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 significant intervening variables. Finally, it
argues that sexual orientation and gender identity have been viewed, in the
history of the field of psychopathology, between two poles: gender
transgression and gender variance/fluidity...
...The present paper
argues that sexual orientation and gender identity have been viewed, in the
history of the field of psychopathology, between two poles: gender
transgression and gender variance/fluidity.
On the one hand, aligned with a position of
“transgression” and/or “deviation from a norm,” people who today are described
as LGBT were labeled as mentally ill. 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,
2012; Kirschner,
2013). In that, they often failed to differentiate between mental
illness and socially non-conforming behavior or fluidity of gender expressions.
This position and the historical roots of this discourse are still reflected in
the practices of some clinicians, ranging from “conversion” therapies to
micro-aggressions in the daily lives of LGBT people, including those
experienced in the care by mental health professionals.
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,
2012). As such, it also recognizes the power of medical
classifications, health discourses and clinical practices in translating the
responsibility of fighting discrimination and promoting LGBT people’s
well-being.
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.g., Pachankis
and Goldfried, 2004) have argued for the importance of continuous
education and training of practitioners in individual and cultural diversity
competences, across professional development. This is in line with APA’s
ethical guidelines (American Psychological Association, 2000, 2012), and it is even more relevant when we
acknowledge the significant and recent changes in this field. 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, 2001) in psychopathology.
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- 1Instituto Universitário de Lisboa ISCTE-IUL CIS, Lisboa, Portugal.
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