LGBTQ Issues / Gender Identity and Sexual Orientation

Although a person’s sexual or romantic orientation or gender identity may not be a source of distress, people who identify as lesbian, gay, bisexual, transgender, queer, questioning, asexual, or any other orientation or gender identity may find that the social stigma of living as a minority is a source of stress or anxiety.

When seeking therapy, whether for issues associated with one’s sexual, romantic, or gender identity or for concerns related to mental health, finding a qualified mental health professional who has experience and familiarity with the challenges members of the LGBTQIA community often face can be critical to successful therapy outcomes.

What Does LGBTQIA Stand For? 

The acronym LGBTQIA, an expansion of the previously used LGBT, was broadened to encompass a greater number of individuals. Some individuals argue the practice of grouping those who are not heterosexual or cisgender (or neither) under this acronym, which may or may not accurately represent their particular sexual orientation or identity, is itself an exclusionary act. Others explore alternative terms, such as GSM (gender and sexual minorities) or LGBTQ+, that they feel may better represent the wide variety of identities and orientations people may have. 

The current acronym represents those who are lesbian, gay, bisexual, transgender, queer and questioning, intersex, and asexual

The "Q" in the acronym stands for both queer and questioning (as these terms are not synonymous. Some people use the term "queer" as an umbrella term instead of LGBTQIA, but not all people identify as queer or choose to use this term. 

Some consider the "A" to stand for "ally" as well as "asexual." but some controversy exists regarding the inclusion of allies in the acronym, as "ally" is not a gender identity or sexual orientation. 

What Issues Might LGBTQIA People Face?

Despite rapidly growing cultural acceptance of diverse sexual and romantic orientations and gender identifications, oppression, discrimination, and marginalization of LGBTQ people persists. Coping with discrimination and oppression, coming out to one’s family, and sorting out an “authentic” sense of self in the face of social expectations and pressures can lead to higher levels of depression, anxiety, substance use, and other mental health concerns for LGBTQ people.

Research shows that youth who identify as LGBTQ are at an increased risk of suicidal ideation and self-harm, particularly when they also experience discrimination based on their sexual or gender identity. According to a 2007 survey, students who identified as lesbian, gay, bisexual, or transgender were almost ten times as likely to have experienced bullying and victimization at school and more than twice as likely to have considered suicide as their heterosexual, non-transgender classmates within the previous year.

Discrimination may take several forms, including social rejection, verbal and physical bullying, and sexual assault, and repeated episodes will likely lead to chronic stress and diminished mental health. Perceived discrimination—the expectation of discrimination—may also lead to diminished mental health. LGBTQ adults, too, may be subject to similar forms of harassment, as well as discrimination with regards to housing, employment, education, and basic human rights.

Many of the concerns and life challenges LGBTQ people bring to therapy are those common among all people. All couples argue over many of the same things—money, sex, the in-laws, quality time—and all people are subject to the same kinds of daily stressors, such as mood swings, workplace concerns, or low self-esteem.

Seeking Therapy for Gender and Sexual Identity Issues

Though many therapists may be qualified to help, sometimes LGBTQ clients feel more comfortable with an LGBTQ therapist, or at least with a therapist who specializes in or has a great deal of experience with LGBTQ issues. Such therapists are not available in every community, but more and more therapists and counselors are providing distance services by phone or over the Internet, and this may help broaden a person’s search for the right therapist. People considering gender confirmation surgery are often required to seek therapy before undergoing surgery. A specialist in this area, if available, is recommended.

Early editions of the Diagnostic and Statistical Manual (DSM) identified homosexuality as a mental disorder, until clinical research demonstrated sexual or romantic attraction to someone of the same gender is a normal, healthy, positive form of human sexuality. Despite the mental health community’s decades-long affirmation of all sexual orientations, sexual orientation change efforts (SOCE) are still provided by some therapists and pursued by some people who feel conflicted about their sexual orientation. Several organizations, including the American Psychological Association and the American Psychiatric Association, oppose sexual orientation change therapy, also known as conversion or reparative therapy, and many states either have banned the practice or are considering bills to ban the practice, particularly for minors. Furthermore, the ethics of the professions of social work, psychology, psychiatry, and marriage and family counseling mandate that therapists provide services to all people without discrimination.

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Gender Dysphoria in the DSM

Gender dysphoria is listed as a psychological condition in the DSM-5 to account for the significant distress a person might experience when their gender identity or expression does not correspond with the gender assigned at birth. In the previous edition, the condition was listed as gender identity disorder, but after receiving criticism about the stigmatizing effect of the word “disorder,” the condition was renamed gender dysphoria to ensure gender noncomformity was not labeled as a mental disorder.

