Interest in Identity: Improving LGBTQ Psychiatric Care

Psychiatry has a long, tortuous history of attempts to develop a coherent theory of homosexuality and gender identity. The early psychoanalytic community viewed homosexuality as pathological, with attempts at therapeutic “cures.” In 1952, homosexuality was diagnosable in the DSM-I as a “sociopathic personality disturbance.” This was followed in 1968 by the DSM-II diagnosis of “sexual deviation” (1). Mental health professionals attempted to “cure” this “disorder” through conversion and realignment treatments, which did not demonstrate effectiveness in altering sexual orientation and often led to serious negative consequences, such as greater rejection, depression, use of illegal drugs, risk-taking behaviors, and suicide attempts (2). By 1973, homosexuality was removed from the DSM-III as a psychiatric disorder (1). The American Psychiatric Association, the American Psychological Association, and many other organizations have denounced the practice of conversion therapy as unethical (3). Twenty states and Washington, D.C., plus multiple municipalities have passed laws making it illegal for licensed clinicians to practice conversion and realignment therapies on minors (4). Despite these admonitions, it is estimated that 20,000 lesbian, gay, bisexual, transgender, and queer (LGBTQ) youths, ages 13–17, will receive conversion therapy from a licensed health care professional before they reach the age of 18. Three times that number will receive conversion therapy from religious or spiritual advisors (5). Adults seeking conversion therapies often struggle with conflicts between their internal experience of identity and the family and religious community affiliations that designate homosexuality as sinful (6).

LGBTQ individuals suffer discrimination, verbal abuse, bullying, and even physical assaults at a significantly greater level than that of their heterosexual counterparts (7, 8). Many individuals in the LGBTQ population have experienced trauma and rejection, and some have been denied health care (9). Discrimination toward the LGBTQ population may be overt, subtle, or even subconscious. Physicians are not immune to this discrimination.

Evidence suggests that subtle ways in which doctors communicate disapproval may negatively affect interaction with and health outcomes of LGB patients. One way in which doctors communicate disapproval is through heteronormativity, or the assumption that everything is normally and naturally heterosexual. (10)

For example, much of the demographic information gleaned in health records utilizes heteronormative language. Simple items for collecting demographic data, such as prompts to designate “sex,” usually referring to the binary male or female, are stigmatizing for individuals identifying as nonbinary. LGBTQ individuals are less trustful of physicians who use heteronormative language (11). These patients typically disclose less personal information. Lack of disclosure and trust may prevent patients from getting needed care and prevent doctors from giving the best health advice possible (12, 13). Individuals who are highly conscious of subtle (and not-so-subtle) stigma toward sexual orientation have demonstrated high levels of depressive and other mental health conditions (14).

Heteronormativity may be considered one aspect of implicit bias. Implicit biases involve associations outside conscious awareness that lead to negative evaluation of a person based on irrelevant characteristics such as race, gender, and sexual orientation. Research on implicit bias suggests that all people exhibit some level of unconscious bias and stereotyping (15). Health care professionals exhibit the same levels of implicit bias as those within the community. Correlational evidence indicates that biases are likely to influence diagnosis and treatment decisions. Implicit prejudice and stereotyping may also affect recommended levels of care. Lack of attention to the implicit bias leads to an exacerbation of health care and access disparities for LGTBQ patients and those in racial-ethnic underserved minority groups (16).

LGBTQ individuals face disparities in mental health treatment, but they also utilize psychological services at greater rates than those of their heterosexual cisgender counterparts (17). Gay, lesbian, and bisexual adolescents appear to be at higher risk for substance abuse, suicide, depression, and school dropout and higher risk sexual behavior than their heterosexual counterparts (18). Gay and lesbian youths who have been rejected by family or who have run away because of homophobia are at an even higher risk, with a suicide attempt rate at 8.4 times that of nonrejected LGBTQ youths. Homeless youths are at substantial risk for a multiplicity of health, social, educational and mental health problems (5).

Health conditions, mental health conditions, and substance abuse disorders may be mitigated by sensitive and appropriate treatment interventions (19). However, studies suggest that LGBTQ patients often find communication with physicians and other health professionals to be difficult. Fears of discrimination or recrimination are common. The provider capacity to listen to and treat patients with respect is enormously important to treatment engagement, adherence, and life change. This has increasingly become a challenge, given the growing diversity of health consumers, the increasing complexity of many health interventions, and continuing pressures to limit time with patients (19, 20).