[Sexual minorities: Concepts, attitudes and structure for an appropriate psychotherapeutic approach]. / Les minorités sexuelles : concepts, prémisses et structure d'une approche clinique adaptée.

Objective To propose a theoretical model and clinical approach to sexual minority patients who consult mental health professionalsMethods Clinicians at the McGill University Sexual Identity Center (MUSIC) who have been treating patients from various sexual minorities for more than 15 years present useful theoretical constructs of gender and sexuality as well as guidelines for the evaluation and treatment of patients consulting for discomfort or confusion surrounding their sexual orientation, their gender identity or both, based on both the current literature and their clinical experience.Results The notions of non-binary construction of gender, of social determinism of gender roles and expression, and of gender creativity are presented. Sexual orientation is divided into four most commonly used dimensions (emotional attraction, physical attraction, behaviour and identity); the fluidity of these and their potential non-concordance are described. The fact that attraction to one gender is independent of attraction to another gender is highlighted. An attitude of openness to all forms of gender expression and sexual orientation constellations is encouraged to allow the patient free exploration of the several facets of their sexuality.Various domains to explore in evaluating sexual orientation and gender as well as therapeutic avenues are proposed. Areas to enquire about include: mental, physical and social experiences of gender, eroticism and sexual fantasies towards all genders, emotional attraction towards them, sexual and romantic experiences, comfort and certainty about one's identity and about disclosing it.Psychoeducation can be used to teach about sexual diversity and to assess the risks and benefits of coming out to self, family, friends, co-workers or strangers. Cognitive strategies can be undertaken to debunk homophobic and transphobic myths which may fuel poor self-esteem. Psychodynamic approaches can be used to heal the narcissistic wounds of homophobia that may lead one to be mistrustful of authority figures or to suppress sexual feelings when emotional attachment becomes important. Some of these dynamic patterns are rooted in past reactions to parental homophobia and the compromises sexual minorities made as children in order to preserve their relationships with their parents. For youth coming out in present times, family support is crucial to well-being and can be enhanced through family therapy. In mixed orientation couples, couple therapy can help both spouses adapt to the coming out of one of the partners and find a new partnership. Group therapy is useful for many of the above issues particularly as it provides a sense of community which is often lacking in minority groups, especially when individuals and their families do not share the same minority status.Conclusion With the proposed framework and an attitude of openness to sexual diversity, clinicians should feel competent to treat sexual minority patients.

[The association of bullying with suicide ideation, plan, and attempt among adolescents with GLB or unsure sexual identity, heterosexual identity with same-sex attraction or behavior, or heterosexual identity without same-sex attraction or behavior]. / L'association des dimensions de l'orientation sexuelle, du harcèlement et du suicide : quelles minorités sexuelles sont les plus à risque ?

Context Bullying is a known risk factor for suicidality, and suicide is the second leading cause of death for adolescents. Both are increased in sexual minority youth (SMY). As SMY are comprised of youth who self-identify as gay, lesbian, bisexual (GLB) or who have same-sex attractions or behaviors, our previous finding that different subgroups have different risks for suicidality is understandable. Given that the difference was along sexual identity lines (GLB vs heterosexual SMY), the analysis of bullying data in the same subgroups was felt to be important.Objective To compare the association of bullying and suicide among heterosexual students without same-sex attractions or behaviors, heterosexual students with same-sex attractions and behaviors, and students with gay, lesbian or bisexual (GLB) or unsure sexual identities.Design The 2004 Quebec Youth Risk Behavior Survey (QYRBS) questionnaire was based on the 2001 Center for Disease Control Youth Risk Behavior Survey, and included items assessing the three dimensions of sexual orientation (identity, attraction and behavior), health risk behaviors, experiences of harassment, and suicidal ideation, plans and attempts.Methods A total of 1852 students 14-18 years of age from 14 public and private high schools in Montréal Québec were surveyed anonymously during the 2004-2005 academic year.Main outcome measure Self reports of suicidal ideation, suicidal plan and suicide attempts in the last 12 months.Results In all, 117 students (6.3%) had a non-heterosexual identity (GLB or unsure) and 115 students (6.3%) had a heterosexual identity with same-sex attraction or behavior. Bullying occurred in 24% of heterosexual students without same-sex attraction or behavior, 32% of heterosexual students with same-sex attraction or behavior, and 48% of non-heterosexually identified students. In multivariable analysis, the common risk factors of age, gender, depressed mood, drug use, fighting, physical and sexual abuse, and age of initial sexual contact were controlled. The reference group was heterosexual students without same-sex attraction or behavior and no bullying. When these students were bullied, they were more likely to have suicidal ideation (odds ratio [OR] = 2.11, 95% confidence interval [CI] = 1.52-2.92) but not suicide attempts. Non-heterosexual students with no bullying were twice as likely to have suicidal ideation (OR = 2.35, 95% CI = 1.24-4.48) and four times as likely when bullied (OR = 4.44, 95% CI = 2.26-8.72). Similarly for suicide attempts, they were not at increased risk when not bullied, but they were almost three times as likely when bullied (OR = 2.87, 95% CI = 1.43-5.78). Heterosexual students with same-sex attraction or behavior were never more likely on any of the suicide measures compared to the reference group, even when bullied.Conclusion This study was the first to show that adolescent students with a non-heterosexual identity will have a disproportionate increase in their suicide parameters when subject to harassment, but that heterosexually identified students with same-sex attraction or behavior did not have an increased risk over heterosexually identified students without same-sex attraction. This suggests that same-sex attraction and behavior on their own are not contributory to suicide risk, and that the efforts of future research as well as public health efforts may be better served by examining the interface between sexual identity and the school, family, and larger culture that surrounds the sexual minority youth. Longitudinal studies looking at the interplay between all these factors are needed.

