You are on page 1of 43

1

MENTAL HEALTH ISSUES IN LGBT
COMMUNITY
DR P.KASIKRISHNARAJA DPM DNB MNAMS

ASSOCIATE PROFESSOR OF PSYCHIATRY
IRT-PERUNDURAI MEDICAL COLLEGE

WHAT IS MENTAL HEALTH?

The World Health Organization defines mental
health as "a state of well-being in which the
individual realizes his or her own abilities, can
cope with the normal stresses of life, can work
productively and fruitfully, and is able to make
a contribution to his or her community.”

LGBT mental health is likewise shaped by a
sense of self-worth, the level of stress to which
people are subjected, and the inclusiveness of
their workplaces and community culture.

2

Definition

Sexual minorities are defined with reference to two
distinct
and
complex
characteristics: sexual
orientation and gender identity. 

Sexual orientation is generally defined as having at
least three dimensions: sexual self-identification,
sexual behavior, and sexual attraction or fantasy (
Saewyc et al., 2004; Sell, 1997).

Researchers have tended to define sexual orientation
by one or another of these dimensions, most often
using as the defining criterion either selfidentification
as
gay/lesbian,
bisexual
or
heterosexual, or the gender of one's sexual partners
(same sex, both same and opposite sex, or opposite
sex).

3

Socio demographics

There are about 2.5 million gays in India of whom 6.54%7.23% are HIV-positive, according to figures submitted by the
government to the Supreme Court.

India's
most recent census yielded the first official count of transgender peo
ple
, at more than 490,000.

During the voter registration process, only 28,341 people registered
as belong to the third gender, but the census clearly indicates a
huge inflation in numbers.

The first and path-breaking estimate came in the Kinsey report on
male sexuality in the US, published in 1948, that an astonishing 46%
males were attracted to both sexes while 37% reported having sex
with other males.

Two other prominent surveys in US — the Hite report of 1991 and
the Janus study of 1993 — reported exclusive homosexuality among
1% to 10% of surveyed people, with male gays slightly higher in
number than lesbians. 

4

The world is not to be divided into sheep and goats  The "Kinsey Reports" found that 37% of males and 13% of females had at least some overt homosexual experience to the point of orgasm. 10% of males were more or less exclusively homosexual. p." (Kinsey. furthermore. It is a fundamental of taxonomy that nature rarely deals with discrete categories. heterosexual and homosexual. The living world is a continuum in each and every one of its aspects.. The world is not to be divided into sheep and goats.  "Males do not represent two discrete populations.. et al. 5 . 1948 Sexual Behavior in the Human Male (1948). 639).

 The Stonewall riots in 1969 in New York City marked a watershed event in the movement.Nosological changes 6  In Diagnostic and Statistical Manual of Mental Disorders (DSM-1) in 1952.“  In DSM-II. with the . published in 1968. Having successfully challenged the police and government attempts to shut down public places where gay people gathered. Homosexuality was designated as "sociopathic personality disturbance.  The publication of DSM-II coincided emergence of the gay rights movement. listed homosexuality as a sexual deviation. gay activists would soon challenge psychiatric authority as well.

Only those who were "in conflict with" their sexual orientation had a mental disorder (SOD). the American Psychiatric Association (APA) defined homosexuality as a mental illness.  The American Psychiatric Association (APA) labeled discrimination in employment based on sexual orientation as irrational in 1988. the APA added immigration and naturalization decisions to areas in which it opposes discrimination against homosexuals.Nosological Changes  Until 1973. It opposed exclusion and dismissal from the armed forces on the basis of sexual orientation in 1990. In 1991.  The DSM-II diagnosis of Sexual Orientation Disturbance (SOD) replaced Homosexuality.  1980's DSM-III where homosexuality (EDH).  Ego-dystonic homosexuality was removed from DSM-III-R (1987).  SOD was replaced by ego-dystonic 7 . Accordingly. individuals comfortable with their homosexuality were no longer considered mentally ill.

published by the American PsychiatricAssociation in 1994  Transgender identity remains in the psychiatric classification under the diagnoses of transvestic fetishism(302.  Gender identity disorder in adolescents or adults (302.3). formerly transsexualism.6) 8 .  And gender identity disorder in children (302. formerly transvestism.DSM-IV & TR  The fourth edition of the Diagnostic and Statistical Manual of MentalDisorders (DSM-IV).85).

