A psychiatrist's role in "coming out" process: context and controversies post-377.

After the Delhi High Court judgment on reading down Section 377 Indian penal code, many individuals of alternate sexuality are wanting to come out to themselves and significant others in their lives. In this process, they often turn to psychiatrists seeking help. However the past of this specialty wherein homosexuality and other sexualities were considered a disease still haunts it with anecdotal reports of reorienting treatments continuing in certain parts of the country. While it is important to not continue with this unethical practice, at the same time, it is also important to be supportive to the issues that this and various other marginalized sexualities in our country face. This viewpoint is an attempt to reiterate certain steps that are to be followed by psychiatrists who find themselves in such clinical consultations.

INTRODUCTION

Psychiatry as a profession has to frequently deal with issues close to a man's mind and heart. Psychiatrists are often faced with the question of what's normal and what's not almost on a daily basis. What is considered abnormal today may not be so tomorrow! This is what happened to homosexuality, when it was removed from the list of mental disorders by American Psychiatric Association back in the 1970s. The legal environment in India, however, is still battling with striking down certain age-old laws that, even though do not call homosexuality a disease, go a long way in pathologizing and stigmatizing it. There is a possibility that as these laws are read down, psychiatrists may face individuals in their clinical consultations seeking help in issues related to coming out of their closets. This article highlights the role that a psychiatrist can play in such individuals’ lives when they are in the process of coming out to themselves or their families.

COMING OUT

Coming out is a term that is often used by lesbian, gay, bisexual and transgender (LGBT) individuals disclosing their sexual orientation and/or gender identity to others. Coming out can be a confusing time for many people and can bring out a number of fears in them, some real and others perceived.[1] It is a long and ongoing process wherein an individual first comes out to oneself and then later to others around him/her. Coming out to oneself is recognizing one's own sexual identity and labeling it, following which the individual may want to tell others about these feelings. Coming out to family members may be particularly difficult. Family relations and bonding play an important role in the individual's decision to come out to them. Weak family relations significantly detract an individual from coming out to family members including parents.[2] Strommen[3] suggested that the reaction of family members to coming out of another member can be traumatic and can be colored by their negative views and attitudes about homosexuality in general. All these and other experiences can make the coming out process an emotional rollercoaster.

THE NEED TO DISCUSS

The country in recent times has seen uproar for a change in certain Victorian laws regarding one's sexual activities in private. The Delhi High Court judgment on Section 377 of the Indian Penal Code in 2009 spilled out a lot of what people wanted and also what they did not want! This “landmark” judgment gave a sigh of relief to some, while it irked many others. The country seemed divided on the issue of legalizing homosexuality, with various religious and spiritual gurus being on one side claiming to be able to treat homosexuality while LGBT activists being on the opposite side rubbishing all such claims. With media giving wide coverage to this news, homosexuality soon became the talk across dinner tables and coffee shops throughout India.

With changing legal and sexuality scene in the country, many previously closeted individuals decided to come out of their closets and live “freely.” Today pride parades and various other “queer” activities are considered a happening thing at least in the über-metros. Kalra and Bhugra[4] propose that with migration and globalization, sexualities are set to change and give rise to multi-sexualism in societies with individuals of diverse sexualities coming to live in neighborhoods in harmony. Kalra[5] discusses how clinical consultations may become more thought provoking with complex clinical situations involving people's sexualities in future. And psychiatrists as “mind-specialists” are going to face such situations more as compared to others. However, psychiatry's history of labeling homosexuality a “disease” and treating it in the past[67] still continues to haunt its present. There have been anecdotal revelations by patients of being given treatment and therapies for getting “rid” of their homosexuality or any alternate sexuality for that matter.

A PSYCHIATRIST'S ROLE

It is important for psychiatrists to update themselves and be prepared to deal with situations where individuals of alternate sexuality may seek help for varying issues ranging from coming out to getting treated of their homosexuality. The experience of coming out is a highly individualized process and there is no general guideline or rule to be followed. Maintaining a non-judgmental attitude across all clinical consultations and additionally assuring confidentiality is of prime importance in such cases. Figure 1 gives an algorithm for use in consultations with individuals of alternate sexuality who are in the process of coming out.

Figure 1

Algorithm for facilitating coming out processes in LGBT individuals by a psychiatrist

A psychiatric history that includes details about various psychosocial issues that an individual is facing is the starting point of such consultations. Knowing about various family members and their attitudes to sex in general and diverse sexualities in particular may help target some of them in future. Ruling out and treating comorbid psychiatric disorders, if found, is important before moving to the next step to ensure a stable course of consultation. Probing into the need and importance of coming out along with other questions would help in knowing patient's concerns in detail [Table 1].

Table 1

Questions in coming out

Because of the societal views that we grow up within our society, self-acceptance can be the first and a particularly challenging aspect of coming out. Families, religions, and different cultural institutions frequently communicate negative messages about sexual orientations other than heterosexuality. These may be the only messages an individual may have heard concerning sexuality, so it can be difficult to accept a different orientation in oneself. It is important for the psychiatrist to help distressed individuals come to terms with self-acceptance. Normalizing the experience of alternate orientation can go a long way in lightening things up for such individuals. It is also of use to tell them of the spectrum of sexualities present in humans and that heterosexuality is not the only one. Knowing that such a spectrum exists can help the individual develop a sense of where he/she falls in this spectrum. It is important for the psychiatrist not to use terms such as “normal” when making any references to heterosexuality, as that automatically pathologizes non-heterosexual sexualities. It is possible that such individuals may feel confused and may deny their identity when going through this phase apart from repeatedly getting the universal “why me” question; however, maintaining a firm stance on one's earlier opinions on alternate sexualities by the psychiatrist only helps lessen their confusion and denial with time. At this time, it is also seen that an individual may consult a psychiatrist asking for help regarding change of orientation. Although such cases may very well appear as those of ego-dystonic homosexuality, it may be advisable to try to find out the basic reason on why the individual is asking for such help. There are high chances of finding an immediate stressor such as a relationship breakup prior to such consultations that makes the individual become negative about these feelings. Helping the individual deal with such precipitating events may help tide over the phase easily and the distress over one's orientation may disappear. This strategy may also help in cases of individuals requesting for a change of orientation in order to enter into heterosexual marriages because of family and societal pressures. However, telling them that the effects of any intervention may be only temporary may make them think twice before going in for any intervention.

