Hero

Videos

Slideshows

Articles

Podcasts

Poll

Psychopharmacologists and psychotherapists are in no way immune to the kinds of lapses in professionalism that from time to time imperil the licenses and careers of other health professionals.

 In particular, effective management of appropriate professional boundaries is an integral and ongoing task for mental health professionals throughout our careers.

 Following presentation and discussion of a fictional anecdote, I will conclude by proposing a typology for the range of professional boundary challenges.

Shots in the Dark: A Realistic Imagined Boundary Violation Anecdote

“Raquelle” and “Kobe,” two PGY-5 psychiatry fellows in a prestigious university-based mental health fellowship program, met at a poorly lit bar near the campus after work on a Friday. They were colleagues—acquaintances who were in the process of becoming work friends. As they finished up a shared half-gallon pitcher of beer, the waiter brought them each a shot of tequila that neither of them had ordered. He explained that this was a gift from a young woman seated alone at the bar. Raquelle looked up and discerned that the gift-giving bar patron appeared to be a high-functioning female graduate student who was a clinic patient under her care. She smiled and waved to the patient, and then discussed with Kobe whether or not it was appropriate for them to drink the shots. Raquelle suggested that they send the tequila back; Kobe argued that to do so was overkill: “Why kick a gift horse in the mouth? She’s already paid for the drinks anyway.” He downed the shot—was it a double, perhaps?—and then pointed out that the patient was gone. After Raquelle downed the other shot, the patient, who had been in the restroom, pulled up a chair and joined them at their table.

Kobe was buzzed, Raquelle was becoming more and more intoxicated by the minute, and her patient was clearly inebriated. Some of the free-wheeling discussion involved the patient’s frustration with being single, and at one point, she deliberately touched Kobe’s thigh. He took care to move her hand off his leg and summoned an Uber, which they took together to the patient’s apartment. They helped her negotiate her way to building’s entrance and bid her farewell. They then proceeded to Raquelle’s apartment, and Raquelle asked Kobe to help her get inside. She invited him in, and they decided to have sex. Things progressed quickly until Raquelle suddenly asked Kobe to stop. He did so immediately and left very shaken up. Raquelle did not return Kobe’s calls that weekend.

On Monday the patient cancelled all of her scheduled appointments and lodged a complaint with the clinic director. After the clinic director interviewed Raquelle and Kobe, first separately and then together, she put the 2 of them on administrative leave and contacted the HR department and legal counsel. It was decided to confer with the medical board about “a couple of young physicians who crossed some lines.”

The messy, unfortunate, and completely avoidable situation that these 2 young physicians found themselves in raises a number of important questions:

1. Is this a spurious matter that is likely to be sorted out promptly without having a negative impact on the career trajectory of these PGY-5 psychiatry fellows?

3. How does the physicians’ drinking factor into our assessment of these boundary challenges, and to what extent does this anecdote indicate a drinking problem that should likely be addressed?

4. What kind of legal exposures exist in this kind of case?

5. What lessons can be taken away from this situation? If the fellows could turn the clock back and proceed differently, what might they have changed?

Perspective of a Psychiatrist With Experience Assisting Physicians With Professionalism Challenges

From the vantage point of having assessed hundreds of physicians with professional boundary challenges, my lived professional experience suggests the following answers to the 5 questions (restated, in brief):

1. A spurious matter without a negative impact?

Not in the least! Possessing an active medical license is more of a privilege than a right, and licensed physicians are expected to face their patients, and the public, with exemplary professional behavior. When a chain of events prompted by flawed decision-making culminates in witnessed behaviors that can readily be deemed unprofessional, complaints to the licensing board, employment actions, and lawsuits may ensue. Once any or all of those “cats are out of the bag,” the involved physicians typically find themselves caught up in a complex, time-consuming, and pricey medicolegal matter that may take months or even years to resolve. In colloquial terms, it is almost impossible to get such a “cat” back in the bag. When significant professionalism concerns arise publicly, the burden of proof typically shifts to the physician, who then needs to demonstrate that they are not at risk of behaving unprofessionally in the future. It is very, very difficult to “prove a negative” to the satisfaction of risk-averse and publicity-sensitive regulatory bodies and employers.