the incongruity for a .  Marked difference between the individual’s expressed/experienced gender and the gender others would assign him or her.  Gender dysphoria has its own chapter in DSM-5 and is separated from Sexual Dysfunctions and Paraphilic Disorders. and it must continue for at least six months. or psychotherapy or counseling to support their gender transition.DSM 5 9  In (DSM-5).  In children. This diagnosis is a revision of DSM-IV’s criteria for gender identity disorder . the desire to be of the other gender must be present and verbalized. This ensures treatment access for individuals who continue to undergo hormone therapy. related surgery.  Emphasize the importance of  distress about diagnosis. people whose gender at birth is contrary to the one they identify with will be diagnosed with gender dysphoria.  DSM-5 diagnosis adds a post-transition specifier for people who are living full-time as the desired gender (with or without legal sanction of the gender change).

. and social and legal transition to the desired Gender To get insurance coverage for the medical treatments. individuals need a diagnosis Gender Identity Disorders Work Group was concerned that removing the condition as a psychiatric diagnosis—as some had suggested—would jeopardize access to care. cross-sex hormones. many of the treatment options for this condition include counseling for transition. gender reassignment surgery.1 0 When it comes to access to care.

   It endorsed an initiative allowing adoption and co-parenting of children by same-sex couples in 2002. the APA approved a position statement supporting the legal recognition of same-sex unions.1 1  An APA position statement in 1998 opposed any psychiatric treatment based on the assumption that homosexuality is a medical disorder or that patients should change their sexual orientation. the APA endorsed the right of gay people to enter into same-sex civil marriage.   The World Health Organization ICD-10 in 1992.  In 2005.  Also in 2000. removed homosexuality from . including "reparative" or "conversion therapies." This was extended in 2000 to a recommendation that ethical practitioners refrain from attempts to change sexual orientation in the absence of research substantiating "reparative" therapies.

officially accepted its normal variant status.0). which was published in 1990.  Ego-dystonic sexual orientation (F66.  Sexual maturation disorder (F66. is defined as: “The individual is uncertain about his or her gender identity or sexual orientation.  Its tenth edition (ICD-10). which causes anxiety or depression. removed homosexuality as a disorder in itself. but contains the five F66 disorders. Many countries have since decriminalized homosexual behavior and some have recognized same-sex civil unions and marriage. in 1992.1 2  The American Psychiatric Association.  Regarding supposed treatments for ego-dystonic sexual orientation.” . and the World Health Organization. the group noted: “Therapies aimed at changing a person’s sexual orientation have been deemed outside the scope of ethical practice. in 1973.” It is therefore particularly applicable to adolescents first questioning their sexuality.1) can be diagnosed when “the gender identity or sexual preference is not in doubt but the individual wishes it were different because of associated psychological and behavioral disorders and may seek treatment to change it”.

or general social and vocational capabilities.1 3  According to Association: the American Psychological “Homosexuality per se implies no impairment in judgment. the American Psychological Association urges all mental health professionals to take the lead in removing the stigma of mental illness that has long been associated with homosexual orientations.” . stability. reliability. Further.

unprotected sex. both of which are associated with increased depression. prejudice. harassment.  LGBT people are also the targets of sexual and physical assault. and hate crimes.  The accumulated stigma. anxiety and suicidal thoughts.  The experience of stigma and discrimination increases internalized homophobia and stress-related cortisol production in LGBT people. drug use. and attempted suicide 1 4 . and this stigma can have a variety of negative consequences throughout the life span.  LGBT people who experience family rejection as adolescents reported high rates of depression.WHY ARE LGBT PEOPLE AT HIGHER RISK?  LGBT people experience stigma and discrimination. and discrimination to which minoritized and marginalized people are exposed is called MINORITY STRESS.

and non-partner violence than lesbian and heterosexual women. and in accessing health or social services. The prevalence of substance use disorders was more than twice as high among LGB people as it was among heterosexuals . childhood physical abuse. and one third were subjected to verbal threats or harassment.  Individuals with multiple marginalized identities (such as racialized LGBT people) were more likely to report excessive substance use. harassment.  Trans people had experienced physical or sexual assault due to being trans. intimate partner violence.1 5  Studies suggest that bisexual women may experience higher rates of childhood sexual abuse. and discrimination with respect to finding stable housing or employment.  High levels of violence.

