October 11 is National Coming Out Day for people who identify as lesbian, gay, bisexual or transgender (LGBT).
This day is set aside to acknowledge the triumph and bravery of those who have come out as LGBT to themselves and their loved ones. Coming out is a never-ending process, not limited to a singular event or moment in a person’s life. Coming out can be an exhilarating and transformative process in the lives of LGBT individuals, but it can also be a source of frustration and loneliness as they attempt to explain their identity to the rest of the world.
The LGBT community frequently confronts prejudice and discrimination based on their sexual orientation or gender identity. This can lead to negative mental health outcomes, such as depression, anxiety and substance use. In some cases, it can lead to death, as evidenced by the startling number of youth who have suicided after facing anti-gay bullying from their peers. LGBT people are more vulnerable to feeling alone, unheard and ridiculed due to the societal stigma unfairly placed upon them.
Likewise, people who have mental health issues often encounter similar feelings of isolation and hopelessness. So for members of the LGBT community who also grapple with mental illness, a double stigma occurs.
According to the National Alliance on Mental Illness (NAMI),
“Some people report having to hide their sexual orientation from those in the mental health system for fear of being ridiculed, rejected or in extreme cases, subjected to physical violence.”
The Family Acceptance Project reports that LGBT people are less likely to seek timely treatment in healthcare settings for fear of provider bias and discrimination.
Unfortunately, this chronic stress within the LGBT population is not uncommon.
A 2003 study on the prevalence of mental disorders among LGBT adults found that they are likely to be at higher risk for depression, anxiety and substance use disorders. The likelihood that LGBT individuals have a mental health disorder doubles when compared to heterosexual men and women.
Yet another study found that lesbian and bisexual women were more than three times likely to have experienced generalized anxiety disorder within the previous year. Gay and bisexual men were more likely to report major depression and panic disorder.
The mental health profession has come a long way, but we have a long way to go.
Up until 1973, the Diagnostic and Statistical Manual of Mental Disorders, more commonly known as the DSM, listed homosexuality as a pathological psychiatric condition. But then, in the 1973 manual, the American Psychiatric Association changed the definition of sexual deviance and further rejected the notion that homosexuality was a mental disorder. A fascinating insider’s look at how this took place can be heard on NPR’s This American Life.
Since then, the DSM has gradually shifted its thinking on homosexuality. When homosexuality was removed from the manual, a new diagnosis, sexual orientation disturbance, was added to describe persons attracted to members of the same sex “who are either disturbed by, in conflict with or wish to change their sexual orientation.” In the fourth and most recent edition of the DSM, there is no reference to homosexuality as a mental disorder.
In the transgender community, the diagnosis of gender identity disorder is often needed in order to get medical services to transition from one gender to another. There is a growing movement that contests the classification of transgendered individuals as “disordered,” and a proposed change to the DSM-V, which will be published in 2013, would create a new category of gender dysphoria instead. While it’s still a contentious issue, many people in the transgender movement acknowledge that retaining a diagnosis in the DSM will make it easier to have mental health services covered by insurance.
So what can mental health professionals do to decrease the double stigma?
In order to provide competent care, it is crucial for healthcare professionals to ensure that the LGBT population can feel comfortable disclosing their sexual orientation or gender identity. Mental health agencies can establish cultural competency models that underscore the acceptance of and respect for the LGBT population. Acknowledge where changes can be made and work within the system to address those issues.
Mental health professionals can educate themselves on proper terminology and common concerns of their LGBT patients; families and friends can do the same. Don’t assume that an individual is a particular gender or sexual orientation because of how they dress or what types of previous romantic relationships they’ve been in. Recognize that being part of the LGBT community comes with its own stressors and be sure to empathize and validate those experiences – use your mentalizing skills! Honor their triumphs and joys. Sit with their sadness, as you would with any other patient.
Just as we make it a priority to establish a therapeutic alliance with patients, we should strive to provide an open and affirming place from the moment a potential patient enters our care. LGBT patients should feel safe to disclose their feelings about their sexuality and gender identity. If they don’t feel supported, they may not be able to fully engage in the treatment process. If an LGBT individual feels comfortable disclosing with mental health professionals, they’re more likely to share their experiences with their peers.
Cultural competency is a learnable skill. Let’s take it upon ourselves to make sure that all patients are welcomed and affirmed!