Mental health providers encounter and provide treatment to those who identify as lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+) in a variety of mental health care settings. To deliver culturally competent, appropriate, and effective mental health care to LGBTQ+ patients, it is important to first acknowledge the effect of stigma. Stigma can include, but is not limited to, employment discrimination, verbal harassment, and physical violence.1 A recent survey in the United States found that 76% of gay or bisexual respondents had experienced an episode of discrimination, whereas 21.4% of lesbian, gay, or bisexual respondents reported being discriminated against over the past 12 months.2 Another study showed 56% of transgender respondents experienced verbal harassment, 37% experienced employment discrimination, and 19% were victims of physical violence.3
There are two traditional models that provide a foundational framework for understanding the mental health disparities between LGBTQ+ people and their cisgender heterosexual counterparts.4 One, the Minority Stress Model, describes the stress processes that include experiences of prejudice, personal expectations of rejection, hiding and concealing one's identity, internalized homophobia, and subsequent coping strategies.5 These experiences, in addition to everyday stressors, are hypothesized to disproportionately compromise the mental health of LGBTQ+ people. Second, the Socio-Ecological Model implies that mental health outcomes are the result of interplay between structural (societal norms, conditions, laws, policies and practices), interpersonal (everyday interactions), and individual (beliefs and behaviors) forms of stigma.1 These two widely accepted models suggest that the mental health disparities that exist for LGBTQ+ people compared to cisgender heterosexual people are the result of disproportionate exposure to stigma-related stress.1,5
A third newly proposed term, Compounded Stigma, as further discussed by Rojas et al.6 in this issue of the journal, further addresses the additive and cumulative effect of one's simultaneous membership to multiple marginalized groups of people who suffer from a mental health disorder, addiction, trauma, and also identify as LGBTQ+.
Current research indicates that LGBTQ+ people experience higher rates of mental health problems compared to their cisgender heterosexual peers.7,8 Stress, anxiety, and depression are more common in this group, which negatively affect various aspects of mental and physical health.9 Previous research has demonstrated that LGBTQ+ adults are especially affected by stress-related mental health conditions, being twice as likely as their cisgender heterosexual counterparts to develop major depressive disorder, anxiety, and substance use disorders.10
Similarly, LGBTQ+ youth show an increased risk for a number of negative mental health outcomes compared to their cisgender heterosexual peers.11 Multiple studies have concluded that LGBTQ+ youth experience elevated rates of emotional distress, mood and anxiety disorders, self-harm, suicidal ideation, and suicidal behavior when compared to cisgender heterosexual youth.12,13 For example, one study showed that LGBTQ+ youth have an increased risk for major depression, generalized anxiety disorder, conduct disorder, substance use disorders, suicidal ideation, and suicide attempts compared to their cisgender heterosexual peers.14
The Centers for Disease Control and Prevention estimate suicide to be the third most common cause of adolescent death in the US.15 There is a substantial body of evidence that demonstrates an even higher risk of suicidal ideation, suicide attempts, and completed suicide by adolescents who identify as LGBTQ+.
A recent meta-analysis reviewed risks of suicide attempts in 2,378,987 cisgender heterosexual and 113,468 LGBTQ+ youth age 12 to 20 years.16 Data were compiled from 35 studies conducted in 10 countries and reported in 24 articles. This study demonstrated an increased rate of attempted suicide for youth who are sexual minorities compared to their cisgender heterosexual peers, with transgendered youth at the highest risk.
Another study evaluated suicide statistics from the National Violent Death Reporting System (NVDRS).17 The NVDRS collected data for people age 12 to 29 years (N = 10,311) between 2013 and 2015 who died by suicide in the US. Of the total completed suicides, 2,209 identified as LGBTQ+. A startling 24% of the completed suicides for those between ages 12 and 14 years identified as LGBTQ+. These data suggest that LGBTQ+ youth are more vulnerable to suicide between ages 12 and 14 years, with a decreasing trend as age progresses.
