Jack Drescher, MD

Among us are psychiatrists who evaluate people fleeing persecution, including those who are lesbian, gay, bisexual, transgender, intersex, and queer (LGBTIQ). We have heard their devastating stories, and we know the mental health consequences of the human rights abuses they have suffered.

“Marina” and her young daughter fled their Central American country after years of persecution based on her lesbian sexual orientation and gender-nonconforming behavior. Her daughter was born after a so-called “corrective rape” by a local gang leader. At the US southern border, the 2 were forced to remain in Mexico under Title 42 [see following] and the Migrant Protection Protocols. During months of forced waiting, they experienced robbery, kidnapping, extortion, and sexual molestation.

Title 42 is a Trump Administration policy continued by the Biden Administration that blocks entry of refugees into the United States at the US-Mexico border under the pretext of public health. Part of US health law, Title 42 prohibits entry into the United States when the director of the Centers for Disease Control and Prevention (CDC) believes “there is a serious danger to the introduction of a disease into the United States.”

Protecting the public from SARS-CoV-2 does not require sacrificing the human rights and well-being of legitimate asylum seekers seeking safe haven from torture and other human rights abuses in the United States. Even some of the CDC’s own physicians argued that halting the asylum process was not based on protecting public wellness and safety. Title 42 can be rescinded in a safe way that is not a risk to public health.

Yet for reasons that probably have more to do with politics than public health, the Biden Administration and the CDC have extended this policy indefinitely. While the United States has historically been a beacon of hope for refugees fleeing persecution, the plight of refugees has been increasingly caught up in electoral politics. The American Immigration Council reports that the Biden Administration has banned more than a half million immigrants from entering into the United States and has increased the number of expulsions over the previous administration by 67%.

American law and international human rights treaties require that the United States and other countries offer the right to seek asylum. According to Karen Musalo, JD, professor and founding director of the Center for Gender and Refugee Studies at UC Hastings, “Until Title 42 is rescinded, the US will continue to be in blatant violation of its domestic and international legal obligations.”

Refugees expelled to the areas of Mexico just south of the border face grave danger. Human Rights First has tracked at least 1500 public reports of rape, torture, murder, and other human rights abuses among refugees in Mexico.

 The Marshall Project reports that the migrant death rate has almost doubled under Title 42.

This situation is disheartening for all who value international laws that protect the right of those who have suffered persecution to seek safety. It is life threatening to those expelled—vulnerable human beings, especially those who are LGBTIQ, those who are living with HIV, Black and African migrants, unaccompanied minors, and families with young children. Anti-LGBTIQ and racist violence are well documented at the border.

Marina and her daughter eventually found safety. An attorney investigating cases of asylum seekers expelled to Mexico identified them as especially vulnerable and took on Marina’s case. A volunteer psychiatrist also evaluated the mental health consequences of her trauma. Asylum was granted in US Immigration Court.

We implore President Biden, his administration, and the CDC to reverse a policy that puts LGBTIQ asylum seekers and other refugees in peril and does not keep COVID-19 and its variants out of the United States. The United States should continue its honorable tradition of offering safe haven to those fleeing persecution and continue to uphold international human rights treaties and conventions that it has long championed. Now is the time to make a comprehensive break with the cruel and harmful immigration policies of the previous administration.

42 U.S. Code § 265 - Suspension of Entries and Imports From Designated Places to Prevent Spread of Communicable Diseases

 is medical director emeritus at the Weill Cornell Center for Human Rights and has a private practice in New York City. 

 is director of the Youth Equity Science/YES Project; a senior visiting fellow at Yale Law School; an assistant clinical professor at Columbia University College of Physicians & Surgeons; and a clinical assistant professor at Weill Cornell Medical College. 

 is an associate professor of clinical psychiatry at Icahn School of Medicine at Mount Sinai. 

 is an Episcopal priest at St George’s Church in Newburgh and St Paul’s Church in Poughkeepsie. 

works with the Division of Gender, Sexuality and Health at Columbia University College of Physicians and Surgeons. 

 is a community and public psychiatrist in New York City. 

 is a psychiatrist, LGBTQ+ Specialty Team (Southern Colorado VA) LGBTQ+, and veteran care coordinator senior instructor at University of Colorado Denver. 

 is a clinical professor of psychiatry at Columbia University and an adjunct professor at New York University. 