2. What professional boundaries were violated?

Drinking heavily in a public setting where crossing paths with patients may likely occur is a bad idea, because alcohol’s disinhibiting effects promote bad decision-making. When psychiatrists accept gifts of various sorts from patients, they may find themselves entering onto a slippery slope without even realizing it.

 In this case, the gift of potent drinks that raised the blood alcohol concentrations of 2 psychiatrists became extremely problematic.

Also, alcohol-fueled intimacy between current work colleagues is never a good idea and has the potential to blow up.

3. What about drinking and the role of alcohol in this professionalism lapse?

Psychoactive substance misuse should always be considered a contributing factor when evaluating unprofessional behavior in health professionals.

 The anecdote demonstrates how physicians with a casual, if not cavalier, attitude about drinking sometimes find themselves “busted” by the likes of medical leaders, HR departments, employers, organizational attorneys, and regulatory bodies. Public drinking by physicians is potentially problematic, especially when it takes place in a setting where meeting up with one’s patients is not unlikely. Free shots of high-potency alcohol were the tipping point in this anecdote, and accepting them as a gift from a patient was extremely problematic. The shots may not have been consumed if the pitcher of beer had not preceded them.

The alcohol-fueled encounter at the table was a clear boundary violation that set other problematic interactions in motion. The Uber ride with the patient and the abrupt discontinuation of treatment come immediately to mind. The culmination of this seemingly innocent attempt to “have a drink after work” was a problematic sexual encounter between 2 physicians “under the influence.” Career-derailing criminal charges sometimes emerge in situations like the one described. In some states, one or both of these physicians might be referred to the state’s physician health program, and after careful assessment, recommendations of specialized treatment and abstinence monitoring may ensue.

Physicians who behave unprofessionally, for whatever reason, may jeopardize their training and employment status, as well their ability to be credentialed and maintain a “clean” license. In this anecdote, the patient who bought the shots has the potential to assert that she was victimized by one or both psychiatrists, and a lawsuit—spurious or not—is possible. Allegations of rape are sometime made when a more intoxicated individual asserts that a less intoxicated individual took advantage of them sexually. Physicians charged with felonies, even without a conviction, find it extremely difficult to progress in their careers.

-Avoid drinking in settings close to work.

-Drink sparingly, especially when in public. Out of an abundance of caution, health professionals who are safe to consume alcohol may want to reduce the NIAAA’s recommended daily and weekly maximum drinking limits by as much as half.

-Before accepting a gift from a patient, ask yourself what could go wrong. “No thanks” is the safest default stance. Recreational substance use has no place in the relationship between mental health professionals and patients.

-Initiating sexual involvement with a colleague is a decision not to be taken lightly. It should be considered with great care and forethought. It should never take place if a power differential exists between the 2 individuals.

-Sexual involvement that is fueled by recreational substance use is fraught with complexity. It may lead to potentially catastrophic unintended consequences.

Concluding Comments on the Scope and Range of Professional Boundary Challenges

Historically, the private practice of psychiatry, psychotherapy, and psychoanalysis has at times occasioned egregious boundary violations.

 In our current hyper-technological era with an environment of rapid-paced and commodified service delivery, health professionals in all specialties and disciplines are at risk of stepping or veering out of bounds. The risk extends beyond patients; it includes colleagues, subordinates, and the public at large. Medical boards throughout the United States have investigated and disciplined physicians for serious digital boundary violations, some of which may have been “innocent” from the physician’s perspective. We are well advised to consider the boundary-violating potential of all our online communications.

Our profession calls on us to establish trust and rapport with each patient. In order to help patients, we hope that they will communicate openly with us about deeply personal situations, behaviors, thoughts, and feelings. The art of psychiatry involves mastering the ability to conduct in-depth interviews and conversations with patients in a caring and nonintrusive way. This task is inherently demanding and may even be onerous at times. Consequently, it may help us to assume that boundary challenges are in the air during each and every mental health encounter.

Professional boundary issues likely exist on a continuum. This is derived from the work of Gutheil and Gabbard, who distinguished between boundary crossings and violations.

Typically, we are most familiar with boundary issues that involve communications, behaviors, or actions with sexual and/or intimacy content. Outside of the interrelated realms of sexuality, intimacy, and seductiveness, there are numerous nonsexual domains where boundary challenges exist. The full range of sexual and nonsexual boundary violations, and how to prevent them, is covered in a 2008 book by Gutheil and Brodsky.

