Advanced Nursing Inquiry and Evidence Based Practice

nternational Review of Psychiatry, 2015 VOL. 27, NO. 5, 463–469

Sexuality and mental health: Issues and what next?

Gurvinder Kalraa, Antonio Ventrigliob & Dinesh Bhugrac

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aFlynn Inpatient Psychiatric Unit, La Trobe Regional Hospital (LRH), LRH Mental Health Services, Traralgon, Victoria, Australia; bDepartment of Clinical and Experimental Medicine, University of Foggia, Foggia, Italy; cHealth Service and Population Research Department, Institute of Psychiatry, King’s College London, De Crespigny Park, London, UK

ABSTRACT Human sexuality plays a major role in an individual’s existence and functioning. In addition, rightly or wrongly sexuality often defines people and also affects social attitudes. These attitudes, if negative, can contribute to stigma and prevent people from help seeking if they are suffering from mental health problems. Recent changes in policy towards same-sex relationships have been positive in many countries including the UK and the USA, whereas in others such as Russia and Uganda attitudes have become more negative and punitive. Sexual activity is seen as having both pleasurable and procreational functions which contribute to society’s attitudes to homosexual behaviour. Inevitably, individual responses to their own sexuality and sexual behaviour will be influenced by social attitudes. To ensure that those with various sexual variations can access psychiatric services without discrimination, various levels of interventions are needed. Here we discuss different levels of intervention and organizational change that may make it possible. Social organization and institutional organization of services need to be sensitive, especially as rates of many mental disorders are high in individuals who may be sexually variant. Those providing services need to understand their own negative attitudes as well as prejudices to ensure that services are emotionally accessible.

ARTICLE HISTORY Received 11 May 2015 Accepted 10 September 2015 Published online 6 November 2015

KEYWORDS Homosexuality, mental health services, sexual varia- tion, organisations


Sexuality is an integral and crucial part of any individ- ual’s personal identity that defines individuals as distinct from others. Sexual orientation and sexual acts enable individuals to connect with others at varying levels of intimacy. Sexuality or sexual orientation needs to be differentiated from sexual act or sexual behaviour as well as sexual fantasy. Often sexual orientation and sexual behaviour are seen as synonymous. This is a mistake that is often made in policy, thereby adding to negative attitudes.

Although sexuality as such is a much wider concept, it has recreational (pleasure-based) or procreational (reproductive) functions. Recreational sex is seen as a purely pleasurable activity. However, seeing sexuality simply as a procreational activity reduces the function of sexuality to a very simplistic view. Not surprisingly this function has been used as being against the laws of nature and thus often as an argument for legal and religious discrimination against sexual variation. Being gay or lesbian was widely considered to be a mental illness until the American Psychiatric Association (APA) removed homosexuality from the list of mental illnesses

from the Diagnostic and Statistical Manual in 1973, following the Stonewall riots and also by changing public opinion, but it continues to be treated as abnormality and illness in many parts of the world even now.

In this paper we discuss the need to understand the various mental health issues that gay individuals face both as part of the minority lesbian, gay, bisexual, and transgender (LGBT) group and consequently by experi- encing higher than expected levels of psychiatric dis- orders. We do not aim to cover issues related to LGBT adolescents or older individuals. We present some ways forward about what can be done to help them in the capacity of mental health professionals.


In the 1980s the emergence of the epidemic of HIV/ AIDS brought both stigma and awareness of alternative sexuality to the fore. Its impacts on the lives of gay men in the 1980s – those who died and those who survived – cannot be measured. It did raise awareness but also increased stigma against gay men in particular who in many cases decided not to seek help. People who grew

CONTACT Gurvinder Kalra Flynn Inpatient Psychiatric Unit, La Trobe Regional Hospital (LRH), LRH Mental Health Services, Traralgon, Victoria, Australia 3844. Tel: +61 351 738 647

� 2015 Institute of Psychiatry

up in heteronormative environments until now started to become more aware of same sex behaviours and the perceived role that the alternative sexuality was playing in the emerging epidemic. Policymakers for a long time ignored the epidemic and it was only with the death of Rock Hudson in the USA that policymakers started to respond. Thereafter increased funding in research development and health care delivery started to make an impact. However, what started as concerns for the physical and sexual health of this population gradually became a struggle for validation of their sexual identities. As mentioned above, although homosexuality had been removed from the DSM-III by the American Psychiatric Association, the spread of AIDS led to both a moral panic and increased stigma against minority sexualities.

