or to others. Children who grow up to be LGB rarely receive family support in dealing with antihomosexual prejudices. On the contrary, beginning in childhood—and distinguishing them from racial and ethnic minorities—gay people are often subjected to the prejudices of their own families and communities. Antihomosexual attitudes include homophobia, heterosexism, moral condemnations of homosexuality, and antigay violence.
Closeted individuals cannot acknowledge to themselves their homoerotic feelings, attractions, and fantasies. Their homosexuality is unacceptable and the feelings are dissociated from the self and hidden from others, out of conscious awareness and not integrated into their public persona.
If and when same-sex feelings and attractions enter into more direct consciousness, an individual becomes homo-sexually self-aware. Such individuals can acknowledge some aspect of their homosexuality to themselves, but this may not lead to accepting those feelings. For example, a homosexually self-aware woman whose religion condemns homosexual behavior may never tell anyone else about those feelings and choose to live a celibate life as a way to avoid the problematic integration of her religious and sexual identities.
When one is consciously prepared either to act on homoerotic feelings or to acknowledge a homosexual identity to others, one may define oneself as lesbian, gay, or bisexual. To identify as lesbian, gay, or bisexual, in contrast to being homosexually self-aware or non-gay (see the next paragraph), is to claim a normative identity. In other words, it requires a measure of self-acceptance. Some LGB individuals may choose to come out to family or intimate acquaintances. Others may come out to people they have met in the gay community and keep a gay identity separate from the rest of their lives.
Finally, a non gay-identified individual has experienced homosexual self-awareness and may have even once identified as lesbian, gay, or bisexual. However, such individuals find it difficult, if not impossible, to naturalize same-sex feelings and attractions. Such persons, while recognizing that they have homosexual feelings, reject them; and despite the low odds of success (American Psychological Association 2009), they may even seek to change their sexual orientation.
Although sexual orientation may be immutable in most people, sexual identities may show more variability across the life span (Diamond 2008). Figure 37-1 outlines four broad "homosexual identities" to illustrate ways in which LGB individuals relate to and identify with their same-sex feelings.
The Kinsey studies (Kinsey et al. 1948, 1953) found rates of homosexual orientation of up to 10% in men but much lower rates in women. These studies were hampered by nonrandom selection of participants and lack of population-based samples. More recent analyses (Chandra et al. 2011) studying large U.S. population-based samples show about 2%-4% of males and l%-2% of females reporting their sexual identity as homosexual; these analyses also show l%-3% of males and 2%-5% of females reporting their sexual identity as bisexual. However, prevalence rates have varied depending on whether homosexuality is defined as an identity or as a behavior. Furthermore, sexual attraction and identity correlate closely but not completely with reports of sexual behavior.
Data on the proportion of transgender people in the U.S. population are lacking, and published estimates are often based on children and adults seeking treatment at specialty clinics for gender dysphoria. One review of prevalence studies (World Professional Association for Transgender Health 2011) cites figures ranging from 1:11,900 to 1:45,000 for male-to-female individuals and 1:30,400 to 1:200,000 for female-to-male individuals. Such figures, however, may represent an underreporting of prevalence, since not all transgender individuals present at specialized gender clinics.
Figure 37-1. Sexual identities (homosexual orientation constant).
LGB = lesbian, gay, or bisexual.
Source. Adapted from Drescher J, Byne W: "Homosexuality, Gay and Lesbian Identities, and Homosexual Behavior," in Kaplan and Sadock's Comprehensive Textbook of Psychiatry, 9th Edition. Edited by Sadock BJ, Sadock VA, Ruiz P. Baltimore, MD, Williams & Wilkins, 2009, pp. 2060-2090.
LGBT people may be disproportionately represented in some psychiatric populations. The Institute of Medicine (2011) summarized some health and mental health concerns of LGBT populations, as shown in Table 37-1.
