(p. 131) Lesbian, Gay, Bisexual, and Transgender Factors in the Process of Acceptance of Mental Illness
Lesbian, gay, bisexual, and transgender (LGBT) individuals with mental illness are uniquely affected by stigma, interfering with recovery from mental illness (Hellman & Klein, 2004; Lucksted, 2004).1 The double stigma of mental illness and LGBT identity may pose barriers to the process of accepting mental illness, an essential component of recovery (Deegan, 1996; Ridgway, 2001; Spaniol & Gagne, 1997). There is a general lack of research, however, on LGBT individuals with mental illness, despite the need for further study of recovery among this group (Hellman & Klein, 2004; Lucksted, 2004).
Research has found an increased incidence of depression, anxiety, bipolar disorder, post-traumatic stress disorder (PTSD), substance use, and suicidality among LGBT individuals (de Graaf, Sandfort, & ten Have, 2006; Gilman et al., 2001). LGBT people tend to have an earlier onset of mental illness than their counterparts and higher rates of major depression and bipolar disorder (Hellman, Sudderth, & Avery, 2002; Kidd, Veltman, Gately, Chan, & Cohen, 2011). They may experience increased risk of comorbid psychiatric disorders, complicating treatment and prognosis (Hellman et al., 2010).
LGBT youth, in particular, have been found to experience high rates of psychological disorders and suicidality as a result of stigma (Mustanski, Garofalo, & (p. 132) Emerson, 2010). Mental health problems in the LGBT community have attracted an increasing amount of attention due to media coverage of high levels of suicidality among youth who are bullied and harassed for their sexual orientation and gender expression (Mustanski et al., 2010). Although many studies focus on suicidality among LGBT youth, there is evidence that the proportion of LGBT youth with any mental illness is also higher than in heterosexual and gender-conforming populations. Victimization due to LGBT status has been found to mediate this relationship between LGBT identity and psychosocial adjustment (Toomey et al., 2010). In other words, the psychological distress among LGBT individuals may be worsened by the increased risk of homophobic and transphobic violence and abuse.
Meyer’s (2003) minority stress model explains the impact of LGBT-related stigma on mental health, as illustrated in Figure 9.1 Stigma has been linked to higher incidences of mental disorders, victimization, and discrimination (Mustanski, Garofalo, & Emerson, 2010). LGBT individuals face higher rates of discrimination and violence than sexual and gender dominant groups (Hellman et al., 2010; Kidd et al., 2011; Mizock & Lewis, 2008). One study found reports of discrimination among individuals with mental illness were highest among LGBT individuals (Corrigan et al., 2003).
LGBT individuals who encounter stigma may internalize the stigma, directing prejudice inward (Hellman & Klein, 2004). This experience is referred to as internalized stigma, also known as internalized homophobia, internalized transphobia, or more broadly, self-stigma. Internalized stigma among LGBT groups may further worsen attempts at socialization and functioning and interfere with quality of life, contributing to a negative sense of self (Hellman & Klein, 2004; Kidd et al., 2011). LGBT individuals with mental illness also may encounter double stigma—the dual prejudice encountered by holding multiple marginalized identities. Double stigma among LGBT individuals with mental illness may inhibit disclosure of mental health problems, interfering with access to rehabilitation services that promote recovery (Cook, 2000).
Stigma can contribute to financial and social difficulties, which can be compounded for people who are both LGBT-identified and diagnosed with a mental illness. Barriers to employment, insurance, family financial support, and partner benefits in many states creates financial stress, worsening mental health (Hellman & Klein, 2004). Individuals with mental illness may become alienated (p. 133) from the rest of the LGBT community, and the reverse may also occur, reducing the social support needed to facilitate acceptance of mental illness (Hellman & Klein, 2004). People with mental illness rely on family members for practical and emotional support, increasing stress for LGBT individuals who have been rejected by family members (Lucksted, 2004). LGBT individuals with mental illness also report barriers to dating and finding a life partner due to hospitalizations in early adulthood (Barber, 2009). Double stigma faced by LGBT individuals with mental illness interferes with relationship-building and social functioning, increasing isolation (Kidd et al., 2011).