Although LGBTQ+ people have higher rates of psychological disorders, notwithstanding, they often do not seek treatment or are less forthcoming during their appointments compared to their cisgender heterosexual peers due to stigma, prejudice, and discrimination by people in the medical community.10 Explicit homophobia in health care exists, including refusal to provide accepted standard of care.18 For example, in a 2007 survey, 16% of physicians surveyed reported that they were “sometimes” or “often” uncomfortable providing treatment to gay patients.19 Another study of nearly 250 third- and fourth-year medical students found that less than one-half of the students asked their patients about same-sex behaviors and 28% said that they were uncomfortable addressing an LGBTQ+ patient's health needs.20
Psychological Testing and Neurocognitive Assessment of LGBTQ+ People
The history of psychological and neuropsychological assessment among LGBTQ+ people, particularly transgender patients, is discouraging. Normative data for standardized testing instruments is minimal for LGBTQ+ people and almost nonexistent for transgender people.21 Although the literature affords some recommendations and guidelines for approaching general psychological practice with LGBTQ+ patients, we were unable to find any established standard assessment guidelines.21,22
Providers are encouraged to develop an understanding of cultural variables, social challenges, and potential stressors specific to this population (eg, gender identity, surgical candidacy consideration) to provide accurate and ethical interpretation.21,22 Having an awareness of the possible effect of genetic determinants of sex, hormone therapy, and surgical procedures on health, mood, and cognition is essential.21,22 It is important to recognize and maintain an understanding of individual differences.21,22
Assessments of mood and personality are often used in the clinical care of LGBTQ+ people, particularly given the high rates of mental health problems supported and due to an increased risk for mistreatment, harassment, violence, and discrimination. Suicide assessment that extends beyond a standard approach is important. However, standard interpretation with some of these measures may be swayed by variables specific to LGBTQ+ people because they are likely to experience more long-term social stress, gender dysphoria, and oppression than their cisgender heterosexual peers. For example, the standard Minnesota Multiphasic Personality Inventory for Adolescents23 and the Minnesota Multiphasic Personality Inventory-224 interpretation is not recommended, as it could lead to over-pathologizing the patient. For example, scale elevations have been observed on the hypochondriasis, hysteria, depression, masculinity/femininity, and paranoia scales among LGBTQ+ patients.21
Tests with nongender-based normative data (eg, Beck Depression Inventory, 2nd ed.; Symptom Checklist-90-Revised) are more appropriate assessment tools when evaluating the LGBTQ+ patient's mood and personality.21,22 If a nongendered scoring option does not exist, scoring the test with both male and female normative data may be preferred.21,22 When this approach is executed, the provider is able to consider scores from both groups, emphasizing results that best align with other obtained information.21,22 If a test is unable to be scored twice, scoring that uses norms for the recognized gender identity may be more appropriate.21 Incorporating scales that assess gender minority stress may be helpful to delineate the potential effect (eg, Gender Minority Stress and Resilience Scale).21
With cognitive measures and neuropsychological assessments, the recommendations mentioned above remain applicable. In addition, incorporation of at least one test within each cognitive domain of interest that does not involve gender-based norms may be helpful, at least for the purpose of comparison.21 Emotional assessment should remain a propriety given rather strong indications regarding the potential for mood symptoms in association with treatments, environmental factors, and identity issues, and possible secondary effect on cognition.21,22 Motor testing has long-established gender norms, which also may be affected through hormonal changes, and therefore interpretation requires careful consideration.22
Although transgender patients may present with surgical candidacy decisions for assessment, we were unable to find specific guidelines or a standardized interview for this purpose. A comprehensive interview, which should include gender identity development and feelings, as well as the understanding of and expectations relating to the procedure, is recommended, with further goals to address standards of capacity.21 Assessments may be reserved for addressing any questions regarding capacity and mental status that remain.21
In reporting, provider impressions would be best to explicitly include a discussion about all of the limitations to interpretation for transparency. This discussion should include the implications of gender status on normative data and the procedures used for diagnostic decision-making.22 Optimal patient feedback regarding assessment results may include more detailed discussion regarding the approach to interpretation, use of normative data, and limitations of interpretability.22
Psychological Treatment of LGBTQ+ People
The American Psychological Association, seeing a need to provide clear and accurate support for LGBTQ+ patients, issued guidelines for psychotherapy with LGBTQ+ patients promoting the use of affirmative therapy.25 Affirmative therapy is defined as culturally relevant and responsive, aware of the myriad issues of injustice affecting clients, and is ultimately empowering.26 In more than 90% of 49 psychotherapy studies reviewed, LGBTQ+ patients preferred providers to be highly knowledgeable about their unique culture. Patients in the studies also generally reported “helpful” therapists who were empathic, communicated positive regard, and demonstrated an ability to form a good working alliance.26 A recent study explored the relationship between affirmation and the therapeutic relationship.27 Results of this study indicated a positive correlation between affirmative practice and strength of the therapeutic relationship.27 Although the defining factors of an affirming stance may seem like common sense, what the patient is actually experiencing can be more difficult to determine from the mental health provider's perspective. A particular concern of providers should be their ability to assess the strength of the therapeutic relationship and how their LGBTQ+ patient experiences affirmation.