 is an assistant professor of psychiatry at Columbia University Medical Center and a consulting psychiatrist at the Hetrick-Martin Institute. 

 is a public psychiatry fellow at Columbia University. 

 has a private practice in New York City. 

 is a consultation/liaison telepsychiatry assistant professor of clinical psychiatry at Weill Cornell Medicine, and an adjunct assistant professor of clinical psychiatry at Columbia University. 

is an assistant clinical professor at the Yale Child Study Center. 

 is a clinical assistant professor in the Department of Psychiatry at New York University’s Grossman School of Medicine, and has a private practice in New York City. 

 is a professor emeritus of clinical psychiatry at Weill Cornell Medical College. 

 is vice chair and residency training director at SUNY Downstate Medical Center. 

 is an associate professor in the Department of Psychiatry at the University of Toronto

 is a psychiatry resident (PGY4) in the Department of Psychiatry at Indiana University School of Medicine, and founder and president of OutCare Health

 is on the faculty and supervisor of psychotherapy at the William Alanson White Institute, and has a private practice in New York City. 

 is director of the Division of Substance Abuse and Addiction Medicine, and an associate clinical professor of psychiatry at the University of California, San Francisco School of Medicine

 has a private practice in New York City.

Tracking the Biden agenda on legal immigration in the first 100 days

. April 29, 2021. Accessed December 1, 2021.

. June 28, 2021. Accessed December 1, 2021.

Delivered to danger: U.S. Government sending asylum seekers and migrants to danger.

. February 19, 2021. Accessed December 1, 2021.

Strict border enforcement policies put migrants in harm’s way. Title 42 is no exception

. May 26, 2021. Accessed December 1, 2021.

Articles

The Group for the Advancement of Psychiatry (America’s mental health think tank) calls for an end to the use of Title 42 to expel asylum seekers at the southern border. This policy places LGBTIQ asylum seekers in particular danger.

Psychiatrists Call for End to Cruel and Harmful Immigration Policy

LGBTQ COMMITTEE OF THE GROUP FOR THE ADVANCEMENT OF PSYCHIATRY

As the number of COVID-19 cases in the United States hits 30 million and continues to cause widespread pain in lives lost and economic devastation, sexual and gender minority youth face particular hardships threatening their lives, mental health, and social development.

In particular, social isolation may be especially challenging. These youths may be quarantining with rejecting family-members and losing contact with supportive social networks. The nature of quarantining means these problems are invisible to the public.

“Aiden,” a 16-year-old boy who is transgender, lives in a community particularly hard-hit by COVID-19. Aiden’s parents refuse to accept his gender identity or call him by his male name or use male pronouns. They frequently yell at Aiden to dress and act like a girl, assigning dishwashing and laundry chores to him alone, and not to his brother, to get him “used to doing girl stuff like you are supposed to.”

Serial COVID-19 outbreaks at Aiden’s school forced him into remote learning. His family has only 1 computer, shared by Aiden and his brother for schoolwork and Aiden’s mother for church meetings. Aiden’s parents banned him from using social media or communicating with friends because his parents believe “that’s where she picked up all this nonsense.” Aiden became completely disconnected from his friends. He was also cut off from affirming and supportive teachers. As tensions in Aiden’s family escalated, fighting became the only interaction between him and his parents.

One evening during a fierce argument, Aiden’s mother pushed him, and he pushed her back. As a result, she fell and had a small laceration on her shoulder. Aiden’s father became angry and punched Aiden in the face. Aiden’s brother called 911. The police arrested Aiden and his father. Aiden was released from jail to a Child Protective Services emergency residence. Because of COVID-19, he was required to spend 14 days isolated in his room, including mealtimes, and was unable to receive visitors. He also faced misdemeanor charges for assaulting his mother. His father also faced charges. Aiden was afraid of returning home because he was petrified of what his father might do to him.

Administration for Children’s Services (ACS) attempted to reunify Aiden with his parents, but over a period of several months, each attempt resulted in further physical altercations between Aiden and his father. Aiden moved into a group home where peers bullied him because of his gender identity. ACS was unable to address the problem because several staff members were hospitalized with COVID-19, and no other group homes were available for transfer. After a bully hit him, Aiden ran away from the group home, and the police could not locate him.

Even before COVID-19, lesbian, gay, bisexual, transgender, questioning (LGBTQ) youth were at 

 of depression, suicidality, and tobacco, alcohol, and other drug use.