[Distinguishing normal identity formation process for sexual minorities from obsessive compulsive disorder with sexual orientation obsessions]. / Distinguer le processus d'acceptation d'une identité sexuelle minoritaire d'un trouble obsessionnel compulsif avec obsessions sexuelles.

Objectives In synthesizing a homosexual or bisexual identity, an individual may go through different stages before coming to a positive healthy identity. It is likely that there will be a period in which homosexual yearnings will be unwanted. Sometimes this distress leads the person to consult a health professional. Conversion therapy has been proven both ineffective and harmful and therefore has been ethically prohibited by all major psychiatric and psychological associations. The responsible clinician will attempt to assist the individual in his acceptance of his sexual minority. Occasionally individuals without homoeroticism consult because of distress related to sexual identity questioning which poses a different problem for clinicians especially if the situation goes unrecognized. The objective of this paper is to describe homosexual obsessive compulsive disorder (HOCD) and distinguish it clinically from the normal process of sexual minority identity formation in western culture.Methods A literature review yielded very few descriptions of homosexual OCD. A retrospective chart review of all patients seen in the last 3 years at the McGill University Sexual Identity Centre was conducted to identify all the cases of OCD. Six cases were found, 4 of which were of HOCD and are presented. Similarities between cases are highlighted.Results All cases were young men with relatively little relationship and sexual experience. Most were rather shy and had some other obsessional history in the past though often at a sub-clinical threshold. Obsessional doubt about their orientation was very distressing and did not abate over time as would normally occur with a homoerotic individual. The four patients who had an obsession of being gay despite little or no homoerotism are presented in detail. They all presented mental compulsions, avoidance and physiological monitoring. Continuous internal debate trying to prove or disprove sexual orientation was a ubiquitous mental compulsion. They all spent a majority of time monitoring their physiological reactions to members of both sexes to check for arousal. They attempted homosexual activity and were disgusted by it, yet this did not end their questioning. They avoided relationships with the opposite sex, being either too anxious to initiate, or too conflicted to maintain them. The obsession with being gay seemed like a horrific thought symptomatic of homophobia, however the level of horror was out of proportion to the patient's overall level of homonegativity suggesting that the horror came mostly from feeling like their core identity was threatened.Conclusion HOCD can present in ways similar to normal homosexual identity formation. A thorough exploration of eroticism towards both sexes as well as prior history of subclinical anxiety should help distinguish the two. Treatment of HOCD should combine education about sexuality and OCD as well as usual OCD treatments such as relaxation techniques, cognitive restructuring, mindfulness training and pharmacology.

Transference and countertransference in therapy with lesbian patients.

ABSTRACT Like gender, sexual orientation is an important determinant of one's perception of human relationships, therefore influencing the therapeutic process. Through a framework derived from cross-cultural therapy literature, this article explores how lesbian patients' transferences are influenced by their perception of their therapists' sexual orientations and how therapists' countertransferences differ according to their sexual orientations. This analysis took shape through dialogue with heterosexual and lesbian therapists working in a variety of settings, some generic mental health settings and some lesbian, gay, and bisexual identified.

Internalized homophobia: a factor in depression, anxiety, and suicide in the gay and lesbian population.

Two-hundred and twenty participants recruited through multiple sampling strategies completed a self-report questionnaire examining: (a) whether internalized homophobia predicts depressive and anxious symptoms, suicide, and substance abuse; and (b) the periods of gay-identity development which were particularly risky for suicide. Results indicate that internalized homophobia, particularly negative feelings towards one's own homosexuality (as measured by the Self subscale of the Nungesser Homosexual Attitudes Inventory), accounts for 18% of the variance in depressive scores and 13% of anxiety scores (using the Beck inventories). Internalized homophobia did not predict suicide independently from depression. The period of greatest risk for both suicidal ideation and suicide attempts was the period of disclosure of one's homosexuality to one's immediate family.