Gay men and lesbians use mental health services in far greater numbers than their percentage of the population would indicate and far more often than do individuals identifying themselves as heterosexual.

Psychiatrists and mental health professionals have considerable reason to be concerned about their interactions with these patients, however, since a large proportion of homosexuals responding to a recent survey said that they are disappointed by these encounters and in some cases deeply offended, according to University of Washington researcher Nancy Nystrom.

Nearly 42 percent of the 1,466 respondents to the national survey she conducted--whose response rate was an unusually high 57 percent--acknowledged seeking a mental health service in the preceding 12 months. In contrast, only about 10 percent to 12 percent of the heterosexual population do so in a typical one-year period, data from the National Institute of Mental Health indicate. She sent her questionnaire to all names on the mailing lists of several gay/lesbian-oriented advocacy and health organizations. About 46 percent of the respondents were women, and 85 percent were white.

That such a large percentage of gays and lesbians get some form of mental health care is not unexpected, said psychiatrist Robert Cabaj, M.D., a consultant to the APA Council on National Affairs and medical director of mental health services for San Mateo County, Calif. These individuals "have developmental tasks to confront that straight people do not have to deal with and then at an early age have to evaluate how this knowledge will affect their lives. Many end up socially isolated, anxious, or depressed and seek relief for their symptoms in therapy."

One-quarter of survey respondents who did have contact with a mental health clinician described the care they received as "poor or inappropriate," said Nystrom, a doctoral candidate in social work who presented her findings at the annual meeting of the American Association for the Advancement of Science in February.

Describing these findings as "alarming and disappointing," Nystrom suggested that the survey responses point to a serious problem not only for providers of mental health care, but also "for those who educate and train those providers."

The grievances described generally fell into five categories, she said. The most often heard complaint was finding oneself in therapy with a "homophobic" therapist, a situation reported by nearly 46 percent of the gay men and lesbian respondents who sought mental health care.

In addition, just over one-third said their therapist "refused to acknowledge" their sexual orientation or dismissed it as a phase that would eventually pass. In most of these cases, Nystrom said, "therapists redefined the respondents' presenting issues as secondary to their sexual orientation."

Despite condemnation from medical and gay rights organizations, the controversial issue of "reparative therapy," in which therapists set out to change the patient's sexual orientation from homosexual to heterosexual, remains alive, the study showed. Nearly 10 percent of respondents reported that their therapist suggested or attempted this strategy, though no respondents had told their therapist that they entered therapy because they wished to become heterosexual.

Two respondents told of being involuntarily committed by their parents after they--having reached age 18 and believing they were beyond the age at which they were vulnerable to reprisals from their parents--revealed their homosexuality to them, Nystrom said in an interview with Psychiatric News.

Another 7 percent indicated that they were the victims of "derogatory verbal comments about their sexual orientation by the therapist." Nystrom cited as an example a respondent who wrote that her therapist insisted that "all you need is a good man" and the problems that prompted the therapy visit would resolve. Another told of a psychiatrist who insisted that the patient could not be gay "at your age."

Particularly "troublesome," Nystrom pointed out, was that four survey respondents--three women and one man--claimed that their therapist engaged in "inappropriate sexual behavior," including intercourse in one case. "He said sleeping with me would be helpful," said the female patient, who slept with her male therapist on the chance that he might be right.

When she compared the respondents who had troubling experiences getting mental health services with those who were satisfied, she uncovered no differences among the two groups linked to varying income or education levels, nor was there any relationship between therapy satisfaction and age, gender, or geographic area.

The level of unhappiness this survey turned up is bound to be discouraging to a segment of the population who clearly feel that they have problems that can best be addressed by a psychiatrist or mental health professional, she suggested. She noted, for example, that a substantial majority--78 percent--of respondents indicated that during the preceding two years they had been the victim of verbal or physical abuse attributable to their sexual orientation.

The psychological and emotional consequences of the homophobia and discrimination in American society will continue to lead gay men and lesbians to therapists, making the lack of attention to "quality assurance" of the therapy they receive a disturbing situation that professionals need to address, she noted. Further studies about "the experiences gay men and lesbians have with mainstream services" are critical, she added. Therapists and researchers need to find out, for example, why these individuals perceive the need for therapy in percentages as large as this survey indicates, including whether this is a conclusion they reach on their own or as the result of pressure from others.

Nystrom also stressed that misperceptions or biases that therapists may have about gays and lesbians could be reduced if researchers undertook surveys designed to elucidate "wellness factors within this group" instead of focusing solely on problems for which therapy is sought.

It is unlikely that many psychiatrists and other physicians will be surprised by what this survey revealed, since it confirms data from a national survey of gay and lesbian physicians conducted in 1994 by the American Association of Physicians for Human Rights (now known as the Gay and Lesbian Medical Association). This survey uncovered widespread discrimination against gay and lesbian physicians within the medical profession and deep-seated bias against homosexual and bisexual patients (Psychiatric News, August 5, 1994).

Among that study's startling findings were that 67 percent of the physicians responding knew of gay, lesbian, or bisexual patients who had received substandard care or were denied care, and 52 percent had personally witnessed the delivery of substandard care or seen care denied to these individuals. In addition, 87 percent of physicians--and 89 percent of psychiatrists--reported hearing their colleagues disparage lesbian, gay, or bisexual patients.

Psychiatrists who treat gay and lesbian patients or who are themselves gay or lesbian will not be surprised by Nystrom's findings, stated Cabaj, a past president of the Gay and Lesbian Medical Association. "An astonishingly high number of homophobic comments are heard throughout medical training and practice," he said.

"It's hard to find any psychiatric or other medical program that teaches information about homosexuality, and several of the ones that do are teaching the outdated illness model," of homosexuality, Cabaj emphasized. --K.H.

(Psychiatric News, April 18, 1997)