Electronic Summer 2023 | Issue 55

Pride and Prejudice: The Underbelly of Psychiatry in the LGBT Community

By: Gary Wu, MD

Since the Stonewall riots in 1969, June is celebrated annually to promote equality and justice in the LGBT population. However, the steps it took to get to where we are today are extremely harrowing and dark. In review, homosexuality was classified as a mental disorder since the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) published in 1952. It wasn’t until 1974 that the diagnosis of homosexuality was removed and replaced with a less stigmatizing term “sexual orientation disturbance.” The diagnosis has undergone many revisions over the years, but is currently known as gender dysphoria in the latest DSM-5-TR. Another way to look at this issue is the transition from a defined gender binary into a the more fluid term “gender identity.” The latter is now an umbrella term that encompasses the complex interplay between different domains including biological sex (assigned at birth), sexual orientation (description of physical, romantic, emotional attraction), and gender expression (how one communicates their gender identity).

With all the advocacy, civil rights protests, and now common perceptions that sexuality outside of the confines of heteronormativity is not a disease, one might beg the question – why is it still a DSM diagnosis?

This is indeed a simple question, with a complex answer. In a recent article describing psychiatry’s role in de-pathologizing gender identity by Dr. Thomas-Castillo and Dr. Rush, they highlight that one aspect of the problem is, unsurprisingly, insurance. For individuals who consider themselves transgender and are seeking gender affirming care, psychiatrists are placed in a gatekeeping role to provide “support” indicating that an individual is sound of mind to proceed with gender affirming procedures and medications. The article gives an elegant answer,

“In this way, the insurance industry and the field of medicine continue to believe that individuals who are [transgender] need psychiatric permission and/or counsel regarding their gender identity.”

The answer, at least part of the answer, to the original question is putting a name to an issue that needs to be addressed. The issue whether gender dysphoria is psychologically or psychiatrically valid is not taken into this particular context. The diagnosis may yet again change names, get redefined, or removed in the future. In the meantime, we as psychiatrists have to continue to manage patients based on what matters in the context of clinical care. Theories such as the minority stress theory have been postulated to explain the higher rates of depression, anxiety, substance abuse in vulnerable LGBT populations. We must recognize and treat comorbid symptoms and do what is best for our patients as they navigate their own journey of gender identity and expression.

Despite being put into an unfortunate gatekeeping role as psychiatrists, we must work with the confines of insurance and the overall healthcare system. With increasing concerns and controversial legislation targeting LGBT populations, it is advisable to remain up to date with the latest practices in your area. Educating yourself and learning to avoid offensive language when documenting/communicating is important for building rapport and trust with patients. This is another month of celebration to highlight the important progress made in the last several decades in areas of human rights, gender expression, and free speech. We all owe it to our patients to be judicious, fair, and equal in decision making and care, wherever they may be on the gender identity spectrum.