 Studies have found high rates of depression. selfharm.  Meta-analysis studies found that sexual minority individuals were two and a half times more likely than heterosexuals to have attempted suicide and had a risk of depression and anxiety one and a half times higher than heterosexuals. anxiety. 1 6 .  LGBT people are almost twice as likely to experience childhood maltreatment.MENTAL HEALTH OF LGBT PEOPLE  Large Canadian studies indicate that LGBT people are more likely than heterosexuals to report unmet mental health needs and were more likely to consult mental health practitioners. obsessive– compulsive and phobic disorders. and alcohol and drug dependence among LGBT people. suicidal thoughts and acts.  Sexual minority women were particularly at risk for substancerelated disorders. while sexual minority men had a higher risk of suicide. interpersonal violence. and personal loss and are at double the risk of developing post traumatic stress disorder as their heterosexual peers.

 According to cultural anthropologist Gayle Rubin. heteronormativity in mainstream society creates a "sex hierarchy" that grades sexual practices from morally "good sex" to "bad sex.“  McCreery states that this heteronormative hierarchy carries over to the workplace. and states that sexual and marital relations are most (or only) fitting between people of opposite sexes. It asserts that heterosexuality is the only sexual orientation or only norm.Heteronormativity   Heteronormativity is the belief that people fall into distinct and complementary genders (man and woman) with natural roles in life." The hierarchy places reproductive. in one of the first major works of  queer theory.  Michael Warner popularized the term in 1991. where gay.  The concept's roots are in Gayle Rubin's notion of the "sex/gender system" and Adrienne Rich's notion of compulsory heterosexuality. lesbian and bisexual individuals face discrimination such as anti-homosexual hiring policies or workplace discrimination that often leaves "lowest hierarchy" individuals such as transsexuals vulnerable to the most overt discrimination and unable to find work. monogamous sex between committed heterosexuals as "good" and places any sexual acts and individuals who fall short of this standard lower until they fall into "bad sex. 1 7 .

 straight privilege.  heteronormativity .  compulsory heterosexuality  or the much lesser known terms heterocentrism. state(-sponsored) homophobia. however. heterosexual bias.  homonegativity. cultural. and from gender theory and queer theory. heterosexism has been described as being "encoded into and characteristic of the major social. more broadly denotes the "system of ideological thought that makes heterosexuality the sole norm to follow for sexual practices“.   Lack of semantic transparency lead. bias. and discrimination in favor of opposite-sex sexuality and relationships. anti-gay bigotry.The Straight Mind (a collection of essays by French writer Monique Wittig). outreach workers. It can include the presumption that other people are heterosexual or that opposite-sex attractions and relationships are the only norm and therefore superior. 1 8 . sexual prejudice.   Heterosexism. and economic institutions of our society" and stems from the  essentialist cultural notion that maleness-masculinity and femalenessfemininity are complementary.  critical theorists and LGBT activists to propose and use terms such as institutionalized homophobia. researchers.  As a bias favoring heterosexuals and heterosexuality.Heterosexism  Heterosexism is a system of attitudes.

natural law.  "God created Adam and Eve. the concept of alternate sexual orientation is rejected or deemed irrelevant. it is therefore a sin. and against nature. among others. the following:  Non-heterosexual persons should keep their sexual orientations private (i.. ungodly.  The attitude that gay men aren't "real" men or lesbians aren't "real" women because of the socially pervasive view that heterosexual attractions or activities are the "norm" and therefore superior. not Adam and Steve (or Madame and Eve)" and similar essentialist cultural notions that malenessmasculinity and femaleness-femininity are complementary. not  Adam and Steve (or Madame and Eve)"  Within a heterosexist ideology or mindset. appeals to authority. 1 9 . they should remain "closeted"). evil or subhuman. universal truths. but others consider to be conventional wisdom or  sociobiological knowledge can include.  A set of more nuanced heterosexist views. or popular beliefs. which some may consider faith."God created Adam and Eve. dogma.  Homosexuality being wrong.e.

this can include policies such as the American military's " Don't ask.Type of heterosexism 2 0  Hate speech. hate mail. lesbians. particularly with regard to health care. mobbing. moral panic. . same-sex partners. housing. using gay men and homosexuality as a  folk devil for the AIDS pandemic. witch-hunts.  Barring gay men. ”  Scapegoating. and bisexuals from serving in the armed forces or from working in the education field. offenders may receive even maximum sentence of capital punishment . and employment.  Sodomy laws when enforced almost exclusively against consenting. suicide or murder victims. don't tell” policy.  Negative portrayals or stereotypes of gay men. and bisexuals solely as villains. and the Islamic Republic of Iran. terms of disparagement.  Organized opposition to gay rights.  Using the gay panic defense in assault or murder cases.  The institution of opposite-sex marriage via explicit definitions.   In some countries where homosexuality is criminalized.   Adoption bans  Legislation that prevents legal and social equality. death threats. lesbians. adult. such as India Saudi Arabia.  Reserving civil unions strictly for opposite-sex couples. labeling such rights and privileges as "special rights" or the "Gay Agenda".