Lesbian, Gay, Bisexual, and Transgender Stigma in Mental Health Settings
LGBT individuals with mental illness express less treatment satisfaction and report experiences of discrimination within mental health settings (Hellman, Sudderth, & Avery, 2002; Kidd et al., 2011). Clinical rapport with LGBT individuals with mental health problems is often disrupted by clinical bias (Hellman et al., 2010). Clinician bias has been found to interfere with LGBT clients’ acceptance, trust, and participation in outpatient, inpatient, and emergency mental health services (Ziguras et al., 2003). Lucksted (2004) described how people with mental illness are often desexualized and dehumanized in treatment settings. As a result, LGBT identities among individuals with mental illness are often overlooked. There may be silence around LGBT identity in the mental health system due to a history of mistreatment, as well as a lack of knowledge and training among providers. Staff may condone transphobia or homophobia by ignoring or not acting upon it, requiring LGBT individuals to be hypervigilant about stigma in the mental health system.
LGBT individuals with mental illness may encounter a number of unique barriers in the mental health system (Lucksted, 2004). They may feel unwelcome by other participants in mental health settings often experienced as “heterosexual institutions” (Hellman & Klein, 2004). They may encounter further heterosexism, homophobia, and transphobia in these settings, reducing openness and feelings of safety (Hellman & Klein, 2004). Transgender individuals, in particular, also have reported alienation by LGB peers in treatment settings, with low numbers of transgender individuals being reported in these programs due to reluctance to participate for fear of peer ostracization (Hellman & Klein, 2004; Hellman et al., 2010).
Transgender and Gender Nonconforming Groups
Transgender people face increased stigma and psychological stressors compared with those of sexual minority groups and their cisgender (non-transgender) peers. The term transgender refers to those individuals whose biological sex does not match their internal sense of gender identity and gender expression. Unlike LGB groups, transgender status corresponds to one’s gender identity as opposed (p. 134) to sexual orientation. These groups are often conflated, however, overlooking important differences in the life experience of transgender individuals (Mizock & Fleming, 2011).
Transgender individuals may experience significantly elevated rates of stigma (Kidd et al., 2011). According to one survey of transphobia encountered by transgender participants, 73% reported being made fun of for being transgender, 39% had been turned down for a job for being transgender, and 24% reported being harassed by the police for being transgender (Longman Marcellin, Scheim, Bauer, & Redman, 2013). Meyer’s minority stress model (2003) was adapted to explain the impact of transphobia on psychological distress and high-risk coping (e.g., substance use, eating issues) in the gender minority stress model (Hendricks & Testa, 2012).
For example, transgender people face increased risk of mental health problems compared with cisgender individuals. According to one study, 20%–50% of male-to-female (MTF) transgender people experienced a major mental illness and 26%–62% reported a history of substance abuse (Nuttbrock et al., 2010). Eating disorders and body image disturbances, as well as anxiety and depressive disorders are also higher among this population compared with the general population (Nuttbrock et al., 2010; Vocks, Stahn, Loenser, & Tegenbauer, 2009). The lifetime prevalence of attempted suicide among transgender individuals has been estimated at an alarming rate of 32% (Clements-Nolle et al., 2006). These rates of psychiatric distress and mental illness have been largely attributed to societal stigma, including factors such as peer bullying, family rejection, and abuse history (Leibowitz & Telingator, 2012).
A controversial diagnosis of gender dysphoria (American Psychiatric Association [APA], 2013), formerly gender identity disorder (APA, 2000), continues to identify many transgender individuals as having a mental disorder. The DSM-5 diagnosis of gender dysphoria includes symptoms of persistent discomfort with one’s biological sex, significant distress, and/or impairment in functioning. Although including gender dysphoria in the DSM may support insurance reimbursement for gender-related care, many feel that inclusion of this diagnosis continues to pathologize transgender individuals.
Transgender individuals, in particular, have reported feeling a burden to educate their healthcare providers, who are rarely educated on transgender care, taking these transgender clients out of the patient role and putting them into the educator role (Lucksted, 2004; Mizock & Lewis, 2008). Although at times this role may be empowering for the client, it can take attention away from one’s own treatment. In addition, providers may evaluate the wellness of transgender individuals based on their identification with their birth gender.