 Although some individuals’ boundary issues may be predominantly sexual or purely nonsexual, individuals with a tendency to “cross the line” may manifest boundary slippage in multiple domains. As in the anecdote we started with, it is not uncommon for slippage, crossings, and violations to occur in conjunction with substance misuse (

). PBI Education, an established professional boundary remediation program that focuses on health professionals, provides a list of boundary problems as common reasons for referral, which can be seen in the following section.

Common Reasons for Referral to a Professional Boundary Remediation Program

-Addictions (chemical, behavioral [ie, gambling, pornography, etc])

-Dual relationships (inappropriate financial, business, or nonsexual social relationships, including with coworkers or trainees; prescribing to friends, family, or coworkers)

-Failure to use a chaperone when indicated or requested

-Inappropriate use of social media, text, or email with patients/significant third parties, coworkers, or students

-Lending or borrowing money, or giving gifts to coworkers, students, or patients or their significant third parties

-Sexual boundary violations (examination of sensitive body areas without gloves, sexualized language, looks, or physical contact even if consensual with current or former patients, coworkers, students, or patients’ significant third parties)

-Supervisory issues (inadequate supervision/delegation, insubordination)

A very wise hospital attorney once advised successive classes of psychiatry residents to avoid professional jeopardy by “imagining the headline.” As we face patient after patient, encounter after encounter, and boundary challenge after boundary challenge, we are well-advised to consider the various slippery slopes that present themselves in the course of our engagement with every single person. Some might say it has never been easier to slip and find yourself at the bottom of a steep hill, bruised and unable to get right back up. It is not a small accomplishment to connect with each patient and provide the help that they need while, at the same time, staying above reproach. Do not be shy about asking for input from trusted mentors if you find yourself starting to slip.

a coaching and consulting psychiatrist and is board-certified in psychiatry, addiction medicine, and coaching (BCC). He launched 

after 8 years directing Physician Health Services, Inc. Dr Adelman is on the faculty of the University of Massachusetts Medical School and serves a consultant in psychiatry in the Division of Alcohol and Drug Abuse of McLean Hospital, an affiliate of Harvard Medical School. He serves as 

Professionalism and Ethics: Q & A Self-Study Guide for Mental Health Professionals.

Boundaries, professionalism, and malpractice in psychiatry.

The price of a gift: an approach to receiving gifts from patients in psychiatric practice.

Disruptive physician behavior: use and misuse of the label.

5. US Department of Health and Human Services; National Institutes of Health; National Institute of Alcohol Abuse and Alcoholism. 

Helping Patients Who Drink Too Much: A Clinicians’ Guide. 

https://pubs.niaaa.nih.gov/publications/practitioner/cliniciansguide2005/guide.pdf

Professional boundary violations by physicians.

Professional ethics for digital age psychiatry: boundaries, privacy, and communication.

The concept of boundaries in clinical practice: theoretical and risk-management dimensions.

Preventing Boundary Violations in Clinical Practice.

10. PBI Education Professional Boundaries Course. PBI Education. Accessed August 24, 2022. 

Here’s how to stay professional in difficult situations. 

Avoid “Shots in the Dark” to Maintain Pristine Professional Boundaries 

All allegations of sexual abuse by children must be taken seriously. Data suggest that the overwhelming majority of children’s allegations are legitimate and true.

 But, in certain situations and circumstances, a child may lie and make up false allegations of abuse. This phenomenon is seen most commonly in child custody cases and in criminal cases.

As a clinical and forensic psychologist, I am often enlisted to help a parent prove his or her innocence in a 

. My task, in these instances, is to try to understand why a child would fabricate a story of sexual abuse against his or her close family member. Based on my experience, here are some of the reasons children lie:

1. Children sometimes make up allegations of sexual abuse because they are looking for attention. When children feel neglected by their parents, they may be inclined to fabricate a story of sexual abuse because they know it will bring them attention. With some kids, negative attention is better than no attention at all. Young children and even teens will make up a story of sexual abuse without understanding the serious custody or criminal implications for the parent in question.