Researchers. A popular implicit association test measuring heterosexism that is open to the public is a virtual laboratory called Project Implicit. thus. have constructed implicit measurements of heterosexism. An example of this would be an  Implicit Association Test. .2 Measurement of 1 heterosexism .

 Stigmatization and persecution of not only these people but also those of other sexual diversity such as transgender.Effects of heterosexism  Marginalization. and anti-LGBT violence and abuse. to remain in the closet in an effort to pass for heterosexual. or metaphorically. lesbophobia. 2 2 . and transsexual people.   Along with homophobia. heterosexism continues to be a significant social reality that compels people to “conceal” their homosexual or bisexual orientation. and  internalized homophobia .

 Role models/advertisements  Bullies/jokes/derogatory terms  Newspaper stories of rejection/hate crimes•  Institutionalized stigma. 2 3 . “spouse” etc.Discrimination  Innocent questions like “girl friend?” “Married?”  Hospital/office intake forms “marital” status.

 It is driven by fear and hatred. 2 4 . harassment. discrimination.Anti-LGBT violence and abuse  "Heterosexism leads to prejudice. as seen by the perpetrator. is to turn the person  heterosexual or to enforce conformity with gender stereotypes.  Corrective rape is a hate crime in which people are raped  because of their perceived sexual orientation or  gender identity. and violence. The common intended consequence of the rape.  The term corrective rape was coined in South Africa after wellknown cases of corrective rapes of lesbians like Eudy Simelane .  Another form of heterosexist violence as social control that most often targets lesbian women is corrective rape: a gang rape of a lesbian to "cure" her of her same-sex attractions.

but the Supreme Court of India overturned that ruling on 11 December 2013. Govt. but in its 172nd report.  Section 377 of the colonial Indian Penal Code defined homosexual acts as "carnal intercourse against the order of nature" and made them illegal.  On 2 July 2009.  The Law Commission of India had historically favored the retention of this section in its 42nd and 156th report. it recommended its repeal. delivered in 2000. of NCT of Delhi .Legal Hurdles in India. 2 5 . stating that the Court was instead deferring to Indian legislators to provide the sought-after clarity. the Delhi High Court held that provision to be unconstitutional with respect to sex between consenting adults. in Naz Foundation v.

meaning or "morbid fear“. Phóbos. refers both to "unreasoning fear of or antipathy  towards homosexuals and homosexuality" and to "behavior based on such a feeling". itself a mix of neoclassical morphemes.  Coined by George Weinberg. a form of heterosexism. 2 6 . a psychologist. and  phobia from the Greek . the term homophobia is a blend of the word homosexual.  Its Institutionalized because of various religion and state sponsored in various Islamic countries. in the 1960s.Homophobia  Homophobia.

Minority stress 2 7 .

Minority stress  Minority stress describes chronically high levels of stress faced by members of stigmatized minority groups.discrimination and stigma. 2 8 . eventually leading to poor mental and physical health. including poor social support and low socioeconomic status.g. high blood pressure.  It may be caused by a number of factors.. numerous scientific studies have shown that minority individuals experience a high degree of prejudice. anxiety) that accrue over time. but the most well understood causes of minority stress are interpersonal prejudice . which causes stress responses (e.  Indeed.

 Minority status leads to increased exposure to proximal stressors.2 9  Three primary tenets:  Minority status leads to increased exposure to distal stressors. which are caused by exposure to proximal and distal stressors. .  Minority individuals suffer adverse health outcomes. due to distal stressors.

 Internalized homophobia .  PROXIMATE FACTORS:  Fear of rejection. and distaste for one’s own minority group following a prejudice event.   Rumination about previous experiences with prejudice.3 0  DISTAL FACTORS:  Discrimination  Prejudice  Victimization  Social exclusion for housing and employment.

and isolation from other members of the minority group. shame and guilt.3 1  For example. LGBT youth and adults who have experienced prejudice about their sexual orientation sometimes choose to conceal their sexual identity from others. repetitive. and obsessive focus on a past event that leads to depressive and anxious symptoms. including intrusive thoughts about the secret. .  Concealing such personal information causes significant psychological distress. anxiety. which is a common psychological phenomenon characterized by a maladaptive.  Exposure to prejudice may lead to rumination.

