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Abstract

Introduction

This position paper addresses the need for psychiatrists to increase their understanding of the mental health needs of people who identify themselves as two spirit, lesbian, gay, bisexual, transgender, queer and other minority sexual orientations and gender identities (2SLGBTQ+) with a particular focus on the need for a more comprehensive approach to care for transgender and gender diverse individuals. While the Canadian Psychiatric Association (CPA) has taken a strong position in advocating for decreasing stigma and discrimination, the focus of antistigma advocacy has centred most significantly on people with mental illness. While doing so, however, the CPA has recognized the ongoing stigma and discrimination in society based on several factors, including sex, gender, race, sexual orientation and religion.¹ Psychiatry has a history of conflating 2SLGBTQ+ identities with mental illness and has, therefore, historically contributed to the stigma and discrimination faced by people who identify as 2SLGBTQ+, affecting not only their mental health but also their access to appropriate mental health care.²

Background

In 1973, after much debate, deliberation and political and societal pressure, the American Psychiatric Association (APA) removed the diagnosis of homosexuality from the Diagnostic and Statistical Manual of Mental Disorders (DSM), Second Edition,^3,4 and issued a position statement in support of gay and lesbian civil rights.⁵ Since that time, all major professional mental health organizations have gone on record to affirm that homosexuality is not a mental disorder. However, controversy remains surrounding the continued inclusion of gender dysphoria^6,7 within the DSM-5 (previously gender identity disorder^8–10 in the DSM-IV). Many health-care professionals who work with people who identify as transgender argue that this diagnosis should also be removed from the DSM because the diagnosis pathologizes transgender identities, while others believe it should remain in the DSM to ensure continued access to appropriate medical treatment (access to hormones and [or] gender-confirming surgeries) for transgender people.^6,7,8,10 The “Position Statement on Discrimination Against Transgender and Gender Diverse Individuals,” released by the APA in July 2012 and reapproved in 2018, states that “being transgender or gender variant implies no impairment in judgment, stability, reliability, or general social or vocational capabilities; however, these individuals often experience discrimination due to a lack of civil rights protections for their gender identity or expression.”¹¹^(p.1)

While the DSM-5 still includes gender dysphoria in its list of mental disorders, the Manual of International Statistical Classification of Diseases and Related Health Problems (ICD-11) removed the term “transsexualism” (previously included in the chapter on mental disorders), replacing it with the term “gender incongruence” (in a newly created chapter called “conditions related to sexual health”).¹² Most people who identify as transgender see this change in the ICD-11 as a great advance, ensuring access to medical transition treatments if desired, while depathologizing transgender identities by placing “gender incongruence” outside of the chapter on mental disorders.¹³

Discussion

The demographic statistics regarding 2SLGBTQ+ identities vary according to the definition used. Most studies worldwide estimate that between two to 14 per cent of the population identify as 2SLGBTQ+.^14,15 Within this heterogeneous population, the experience of each individual member of the 2SLGBTQ+ community varies widely depending on numerous potentially intersectional factors, including ability, age, sex, gender, ethnoracial group, nationality, religion, socioeconomic status, geographical location and other factors. However, what is common to sexual and gender minorities is that experiences of individual and systemic oppression (minority stress) can often threaten their health and well-being.² The history of discrimination and the associated shame concerning 2SLGBTQ+ identities has meant that many health professionals, including mental health professionals, are poorly informed about 2SLGBTQ+ issues and are unfamiliar with appropriate terminology and acceptable language.^2,16

Both sexual orientation and gender identity may be most usefully understood as existing along a continuum.¹⁷ Sexual orientation refers to how one thinks of oneself in terms of one's emotional, romantic or sexual attraction, desire or affection for another person.¹⁷ It is very important to note, however, that sexual behaviour is not always congruent with sexual orientation or identity. For example, a person who has sexual relations with men and women may not identify as bisexual. Gender identity is one's internal and psychological sense of oneself as male, female, both or neither.¹⁸ It is also important to note that one's gender identity is totally independent of one's sexual orientation. For example, regardless of whether someone identifies as cisgender, transgender, nonbinary (or any other gender identity), they can identify as having any sexual orientation. A glossary at the end of this document provides additional information about terms used in this position paper and other important terms related to 2SLGBTQ+ issues.^18,19

