LGBT / Gender and Sexual Identity Issues

Two women on bench with son

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, intersex, or any other type of non-conforming sexual or gender identity (known as LGBT, LGBTQ, or LGBTQIA, among others) may find that the social stigma of living as a sexual 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 everyday concerns, finding a qualified mental health professional who has experience and familiarity with issues that confront the LGBTQ community can be critical to successful therapy outcomes.

Potential Issues Faced by Lesbian, Gay, Bisexual, Transgender, and Queer Individuals

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—will 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.

A young, female couple faces the camera in an embraceOf course, many of the issues that LGBTQ people might bring to therapy are those that are 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.

Selecting a Therapist 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 sex reassignment 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 identified homosexuality as a mental disorder, until clinical research demonstrated that sexual or romantic attraction to someone of the same sex 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 as Listed in the Diagnostic and Statistical Manual (DSM)

Gender dysphoria is listed as a psychological condition in the DSM-5 to account for the significant distress a person might experience when a person’s gender identity or expression does not correspond with that person’s physical sex 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 in adults requires:

  • A notable conflict between their gender identity or expression and the sex 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.

Diagnosis of gender dysphoria in children requires:

  • Verbalization of the desire to be the other gender.

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 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 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 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 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.
  • Male to female transition: Ray, 40, is directed to therapy by his primary care physician after Ray decides he wants to transition from male to female, undergo sex reassignment surgery, and 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.


  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. 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
  3. Gender Variance: A Primer. (2001). Gender Education & Advocacy, Inc. Retrieved from
  4. Mental Health. (2013). LGBTQ Science. Retrieved from
  5. Report of the APA Task Force on Appropriate Therapeutic Responses to Sexual Orientation. (2009). American Psychological Association. Retrieved from


Last updated: 08-04-2015

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