Working with lesbian, gay, bisexual and transgender people

This chapter sets out to acknowledge the diversity of the sexual and gender minority while drawing the reader’s attention to the common experiences of discrimination and marginalisation that LGBT people face and the impact of these on psychological well-being. It also looks at ethical approaches to working with LGBT people, starting with the practitioner’s own stance in relation to this work. You may think it unnecessary to say it, but first and foremost lesbian, gay, bisexual and trans (LGBT) people arc people. So all the skills available to the practitioner arc relevant here. Commonly used language may suggest otherwise, however. The current habit of using the term ‘the gays’ suggests an all-consuming identity that ignores other characteristics, even the fact that gay men arc (hu)men. Lesbians have had to endure this for some time of course. Along with this reductionism can come assumed homogeneity; as if a book chapter like this can assume total relevance to all sexual and gender minority people. There is as much variation in this population as there is in the heterosexual population. The most commonly used model of sexual identity formation (Cass, 1979, 1996) suggests a final phase of identity synthesis when lesbian, gay and bisexual (LGB) people acknowledge sexuality to be merely one aspect of who they are. Diversity also extends to the range of identities and expressions of sexuality and gender within the sexual minority and so the term LGBT will not fully reflect the makeup of this population. Trans agendas have become aligned with those of the LGB communities because of common experiences of marginalisation and discrimination, but not without some disagreement (BPS, 2012), and this again warns us against assuming homogeneity. A ‘queer’ identity has been adopted by those who wish to move beyond simplistic dichotomies of sexuality and gender and this position is supported by queer theory (Scidman, 1996). Similarly, there arc a range of gender minority identities, which fall under the umbrella term of trans and include for instance identities of gender quecmcss, androgyny and the third sex (BPS, 2012). However, despite these important caveats there arc ethical considerations specific to these populations that require attention, especially if we remember that Psychology and Psychiatry have a long history of pathologising LGBT people (BPS, 2012).

Presence in services

If we acknowledge that same-sex attraction is a normal variant of human sexuality (BPS, 2012) then therapists will encounter sexual minority people in their practice. More recent surveys have found lesser numbers of LGB people in the population than the often reported 10% from the early Kinsey surveys in the US (Kinsey ct al., 1948, 1953). Survey methods in this area are fraught with difficulties, of course, and it is probably safe to assume that numbers represent an under-estimation due to reluctance to disclose or differences in self-identity and labels used. The Observer British sex survey of 2014, which ensured anonymity via online data collection, found that 8% of people described themselves as homosexual or bisexual. However, 21% of those aged 16-24 defined themselves as homosexual or bisexual. At present, there is no official estimate of the trans population. The Gender Identity Research & Education Society (GIRES) estimated in 2011 that about 1% of the UK population experience some degree of gender variance.

Psychological distress

Whatever the true figures, it is unarguable that LGBT people arc regular users of psychological services, and the numbers of LGBT service-users arc increasing. There has been a rapid rise in referrals to gender identity clinics nationally, with some clinics’ referrals rising by several 100% (The Guardian, 2016). This is provoking much discussion and docs not simply suggest an increase in psychological distress related to gender identity alone. Many have wondered if shifts in acceptance and a move towards non-binary perspectives, accelerated through media coverage and social media presence are playing a role (Transgender Trend, 2017).

There are many indications that LGBT people are at increased risk for psychological distress but it is important to stress that this is not related per se to their sexual or gender identity but to experiences of discrimination, rejection and stigma that results from societal systems’ positioning of the sexual minority. Stonewall’s 2018 survey of over 800 trans people reveals the impact that discrimination and exclusion arc having on trans people’s quality of life. Two in five trans people had to deal with a hate crime or incident in the last 12 months. More than a quarter had experienced domestic violence, and one in four had experienced homelessness at some point. The National Institute for Mental Health in England (2007) systematic review of the mental health of LGB people found that rates of attempted suicide more than double for lesbian, gay and bisexual people and they arc one and a half times more likely to experience depression. Meyer (1995) introduced the concept of ’minority stress’, which is a way of understanding the impact of being part of a group less valued by society, which can lead to internalised negativity and expectations of rejection and discrimination.

These difficulties can be exacerbated by the actual experience of accessing services which arc frequently discriminatory themselves (PACE, 1998). Stonewell conducted research in Wales which found that 39% of sexual minority people entering services experienced homophobia (Central and North West London NHS Foundation Trust, 2012). Although many trans people do not opt for medical interventions, those who do are required to undergo psychological assessment in order to pursue gender reassignment. Many trans people, as it is with many LGB people, will come to services with difficulties not related to their gender or sexual identity, yet it may be difficult for trans people to access non-spccialist services (BPS, 2012). If they do access them the experience can be very disappointing. For instance, two in five trans people said that healthcare staff lacked understanding of specific trans health needs when accessing general healthcare services in the last year (Stonewall, 2018). The reader can increase their familiarity with the fight for LGBT equality by referring to the timeline presented on Stonewall’s website (www.stoncwall.org.uk/about-us/ kcy-dates-lesbian-gay-bi-and-trans-cquality).