Stigma and discrimination based on sexual orientation and/or gender identity have a tremendous negative impact on the mental health of 2SLGBTQ+ people.^20,21 Sexual and physical assault are also risk factors for mental health issues, as is bullying for youth.²² Risks for 2SLGBTQ+ youth can be reduced by family acceptance and connection with other 2SLGBTQ+ youth.^22–25 In fact, lesbian, gay, bisexual and transgender (LGBT) youth who come from highly rejecting families are more than three times as likely to have attempted suicide than LGBT peers who reported no or low levels of family rejection.²⁴ In an Ontario-based study, a staggering 77 per cent of people who identified as transgender reported having seriously considered suicide at some time in their lives, 43 per cent reported attempting suicide at some point in their lives and 10 per cent reported attempting suicide in the past year.^26,27 In a Canada-wide study of 2873 trans and nonbinary people aged 14 and over, one in three participants reported having considered suicide in the past year and one in 20 participants reported attempting suicide in the past year.²⁸ In the largest survey to date of gender variant and transgender people (N = 6,450), 41 per cent reported attempting suicide at some point in their lives.²⁹ A recent meta-analysis³⁰ demonstrated that people who identified as lesbian, gay or bisexual had a higher risk for mental disorders than people who identified as heterosexual in all investigated diagnostic categories (i.e., depression, alcohol use disorder, anxiety disorders and suicidality). The risk for depression and suicidality was higher in people who identified as bisexual compared with lesbians and gay people.³⁰

The marginalization and discrimination experienced by 2SLGBTQ+ people also contribute to barriers to accessing health and support services.^20,31,32 These barriers are compounded by health-care providers often lacking the appropriate knowledge and skills around 2SLGBTQ+ health.^33–37 Many 2SLGBTQ+ people fear and avoid traditional health-care settings to protect themselves from mental or physical harm from potentially homophobic health-care providers.^38,39 Negative experiences with health-care professionals after disclosing sexual orientation such as the provider being visibly uncomfortable, harsh or abusive language, physically rough or abusive exams and actually being refused care, shape the future use of health services.³⁹ “Reparative” or “conversion therapy,” a range of pseudo-scientific treatments that aim to change a person's sexual orientation from homosexual to heterosexual or gender identity from transgender to cisgender, is a source of worldwide controversy. In 2000, the APA⁴⁰ condemned:

psychiatric treatment, such as reparative or conversion therapy which is based upon the assumption that homosexuality per se is a mental disorder or based upon the a priori assumption that the patient should change his/her sexual homosexual orientation . . . Ethical practitioners refrain from attempts to change individuals’ sexual orientation.⁴⁰^{(p. 1 and 4)}

More recently, in 2020, the APA released a position statement⁴¹ that included the following: “Efforts to change an individual's sexual orientation or gender expression have been shown to be harmful and potentially deadly.” The position statement continues with the following assertion:

APA condemns any practice that aims to change one's sexual orientation or gender expression in the form of conversion therapy, or any other similar type of therapy, as ethically and morally wrong and, additionally, these practices represent a significant risk of harm by subjecting individuals to forms of treatment that have not been scientifically validated.⁴¹^{(p. 1)}

For transgender people, lack of access to affirming treatments such as both hormonal and surgical treatment can adversely impact their mental health.^42–44 A review of practice guidelines for the care of transgender people is beyond the scope of this position paper, but these types of guidelines are published and available for clinicians to access.^44–47 The Canadian Medical Protective Association,⁴⁸ the American Psychological Association⁴⁹ and the APA⁵⁰ have all released statements or policies identifying the critical importance of access to care for transgender and gender variant people.