The process of coming out for gay individuals is a highly critical time in their lives and has been shown to be associated with increased drug and alcohol use, unsafe sex practices, self-harm, suicide attempts and completed suicide. It is common to pathologize people on the basis of their varying sexual orientation and attraction (Bartlett et al., 2001; Kalra, 2012). These stigmatizing attitudes by society are often reflected by health profes- sionals too. An additional factor which often gets ignored is the perceived and real power held by the mental health professional, which can then act as a major factor in alienating individuals and also stopping them from seeking help. This stigmatizing attitude can be both open and discreet. Such fear of pathologization often leads to under-utilization of health services, increased sexual and mental health issues and impacts on overall quality of lives. An interesting report named Enough is Enough published by the Victorian Gay and Lesbian Rights Lobby in Australia (Victorian Gay and Lesbian Rights Lobby, 2000) showed that discrimination could be experienced in a range of places including educational institutions, workplace, accommodation, and health services. Discrimination was also more commonly experienced by people from rural than metropolitan areas. This finding has clear and major implications in terms of policy-making and implementation at multiple levels including health care delivery. Discrimination and attitudes about alternative sexuality are more likely to be difficult in the older individuals. As is often the case, older individuals are not seen as having sexual needs and alternative sexualities can create more negative attitudes in these groups.

On the other hand, bisexual individuals may identify themselves as neither heterosexual nor homosexual and are likely to be excluded by both the mainstream and gay and lesbian support networks; transgender individuals tend to be the most marginalized of the LGBT

population. Along with the unmet mental health needs of this population it has been observed that the rates of homelessness in LGBT youth is higher due to reasons such as the individuals running away from families who reject them due to their sexual orientation or gender identity, or them being evicted out of their homes by their families (Keuroghlian et al., 2014). Often the mean age of becoming homeless in such youths is as young as 14 years and has been considered to be a coping strategy (Rosario et al., 2012) even before parents reject their sexuality or the individual rejects their parents fearing potential stigma and resulting rejection. High rates of infection and malnutrition can accompany homelessness.

Risk factors

Research has suggested certain specific risk factors that this population shares for poor mental health and suicidality (Crisp & McCave, 2007) including stigma and discrimination at all levels in society, fear of and experiences of violence, rejection from family and friends, homelessness, drug and alcohol use, suicidality and completed suicides among friends. Sexual orienta- tion has been shown as a risk factor for suicidal behaviour (King et al., 2008; Nicholas & Howard, 1998; Silenzio et al., 2007) and such behaviour is reportedly most likely to occur after the person has self-identified as gay but before having a same sex experience and publicly identifying as gay (Nicholas & Howard, 1998) or coming out. Co-morbidity of mental and physical illness and additional impact of alternative sexualities can contribute further stress. Detailed epidemiological findings in different psychiatric disorders are described by Cabaj and Stein (1996) and Levounis et al (2012). Being a minority adds stress related to isolation and alienation but also may add to external and internal stigma.

There is an expanse of literature that demonstrates a higher rate of such difficulties including psychosocial distress, leading to negative mental health outcomes in sexually variant individuals (Diamant & Wold, 2003). A meta-analysis by King et al. (2008) showed a higher risk of depression and anxiety disorders over a period of 12 months or lifetime in LGB populations. The findings of this meta-analysis do raise valid concerns given that this meta-analysis covered a vast literature database includ- ing grey literature databases over a prolonged period from 1966–2005. The papers included had clearly defined criteria for sexual orientation and mental health outcomes. The authors included studies with varied sampling methods such as snowballing in order to allow for differences in reluctance to disclose sexual orientation by participants.