2. A child who is angry with a parent may decide to accuse that parent of sexual abuse. For example, a child might be mad at a parent for seeking a divorce, or for real or perceived favoritism of a sibling.

3. Children, particularly those embroiled in dysfunctional family situations, sometimes falsely report sexual abuse to have the accused parent removed from the child’s life. For example, a girl who has a rocky relationship with her father or stepfather may accuse him of sexual abuse to remove him from the family because of his verbal hostilities, drug abuse, or overly harsh discipline.

4. In contentious child custody cases, a child may fabricate a story of sexual abuse against one parent at the encouragement of the other parent who 

wishes to gain leverage in the legal proceeding

. Children and teens are especially susceptible to suggestions, manipulation, brainwashing, and coaching by a parent.

5. Some children make up a story of sexual abuse against a parent to “explain away” their own sexual misbehavior or other inappropriate actions. For example, a child might accuse a parent of sexual abuse who has recently discovered that the child has been sneaking out of the house to have sex. Or a child might lie about parental sexual abuse after being arrested for shoplifting. 

Red Flags for Detecting Children’s False Claims

In every case of alleged sexual abuse, the mental health expert must approach it with an open mind.

 All possible hypotheses should be explored; tunnel vision must be avoided. It is imperative to consider all available evidence to either corroborate or refute the claim of sexual abuse. While most claims of sexual abuse are true from a statistical standpoint, some are lodged falsely and must be exposed. In a 

, a parent’s custodial time can be lost if the allegation is not debunked. In a criminal case, a parent’s very freedom is at stake since incarceration is a probable penalty.

There are several red flags that point to a false allegation of sexual abuse by a child. These include:

1. In a forensic interview, a sexually abused child is typically anxious, scared, worried, conflicted, ambivalent, and prone to recantations. In contrast, a child who is calm, cool, collected, and smooth may be fabricating the allegation of abuse.

 While this rule of thumb holds true, there are of course exceptions.

2. A timeline of events and actions will often reveal a fabricated allegation. An allegation of sexual abuse that occurs within days or a few weeks of a major event can reflect a fabricated story. For example, I had a case where an allegation of sexual abuse occurred within 72 hours of a husband asking for a divorce. The wife was shocked and scared of losing custody of their 3 children. The allegation of abuse was lodged to gain leverage in the child custody battle that was imminent.

3. If the first allegation of sexual abuse occurs during a divorce and/or child custody proceeding, a fabricated story should be considered. If multiple allegations are made during the proceeding, that is a huge red flag for fabrication.

4. If it is well-established that a child is being manipulated or coached by a parent, that child’s allegation of sexual abuse against the other parent must be scrutinized. As mentioned earlier, children and teens are easily manipulated by a parent and can be unwitting participants in a false allegation claim.

5. If the parent in question does not have a prior history of inappropriate sexual activity, criminal behavior, or serious substance abuse, it is more likely that the current allegation of sexual abuse is false.

6. If the child or a member of the family has a history of making previous similar allegations of abuse against others, it is more likely that the current allegation claim is false.

7. Some children, especially younger ones, will believe sexual abuse happened to them if they are repeatedly asked leading questions by a parent, investigator, or evaluator. Children want to please authority figures and will take their cues from them. In such circumstances, very young children have a difficult time distinguishing fact from fantasy.

8. Sometimes a parent will misconstrue or misinterpret what a child says and then magnify it into an act of sexual abuse. This happens with younger children most often. For example, if a father touches a young child’s “private parts” while giving a bath.

As I have encountered first-hand in cases, most adults find it implausible that a child would make up a false allegation of sexual abuse against a close or extended family member. Attorneys, mediators, district attorneys, judges, and even mental health practitioners make the mistake of taking a child’s word at face value without careful determination of its truthfulness.

False allegations of abuse by children do happen in both custody and criminal cases. Children lie for a variety of reasons and those reasons must be exposed. That is the task of the mental health professional in such a case.

Finally, it is also important to note that the number of false allegations of child sexual abuse is lower than the number of children who do not disclose such abuse or who lie by saying it did not occur.

 To be clear, sexual abuse of children continues to be a major problem and we must not turn a blind eye to the enormity of the psychological damage to our youth.

is a clinical and forensic psychologist in private practice in Birmingham, Alabama. He is also clinical associate professor in the department of psychology at the University of Alabama at Birmingham. Dr Blotcky can be reached at alanblotcky@att.net.