 These increased risks stem from elevated rates of rejection, discrimination, and victimization. During the pandemic, risks were further compounded by the loss of relationships in schools, clubs, or other community venues where LGBTQ youth found support and affirmation. Laura Erickson-Schroth, MD, a psychiatrist at the Hetrick-Martin Institute, a New York City-based LGBTQ youth organization, reported that youth members of the institute are looking for more frequent counseling sessions. According to her, there were at least one-third more requests for initial psychiatry visits during 2020 than during the same period in 2019.

 found one-third of the city’s youth in foster care identifies as LGBTQ, an order of magnitude greater than the general population.

 Nearly three-quarters of these youth are Black, and one-third identify as Hispanic/Latino. LGBTQ youth are placed in group homes and other campus settings rather than foster families more often than their non-LGBTQ peers, and they are more likely to be dissatisfied with their placement. The study also found these youth experience a greater burden of depression.

According to Dylan Waguespack, director of public policy and external affairs of 

, 20% to 40% of homeless youth identify as LGBTQ. True Colors United is a national organization dedicated to ending LGBTQ youth homelessness. Although family conflict, involvement in the foster care system, and involvement in the criminal justice system are among the factors that contribute to homelessness among these youth, poverty is often the root cause. Not only are these youth at risk for adverse mental health outcomes because of rejection and discriminatory behaviors, they often face traumatic experiences through conflict with their families, involvement in overwhelmed and poorly informed state programs.

Agencies that previously made efforts to address racial, social, gender, or sexuality based inequities before the pandemic have become even more overwhelmed with the increase in housing and food insecurity, increased unemployment, instability in the agency’s own staff, and the need to rapidly implement physical distancing and other public health measures in routine work. Overwhelmed and encumbered agencies are increasingly unable to provide critical services for LGBTQ youth, leaving them powerless in impeding a downward spiral into homelessness and associated negative ramifications.

Even as the pandemic ends, there may be continual struggles and support needs. Fortunately, there are ways psychiatrists and other mental health care professions can help.

Some of these methods include the following:

Financially donate to organizations that support or serve LGBTQ youth.

Advocate for programs that decrease income inequality and promote housing and food security.

Enable rapid interventions to prevent LGBTQ youth from entering the foster care and criminal justice systems.

Use clinical, teaching, institutional, and forensic roles to speak out and advocate for this vulnerable group of young people.

Share resources and references for supportive organizations with patients who are LGBTQ (

LGBTQ youth have long experienced marginalization and significantly increased risk of poor mental health outcomes. The COVID-19 pandemic sharpened the crisis and brought clarity to the precariousness of social service agencies that address those needs. Strengthening the support system for these youth and their allies and making agencies more inclusive of their voices is critical to help these young people achieve a healthy and fulfilling life.

is the director of the Youth Equity Science/YES Project and senior visiting fellow at Yale Law School. He is also an assistant clinical professor at Columbia University and an adjunct clinical assistant professor at Cornell Weill Medical College.

the medical director emeritus at Weill Cornell Center for Human Rights. Dr Barberis the past president and journal editor for the Association of LGBTQ Psychiatrists and is an MDiv candidate at Union Theological Seminary.

is a community and public psychiatrist in New York City.Dr Drescher is a clinical professor of psychiatry at Columbia University and an adjunct professor at New York University. He is also a distinguished life fellow of the American Psychological Association and the past president of the Group for Advancement of Psychiatry

is an assistant professor of psychiatry at Columbia University Medical Center and a consulting psychiatrist at Hetrick-Martin Institute for LGBTQ youth.

. 2020;18(3):268-276. doi:10.1176.appi.focus.20200018
2. Sandfort TGM. Experiences and well-being of sexual and gender diverse youth in foster care in New York City: disproportionality and disparities. November 2020. Accessed January 5, 2020. 

https://www1.nyc.gov/assets/acs/pdf/about/2020/WellBeingStudyLGBTQ.pdf

Overwhelmed and encumbered agencies are increasingly unable to provide critical services for LGBTQ youth, leaving them powerless in impeding a downward spiral into homelessness and associated negative ramifications. There are 5 ways psychiatrists can help.

Helping LGBTQ Youth During the Pandemic

As the number of COVID-19 cases in the United States rockets past 21 million, causing widespread pain in lives lost and economic devastation, lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth face particular hardships threatening their lives, mental health, and social development.