Provider intuition is generally an ineffective source from which to make accurate predictions related to patient care, including patient outcomes, the strength of the therapeutic alliance, and the provider's level of competence.28–32 Hence, if providers rely solely on their own internal assessment of how they are being experienced by their patients (eg, levels of patient-perceived provider affirmation or strength of the therapeutic relationship), there is a strong likelihood they will misattribute or incorrectly assume they have been successful in situations where the patient would disagree. This risks the provider being surprised by or failing to prevent patient deterioration or discontinuation of treatment. A crucial component of ethical care is reliance on other sources of feedback and assessment to gauge all patients' treatment experience.
One promising approach addressing this issue is routine outcome monitoring and alliance feedback.33 Another is the Session Rating Scale, which is a brief measure that focuses on this area of needed assessment.34 Regular use of such a measure by mental health care professionals can provide a reference point allowing a more accurate assessment of their current connection with the patient. When scores are low, that information can then be constructively applied to taking needed action for repairs or strengthening.
Intentional solicitation and use of patient feedback should be considered a required component to any psychotherapeutic work. Honoring patients as the expert on their unique experiences, as well as requesting feedback, also demonstrates that the provider is humble and willing to improve when needed.
Additionally, assessing and processing the LGBTQ+ patient's “coming out” experience (process that LGBTQ+ people go through as they work to accept their sexual orientation/gender identity and share that identity openly with other people) provides not only a wealth of clinical information, but also through the sharing of this milestone, psychotherapists and patients are given an opportunity for bonding and building a strong therapeutic alliance. Even if there are no identifiable issues surrounding coming out for the LGBTQ+ patient, by acknowledging and discussing this event, it demonstrates an affirmative approach by the provider. Issues that often surface as individual patients share their coming out story include family acceptance or rejection, past traumas such as bullying or teasing, spiritual or religious conflicts, self-esteem and self-concept issues, interpersonal issues within intimate relationships, and current support systems or lack thereof.35Table 1 lists questions a mental health provider working with an LGBTQ+ patient might consider asking.
Questions a Mental Health Provider Working with an LGBTQ+ Patient Might Ask
These questions help the mental health provider and patient identify treatment goals that might otherwise be missed if the provider did not openly explore these areas. As the therapeutic process develops, the provider, just by asking more questions, will have valuable information and understanding of how the patient's LGBTQ+ status might be a factor in other life domains such as family, work, self-concept, and interpersonal relationships. Discussing the patient's unique experiences as a member of the LGBTQ+ community may also offer therapeutic insight into the patient's overall personality style, how they view their self in relation to others, and how they may have developed both positive and negative defense mechanisms.
It is important for mental health providers who encounter and provide treatment to those who identify as LGBTQ+ to understand the predisposition of stigma and existing disparities in mental health problems for LGBTQ+ individuals, including the increased risk of suicide. It is necessary for providers to consider how the patient's LGBTQ+ status may affect the outcome results of various assessments because most normative data is most often based on cisgender heterosexual samples, and therefore, places the LGBTQ+ patient at risk of over-pathologizing. Furthermore, treatment for LGBTQ+ individuals should include components of affirmative therapy that not only demonstrate to the patient that the provider is open to treating someone who is LGBTQ+, but is also able to communicate and ask questions about the patient's unique experience as an LGBTQ+ person in relationship to their families, friends, employers, and the community as a whole.