The opinions expressed are those of the author and do not necessarily reflect the opinions of

1. Cyr M, Bruneau G. False allegations of child sexual abuse. In: St-Yves M, Tanguay M, eds. 

The Psychology of Criminal Investigations: The Search for the Truth

Children’s suggestibility: characteristics and mechanisms.

3. London K, Bruck M, Ceci SJ, Shuman DW. 

Disclosure of child sexual abuse. What does the research tell us about the ways that children lie?

4. O’Donohue WT, Fanetti M. Forensic Interviews Regarding Child Sexual Abuse: A Guide to Evidence-Based Practice. Springer International Publishing; 2016.

5. Blotcky AD. Child abuse allegations: sorting out lies versus truths. 

https://www.psychiatrictimes.com/view/child-abuse-allegations-lies-versus-truths

An examination of the types of leading questions used by investigative interviewers of children.

Policing An International Journal of Police Strategies and Management.

. False statements and the differential diagnosis of abuse allegations.

Here’s how to distinguish false allegations of sexual abuse. 

False Allegations of Sexual Abuse

The following poster presentations at the American Pharmacists Association (APhA) Annual Meeting & Exposition highlighted a number of changes facing psychiatry today.

Concurrent Benzodiazepine, Opioid Use Risks

Because more than 30% of overdoses involve a combination of benzodiazepines and 

, and more than 115 Americans die from opioid overdose every day, the investigators conducted this study to assess how much patients know about the increased risk of adverse events, overdose, and death associated with taking 

 and opioids concurrently. They also focused on the role of education, surveying study participants both before and after educational intervention. The study included 9 participants (33% male; 66% female; median age 59 years) who had been prescribed a benzodiazepine (Xanax [alprazolam], 77%; Klonopin [clonazepam], 22%; or Ativan [lorazepam], 11%) and an opioid (Norco [hydrocodone/acetaminophen], 55%; Percocet [oxycodone/acetaminophen], 22%; Roxicodone [oxycodone], 11%; or Roxanol [morphine sulfate], 11%). Participants were surveyed both before and after receiving information detailing the increased risks associated with concurrent benzodiazepine and opioid use. Each survey asked them to rank their knowledge of the medications, the potential adverse effects and 

 risk of the medications, and the risks of alcohol consumption on a scale from “unaware” to “minimal” to “good” to “excellent.”

In the presurvey, each knowledge category was divided among “excellent,” “good,” and “unaware” rankings, with “minimal” only appearing in the knowledge of overdose category at a little over 20%. Most participants ranked their knowledge as “excellent” in only the knowledge of medications category (a little more than 40%), with “good” leading the rankings in the potential adverse effects and alcohol consumption categories nearly 60% and a little more than 40%, respectively. Around 20% of participants ranked their knowledge as “unaware” across all 4 knowledge categories. In the postsurvey, no participants ranked their knowledge as “unaware” or “minimal” in any category. In both the knowledge of medications and the potential adverse effects categories, patients ranked their knowledge as “good” or “excellent” at around 80% and around 20%, respectively. In knowledge of 

, the majority of participants (around 90%) ranked their knowledge as “excellent,” with the remaining 10% ranking it as “good,” and 100% of participants ranked their knowledge of overdose—the category with the most varied results in the presurvey—as “excellent.”

Although patient education resulted in clear improvement of self-reported knowledge and understanding, only 1 participant changed their medication regimen to lower the risks of adverse events. According to the investigators, this means that patients are reluctant to change their prescribed medications even with greater awareness of the risks.

“Overall, patients can have a good baseline knowledge, but the results of this study demonstrate how pharmacists can further improve patient understanding… and knowledge of the medications [patients] are currently prescribed,” the investigators concluded.

In their poster presentation, Kafi Friday, BA, PharmD candidate 2023; and Prashant Sakharkar, PharmD, MPH, explained that sexual minorities, or individuals with nonheterosexual sexual orientation, face increasing challenges in achieving health equity, due to stigma and discrimination.

 Via a retrospective cohort study, the investigators sought to examine health disparities and level of depression among 

; compare the prevalence of sexually transmitted infections, 

, illicit drug use, and alcohol use in use in sexual minorities; and determine predictors of depression among sexual minorities.

