Welcoming LGBTQ+ Patients to Your Practice
I’ve been a psychotherapist for over 35 years, specializing in work with gay men and gay male couples, and despite an overall increase in LGBTQ+ acceptance, some medical and mental health providers still lack education or experience dealing with this population. But it isn’t too late for all that to change!
Trainings on working with LGBTQ+ patients ought to be prioritized in higher-level educational institutions as well as academic and professional conferences. The confidence that providers gain as a result of additional training has a lasting impact on patients, including knowledgeable and thorough care in the medical and mental health arena. Patients will benefit from extra caring and attention instead of feeling overlooked or discriminated against which is an unfortunate reality for many people seeking care.
I specialize in training providers about issues unique to gay men. Even though they present in healthcare settings as established and successful adults, understanding their history will help providers appreciate how patients seeking medical or mental health care are far more vulnerable than they appear. I will highlight some issues about gay development to help providers appreciate specific challenges.
Childhood
Imagine growing up in a world where you know you shouldn’t be who you are, that something about you isn’t right. You know this even if you can’t pinpoint exactly what that “something” is. You simply are different — and it is not okay. You also know that you can’t let anybody in on the secret you’re holding, even though your secret identity isn’t formed. Shame is synonymous with being. You spend many childhood years trying to fit in and covering up the essence of who you are, knowing that you’ll be ridiculed for being different from others — which is intolerable in the community where you were raised. You even may face the risk of being verbally and physically abused, not only by your peers, but also by your family, simply because you don’t fit the mold they have laid out for you.
This cloud you live under is kept top secret. Some people may be aware of it; others won’t.
Growing up gay is painful. Gay liberation and acceptance are still relatively new, and the struggles that come along with wanting to be accepted are still central to gay youth today. Because gay acceptance has become more mainstream, the assumption is that everything is better now, but that’s still far from the truth. Regardless of how young someone is, or how well his parents treat him when coming out, or how supportive his friends are, the notion of shame and the fear of betrayal still haunt gay youth even today. The risk of rejection is still greatly feared.
I present this to you so you may recognize that, despite how well-adjusted he may seem, or somehow “ought to be,” there are still painful memories within reach, and these memories direct him today.
The truth is gay boys feel different from others and are aware of this difference as early as they can remember. Richard Isay in Being Homosexual was the first psychiatrist, back in the 1980s, to note, research, and characterize this sense of “different-ness” in gay boys and to share his findings with others. He concluded that gay boys were more sensitive, cried easily, were frequently drawn to aesthetic interests such as art or music, and were often less aggressive than other boys. These boys were also not interested in sports, and even at this young age were made fun of by other kids.
Teenage years were especially painful, where being made fun of only got worse, and feeling isolated and feeing lonely was common. Added to these sources of pain was the probability that their fathers were detached and hostile, perceiving their son as different, withdrawing from him because he wasn’t athletic or was too sensitive, while frequently favoring another son for being a more of a boy. Sometimes these fathers weren’t even aware of what they were doing, but their gay son was certainly attuned to assumptions and behavior, which only reinforced his need to maintain secrecy.
I’ve heard hundreds of stories from my clients. These painful experiences left visceral memories that can be easily accessed and rise to the surface as pain. I myself had similar experiences growing up. Frequently these stories are now shared in jest, at parties, with family, or in group therapy, maybe decades later, but the humor only masks the pain from years back. Many gay men have similar versions of the same story, where the pain and humiliation lays below the surface.
Adolescence
Adolescence is a painful time for everybody, but LGBTQ+ teens experience disproportionately higher rates of depression and suicidal ideation, as well as suicide attempts or actual suicide. We live in a cruel world where being different is still a source of ridicule. Sadly, studies reveal that a high percentage of these youth hear negative and judgmental things about being gay in their households, which only reinforces isolation as well as shame. Not only are these facts grim, they are also real. They need to be taken seriously and the urgency of providers understanding this is paramount. In an effort to combat these negative effects, communities that educate and normalize the experiences of being gay are able to influence families to be more accepting.
Normalizing being gay is needed throughout all our communities. This includes workplaces, churches, and other religious institutions, school systems, medical practices and more. The lack of education needs to be turned around so gay youth can experience the trickle-down effect of acceptance. Instead of telling others what to do, or how to feel, sharing stories is a simple way to educate. Hearing others’ stories helps people form their own opinions and feelings about LGBTQ+ experiences.
