Note: It is the policy of the Canadian Psychiatric Association to review each position paper, policy statement and clinical practice guideline every five years after publication or last review. Any such document that has been published more than five years ago and does not explicitly state it has been reviewed and retained as an official document of the CPA, either with revisions or as originally published, should be considered as a historical reference document only.# Introduction
The Canadian Psychiatric Association (CPA) has taken a strong position in advocating for decreasing stigma and discrimination, albeit, mostly with a focus on people with mental illness. While doing so, however, the CPA has recognized the ongoing stigma and discrimination in society based on sex, race, sexual orientation and religion. 1 Unfortunately, psychiatry has a history of conflating lesbian, gay, bisexual, transgender and (or) queer (LGBTQ) identities with mental illness and has, therefore, historically contributed to the stigma and discrimination faced by people who identify as LGBTQ, affecting not only their mental health but also their access to appropriate mental health care. This position paper addresses the need for psychiatrists to increase their understanding of the mental health needs of people who identify themselves as LGBTQ.
In 1973, the American Psychiatric Association removed the diagnosis of homosexuality from the Diagnostic and Statistical Manual of Mental Disorders (DSM), Second Edition, 2,3 and issued a position statement in support of gay and lesbian civil rights. 4 All major professional mental health organizations have since gone on record to affirm that homosexuality is not a mental disorder. However, controversy remains surrounding the recent inclusion of gender dysphoria 5,6 within the DSM-5 (previously gender identity disorder  in the DSM-IV). Many argue that this diagnosis should also be removed from the DSM because the diagnosis pathologizes transgender identities, while others believe it should remain in the DSM to ensure continued access to appropriate medical treatment (access to hormones and  gender-confirming surgeries) for transgender people.
The "Position Statement on Discrimination Against Transgender and Gender Variant Individuals," released by the American Psychiatric Association in July 2012, states that being transgender or gender variant implies no impairment in judgment, stability, reliability, or general social or vocational capabilities; however, these individuals often experience discrimination due to a lack of civil rights protections for their gender identity or expression. 10, p 1
The prevalence of LGBTQ identity varies according to the definition used, specifically whether one is referring to sexual behaviour, identity, or attraction. Most studies worldwide estimate that about two to 14 per cent of the population identify as LGBTQ.  Within this heterogeneous population, the experience of each individual member of the LGBTQ community varies widely depending on numerous potentially intersectional factors, including ability, age, sex, ethnoracial group, nationality, religion, socioeconomic status, geographical location, and other factors. What is common, however, to sexual and gender minorities is that experiences of individual and systemic oppression can often threaten their health and well-being. Unfortunately, the history of discrimination and the associated shame concerning LGBTQ identities has meant that many mental health professionals are poorly informed about LGBTQ issues and are unfamiliar with appropriate terminology and acceptable language.
Both sexual orientation and gender identity may be most usefully understood as existing along a continuum. Sexual orientation refers to how one thinks of oneself in terms of one's emotional, romantic, or sexual attraction, desire, or affection for another person. 14 It is very important to note, however, that sexual behaviour is not always congruent with sexual orientation or identity. It is also important to note that one's gender identity is totally independent of one's sexual orientation. Gender identity is one's internal and psychological sense of oneself as male, female, both, or neither. 15 A glossary at the end of this document provides additional information about terms used in this policy statement and other important terms related to LGBTQ issues. 15,16 Stigma and discrimination based on sexual orientation and (or) gender identity have a tremendous impact on the mental health of LGBTQ people. 17 Sexual and physical assault are also risk factors for mental health issues, as is bullying for youth. 18 Risks for LGBT youth can be reduced by family acceptance and connection with other LGBT youth. 19,20,21 In fact, LGBT youth who come from highly rejecting families are more than three times as likely to have attempted suicide than LGBT peers who reported no or low levels of family rejection. 20 In a recent Canadian study, a staggering 77 per cent of people who identified as transgender reported having seriously considered suicide at some time in their lives, 43 per cent reported attempting suicide at some point in their lives, and 10 per cent reported attempting suicide in the past year. 22 In the largest survey to date of gender-variant and transgender people (N = 6,450), 41 per cent reported attempting suicide at some point in their lives. 23,24 The marginalization and discrimination experienced by LGBT people also contributes to barriers to the access of health and support services. 25,26 These barriers are compounded by health care providers often lacking the appropriate knowledge and skills around LGBT health. 25 LGBTQ participants in a national study found the level of knowledge of health care professionals "to be inadequate, the amount of homophobic reactions to their lives to be unethical, and the willingness of the health care system to adapt to their needs to be minimal." 