In particular, social isolation may be especially challenging for LGBTQ youth. They may be quarantining with rejecting family-members and losing contact with supportive social networks. The nature of quarantining means these problems are invisible to the public.

Aiden, a 16-year-old transgender boy, lives in a community particularly hard-hit by COVID-19. Aiden’s parents refuse to accept his gender identity, call him by his male name, or use male pronouns. They frequently yell at Aiden to dress and act like a girl, assigning dishwashing and laundry chores to him alone—and not to his brother—to get him “used to doing girl stuff like you are supposed to.” 

Due to serial COVID-19 outbreaks at Aiden’s school, he is forced into learning remotely. His family has only 1 computer, shared by the 2 siblings for schoolwork and Aiden’s mother for church meetings. Aiden is banned from using social media or communicating with friends because his parents believe “that’s where she picked up all this nonsense.” Aiden has become totally disconnected from his friends. He is also cut off from affirming and supportive teachers. As tensions in Aiden’s family escalate, fighting becomes the only interaction between him and his parents.

Even before COVID-19, LGBTQ youth were at higher risk for depression, suicidality, and tobacco, alcohol, and other drug use.

 Moreover, this increased risk stems from increased rates of rejection, discrimination, and victimization. During a pandemic, risk is further compounded by loss of relationships in school, clubs, or other community venues where LGBTQ youth find support and affirmation. Laura Erickson-Schroth, MD, MA at the New York City-based LGBTQ youth organization, Hetrick-Martin Institute, reports youth members are asking for more frequent counseling sessions. They have made at least a third more requests for initial psychiatry visits during 2020 than during the same period in 2019. 

One evening, during a fierce argument, Aiden’s mother pushes him and he pushes her back. She falls, suffering a small laceration on her shoulder. Aiden’s father becomes angry and punches Aiden in the face. Aiden’s brother calls 911. The police arrest Aiden and his father. Aiden is released from jail to a Child Protective Services (CPS) emergency residence. Because of COVID-19, he is required to spend 14 days isolating in his room, including mealtimes, and he is unable to receive visitors. He faces misdemeanor charges for assaulting his mother; and his father may also face charges. Aiden is afraid of returning home, as he is petrified of what his father might do to him. 

A study commissioned by New York City’s Administration for Children’s Services (ACS)

 found one third of the city’s youth in foster care identify as LGBTQ, an order of magnitude greater than the general population. Nearly three quarters of these youth are African American and one-third identify as Latinx. LGBTQ youth are placed in group homes and other campus settings rather than foster family placement more often than their non-LGBTQ peers, and they are more likely to be dissatisfied with their placement. The study also found LGBTQ youth experience a greater burden of depression.

ACS attempts to reunify Aiden with his parents, but each attempt over several months results in further physical altercations between Aiden and his father. Aiden moves into a group home where he is bullied by some peers because of his gender identity. The agency is unable to address the problem because several staff are hospitalized with COVID-19 and no other group homes are available for transfer. After a bully hits him, Aiden runs away from the group home and the police have yet to locate him.

, a national organization dedicated to ending LGBTQ youth homelessness, says 20 to 40 percent of homeless youth identify as LGBTQ. Contributors to LGBTQ youth homelessness include family conflict, involvement in the foster care system, and involvement in the criminal justice system. Poverty is often the root cause. Not only are LGBTQ youth at risk for adverse mental health outcomes because of rejecting and discriminatory behaviors, they often face traumatic experiences through conflict with their families, involvement in overwhelmed and poorly informed state programs, and homelessness. 

COVID-19 exacerbates these problems. Agencies that might have made efforts to address racial, social, gender, or sexuality based inequities before the pandemic have become even more overwhelmed with the increase in housing and food insecurity, increased unemployment, instability in the agency’s own staff, and need to rapidly implement physical distancing and other public health measures in routine work. Overwhelmed and encumbered agencies are increasingly unable to provide critical services for LGBTQ youth, leaving them unable to impede a downward spiral into homelessness and associated negative sequelae. 

- Increase representation in leadership bodies so marginalized youth can help shape successful programs and interventions. 

- Reevaluate policies and practices that harm or further alienate LGBTQ youth. 

- Create resources to hire LGBTQ youth as peer advocates who can help engage others at the front lines of service delivery. 