Families who have experience with LGBTQ+ issues — older relatives, workplace friends, etc. — tend to be more accepting. Having the experience of loving or respecting someone who is already out can serve as a role model for acceptance. Even if it is unspoken in families, the reference of having a “normal” or nice quality of life is extremely comforting and serves as an important model for family or community members. I remind my clients that each of us may be the person who encourages or normalizes the experiences of being gay. It’s ironic that the people who experience the most shame and have the worst opinions of themselves are actual role models, even without realizing it’s happening, something I remind people of over and over again!
The Body as Denigrator
We are experts at mild dissociation. Our body has been one of our enemies. In our early days, we experienced deeply humiliating situations, in particular when it came to sports. Self-blame and feeling uncoordinated were distortions we believed to be true, as if something were wrong with how our bodies worked. It seemed that other boys had some synchronistic ability inside that we didn’t possess. (How ironic that so many adult gay men become athletes and successfully harness these abilities in their own ways!)
Awareness of sexual feelings in the body was a strong tidal wave that couldn’t be pushed back. But those feelings desperately needed to be denied as far as we were concerned. Despite attempts to fight back these forces within, the storm eventually surged, just offering up another betrayal in which our bodies were the enemy.
When we’re finally able to come out, we long for the solace we find in being part of the gay community, a place where we can feel comfortable, accepted, and even flourish. While that may all be true, there’s another challenge: the gay male community is an environment where physical and sexual ideals are superhuman, difficult if not impossible for most to attain. Physical perfection and hypersexuality become expectations, with porn-star performance the model. Again, the body betrays.
Your work as a therapist in helping your clients befriend their bodies is paramount.
The socialization of masculinity for boys presents its own challenges, especially in regards to vulnerability and shame. Now children can be raised as gender-neutral or non-binary, which is more freeing regarding gender and expectations, but not all families are liberal or open with their thinking. The variability in regards to gender continues to shift and indeed is exciting, yet will take more time to be accepted and evolve.
In the meantime, defining the LGBTQ+ category can be helpful in classifying issues unique to us, helping others appreciate how our day-to-day existence or identity is different from others. One drawback is being lumped in one category without understanding the differences that do exist. Boys are girls are raised with different pressures and expectations, and by adulthood, gays and lesbians have had vastly different experiences where it may be unfair to be lumped together as if we were one.
Providing one LGBTQ course isn’t enough in the medical, mental health, and academic worlds. More expansion and detail are needed in educating providers about the nuances of each category. Lesbian, Gay, Bisexual, Transgender, Queer or Questioning, + (pansexual, pangender, gender variant) is a huge category with subsets and categories that are more detailed than the acronym LGBTQ+.
Vulnerability and rejection don’t end with puberty but continue well into adulthood. This is especially true for those with double-minority status, being a minority within the family and community -based on being gay, and being a minority in the larger world- based on race or ethnicity. This potentiates shame, feelings of failure, and negative self-schemas. It also includes blatant rejection from communities and families who ideally would support their loved ones.
Growing up closeted and fearing rejection, abuse, and physical violence is not unusual for kids, especially those raised in religious households. When he is finally old enough to be able to leave home, especially if his home wasn’t safe, the young gay man is suddenly facing vulnerabilities of racial inequality from the outside world where danger lurks possible more strongly. Additionally, the gay community can be racist, thereby rejecting those who seem different from themselves and their subgroup. Hopes of fitting in may be met with rejection and bullying from the very place that was hopefully going to be a haven. The intersectionality of culture, race and religion and sexuality is dangerous for far too many people.
So now what?
Since there is a greater acceptance and awareness of working with gay men, now is a wonderful opportunity for you to do more, for yourself first! I offer my own two books (Unwrapped: Integrative Therapy with Gay Men and Mindfulness Tools for Gay Men: A Clinician’s Guide) as resources, but also suggest a few other ideas. Speak to people you know are gay, or who have experience working with the LGBTQ+ population. Dialogues and stories are motivating. Being able to ask questions in a safe context will help answer your questions or concerns. Consider a regular discussion or supervision group pertaining to LGBTQ+ topics where case examples, literature, and education arepart of this experience. Consider getting consultation with a gay therapist like myself to discuss tricky cases and help with personal challenges you struggle with. Or, ask your workplaces to provide additional trainings and consider offering to help arrange this. There are a variety of corporate trainers who specialize in working with LGBTQ+ clients and diversity. (I am wondering if this should be put in bullet format instead).
Instead of waiting for your clients to educate you, and losing some as a result, take the time and make the effort to educate yourself. You will experience a deeper connection with patients and the mutual satisfaction will contribute to more successful outcomes in your practice.