In spite of challenges and stigma encountered by LGBT individuals, there are vast strengths and sources of resilience within these communities, which have been found to help in coping with stigma. One study found identity pride, sense of self-worth, acceptance from others, and supportive peers and community to be vital sources of resilience among gay and bisexual youth (Harper, Brodsky, & Bruce, 2012). Other research has found activism, hope, spirituality, and (p. 135) awareness of stigma to be key resilience factors among transgender individuals in particular (Kosenko, Rintamaki, Raney, & Maness, 2013; Singh, Hays, & Watson, 2011). Not only may these strengths be instrumental in coping with and reducing internalization of stigma, they may potentially benefit the acceptance process. The link between resilience factors and acceptance of a mental health problem among LGBT individuals deserves further exploration.
The literature suggests a gap in research on the process of acceptance of mental illness for LGBT individuals with serious mental health problems. Little is known about the process of acceptance of mental illness for LGBT individuals who face a number of barriers related to LGBT and mental illness-related stigma. This next section features three case narratives from our research presented to explore factors in the acceptance process in the narratives of LGBT participants with serious mental illness. The case narratives include a presentation of the person’s LGBT background and mental illness narrative, definition of the acceptance process, and the description of barriers and facilitators to the acceptance process.
“AJ” is a transgender individual who uses a male pronoun, is biologically male, in his early twenties, and alternatively identifies his gender identity as transgender, genderqueer, and male, and his sexual orientation as gay or queer. Genderqueer is an identity often included under the transgender umbrella to refer to individuals whose identity does not align with binary notions of gender and who identify with neither, both, or a combination of male and female genders.
During his first month of college, when AJ was 18 years old, he was diagnosed with bipolar disorder with psychotic features. Before his diagnosis, he felt he could do anything. “On my blog I wrote down that I thought I could take over New York City, like I would be the next huge fashion designer.” Once he received his diagnosis, this plan changed. “It not just brought me down to earth, but made me feel subterranean. Like this leech off the society.” Although his parents were somewhat accepting of this diagnosis, they often interpreted any change in his mood as a symptom of his disorder. He described feeling limited and even trapped by the mental illness label, unable to escape the diagnosis and associated stigma.
AJ preferred to refer to his experience of bipolar disorder as, “… panpolar. I’m not just bi, I’m pan. I’m either manic or depressed or somewhere in-between. Panpolar with severe passion … It doesn’t sound so linear. It’s more cyclical… .” This terminology around mental health also was reflected in his experience of gender. “I feel the same way about gender. I don’t feel like I’m fully a man. I feel like I’m somewhere between man and trans. So that’s why I think of myself as genderqueer.”
(p. 136) AJ also described how his mental health experiences inform his thoughts and feelings around his gender identity: “I’ve been through so much … that I don’t really care what people will think of my gender. That’s such a minor thing.” However, AJ had encountered problems related to double stigma. He described one scenario where he was forcibly institutionalized for erratic public behavior involving unusual dress. During that incident, the emergency medical technicians were amused by his clothing and took pictures of him without his consent before they brought him to the hospital. On another occasion, one of the security guards at the hospital teased him for being gay. AJ described these multiple experiences of stigma surrounding his mental health, sexual, and gender identities as significant barriers to accepting his mental illness.
AJ indicated that he has come to accept his mental health problems. He stated that at times, “I feel like I’m just a person that’s flawed, mentally … It’s also a gift, but it’s definitely a flaw because of how extreme it can get … I feel like I have a positive view of myself at this point, but it took a while to get there.” He defined acceptance as: “knowing that you’re living with it, and trying to reach your goals despite your flaws,” as well as finding a way to “build a bridge and get over it.” Some facilitators to accepting his mental health problems included journaling and monitoring his symptoms, as well as his aforementioned development of preferred terminology for his mental health experiences. He described barriers to acceptance of his mental illness to include stigma from mental health providers, family members, and the loss of friendships. In the end, AJ came to accept his mental illness through the use of creative coping activities such as journaling and art, as well as creating his own language to capture his mental health experiences accurately and with self-affirmation.
“Allison” is a lesbian-identified, cisgender woman in her thirties who was diagnosed with double depression in college. Double depression involves a depressive episode superimposed on a preexisting Persistent Depressive Disorder, formerly Dysthymic Disorder. Allison has received many other diagnostic labels over the years, including Borderline Personality Disorder, but her current, working diagnoses are PTSD and Schizoaffective Disorder. Allison’s symptoms dramatically worsened several years prior to the present interview, when she began to hear voices in the cubicle next to her at work. Allison lost her job in journalism and was hospitalized several times that year for suicidality and severe depression, feeling her personality was forever changed. In addition to the loss of her career and her wife, she believed she also lost friends because, “mental illness as a whole affects the way people look at you, and that can be huge.”