27, p 9 Many LGBTQ people fear and avoid traditional health care settings to protect themselves from mental or physical harm from potentially homophobic health care providers. 13 Negative experiences with health care professionals after disclosing sexual orientation such as "being told their sexuality was pathological, experiencing 'rough' internal exams and actually being refused care" 28, p 192 shaped future use of health services. Reparative or conversion therapy, a range of pseudo-scientific treatments that aim to change a person's sexual orientation from homosexual to heterosexual, has been a source of controversy worldwide. The American Psychiatric Association 29 has condemned psychiatric treatment, such as reparative or conversion therapy which is based upon the assumption that homosexuality per se is a mental disorder or based upon the a priori assumption that the patient should change his/her sexual homosexual orientation... Ethical practitioners refrain from attempts to change individuals' sexual orientation. p 1 and 4 For transgender people, lack of access to both hormonal and surgical treatment can adversely impact their mental health. 30 A review of practice guidelines for the care of transgender people is beyond the scope of this position paper, but these types of guidelines are published and available for clinicians to access.  The American Medical Association, 34 the American Psychological Association, 35 and the American Psychiatric Association 36 all have position statements stating the critical importance of access to care for transgender and gender-variant people.
The Mental Health Strategy for Canada (Changing Directions, Changing Lives) 37 identifies addressing the specific mental health needs related to gender and sexual orientation as a priority. The strategy specifically recommends increased understanding by professionals and the public of differences in mental health related to gender and sexual orientation. They also specifically recommend improving the capacity of LGBT organizations to address the stigma of mental illness and to work with local mental health services to support their community.
Stereotypes of all kinds can have an impact on the way LGBT people living with mental health issues are treated, both within the LGBT community and within the mental health system. People who identify as LGBTQ who also happen to have mental health issues often experience a double stigma or dual alienation in which they feel they are not accepted within the mental health community because of their LGBTQ identities and are also not accepted within the LGBTQ community because of their mental health issues. 38
The Canadian Psychiatric Association affirms the following:
- The CPA opposes all public and private discrimination based on sexual orientation, gender identity and gender expression and supports the repeal of discriminatory laws and policies.
- The CPA supports the passage of laws and policies protecting the rights, legal benefits and privileges of all people regardless of their sexual orientation, gender identity or gender expression.
- The CPA supports the provision of high-quality mental and medical health care treatment for all people and, therefore, expects all psychiatrists to provide appropriate, nondiscriminatory treatment to all people, regardless of their sexual orientation, gender identity or gender expression.
- The CPA supports efforts to provide fair and safe environments for people who identify as transgender or who are gender variant or gender nonconforming in institutional settings, such as supportive living environments, long-term care facilities, nursing homes, treatment facilities, shelters and prisons.
The CPA also supports access to appropriate treatment in institutional settings for people of all gender identities and expressions, including gender transition therapies.
- The CPA supports efforts to provide safe and secure educational environments at all levels of education, as well as foster care environments and juvenile justice programs, that promote an understanding and acceptance of all youth, regardless of their sexual orientation, gender identity or gender expression.
- The CPA recognizes the efficacy, benefit and medical necessity of gender transition treatments for appropriately evaluated people and calls upon Provincial Health Insurance Plans to cover these medically necessary treatments.
- The CPA supports educating psychiatric residents and psychiatrists about how to explore patients' perceptions of their sexual orientation, gender identity and gender expression using LGBTQinclusive questions and gender-neutral language. The CPA also supports educating all psychiatric residents and psychiatrists about the potential for mental health care disparities in LGBTQ communities and about some of the specific issues that can apply when working with people who identify as LGBTQ (for example, homophobia and transphobia, family rejection and the coming out process).
- The CPA opposes the use of reparative or conversion therapy, given that such therapy is based on the assumption that LGBTQ identities indicate a mental disorder and (or) the assumption that the person could and should change their sexual orientation and (or) their gender identity and gender expression.
- The CPA encourages physician practices, medical schools, hospitals and clinics to broaden any nondiscrimination policies or statements to include sexual orientation, gender identity and gender expression.
- The CPA encourages the use of respectful and appropriate language with all LGBTQ patients and specifically encourages using the patient's preferred name and pronouns with transgender patients.
- The CPA encourages the creation of a welcoming and affirming environment for LGBTQ people by creating an office space and (or) hospital unit that affirms people's identity (for example, using genderneutral language on forms and providing genderinclusive washrooms when possible).