Further research is needed to identify causes for mental health disparities in LGBT populations. Social stigma and bias have been proposed as causative factors. Other proposed factors contributing to minority stress have included poor selfesteem (from internalization of social attitudes) and perceived inability to lead an open life, leading to loss of protective factors for mental health such as being in a steady relationship (Sandfort et al. 2006).
Because all diagnostic evaluations rely on the clinical interview, the interviewer should strive to maintain an empathic, nonjudgmental stance; otherwise, important clinical information necessary for proper diagnosis may be missed. Therapeutic tact is important when working with stigmatized populations, and consultation is recommended if and when one is aware that personal biases or limited knowledge of LGBT issues may interfere with a thorough evaluation (Drescher 2001).
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Table 37-1. Health and mental health concerns of lesbian, gay, bisexual, and transgender (LGBT) populations |
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Health and mental health concerns |
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Youth |
Lesbian, gay, and bisexual (LGB) youth are at increased risk for suicidal ideation and attempts as well as depression. The same may be true for transgender youth. Smoking, alcohol consumption, and substance use may be higher among LGB than among heterosexual youth. Little research exists on transgender youth. |
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Adults |
As a group, LGB adults experience more mood and anxiety disorders, more depression, and elevated risk for suicidal ideation and attempts compared with heterosexuals. Little research exists on mood and anxiety disorder prevalence in transgender populations. LGB adults may have higher rates of smoking, alcohol use, and substance use than heterosexuals. Most research is on women, with less known about gay and bisexual men. Limited research among transgender adults indicates that substance use is a concern. |
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Elderly |
Elderly LGBT adults experience stigma, discrimination, and violence across the life course. |
Source. Adapted from Institute of Medicine 2011.
It is particularly important to establish a trusting relationship with LGBT patients when discussing their sexual or gender identity. They may require greater assurances of confidentiality than other patients. For example, diagnostic evaluations may require obtaining collateral information; such sources might include a same-sex partner, family members unaware of the patient's sexual identity, or LGBT-identified friends. When safety issues, as in the evaluation of a suicidal patient, require contacting a patient's family or friends, the collection of necessary information does not necessarily require disclosing the patient's sexual or gender identity (outing). In emergency settings, however, a discharge back to family or other caregivers may require evaluating their sensitivity and responses to having learned the patient's sexual or gender identity.
Sexual orientation or gender identity may play an important role in understanding some patients' presenting problems, such as suicidal feelings associated with coming out, substance abuse patterns of LGBT subgroup populations, or psychiatric comorbidity associated with general medical conditions such as HIV. For all patients, a complete evaluation should include a sexual history with information about sexual orientation, gender identity, intimate relationships, extent to which the patient is "out," and sexual practices. In considering HIV risk factors, it is important that bisexual and lesbian-identified women not be excluded; they may be at risk for HIV from male sexual partners or other behaviors such as shared needles. Being in a conventional heterosexual marriage does not exclude the possibility that a patient might be engaging in same-sex sexual behavior or be transgender. Psychiatric evaluation performed in the setting of a trusting working relationship can help facilitate a patient's willingness to receive appropriate medical care, including HIV testing.
Sexual or gender identity should be part of a patient's psychosocial evaluation, including primary support group, education, housing, access to health care, and occupational, economic, and legal issues. A diagnostic interview of a lesbian, gay, bisexual, or transgender patient should include an assessment of support networks other than family and friends, including work, religious organizations, and community groups. The patient may be estranged from biological family and relying on a network of friends (family of choice). She may not feel comfortable being out at work. Her religion may be welcoming, tolerant, or intolerant. She may be involved in volunteer activities with LGBT organizations or receiving services from one. A psychosocial assessment includes a history of relationships with partners, including children from current or past relationships. For some LGBT patients, this includes past opposite-sex marriages.
General principles of psychotherapy can be applied to work with LGBT patients. However, this psychotherapeutic work sometimes draws attention to aspects of the therapy process that may be overlooked in treatment of non-LGBT patients. This section discusses some specific factors to consider when treating LGBT patients.
