how to clinically approach homosexuality

1. Evaluation and clinical approach to
homosexuality
Samraa M Suliman, MD
American board Adult Psychiatrist
American board Child and Adolescent Psychiatrist
Assistant professor, KAAU

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Is homosexuality a mental
illness?
American Academy Of Child And
Adolescent Psychiatry.
American Academy Of Psychiatry
American Academy Of Pediatric
American Psychological Association
National Association Of Social Worker

3. American Psychiatric Association removed homosexuality from the DSM in 1973, stating that
"homosexuality per se implies no impairment in judgment, stability, reliability, or general
social or vocational capabilities." After thoroughly reviewing the scientific data, the American
Psychological Association adopted the same position in 1975

4. Sexual Development:
Psychology
Biology Psycho-Cultural

5. Psychology:
Freud psychosexual Developmental stages
Oral (0-18)
Anal (18-36m)
Phallic (3-6 y)
Latent (6- puberty)
Gental ( Puberty on)

6. Biology:
Tanner stages

7. Notable pattern in two region of the human genome ,
chromosome X and Chromosome 8
Brain structure
Pre-natal hormonal exposure
Intersex children

8. Psych-Cultural:
Infant And Toddlers(0-5 years)
They know their gender and develop their gender identity.
Behavior influenced by family.
Self exploration, disinhibition.
Interest in genitalia and other’s genitalia.
Explore sexuality through play.

9. School age(5-9)
More contact with other children and more influence from peers.
Become self conscious and more disinhibited.
Increase in masturbation.
Same sex friendship.
Show stereotype male and female roles.
Concept of marriage and living together.

10. Early adolescents(9-12 years)
Period of significant change
Enter puberty – physical, social, emotional aspects
Increased peer contact
Increased experimentation
Inhibition may increase/decrease
Continue to learn society’s expectations about gender Roles and behaviors
Develop sense of expectations concerning adult roles

11. Adolescent(13-18 years)
Developing sense of own identity and values
Experimenting with sexual activities
Puberty continues
Separation from family, developing relationships with
Peers
Intimacy with peers of both sexes, falling in love
Developing sense of privacy

12. Where do we start from?

13. Definitions:
Sexual
Orientation
Gender Identity
Gender Role
Gender
Sex
Bisexual
Homosexual
Hetrosexual

14. Gender/Sex:
Biological and physiological state of a being
XX or XY
Gender Identity:
A person's private sense and subjective experience of their own gender and
gender Role
Gender Role:
socially constructed roles, behaviors, activities, and attributes that a given society considers
appropriate for men and women.

15. Sexual Orientation:
Pattern of emotional, romantic and/or sexual attractions to men,
women or both sexes.
Homosexual, Hetrosexual and Bisexual

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Question:
John is a 22 year old:
Gender :Male(XY)
Gender Identity: Female
Attracted to another male
John’s sexual orientation would be?
Homosexual
Hetrosexual
Bisexual

18. Evaluation:
History/ Examination
Investigation
Differential Diagnosis
Management

19. History:
How to ask?

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Co-morbidity
71% for Axis I disorders (primarily
mood and anxiety disorders)
42% for comorbid personality
disorders, primarily a cluster
45% for substance-related disorders
6.5% for psychotic disorders
3.2% for eating disorders.9 B
diagnosis
AlWAYS screen for safety and suicidal
ideation

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Investigations:
Consult or refer with an
endocrinologist
Obtain: CBC, LFT, U&E, RFT,
TFT.
Testesron,LH,FSH,oestradiol,
Prolactin
Karyotyping

22. Management:
Establish Safety
Treat Co-morbidity
Parental and family support
Regular review to monitor gender identity
The use of DBT and motivational interviewing skills

23. DBT
Dialectal Behavior Therapy
Motivational
Interviewing

24. Motivational Interviewing:
is a method that works on facilitating and engaging intrinsic motivation within the
client in order to change behavior. MI is a goal-oriented, client-centered counseling
style for eliciting behavior change by helping clients to explore and resolve
ambivalence.

25. William R Miller and Stephan Rollnick
None directive client centered psychotherapy
More than 1200 publications.
Client response significantly effected by the therapist
trait and contextual aspect of delivery. Factors are not
easy standardized by following a treatment manual

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Avoid Common trap:
The Assessment Trap
The Expert Trap
The Premature Focus Trap
The Labeling Trap
The Blaming Trap
The Chat Trap

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Establish engagement
Establish Ambivalence
Focus in Ego syntonic and Ego
dystonic

28. Motivational Interviewing concepts:
Express Empathy
Develop Discrepancy
Avoid arguments
Roll along with the resistance
Support self reliance

29. DBT

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Distress Tolerance:
What is a crisis?
Is it happening all the time?
Can it be solved?
It’s surviving without making
the situation worse.
Tolerating distress not removing
it
“ Live to fight another day”

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Distract
Self sooth
Improve the moment
Pros and Cons

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1.Distraction
Activities
Contributing
Comparison ( Self and other)
Emotion( Opposite emotions)
Sensation

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2. Self soothing
Five senses:
Vision
sound
smell
touch
taste

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Improve the
moment:
Accept the pain and reduce
suffering
Relaxation, Yoga
Prayer
Meaning ( This too shall pass)
Stay in the moment

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