Editorial

Sexual orientation is a major component as well as a key determinant of the identity of human being. All of us carry multiple identities which have been described as micro-identities (Wachter et al. 2015). Sexuality comprises of innate orientation and identification as being attracted to same sex, opposite sex, both or neither or plurisexual or pansexual. Sexual minorities include gay, lesbian, bisexual, asexual individuals. As there is not a massive amount of research data on asexual individuals for the purposes of this themed issue focus has been on gay, lesbian and bisexual individuals as part of the sexual minorities. Sexual orientation, thus has been shown to be an important vulnerability to psychiatric disorders. Rates of various psychiatric disorders including depression, anxiety, suicidal ideation, suicidal acts have been shown to be consistently higher. This has been attributed to minority stress as defined by Meyer. We are aware that mental health and sexual orientation intersect with other issues of personal, cultural and social identity. Furthermore, as most of the research on the topic has come from high-income countries, it is difficult to be certain about the exact numbers and detailed epidemiological data for a number of reasons. These include self-identification, stages of coming out and societal attitudes especially if they are negative and not welcoming. However, this is likely to be around 5% of the population. A recent survey from the USA has suggested that the numbers of people identifying themselves as gay, lesbian or bisexual has increased (Jones 2021). Some exciting findings from Hatzenbuehler et al. (2012, 2013, 2017) have demonstrated clearly that once inequality has been eliminated by changes in law bringing about equal rights including marriage equality, rates of psychiatric morbidity of psychiatric morbidity in these groups tend to fall. This has to be seen in the context of how Bullough (1976) defined cultures as sex-positive (where sex is used as a source of pleasure) and sex-negative cultures (where sexual act is used for procreative purposes).

It needs to be emphasised that although term community is often used for this group, like any other group there remains a major degree of diversity with each individual member with distinct and unique experiences, upbringing, cultural factors including responses to their own sexual orientation, processes and stages of coming out which can generate varying responses from others including healthcare professionals. Not surprisingly negative attitudes by the healthcare professionals will lead to delays in help-seeking and engagement thereby contributing to negative outcomes. The mental healthcare needs of individuals especially across various vulnerable minority groups differ and must be taken into account in any healthcare as well as policy development. More importantly health cannot be seen in isolation from education, employment, housing, justice etc. Improving access and reducing stigma both towards minorities but also towards psychiatry and psychiatric services will help reduce double jeopardy that sexual minorities with psychiatric illnesses face. Psychiatry has often stepped into treating and managing behaviours which are seen as abnormal or deviant by the society at its behest. These interventions may be seen as helpful by healthcare professionals but can also psychiatrise behaviours. Decriminalisation and demedicalisation of same-sex behaviours in many cultures and countries was initiated by social changes.

Sexuality or the capacity for sexual feelings, forms an integral part of an individual’s identity. Sexuality is deemed to have three key components – behaviour, fantasies and innate orientation. Sexual behaviour often gets equated with sexual orientation which in reality is much more complex. Sexual orientation is an innate form of sexuality which affects sexual preferences both in behaviour and fantasy. Sexual desire, sexual fantasy and sexual act are inter-related. Depending upon the availability of sexual partner the act can be same sex or opposite sex and sexual fantasies can be same sex or opposite sex at the same time. Sexual behaviour thus can be fluid depending upon desire, availability of sexual partner and cultural factors and expectations and is dictated by accessibility to sexual partners. The purpose of sexual act can be recreational or procreative. This is strongly influenced by the attitudes of cultures in which individuals grow up, live, age and play. Broadly, factors such as culture, personal and family identities, religion, societal influences and social expectations all help mould an individual and their personal and sexual identities. Variations from heteronormative sexuality and behaviour have been pathologised depending upon cultural norms and expectations. Clinical practice of psychiatry perhaps more than any other medical practice is influenced by geopolitical and social determinants of health and at its core is the bio-psycho-social model which is used to understand aetiology of psychiatric illnesses and therapeutic interventions. Cultures play a major role in influencing causation, explanation, help-seeking and outcomes of psychiatric disorders. Cultures and through these, societies define and dictate what is normal and what is seen as deviant but more importantly how to deal with these.

Over the past five decades or so in many countries, negative attitudes towards non-heterosexual behaviours have started to shift and change due to many factors such as political activism, increased recognition of minority rights, human rights and research findings. Although in some countries these positive shifts have improved levels of acceptance and acknowledgement but these gains are at risk due to changes in political environments in many settings. Although sexual variations are often considered to be part of normal human experience, these observations are by no means universal as in many countries death penalty exists for same-sex behaviours.

Sexual orientation is increasingly recognised as an important demographic characteristic in health research especially in many high-income countries. In low and middle-income countries, this is often not part of the research question when considering vulnerable populations or healthcare delivery.

LGBT (Lesbian, Gay, Bisexual, and Transgender) is a commonly used and understood acronym in social activism and development of social policy. Of late, terms such as LGBTQ + or QUILTBAG (Queer, Undecided, Intersex or Indeterminate, Lesbian, Bisexual, Asexual and Gay) are used as a matter of convenience in research as well as policy thereby ignoring the diversity and heterogeneity of these different groups. It needs to be emphasised that each individual has distinct and unique experiences, individual upbringing and individual responses to their own sexual orientation, gender and sexual identities.

In this themed issue we have a range of papers illustrating mental health needs of these vulnerable groups. Thus, their healthcare needs must be recognised at all levels and vulnerability factors including social attitudes must be taken into account when developing healthcare policies and delivering healthcare. International Review of Psychiatry set up its first Commission with members from around the world including some of the editors of this volume. We believe that it was right for the Commission to focus on variation in sexual orientation i.e. lesbian, gay and bisexual (LGB) groups. There are several challenges embedded in this issue for this group but their mental health needs must be met. AS the Commission illustrates, conversion therapies have no scientific basis and should be abandoned forthwith. In this issue we have not included asexual or plurisexual, e.g. pansexual or polysexual individuals as research into these groups is lacking and perhaps the time is right to explore their healthcare needs as a matter of some urgency.