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.

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).

Engaging LGBTQ Individuals: Principles of Narrative Medicine

Narrative medicine is an outgrowth of medical humanities and bioethics. Narrative work in psychiatry strives to put biomedical science in perspective while keeping empathic and meaningful connections with patients at the center of psychiatric practice (21). Narrative psychiatrists recognize that the stories people tell about themselves not only describe their lives but also shape their lives. This life narrative scaffolds identity and meaning that help define the “self.” Patients who are able to shape and reshape this narrative in a more self-affirming and adaptive manner demonstrate less depression, less substance use, and fewer health issues (22).

The narrative understanding of mental health models is consistent with values-based practice (VBP). VBP assumes that all clinical decisions stand on “two feet”—facts and values. Although evidence may suggest one course of treatment, the final decision about the treatment plan depends on how the intervention lines up with the person’s life choices, life goals, and narrative identity (23). This philosophy and treatment method aligns with the essential empathic therapeutic connection required in the treatment of LGBTQ individuals. The narrative life story helps identify how the individual integrates experiences to create a sense of meaning and coherence. It explores where they have been and where they want to be, and it allows a retelling of the narrative in a self-affirming, motivating life trajectory (22).

Clinical Vignette

Morgan handed the initial intake questionnaire back to the receptionist and took a seat, looking disgruntled—with leg bouncing and nail-picking. Morgan had been in psychotherapy for 3 years since starting college, but this was the first psychiatry evaluation for medication. The therapist felt that Morgan was depressed and anxious and that medication would help. Morgan agreed but was suspicious of psychiatric care. “Will they just try to ‘drug’ me? Will they be critical or condescending?” Morgan pondered. By the time Dr. Jayne entered the waiting area and called Morgan to the office, Morgan was feeling uneasy.

“Hello, Ms. Johnson,” Dr. Jayne said, smiling pleasantly and showing Morgan to the office.

“Actually, I prefer the pronoun ‘they,’” Morgan said resolutely.

“Oh, yes, I see that you crossed out ‘male or female’ and wrote in ‘they,’” Dr. Jayne said agreeably, reviewing the intake form. “Oh, I notice in your medical record you are ‘Mary Johnson.’ Is ‘Morgan’ a nickname?” Dr. Jayne inquired.

Morgan frowned. “Does it still say ‘Mary’? I legally changed my name—it should say ‘Morgan.’”

Dr. Jayne typed something into the electronic medical record and then picked up the intake clipboard and scanned the page. “Oh, I see that you are married to Steven. Do you have children?” she inquired.

“No, my partner is Stephanie. She hasn’t gotten a chance to change her name yet. It’s expensive, you know,” Morgan replied curtly.

“So, is Steven a woman?” Dr. Jayne asked, trying not to appear perplexed.

“Stephanie is trans. She’s a woman,” replied Morgan curtly. “And, no. We don’t have children. Neither of us want them. At least not now. We might adopt in the future. I’m ace.”

“Ace?” Dr. Jayne inquired, the pretense of understanding discarded.

Morgan did an eyeroll in exasperation. “You know—ace. Asexual?”

“Oh, yes, of course,” Dr. Jayne answered, perceptively blushing.

Dr. Jayne was cognizant that Morgan appeared frustrated and upset. She gazed pensively out the window and took a deep breath. When she turned back to look at Morgan, her demeanor was transformed.

“Morgan, I realize that I have been insensitive. I’m very sorry. I obviously have upset you, and I’m upset with myself for not being more open about who you are—you know, as a person.”

Morgan’s eyes widened in surprise. “Well, I’m sorry I was upset with you,” Morgan replied instinctively.

“No, Morgan. I’m the one who needs to be sorry. If you will give me a second chance, can we start over?” Dr. Jayne implored.

“OK,” Morgan replied, agreeably.

Dr. Jayne swiveled 360° in her chair. When she was again facing Morgan, she smiled and started introductions again.

“Hello, Morgan. I’m glad to meet you. My name is Dr. Patty Jayne. I see that you prefer the pronoun ‘they.’ Your medical record uses the name ‘Mary.’ Can you tell me a little bit about your life journey so that I can understand you better?”

Dr. Jayne and Morgan burst out in laughter at Dr. Jayne’s performance. “You have taught me something, Morgan,” Dr. Jayne said, her face turning serious. “I aspire to be open-minded and nonjudgmental. Sometimes, unconscious bias comes through anyway. Thank you for helping me address this.”