Changing Directions, Changing Lives: The Mental Health Strategy for Canada⁵¹ and the Mental Health Strategy for Canada: A Youth Perspective⁵² both discuss the importance of addressing specific mental health needs related to gender and sexual orientation. These documents specifically recommend increased understanding by professionals and the public about mental health differences related to gender and sexual orientation. They also specifically recommend improving the capacity of 2SLGBTQ+ organizations to address the stigma of mental illness and to work with local mental health services to support their community.

Stereotypes of all kinds can have an impact on the way 2SLGBTQ+ people living with mental health issues are treated, both within the 2SLGBTQ+ community and within the mental health system. People who identify as 2SLGBTQ+ who also happen to have mental health issues often experience a double stigma or dual alienation in which they feel they are not accepted within the mental health community because of their 2SLGBTQ+ identities and are also not accepted within the 2SLGBTQ+ community because of their mental health issues.⁵³

Recommendations

The CPA affirms the following:

The CPA opposes all public and private discrimination based on sexual orientation, gender identity and gender expression and supports the repeal of discriminatory laws and policies.

The CPA supports the passage of laws and policies protecting the rights, legal benefits and privileges of all people regardless of their sexual orientation, gender identity or gender expression.

The CPA supports the provision of high-quality mental and medical health-care treatment for all people and, therefore, expects all psychiatrists to provide appropriate, nondiscriminatory treatment to all people, regardless of their sexual orientation, gender identity or gender expression.

The CPA supports efforts to provide appropriate and safe environments for people who identify as transgender or who are gender variant or gender nonconforming in institutional settings, such as supportive living environments, long-term care facilities, nursing homes, treatment facilities, shelters and prisons. The CPA also supports access to appropriate treatment in institutional settings for people of all gender identities and expressions, including gender-affirming and transition-related therapies.

The CPA supports efforts to provide safe and secure educational environments at all levels of education, as well as foster care environments and juvenile justice programs, that promote an understanding and acceptance of all youth, regardless of their sexual orientation, gender identity or gender expression.

The CPA recognizes the efficacy, benefit and medical necessity of gender transition treatments for appropriately evaluated people and calls upon provincial health insurance plans to cover these medically necessary treatments, including travel expenses associated with required appointments and surgeries.^44,54

The CPA supports educating psychiatric residents and psychiatrists about how to explore patients’ perceptions of their sexual orientation, gender identity and gender expression using 2SLGBTQ+-inclusive questions and gender-inclusive language. The CPA also supports educating all psychiatric residents and psychiatrists about the potential for mental health-care disparities in 2SLGBTQ+ communities and about some of the specific issues that can apply when working with people who identify as 2SLGBTQ+ (e.g., homophobia and transphobia, family rejection and the coming out process).

The CPA supports psychiatrists assessing and addressing social determinants of health with all of their clients/patients, including those who identify as 2SLGBTQ+, given that gaps in these domains disproportionately affect this population's health outcomes and access to care.^44,54,55

The CPA opposes the use of reparative or conversion therapy, given that such therapy is based on the assumption that 2SLGBTQ+ identities indicate a mental disorder and/or the assumption that the person could and should change their sexual orientation and/or their gender identity/expression. The CPA calls upon all levels of government to legislate against such “therapies” given they are harmful and unethical.

The CPA encourages physician practices, medical schools, hospitals and clinics to broaden any nondiscrimination policies or statements to include sexual orientation, gender identity and gender expression.

The CPA encourages the use of respectful and appropriate language with all 2SLGBTQ+ patients and specifically encourages using the patient's preferred name and pronouns.

The CPA encourages the creation of a welcoming and affirming environment for 2SLGBTQ+ people by creating an office space and/or hospital unit that affirms people's identity (e.g., using gender-inclusive language on forms and providing gender-inclusive washrooms when possible). Please see Table 1 for further suggestions for creating a positive space.

