Sexuality and Gender in Psychiatry: Ethical and Clinical Issues

The inclusive lesbian, gay, bisexual, transgender, and queer community (LGBTQ+) is a diverse and underserved population in the United States. The prevalence of mental illness among this population makes the ethical considerations surrounding evaluation and treatment for this population particularly compelling. Compared with their heterosexual counterparts, LGBTQ+ youths have higher rates of mental illness, including depression, suicide, anxiety, posttraumatic stress disorder, and alcohol and drug misuse, as well as preventable sexually transmitted infections (1). Elevated rates of mental illness may be attributed to the high degree of stress and discrimination faced by LGBTQ+ individuals compared with that of heterosexual and cisgendered individuals (i.e., those whose gender identity matches the sex assigned at birth) (2).

More specifically, the elevated prevalence that exists is likely attributable to persistent social stigma and discrimination that have been internalized by many individuals in this population. Both internalized and externalized homophobia and transphobia can contribute to problems with self-acceptance, anxiety, depression, forming intimate relationships, and being open about one’s sexual orientation (i.e., an individual’s innate attraction to members of the same sex, opposite sex, or both sexes) and gender identity (i.e., an individual’s identification as male, female, or other gender) (3). Therefore, it is paramount for mental health care providers to attune to this population.

Working with LGBTQ+ populations can be challenging for some providers in the field of psychiatry, given the amplified degree of vulnerability and intimacy that can exist in therapeutic relationships. Additionally, physicians and health professionals often have little to no formal training in human sexuality and gender identity, despite their important role in human development, psychology, and relationships (2). Nevertheless, psychiatrists, after educating themselves, should strive for open discussion of issues pertaining to gender and sexuality with their patients to develop a therapeutic alliance and normalize conversations surrounding these topics. In this article, I attempt to emphasize ethical guidelines when working with LGBTQ+ populations, with a focus on understanding and confronting common limits on expertise and scope of practice with working with LGBTQ+ patients.

The following case vignettes illustrate scenarios that may be encountered by psychiatrists treating the LGBTQ+ patient population. Relevant ethical aspects of the vignette are subsequently discussed, and suggestions are offered regarding pertinent opportunities to use the culturally and structurally competent psychiatrist’s skills for the patient’s benefit.

Case 1

An outpatient psychiatrist encounters the mother of one of his patients in the hallway of the clinic. The patient, a 19-year-old male who identifies as gay, had previously come out to his psychiatrist. At his last appointment, he shared he was thinking of coming out to his parents as well. The mother, visibly irritated, corners the psychiatrist in the hallway and begins to ask him numerous questions regarding her son’s psychiatric treatment. After responding that he is unable to answer questions about the patient’s direct care, the psychiatrist is then asked about the neuropsychiatric basis for homosexuality.1.1. What is the best response to the mother’s question?

•   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.

Case 2

Julia, a 22-year-old transfeminine patient with a psychiatric history of bipolar disorder I, follows up with a psychiatry clinic after a recent hospitalization for a manic episode. After discussing further changes in her medication doses, the patient visit wraps up, and she is scheduled to have a follow-up clinical appointment in one week. After Julia checks out of the clinic, she notices that male pronouns are used in the automated postclinic-visit summary provided to her by the front desk clerk.2.1. Which of the following interventions is LEAST likely to improve the patient’s likelihood of returning to the clinic?

•   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.

Answers

• 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.

Discussion

The preceding cases illustrate just a few examples of ethical quandaries encountered by the LGBTQ+ population when trying to access appropriate mental health care. Some of the psychological distress experienced in this population can be attributed to trying to hide one’s identity because of the safety concerns that some individuals may have (e.g., concern for the consequences of coming out and how this may affect their career) as well as the lack of culturally and structurally appropriate care. However, many individuals find that coming out, or revealing of one’s LGBTQ+ identity, often reduces anxiety (2).

Providers must be mindful of their biases regarding what constitutes “normal” human sexual behavior and forms of gender expression, which may compromise the therapeutic alliance. Utilizing psychotherapy to explore the etiology of the patient’s sexual identity, gender identity, or both may ultimately be distracting and unhelpful in exploring present stressors (6). It is also important for both trainees and supervisors to recognize the limits of their knowledge in working with the LGBTQ+ community and ask patients or more experienced colleagues for guidance, consultation, or supervision when needed. More information on commonly used terms that may be helpful to know when working with LGBTQ+ patients can be found in the appendix of the APA’s Textbook of Psychiatry (2).

Culturally and structurally competent health care, advocacy, and policy making can improve health disparities for LGBTQ+ youths (1). Examples of efforts in health care settings to establish themselves as sources of support for the LGBTQ+ community include intake and questionnaire forms that are LGBTQ+ friendly, marketing or branding of the clinical environment, and making available learning materials for culturally and structurally competent care for this population. In addition to modeling respectful interactions between patient and provider (as well as between providers), psychiatrists may refer parents of LGBTQ+ individuals to existing reputable resources for supporting their children (7). Overall, health care systems must evolve to meet the needs of the LGBTQ+ population.