Kathrine Bakke-Friedland, PhD

Pride month and Pride parades are so much more than joyful celebrations. Pride also communicates the need to bring attention and awareness to the many people who continue to suffer, hide, and even die due to their sexual orientation or gender identity. There have been many gains in regard to legislation and changes in societal attitudes and beliefs since the Stonewall riots in 1969, one of the first major LGBTQ+ uprisings. However, countless reports and surveys clearly indicate that we have a long way to go to ensure safety, equality, and acceptance for everyone. Recently there has even been movement towards less acceptance, inclusion, and tolerance of gender and sexual minorities.

I have worked in the LGBTQ+ community as a therapist, researcher, and advocate since the early 1990s and have seen the devastating consequences of growing up as either a sexual minority or a gender nonconforming person. When asked why sexual and gender minority persons have higher rates of mental health conditions, I have consistently replied: “Because it is extremely challenging, if not impossible, growing up and becoming healthy in a society where you are repeatedly told that who you are as a person is wrong.” When heterosexuality and being cis-gender is assumed, a person consistently receives messages indicating that being anything else is abnormal. These messages are damaging to a person’s core sense of self.

Continued Discrimination and High Rates of Mental Suffering

Data from the Trevor Project (2020), which surveyed over 40,000 LGBTQ youth ,showed that in the past year:

  • 4 in 10 had seriously contemplated suicide,
  • about 7 in 10 had symptoms indicative of both depression and anxiety,
  • 6 in 10 had experienced pressure to change their sexual orientation or gender identity,
  • 7 in 10 had been discriminated against,
  • and more than 3 in 10 reported that they had been physically threatened or harmed due to their identity during their lifetime.
Increased Stress Due to Minority Status

Meyer (1995, 2003) proposes that gender and sexual minorities experience increased stress due to transphobic and homophobic social conditions. The Minority Stress Model has greatly influenced the current APA guidelines for psychological practice with sexual and gender minority persons. The model shows how factors such as discrimination, violence, threats, harassment, and heteronormative and cis-gender societal messages can become internalized and negatively affect a person’s thoughts, emotions, and behaviors.

Cost of Concealment

If an individual chooses not to reveal their sexual or gender identity, it is possible for them to conceal their minority status. While concealing one’s identity can provide temporary safety and lower the chance of rejection and other negative consequences, it comes at a cost. Pachankis (2007) describes the cost as lack of care and feedback from others about one’s authentic self, the increased potential for internalizing others’ and society’s homophobic or transphobic views, incongruence between public and personal self, hypervigilance and preoccupation with trying to “pass” as heterosexual or cis-gender, and increased rates of mental and physical distress.

Affirmative Cognitive Behavior Therapy

I have found Affirmative Cognitive Behavior Therapy (CBT) to be especially useful when serving my sexual and gender minority clients, and I consider affirmative therapy to be equivalent to providing culturally competent treatment. CBT emphasizes collaboration, Socratic questioning, and case conceptualization which validates and affirms the person’s prior experiences and context in lieu of how core beliefs develop. While I work within the traditional CBT framework, I incorporate affirmation throughout all stages of treatment. I am aware of the minority stress model and the cost of concealment, and I teach clients about the model and its impact. This can help increase understanding and self-compassion and decrease negative self-talk and beliefs.

Case Example

Consider the case of “John,” a male client who was referred to me with symptoms of anxiety, depression, suicidal ideation, and noncompliance with recommended medical care for a serious medical condition. He had grown up in a religious home with rigid traditional values and messages of how “homosexuality was the devil’s work.” He did not marry or show interest in women, and, after being relentlessly harassed by the elders in the church, he reluctantly admitted his attraction to men. John was coerced into two years of conversion treatment through a fundamental church, after which he married a woman and had a child. The marriage failed and he blamed himself for “being weak, sick, and tempted by the devil.” He described himself as “disgusting and awful.” He experienced extreme shame and thought he deserved to die. His assumption was that nobody could tolerate him if he was himself, he would be lonely forever, and life would be unbearable.

Together we developed a case conceptualization where he clearly saw how his automatic thoughts, assumptions, and beliefs were a result of his previous experiences. We discussed how the many factors outside of his control had harmed him. Repeated hateful messages, violence through conversion treatment, and ongoing harassment caused him to internalize the messages he had received since childhood. I explained the process of how we learn to believe what we do, and how we can alter these beliefs through new experiences and by testing the validity of long-held assumptions. The therapeutic relationship was particularly important in that his painful experiences were validated and believed. He was surprised to be met with respect and care, and stated more than once: “At least you can tolerate me when I cannot tolerate myself.” I explained to him repeatedly that my personal belief and scientific evidence supports that all sexual orientations are normal, and that all credible professional organizations consider treatment aimed at changing sexual orientation harmful and unethical.

As is often the case in affirmative CBT, learning through corrective experiences in addition to cognitive restructuring, was helpful for John. Over time he found a new church where he was told that God indeed loved him, he made new friends, took needed medication, and began to take care of his body. His symptoms of depression lessened, and although he continued to struggle with many self-critical thoughts, he learned how to alter these and not act upon urges to self-harm.

Conclusion

On my run this morning I ran past a daycare with two large rainbow flags waving in the wind, and I almost cried with joy as I thought about the small child who may need to get the message: “You can love who you want and be who you are!”

Beck Institute is committed to promoting the availability of evidence-based, quality mental health services for everyone in need, and has for years provided training to professionals who serve the LGBTQ+ community.

References:

Meyer, I. H. (1995). Minority stress and mental health in gay men. Journal of Health and Social Behavior, 36, 38-56.

Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129, 674-697.

Pachankis, J. E. (2007). The psychological implications of concealing a stigma: A cognitive-affective-behavioral model. Psychological Bulletin, 133 (2), 328-345.

www.thetrevorproject.org (2020) National Survey on LGBTQ Youth Mental Health