Issues Arising in Psychotherapy With Lesbian, Gay, Bisexual, and Transgender Patients

The LGBT community is not a homogenous group. Members of the community represent a diversity of racial, ethnic, cultural, and socioeconomic backgrounds. However, all of the members of the LGBT community are unified in that they belong to a stigmatized minority group. The minority stress model (1) has shown that individuals in a minority group may be at higher risk for mental health disorders as a result of being subjected to stigmatizing attitudes, discriminatory policies, and other social stressors imposed by members of a majority group. As a result, LGBT individuals, like members of other stigmatized minority groups, may be subject to significant stress, prejudice, hostility, and expectations of rejection, which can all contribute to a considerable and disparate mental health burden (1).

Studies have shown that cumulative, chronic stress among LGBT individuals can lead to increased risk of substance use disorders, depression, anxiety, suicide, and self-harm, among other mental health issues (2–4). Furthermore, these risks, including disparities in access to health care, may vary from one sexual minority group to another. In general, however, compared with heterosexual and cisgender individuals, members of the LGBT community have more than a twofold increased likelihood of attempting suicide, and their risk for depression and anxiety disorders is almost double that of individuals who do not identify as LGBT (5, 6). Substance use is also significantly more prevalent among the LGBT community, with rates of illicit substance use, such as use of cannabis, cocaine, methamphetamine, cigarettes, and opioids, twice as high among LGBT individuals (7).

Despite the significant mental health burden that many members of the LGBT community may experience, these patients often delay or forgo seeking treatment because of concerns about discrimination or because of previous mistreatment in a medical setting (8–10). In particular, they may avoid mental health treatment because of its not-so-distant history of pathologizing LGBT identities and behaviors as psychiatric abnormalities (11, 12). Knowledge of psychiatry’s history and theorizing about LGBT individuals (11) may help clinicians understand the resentment and avoidance that some LGBT patients may have toward mental health practitioners.

It is not unusual in the developmental histories of LGBT patients to have experienced some period of difficulty in acknowledging to others either their sexual orientation or gender identity. Colloquially, this state of mind is referred to as “being in the closet,” and those who hide their identities are referred to as “closeted.”

Having to hide an aspect of one’s identity in such a way is not a typical experience for those with heterosexual orientations or cisgender identities. The experience can be analogous to members of other stigmatized groups whose differences from the majority’s public expressions are not immediately apparent. For example, persecuted religious minorities may be forced to practice their faith in secret, or individuals of mixed race or ethnicity may need to hide their family origins to “pass” as a member of some other religious, racial, or ethnic majority.

However, there is an important difference between the latter minority groups and LGBT individuals. Members of most minority groups learn coping mechanisms from their families and communities to deal with the majority’s prejudices. However, only until relatively recently have the children who grow up to be LGBT received family support to deal with anti-LGBT prejudices. All too often, their families of origin share the same prejudices of the heterosexual or cisgender majority. As one gay patient put it, “We are the only minority group born into the enemy camp” (14). Lending support to that observation is the fact that 30% of homeless youths are LGBT, most often resulting from being forced out of their home or feeling a need to run away from home because their sexual orientation, gender identity, and/or gender expression are not accepted (15).

Given the consequences of widespread negative attitudes toward LGBT individuals, it is not surprising that they may be unable to acknowledge to themselves, or reveal to others, any homoerotic feelings, attractions, or fantasies. Transgender individuals may experience a similar need to hide their gender dysphoria or any gender nonconforming feelings or behaviors. Individuals who find such thoughts and feelings unacceptable may not only hide them from others, they may keep them out of conscious awareness to themselves in a dissociative manner (16). Clinical presentations related to being in the closet can vary in severity, from the less intense case of a young adult man considering the possibility that he might be gay to more severe manifestations, in which any hint of same-sex feelings resides totally out of conscious awareness. By dissociating anxiety-provoking knowledge about the self, some individuals can live a whole double-life and yet, in some ways, not know it (14, 17).

From a clinical perspective, it should be noted that keeping aspects of the self hidden or separated is often difficult and harmful. Hiding creates difficulties, such as in accurately assessing other people’s perceptions of oneself or recognizing one’s own strengths. The impact of having to dissociate aspects of the self inevitably affects self-esteem, often making it difficult to recognize one’s accomplishments as reflections of one’s own abilities. Nevertheless, some individuals are able to maintain states of closetedness for long periods of time. Staying in the closet is sometimes done for religious reasons; at other times it is due to personal choice, such as an individual’s efforts to maintain a stable, heterosexual, cisgender marriage.

