Improving the approach to LGBTQ persons in mental health care settings: a clinician's perspective

In 1974, the American Psychiatric Association (APA) removed the diagnosis of homosexuality from the DSM-II1, 2. In 1990, the World Health Organization (WHO) followed suit, removing the homosexuality diagnosis from the ICD-103. In 2019, the WHO went a step further and removed the diagnosis of "transsexualism", now renamed "gender incongruence", from the ICD-11 chapter on mental disorders. By placing gender incongruence in a new chapter called "Conditions related to sexual health", the ICD sought to destigmatize transgender individuals in the 21st century, much as the APA destigmatized gay and lesbian people in the twentieth4, 5. These depathologizing changes, which reflect and integrate changing cultural beliefs and values regarding sexual orientation and gender identity, have shifted the mental health mainstream's clinical focus in working with lesbian, gay, bisexual, transgender and queer/questioning (LGBTQ) persons. Historically, psychiatrists and other mental health professionals spent many psychotherapy sessions trying to determine what caused homosexuality, or gender incongruence, in unsuccessful efforts to "cure" these persons. However, two people having a conversation in a room will never discover the "cause(s)" of anyone's sexual orientation or gender identity6. Today, it is acknowledged that the "determinants" of any sexual orientation (homo-, bi- or hetero-) or gender identity (transgender or cisgender) remain unknown. Consequently clinicians, instead of seeking to find out "why" persons are LGBTQ in efforts to change them, have now shifted focus to thinking about "how" to help these individuals more openly and adaptively live their lives as LGBTQ persons. This shift was embodied in the US Institute of Medicine's landmark report The Health of Lesbian, Gay, Bisexual and Transgender People7, which highlighted the need for more research, including studies on the role of social influences on the lives of LGBTQ people and how to address inequities in their health care. While research has been done in the last decade, more is needed. As clinicians await the results of further research, there are some suggestions that the individual practitioner can follow to improve the approach to LGBTQ persons in mental health care settings. First, many LGBTQ persons report experiencing disapproval, discrimination and even abuse in clinical settings. Consequently, they may avoid medical care if and when they can. And, when unable to avoid care, they may be reluctant to reveal their sexual orientation or gender identity without clear evidence of a clinician's non-judgement and acceptance. This requires clinicians, in doing evaluations, to not automatically presume that all individuals, couples or members of families are heterosexual or cisgender. When inquiring about relationships, it is best to ask open-ended questions without presuming that one knows the gender of a patient's partner. For example, in many Western countries, and increasingly in other parts of the globe, not all marriages are heterosexual. Patient self-report intake forms should allow for responses regarding diverse sexual orientations, gender identities and family arrangements. Recognition of alternative family and social relationships is particularly important when psychiatrically evaluating LGBTQ persons in emergency departments and acute inpatient settings. For patients living in communities and cultures that accept their identities, contact with an LGBTQ person's social support system is routine. However, in places and cultures where homosexuality and transgender presentations are less accepted, recognition by clinicians may be challenging. Yet, clinicians should keep in mind that the person or people who know most about a patient's mental state and function may not have a state-recognized legal relationship. Consequently, it may be necessary to obtain information from them to identify potential sources of a patient's problems. Ideally, in working with LGBTQ populations, it should be the patients' well-being, not the state, that determines who should be contacted and spoken with. In some countries and communities, it is increasingly common for LGBTQ patients to seek out mental health practitioners who identify publicly as members of that community. Although practitioners since the time of Freud have been cautioned about self-disclosing to patients, openly LGBTQ psychiatrists are increasingly present in many places. Today, they are in a unique position to advocate for improved services for the patient populations they treat8. Violence perpetrated against LGBTQ individuals is common across cultures and may lead to post-traumatic stress disorder, depression, and a range of other mental health problems. Perpetrators of anti-LGBTQ violence may include strangers, family members, co-workers and sometimes authority figures. Complicating matters, those who experience violence, or sexual or domestic abuse, may not wish to report their experiences or seek help, due to fear that disclosing their sexual or gender identity may elicit judgmental responses – and even harassment – from police or social service workers. Ideally, clinicians sensitive to this reality can advocate for fair treatment of LGBTQ patients who have experienced violence and are dealing with insensitive bureaucracies. Even in the absence of violence, clinicians should be sensitive to patient anxieties regarding the ubiquity of anti-LGBTQ attitudes, sometimes referred to as "minority stress"9. Patients may feel misunderstood when clinicians deny or minimize the extent to which this phenomenon colors their lives and affects their self-esteem. The most severe expression of anti-LGBTQ attitudes may be seen in increased rates of suicidal ideation among LGBTQ populations, particularly among young people who are sorting out their sexual or gender identities. LGBTQ youth often hide their sexual or gender identity concerns from parents, and may not readily turn to them for support. In the US, for example, this issue is exacerbated in socially conservative states where efforts to identify the mental health needs of LGBTQ youth are regarded as "recruitment" or "grooming". Psychiatrists treating LGBTQ young people need to be aware of the sociocultural conditions that may exacerbate their patients' psychological distress. In conclusion, it is not unusual for LGBTQ patients to face stigma and discrimination in their families, their communities and in the wider world. These experiences have mental health consequences which clinicians often encounter. One way to mitigate this stress is by demonstrating to patients, in both words and deeds, that they will not have to face stigma and discrimination in the clinical setting. This is a task which any ethical psychiatrist can and should be able to perform.