Without belaboring the obvious, all patients, not just LGBT ones, benefit from a therapeutic environment based on respectful principles. Homosexuality and transgender presentations can evoke uncomfortable feelings in clinicians; when these emerge in treatment, they need to be tolerated, legitimized, and treated as valuable for further exploration by the therapist. LGBT patients usually come into treatment with some history of shame about their identities. To compensate for that history, it is a prerequisite in doing psychotherapy with LGBT patients that therapists themselves be able to accept their patients' sexual or gender identity without inadvertently shaming the patient.
One means of expressing respect is to be wary of psychotherapeutic interventions intended to elucidate the presumed causes of a patient's sexual orientation or gender identity, just as therapists do not usually try to determine the "causes" of a patient's heterosexuality. There is little empirical evidence supporting the hypothesis that psychotherapies of any kind will reveal the "causes" of a patient's sexual orientation or gender identity—or effect changes in them. Instead, a patient's own search for etiological explanations may be used to reduce anxieties and may limit more helpful psychotherapeutic exploration of ongoing problems in living.
Another means of expressing respect is to avoid imposing medicalized terminology when speaking to and about patients. For example, referring to a self-identified gay man or lesbian as "a homosexual" could be construed as offensive. Transgender patients should be directly asked which pronoun they prefer to use when referring to themselves.
Finally, many LGBT individuals internalize antihomosexual and transphobic attitudes of the dominant culture. In times of stress, and regardless of where they are in their own coming-out process, LGBT individuals may become self-critical or self-condemning. This may lead them to regard their sexual or gender identity, rather than particular life circumstances, as being the cause of their distress.
A therapist would do well not to assume anything about the sexual practices of a particular lesbian, gay, bisexual, or transgender patient, or of any patient, for that matter. Even with heterosexual patients, talking about sexual practices that differ from those of the therapist can generate shame or other uncomfortable feelings in a patient and countertransferential anxieties in a therapist. Similarly, when LGBT patients reveal their sexual selves, they may evoke a range of countertransference responses. It is one thing for a therapist to accept a patient's homosexuality in the abstract. It is another thing altogether for a therapist to feel sufficiently comfortable and nonjudgmental to listen and take a sexual history in a way that respects the patient's subjectivity and avoids shaming the patient.
When conducting psychotherapy, the therapist should be aware of his or her own judgments, including the therapist's beliefs about what constitutes "normal" human sexual behavior. Because most psychiatrists and other health and mental health professionals have little or no training in human sexuality, it is not an uncommon occurrence for clinicians to offer professional opinions based on personal belief systems. Therapists should also be aware of the extent to which any theory they learned has embedded within it judgments about "normal" and "abnormal" sexuality.
A 35-year-old lesbian woman had anxiety symptoms consistent with a DSM diagnosis of generalized anxiety disorder. She quickly experienced a reduction in symptoms after treatment with a combination of benzodiazepines taken as needed and supportive dynamically oriented psychotherapy. As treatment proceeded, the therapeutic focus shifted to interpersonal stressors that exacerbated her anxiety These stressors included difficulties accepting the authority of her male employer and anxieties related to expressions of intimacy with her wife.
The patient's developmental history included severe physical abuse by her mother from age 5 years through adolescence. Her father was reported to have done nothing to stop the violence and made excuses that the patient experienced as rationalizations for his wife's behavior. At age 16, the patient ran away from home and never recontacted her parents. In recounting this history, the patient experienced intense affective states of fear, rage, and anxiety, as well as flashbacks. This led to a modification of her diagnosis to posttraumatic stress disorder, which responded to antidepressants added to her treatment.
In her present circumstances, the patient described her relationship as "loving" and her wife's "kindness" as enabling them to stay together despite the patient's long-term difficulties with intimacy. She described an evening of "lovemaking" in which she described herself as "so happy, it was as though I had this out-of-body experience where I felt like I gravitated out of myself and I was watching me in a really happy movie."
