Vernon A. Rosario, MD, PhD

I recently received a consultation request from a colleague concerning an autistic male to female transgender adolescent who had started on cross sex hormones. She had also recently revealed her years-long identification as a cat, and this trans-species or “otherkin” identity was of greater distress than the gender dysphoria.

Seemingly unusual and overlapping erotic and psychological identities are nothing new to clinicians specializing in matters of sexuality. I have treated or consulted on cases of teenagers erotically attracted to cross-dressing, children, giantesses, extraterrestrial aliens, decapitation videos, and a fair number of trans-species identifications.

Physicians (especially psychiatrists) have long had the privilege of hearing patients’ most intimate revelations about their sexual behaviors and inner lives. Doctors since antiquity have dealt with matters of fertility, potency, and sexually transmitted diseases. However, it only has been since the 19th century that Western physicians systematically have studied and classified the broad diversity of human sexuality.

Victorian sexologists lumped all non-heterosexual, extramarital eroticism under the rubric of sexual perversions. In 1886, Richard von Krafft-Ebing’s 

 became the bible of paraphilias; he coined many of the terms we still use today, like 

. During the 20th century, the list of what is considered 

 has been whittled down significantly. Mid-century sex researchers, like Alfred Kinsey, PhD, demonstrated that what had been considered rare and pathological behavior was actually commonplace: masturbation, homoeroticism, extra-marital affairs, and fetishism.

Cultural politics also revolutionized public sentiment on sexuality. The Civil Rights movement, feminism, and gay pride all contributed to changing attitudes about interracial relationships, women’s sexuality, and gay sex. Far from the time and mindset of Krafft-Ebing, many of those so-called perversions are now considered part of the great variety and color of human mating dances.

Classical psychoanalysis placed sexuality at the center of human psychological development. While Freudian theory was initially criticized for its pansexualism and emphasis on erotic fantasy (particularly in children), the general public has come to expect us shrinks to possess special insight into sexuality. Unfortunately, psychiatric education has failed on this count.

Surveys of training directors find that little didactic time is devoted to even traditional matters of reproductive health or women’s sexuality. Instead, psychiatric residents are most likely to learn about sexual adverse effects of medications and strategies for treating them.

 Training directors are open to having lectures on LBGT sexuality, for example, but cannot find the time in the psychopharmacology curriculum or the right faculty to teach this important area.

A particularly novel challenge for clinicians is the impact of the internet on the lives of adults and children alike. The internet has supported a type of erotic speciation far beyond that of even the 19th century medicalization of sexual perversities (the term 

 was astutely coined by Gayle Rubin, PhD).

 The internet has allowed individuals who might have felt like they were the only people in the world with a particular sexual (or other) inclination to discover that they are not alone. Furthermore, the internet helps people to nurture their sexual interests with textual and visual erotica as well as emotional support and even compatible partners. Some of these erotic interests may just be creative pleasures that add to the diversity of sexuality. Some, however, may be illegal, cause distress to individuals, be of concern to parents, or become too time consuming.

When people turn to mental health professionals about sexual problems-cyber or otherwise-how comfortable and informed are we? This collection of articles makes a valuable contribution to updating psychiatrists on challenging issues of sexuality. But they are just a launching point to help clinicians feel more at ease in supporting patients in their exploration of the spectrum of sexuality and untangling psychiatric problems from the effects of cultural opprobrium. These are not easy distinctions but require professional wisdom and nonjudgmental curiosity.

Dr Rosario is an Associate Clinical Professor in the Department of Psychiatry at the UCLA David Geffen School of Medicine, and a child and adolescent psychiatrist with the Los Angeles County Department of Mental Health. He reports no conflicts of interest concerning the subject matter of this Special Report.

1. Levine SB, Scott DJ. Sexual education for psychiatric residents. 

2. Hirschtritt M, Noy G, Haller, E, Forstein M. LGBT-specific education in general psychiatry residency programs: a survey of program directors. 

3. Rubin G. Thinking sex: notes for a radical theory of the politics of sexuality. Vance C, Ed. 

. London: Routledge & Kegan, Paul; 1984: 267-319 .

Articles

When people turn to mental health professionals about sexual problems-cyber or otherwise-how comfortable and informed are we?