Allison recounted significant mistreatment in the mental health system based on her mental health and sexual identity. She described being mislabeled with borderline personality disorder as “traumatic” because of the stigma associated (p. 137) with this label: “One of the reasons they said that I had borderline personality disorder was because I was given a psychiatric test by a really cute young woman my age, and I thought she was cute, and I was asking her a few questions about herself. And anyway, they said that I was paying too much attention to her, and that was a symptom of borderline personality disorder. I was like, ‘I’m just gay and lonely.’ ” Another incident of mistreatment occurred during an inpatient stay. “I had a doctor who flirted with me when I was in the psychiatric hospital and was like, ‘If I were your age, I would go out with you.’ … He just told [my parents] I needed a good boyfriend, and that I wasn’t really gay.”
Allison believes her dual coming out process and first episode of psychosis contributed to her mental health symptoms being initially dismissed by her providers. In one scenario, her mental health problem was attributed to her sexuality: “Some of the doctors were like, ‘Oh, what would you do if you thought that you didn’t have everything figured out by the time you were 21, you’d check yourself into a mental hospital?’ … It wasn’t all an identity issue at all. It was my first bad bout with mental illness.”
She described another incident of mistreatment: “I was coming out as gay at the same time as I was going through my first severe onset of mental illness when I was in college, and all that got tangled up with these sort of conservative Southern doctors. I lived in Kentucky at the time, and I had a doctor who told me that there were scientific studies that showed that if I killed myself I would go to Hell … I thought that was a horrible thing to tell a patient.” Allison also described feeling treated like “a mental patient” by both her primary care physician who was no longer as willing to engage with her during appointments, and by her ex-wife, who she felt was unable to see Allison as a “human being” after her diagnoses.
Allison defined acceptance as having both negative and positive connotations for her. The negative side included, “that I feel like I’m not going to go for as challenging of a career in order to have a little less stress in my life, or a lot less stress in my life. But the positive side of acceptance would be sort of being kind and realistic about my mental state right now, and not putting myself in so much turmoil.” She described feeling more work was needed to facilitate her acceptance process: “Something is different now in my brain. It feels different. I feel more fragile. So, it’s just something I’m really struggling with. It’s probably some middle ground is where I have to have some compassion for myself, and yet understand that I do have to try to get over the fear of stress.” Allison described some of the facilitators to her acceptance of mental illness as finding a supportive community and church, as well as attending a therapy group and psychosocial rehabilitation center. Barriers to acceptance included the denial of her mental illness by her family members, the negative prognosis of her schizoaffective diagnosis, as well as a sense of loss of her professional identity and self-worth. Ultimately, Allison came to accept her mental illness by connecting with these various supportive communities and accessing mental health resources where she was treated fairly, without stigma or prejudice.
(p. 138) Case 3—Adam
“Adam” identifies as a transgender, heterosexual male in his sixties. He is biologically male and at times presents as female, preferring the general use of a male pronoun. Adam’s working diagnosis is bipolar disorder, although he has received many diagnoses over the years. He received his first diagnosis of obsessive-compulsive disorder at age 17 when seeking an exemption from the draft during the Vietnam War. Adam received a number of different mood disorder diagnoses at the time, which led him to question their legitimacy. As a result, he did not seek professional help following other bouts of depression. In his thirties, Adam was hospitalized for the first time for a suicide attempt. Given ongoing physical and mental health issues, Adam and his fiancé separated. He stated, “I really did not expect, at 50, something from my life to be like this. A lot of just letting go of stuff … kids or a place to live and a career that works.”
Adam described his gender identity as being more androgynous than male or female, preferring a self-ascribed term of “gender chameleon.” Adam indicated that he is not necessarily accepted in the transgender community because of his unique identification: “I even disturb some people in the trans community sometimes because I don’t fit … a style that certain folks fit into … I thought it would be more freedom of expression in the people that left the gender binary constraints. But it seems like there are just new classifications, new communities … that define themselves as separate from each other.” Adam also described a lack of interest in and acceptance of his gender expression and identity by his therapists, which sometimes led to inaccurate or misleading reports. For example, Adam recalled feeling his makeup was described in disparaging terms in one provider’s report, leaving him to feel exotified: “… like I was being described as a biological entity or something.”