Dissociating during intimacy is not unusual for one who has been severely traumatized. However, the patient's intense emotions generated complex responses in the therapist, a gay man who found himself uncharacteristically reluctant to inquire too deeply or ask directly about the sexual details when she felt herself "leave" her body.
Part of the therapist's reluctance came from sensing his patient's vulnerability to intrusions. However, the therapist privately noted some internal discomfort inhibiting him from asking for descriptions of physical intimacy in his patient's lesbian relationship. He contrasted his unusual tentativeness in this case with the ease he felt in asking about intimate sexual details in gay men he treated, even those as traumatized as this lesbian patient. He decided to take the issue up in peer supervision, asking his colleagues, "How do therapists, in general, learn to comfortably talk about the intimate sexual activities of their patients if those sexual practices are dissimilar to their own?"
The Centers for Disease Control and Prevention reported that as of 2008 (the most recent year for which national estimates are available), 1.1 million people in the United States were HIV positive and 20% of those people were not aware of being infected. Although there have been increasing rates of HIV exposure worldwide due to unprotected heterosexual sex, in the United States unprotected sex between men who have sex with men remains an important risk of HIV transmission (Halkitis et al. 2005). Adequate assessment of HIV risk factors includes 1) obtaining a risk history (especially high-risk behavior such as penile-vaginal intercourse without a condom or penile-anal intercourse without a condom), 2) considering the need for HIV antibody testing, 3) encouraging risk reduction, and 4) encouraging appropriate medical treatment.
Issues that may arise when counseling gay men about HIV testing include 1) fear of learning one has HIV, 2) fear of having exposed one's partners to HIV, 3) fear of having one's sexual "indiscretions" exposed, 4) fear of abandonment if found to be HIV positive, and 5) concerns about informing sexual partners. An assessment of suicide risk factors is important.
Men who have unprotected sex with men and who frequently change partners may be at especially increased risk of HIV exposure. Also, the presence of other sexually transmitted infections (STIs) may increase the risk of HIV transmission, so inquiring about STIs should be part of HIV risk assessment. Appropriate treatment referrals should be made if STIs are present. Because minority populations—in particular, Latino and African American populations—are overrepresented among individuals who are HIV positive, it is especially important to ensure that adequate risk assessment and counseling are performed for minority patients. In assessment of HIV risk factors, it is important to assess not just risky sexual behaviors but also injection drug use or other drug use, such as crystal methamphetamine ("crystal meth"), that may make risky sexual behavior more likely (Forstein et al. 2006; Wainberg et al. 2006).
Psychiatrists can play an important role in both assessing risk factors for HIV exposure and providing education about risk reduction and HIV testing. They can play a role in monitoring and encouraging treatment adherence to complicated medication regimens. In addition, comorbidity of HIV and psychiatric disorders may play an important role in treatment nonadherence. For example, individuals who are HIV positive and have a depressive disorder are, in general, at risk for poor outcomes such as worsened disease or death (Forstein et al. 2006).
An asymptomatic HIV-positive gay man, feeling depressed and anxious, presented for a psychiatric consultation. The patient was also using crystal meth and engaging in risky sexual behaviors, including unprotected anal intercourse, colloquially referred to as "barebacking" (Halkitis et al. 2005). As the psychiatrist took a sexual history, the patient blandly described his unsafe sexual activities, making no direct connection between those behaviors and his depressive and anxious symptoms. The psychiatrist, feeling uncomfortable as the patient's history unfolded, said nothing about her inner responses but just listened and asked neutral questions.
Toward the session's end, the patient reported feeling dread that kept him awake the night before, although he could not locate its source. The therapist responded that she, too, had experienced feelings of dread earlier in the session during the patient's account of his self-damaging activities. She felt frightened and out of control, saying this directly to the patient, and wondered if her feelings made sense to him.
