Jack Drescher, MD

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. 

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

Articles

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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Suicide Attempts Among Transgender and Gender NonConforming Adults: Findings From the National Transgender Discrimination Survey

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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.

Impact of Sexual Orientation and Gender Identity on Suicide Risk: Implications for Assessment and Treatment

In the jargon of contemporary homosexual culture, those who hide their sexual identities are referred to as either 

. Revealing one's homosexuality is referred to as 

. Clinical experience with gay patients reveals hiding and revealing behaviors to be psychologically complex.

In the developmental histories of gay men and women, periods of difficulty in acknowledging their homosexuality, either to themselves or to others, are often reported. Children who grow up to be gay rarely receive family support in dealing with antihomosexual prejudices. On the contrary, beginning in childhood--and distinguishing them from racial and ethnic minorities--gay people are often subjected to the antihomosexual attitudes of their own families and communities (Drescher et al., 2004). Antihomosexual attitudes include homophobia (Weinberg, 1972), heterosexism (Herek, 1984), moral condemnations of homosexuality (Drescher, 1998) and antigay violence (Herek and Berrill, 1992). Hiding activities learned in childhood often persist into young adulthood, middle age and even senescence, leading many gay people to conceal important aspects of themselves.

Closeted individuals frequently cannot acknowledge to themselves, let alone to others, their homoerotic feelings, attractions and fantasies. Their homosexuality is so unacceptable that it must be kept out of conscious awareness and cannot be integrated into their public persona. Consequently, these feelings must be dissociated from the self and hidden from others.

If and when same-sex feelings and attractions can no longer be kept out of consciousness, the individual becomes homosexually self-aware. Individuals to whom this happens can acknowledge some aspect of their homosexuality to themselves. While homosexually self-aware people might consider accepting and integrating these feelings into their public persona, acceptance is not a pre-determined outcome. For example, a religious, homosexually self-aware man may choose a celibate life to avoid what, for him, would be the problematic integration of his religious and sexual identities.

Individuals who are either consciously prepared to act on their homoerotic feelings or to reveal a homosexual identity to others usually define themselves as 

. To be gay, in contrast to being homosexually self-aware, is to claim a normative identity. In other words, defining oneself as gay usually requires some measure of self-acceptance. A gay person may choose to come out to family or intimate acquaintances. Others may come out to people they have met in the gay community while keeping their gay identity separate from the rest of their lives.

Another homosexual identity is the non-gay-identified individual. These people have experienced homosexual self-awareness, may have acted on their feelings, and may have even once identified as gay or lesbian. However, such individuals find it difficult, if not impossible, to naturalize their same-sex feelings and attractions. While recognizing their homosexual feelings, these individuals reject the feelings and, despite the low odds of success, may even seek to change their sexual orientation (Shidlo et al., 2001).

The above classification of homosexual identities privileges the role of self-definition. These identities are not mutually exclusive; there is often overlap between and differing motivations within them. They are shaped by individual and cultural factors. Consequently, when individuals become homosexually self-aware, there is a wide range of psychosocially constructed attitudes and responses they may develop toward their own homosexuality. For example, a homosexually self-aware man may initially identify himself as gay but then regret that decision and return to his earlier practices of hiding. Another may choose a non-gay identity, attempt a "sexual conversion" therapy, but then later decide to accept his homosexual feelings and come out.

What psychological mechanisms facilitate separating one's sexual identity from the rest of one's persona? Sullivan's (1956) concept of dissociation may be illuminating, particularly its most common aspect: selective inattention. A ubiquitous, nonpathological process, selective inattention makes life more manageable, like tuning out the background noise on a busy street. However, through dissociation of anxiety-provoking knowledge about the self, a whole double life can be lived and yet, in some ways, not be known. Clinical presentations of closeted gay people may lie somewhere in severity between selective inattention--most commonly seen in the case of homosexually self-aware patients thinking about "the possibility" that they might be gay--to more severe dissociation--in which any hint of same-sex feelings resides totally out of conscious awareness. More severe forms of dissociation are commonly observed in married men who are homosexually self-aware but cannot permit the thought of themselves as gay (Roughton, 2002).