Adam discussed how the term, “gender chameleon,” allowed him the freedom to make his gender as important to his daily life as he chooses. For example, on one outing he was heckled by a man who stood in Adam’s way and would not let him pass. “I’m totally in girl mode and some little punk wants to mess with me and I just, I didn’t say anything. He just got in my way and I just sort of like turned a shoulder and banged right into him and kept walking. I didn’t say anything because I knew what he was up to. So that’s totally male. That’s not the way a girl would deal with it, unless she was pretty tough.” Adam indicated that his “gender chameleon” identity allowed him to adjust his gender expression in response to safety and stigma in the external environment.
When asked to define acceptance of mental illness, he replied: “First of all, accepting that I have to take as much medicine as I do, and when I’m supposed to, indefinitely, and … to know that that’s just the truth … I can’t do anymore what I used to be able to do.” One facilitator to his acceptance was his development of the term “mind disorder” to refer to his mental health problems as opposed to the term “mood disorder.” He explained, “It’s bigger … A mood disorder is easier to equate with some kind of weakness … The mood thing can get a little bit played wrong, or the thing, ‘Oh everybody feels sad sometimes.’ Well, (p. 139) yes everybody does but not for like six months at a stretch.” He described the primary barriers to acceptance of mental illness to include mistreatment in the mental health system due to mental illness and LGBT-related stigma, multiple misdiagnoses, and the loss of relationships, such as that with his fiancée. In due course, Adam came to accept his mental illness through a positive alliance with a psychotherapist, learning about the nature and effective treatment of his mental health condition, as well as developing affirmative ways of speaking about and understanding his mental health problems.
Understanding Acceptance for Lesbian, Gay, Bisexual, and Transgender Populations with Serious Mental Illnesses
A number of experiences of double stigma of mental illness and LGBT identity were encountered within this group and are summarized in Table 9.1. These factors can be grouped into identity factors, relational factors, and systemic factors. Within the identity factor, barriers were related to language and stigmatizing diagnostic labels. Identity-related facilitators to acceptance included developing preferred terminology and self-defined language. Examples of such terms included “panpolar,” “mind disorder,” or “gender chameleon” to affirm the unique LGBT and mental health experiences of the participants. This was a notable finding in the present study. This facilitator highlighted the importance of creating one’s own language to capture one’s unique understanding, experience, and meaning associated with this terminology. Other identity-related barriers included the loss of professional identities that interfered with acceptance of mental illness. The affirmation of positive LGBT identities facilitated acceptance of mental illness.
Table 9.1. Factors in the Acceptance of Mental Illness Among Lesbian, Gay, Bisexual, and Transgender Participants
In the category of relational factors, key facilitators included the development of social and mental health supports that were free from stigma. Social barriers (p. 140) included the stigma toward mental illness and LGBT identities encountered in the family and in the mental health system, and the loss of relationships. In the category of systemic factors, the barriers included mental health systems that were stigmatizing of LGBT and mental illness identities. Facilitators within the systemic level included mental health systems that were affirmative of LGBT identities and avoided stigma toward mental illness.
These findings can be explained in terms of the impact of stigma on the acceptance process of individuals with mental illness, compounded by the double stigma of LGBT and mental illness identities and the associated derogatory terminology. LGBT individuals with mental illness, therefore, may particularly benefit from feeling empowered to develop affirmative language to characterize their unique mental health and LGBT identities. Given the compounded loss of relationships, work identity, and increased prejudice experienced due to LGBT and mental illness related stigma, having the power to define one’s own identity and mental health status and to overcome losses through the addition of new social and mental health supports may be particularly significant for LGBT individuals with mental illness.
The participants described experiences of stigma in the mental health system, sometimes receiving multiple pathologizing diagnoses. In addition, their mental health problems were sometimes attributed to their LGBT identities. These encounters with stigma served as key barriers to their acceptance of mental illness, adding to the losses of work and relationships associated with mental illness-related impairment. One’s ability to accept and understand one’s sexual or gender minority identity appears to facilitate the acceptance of mental illness. A heightened awareness of homophobia and transphobia in the mental health system also appeared to support acceptance of one’s mental illness.