The patient responded that he, too, felt out of control. He also felt shame and guilt that he might infect others. Yet since childhood he had used a bland facade as a way of living with alcoholic parents' physical and verbal abuse. He had experienced his HIV diagnosis as traumatic; by pretending he had no feelings about his positive serostatus, the patient was trying to dissociate himself from thinking about anything that might remind him of HIV.
The psychiatrist listened but made no rush to judgment, allowing the patient to talk about his feelings. Her remarks induced anxiety in the patient but nevertheless succeeded in drawing attention to his feeling that he lacked agency in controlling his own behavior. This exchange eventually allowed them to develop a treatment plan that included a harm reduction approach to crystal meth abuse (Wainberg et al. 2006) and getting into a substance abuse treatment program; frank conversations about using condoms and the incentives and risks of barebacking (Halkitis et al. 2005); and, finally, treatment of his underlying depressive disorder with combined psychotherapy and pharmacotherapy.
Sexual orientation is defined as the sum of an individual's sexual attractions and fantasies over a demarcated period of time. If the accumulated experiences of sexual attractions are toward the same sex, the orientation is homosexual; if the attractions are primarily toward a different anatomical sex, then the orientation is defined as heterosexual. If one has significant periods of attraction to or fantasies about members of-both sexes, one's orientation is defined as bisexual.
Sexual identity is a more subjective concept and includes one's feelings and attitudes toward one's sexual attractions. A sexual identity can change when an individual changes perspective about his or her sexual feelings. For example, when a gay person decides he is "ex-gay," his sexual attractions may not have changed, nor may they ever change; what can change, however, is his attitudes about his own homosexuality from subjective acceptance to rejection.
In American society, being black, Hispanic, Asian, or native American and lesbian, gay, bisexual, or transgender makes one a "double minority." For ethnic and racial minority LGBT patients, this can be a significant clinical issue. These individuals may present as having difficulties associated with living in a society that generally condemns homosexuality and tolerates racial and ethnic prejudice. Being a member of a "double minority" often entails interpersonal and familial issues, as well as intrapsychic conflicts that can affect the successful development of an affirmative identity and self-esteem. These issues may include not feeling accepted by either the ethnic or racial minority group or gay culture ("No group wants all of me"); having difficulty choosing a primary group identification ("Am I ethnic minority first or gay first?"); and dealing with overt and covert racism, homophobia, and sexism (within both the minority communities and the gay community). A therapist can help a double-minority patient uncover, identify, and resolve some of these conflicts.
Lesbian patients may experience discrimination and stress both as women and for being gay. Compared with gay men, lesbians are often subject to greater social invisibility and fewer role models. Studies using population-based samples and reports of self-identified sexual orientation (rather than sexual practices) found that in comparison with heterosexual women, lesbian women reported higher daily alcohol intake, higher rates of depression and antidepressant medication usage, greater emotional stress as teenagers, higher rates of eating disorders, greater frequency of suicidal ideation in the past 12 months, a more frequent history of suicide attempts, and more days of poor mental health within the past month (Diamant and Wold 2003; Institute of Medicine 2011; Koh and Ross 2006). Lesbians and bisexual women may be at higher risk than heterosexual women for breast cancer (Case et al. 2004).
Lesbian women may first become aware of same-sex attraction and have sex at a later age than gay men. They may heterosexually marry only to become aware of their homoerotic feelings well into the marriage. Some studies have shown decreased rates of masturbation and sex for lesbians and a relative importance of nongenital physical contact, with sexual satisfaction determined not just by frequency of sex but also by emotional factors. Lesbians in coupled relationships may show more cohesion and relatedness than gay or straight couples, according to some older studies. Oral-genital and manual-genital sexual contact may be more common than vaginal sex with the use of a dildo. Some lesbian couples may face issues of sexual satisfaction that arise when both partners are relatively passive in initiating sex, and treatment may be helpful in exploring what might be making some patients reluctant to express their desire for sex.