- White Hughto JM, Reisner SL, Pachankis JE. Transgender stigma and health: a critical review of stigma determinants, mechanisms, and interventions. Soc Sci Med. 2015;147:222–231. https://doi.org/10.1016/j.socscimed.2015.11.010 PMID: doi:10.1016/j.socscimed.2015.11.010 [CrossRef]26599625
- Choi KH, Paul J, Ayala G, Boylan R, Gregorich SE. Experiences of discrimination and their impact on the mental health among African American, Asian and Pacific Islander, and Latino men who have sex with men. Am J Public Health. 2013;103(5):868–874. https://doi.org/10.2105/AJPH.2012.301052 PMID: doi:10.2105/AJPH.2012.301052 [CrossRef]23488483
- Bockting WO, Miner MH, Swinburne Romine RE, Hamilton A, Coleman E. Stigma, mental health, and resilience in an online sample of the US transgender population. Am J Public Health. 2013;103(5):943–951. https://doi.org/10.2105/AJPH.2013.301241 PMID: doi:10.2105/AJPH.2013.301241 [CrossRef]23488522
- Smedley BD, Stith AY, Nelson AR, eds. Unequal treatment: confronting racial and ethnic disparities in health care. https://www.nap.edu/catalog/10260/unequal-treatment-confronting-racial-and-ethnic-disparities-in-health-care. Accessed September 11, 2019.
- Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129(5):674–697. https://doi.org/10.1037/0033-2909.129.5.674 PMID: doi:10.1037/0033-2909.129.5.674 [CrossRef]12956539
- Rojas JI, Leckie R, Hawks EM, Holster J, del Carmen M, Ostermeyer BK. Compounded stigma in LGBTQ+ people: a framework for understanding the relationship between substance use disorders, mental illness, trauma, and sexual minority status. Psychiatr Ann. 2019;49(10):446–452. doi:10.3928/00485713-20190912-01 [CrossRef]
- Lee JH, Gamarel KE, Bryant KJ, Zaller ND, Operario D. Discrimination, mental health, and substance use disorders among sexual minority populations. LGBT Health. 2016;3(4):258–265. https://doi.org/10.1089/lgbt.2015.0135 PMID: doi:10.1089/lgbt.2015.0135 [CrossRef]27383512
- Keuroghlian AS, Ard KL, Makadon HJ. Advancing health equity for lesbian, gay, bisexual and transgender (LGBT) people through sexual health education and LGBT-affirming health care environments. Sex Health. 2017;14(1):119–122. https://doi.org/10.1071/SH16145 PMID: doi:10.1071/SH16145 [CrossRef]28160786
- Gay and Lesbian Medical Association. Guidelines for care of lesbian, gay, bisexual and transgender patients. https://www.rainbowwelcome.org/uploads/pdfs/GLMA%20guidelines%202006%20FINAL.pdf. Accessed September 11, 2019.