Erotic and Psychological Identities

The US Department of Health and Human Services reports that the general health and mental health needs of lesbian, gay, bisexual, and transgender (LGBT) patients are undermet.

 A 2011 survey of US and Canadian medical schools found that only a mean 5 hours were devoted to teaching about LGBT health and a third of schools did not address the topic at all during clinical training.

 The time devoted to LGBT mental health in psychiatry residency programs is equally limited. Yet, the LGBT population may have a greater risk for general health and mental health problems. Rates of suicidality are 3 to 4 times higher in LGBT youths than in heterosexual youths, and LGBT youths are 2 to 3 times more likely to attempt suicide; they are also more likely to be homeless. Moreover, LGBT populations have some of the highest rates of tobacco, alcohol, and other drug use.

Data from a large, nationally representative study of adults in the US found a higher prevalence of mental health disorders in LGB than in heterosexual respondents.

 For example: gay and bisexual men were 3 times more likely to meet major depression criteria and 4.7 times more likely to suffer panic disorder in the past year. Almost 20% of the gay-bisexual men had 2 or more comorbid disorders. There was a higher prevalence of generalized anxiety disorder and more comorbid disorders among lesbian and bisexual women than among heterosexual women. Compared with heterosexuals, LGB respondents reported higher 12-month use of mental health care. Elderly LGBT persons grapple with higher barriers to health care because of isolation and lack of culturally sensitive providers. Surveys of transgender individuals find distressingly high prevalence rates of HIV infection/sexually transmit- ted diseases, victimization, mental health issues, and suicidal ideation.

It is important to put these data into a historical context. The psychiatric profession pathologized homosexuality for over a century, lending scientific legitimacy to the broader cultural stigmatization of minority sexualities. It was only in 1973 that the American Psychiatric Association (APA) removed homosexuality from DSM-II, despite vitriolic objections from prominent psychoanalysts. Even today, there are ongoing court battles against groups that promote so-called sexual orientation change efforts, or reparative therapy, despite the fact that the practice has been declared unethical and potentially harmful by both the APA and the American Psychological Association.

Psychiatrists should be broadly familiar with “coming out” as a developmental process of sexual/gender exploration, psychological self-recognition, disclosure to others, and community identification. Coming out also has a historical dimension associated with the individual psychological one. In the Roaring Twenties, “coming out” referred to a person’s initiation into the thriving “gay” world of bars and dance clubs in large cities. Post–World War II, homosexuality was broadly persecuted (including by psychiatry), and most gays had to be extremely discreet (ie, “in the closet”). A radical generation of gay rights activists in the 1960s pushed for decriminalization, destigmatization, and depathologization. Led by chants of “Off the couches, into the streets!” the DSM-II change in 1973 was perhaps the activists’ earliest institutional victory.

The interconnectedness of social and psychological factors was clear in Barry Dank’s

 definition of coming out in the gay world: “Identifying oneself as being homosexual.” For this to happen, Dank noted 2 essential prerequisites: a new social context with homosexuals or knowledge of homosexuality, and substituting the illness stereotype for a destigmatized lifestyle model. Dank predicted that as this happened, gay people would come out at an earlier age and in greater numbers, and their lifestyle would be integrated with their general social life.

Multiple theoretical models of gay identity formation have been proposed since then. Troiden

. This stage usually occurs before puberty, when the individual may not even be aware of homosexuality or not see it as personally relevant. Yet, there is a diffuse sense of marginality or being different from same-sex peers because of gender stereotypes rather than sexual orientation per se.

. This stage usually emerges in adolescence, when the individual begins to realize that feelings and behaviors could be perceived as homosexual. This often causes inner turmoil, particularly when notions of homosexuality are inaccurate or highly stigmatized. Sexual experimentation, both heterosexual and homosexual, is common during this stage and helps resolve confusion. Individuals can respond to identity confusion with acceptance or various defensive strategies, such as denial, avoidance (eg, escapist substance use, anti-homosexual attitudes, indiscriminate heterosexual activity), or redefinition (eg, “It was just with that one person”; “I was drunk”).

. This stage usually occurs during late adolescence or later and involves varying degrees of self-definition as “gay,” “lesbian,” “bisexual,” and other emerging identity labels, as well as disclosure to peers and family.