This study confirmed several findings in the extant literature. It is common in mental health settings to consider gender variance as a symptom of an individual’s mental health problems (Mizock & Fleming, 2011). As reflected in these narratives, mental health professionals often attribute a mental illness to one’s sexuality or gender variance (Kidd et al., 2011). Once in the mental health system, sexual and gender minority individuals may face misunderstandings and mistreatment from other patients and staff (Lucksted, 2004), as evidenced by the present case narratives. These findings also confirmed research from another branch of this study that community acceptance was central to one’s self-acceptance of mental illness, with barriers to self-acceptance being the double stigma imposed by mental health providers and community members (Mizock, Russinova, & Millner, 2014).
Findings related to the importance of language and identity development in facilitating the process of acceptance of mental illness correspond to literature on sexual and ethnic identity development. Research on gay identity development has found that higher levels of well-being may be reported at later stages of gay identity development, when the final stages of “Identity Pride” and “Identity (p. 141) Synthesis” take place (Cass, 1979). Similarly, the present dataset found that acceptance of mental illness was facilitated by a strong sense of LGBT identity and awareness of stigma. Ethnic identity development literature also has found that having a strong, positive ethnic identity among marginalized ethnic groups can serve as a protective factor for anxiety, depression, and substance abuse (Williams, Chapman, Wong, & Turkheimer, 2012).
A positive sense of ethnic identity has been identified as a protective factor in the impact of marginalization on factors such as academic achievement and general coping with stigma (Umaña-Taylor, Wong, Gonzales, Dumka, 2012). Likewise, a positive sense of LGBT identity may serve as a protective factor in the impact of mental illness stigma among LGBT individuals and may help to facilitate acceptance of mental illness. Therefore, the ability to form a positive sense of LGBT identity in the face of homophobia and transphobia may facilitate acceptance of mental illness and positive identity development surrounding one’s mental health experiences, and may reduce the impact of stigma on psychiatric symptoms and maladaptive coping, such as substance abuse. Future research might investigate further the potential associations reflected in these participants’ narratives.
Applications to Clinical Work
A number of clinical implications follow these findings. For one, there is a clear need for increased training of health professionals in the area of LGBT mental health to reduce stigma and discrimination, which may be intentional or unintentional. Therapists should inquire about the gender and sexual identity of people with mental illness to ensure holistic care and investigate any potential experiences of stigma that might need to be addressed. Clinicians should avoid attributing mental health symptoms to LGBT identity, but might consider the effects of stigma on psychological distress.
Clinicians can work with LGBT individuals with mental illness to increase social supports and develop affirmative community and vocational identities in the face of stigma-related losses in these areas. Using language that is stigma-free can be another important element of culturally sensitive care for LGBT individuals with mental illness. Investigating the person-specific definitions of acceptance of mental illness may be helpful to this process, as well as working with individuals with mental illness to identify positive definitions of acceptance of mental illness (as opposed to notions of “giving up”) in order to promote recovery.
Given the unique obstacles facing those who are LGBT-identified and have a mental illness, it is important that clinicians be sensitive to their treatment needs. Clinicians can take a sexual and gender history among individuals with mental illness to ensure increased awareness of stigma and address this in their mental health care (Barber, 2009). A strengths-based, self-determination (p. 142) approach to care also can heighten trust and participation in mental health services (Hellman et al., 2010). Cook (2000) has called for the psychiatric disability community to “stand solidly in support of this group’s right to sexual self-determination and expression of sexual identity” (p. 203). This intention also should be applied to issues of gender identity in the case of transgender individuals. LGBT clients should be made aware of their rights in the context of mental health settings and be supported in taking action against experiences with transphobia and homophobia. Providers themselves can engage in advocacy and activism to reduce the stigma encountered in the broader public by LGBT people with serious mental illness.
Some specialized services for LGBT people with mental illness exist (Hellman et al., 2010) and more need to be developed. Mental health agencies can make LGBT clients more comfortable through the coordination of LGBT mental health support groups, couples and family therapy, referrals to safe community services, staffing openly LGBT professionals within these agencies, and coordinating LGBT pride events (Israel et al, 2008). Inpatient staff should consider appropriate discharge planning for shelters, day programs, and other rehabilitation services and resources that are inclusive and sensitive to LGBT individuals. Inpatient staff can implement a no-tolerance policy for transphobia and homophobia among peers and other staff members to reduce encounters with stigma in inpatient settings. Consultation and supervision of staff by providers with LGBT expertise can help to ensure that the treatment environment is affirming of LGBT identities, as can ongoing surveys of LGBT-client satisfaction.