The rates of substance use such as cigarette smoking and alcohol (including risky single occasion drinking, RSOD) have also been shown to be much higher in LGBT populations (Hagger-Johnson et al., 2013). Fergusson et al. (2005) have pointed out that these associations are more marked for men than women. Broader social and cultural attitudes towards alternative sexuality affect not only rates of mental illness but obviously attitudes to help seeking and sexual activity. It is inevitable that socio-economic and educational status will play a role in self-identification of gender, gender role, and emotional distress, which may or may not be linked with gender role. In a fascinating study, Hatzenbuehler et al. (2009) investigated the modifying effect of state-level policies on the association between mental health and sexuality in a survey of 34,653 participants of whom 577 were identified as LGBT individuals. In the states where there were no policies providing protection to LGBT individuals in place, the rates of any mood disorder were nearly twice (20.4%) in comparison with the heterosexual sample (10.2%), anxiety disorder 30.1% in comparison with 16.1%, and substance abuse was 40.8% compared with 20.9%, but alcohol use was almost two and half times and drug disorders were five times more common in LGBT individuals. Psychiatric co-morbidity among LGBT individuals was three and half times higher. In a later study, Hatzenbuehler et al. (2012) also found that, after the legalization of same-sex marriage, sexual minority men had a significant decrease in mental health care visits as well as a reduction in hospital visits related to physical ill-health, in comparison with data 12 months prior to legalization. This reduction thus seems to suggest that social factors play an important role in the mental and physical health of sexual minority individuals.

Results from the Longitudinal Study of the Health of Australian Women (McNair et al., 2005) showed that 38% of same-sex-attracted female respondents between the ages of 22–27years had experienced depression compared to only 19% of heterosexual female respond- ents, and also experienced higher levels of anxiety (17.1% versus 7.9%). This was found after adjustments were done for age, region of residence and education. The study, however, does not point out whether depression occurred independently of coming out or recognizing the same sex feelings in these women. In the same study, sexually variant women i.e. women who self-identified as bisexual or lesbian, were more likely to have tried to harm or kill themselves in the previous 6 months. Higher rates of self-harm and suicidal thoughts have been linked to violence and harassment in same-sex-attracted indi- viduals (Hillier et al., 2005), confirming findings from

other parts of the world. Both population-based and twin studies from different countries have found that LGB people are three to six times more likely to attempt suicide than heterosexual people (Herrell et al., 1999). This risk is further increased in culturally and linguis- tically diverse (CALD) background populations (Haas et al., 2011).

Sexually variant women were also significantly more likely to report cigarette smoking (Hughes & Jacobson, 2003), risky alcohol use (7% compared to 3.9%), marijuana use (58.2% versus 21.5%), use of other illicit drugs (40.7% versus 10.2%) and injecting drug use (10.8% versus 1.2%) (Hillier et al., 2004). In a popula- tion-based telephonic survey in Los Angeles (Diamant & Wold, 2003), depressed women who identified them- selves as lesbians were more likely to be using an antidepressant medication and reported significantly more days of poor mental health compared to hetero- sexual women. Not entirely surprisingly, these mental health disparities are not only found in adults but also in adolescence and young adults, with sexual minority youths (age 5 18 years) reporting significantly higher suicidality and depression symptoms (Marshal et al., 2011). In an interesting longitudinal study, Fergusson et al., (1999) followed up a birth cohort of 1265 children born in Christchurch (New Zealand) over a 21-year period. At 21years of age, 1007 sample members were questioned about their sexual orientation, with 2.8% subjects being classified as being of gay, lesbian or bisexual orientation. Data was gathered on a range of psychiatric disorders including suicidal ideation and attempts over the period from age 14–21years and it was observed that gay, lesbian and bisexual young people were at increased risk of major depression, generalized anxiety disorder, conduct disorder, nicotine dependence, other substance abuse and dependence, multiple dis- orders, suicidal ideation and suicidal attempts. More recently Needham (2012) showed that these disparities persist over time, as the youth transitions into adulthood. Data for this study were collected from four waves of the National Longitudinal Study of Adolescent Health, with the respondents being in grades 7–12 at wave 1 and aged 24–32 at wave 4. A particular strength of the study is that it captures the respondents’ trajectories as the ones who consistently report heterosexual attraction versus those who consistently report LGB attraction, those who report a transition to LGB attraction and those who report a transition to heterosexual attraction. Sexually variant individuals show similar problems with respect to their physical health (Frost et al., 2015) including greater likelihood of sexually transmitted infections, such as HIV/AIDS (Halkitis et al., 2004). Such poor health behaviours and negative physical and mental health


outcomes are associated with poor access to health care in sexual variant individuals (Diamant et al., 2000). For a number of reasons, including the illegal nature of such behaviours in many countries, individuals either resist or delay seeking health care from mainstream health care providers, contributing to a chronic nature of some of the conditions.

