Understanding the Needs of Lesbian, Gay, Bisexual, and Transgender People Living With Mental Illness

Christian Huygen, PhD

In This Article

Inclusive Approaches to Serving LGBT Patients

Rainbow Heights Club, where I have served as Director for the past 3 years, is an agency that provides advocacy and psychosocial support to LGBT adults living with Axis I psychiatric diagnoses. The agency, which is funded largely by New York City's Department of Health and Mental Hygiene, was founded largely to address the fact that this population is vulnerable and underserved.

The following guidelines, excerpted from Rosenberg and colleagues,[14] constitute relatively simple and concrete steps that can lower the barriers to effective treatment, build working alliances, support disclosure and dialogue, and improve treatment compliance.

  • Use inclusive language. This simple shift is perhaps the most important first step a clinician can take in building working relationships with consumers. In many clinics and inpatient units, male patients are routinely asked, "Are you married, or do you have a girlfriend?" Many LGBT consumers will interpret this question as a signal that the person asking it is unwilling to hear about other kinds of relationships. Language like this implies that care providers and institutions would prefer that LGBT consumers remain silent and invisible. Inclusive language, such as "Are you in a relationship right now?" or "What kinds of people do you tend to have relationships with?," is simple to use and may encourage a much broader range of disclosures;

  • Be aware of subtle signals you may be sending. As noted, nearly all LGBT people at some point in their lives have lost or disrupted relationships with friends, family members, or religious communities by disclosing their sexual or gender identity. As a result, many of them are extremely aware of possible cues indicating whether a given person may or may not be accepting and supportive of them. For this reason, hanging a small pro-LGBT flyer in your waiting room, or posting information about LGBT resources on a bulletin board in your office or community, may help LGBT consumers feel that their disclosures are welcome;

  • Welcome and normalize disclosures of sexuality or gender identity. A tentative disclosure of LGBT identity or experience can be welcomed with a simple "I'm glad you told me that." This can be followed with the same kinds of questions that would follow upon any consumer's mentioning of a relationship or experience, such as "What's he like?" or "Where did you meet her?" Showing an LGBT consumer that you are willing to put yourself in his or her shoes (eg, "That must have really hurt," or "That's great, I'm happy for you!") can have a tremendous effect on the working alliance and undo some of the estrangement from the mental health establishment that LGBT consumers have experienced. Many LGBT consumers report being stunned and deeply moved upon learning that their care providers empathize with them, support them, and wish them happiness;

  • Use knowledge about a consumer's sexuality in discharge planning. At Rainbow Heights Club, a number of members have an extensive history of decompensations and hospitalizations and yet have managed to maintain long-standing, supportive, intimate relationships. When considering discharge-related and treatment compliance issues, the patient's romantic partner, extended family, and network of friends are all potential members of your treatment team and should be welcomed into family meetings. Partners, loved ones, friends, and family can provide crucial information, support with treatment compliance, and ongoing monitoring of the consumer's mental status. Welcoming these collateral contacts and taking them seriously can amplify the effectiveness of your work, demonstrate the fact that you value and support these relationships, and generate better outcomes. Conversely, if you never hear about these relationships in the first place, your ability to effectively support your patient's recovery is diminished;

  • Avoid both over- and under-pathologizing. Echoing the mental health field's past tendency to pathologize same-sex desires and gender-discordant identities, some care providers interpret any expression or exploration of sexual or gender identity by a patient as further evidence of the person's mental illness. However, our patients' efforts to explore, understand, and express their sexuality, and to find connections with others, are often the locus of a great deal of creativity, resilience, courage, and even playfulness. These qualities deserve our support and admiration. By contrast, it is not helpful to assume that every possible expression of a consumer's sexuality or gender identity is to be celebrated. Sexual behavior has the potential to be destructive to both self and others in people with and without mental illness. Any such activity can and should be pragmatically evaluated in terms of its effects on the consumer's physical and emotional health, self-esteem, and relationships;

  • Be comfortable with your own sexuality. Issues of sexuality and gender identity raise anxiety and discomfort for many people. However, it is unfair and unethical to allow one's patients to suffer the fallout of this. As care providers, we must resolve our issues and conflicts concerning our sexuality and gender identity so that we can work effectively to help our patients build lives, identities, and relationships of their own choosing.


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