During this “coming out” phase, the quality of the individual’s LGBT contacts and the reactions of people to the disclosure are critical to identity formation. For example, positive reaction from a physician or psychiatrist helps reduce stigma and guilt and can guide individuals coming out to positive role models.

. During this stage, the individual gains self-acceptance and comfort with his or her sexual identity. With this, stable love relationships become possible and private and public identities are integrated into diverse spheres of life. Often this starts with the exploration of the LGBT community and may continue with openness at work, in social and community activities, in religious and civic associations, etc. This can be an ongoing, lifelong process as the individual encounters new people and organizations. This is not a uniform, linear trajectory, particularly since other identities must be negotiated along the way: ethnicity, class, religion, geographical origin.

Javier is a 16-year-old first-generation Mexican American born in San Diego. He has been aware of his same-sex attraction since fifth grade. He dated girls in junior high school, but since then he has become more certain of his gay sexual orientation. However, this conflicts with his Roman Catholic upbringing. He is very close to his mother and is afraid she will be heartbroken if he does not marry and have children. He asks if he will go to hell if he pursues his gay inclinations.

As in dealing with any patient, the clinician has to be respectful of Javier’s religious and cultural values. However, it is not the role of psychiatrists to get their patients to conform to religious dogma. The clinician might explore what Javier’s core moral values are and whether they actually conflict with his sexual orientation. He may not be aware that gay marriage is legal in many states and that increasing numbers of gay couples are choosing to start families by adopting children or through surrogacy. (Growing numbers of LGBT individuals and couples are raising children: 39% of these couples are non-white and an inordinate number are economically disadvantaged.) Javier could also be referred to Dignity, the Catholic LGBT community organization.

Not surprisingly, many LGBT individuals avoid getting mental health care or fear disclosing their sexual/gender identity to a doctor. It is incumbent on physicians to create a welcoming, inclusive, and nonjudgmental environment for LGBT patients by being informed about sexual/gender terminology (

) and being open to learning more, since new identities are constantly emerging, particularly among youths.

Patients are individuals with their own sexual behavior; avoid common assumptions when taking a sexual history:

• Do not assume that patients are heterosexual just because they have not said otherwise

• Do not assume that LGBT patients do not have children

• Do not assume that self-identified gay men do not have sex with women or that lesbians never have sex with men

• Do not assume that early same-sex erotic feelings are merely a passing phase, and therefore not to be taken seriously

• Avoid conceptualizing gender identity confusion as an immediate need to establish a male or female gender identity

• Avoid common stereotypes (eg, all gay men are promiscuous, all lesbian couples experience “bed death”)

• Do not assume that domestic violence does not occur with LGBT couples

• Do not assume relationship sex roles, ie, that one partner is the “top” (insertive partner) and therefore the other is the “bottom” (receptive partner)

Language that does not presume the patient’s heterosexuality allows the clinician to comfortably and routinely ask about a patient’s sexuality, sexual behaviors, and gender identity. Some examples of exclusive language are:

• Asking a female patient: “Do you have a boyfriend?”

• Asking a male patient: “When did you first become interested in girls?”

• “Are you currently in an intimate relationship?”

• “How committed are you to your partner?”

The LGBT Issues Committee of the Group for the Advancement of Psychiatry (GAP) has developed an extensive syllabus with scholarly references and Internet resource links to help mental health professionals develop cultural competence in treating LGBT patients. The GAP syllabus covers the medical history of the treatment of homosexuality and transgenderism, how to obtain a sexual history, ethical issues in treatment, and general health issues specific to LGBT populations. The mental health care of transgender persons and intersex persons (ie, those with disorders of sex development) is discussed in detail, since these are relatively newer and rapidly evolving areas. Child psychiatrists are sure to see patients with gender-variant behavior and “genderqueer” or “genderfluid” identity (a topic that still has no professional consensus for treating preadolescents).