Minority stress

A useful way of understanding how individuals with alternative sexuality are impacted due to their sexuality is the concept of ‘minority stress’. This explanatory framework put forward by Meyer (1995) describes the relationship between mental health and sexual variation. Individuals with alternative sexuality experience the burden of a minority status in addition to the routine stressors experienced by them on a day-to-day basis. Growing up, such individuals come to realize that they are part of a group that is less valued by society and is vulnerable to prejudice and discrimination. These nega- tive experiences are internalized, leading to future negative expectations from one’s own identity and sexuality, often increasing one’s vulnerabilities and risks. This model thus helps us understand how individuals with alternative sexuality navigate their lives and the associated stresses with a resultant increase in their likelihood of developing mental health difficulties.

Stresses experienced by lesbian individuals may be different from those experienced by gay men who may experience challenges to the notions of culturally expected masculinity. It has been argued that a reason for excluding female same-sex activity from discrimin- atory law against same-sex behaviour in men was because Queen Victoria did not believe that women had these notions. Furthermore we know that cultures not only dictate specific gender roles assigned but also have different gender role expectations, and this may further contribute to increased alienation leading to higher rates of mental disorders. In addition, cultures have been described as sex-positive and sex-negative (Bullough, 1976): sex- positive cultures have a strong emphasis on sexual activity as a means for pleasure, whereas in sex-negative cultures sexual activity is about procreation and propagation of the family name, thus attitudes to alternative sexuality and alternative sexual activity will vary dramatically within a given culture. The inclusive recreational viewpoint towards sexuality has been seen as underpinning the LGBT activism seen in the Western world, while the reductionist procreational viewpoint has been argued to view alternative sexuality as pathology in some other parts of the world. Strong

religious views, of whatever denomination, indicate that religious views can often subjugate basic human rights.

What is needed?

Professional factors

Often health care professionals are uncertain how to react and what to do when an individual comes out to them about his/her sexuality (PriceWaterhouse Coopers, 2011). Part of the reason for this is poor training of the health professionals in the area and a lack of under- standing as well as interest. In addition, personal values based on religion may also play a role. Alternative sexuality is an often ignored area in psychiatric training, with the subject occupying only a minute portion of training curricula. This often reflects the real-world situation where only a proportion of such individuals seek help for varied reasons discussed earlier in this paper. Increasingly in some countries training curricula are beginning to include sexual variations. It is important that such training and education endeavours to continue to educate mainstream health-care providers especially in psychiatry. Models similar to cultural competence training need to be developed, although Levounis et al. (2012) have described some approaches. Thus it is important that a sensitive attitude towards individuals from sexual minorities is encouraged and to reduce sometimes automatic assumptions during consultations that people are always heterosexual. To this effect, mental health professionals need to begin using inclusive language such as ‘partner’ instead of ‘husband’ or ‘wife’.

It is critical that professionals exploring non-hetero- sexuality and working through issues of same-sex attraction and/or diversity of gender expression are supported during their process with non-judgemental attitude. Accurate information needs to be available for health professionals in an environment of support and safety. It is important that the practitioner does not over- emphasize the sexual orientation of the client and attribute all the presenting problems purely to their sexual orientation. Instead the practitioner should be able to view the individual, their sexual orientation, and the presenting mental health problem as different dimensions and work accordingly. Mental health pro- fessionals are in a unique position to address heterosex- ism and homophobia at different levels in the society and taking on the role of being advocates for their patients.

Mental health professionals need to understand that homosexuality is not a mental illness and hence does not require treatment or conversion therapies. They should consider resorting to gay affirmative therapies rather than utilizing reorientation frameworks in their


therapeutic work with such individuals. Gay affirmative practice has been suggested as the most effective framework that can guide the work of mental health professionals with the LGBT population (Crisp, 2007). This framework helps to ‘affirm a gay, lesbian or bisexual identity as an equally positive human experience and expression to heterosexual identity’ (Davies, 1996). This practice model helps practitioners consider specific issues that affect the LGBT population, ways that traditional practices/therapies may not help such indi- viduals and help them tailor such services or therapies to fit work with such clients (Appleby & Anastas, 1998). The key principles underlying such practice discourage assuming an individual’s sexuality and include the possibility of considering same-sex desires and fantasies as normal variation of human sexuality. Thus normal- ization of alternative sexual behaviours can help reduce stigma and discrimination. Such approaches also encour- age practitioners to identify and deal with heterosexism in themselves (Appleby & Anastas, 1998). There is no evidence that curative or reparative therapies work. These approaches may work on the behaviour but not the orientation/ identity continuum.