# Glossary of Terms
The following terms and definitions may be used differently by different people in different regions and are not standardized. They are compiled from several sources, 15,16,39 with the acknowledgement that they will change over time as the thinking, attitudes and discourses around LGBTQ issues continue to evolve. 14
Ally: Someone who advocates for and supports members of a community other than their own, reaching across differences to achieve mutual goals.
Biphobia: Irrational fear and dislike of bisexual people. Bisexuals may be stigmatized by heterosexual people as well as by lesbians, gay men and transgender people.
A person who is attracted to and may form emotional, romantic and (or) sexual relationships with both men and women, though not necessarily equally or at the same time.
A person who by nature or by choice conforms to gender-and (or) sex-based expectations of society (also referred to as gender normative).
Cisgenderism: Assuming every person to be cisgender, therefore marginalizing those who identify as transgender in some form. It is also believing cisgender people to be superior, and holding people to traditional expectations based on gender, or punishing or excluding those who do not conform to traditional gender expectations.
Coming out: Recognizing one's own sexual orientation or gender identity and being open about it with oneself and (or) with others. This often occurs in a significant moment as well as throughout one's life, with each person to whom one chooses to come out.
A person who dresses in the clothing socially assigned to a gender that is not associated with their sex of origin, for recreation, expression or art, and (or) for erotic gratification, but who are usually comfortable with their anatomy and do not wish to change it (that is, they are not transsexual). Crossdressers may be male or female, and can be hetero-, homo-or bisexual. This term has replaced transvestite, which is now considered outdated and offensive.