Diagnosis of gender dysphoria requires: 

  • A notable conflict between their gender identity or expression and the gender they were assigned at birth that persists for at least six months.
  • Measurable impairment or distress in routine functions, such as social or professional, as a result of the condition.

For gender dysphoria to be diagnosed in a child, the child must manifest six out of eight criteria, among them the child's insistence they are not the gender assigned at birth; a strong dislike of their own sexual anatomy; and a strong desire for clothes, toys, and activities typically associated with another gender. 

For gender dysphoria to be diagnosed in adolescents and adults, the individual must meet at least two of six criteria, among them a conflict between the gender assigned at birth and the gender experienced, the desire to have different anatomical characteristics/characteristics of a gender other than the gender assigned at birth, and the experience of feelings and reactions typically associated with a gender other than the gender assigned at birth. 

Case Examples

  • Anxiety and confusion over sexual orientation: Sonja, 32, enters therapy for anxiety and identifies ambivalence about her sexual orientation as a major factor. While Sonja has always been attracted to women, she is also sometimes attracted to men, and she feels she is betraying her current partner, a woman, by even considering such thoughts. She is confused about her true orientation. The therapist assures her she needn’t label herself one way or the other, and explores with her, in a neutral, accepting manner, the nature of her attractions, her desires for the future in terms of relationships, her emotions about her current partner, and her desire—which Sonja somewhat guiltily reveals—to bear a child. After several months, Sonja decides she could consider dating men someday, but she’s still quite attached to her current partner, and, in joint sessions, the couple begins discussing the possibility of Sonja becoming pregnant by artificial insemination.
  • Couple in conflict over coming out: John and Paolo, in their mid 30s, seek couples sessions to deal with their constant fighting. The therapist treats their relationship as he would any other couple's relationship, helping them address communication skills and anger management in particular. As the work proceeds, it is revealed that John is out to his family (who accepts him entirely) and publicly, while Paolo does not want his family to know he is gay. This is frustrating to John, who wants a “normal life, including Paolo’s family being part of my family.” The therapist helps Paolo communicate the terrible anxiety he feels in light of his family’s orthodox religious beliefs, and John comes to understand that Paolo’s family will likely never accept him or his relationship with Paolo. John is able to begin making peace with this reality, which brings the two closer.
  • Gender transition: Ray, 40, is directed to therapy by a primary care physician after Ray decides to begin outwardly transitioning from male to female, with hormones, gender confirmation surgery, and a name change. Rachelle (Ray's chosen name) reports she has experienced significant distress from trying to live as a man when she is in fact a woman. The therapist, who was recommended due to her experience with transgender individuals, explores with Rachelle her personal history: when she first knew she was a woman, her difficulties trying to conform to a male identity, and her expectations for life going forward. The therapist also helps Rachelle process her feelings of sadness, anxiety, and anger about the way she has been treated by her family because of her gender identity. They also discuss possible complications of transition and the varied feelings Rachelle may experience after the surgery. The therapist is able to report to Rachelle's doctor, with her permission, that Rachelle is fully aware of the complexities and risks of her decision. Rachelle begins hormones and plans to schedule her surgery, continuing in therapy as she adjusts to living as her true self, addressing the ways doing so impacts her daily life. Her therapist continues to provide support throughout the process.


  1. Almeida, J., Johnson, R. M., Corliss, H. L., Molnar, B. E., and Azrael, D. (2009). Emotional distress among LGBTQ youth: The influence of perceived discrimination based on sexual orientation. Journal of Youth and Adolescence, 38(7), 1001-14. Retrieved from
  2. Diagnostic and statistical manual of mental disorders: DSM-5. (5th ed.). (2013). Washington, D.C.: American Psychiatric Association.
  3. Feldman, J., MD, PhD, and Spencer, K., PhD. (2014). Gender dysphoria in a 39-year-old man. Canadian Medical Association. Journal, 186(1), 49-50. Retrieved from
  4. Gender variance: A primer. (2001). Gender Education & Advocacy, Inc. Retrieved from
  5. Mental Health. (2013). LGBTQ science. Retrieved from
  6. Report of the APA Task Force on appropriate therapeutic responses to sexual orientation. (2009). American Psychological Association. Retrieved from
  7. Schulman, M. (2013, January 9). Generation LGBTQIA. Retrieved from


Last updated: 07-29-2016

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