What Psychiatrists and Other Mental Health Professional Can Do:

- Donate financially to organizations that support or serve LGBTQ youth.

- Advocate for programs that decrease income inequality and promote housing and food security.

- Enable rapid interventions to prevent LGBTQ youth from entering the foster care and criminal justice systems.

- Use clinical, teaching, institutional and forensic roles to speak out and advocate for this most vulnerable group of young people.

- The Trevor Project – A national 24-hour, toll free confidential suicide hotline for LGBTQ youth. 

- The Family Acceptance Project – An initiative which helps ethnically, racially and religiously diverse families learn to support their LGBTQ children. 

- PFLAG – A national organization with local chapters providing support for LGBTQ+ people, their parents and families, and allies. 

- Trans Student Educational Resources (TSER) – A youth-led organization dedicated to transforming the educational environment for trans and gender non-conforming youth. 

- Gay, Lesbian, and Straight Education Network (GLSEN) – An organization that works to Ensure All Students Have a Safe Place to Learn. 

All of the authors are members of the LGBTQ Committee of the Group for the Advancement of Psychiatry.

is the director of the Youth Equity Science/YES Project and Senior Visiting Fellow at Yale Law School. He is also an assistant clinical professor at Columbia University, and an adjunct clinical assistant professor at Cornell Weill Medical College.

is the Medical Director Emeritus at Weill Cornell Center for Human Rights.

is the past president and journal editor for the Association of LGBTQ Psychiatrists, and is a MDiv candidate at Union Theological Seminary.

is a community and public psychiatrist in New York City.

is a clinical professor of psychiatry at Columbia University and an adjunct professor at New York University. He is also a Distinguished Life Fellow of the American Psychological Association and the past president of the Group for Advancement of Psychiatry.

assistant professor of psychiatry at Columbia University Medical Center and a consulting psychiatrist at Hetrick Martin Institute for LGBTQ Youth.

1. Lothwell L, Libby N, Adelson S. Mental health care for LGBT youths. 

2. Sandfort TGM. Experiences and well-being of sexual and gender diverse youth in foster care in New York City: disproportionality and disparities. November 2020. Accessed January 5, 2020. 

The pandemic has exacerbated many existing dangers, and introduced a few new ones.  

Impact of COVID-19 Crisis on LGBTQ Youth

It is not unusual for patients to seek consultation with psychiatrists and other mental health professionals with questions about their sexuality. These questions can arise irrespective of age, gender, and actual sexual practices. They come up in people who are single-and even in those in heterosexual marriages with children. What follows are some useful definitions and clinical examples for therapists who wish to address these patient concerns.

[[{"type":"media","view_mode":"media_crop","fid":"53326","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_2905034459696","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"6648","media_crop_rotate":"0","media_crop_scale_h":"194","media_crop_scale_w":"250","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":"Â© shutterstock.com","typeof":"foaf:Image"}}]]First, it is important to distinguish between sexual orientation, sexual identity, and sexual behavior. A sexual orientation is a person’s erotic response tendency or sexual attractions, be they aimed at individuals of the same sex (homosexual), the other sex (heterosexual), or both sexes (bisexual). Sex researchers call exclusive homosexual attractions a “Kinsey 6” and exclusive heterosexual attractions a “Kinsey 0.” Someone who is equally attracted to men and women is a Kinsey 3.

A sexual identity-sometimes referred to as a sexual orientation identity-refers to the subjective experiences of one’s own sexual desires, attractions, or behaviors. Sexual behavior is a descriptive term that does not account for motivation or identity. For example, the CDC tracks HIV infections using the behavioral definition of men who have sex with men (MSM) because not all MSM identify as gay.

Consider the case of Bob, a 35-year-old heterosexual married father of 4. He sought consultation because, in recent months, he had become increasingly sexually and emotionally involved with another heterosexual married man. Their wives were unaware of the relationship as the 2 men had met on a social media app. Nor were they likely to as the heterosexual couples were not close in age and traveled in very different social circles.

Bob reported fleeting, anonymous homosexual encounters since age 15 and then throughout his marriage of many years. While he and his wife were no longer sexually active, he wished to preserve their marriage and keep his family intact. Thus, he became distressed a year before the consultation when he began to think he might be “bisexual.” He was seeking professional help because he was obsessing about the other man, which made him think “I might be gay.” When asked how he had previously understood his many years of having sex with men, he sheepishly replied, “I thought I was just fooling around.”