After the assessment, coconstructing a treatment plan, discussing medication options with benefits and potential adverse effects, creating a safety plan and communication methods, and agreeing on a plan for collaboration between Morgan and their therapist, Dr. Jayne smiled warmly at Morgan. “I look forward to working with you, Morgan,” Dr. Jayne said earnestly.

“And I look forward to working with you, too!” Morgan said theatrically. They both burst out in laughter as Morgan left the office.

Tips for Addressing Treatment Engagement With LGBTQ Patients

LGBTQ and gender-nonconforming individuals often present to the psychiatrist’s office with a history of discrimination and insensitivity by health care providers (13). Suspiciousness, difficulties forming a trusting therapeutic relationship, and ambivalence about treatment recommendations are logically expected. Despite a philosophy of impartiality, psychiatrists suffer from unwanted unconscious bias (15). This needs to be acknowledged and continually addressed to provide the best quality of care to all patients.

In the earlier vignette, Dr. Jayne was committed to an open and accepting therapeutic relationship with her patients. She was embarrassed and distressed by her missteps of language and attitude when working with a gender-nonconforming patient. Her ability to self-reflect, acknowledge her missteps, apologize, and “do better” allowed Morgan to authentically connect—with Dr. Jayne’s openness, humanity, commitment, and caring. Dr. Jayne reoriented to the patient’s life journey narrative to negotiate the impasse.

Psychiatrists are wise to acknowledge that all human interactions, including prescribing medicines, involve human meaning and narrative choices. This is thought to explain the placebo effect of medication effectiveness. Common factors of relationship, rapport, and respect are often critical for good outcomes in pharmacotherapy. Ongoing curiosity and interest in the patient as a person may be the one of the “best medicines” at the psychiatrist’s disposal (24).

The following are tips for providing compassionate care to LGBTQ patients:

1. Appraise the clinical environment. Is it welcoming to all patients? A rainbow sticker on a window where patients may see it can be affirmative for LGBTQ patients. Single-use restrooms can be designated gender neutral. Ensure that intake forms and demographic information in the medical record include multiple gender choices and designate the patient’s preferred pronoun.

2. Consider that building security and reception staff, as well as clinicians, benefit from ongoing educational efforts to provide a welcoming environment to all patients. The use of gender-neutral language and cultural sensitivity enhances comfort and increases the likelihood of patients returning.

3. Inquire about what motivated your patient to seek psychiatric care now. Narrative inquiry is often an optimal method of demonstrating a genuine curiosity in the patient’s life story. Asking what the patient hopes the treatment will achieve begins the narrative. Open-ended questions help chronicle the patient’s “life story.” Underscore the importance of stories for clinical meaning-making and how each patient’s unique narrative sets the stage to determine the trajectory in which they want their lives to proceed.

4. Explain the concept of VBP—in which decisions are determined on the basis of medical “facts” as well as patient values. It is helpful to reassure patients that their values matter and that they are equal partners in making decisions about their care.

5. Consider that many LGBTQ individuals have suffered discrimination and humiliation in the community, even from those meant to provide care. Address this and explore together how to engage most productively.

6. Let your patients teach you. Even if you are an LGBTQ psychiatrist, each person’s life narrative and identity is unique. For psychiatrists who are less practiced at working with the LGBTQ population, acknowledge when you have made a pronoun error or have demonstrated implicit bias and when you have been insensitive. Patients (and all people) respond to authenticity. Mistakes can be forgiven in the context of a physician who authentically cares about the person.

7. Consider whether medication may be indicated for treating psychiatric symptoms. Explore the meaning of the medication, in addition to discussing risks and benefits, in the informed consent process.

8. Address barriers to treatment. Inquire about impediments to treatment adherence and engagement, such as insurance limitations, financial struggles, lack of transportation, privacy concerns, and many others. Address these through case management and other resources.

9. Work on safety planning. Even if suicidality is not the presenting complaint, epidemiology data suggest that LGBTQ individuals are at higher probability for risk-taking behaviors, depression, substance abuse, and suicide attempts. Making and reinforcing a safety plan at each meeting helps seal the alliance and may improve help-seeking if they experience impulses for self-harm.

10. Continually help the patient reconstruct their personal narrative in a self-affirming manner. Promote activities and creative outlets that enhance well-being.