LGBT people with serious mental illness face a number of barriers and facilitators to the acceptance process, largely related to double stigma. People with serious mental illness from a variety of LGBT backgrounds can be supported in drawing from awareness of stigma to identify various resources and actions to affirm a positive sense of themselves in accepting and dealing with the experience of mental illness. This research highlights the importance of recognizing and addressing the specific needs of sexual minority and gender nonconforming individuals with mental illness. The development of policy to protect LGBT individuals with mental illness is needed to reduce institutional barriers and enhance systemic change. Additional research and implementation of culturally responsive interventions for individuals with LGBT identities can help to reduce the effects of double stigma and facilitate acceptance of oneself and one’s mental illness. This growth in public acceptance of people who are LGBT and have mental illness identities is a powerful route to promoting the process of acceptance within the individual.
(p. 143) Clinical Strategies
• Ask directly about how clients with serious mental illness identify their gender identity and sexual orientation.
• Ask about clients’ sexual practices and preferences, where culturally appropriate. Ask about any changes in these identities and practices over time.
• Identify and reflect the terminology surrounding gender, sexuality, and mental health that is preferred by the client.
• Explore any experiences of double stigma surrounding identification as a sexual or gender minority as well as a person with mental illness.
• Identify any past experiences of stigma, discrimination, abuse, or other sources of prejudice in the context of one’s social network, community, family, mental/medical health agencies, work, or other settings. Validate the person’s identification of stigma in these settings.
• Avoid relying on your clients to educate you about their community and identity. Although clients sometimes may find this role empowering, it is also important to become informed on your own and support the client in maintaining his or her role as recipient of care.
• Participate in formal training in LGBT mental health care. Consider conducting a training for your treatment team or hosting an outside speaker to do so in order to enhance cultural competence in the care of others in your work setting.
• Consult with LGBT specialists in mental health when less informed about serving individuals from this community.
• Avoid attributing mental health symptoms to LGBT identity. Do consider the effects of stigma on psychological distress.
• Enhance social supports in the life of LGBT people with serious mental illness.
• Identify how potential experiences of homophobia or transphobia may affect one’s process of acceptance of mental illness. Identify the barriers and facilitators to acceptance for LGBT clients with mental illness and enhance facilitators in the person’s life.
• Educate LGBT clients with serious mental illnesses about their rights in mental health settings and support them in taking action against transphobia and homophobia in these settings.
• Assist LGBT clients in accessing peer supports that may include informal or more formal peer groups and social events to enhance support and identity pride.
• Ensure that any clinical paperwork that you use includes options for transgender clients under gender, as well as gay and bisexual under sexual orientation. Include write-in options for these categories in order to be inclusive of people who do not identify with these categories but would describe themselves in other ways.
(p. 144) Discussion Questions
1. Some mental health clinics work with children and adolescents who experience gender variance, and affirm their experience of their gender. Explain whether you agree or disagree with this practice. What mental health impact might this practice have on transgender people who also have a serious mental health problem?
2. Some LGBT individuals with serious mental illness feel rejection from both communities—LGBT as well as groups with serious mental illness. Explain how stigma may be operating in these situations. Describe any personal knowledge or clinical experiences you may have had that demonstrate this phenomenon either in LGBT or other groups that experience oppression.
3. Gender Identity Disorder was a diagnosis in DSM-IV-TR that was changed in DSM-5 to Gender Dysphoria. Explain if you agree or disagree with keeping Gender Dysphoria in the DSM-5. Debate the pros and cons of having this diagnosis in DSM-5 and how this might impact the acceptance process for a transgender person with a major mental health problem.
1. Treatment team handout. Create a handout defining the most current terminology used with LGBT individuals that may be less familiar to the traditional practitioner (e.g., genderqueer, heteroflexible, pansexual, bigender). Review your\handout with a class, treatment team, or in another setting. Explore respectful ways of addressing and discussing individuals from these groups in mental health settings.
2. Human rights. Conduct research online about the rights of LGBT individuals in medical and mental health settings as they pertain to your state. In a group, each person might be assigned a different state, setting, or other part of a category in order to break up this task. Share this research with one another and compare differences across settings, states, etc. Identify and discuss differences in laws and what changes still need to be enacted. Explore how one might defend one’s clients’ rights in the settings that you (might) work in.
3. History of treatment. Conduct research on the history of treatment of LGBT individuals in mental health settings. This research might include reparative therapy for gender and sexual orientation and current practices and restrictions against this practice today.