After developing a sense of one's identity and successful self-acceptance, most LGBT individuals may want to meet other people with a similar orientation and experience. Learning that many others have been through similar circumstances can help lessen the sense of isolation. During this time, it can be helpful to become aware of the gay/lesbian/bisexual culture that exists around in one's area. Passing on a “You are not alone” message significantly reduces their anxieties. The psychiatrist should be aware of various support groups and organizations working in areas of alternate sexuality for making appropriate referrals. Such resource groups may serve as a significant help for distressed individuals.

There are also chances that the individual would want to come out to others after this step. Coming out to others is likely to be a positive experience only when the individual is more secure with self and less dependent on others for positive self-concept. This can help deal with a variety of responses the individual might receive in the process. Choosing an appropriate time and place carefully and being prepared for an initial negative reaction from some people always helps and a psychiatrist can help a great deal in preparing the individual for this, for instance through role playing in the clinic. An individual can also to rehearse “coming out in front of a mirror.”

It can be difficult to decide whom to tell and the psychosocial history taken early on in the consultation can be of great help at this stage. It is usually a good idea to come out first to those who are most likely to be supportive. This might be a close friend or another gay/lesbian/bisexual person. The latter can be particularly helpful because they have experienced at least some stages in the process of coming out. Sharing experiences can help lessen feelings of isolation. It is important to reiterate that things are to be done in one's own time without a need for hurry. Coming out to heterosexuals can be particularly difficult. It will help to understand that some heterosexuals will be shocked or confused initially. There may be initial rejection, but through time, they may become more accepting. When it comes to family, some members of the family may be supportive while others may be rejecting. Studies also point to a favorable change in attitudes and reactions of parents toward their children after they come out,[8] with most of them initially reacting negatively but becoming more accepting over time. A psychiatrist's role at this step would be psycho-education of the family members and removing any myths about homosexuality. It is also advisable not to pressurize them and expect a quick acceptance; like the individual, even the family members are entitled for their opinions and views. At this stage, they may have various questions regarding the future of their family member, expected loneliness in old age, or various other issues. These are all justified questions and are better addressed as they arise. There are also cases where families bring their members who are LGBT for help and seek reorientation therapy. Clearly maintaining one's limitations, telling the ineffective and unethical nature of such “reparative” treatments may deter them from going any further. Using culturally suitable examples such as that of Arjuna living cross-dressed in Mahabharatha and of Lord Ayyappa being born out of intercourse between Shiva and Vishnu,[9] may help normalize the experience for family members. At this stage, some individuals may want to bring out their relationships all at once in front of their family by introducing their partners to them, but this should not be recommended for fear of retaliation and giving the family members sufficient time to cope with their realities. It is important for psychiatrists to understand that the individual in coming out process may face disapproval and stigmatization not only from society, but also from their own family members and peer groups. Coming out to family members, especially parents, is a major decision and hurdle in LGBT individuals.[1] Telling the parents that their acceptance and support plays a significant role in the psychological well-being of LGBT individuals[10] may help ease things a bit. Carnelley et al.[11] reported that LGB individuals who perceived their mother as accepting in childhood were more likely to have come out to her and parents who were perceived as accepting and independence-encouraging in childhood reacted more positively to their child's sexual orientation.

Once an individual has come out to family members, another issue that may arise for families is fear of stigmatization. Families may then have to go through the same stages of coming out to others. However, telling them that it is a completely personal matter and they need not come out if they do not wish to may help lessen this burden. At the same time, psychiatrists may have to help them deal with emotions of self-blame where family members blame themselves and their child-rearing practices for having caused such a change in orientation. By “coming out” themselves, straight parents and relatives show their support to LGBT issues and also reduce the stigma of belonging to an alternate sexuality.[10] In this context, it is useful to know that traditional family values play an important role in predicting coming out experiences with strongly traditional families being less acceptable of alternate sexualities.[12] Sometimes families are more keen on knowing about sexual lives of their member who has just come out. It is advisable to refrain from giving them explicit details about one's sexual life as this further ‘sexualizes their sexuality’ and rips it of any emotional aspects.

CONCLUSION

The landmark Delhi High Court judgment about reading down Section 377 Indian penal code has opened up a Pandora's Box across the country. In the aftermath of this landmark, many individuals may feel it is important to come out to those around them. With restrictive legal dimension removed, these individuals may still be caught in the quagmires of their traditional family, cultural values and self-identity. Also, at this point, they may turn to psychiatrists for help. A psychiatrist's role in such cases is attempt to destigmatize and depathologize any alternate sexuality in such individuals and help the family come to terms with the same. Apart from dealing with individuals of alternate sexuality who may be psychiatrically ill or vice versa, there is no role of psychiatrists to deal with changing orientation of these individuals.