- Pachankis JE. The scientific pursuit of sexual and gender minority mental health treatments: toward evidence-based affirmative practice. Am Psychol. 2018;73(9):1207–1219. https://doi.org/10.1037/amp0000357 PMID: doi:10.1037/amp0000357 [CrossRef]30525805
- Russell ST, Fish JN. Mental health in lesbian, gay, bisexual, and transgender (LGBT) youth. Annu Rev Clin Psychol. 2016;12(1):465–487. https://doi.org/10.1146/annurev-clinpsy-021815-093153 PMID: doi:10.1146/annurev-clinpsy-021815-093153 [CrossRef]26772206
- Fleming TM, Merry SN, Robinson EM, Denny SJ, Watson PD. Self-reported suicide attempts and associated risk and protective factors among secondary school students in New Zealand. Aust N Z J Psychiatry. 2007;41(3):213–221. https://doi.org/10.1080/00048670601050481 PMID: doi:10.1080/00048670601050481 [CrossRef]17464702
- Marshal MP, Dietz LJ, Friedman MS, et al. Suicidality and depression disparities between sexual minority and heterosexual youth: a meta-analytic review. J Adolesc Health. 2011;49(2):115–123. https://doi.org/10.1016/j.jadohealth.2011.02.005 PMID: doi:10.1016/j.jadohealth.2011.02.005 [CrossRef]21783042
- Fergusson DM, Horwood LJ, Beautrais AL. Is sexual orientation related to mental health problems and suicidality in young people?Arch Gen Psychiatry. 1999;56(10):876–880. https://doi.org/10.1001/archpsyc.56.10.876 PMID: doi:10.1001/archpsyc.56.10.876 [CrossRef]10530626
- Centers for Disease Control and Prevention. Leading causes of death reports, 1981–2017. https://webappa.cdc.gov/sasweb/ncipc/leadcause.html. Accessed on September 11, 2019.
- di Giacomo E, Krausz M, Colmegna F, Aspesi F, Clerici M. Estimating the risk of attempted suicide among sexual minority youth, a systematic review and meta-analysis. JAMA Pediatr. 2018;172(12):1145–1152. https://doi.org/10.1001/jamapediatrics.2018.2731 PMID: doi:10.1001/jamapediatrics.2018.2731 [CrossRef]30304350
- Ream GL. What's unique about lesbian, gay, bisexual and transgender (LGBT) youth and young adult suicides? Findings from the national violent death reporting system. J Adolesc Health. 2019;64(5):602–607. https://doi.org/10.1016/j.jadohealth.2018.10.303 PMID: doi:10.1016/j.jadohealth.2018.10.303 [CrossRef]30711364
- National Academies Press. The health of lesbian, gay, bisexual, and transgender people: building a foundation for better understanding. https://www.nap.edu/read/13128/chapter/1. Accessed September 11, 2019.
- Smith DM, Mathews WC. Physicians' attitudes toward homosexuality and HIV: survey of a California Medical Society-revisited (PATHH-II). J Homosex. 2007;52(3–4):1–9. https://doi.org/10.1300/J082v52n03_01 PMID: doi:10.1300/J082v52n03_01 [CrossRef]
- Sanchez NF, Rabatin J, Sanchez JP, Hubbard S, Kalet A. Medical students' ability to care for lesbian, gay, bisexual, and transgendered patients. Fam Med. 2006;38(1):21–27. PMID:16378255
- Keo-Meier CL, Fitzgerald KM. Affirmative psychological testing and neurocognitive assessment with transgender adults. Psychiatr Clin North Am. 2017;40(1):51–64. https://doi.org/10.1016/j.psc.2016.10.011 PMID: doi:10.1016/j.psc.2016.10.011 [CrossRef]28159145
- Trittschuh EH, Parmenter BA, Clausell ER, Mariano MJ, Reger MA. Conducting neuropsychological assessment with transgender individuals. Clin Neuropsychol. 2018;32(8):1393–1410. https://doi.org/10.1080/13854046.2018.1440632 PMID: doi:10.1080/13854046.2018.1440632 [CrossRef]29463167
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- Alessi EJ, Dillon FR, Van Der Horn R. The therapeutic relationship mediates the association between affirmative practice and psychological well-being among lesbian, gay, bisexual, and queer clients. Psychotherapy (Chic). 2019;56(2):229–240. https://doi.org/10.1037/pst0000210 PMID: doi:10.1037/pst0000210 [CrossRef]
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Questions a Mental Health Provider Working with an LGBTQ+ Patient Might Ask
■ How do you feel about being LGTBQ+ or (other stated identity)?
■ Do your family, friends, and/or coworkers know that you are LGTBQ+ or (other stated identity)?
■ How do you feel like your family relationships, friendships, or employment would be affected by disclosing your LGBTQ+ status?
■ Are there any particular issues that you are dealing with that relate to your being LGTBQ+ or (other statedidentity)?