Sexuality and Gender in Psychiatry: Ethical and Clinical Issues

  A.Discuss different brain MRI findings between patients who identify as LGBTQ+ and those who identify as heterosexual.

  B.Listen to the mother’s concerns and encourage her to have a discussion with her son in an effort to better understand his needs.

  C.Dismiss the mother without answering the question.

  D.State that there is no established biological basis for homosexuality, though this is an active area of ongoing research.

  E.Ask the mother to come with her son and family to next week’s appointment to facilitate a family discussion on this topic.

  A.Create a gender identity category in the demographics section of the electronic medical record.

  B.Post materials and resources for the clinic that are LGBTQ+ friendly.

  C.Use gender-neutral language in the postclinic-visit summary.

  D.Offer the patient an opportunity to switch providers at the same clinic.

  E.Ask the clinic’s leadership to offer LGBTQ+ allyship training.

1.1 The answer is B. This case illustrates conflict between several ethical principles, including beneficence (i.e., ensuring a harmonious relationship between the patient and his parents), nonmaleficence (i.e., avoiding reinforcing the mother’s distraction from providing adequate support to her son with unproductive questions regarding his sexuality), privacy (i.e., protecting private patient health information from his mother), and veracity (i.e., answering the mother’s challenging questions truthfully while respecting the boundaries of the patient’s personal life). The mother is preoccupied with her son’s sexuality, perhaps out of the hope that it would be a mutable characteristic. Her attitude is not uncommonly experienced by those in LGBTQ+ populations and is often anticipated by providers when patients come out to them. Inability to accept a family member’s sexuality can have important negative consequences, as patients who identify as gay, lesbian, or bisexual may be at increased risk for suicide, particularly because of lack of social support, acceptance, and understanding from close relationships.

Conversations focused on the biology of homosexuality can serve as distractions from helping families understand what they find unacceptable about it. Moreover, the “causes” of homosexuality, bisexuality, and gender identities are unknown (2); thus, speculation about their origins may be an unfruitful clinical activity. Beneficence ultimately guides culturally and structurally competent physicians to ensure optimal care of LGBTQ+ patients and the potential interpersonal precipitating or perpetuating factors in a patient’s psychiatric symptoms. Gaining a clear understanding of the family’s underlying concerns and encouraging a similar effort on their behalf to understand their LGBTQ+ child’s struggles is an important first step toward facilitating a safe and supportive environment for all patients.

2.1 The answer is D. Many psychiatrists will work with a transgender or nonbinary (i.e., having spectrum gender identities that are not exclusively masculine or feminine) patient at some point in their careers. Although epidemiologic studies have shown that roughly 1 million adults in the United States (390 persons per 100,000) identify as transgender, this statistic is likely an underestimate, given the social stigma attached to these individuals (4). It is important for the psychiatric team to effectively advocate for the patient because of the health inequities that the LGBTQ+ community faces. Transgender and nonbinary adults are more likely to experience serious psychological distress and thoughts of suicide when compared with cisgender adults (5). Transgender patients are also subject to acts of violence, harassment, and discrimination, and they often face challenges in accessing appropriate health care and insurance coverage of related services (2).

If LGTBQ+ patients receive mental health care in a nonfriendly environment, this may lead to early termination of the therapeutic relationship. Affirming a patient’s identity is important in any therapeutic relationship, and it is paramount in the care of LGBTQ+ patients if providers are to uphold the ethical principle of justice (fairness and equality in the distribution of resources) in their practice. One concrete example of this principle in action is when coworkers foster an inclusive environment by introducing themselves with their pronouns. Further, it is worth noting that the care provided to the patient in this example extends beyond the relationship with the psychiatrist and into the manner in which the clinic interfaces with the patient. I encourage providers to think about ways in which their practice may or may not be an environment that is LGBTQ+ friendly. It is important that providers work to understand and faithfully address their practice’s shortcomings in meeting the needs of this population rather than referring care elsewhere. This action further reflects the important ethical skill of identifying an institution’s biases and having open discussions with leadership to provide appropriate ethical care. In this manner, each provider can have opportunities to improve their personal expertise in understanding nuances in LGBTQ+ issues.