Depression Assessment: Lesbian, Gay, Bisexual, Transgender and Questioning People

Lesbian, gay, bisexual, transgender, and queer or questioning (LGBTQ) people experience higher rates of depression compared to the general population (30% vs. 16%) and are less likely to receive treatment. Although many laws protecting the rights of LGBTQ people have been passed in recent years, they continue to face a high degree of societal discrimination. This discrimination may account for the higher rate of depression and lower rate of treatment among individuals identifying as LGBTQ. 
 
Historical Context of LGBTQ Identity and Mental Health
All major mental health disciplines now consider identifying as LGBTQ part of normal human variability. In recent years mental health providers and the public-at-large have come to better understand the difference between sexual orientation (i.e. who a person is sexually attracted to) and gender identity (i.e. what gender does an individual most closely identify with). However, this stance reflects an important evolution within mental health thinking on LGBTQ issues. As a potent example, being gay or lesbian itself was listed as a mental health disorder until 1973 when it was removed from the US diagnostic manual for mental health disorders. In addition, there are still places offering “treatments” claiming to help lesbian or gay people “become straight”, sometimes called “reparative therapy” or “gay conversion therapy.” However, there is no evidence this type of treatment is effective and, in fact, it may actually contribute to emotional problems such as depression. Reparative therapy has been officially condemned by numerous professional associations including the American Psychological Association and the American Psychiatric Association. It is now illegal to conduct the therapy on children in several states.
 
Research on Depression Among LGBTQ People
Researchers who study depression among LGBTQ people focus on 2 main questions:
• How does identifying as LGBTQ affect mental health?
o LGBTQ people must deal with discrimination based on their sexual orientation or gender identity which can cause some people to keep their sexual orientation or gender identity a secret from others.  Fears of revealing one’s sexual orientation or gender identity, or “coming-out” can lead to depression in addition to other problems like anxiety, alcohol and substance use, and suicide.
• What treatments can treatment be helpful?
o There are several treatments that are effective for treating depression among LGBTQ people such as CBT and antidepressant medications.  The section below discusses additional considerations for how these treatments might be tailored for LGBTQ people.
 
Considerations for Treatment with LGBTQ People
Following the general treatment guidelines  for depression is always a good place to start for anyone experiencing depression, including LGBTQ people. If difficulties arise in encouraging a loved one to seek treatment and/or consider treatment options for depression, a logical place to start is to identify barriers, normalize reasons for declining treatment, and problem-solve strategies for overcoming barriers. For example, a common reason for not seeking treatment among LGBTQ people is concern that heterosexual therapists “don’t get it” and might repeat some of the hurtful messages that have already been experienced.  A helpful response to this barrier is to validate this concern, “Yeah, I wouldn’t want to open to someone who doesn’t understand me either,” and identify potential solutions such as finding a therapist who is also a member of the LGBTQ population or has special training.  It is also a good idea to encourage someone who is on the fence about engaging in treatment to test it out with 1 or 2 appointments before committing to a full course of treatment. Self-help materials offer another outlet for receiving treatment. 
 
Additionally, the American Psychological Association makes specific recommendations for practicing psychotherapy with lesbian, gay and bisexual  people including: 
1. Psychologists strive to understand the effects of stigma (i.e., prejudice, discrimination, and violence) on the lives of lesbian, gay, and bisexual people. 
2. Psychologists understand that lesbian, gay, and bisexual orientations are not mental illnesses; that same-sex attractions, feelings, and behavior are normal variants of human sexuality; and that efforts to change sexual orientation have not been shown to be effective or safe. 
3. Psychologists are encouraged to recognize how their attitudes and knowledge about lesbian, gay, and bisexual issues may be relevant to assessment and treatment and seek consultation or make appropriate referrals when indicated. 
4. Psychologists strive to distinguish issues of sexual orientation from those of gender identity when working with lesbian, gay, and bisexual clients. 
 
Sources

 
• Lifetime Prevalence of Mental Disorders and Suicide Attempts in Diverse Lesbian, Gay, and Bisexual Populations, Ilan H. Meyer, PhD, Jessica Dietrich, MPH, and Sharon Schwartz, PhD, American Journal of Public Health: June 2008, Vol. 98, No. 6, pp. 1004-1006.
• Guidelines for Psychological Practice With Lesbian, Gay, and Bisexual Clients, APA, 2012, American Psychologist, Vol. 67, No. 1, 10–42 DOI: 10.1037/a0024659