Some closeted gay people can reflexively speak without revealing the gender of the person being discussed or without providing any gendered details of their personal lives. Sedgwick (1990) called "'Closetedness' ... a performance initiated as such by the speech act of a silence--not a particular silence, but a silence that accrues particularity by fits and starts, in relation to the discourse that surrounds and differentially constitutes it." Toward that end, a gay person might avoid references to gender altogether: "I went out last night with 

 I've been dating for the last few weeks. 

 talked about the possibility of going to the beach next weekend." A heterosexual listening to these words might automatically assume a heterosexual relationship was being discussed.

It can be painful to keep significant aspects of the self hidden or to vigilantly separate aspects of the self from each other. Constant hiding creates difficulties in accurately assessing other people's perceptions of oneself, as well as recognizing one's own strengths. Dissociation's impact on self-esteem can also make it difficult to feel one's actual accomplishments as reflections of one's own abilities. Transparency, invisibility, losing one's voice, and being stuck behind walls or other barriers are some of the terms used to describe the subjective experience of dissociative detachment (Drescher, 1998).

For some gay men, "Hiding and passing as heterosexual becomes a lifelong moral hatred of the self; a maze of corruptions, petty lies, and half truths that spoil social relations in family and friendship" (Herdt and Boxer, 1993). There are many gay men who, before they came out, were either "gay-baiters" or "gay-bashers" themselves.

Attacking those perceived to be gay serves several functions. One penile plethysmography study indicated that men with strong antihomosexual beliefs actually had significant homosexual arousal patterns (Adams et al., 1996). Strong antihomosexual feelings may represent an effort to control perceptions of a gay-basher's own sexual identity. This might translate as, "If I attack gay people, no one will think I am gay." Psychoanalysts call this defense "identification with the aggressor" (Freud, 1966). It may represent intrapsychic efforts to maintain a psychological distance from one's own homoerotic feelings. In other words, it is an effort to strengthen dissociative tendencies.

Coming out may be the most commonly shared cultural experience that defines the modern gay identity. Historically, the term was an ironic reference to debutantes "coming out into society" (Chauncey, 1994). In contemporary usage, "coming out of the closet" means telling another person that one is gay.

Years spent in the closet can make the prospect of revealing oneself an emotionally charged experience. However, the process is not just about revealing oneself to others--in coming out, gay people integrate, as best they can, dissociated aspects of the self. Herdt and Boxer (1993) classified coming out as a ritual process of passage that requires a gay person to 1) unlearn the principles of natural or essentialist heterosexuality; 2) unlearn the stereotypes of homosexuality; and 3) learn the ways of the lesbian and gay culture they are entering. Finally, as gay people must decide on a daily basis whether to reveal and to whom they will reveal themselves, coming out is a process that never ends.

Coming out to oneself is a subjective experience of inner recognition. It is a moment that is sometimes charged with excitement and at other times with trepidation. It is a realization that previously unacceptable feelings or desires are part of one's self. It is, in part, a verbal process--putting into words previously inarticulated feelings and ideas. It is a recapturing of disavowed experiences.

Coming out to oneself may precede any sexual contact. Sometimes, the moment of coming out to oneself is sexually exciting. Some gay people describe it as a switch being turned on. "Coming home" or "discovering who I really was" are how gay people frequently describe coming out to themselves. In the language of Winnicott (1965), it can be experienced as a moment in which they make contact with their true selves.

Coming out to oneself may be followed by coming out to others. Such revelations are not always greeted with enthusiasm, and fear of rejection often plays a significant role in a gay person's decision about who to tell or whether to come out. For those who cannot come out in their hometown, moving to another city offers opportunities to come out among strangers. It can be exhilarating to come out in new and faraway places where one is not known to either family or friends. After making such a move, gay people may completely (and perhaps dissociatively) sever relationships with their past lives.

