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LGBT Issues (Lesbian, Gay, Bisexual, Transgender)

Thanks to a higher level of social acceptance for diverse sexual orientations and gender identifications, more and more gay men, lesbians, bisexual people and transgendered people are seeking therapy, sometimes for issues related to their orientation or gender identity, sometimes simply for the same issues – depression, anxiety, relationship difficulties, and so forth – for which anyone else seeks therapy.



Stressors and Struggles for LGBT Persons

Folks who identify as a member of the LGBT community may experience stressors not experienced by “straight” people. Although there is a wider social acceptance of LGBT persons than there was just 10 or 20 years ago, prejudice is certainly still prevalent, particularly outside of major coastal metropolitan areas. Dealing with prejudice, coming out to one’s family, sorting out an “authentic” sense of self in the face of social expectations and pressures – all this can lead to higher levels of depression and anxiety for LGBT folks. Research proves that suicide rates are higher among teens who are gay or lesbian than among heterosexual adolescents. For adults, being openly gay in the workplace or in public is not always easy. Therapy can help manage the choices and emotions that are, sadly, still inevitable for most LGBT people.


On the other hand, much of what a gay, lesbian, bisexual or transgendered person might bring to therapy can be basically the same was what a straight person would bring. Gay couples fight over many of the same things straight couples fight about – money, sex, the in-laws, quality time, for example – even if they also may argue over issues of coming out and having a public identity as a gay couple, which a straight couple wouldn’t have to face.


Psychotherapy for LGBT Issues

While homosexuality has not been officially considered a mental disorder since 1973, some therapists still see it as essentially dysfunctional. It is a good idea to find out where a therapist stands on this issue before engaging in treatment with that person. Any good therapist should be able to help LGBT individuals and couples, but sometimes LGBT clients feel more comfortable with an LGBT therapist, or at least with a therapist who specializes in or has a great deal of experience with LGBT issues. Such therapists are not available in every community, but LGBT individuals should be aware that the ethics of the professions of social work, psychology, psychiatry, and marriage and family counseling mandate that therapists provide services to all persons without discrimination. People considering a sex change are often told they must seek therapy before undergoing surgery. A specialist in this area, if available, is recommended.


Controversy Over Gender Identity Disorder in the DSM

While sexual orientation is not relevant to diagnostics, gender identity disorder is still identified as an illness in the DSM. This is controversial. Many therapists would nowadays focus on helping a person who identifies as the gender opposite their own anatomy to find the best way to live a happy life, whether by obtaining a sex change, finding a community of transgender people, living with an ambiguous gender identity, or by some other means; few therapists would attempt to facilitate a “cure” for this “disorder,” resulting in the person coming to identify as their anatomical gender and ceasing to identify as its opposite, unless that was the desire of the person. Even in that case, many therapists would encourage a person to accept that their gender identity will remain the opposite of their anatomical one.


There are professionals who believe that transgender tendencies can be cured. Again, it is recommended that LGBT persons inquire as to the beliefs of a potential therapist before beginning therapy, and that they consider specialists in this area when available.


DSM Criteria for Gender Identity Disorder 

Diagnostic Criteria for Gender Identity Disorder


A. A strong persistent cross-gender identification (not merely a desire for any perceived cultural advantages of being the other sex). In children, the disturbance is manifested by four (or more) of the following:


• Repeatedly stated desire to be, or insistence that he or she is, the other sex.

• In boys, preference for cross-dressing or simulating female attire; In girls, insistence on wearing only stereotypical masculine clothing.

• Strong and persistent preferences for cross-sex roles in make believe play or persistent fantasies of being the other sex.

• Intense desire to participate in the stereotypical games and pastimes of the other sex.

• Strong preference for playmates of the other sex.


In adolescents and adults, the disturbance is manifested by symptoms such as a stated desire to be the other sex, frequent passing as the other sex, desire to live or be treated as the other sex, or the conviction that he or she has the typical feelings and reactions of the other sex.


B. Persistent discomfort with his or her sex or sense of inappropriateness in the gender role of that sex.


In children, the disturbance is manifested by any of the following:
In boys, assertion that his penis or testes are disgusting or will disappear or assertion that it would be better not to have a penis, or aversion toward rough-and-tumble play and rejection of male stereotypical toys, games, and activities.
In girls, rejection of urinating in a sitting position, assertion that she has or will grow a penis, or assertion that she does not want to grow breasts or menstruate, or marked aversion toward normative feminine clothing.


In adolescents and adults, the disturbance is manifested by symptoms such as preoccupation with getting rid of primary and secondary sex characteristics (e.g., request for hormones, surgery, or other procedures to physically alter sexual characteristics to simulate the other sex) or belief that he or she was born the wrong sex.


C. The disturbance is not concurrent with physical intersex condition.


D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.


Code based on current age:


• 302.6 Gender Identity Disorder in Children

• 302.85 Gender Identity Disorder in Adolescents or Adults


Specify if (for sexually mature individuals):


• Sexually Attracted to Males

• Sexually Attracted to Females

• Sexually Attracted to Both

• Sexually Attracted to Neither


Anxiety from Confusion on Sexual Orientation - Case Example

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 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 that she needn’t immediately – or ever – 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 is open to the eventuality of dating men, but still quite attached to her current partner, and, in joint sessions, the two begin discussing the possibility of Sonja becoming pregnant by artificial insemination.


Conflict in Gay Couple Over Partner Not Wanting to "Come Out" - Case Example

John and Paul, in their mid 30’s, seek couple’s sessions to deal with their constant fighting. The therapist treats their relationship, at first, as he would any other couple, working on 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 Paul does not want his family to know he is gay. This is frustrating to John, who wants a “normal life, including Paul’s family being part of my family.” The therapist helps Paul communicate the terrible anxiety he feels in light of his family’s orthodox religious beliefs, and John comes to understand that Paul’s family will likely never accept him or his relationship with Paul. John is able to begin making peace with this reality, which brings the two closer.


Transgender Man to Woman Finding Psychological Support and Stability - Case Example

Ray, 40, is directed to therapy by his primary care physician after Ray decides he wants to have an operation to change his anatomy from man to woman, and to change his name to Reyna. Ray reports he has suffered for a long time trying to live as a man when he in fact feels like a woman. The therapist, who was recommended due to her experience with transgender persons, explores with Ray his personal history, including the origins of his feelings of being a woman, his struggles to live as a man, and his expectations for living as a woman. The therapist makes it clear Ray will have her support whether or not the surgery takes place. The therapist also helps Ray process feelings of sadness, anxiety and anger about the way he has been treated by his family because of his gender identity. The therapist is able to report to Ray’s doctor, with Ray’s permission, that Ray is fully aware of the complexities and risks of his decision, and that she has no objection to the surgery taking place. By the end of their sessions, the therapist is calling Ray “Reyna,” by Reyna’s request, and Reyna utilizes therapy sessions to grow more comfortable fully taking on a female identity. The therapist continues to provide support throughout the process.


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Last updated: 01-03-2014


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