The study’s results painted a grim picture for sexual minorities: sexual minorities were 3 times more likely to have gonorrhea and chlamydia infection, 65% more likely to use illicit drugs, 52% more likely to be a smoker, 3 times more likely to experience 

, and 2 times more likely to see a mental health clinician.

These findings suggest that depression can be a consequence of health and behavioral disparities. Screening—particularly in females who identify as a sexual minority, smoke, use illicit drugs, are under the age of 45, and are poor—might help in early intervention. Furthermore, the investigators noted future research should examine the association of depression, 

Want to learn more on the advances in psychiatry? Join us this August at the 2022 Annual 

™ World CME Conference. For more information and to register, visit 

1. Baciu A, Negussie Y, Geller A,alWeinstein JN, eds. 

Communities in Action: Pathways to Health Equity.

Catch up on all the latest from the American Pharmacists Association (APhA) Annual Meeting & Exposition.

APhA Conference Addresses Depression, Benzos

Teralyn Sell, PhD, MS, NCC, LPC, shares tips on how to improve patient libido, which can greatly impact mental health. 

holds a doctorate in psychology and is the founder of Pro Recovery Rx, a supplement line dedicated to supporting brain health for individuals in addiction recovery. She also teaches a class called NeuroHealth Coach, which helps professionals integrate brain health into their daily lives.

What 3 emotional stressors may be impacting your patient's sex drive? 

3 Emotional Stressors That Impact Libido

Kafi Friday, BA, PharmD candidate 2023; and Prashant Sakharkar, PharmD, MPH, shared their poster “Examining Health Disparities and Level of Depression among Sexual Minorities: A Population based Cross-sectional Study” at the American Pharmacists Association 2022 Annual Meeting and Exposition.

Friday and Sakharkar argued that sexual minorities, or individuals with nonheterosexual sexual orientation, face increasing challenges in achieving health equity, due to stigma and discrimination.

 In a retrospective cohort study, the investigators sought to examine health disparities and level of depression among sexual minorities; compare the prevalence of sexually transmitted infections, smoking, illicit drug use, and alcohol use in use in sexual minorities; and determine predictors of depression among sexual minorities.

The study’s results painted a grim picture for sexual minorities: sexual minorities were 3 times more likely to have gonorrhea and chlamydia infection, 65% more likely to use illicit drugs, 52% more likely to be a smoker, 3 times more likely to experience severe depression, and 2 times more likely to see a mental health clinician.

These findings suggest that depression can be a consequence of health and behavioral disparities. Screening—particularly in females who identify as a sexual minority, smoke, use illicit drugs, are under the age of 45, and are poor—might help in early intervention. Furthermore, future research should examine the association of depression, gender, and sexual minority status.

1. National Academies of Sciences, Engineering, and Medicine; Health and

Medicine Division; Board on Population Health and Public Health Practice;

Committee on Community Based Solutions to Promote Health Equity in the

United States; Baciu A, Negussie Y, Geller A, et al. 

According to this study examining sexual minority patients, depression can be a consequence of health and behavioral disparities. 

A Consequence of Health Disparities: Depression Among Sexual Minorities

In 1970, a group of gay and lesbian activists made history when they disrupted the annual meeting of the American Psychiatric Association (APA) in San Francisco. Outside the convention center, they formed a human chain to prevent visiting psychiatrists from entering. Inside, they interrupted sessions on transsexualism, laughed at a purported expert on homosexuality, and were so disruptive that a panel titled “Issues of Sexuality” it had to be adjourned.

A year later, they returned with the same demand: delist homosexuality from APA’s Diagnostic and Statistical Manual—where it had been classified as a sexual deviation.

In 1972, the APA allowed a panel of gay activists to make their case. Among them was John E. Fryer, MD, a psychiatrist who appeared in disguise, worried he might lose his license because he was gay.

In 1973, the APA put the issue to a vote, with the majority of attending psychiatrists agreeing to remove homosexuality as a mental disorder from DSM-III. However, the APA compromised by replacing the term 

. This, they argued, would allow homosexuality to be considered an illness if an individual distressed with being gay sought psychiatric help to reverse it.