In contemporary usage, “coming out of the closet” means telling another person that one is lesbian, gay, bisexual, or transgender. A less commonly used term, but one with clinical significance is “coming out to oneself.” Patients often describe this occurrence as their first subjective experience of inner recognition. Coming out to oneself as lesbian, gay, or bisexual may precede any sexual contact or may occur during a sexual moment. Some describe the moment as a switch being turned on, “coming home,” or “discovering who I really am.” The experience may be charged with excitement or with trepidation. It is a realization that previously unacceptable feelings or desires are part of one's self. It is, in part, a verbal process of putting into words what were previously inarticulate feelings and ideas. Coming out of the closet may also be conceptualized as a recapturing of disavowed experiences. From a psychological perspective, it means a reduction in dissociation and the possibility of integrating previously unacceptable aspects of the self (14, 19).

Coming out to oneself may precede coming out to others. Herdt and Boxer (20) have described coming out as a ritual process of passage requiring a lesbian, gay, or bisexual person to unlearn principles of essentialist heterosexuality, unlearn stereotypes of homosexuality, and learn the ways of LGBT culture. In coming out, LGBT individuals must decide, perhaps daily, whether to reveal and to whom they will reveal. Consequently, coming out is a process that never ends. Furthermore, such revelations are not always greeted in a welcoming manner. Fear of rejection often plays a significant role in an LGBT individual’s decision about whom to tell or whether to come out. A need to conceal their identity may be based on reasonable concerns, as in the case of LGBT individuals living and working in socially and politically conservative religious environments. Clinicians would be unwise to advise a patient to come out to anyone without knowing something about that person’s attitudes and opinions. Even with such knowledge, the psychiatrist cannot always predict accurately the consequences of making such a revelation on the relationship between the two people.

Given the social stigma and ubiquity of anti-LGBT attitudes, why come out at all? In most cases, coming out offers LGBT individuals the possibility of integrating a wider range of previously split-off affects, not just those having to do with sexuality and gender. Coming out can lead to greater ease in knowing oneself and expressing oneself to others, which in turn can lead to an enormous enrichment of work and relationships. Such activities constitute a reasonable definition of mental health.

The term “outing” refers to the involuntary revelation of an individual’s LGBT identity by another party. Some activists believe that deliberately exposing a closeted LGBT person to potential personal or public humiliation is justifiable, particularly if the closeted person is a public figure who espouses anti-LGBT beliefs and supports anti-LGBT public policies. This belief has accounted for revelations of, among others, a conservative U.S. congressman (22) and an influential megachurch pastor (23). Sometimes outing is done as an act of revenge by vindictive acquaintances or spurned lovers. Blackmailers may threaten to out an individual for financial or political remuneration. Historically, some politicians have tried to discredit an opponent by exposing them as LGBT (24).

A severe dissociative split between any LGBT identity and internalized anti-LGBT attitudes may account for the mental gymnastics of politically and religiously conservative individuals, allowing them to live with such stark contradictions. Such dissociation often serves as a defense against profound anxiety and shame. In the subjective experience of the outed individual, outing is experienced as a form of psychological violence.

It is not unusual for LGBT patients, when first beginning psychotherapy, to have a fantasy of discovering the causes of their sexual orientation or gender identity during the process. These fantasied beliefs are often enabled, sometimes even encouraged, by clinicians who believe that two people talking in a room have the necessary tools to discover the origins of either homosexual or transgender identities.

In reality, any “causes” remain unknown (26). This knowledge gap does not stop, and will probably never stop, continued theorizing by patients and therapists. A therapist’s own theories about gender and sexuality, however, may distract from therapeutic goals. Furthermore, patients’ etiological theories, when offered, provide insight into both positive and negative attitudes they may assign, consciously or unconsciously, to their own sexual or gender identity.

In contrast, heterosexual patients do not come seeking psychotherapeutic treatments to find out why they are straight. Nor do nontransgender patients expect to learn from a therapist why they are cisgender. Nor are most therapists likely to even raise the questions, “Do you ever wonder why you are heterosexual?” or “Do you ever wonder why you are cisgender?” with patients. The presumptions are that heterosexuality and cisgender identities are nature’s default setting.

