Some members of the LGBTQIA+ community endure discrimination at the doctor’s office. Others simply avoid getting care. In this Psychiatric Times article, Summer R. Thompson, DNP, PMHNP-BC, discusses why this at-risk community needs better outreach.
In 1970, a group of gay and lesbian activists made history when they disrupted the annual meeting of the American Psychiatric Association (APA) in San Francisco. Outside the convention center, they formed a human chain to prevent visiting psychiatrists from entering. Inside, they interrupted sessions on transsexualism, laughed at a purported expert on homosexuality, and were so disruptive that a panel titled “Issues of Sexuality” had to be adjourned.
The APA took the final step in 1987 and dropped this reference completely. They officially adopted what is considered a normal variant view on sexual identity. Individuals could, they acknowledged, be born gay.
Resources for treating LGBTQIA+ patients
It is against this backdrop that the uneasy relationship between psychiatry and the lesbian, gay, bisexual, transgender, queer, and intersex community (LGBTQIA+) continues to evolve.
Members of the LGBTQIA+ community are at increased risk for mental health issues associated with minority stress, or the unique experiences associated with homophobic victimization. Many grapple with feelings of shame, rejection, and depression. As a result, they experience higher rates of homelessness, substance abuse, and suicide.
Health disparities in the LGBTQIA+ community
As of 2017, there were 9 million adults in the United States, about 3.8% of the country’s population, who identified as lesbian, gay, bisexual, or transgender.
According to a 2013 survey of LGBTQIA+ Americans, 39% said they had been rejected by a family member or friend because of their sexual orientation. About 30% said they had been attacked or threatened because of it, and 58% said they were the target of jokes or slurs.
LGBTQIA+ individuals are more than twice as likely to experience a mental disorder compared to heterosexual men and women. They are also 2.5 times more likely to experience depression, anxiety, and substance misuse.
When LGBTQIA+ people turn to mental health providers for help, they are often let down. Almost one-sixth of LGBTQIA+ adults have felt discriminated against at a doctor’s office, while one-fifth say they avoid medical care altogether due to their fear of discrimination.
Nurturing a vulnerable community
For decades, psychiatry viewed being gay as a degenerative disorder. It created a deep scar that the mental health industry must now work to mend by setting aside biases, broadening our understanding, and earning the trust of LGBTQIA+ patients. To do so, it is vitally important to refrain from making assumptions about a patient’s gender, sexuality, or sexual identity. It is always necessary to ask about an individual’s pronouns.
Creating a therapeutic container is essential for holding patients in a safe place that allows them to express any feelings of pain and shame. This is based on Carl Jung’s concept that compares the therapeutic container to an alchemical container that safely holds the feelings and thoughts of patients and analysts alike.
The following guidelines can be used to create a therapeutic container:
- Validate the sociopolitical issues confronting a patient’s marginalized community
- Do not assume their psychological problems are a function of their sexuality
- Affirm individual life choices
- Help clarify one’s needs and desires
- Validate and work on self-esteem
- Connect patients with appropriate communities and networks
By providing competent care as clinicians, we can continue to bridge the gap of trust and open new appropriately informed ways to treat and support the LGBTQIA+ community. In a sign of hope for the future, the American Psychoanalytic Association issued what it called an “overdue apology” in 2019 to members of the LGBTQIA+ community for its “role in the discrimination and trauma caused by our profession.” The mental health community needs to focus on restorative justice on both the macro and micro levels. This can include educating themselves and their peers, centering learning from LGBTQI individuals, using cultural safety and trauma-informed frameworks for care, and reducing gatekeeping to gender-affirming care.