The APA took the final step in 1987 and dropped this reference completely. They officially adopted what is considered a normal variant view on sexual identity. Individuals could, they acknowledged, be born gay.

It is against this backdrop that the uneasy relationship between psychiatry and the 

lesbian, gay, bisexual, transgender, queer, and intersex community

 (LGBTQI) continues to evolve. While there are far more protections than there were in the 1950s, this is a group that still struggles to find acceptance, especially its 

The ideal model of health care is that patients receive unbiased care regardless of gender identity or sexuality. In reality, however, clinicians may both consciously and subconsciously discriminate against members of the LGBTQI community, causing many to forego needed care.

 associated with minority stress, or the unique experiences associated with homophobic victimization.

 Many grapple with feelings of shame, rejection, and depression. They are the target of abuse, trauma, and bullying. As a result, they experience higher rates of homelessness, substance abuse, and suicide.

As mental health professionals, it is our ethical responsibility to identify our biases as clinicians. We need to educate ourselves about the needs of this unique and ever-evolving population, to provide the best care possible, and to do so in a way that does not perpetuate the stigma and trauma many sexual minorities contend with daily.

Health Disparities in the LGBTQI Community

As of 2017, there were 9 million adults in the United States, about 3.8% of the country’s population, who 

identified as lesbian, gay, bisexual, or transgender

It takes incredible courage to come out in front of family, friends, school, work, and society at large. It can be an extremely vulnerable experience that can elicit reactions of anger, rejection, and even violence from others. Additionally, there are many subpopulations within the LGBTQI community that have their own unique risk factors that must be considered in the context of care.

, 39% said they had been rejected by a family member or friend because of their sexual orientation. About 30% said they had been attacked or threatened because of it, and 58% said they were the target of jokes or slurs.

LGBTQI individuals are more than twice as likely to experience a mental disorder compared to heterosexual men and women. They are also 2.5 times more likely to experience depression, anxiety, and substance misuse.

Almost 12% of gays, lesbians, and bisexuals have considered attempting suicide, compared to 2.3% of heterosexual individuals. With transgender individuals, this number jumps significantly to 30.8%.

Another big challenge facing the LGBTQI community is substance abuse and homelessness. 

 on drug use and health revealed that 39.1% of sexual minorities used illicit drugs, compared to 17.1% among sexual majorities.

 than non-LGBTQI youth. And black LGBTQI youth were even more at risk for homelessness. While 7% of black non-LGBTQI youth were homeless in the United States, that number jumped to 16% for black LGBTQI youth.

These statistics for youth are particularly troubling. More youth are coming out as gay or transgender at younger ages, perhaps due to the growing social acceptance for LGBTQI communities. The average age of coming out was around 14 years old, according to data collected between 2000 and 2010. A decade earlier, this age was 16. In the 1970s, it was 20. Despite this trend, concerns about the rising prevalence of adolescent LGBTQI mental health issues are increasing.

Perhaps because they are already grappling with identity development, adolescents are already at increased risk for suicide; it is a 

 LGBTQI youth, however, tend to have higher rates of mental health issues, with 18% meeting the criteria for depression, 11.3% experiencing posttraumatic stress disorder, and 31% reporting suicidal behavior at some point during their lives. This compared to national youth rates of 8.2%, 3.9%, and 4.1%, respectively.

The reason behind these rates may have to do with increased peer pressure experienced during these ages. One 2012 study pointed to stronger prejudicial attitudes and homophobic behaviors among youth 12 to 18 years old, especially among boys.

 revealed that 86% of LGBTQI students experienced harassment or assault at school, according to the Gay, Lesbian, & Straight Education Network (GLSEN), a national organization that supports the LGBTQI community in K-12 schools.

When LGBTQI people turn to mental health providers for help, they are often let down. Almost one-sixth of LGBTQI adults have felt discriminated against at a doctor’s office, while one-fifth say they avoid medical care altogether due to their fear of discrimination, 

 conducted by Harvard University, National Public Radio, and the Robert Wood Johnson Foundation.

A 2018 Harvard panel said health care providers were woefully unprepared to address the needs of the LGBTQI community. Panelists said providers needed to do a better job gathering data about these patients, even if it meant asking them direct questions about their sexual health.