Historically, however, it was not altogether unusual for heterosexual, cisgender therapists to bring up questions of etiology to their LGBT patients. Yet, if a therapist took the unusual step of doing so with heterosexual, cisgender patients, it is unlikely that those patients would be interested in pursuing such a line of inquiry—or paying a therapist for any such insights. Sigmund Freud once remarked on the need to question the origins of heterosexuality, stating, “Thus from the point of view of psycho-analysis the exclusive sexual interest felt by men for women is also a problem that needs elucidating and is not a self-evident fact based upon an attraction that is ultimately of a chemical nature” (27). Yet, with a few exceptions (28, 29), psychoanalysts have not concerned themselves with the question nor have they typically offered treatment to find out why their patients are heterosexual or cisgender.

Why do some LGBT patients put up with such inquiries about the origins of their sexual identity or gender identity? One consequence of belonging to a stigmatized minority group is the desire to find a narrative to explain one’s “difference” from the majority. In the case of lesbian, gay, and bisexual people, these etiological narratives take three forms: theories of normal variation, theories of pathology, and theories of immaturity (14, 30). Transgender narratives take form as either normal variation or pathology.

Theories of pathology define a homosexual or bisexual orientation or a transgender identity as psychopathological, a disease or abnormal condition that deviates from biologically predetermined heterosexual, cisgender development. Such theories first gained prominence during the 19th century, most notably in Krafft-Ebing’s Psychopathia Sexualis (31). These etiological theories are based on the following assumptions: adult heterosexuality and being cisgender is the normal, nondiseased state; deviations from conventional gender role expectations are symptoms of disease; and some external, traumatizing pathogenic agent has prevented the individual from becoming heterosexual or cisgender. The external traumatizing event can occur pre- or postnatally and may include intrauterine hormonal exposure, excessive mothering, insufficient fathering, seduction, or a decadent lifestyle.

Theories of normal variation regard homosexuality and transgender presentations as phenomena that occur naturally and that are not signs of illness or psychopathology. Left-handedness is often used as an analogy in these narratives. Today, being in the left-handed minority is not defined as illness, although it may have disadvantages. In the past, being left-handed led to social opprobrium; the word “sinister” is derived from a Latin root connoting the left side. Historically, left-handed children were often treated as if they were abnormal and cured of their nonconforming behavior by being forced to write right-handed. The research of Alfred Kinsey et al. (32, 33) played a significant role in the eventual dissemination, among both health professionals and the general public, of theories of homosexuality as a normal variation. Today, the belief that one is born gay or transgender is the most common theory of normal variation.

Theories of immaturity regarding homosexuality are found in the field of psychoanalysis. Freud, for example, saw homosexuality as a developmental arrest or a psychosexual fixation (27). Immaturity theories are frequently confused with theories of pathology. However, an inability to mature is not necessarily the same thing as being ill. Whereas pathologizing theories treat homosexuality as deviant and abnormal, immaturity theories regard homosexuality as a normal step, ideally a passing phase, to be outgrown on the road to adult heterosexuality. Harry Stack Sullivan hypothesized that children who ultimately became homosexual as adults were members of the “out-group, if only with respect to so-called mutual masturbation and other presumably homosexual activity which went on in this group of boys as preadolescent pals” (34). In maintaining that homosexuality could be a normal part of the heterosexual experience, theories of immaturity were more inclusive and compassionate than theories of pathology. They allowed for the possibility of a lesbian, gay, or bisexual person becoming sufficiently mature to become heterosexual, if they are motivated enough and have adequate adult (meaning heterosexual) guidance.

Yet etiological theories are not formulated in an objective vacuum. All of them contain underlying value judgments about the impact of being LGBT on the social order, on an individual’s worth within that order, or on the relationship between being LGBT and the intent of a higher force (14, 30). A higher force may include God, other deities, spiritual beings, nature, and even an anthropomorphized conceptualization of evolution. Among the key words in the morality tales underlying etiological theories are “social benefit” and “social harm,” “good and evil,” “health and illness,” “adaptive and maladaptive,” “holy and sinful,” or “mature and childish.”

For patients, their own etiological theory is likely to have a personal meaning and an affective charge. A therapist who authoritatively claims knowledge of the definitive etiology of being lesbian, gay, bisexual, or transgender would have difficulty appreciating how etiological narratives serve as vehicles for other issues. For example, a gay man asking, “What is the cause of homosexuality?” may simply be asking, “Why do I feel different from everybody else?” It is only by recognizing the often-irrational underpinnings of the psychotherapeutic search for origins that the focus of treatment may shift from trying to figure out why a patient is LGBT to helping a patient learn how to be LGBT.