Many patients believe there will be a better connection if the health care professional shares something of himself: gender, language, ethnicity, age, religion, physical ability/disability, or sexuality. A psychiatrist’s self-disclosure of any aspect of identity presents challenges to and opportunities for the therapeutic process. Some physical aspects may seem inevitably evident, but even these may not be so obvious to the patient: a psychiatrist may be transsexual or may not identify with the patient’s perception of his ethnicity. Disclosure of sexuality may be evident (or construed) from photographs, a wedding band, or fashion, but it usually needs to be explicit. LGBT patients may prefer an LGBT therapist, with whom they feel safe. But being LGBT does not guarantee that a psychiatrist does not foster harmful transference or engage in judgmental countertransference (

The physical and mental health treatment of transgender persons has evolved dramatically since the 1950s, when Christine Jorgensen first brought transsexualism to broad public awareness. Jorgensen’s endocrinologist, Harry Benjamin, strove to legitimize research, diagnosis, and treatment, by founding the Harry Benjamin International Gender Dysphoria Association, now known as the World Professional Association for Transgender Health (WPATH). The 

Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People

 (SOC), published by the WPATH, is an evidence-based consensus on best practices of care for this diverse population.

Early versions of the SOC specified a fairly high bar for “triadic” treatment (mental health, hormonal, and surgical), with the expectation of full transitioning from natal sex to “opposite sex” in gender identity, gender role, hormones, and somatic sex traits (if affordable). The current SOC recommends a more flexible approach, customized to the individual’s needs. Psychiatrists are no longer “gatekeepers” to transgender care and lengthy psychotherapy is no longer an absolute requirement for hormonal and surgical interventions.

Many specialized gender clinics have adopted an “informed consent” protocol for physicians to prescribe hormones for transgender adults without requiring assessment or treatment by a mental health professional. One mental health assessment is recommended for a referral for breast/chest surgery, and assessment by 2 mental health professionals is recommended before genital surgery.

Ideally, psychiatrists, endocrinologists/internists, and surgeons work together in an integrated gender clinic; however, this is rare. Therefore, it is incumbent on those who care for transgender individuals to be thoroughly familiar with the SOC and consult closely with treating colleagues.

A psychiatrist not only verifies the diagnosis of gender dysphoria and assesses a patient’s informed consent to various hormonal and surgical options, but also assesses and treats any psychiatric disorders and provides support for exploration of gender identity, gender role, and sexuality. While psychotherapy is no longer a requirement for gender transitioning, many transgender individuals may benefit from support in this process through the life cycle, since it touches broadly on their relationships with family, friends, coworkers, partners, and an often transgender-hostile society.

LGBT individuals, like all other individuals, have rich, complex cultural backgrounds that shape their psychological development, resilience, and distress. These interwoven cultural threads cannot be reduced to a single profile. The psychiatrist’s challenge is to establish a trusting relationship in which sexuality and gender (some of the most stigmatized aspects of identity) can be safely discussed in the broad context of patient care and the patient’s understanding of health and illness.

The Tables and Case Vignette are adapted from The Group for the Advancement of Psychiatry syllabus on LGBT mental health, available at 

Dr Rosario is Associate Clinical Professor in the department of psychiatry at the University of California, Los Angeles. He reports no conflicts of interest concerning the subject matter of this article.

 HealthyPeople.gov. Lesbian, Gay, Bisexual, and Transgender Health. 

http://www.healthypeople.gov/2020/topics-objectives/topic/lesbian-gay- bisexual-and-transgender-health

 Obedin-Maliver J, Goldsmith ES, Stewart L, et al. Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education. 

 Marshal MP, Dietz LJ, Friedman MS, et al. Suicidality and depression disparities between sexual minority and heterosexual youth: a meat-analytic review. 

 Cochran SD, Mays VM, Sullivan JG. Prevalence of mental disorders, psychological distress, and mental health services use among lesbian, gay, and bisexual adults in the United States. 

 Herbst JH, Jacobs ED, Finlayson TJ, et al; HIV/AIDS Prevention Research Synthesis Team. Estimating HIV prevalence and risk behaviors of transgender persons in the United States: a systematic review. 

 Troiden RR. The formation of homosexual identities. In: Herdt G, ed. 

. Binghamton, NY: Harrington Park Press; 1989:43-74.

 World Professional Association for Transgender Health. 

Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People, Version 7

Because there is a higher prevalence of mental health disorders in LGBTs than in heterosexuals, psychiatrists should be broadly familiar with the process of sexual/gender exploration, psychological self-recognition, disclosure to others, and community identification.

Vernon A. Rosario, MD, PhD

Articles

Erotic and Psychological Identities

Cultural Competence and LGBT Issues in Psychiatry