Lesbian couples or single women considering children may be making decisions about whether to adopt or to become pregnant; deciding which partner or if both should become pregnant and in what order; and, if they use donor insemination, whether to use known or anonymous donors. Family stresses in lesbian couples may include adoption issues, such as whether a female partner can legally adopt the biological child of her partner.
There are some gay men who present in treatment with "effeminate" mannerisms, gestures, or voices. Boyhood effeminacy, or gender variance, can sometimes be part of the normal developmental history of gay men entering treatment, even those who may appear conventionally masculine as adults. However, the social impact of marked effeminacy can be enormous; in many cultures, there is no child more despised than the "sissy." Thus it is not uncommon for gay men in treatment to report that, as children, teachers, peers, and even family members teased or bullied them. Not only are shaming experiences traumatic, they may also, in some cases, make it difficult for these individuals to fully trust authority figures—including mental health professionals. A clinician's awareness of and sensitivity to the trauma and stigma engendered by reactions to effeminacy can be helpful in treating this subgroup of gay men.
Another treatment issue may pertain to middle-aged or older gay men living in urban gay communities who experienced multiple losses in the first decade of the AIDS epidemic. Prior to the development of today's life-prolonging antiviral drugs, mortality from HIV infection was quite high. There are older gay men who lost scores of friends and acquaintances. For some, these decimated support networks were never reconstituted. Such individuals may present in treatment with social isolation, unresolved bereavement, and even posttraumatic stress disorder.
Gay men considering having children face many of the same decisions and legal obstacles experienced by lesbian women. Adoption issues are similar for gay men, but gay men wishing to have a biological child may do so through surrogacy.
Bisexual individuals represent a small percentage of the LGB population. In treatment, bisexual patients may report alienation from gay, lesbian, and heterosexual communities. Within the gay and lesbian communities, some have been told they are "not really bisexual" but just unwilling to commit to a gay or lesbian identity. Although it is true that some gay and lesbian individuals first identify as "bisexual" before coming out, some people are bisexual in both behavior and desire. At times, individuals may be "serially bisexual," that is, attracted to individuals of one sex at a time—for example, first homosexual, then heterosexual, then homosexual again. Some bisexual individuals enter treatment because of difficulties they may be having in accepting the conventions of marriage or monogamous relationships; some bisexual individuals may feel that having to choose a partner of one sex unfairly denies them access to partners of the other sex.
As stated earlier in the chapter, sexual orientation and gender identity are independent variables in most individuals. Consequently, knowledge of a person's gender identity indicates nothing about that person's sexual orientation. An ostensibly heterosexual individual, born with a male body and attracted to women, may become a woman and remain attracted to women after transitioning. Another treatment issue of no small consequence to transgender patients is how they wish to be addressed. For example, a preoperative trans man, even in the early stages of transitioning from a woman to a man, will often prefer to be called by a man's name and to be referred to with masculine pronouns. It is possible for such individuals to meet strong resistance to this request from family, friends, government officials, employers, and even treating psychiatrists. Transgender individuals may also require psychotherapeutic help in the process of transitioning from one gender to the other (World Professional Association for Transgender Health 2011).
Traditions of psychotherapeutic neutrality assert that therapists should not bring personal issues into the treatment setting. In recent years, critics have questioned concepts of neutrality and argue that a therapist's subjectivity inevitably shapes the patient narratives that emerge in treatment. From this perspective, a sexual identity, in part, can sometimes be seen as a narrative about the meaning of one's sexual feelings. This is true of both the patient and the therapist, each of whom will have a sexual identity based on life experiences.
However, the revelation of a therapist's subjectivity to a patient is still a controversial subject in some quarters. For those who frown upon self-revelation, openly gay therapists can only exist as countertransferential enactments. Yet today many LGBT therapists are working openly in their professional communities. Their presence raises the question of whether therapists should tell patients about their own sexual identities.