One should look at the LGBT populace as a distinct cultural group that shares unique experiences and has specific needs. The gay affirmative practice model has also been referred to as a form of cultural competency model that encourages professionals to practice in a culturally sensitive way similar to practice with racial and ethnic minority groups (Crisp & McCave, 2007; Van Den Bergh & Crisp, 2004).

Organizational level

With growing recognition of sexuality as a key part of sexual identity of individuals, it is highly likely that mental health services will deal with many individuals seeking their services in the process of understanding psychiatric and emotional distress whether it occurs at the time of coming out or later. This means that wherever possible services should address LGBT issues in their planning and development policies and show their support to such populations by formulating inclusive and sensitive policies. This needs to be backed by continuous quality improvement through programme evaluation, monitoring, and review of performance. It is crucial that LGBT issues are addressed in existing organization policies and cultural competency training is made mandatory for health-care staff. Organizations also need to look into having specific policies for culturally and linguistically diverse populations and immigrant populations who identify themselves as sexual minorities.

The field of mental health is now increasingly being guided by the recovery framework (Slade et al., 2014) and one could look at utilizing the same framework within the LGBTI population. Such an approach high- lights the need to understand the narrative and the lived experiences of individuals whose sexual variation marks them out, and learn from them in order to guide our working relation with this population. Individuals with such lived experience could be part of mental health services, especially those accessed by such populations or the ones that are moving towards LGBT-friendly models. These peer-support workers will need training and policies will need to change accordingly. As in the case of cultural psychiatry, there is a possibility that individ- uals from LGBT organizations and communities may act as culture-brokers and culture-mediators working with teams and conveying information both to the team and also to the community as a whole. Strengthening partnerships between government and non-government sectors in areas with poor resources may help bridge some of the gaps in the mental health-care needs of this population. Various examples of voluntary agencies working with statutory organizations exist in different countries and service planners need to explore local models of good practice.

It is crucial that health services work with other partners such as education, justice and other stake- holders to develop and deliver services which are sensitive as well as acceptable.

Service planning

From the above discussion it is quite apparent that the LGBT population has specific mental health needs that may not be addressed by standard mental health services. This therefore calls for specific services that cater to the population who identify themselves as alternative sexu- ality individuals. There is a possibility of combining such services with a strong mainstream mental health service system especially in under-resourced places such as in rural areas. The evident gap between mental health needs and resources to help those in need calls for interven- tions at different levels as discussed under. Models such as female only wards and services provide an exemplar on how services can and should be developed. Whether there need to be separate services for LGBT patients needs further detailed exploration. In addition, therapist matching needs to be considered and research trials in service development need to be taken forward to see whether this will produce better rates of engagement and satisfaction. However, such approaches are only possible in some parts of the world where there is better legal acceptance of sexual variations.



Sexuality is a key part of an individual’s identity and social functioning. Cultures and societies define deviance especially in terms of behaviour, and individuals with alternative sexuality can thus be made to feel accepted, ignored, discriminated against or stigmatized. It is likely that discrimination against LGBT individuals can be minimized, especially if legal recourse is applied. However, the psychiatric profession needs to take on specific tasks related to training and service planning. We recognize that some of these factors do not apply to all the cultures around the globe but we believe that aspirational models need to be encouraged. While delivering services, health care professionals must be trained appropriately and the systemic change in the organization and institutions must be modulated to develop services which are physically and emotionally accessible. Various models of good practice and gay affirmative therapies exist and it is crucial that good epidemiological evidence is collected to plan, develop and deliver services. Frameworks for assessment and management must be LGBT sensitive and voluntary organizations can be involved as both instigators and moderators as well as mediators, advocates and brokers.

Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.


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  • Sexuality and mental health: Issues and what next?
    • Introduction
    • Challenges
    • Risk factors
    • Minority stress
    • What is needed?
    • Conclusions
    • References


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