 For many providers, improvements in mental health care must be based on increased education and understanding of how different people experience and express gender identity.

Understanding Gender Identity and Expression

Today, there are increasing efforts being made to explore what, exactly, gender is and how it should be defined. In Eurocentric models rooted in colonialism, gender has been identified as a 

that distinctly categorizes individuals as either male or female based on their sex.

 It operates on the idea that gender can be visually seen as a bodily characteristic, with males having penises and females having vaginas. Gender-identity research is shifting away from this binary approach and acknowledging that the idea of gender exists on a spectrum. It is not defined by simplistic biological characteristics and is 

While our understanding of the concept of gender is evolving, gender has been postulated to encompass 4 parts: anatomical sex, gender identity, legal gender, and gender expression. Anatomical sex generally refers to genitalia, chromosomes, and bodily attributes. Gender identity refers to one’s sense of self, which can be fluid and change over time and within context. Legal gender is tied to an individual’s assigned gender at birth and is used as a way to measure differences between genders, such as health and wage disparities. Gender expression is how a particular individual presents their gender identity to society, usually through appearance, dress, and behavior. Cisgender refers to those whose self-defined gender identity matches their assigned gender at birth. Transgender refers to others whose assigned gender at birth does not match their self-identified gender.

The problem with a simple binary description of gender identity tends to be with its limitations. In research studies, for example, most demographics include gender responses with very little reflection on why it is included or 

 This standard fails to consider findings related to other gender identities, which can provide results that are inaccurate or misrepresented. Additionally, by only giving male or female as gender options, it immediately discriminates against anyone who does not identify as either.

This discrimination continues in other areas. Even though APA’s recognition of gender dysphoria as a diagnosis is not necessarily stigmatizing, it is the gatekeeping of care that perpetuates the stigma. In addition to a gender dysphoria diagnosis, transgender individuals, for example, need to jump through significant hoops to access gender-affirming care—including psychological evaluations, letters of support, and therapy.

These are just some examples of how the mental health community needs to shift awareness to treat a population desperately in need of treatment and acceptance.

For decades, psychiatry viewed being gay as a degenerative disorder. It created a deep scar that the mental health industry must now work to mend by setting aside biases, broadening our understanding, and earning the trust of LGBTQI patients. To do so, it is vitally important to refrain from making assumptions about a patient’s gender, sexuality, or sexual identity. It is always necessary to ask about an individual’s pronouns. Do not refer to them as preferred pronouns; they are simply pronouns.

Clinicians are obligated to be aware of their own biases, both conscious and subconscious, that can potentially negatively influence the care provided to their clients. This will help avoid any countertransference of opinion from provider to client.

Creating a therapeutic container is essential for holding patients in a safe place that allows them to express any feelings of pain and shame.

 This is based on Carl Jung’s concept that compares the therapeutic container to an alchemical container that safely holds the feelings and thoughts of patient and analyst alike.

 authors Caroline Shahbaz, BBSc(Hons), MPsych, MA; and Peter Chirinos, MA, LPC, NCC, DCC; offer the following guidelines to create a therapeutic container:

- Validate the sociopolitical issues confronting a patient’s marginalized community

- Do not assume their psychological problems are a function of their sexuality

- Connect patients with appropriate communities and networks

LGBTQI patients may engage in sexual activities that a provider may find disturbing and uncomfortable, which is indicative of a clinician’s own conscious and unconscious biases that can impede a patient’s progress in care. As with any patient population, when treating sexual minorities, competent care as it relates to this population must be the standard of practice and directly translates into making patients feel accepted and validated.

The uneasy relationship between psychiatry and the LGBTQI continues to evolve. How can it be influenced for the better? 

Sexual & Sexuality

Avoid “Shots in the Dark” to Maintain Pristine Professional Boundaries

False Allegations of Sexual Abuse

APhA Conference Addresses Depression, Benzos

3 Emotional Stressors That Impact Libido

A Consequence of Health Disparities: Depression Among Sexual Minorities

Bridging the LGBTQI Gap in Care: Why Psychiatrists Need To Do More To Treat These At-Risk Communities

What Is an SGM Community?

The Negative Impact of Current Legislation on Gender Diverse Adolescents

Special Considerations for SGM Youth Online

What Constitutes an SGM Community?