# Cultural homophobia or heterosexism:
The social standards and norms that dictate that heterosexuality is better or more moral than nonheterosexuality.
Discrimination: Negative behaviour or actions toward a person or group of people based on prejudicial attitudes and beliefs about the person's or group's characteristics, such as sexual orientation, gender identity or gender expression.
Gay: A person whose primary sexual orientation is to members of the same sex or gender. Gay can refer to men and women (boys and girls), although many homosexual women (girls) prefer the term lesbian.
Gender-confirming surgeries: Surgical procedures by which a person's physical appearance and function of their existing sexual characteristics are altered to resemble that of the sex or gender to which they are transitioning.

# Gender expression:
The way in which a person expresses their gender identity through clothing, behaviour, posture, mannerisms, speech patterns, activities and more.
Gender identity: One's internal and psychological sense of oneself as male, female, both or neither.
The assumption that all people must conform to society's gender norms, and specifically, the binary construct of only two genders, corresponding to the two sexes (female and male). This belief in the binary construct as the most normal and natural and a preferred gender identity does not include or allow for people to be intersex, transgender, transsexual, or genderqueer.
Gender nonconforming: A person who does not conform to society's expectations of gender expression based on the gender binary or expectations of masculinity and femininity.
Genderqueer: A person who experiences a very fluid sense of their gender identity and who does not want to be constrained by absolute concepts. Instead, they prefer to be open to relocating themselves on the gender continuum.
Gender variant: A synonym for gender nonconforming, which is preferred to gender variant because variance implies a standard normativity of gender.
Heterosexual: Of, relating to, or characterized by a primary sexual orientation towards members of the other sex or gender. Heterosexual people are often referred to as straight.
The assumption that everyone is, or should be, heterosexual, and that heterosexuality is inherently superior to and preferable to all other sexual orientations.
Heterosexual privilege: Benefits derived automatically by being (or being perceived as) heterosexual that are denied to gay men, lesbians, bisexual men and women, queer people, and all other nonheterosexual sexual orientations.
Homosexual: Of, relating to, or characterized by an emotional, romantic and (or) sexual attraction predominately to a person of the same sex or gender. As this term is historically associated with a medical model of homosexuality, most people would prefer to selfidentify as gay, lesbian or queer.
The irrational fear or hatred of, aversion to, and discrimination against homosexuals or homosexual behaviour.
Internalized homophobia: The experience of guilt, shame or self-hatred in reaction to one's own feelings of attraction for a person of the same sex or gender as a result of homophobia and heterosexism.
Interpersonal or external homophobia: Overt expressions of internal biases, such as social avoidance, verbal abuse, derogatory humour and physical violence.
Intersex: A person who has some mixture of female and male genetic and (or) physical sex characteristics. Intersex people may have external genitalia that do not closely resemble typical male or female genitalia, the appearance of both female and male genitalia, the genitalia of one sex and the secondary sex characteristics of the other sex or have a chromosomal make-up that is neither XX nor XY. An outdated term formerly used was hermaphrodite. An intersex person may or may not identify as part of the transgender community.
Institutional homophobia or heterosexism: Refers to the many ways that governments, businesses, religious institutions, educational institutions and other organizations set policies and allocate resources that discriminate against people based on sexual orientation.
Lesbian: A girl or woman whose primary sexual orientation is to other girls or women or who identifies as a member of the lesbian community.
Prejudice: An unjustified or incorrect attitude toward an individual or group of people based solely on their membership in a social group, such as the LGBTQ community.
Queer: In contemporary usage, queer is an inclusive, unifying, sociopolitical and self-affirming umbrella term encompassing a broad range of sexual and gender expression, including people who identify as gay, lesbian, bisexual, transgender, intersex, genderqueer or any other nonheterosexual sexuality or nonconforming gender identity. Queer is a reclaimed term, which was previously seen as derogatory, but many people (though not all people) within the LGBTQ community are comfortable using this term.
Questioning: A self-identification sometimes used by those exploring personal issues of sexual orientation and (or) gender identity.

# Reparative or conversion therapy:
A range of pseudoscientific treatments that aim to change a person's sexual orientation from homo-to heterosexual.

# Sexual behaviour: Refers specifically to sexual actions
-r what a person does sexually. Sexual behaviour is not necessarily congruent with sexual orientation and (or) sexual identity.

# Sexual identity:
Refers to a person's identification to self (and others) of one's sexual orientation. It is not necessarily congruent with sexual attraction and (or) sexual behaviour.

# Sexual orientation:
Refers to how one thinks of oneself in terms of one's emotional, romantic or sexual attraction, desire or affection for another person.
Transgender or trans: Someone whose gender identity or expression differs from conventional expectations of masculinity or femininity. It is often used as an umbrella term that includes people who identify as cross-dressers, transsexuals, two-spirit, intersex and genderqueer.
Transition: A complicated, multi-step process that can take years as transgender and (or) transsexual people align their anatomy and (or) their gender expression with their gender identity.
Transphobia: Irrational fear or dislike of transsexual and (or) transgender people.
Transsexual: A person who has a gender identity that is not in keeping with their physical body. Transsexual people typically experience discomfort with this disparity and seek to modify their body through hormones and (or) surgical procedures to bring their bodies closer to their gender identity.
Transvestite: See cross-dresser.
A term used by some North American Aboriginal societies to describe those people in their cultures whose nature is comprised of both male and female spirits. People who identify as two-spirit may also identify as gay, lesbian, bisexual, transgender, intersex, transsexual or have multiple gender identities.
The authors thank Dr. Tara La Rose, Dr Karine Igartua, Dr. Gail Knudson, Nicole Nussbaum, Dixon Challoner, and Gale Melligan for their suggestions and assistance in the preparation of this position paper.