This book brings issues experienced by lesbian, gay, bisexual, transgendered (LGBT) people into the context of addressing other mental health concerns. They are described in a way designed to help clinicians, trainees, and other mental health professionals address the mental health needs of LGBT people while remaining cognisant of such aggravating factors as homophobia and discrimination and other psychosocial factors faced by this cohort. The first five chapters highlight some of the concerns that affect LGBT populations, including coming out, heterosexist attitudes, the ‘don't ask, don't tell’ mentality in the US military, legal issues, gay parenting, the use of the colloquial term ‘coming out’, and sexual identity in patient-therapist relationships are discussed. The objective is for psychiatry to meet and understand the LGBT experience by including discussions of recent changes, such as the on-going national debate in the United States concerning marriage equality, with its resulting legal uncertainties. While the utility of this to Irish and other clinicians outside the United States is arguably limited, the reader might do well to extrapolate the effect of the experience of repressive legislation on this patient cohort and its impact on overall mental health functioning. Certainly similar debates are taking place in Ireland and elsewhere, and even with the details of legislation being variable, consideration of this in one's home jurisdiction would be valuable and of great utility. The authors include discussions of what is yet to be gained in their own jurisdiction, and how this affects patients and families. As such, this book can be of great use to help Irish clinicians deal with LGBT-related issues within their own shared context.
The LGBT Casebook can be of value for all levels of clinician. It includes definitions and descriptions of some of the issues faced by LGBT people. Certain experiences are common to all LGBT individuals, such as the anxiety of being ‘secretly’ or covertly gay or trans, or that of coming out (embracing one's identity). Others are more particular to an individual's sexual orientation or gender identity; the difference and interface of which is addressed. Each chapter concludes with a summary of key points and multiple-choice questions, including answers and explanations, giving the reader an almost micro-CPD format. Divided into two sections, the first chapter includes abundant background material. These beginning chapters provide an excellent insider's view into the LGBT experience. This includes insight into the developmental perspective and the many variants of gender- and sexual-based identity and behaviour. The book also provides a good discourse on the coming out process. There is a good discussion regarding the special challenges of coming out later in life, and coming out and other experiences as a racial minority who is also LGB or T. Some of the important issues that arise in the coming out process, which can be severe and result in loss of work, family, and community, are discussed. Obviously there cannot be a comprehensive overview of the myriad Axis IV potentialities faced by this cohort, but the reader will see the impact and ramifications of these on overall functioning, and can begin to apply this understanding to their own caseload. Offered advice, such as encouragement not to collude with clients’ avoidance and to gently engage around issues of orientation and identity when appropriate is sound and would be of great utility to those clinicians who have not dealt with members of this population. Clinicians with limited experience in working with the LGBT population can gain a better understanding of psychiatric diagnoses within the context of an LGBT individual's everyday life, and how their sometimes unique axis-IV issues can contribute to and impact their mental health problems. There is also a chapter dedicated to issues of sexuality in the therapeutic relationship and whether/or how clinicians should come out to their LGBT clients, with four ‘clinical vignettes’ presented for consideration.
Most of the second section is dedicated 20 case studies that focus on particular presentations and the LGBT client. Clearly DSM-IV-TR oriented, various axis I disorders are discussed, substance dependence, anxiety disorders, psychotic disorders, and axis II borderline personality disorder and V-codes are included, as are some axis IV and V codings. The cases are accompanied with DSM-IV diagnostic criteria, as well as recommendations for medication and psychotherapy.
I was pleased to see the level of attention given to patient diagnosed with Gender Identity Disorder (3012.85) As a clinician whose caseload is 70–75% comprised of people with this condition, I am very much aware of the need for increased attention and treatment information sharing among clinical colleagues in Ireland. I had expected that I would admonish its relative exclusion, and point out some of the complexities of gender identity issues relative to ones of sexual orientation. One reviewer rightly points out that it is often is the case that the letter in the acronym LGBT that is most lost is ‘T’, or the transgender client. I did not find this to be the case in this book. The needs of the transgender individual sometimes overlap to some degree with the needs of LGB individuals, but transgender people have their own distinct issues, particularly when exacerbated by co-morbid disorders and condition can face even more pervasive discrimination and problems. This is given adequate attention in the case studies, although it is right to point out that hard data about the transgender experience are frequently lacking-herein, and elsewhere. The LGBT Casebook can hopefully foster motivation within human sciences generally to continue to gather data and experience to advance our understanding of the often complex needs of transgender clients.
Although Ireland is more enlightened presently than in past decades, it still takes courage for many LGBT individuals to ‘come out of the closet’ and embrace their sexual orientation and identity here. This process, and facing and dealing with internal and societal conflicts related to sexuality and gender roles, can exacerbate fears and anxieties that in turn can permeate other aspects of an LGBT individual's life – particularly when seeking psychiatric treatment.
It is important to recognise that some transgender individuals contest the treatment of gender identity disorder, often requisite for sex reassignment therapy, as a mental disorder. The DSM-V (as well as the new Standards of Care, Seventh edition, World Professional Association for Transgender Health, 2011) has been worded in such a way as to accommodate and reflect this shift. The advice given in The LGBT Casebook regarding clinical approach and respect for transgender rights appears to be philosophically aligned, and is not likely to be dated soon. Our responsibility as clinicians is to continue to gather data that will contribute to the growing pool of knowledge that informs policies and best practice for people who are struggling with internal and external issues around their sexuality, gender orientation, and mental health needs where indicated.