3 2  Internalized homophobia has been linked to  self-harm and eating disorders as well as sexual risk-taking behavior. which predicts long-term mental health outcomes.  Both distal and proximal social stressors are associated with negative mental health outcomes among sexual minorities.  Internalized homophobia has also been linked to general psychological distress.  .

Mephedrone(Love drug). 3 3 .and GHB/GHL (γButyrolactone (GBL).  Sexualized drug use by men who have sex with men(MSM).  Cathinones. a family of synthetic chemicals that imitate the effects of speed and ecstasy.  Previously (10 yrs ago) Common among older HIV positive gay men.  Term originated from Gay applications like Grindr And web pages like BBRT(BareBackRealTime).  Its usually defined for Gay people taking drugs like Crystal Meth.  Alcohol is another common drug sought after to facilitate Sex.Chemsex  Slang term for chemical sex.

bringing the total number monitored by European regulatory agencies during the year to more than 350. morphine. AH-7921.3 4  Almost 250 substances were detected in the last four years in Europe. respectively. They are often marketed online as legal highs or "research chemicals“  most are sourced legally as powders from China or India and sold through more than 650 websites offering them to European customers. LSD. including 251NBOMe. which are being sold as replacements for. cocaine and ketamine were doing rounds among gay community world wide. known as cannabinoids.   81 new substances in 2013.  Four potent and harmful groups of chemicals.   29 – of the new drugs detected last year were synthetics imitating the effects of cannabis. . MDPV and methoxetamine.

there has been a shift towards a technology. being hospitalized. social and sexual networks. In the 1980s and 1990s gay men would meet in bars. clubs and community centers. having panic attacks or convulsions.and home-based cultural scene" .  "There has been a change in gay cultural. But with the rise of the internet and social media apps.3 5  Men who use substances such as crystal meth while having sex are at risk of overdosing. serious mental health issues and sexual assault. losing consciousness.

3 6 .

3 7 .

3 8 .

3 9 .

panic attacks. and associated negative sequelae (Makadon Hj et al.Mental health  Sexual minorities are at a risk for developing emotional disorders because of the stigma and discrimination. violence and hetero normativity of the society. Parveen S.)  They are physically. and sexually abused. 4 0 . Bhuiyan MI et al)  Suicide risk has been shown to be greatly elevated for men in same-sex partnerships (Mathy RM. psychological distress. poverty. increasing their risk of homelessness.(Khan SI. suicidal ideation.  Transgenders were forced out of their homes or chose to leave home because of parental rejection or fear of rejection. verbally. body image disturbance and eating disorders. which gets manifested as depression. Hussain MI. Cochran SD et al).

4 1  Sexual minority adolescents leave home more frequently in search of their identity. and are victimized and forced for sex more often.  They use highly addictive substances more frequently to overcome their sorrows and have more sexual partners than their heterosexual counterparts. .

and frequently change their residence.Social well-being:  Discrimination. 4 2 . ration card. Subsequently.  Sexual minorities find it difficult to get a house on rent. many of them do not get. These marriages end up in marital disharmony. They are discriminated inside the premises of the educational institutions. voters ID.  They are not considered for government jobs. stigma and atrocities diminish self-esteem and sense of social responsibility. Thus it is difficult for them to produce proof of residence. divorce or continue with poor quality of life.  Many of them end up in marital/heterosexual relationships against their will because of family and societal pressure.  Legal inheritance is often denied by their family members. passport and many of them do not even get a caste certificate.

 Be aware that minority stress may negatively impact physical and mental health Be alert to possible social contributors in both mental and physical illnesses. there should be a recognition that legal and social equity for LGBT people is a health issue as well as a political one. and explore the degree to which internalized negative social messages may be contributing to their health concerns. and the effect of minority stress. 4 3 .IMPLICATIONS FOR HEALTH CARE PROVIDERS  Providers should be aware of the broader social and legal context in which their LGBT clients live.  Health care providers should be aware of resources available to help those LGBT people at greatest risk for suicide  Given the WHO’s definition of mental health.  Clients who belong to multiple marginalized communities may face more barriers to maintaining good mental health.  Suicide response and crisis intervention staff may need additional training to ensure that LGBT clients are not subjected to stereotyping or discrimination and that the gender of trans clients is not misidentified.  Promoting family acceptance of LGBT adolescents and encouraging them to connect with LGBT culture is essential to reducing health disparities among LGBT youth.