A therapist's recognition and respect for individual differences allows multiple possibilities in the coming out process. There is no single way to come out, a fact sometimes overlooked by well-intentioned therapists trying to affirm a patient's homosexuality. Every coming out situation may be associated with anxiety, relief or both.

As previously stated, being gay, in contrast to being homosexually self-aware, is to claim a normative identity. From this perspective, coming out to oneself is integrative and often serves to affirm a patient's sense of worth. It is a prerequisite of this work that therapists be able to accept their patients' homosexuality as a normal variation of human sexuality, and that they value and respect same-sex feelings and behaviors as well (Drescher, 1998).

A therapist fluent in the meanings of coming out can point out both obstacles to and inhibitions of the process. However, patients may hear therapist fluency as tacit encouragement to "hurry up and come out," even rebuking a therapist for perceived efforts to force movement in that direction. Therapists need to be aware they can be heard this way and treat it as grist for the psychotherapeutic mill.

Therapists should recognize gay patients' struggles to define themselves as the important therapeutic focus--and that this is not a typical struggle for those who claim a heterosexual identity. Gay patients face a whole set of decisions unlike anything heterosexuals face. Hiding from oneself depends upon dissociative defenses, while coming out to oneself holds the possibility of psychological integration. An implicit value of psychotherapy is that integration is more psychologically meaningful than dissociation. Consequently, therapists cannot be neutral about coming out to the self.

Coming out to others can be fraught with danger. A need to hide may be based on reasonable concerns, as in the case of gay men and women serving in the military. A therapist would be unwise to advise a patient to come out without knowing the attitudes and opinions of the intended object of the patient's revelation. A therapist cannot fully predict the consequences of such a revelation on the relationship of those two people. Again, coming out to others needs to be addressed in a way that recognizes individual differences.

Internalized, antihomosexual attitudes are often rigid and disdainful of compromise or "relativism." A patient's dogmatic belief system may not recognize the concept of respectful disagreement. Nevertheless, exploration of such internalized, moral absolutes, and the identifications from which they stem, requires therapeutic tact. Some patients may try to resolve inner conflicts about being gay by selectively attending to their antihomosexual identifications. Unable to tolerate conflicting feelings about homosexuality, these patients rather unconvincingly tell themselves, "It is OK to be gay." This approach reverses the feelings and identifications of a closeted identity. In the subjectivity of the latter, heterosexuality is idealized and homosexuality dissociated. After coming out, being gay is idealized, while disapproving feelings are denied. Therapeutic holding entails being able to contain both sides (Winnicott, 1986).

When gay patients understand their own antihomosexual attitudes--and the defenses against them--they have a wider view of themselves. As patients feel more comfortable with themselves, they may begin to feel more comfortable with others. Not only does this encourage self-awareness, increase self-esteem and enhance the quality of relationships, it helps a patient more accurately assess the implications of coming out. If a patient chooses to come out, the decision needs to be carefully explored. Conversely, the same is true if a patient decides not to come out.

Given the social stigma, the severity of antihomosexual attitudes in the culture and the difficulties associated with revealing one's sexual identity, why would a gay person come out at all? "Most frequently coming out involves choices about how to handle moments of ordinary, daily conversation" (Magee and Miller, 1995). Furthermore, coming out offers gay people the possibility of integrating a wider range of previously split-off affects, not just their sexual feelings (Drescher et al., 2003). Greater ease in expressing themselves, both to themselves and to others, can lead to an enormous enrichment of their work and relationships. To many, such activities constitute a reasonable definition of mental health.

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Homosexual identities can be described as closeted, homosexually self aware, gay/ lesbian and non-gay identified. This classification privileges the role of self-definition. In coming out, gay people integrate, as best as they can, dissociated aspects of the self. As gay people must decide on a daily basis whether to reveal and to whom they will reveal, coming out is a process that never ends.

Jack Drescher, MD

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