IMAGINE growing up feeling and identifying in ways that society does not expect you to. Imagine having to hide your identity or else be easy prey for bullies. Having to deal with your family’s disapproval and their constant need to ‘fix’ you — for something they either consider a failure in upbringing or a character flaw — can also be extremely overwhelming. A society that has limited or no understanding of the Lesbian, Gay, Bisexual, Trans-gender/sexual and Queer (LGBTQ) population can greatly impact the well-being of individuals who identify with this community.
The mental health vulnerabilities of LGBTQ communities as a result of the stigma and societal discrimination are well documented in the West. Research shows increased suicidal behaviour, substance use, sexual and physical violence. Anecdotal evidence from Pakistan also shows similar trends.
The LGBTQ community was long misunderstood by the mental health field, but much has changed in the last few decades. Homosexuality, once considered a psychological disorder, was removed from the US Diagnostic and Statistical Manual of Mental Disorders in the 1970s. Similarly, gender identity issues are no longer categorised as a disorder. Many mental health associations have discarded controversial practices such as ‘conversion therapy’ due to their potential harmful impact and ineffectiveness, and ethical guidelines of practice have been developed.
Therapists must develop ethical, LGBTQ-friendly guidelines.
Just like the rest of the world, an LGBTQ community has always existed in Pakistan. Organised in both informal and formal groups, they have supported each other in navigating societal challenges. The legal environment remains a threat for the community, and is among one of the barriers to access of all forms of services. It was only in 2018 that the Transgender Persons (Protection of Rights) Act was passed. The right to health mentioned in the act stipulates that the medical curriculum be reviewed to meet the needs of transgender people, and that healthcare facilities provide a safe and enabling environment. Although the act does not cover the entire spectrum of the LGBTQ population, it is an encouraging step forward.
Having worked on mental health issues in Pakistan, I have noted an overall upward trend in mental health-seeking behaviour, especially among young people — including the LGBTQ community. LGBTQ people seeking mental health services are aware of the social stigma and need for support to work through past traumatic experiences and current challenges in their lives. My personal experience has shown they display greater acceptance of their sexuality and identity, and some have been able to open up to their families or have learnt better ways of coping and developing protective support networks outside the family.
However, unsupportive experiences with mental health professionals are often cited by LGBTQ clients and acquaintances. Being judged, not feeling respected or simply being told to ignore their thoughts, offer ‘repentance’ or get married as a ‘cure’ are some common details that are cited about these experiences. Breaking client confidentiality and disclosing information shared in therapy to their families without their consent is another unethical practice that is often brought up. One would not have to look too far to understand why this may be happening.
The psychology and medical curriculum in Pakistan is somewhat silent about the LGBTQ community and the issues they face. Even if brought up during clinical training, cases are mostly discussed in the context of disorders and rarely from a social or human rights perspective. This lack of understanding of social context may affect an individual’s assessment, whose symptoms may be misdiagnosed as a psychological disorder whereas they may, in fact, be a normal reaction to their experiences. Societal taboos and myths about LGBTQ people that are ingrained in the minds of mental health professionals (who have grown up in the same society) requires continued training that focuses on personal blocks and value clarification. A human rights-based understanding of their issues could also help deepen understanding beyond a medical disease-based model.
We mental health professionals have a lot of work to do to bring our house in order. This may involve reviewing our medical and psychology curriculum, and training and supervision assessments, or developing LGBTQ-friendly standards of practice. If such steps are not taken, we may end up harming a community that is a misunderstood minority, and thus vulnerable to our own lack of sensitivity, personal barriers, and knowledge.
Until the time we have such regulations, it is upon each of us to access information and connect with groups that work at sensitising professionals — and, if we cannot overcome our biases, let us adhere to the principle of ‘do no harm’ and refer our clients to those who are more open to LGBTQ issues.
The writer is a clinical psychologist.
Published in Dawn, July 10th, 2019