LGBTQ+ identities and therapy: the history

February is LGBT history month. Let’s have a look at the history of LGBT clients in therapy.

LGBTQ+ clients have traditionally had a tough time in the mental health system. This is ironic as LGBTQ+ individuals utilize psychological services more extensively than heterosexual and cisgender folk (Berke et al, 2016).

The beginnings

Let’s start with Mr Freud, the founder of psychoanalysis. He held the heterosexist belief that male-female pair-bonding was the developmental norm for adult sexual behaviour. His theories then became the foundation for treatments attempting to “cure” homosexual and gender-nonconforming behaviours (Istar Lev, 2013). This is where conversion therapy comes in.

Conversion therapy

Conversion therapy is an umbrella term for any treatment aiming to change somebody’s sexual orientation or gender identity, such as electroconvulsive shock treatments, and talking (Trispiotis and Purshouse, 2021).

Sadly, conversion therapy is still happening today in the UK, after the government failed to act on its promise to ban it (Stonewall).

Conversion therapy is extremely harmful and is underpinned by the premise that being LGBTQ+ is wrong, or an illness to be cured. When considering how this has happened, it could also be useful to look at the history of the DSM (Diagnostic and Statistical Manual of Mental Disorders).

The DSM

The DSM is the authoritative guide to the diagnosis of mental disorders.

The first edition of the DSM was released in 1952, and homosexuality was classified as “sociopathic personality disturbance”. In 1968, it was listed as a mental disorder, in the same category as paedophilia. This was the period that the gay rights movement was catalysed by the Stonewall riots, in 1969. Homosexuality was ‘taken out’ of the DSM in 1973, and was replaced by “sexual orientation disturbance”, implying that one is distressed by their sexual orientation, rather than the systems that perpetuate prejudice. The most recent DSM, the DSM 5, thankfully does not include any diagnostic category related to sexual orientation.

History, however, is repeating itself with trans and gender non conforming folk. In 1980 the DSM 3 introduced gender identity disorder, and the DSM 5 now lists ‘gender dysphoria’. That’s right, gender dysphoria is still considered to be a pathology, whilst cisgender identities are considered the norm.

It is no surprise then that trans and gender non-conforming individuals are particularly at risk of poor mental health. Su et al (2016) conducted an online survey comparing the mental health of non-transgender individuals within the LGBTQ+ community with transgender individuals, finding that transgender identity was associated with greater reported discrimination, depression and attempted suicide.

LGBTQ+ affirmative therapy

The term "gay affirmative therapy" was developed by Alan K. Malyon in 1982, and is based on the fundamental concepts that homosexuality is not a psychopathology and that gay people do not suffer from mental illness as a result of their homosexuality. Central to this approach is the attempt to create a supportive and accepting atmosphere in order to enhance the dignity and self-respect of gay clients . Gay affirmative practise has led to an increased focus on how transgender identities can be depathologised (Istar Lev). Trans affirmative practice refers to a non-pathologising approach to clinical practice that accepts and validates all experience of gender (Austin and Craig, 2015).

Research has consistently shown that LGBTQ+ affirmative therapy creates trust in the therapeutic relationship and is key to the client’s sense of mental health and wellness.

The history of pathology from the systems that are created to support those in need is one of the reasons that LGBTQ+ affirmative practises are so important: therapy should never become a place where more harm is done. I hope that LGBTQ+ affirmative attitudes will become the norm across the board for all healthcare professionals.