It would be an error to assume that a therapist, by virtue of being lesbian, gay, bisexual, or transgender, automatically has greater insight into the issues that bring LGBT patients into treatment. Simply being gay or transgender is no substitute for training in psychotherapy. One need not be lesbian, gay, bisexual, or transgender to treat LGBT patients any more than one need be heterosexual to treat heterosexual patients. Nevertheless, in many communities, LGBT patients have the option of finding well-trained therapists, heterosexual or LGBT, who are comfortable with and knowledgeable about gay people's lives. A therapist who knows little about the lives of LGBT patients will sometimes find some who are willing to share that information. Other patients may feel that their time should not be used to educate a naive therapist.
There may be times when directly revealing the therapist's sexual identity can be helpful to a patient, although heterosexuals may be unaccustomed to the need for such declarations. Heterosexual therapists may assume that the patient cannot determine their true sexual identities. However, a sexual identity, gay or heterosexual, is more than just an orientation, and therapists always provide indirect clues about their own identities, even when they will not provide direct confirmation. Because LGBT people learn early in life that revealing one's sexual identity may be fraught with dangers, some develop a sensitivity—or gaydar—regarding the sexual identities of others.
Gay therapists who live closeted professional lives have a particular need to hide. They also experience their own homosexuality as something secretive and shameful. Isay (1991) believes gay and lesbian analysts should always come out to their patients lest they counter-transferentially perpetuate patients' feelings of secrecy and shame. However, this is not the only meaning of coming out, nor does coming out prevent other enactments in the transference and countertransference of secrecy and shame. Any therapist, regardless of his or her own sexual identity, should evaluate a patient's need for the therapist to come out on an individual basis and should be prepared to do so when necessary.
Key Clinical Points
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Appendix: Definitions of Commonly Used Terms
Androphilic Attracted to men; can describe men or women.
Antigay violence Physical violence directed at people because they are gay or thought by attackers to be gay. Colloquially referred to as gay bashing; the latter term can describe antigay verbal abuse as well.
Antihomosexual attitudes Attitudes such as antigay violence, heterosexism, homophobia, and moral condemnations of homosexuality.
Bisexual Erotically attracted to both men and women; the term can refer to a sexual identity and/or a behavior.
Cisgender or cissexual A term used in the transgender community to describe individuals whose gender identities align with their assigned sex at birth (nontransgender).
Closeted A colloquial term describing individuals who hide their homosexuality or gender identity from others. Being "in the closet" or "closeted" involves a range of psychological and behavioral activities intended to keep an individual's sexual or gender identity a secret.
Coming out A process in which a lesbian, gay, bisexual, or transgender person accepts his or her sexual or gender identity ("coming out to oneself") and/or discloses that identity to others ("coming out to others").
Down low (DL) A colloquial term that originated in the African American community to describe men who have sex with men. Men "on the down low" engage in homosexual or bisexual behavior without adopting a gay or bisexual identity.
Gay Colloquial, affirmative term for homosexual; refers to men or women, although some women may identify more with the term lesbian.
Gaydar A colloquial play on "radar," referring to a presumed capacity to sense another person's sexual identity, ostensibly by relying on outward appearance, behaviors, and other cues.
Gay-friendly Fostering an environment accepting of and open to LGBT people; can describe institutions or individuals.
Gender A cultural concept based on some combination of social, psychological, and emotional traits associated with masculinity or femininity.
Gender dysphoria Discomfort with one's assigned sex at birth. Also a DSM-5 diagnostic category replacing DSM-IV's gender identity disorder diagnoses.
Gender expression How individuals demonstrate their gender to others via manner of dress, behaviors, and appearance.
Gender identity A person's self-identification as male, female, or other gender (e.g., genderqueer); often erroneously conflated with sexual orientation.
Gender identity disorder Diagnosis in DSM-IV-TR (American Psychiatric Association 2000) and ICD-10 (World Health Organization 1992): In DSM-IV-TR this diagnosis refers to children, adolescents, and adults. In ICD-10 there are separate diagnoses for gender identity disorder of childhood (GIDC) and gender identity disorder in adolescence and adulthood;, the latter diagnosis is applicable to transsexualism. The DSM-IV-TR and ICD-10 diagnoses are characterized by persistent gender dysphoria, which in the case of adults may lead them to seek out sex reassignment surgery.