Table 1.

Creating a Positive Space.

Creating a positive space

Use inclusive language in interviews and intake forms.

Reflect back the language used by your patient, including using their preferred name and pronouns.

Do not make any assumptions about patient's sexual orientation or gender identity.

Display posters/pamphlets/signs that are inclusive of 2SLGBTQ+ people and issues.

Offer gender-inclusive bathrooms.

Post a nondiscrimination policy that includes sexual orientation, gender identity and gender expression

Accept and celebrate diversity.

Glossary of Terms

The following terms and definitions may be used differently by different people in different regions and are not standardized. They are compiled from several sources,^19,56,57 with the acknowledgement that they will change over time as the thinking, attitudes and discourses around 2SLGBTQ+ issues continue to evolve.

Ally: Someone who advocates for and supports members of a community other than their own, reaching across differences to improve 2SLGBTQ+ rights.

AFAB/AMAB: Acronyms meaning “assigned female at birth/assigned male at birth”.

Asexual: Sometimes called “ace” for short, asexual refers to a complete or partial absence of sexual attraction or lack of interest in sexual activity with others. Asexuality exists on a spectrum where asexual people may experience no, little or conditional sexual attraction.

Biphobia: Irrational fear and dislike of bisexual people. Bisexuals may be stigmatized by heterosexual people as well as by lesbians, gay men and transgender people.

Bisexual: A person who is attracted to and may form emotional, romantic and/or sexual relationships with people with the same, and to people with a different, gender and/or gender identity as themselves. People who identify as bisexual need not have had equal experience—or equal levels of attraction—with people across genders, nor any experience at all: it is merely attraction and self-identification that determine orientation.

Cisgender: A person who by nature or by choice conforms to the gender assigned to them at birth and/or the sex-based expectations of society (also referred to as gender normative).

Cisgenderism: Assuming every person to be cisgender, therefore marginalizing those who identify as transgender in some form. It is also believing cisgender people to be superior, and holding people to traditional expectations based on gender, or punishing or excluding those who do not conform to traditional gender expectations.

Coming out: Recognizing one's own sexual orientation or gender identity and being open about it with oneself and/or with others. This often occurs in a significant moment as well as throughout one's life, with each person to whom one chooses to come out.

Discrimination: Negative behaviour or actions toward a person or group of people based on prejudicial attitudes and beliefs about the person's or group's characteristics, such as sexual orientation, gender identity or gender expression.

Gay: A person whose primary sexual orientation is to members of the same sex or gender. A person of any gender identity can identify as gay, although many female-identified people who are attracted to other female-identified people prefer the term lesbian.

Gender-affirming treatments: A suite of social, medical and surgical treatments through which a person's esthetic, physical appearance and/or function of their existing sexual characteristics are altered to more closely resemble that of the sex or gender to which they are transitioning.

Gender creative: Sometimes also known as “gender non-conforming” or “gender expansive”; often in reference to children, but not always. Someone who is gender creative is someone who rejects expected gender roles and stereotypes, expresses a gender identity that is different from the one they were assigned at birth or self-identifies outside the categories of the male/female binary.

Gender expression: The way in which a person expresses their gender identity through clothing, hairstyle, make-up, behaviour, posture, mannerisms, speech patterns, activities and more.

Gender identity: One's internal and psychological sense of oneself as male, female, both, neither or outside these two categories.

Genderism: Sometimes referred to as cisgenderism; the assumption that all people must conform to society's gender norms, and specifically, the binary construct of only two genders, corresponding to the two sexes (female and male). This belief in the binary construct as the most normal and natural and a preferred gender identity does not include or allow for people to be intersex, transgender or genderqueer.

Gender nonconforming: A person who does not conform to society's expectations of gender expression based on the gender binary or expectations of masculinity and femininity.

Genderqueer: A person who experiences a very fluid sense of their gender identity and who does not want to be constrained by absolute concepts. Instead, they prefer to be open to relocating themselves on the gender continuum.