Behaviorally, Bob had been bisexual because he was having sex with men at the same time he was having sexual relations with his wife. It was possible he had a bisexual orientation if he was aroused by the idea of having sex with both men and women. However, he readily admitted at the consultation that he had always thought about men when having sex with his wife or even when masturbating.

Is Bob gay? Not really. A gay identity usually requires some level of acceptance of one’s homosexual attractions and fantasies. Bob was in a state of panic because he was not accepting those feelings as part of his identity. How might one think about Bob’s sexual identity?

From a colloquial perspective, Bob was “in the closet,” meaning that he was hiding his homosexual self from others. However, a psychologically closeted individual is unable to acknowledge to himself that he has homoerotic feelings and fantasies. This state of mind is often retrospectively captured in the expression, “I didn’t want to admit those feelings to myself.” This was the case with Bob, who used to think of those feelings as “fooling around.” By this he meant he had thought his homosexual interests were “normal” because a normal man seeks out any sexual outlet he can find.

As Bob’s feelings for his married friend intensified, he began shifting to a homosexually self-aware identity. He was beginning to acknowledge his homoerotic or same-sex feelings and attractions to himself. The dilemma that brought him into consultation was whether he would further integrate those feelings into his identity; and if he did, how would he do so? Therapists should not take an eventual acceptance for granted. Some homosexually self-aware persons consciously struggle against accepting same-sex attractions or relationships as part of a public identity. They adopt non-gay identities-some who tried to accept those feelings but later rejected them identify as “ex-gay.”

From this perspective, Bob could be described as having a homosexual orientation and as having engaged in bisexual behavior. At the time of the consultation he appeared to be shifting between a closeted and a homosexually self-aware identity. The outcome of Bob’s sexual identity crisis is unknown because he never returned after 2 visits.

John, on the other hand, is a patient with a more common presentation of shifting sexual identities. He was 25 years old when his primary care physician referred him for treatment of an anxiety disorder characterized by a recurrent fear of having contracted HIV. This anxiety emerged after a brief homosexual experience-John’s first-with a co-worker several months earlier after both of them had gone out drinking. Although their sexual behavior, mutual masturbation, was not high-risk for contracting HIV, the patient obsessed about being seropositive. At the time of consultation, John had undergone monthly HIV tests, all of which were negative, but none of those results assuaged his anxiety. What did help were several months of treatment, including short-term benzodiazepine use, starting an antidepressant medication, and weekly psychodynamic psychotherapy.

John had been raised in a religious tradition that condemned homosexuality, and he still attended services regularly. He had dated women and had a steady girlfriend with whom he had a sexual relationship in college-despite his religion’s objections to premarital sex. Yet after his HIV anxiety diminished, an ongoing question in psychotherapy was whether he was gay. John repeatedly asked the therapist to tell him if he was.

The therapist, however, declined. He told John it was not for him to define a patient’s sexual identity and that psychotherapy was a process in which he had to decide on his own. He told John that of the many men he treated who eventually came to identify as gay, most reported feelings of sexual attraction for other boys or men from an early age. He also mentioned studies of men who experienced shifts in their sexual orientation as adults. However, the therapist did not know whether John fit into any of these categories.

The therapist, rather than defining John’s identity for him, could help his patient tolerate the anxiety of uncertainty experienced as he sorted his identity out. At times, this involved taking a didactic approach to explain contemporary theorizing and research about human sexuality. For example, the therapist told John that one homosexual experience does not make a person gay; that development of any sexual orientation is complex; that to this day, no one knows the “causes” of either heterosexuality or homosexuality; and the aforementioned differences between behavior, orientation, and identity.

Initially, the therapist saw both John’s behavior and orientation as bisexual while in a homosexually self-aware state of mind. However, the therapist was cautious about assuming the patient would adopt a gay identity. In any event, his first year of treatment rarely focused on sexual identity but instead dealt with anxieties about AIDS, work, and relationships.

After a year, John was less anxious about HIV. During one session, the therapist mentioned in passing John’s uncertain sexual identity. John responded by revealing to the surprised therapist that he had already decided months earlier that he was gay. He then provided some developmental history he had previously omitted. He acknowledged that he had childhood sexual fantasies about men and that he would think about men while having sex with his college girlfriend, his only heterosexual relationship.

