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Historical Roots of Psychopathology View all 10 Articles. Numerous controversies and debates have taken place throughout the history of psychopathology and its main classification systems with regards to sexual orientation and gender identity. These are still reflected on present reformulations of gender dysphoria in both the Diagnostic and Statistical Manual and the International Classification of Diseases, and in more or less subtle micro-aggressions experienced by lesbian, gay, bisexual and trans patients in mental health care.
The present paper critically reviews this history and current controversies. It reveals that this deeply complex field contributes i to the reflection on the very concept of mental illness; ii to the focus on subjective distress and person-centered experience of psychopathology; and iii to the recognition of stigma and discrimination as ificant intervening variables. Numerous controversies and debates have taken place throughout the history of psychopathology and mental health care with regards to lesbian, gay, bisexual and transgender LGBT people.
The present paper aims to review relevant concepts in this literature, its historical and current controversies, and their relation to the main psychopathology classification systems. Concepts and definitions that refer to sexual orientation and gender identity are an evolving field. Many of the terms used in the past to describe LGBT people, namely in the mental health field, are now considered to be outdated and even offensive. Sexual orientation refers to the sex of those to whom one is sexually and romantically attracted American Psychological Association, The American Psychological Association a , p.
In this paper we use the prefix trans when referring to transsexual people. As in the case of sexual orientation, people perceived or described by others as transgender — including transsexual men and women — may identify in various ways e. Lesbian, gay, bisexual and transgender people often suffer from various forms of discrimination, stigma and social exclusion — including physical and psychological abuse, bullying, persecution, or economic alienation United Nations, ; Bostwick et al. Moreover, experiences of discrimination may occur in various areas, such as employment, education and health care, but also in the context of meaningful interpersonal relationships, including family e.
Accordingly, several studies strongly suggest that experiences of discrimination and stigmatization place LGBT people at higher risk for mental distress Cochran and Mays, ; Dean et al. In addition, transgender people have been identified as being at a greater risk for developing: anxiety disorders Hepp et al. Nuttbrock et al.
In particular, adolescence has been identified as a period of increased risk with regard to the mental health of transgender and transsexual people Dean et al. In sum, research clearly recognizes the role of stigma and discrimination as ificant intervening variables in psychopathology among LGBT populations.
Nevertheless, the relation between sexual orientation or gender identity and stress may be mediated by several variables, including social and family support, low internalized homophobia, expectations of acceptance vs. Thus, it seems important to focus on subjective distress and in a person-centered experience of psychopathology. However, the diagnostic change did not immediately end the formal pathologization of some presentations of homosexuality. The removal from the DSM of psychiatric diagnoses related to sexual orientation led to changes in the broader cultural beliefs about homosexuality and culminated in the contemporary civil rights quest for equality Drescher, Mental health diagnoses that are specific to transgender and transsexual people have been highly controversial.
In the past few years, there has been a vehement discussion among interested professionals, trans and LGBT activists, and human rights groups concerning the reform or removal of trans gender diagnoses from the main health diagnostic tools. However, discourses on this topic have been inconclusive, filled with mixed messages and polarized opinions Kamens, Overall, mental health diagnoses which are specific to transgender people have been criticized in large part because they enhance the stigma in a population which is already particularly stigmatized Drescher, Although the changes were welcomed e.
Nevertheless, attention is presently turned to the ongoing revision of the ICD. Various proposals concerning the revision of trans gender diagnoses within ICD have been made, both originating from transgender and human rights groups e. Recently, there has been a greater concern in the mental health field oriented to the promotion of the well-being among non-heterosexual and transgender people, which has paralleled the diagnostic changes.
This is established, for instance, by the amount of literature on gay and lesbian affirmative psychotherapy which has been developed in recent decades e. These ethical guidelines highlight, among several issues, the need for clinicians to recognize that their own attitudes and knowledge about the experiences of sexual minorities are relevant to the therapeutic process with these clients and that, therefore, mental health care providers must look for appropriate literature, training, and supervision. However, empirical research also reveals that some therapists still pursue less appropriate clinical practices with LGBT clients.
In a review of empirical research on the provision of counseling and psychotherapy to LGB clients, Bieschke et al. Moreover, there is evidence of other forms of inappropriate while less blatant clinical practices with LGBT clients e. Even those clinicians who intend to be affirmative and supportive of LGBT individuals can reveal subtle heterosexist bias in the work with these clients Pachankis and Goldfried, Heterosexual bias in counseling and psychotherapy may manifest itself also in what Brown , p.
The former would have access to physical transition, and the later would be denied any medical intervention other than psychotherapy. Research shows that currently trans people still face serious challenges in accessing health care, including those related to inappropriate gatekeeping Bockting et al. Some mental health professionals still focus on the assessment of attributes related to identity and gender expressions, rather than on the distress with which trans people may struggle with Lev, ; Serano, It seems clear that social and cultural biases have ificantly influenced — and still do — diagnostic criteria and the access to hormonal and surgical treatments for trans people.
Controversies and debates with regards to medical classification of sexual orientation and gender identity contribute to the reflection on the very concept of mental illness. Moreover, trans gender diagnoses constitute a ificant dividing line both within trans related activism e. Thus, it may be important to understand how the debate around trans diagnoses may be driven also by a history of undue gatekeeping and by stigma involving mental illness.
Inevitably, classification systems reflect ed the existing social attitudes and prejudices, as well as the historical and cultural contexts in which they were developed Drescher, ; Kirschner, In that, they often failed to differentiate between mental illness and socially non-conforming behavior or fluidity of gender expressions.
On the other hand, lined up with a position of gender variance and fluidity, changes in the diagnostic systems in the last few decades reflect a broader respect and value of the diversity of human sexuality and of gender expressions. This position recognizes that the discourse and practices coming from the mental health field may lead to changes in the broader cultural beliefs Drescher, In conclusion, it seems crucial to emphasize the role of specific training and supervision in the development of clinical competence in the work with sexual minorities.
Several authors e. Furthermore, it is founded on the very notion that LGBT competence assumes clinicians ought to be aware of their own personal values, attitudes and beliefs regarding human sexuality and gender diversity in order to provide appropriate care. These ethical concerns, however, have not been translated into training programs in medicine and psychology in a systematic manner in most European countries, and to the mainstreaming of LGBT issues Goldfried, in psychopathology.
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Sexual Orientation and Gender