Gender variant: A synonym for gender nonconforming, which is preferred to gender variant because variance implies a standard normativity of gender.

Heterosexual: A person whose primary sexual orientation is to people of a different sex or gender than their own. Heterosexual people are often referred to as “straight.”

Heterosexism: The assumption that everyone is, or should be, heterosexual and that heterosexuality is inherently superior to and preferable to all other sexual orientations.

Heterosexual privilege: Benefits derived automatically by being (or being perceived as) heterosexual that are denied to all other nonheterosexual sexual orientations.

Homosexual: A person who has emotional, romantic and/or sexual attraction predominately to a person of the same gender. As this term is historically associated with a medical model of homosexuality, most people would prefer to self-identify as gay, lesbian or queer.

Homophobia: The irrational fear or hatred of, aversion to, and discrimination against homosexuals or homosexual behaviour.

Internalized homophobia: The experience of guilt, shame or self-hatred in reaction to one's own feelings of attraction for a person of the same sex or gender as a result of homophobia and heterosexism.

Interpersonal or external homophobia: Overt expressions of internal biases, such as social avoidance, verbal abuse, derogatory humour and physical violence.

Intersex: A person who has some mixture of female and male genetic and/or physical sex characteristics. Intersex people may have external genitalia that do not closely resemble typical male or female genitalia, the appearance of both female and male genitalia, the genitalia of one gender and the secondary sex characteristics of a different gender or have a chromosomal make-up that is neither XX nor XY. An outdated term formerly used was hermaphrodite.

Institutional homophobia or heterosexism: Refers to the many ways that governments, businesses, religious institutions, educational institutions and other organizations set policies and allocate resources that discriminate against people based on sexual orientation.

Lesbian: A female-identifying individual whose primary sexual orientation is to other female-identifying individuals or who identifies as a member of the lesbian community.

Nonbinary: An umbrella term for gender identities that fall outside of the man–woman binary, anywhere along the gender spectrum.

Pansexual: A person who is attracted to other people regardless of gender identity.

Prejudice: An unjustified or incorrect attitude toward or idea about an individual or group of people based solely on their alleged membership in a social group, such as the 2SLGBTQ+ community.

Queer: In contemporary usage, queer is an inclusive, unifying, sociopolitical and self-affirming umbrella term encompassing a broad range of sexual and gender expression, including people who identify as gay, lesbian, bisexual, transgender, intersex, genderqueer or any other nonheterosexual sexuality or nonconforming gender identity. Queer is a reclaimed term, which was previously seen as derogatory, but many people (though not all people) within the 2SLGBTQ+ community are comfortable using this term.

Questioning: A self-identification sometimes used by those exploring personal issues of sexual orientation and/or gender identity.

Reparative or conversion therapy: A range of pseudo-scientific treatments that aim to change a person's sexual orientation from nonheterosexual to heterosexual or a person's gender identity from noncisgender to cisgender.

Sexual behaviour: Refers specifically to sexual actions or what a person does sexually. Sexual behaviour is not necessarily congruent with sexual orientation and/or sexual identity.

Sexual identity: Refers to a person's identification to self (and others) of one's sexual orientation. It is not necessarily congruent with sexual orientation and/or sexual behaviour.

Sexual orientation: Refers to how one thinks of oneself in terms of one's emotional, romantic or sexual attraction, desire or affection for another person.

Transgender or trans: Someone whose gender identity or expression differs from their assigned gender at birth. It is often used as an umbrella term that includes people who identify as two spirit, genderqueer and nonbinary.

Transition: A process through which transgender people align their anatomy and/or their gender expression with their gender identity.

Transphobia: Irrational fear or dislike of transgender people.

Two spirit: A term used by some North American Indigenous peoples to describe those people in their cultures whose nature is comprised of both male and female spirits. People who identify as two spirit may also identify as gay, lesbian, bisexual, transgender, intersex, or have multiple gender identities.

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