John was “coming out” to his therapist. In everyday usage, coming out means telling another person that one is gay (lesbian, bisexual, transgender). However, the process is not just the interpersonal act of telling others. There are also intrapsychic aspects to the process that require integration of dissociated aspects of the self. John had been doing so on his own, without sharing his thoughts with the therapist. His internal shift in his self-identification, from homosexually self-aware to gay, could be seen as coming out to himself.

At that point, the therapist revised his assessment. He thought of John as having a homosexual, rather than a bisexual, orientation and a gay, rather than a homosexually self-aware, identity. The history of bisexual behavior remained the same.

Once John came out to himself, and as is often the case, he began a process of coming out to others-starting with his therapist. I consider the therapist’s experience of surprise as just one part of the gratifying work of letting patients come to their own conclusions at their own pace.

Dr. Drescher is a psychiatrist and psychoanalyst in private practice in New York City. He reports no conflicts of interest concerning the subject matter of this article.

It is not unusual for patients to seek consultation with questions about their sexuality. This article provides useful definitions and clinical examples for therapists who wish to address these patient concerns.

“Doctor, Am I Gay?” A Primer on Sexual Identities

Evidence indicates that lesbian, gay, bisexual, and transgender (LGBT) populations are at increased risk for suicide.

 This article reviews what is known and unknown about LGBT suicide risk, discusses risk and protective factors for LGBT adolescents and adults, and provides recommendations for assessing and treating LGBT patients.

Researchers measure sexual orientation on the basis of sexual behavior or sexual identity. The two constructs identify different populations, however. An estimated 8.2% of US adults report lifetime same-sex sexual behavior and 3.5% identify as lesbian, gay, or bisexual.

 Sexual attraction is also used to measure orientation, although this is even less definitive of minority sexual identity than sexual behavior.

The prevalence of transgender people in the US is estimated at 0.3%.

 This includes individuals who transition from natal sex to another distinct gender (usually with transition-related health services) and persons who are transgender part-time, who cross-dress, or who identify as gender-nonconforming. Gender identity and sexual orientation are different but sometimes overlap. In one survey of transgender adults, 71% identified as gay/lesbian, bisexual, or “queer”; 23% as heterosexual; and 6% as asexual or other.

Because sexual orientation and gender identity are not systematically recorded at time of death, the number of LGBT deaths from suicide (or any other cause) is not known. This is a barrier to understanding and addressing LGBT suicide risk. Studies asking whether LGB people are over-represented among suicide decedents have produced inconsistent or inconclusive findings. However, high rates of suicide have been reported among individuals receiving medical interventions for gender transition.

 Findings from a recent Australian study indicate that depression, relationship problems, and other life stressors were more prevalent among LGBT suicide decedents than among non-LGBT decedents, and the LGBT decedents were less likely to have received psychiatric treatment.

There is strong evidence of elevated rates of suicide attempts in sexual minorities. Lifetime suicide attempts, on average, are 4-fold higher in gay and bisexual men, and twice as high in lesbian and bisexual women, compared with heterosexuals.

 Among adolescents, those who are LGB report making a lifetime suicide attempt at 3 times the rate of heterosexual youths.

 Moreover, LGB youths report 4 times as many medically serious attempts. Recent research suggests adolescent suicide risk is more strongly associated with LGB identity than with same-sex sexual behavior and is higher in behaviorally bisexual youths than in those with exclusively same-sex sexual behavior.

Surveys of transgender adults likewise suggest high rates of suicidal behavior in gender minorities: lifetime suicide attempts have been reported by 25% to 43% of respondents.

 While the self-identified samples may not be representative of transgender populations as a whole, the consistency of survey findings suggests lifetime suicide attempts are likely more prevalent in transgender individuals than in the US general population, in which suicide attempts are reported by fewer than 5% of adults.

The higher prevalence of suicide attempts in LGBT adults and adolescents has been linked to the higher incidence of mental disorders in these populations-in particular, depression, anxiety, and substance abuse.

 High rates of depression and panic disorder have been observed among gay and bisexual males, while substance use disorders are more prevalent in lesbian and bisexual women than in heterosexual women.