Gender incongruence Diagnosis that will replace transsexualism and GIDC in ICD-11 (Drescher et al. 2012).
Genderqueer A colloquial term to describe a gender identity of a person whose internal sense is of being between two genders, neither purely masculine nor purely feminine.
Gender role The outward behaviors and dress that distinguish one as male or female.
Gender variant, gender variance Nonpathologizing ways to describe individuals with gender-atypical behavior or self-presentations.
Gynephilic Attracted to women; can describe men or women.
Heterosexism A belief system that naturalizes and idealizes heterosexuality and either dismisses or ignores LGB subjectivities.
Heterosexual Refers to sexual behaviors between individuals of different sexes, a sexual orientation, and/or a sexual identity.
Homophobia, external The irrational fear and hatred that heterosexual individuals may feel toward LGB people. Treatment of Lesbian, Gay, Bisexual, and Transgender Patients Homophobia, internal The self-hatred LGB people may feel toward themselves; also internalized or interiorized homophobia.
Homosexual As an adjective, denotes either same-sex sexual behaviors or a same-sex sexual orientation. Historic usage of homosexual as a psychopathological term in medicine and psychiatry makes contemporary usage as a noun offensive to many LGB people.
Homosexuality A broad term encompassing same-sex behaviors, orientation, attractions, and identities.
Intersex Historically known as hermaphroditism; more recent usage refers to diverse presentations of ambiguous or atypical genitals, or disorder of sex development (the currently used term replacing intersex [Hughes et al. 2006] and also used in DSM-5 as a specifier for the gender dysphoria diagnoses); sometimes confused with transsexualism.
Lesbian Refers to women erotically attracted to women; a sexual identity.
Men who have sex with men (MSM) An epidemiologic and public health term describing men who may have not adopted a gay identity but whose behavior includes sex with other men.
Moral condemnations of homosexuality Beliefs that regard homosexual acts as intrinsically harmful to the individual, the individual's spirit, and the social fabric. Such beliefs are often religious in nature, although some are secular.
Outing Colloquial term for an unwanted revelation by a third party of a closeted individual's homosexuality to others; often intended to inflict harm on the person being "outed."
Queer Historically, a derogatory term for LGBT people; adopted as a sexual identity in the 1990s by younger gays and lesbians. Also a descriptive term used in academia (queer theory, queer studies).
Sex The biological attributes of being male or female; compare with gender.
Sex reassignment surgery The surgical procedures used in treating individuals with gender dysphoria; also gender reassignment surgery, gender confirmation surgery.
Sexual behavior An individual's sexual activities (homosexual, heterosexual, bisexual), irrespective of sexual orientation or sexual identity.
Sexual identity (sexual orientation identity) The subjective experience of one's sexual orientation. Although sexual orientation is usually immutable, sexual identities are not. Calling oneself gay or lesbian is a subjective affirmation of a homosexual orientation.
Sexual orientation An individual's innate attraction to members of the same sex (,homosexual), the opposite sex (heterosexual), or both sexes (bisexual). Recognition of one's homosexual orientation does not necessarily or automatically lead to acceptance of a gay or lesbian sexual identity.
Transgender Refers to someone whose gender identity (or gender expression) and sex are discordant or not conforming to social norms. Gender identity and sexual orientation are independent variables insofar as one's gender identity does not automatically reveal one's sexual attractions.
Trans man (female to male) Someone assigned at birth as a female (assigned female, natal female) but identifying as a man.
Transphobia A range of negative attitudes and feelings toward transsexual or transgender individuals.
Transsexual An individual who has undergone sex reassignment surgery, either male to female or female to male.
Trans woman (male to female) Someone assigned at birth as a male (assigned male, natal male) but identifying as a woman.