 These findings suggest different gender patterns among LGB persons than among the population as a whole, which may be related in part to lower tolerance of sexual orientation differences in men than in women.

 attributes elevated rates of mental disorders and suicidal behavior in sexual minorities to greater exposure to prejudice, discrimination, and victimization as well as to internalization of negative social views. Hatzenbuehler and colleagues

 found that discriminatory laws and policies increase the prevalence of mental disorders in LGB adults. Hatzenbuehler

 also observed increased suicide attempts in LGB youths who lack supportive social environments, including protection against bullying and discrimination. Family rejection is also strongly related to depression and suicide attempts in LGB youths.

Concealment of sexual orientation (“closetedness”) because of anticipated stigma is also linked to mental health problems.

 Nondisclosure of transgender status is associated with lower risk of suicide attempts, possibly because hiding protects against rejection, discrimination, and victimization, which are otherwise strongly linked to suicide attempts in transgender populations.

Connectedness to sexual minority communities and positive sexual identity protect against suicidal behavior among LGB adults.

 Among youths, protective factors include family connectedness and acceptance; perceived caring of other adults; and school safety, acceptance, and peer support.

While assessing suicide risk in LGBT persons can be similar to assessing risk in non-LGBT individuals, there are differences. Individuals in diverse settings may require different approaches, and each population and setting must be evaluated individually. Treatment requires that practitioners be familiar with the cultural milieu of LGBT life.

 Clinicians must be cognizant of the impact that antihomosexual and antitransgender attitudes can have on the normal psychosocial development of LGBT persons; they must also recognize extreme situations that may arise. In addition, they need to be aware of and ask about events that a patient-perhaps in the closet or fearing lack of support from a medical/psychiatric authority-may not offer spontaneously. The following questions are worth thinking about when assessing suicidal risk in LGBT patients.

• Is the adolescent being bullied for gender atypical behavior?

• Has the adolescent been rejected after coming out to a family member or friend?

• Has the adolescent been thrown out of his or her home by unaccepting parents practicing “tough love”?

• Who should be contacted: the family or social services?

• Is a desperate transgender patient unable to access needed medical care for transition?

• Is a young adult’s suicidal ideation due to using “party drugs” or “club drugs?”

• If suicidal ideation is a response to a recent breakup, can the evaluator talk about same-sex relationships in a nonjudgmental way?

• Has someone “outed” (involuntarily revealed the sexual identity of) a closeted patient who does not want to be out?

• Is the patient so extremely “closeted” and self-loathing that he is socially isolated, with no gay friends?

• Is the patient engaging in unsuccessful “conversion therapy” in an attempt to change sexual orientation

• Is the patient experiencing workplace harassment or does he live in a state that does not have antidiscrimination protections for LGBT people?

• Does the patient live in a state that forbids a legal relationship with a partner’s biological child?

• Are the parents of a transgender child receiving death threats?

These are examples of the special kinds of social problems faced by LGBT patients, and it is highly recommended that clinicians who treat these populations anticipate and understand the potential effects of these stressors on suicide risk.

With the above factors in mind, clinicians need to think about who should be notified for collateral information during assessment. Who knows about the patient’s sexual identity? The adolescent living at home may not be out to his parents. The young adult may be estranged from his biological family, relying on a network of friends (family of choice). Assessing risk may require assessing support networks, if any, other than family and friends, including work, religious organizations, and community groups. While taking a collateral history, informing family members may reduce risk-although for closeted individuals, revealing information about sexual identity to unsuspecting family may have the opposite effect.

Hospital discharge planning that does not take into account the patient’s support system and psychosocial stressors associated with being in the closet may increase suicide risk. After discharge, referral to a therapist culturally competent about LGBT issues who also knows how to treat suicidal patients reduces risk.

In 2011, a groundbreaking Institute of Medicine (IOM) report made policy recommendations to improve the physical and mental health of LGBT populations.

The IOM recommended research using cross-cutting perspectives, such as minority stress; life course; and demographic features, including racial, ethnic, socioeconomic, and geographic diversity. The IOM also recommended that data on sexual orientation and gender identity be collected in electronic health records (EHRs), when possible. EHRs can be designed to alert clinicians when particularly high-risk individuals are seen, such as those with a documented psychiatric disorder or a history of past suicide attempts.

Dr Haas is Senior Consultant at the American Foundation for Suicide Prevention. Dr Drescher is Clinical Professor at New York Medical College and Adjunct Professor at New York University in New York. They report no conflicts of interest concerning the subject matter of this article.

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