Les minorités sexuelles : concepts, prémisses et structure d’une approche clinique adaptée Sexual minorities: Concepts, attitudes and structure for an appropriate psychotherapeutic approach

Résumé

Depuis la dépathologisation de l’homosexualité par les sociétés savantes en santé mentale, la formation des psychothérapeutes sur les minorités sexuelles comporte des lacunes. On préconise souvent de traiter les patients issus de ces minorités comme tous les autres. Or, le développement identitaire de ces personnes comporte des particularités qu’il est nécessaire de connaître pour adapter les évaluations et les interventions psychothérapeutiques comme il se doit. Le présent article propose un cadre théorique, des outils d’évaluation et des pistes thérapeutiques pour accompagner une personne issue d’une minorité sexuelle qui consulte un professionnel en santé mentale.

Les concepts de non-binarité de genre, de construction sociale des rôles de genre, les dimensions distinctes de l’orientation sexuelle (attirance émotive, attirance physique, comportement et identité sexuelle), l’indépendance des attirances envers un sexe et envers l’autre, l’impact et les manifestations de l’homophobie ainsi que le processus identitaire sont décrits dans le présent article. Une attitude d’ouverture quant à la diaspora sexuelle est prônée afin d’accueillir le patient et de lui permettre une exploration ouverte dans un cadre thérapeutique sécurisant et sans danger.

Les différentes facettes à explorer lors de l’évaluation de la sexualité sont énumérées. Des pistes de traitement psychoéducatif, cognitif et psychodynamique sont proposées, entre autres : déconstruire les mythes pour réduire l’homophobie ou la transphobie, panser les blessures narcissiques et relationnelles dues à l’homophobie, analyser le pour et le contre d’un mode de vie authentique, avec ou sans « sortie du placard » ou coming out. L’apport des interventions familiales et des thérapies de groupe est aussi exposé.

Mots-clés :

• genre,
• orientation sexuelle,
• psychothérapie,
• homophobie,
• transphobie

Abstract

Objective To propose a theoretical model and clinical approach to sexual minority patients who consult mental health professionals

Methods Clinicians at the McGill University Sexual Identity Center (MUSIC) who have been treating patients from various sexual minorities for more than 15 years present useful theoretical constructs of gender and sexuality as well as guidelines for the evaluation and treatment of patients consulting for discomfort or confusion surrounding their sexual orientation, their gender identity or both, based on both the current literature and their clinical experience.

Results The notions of non-binary construction of gender, of social determinism of gender roles and expression, and of gender creativity are presented. Sexual orientation is divided into four most commonly used dimensions (emotional attraction, physical attraction, behaviour and identity); the fluidity of these and their potential non-concordance are described. The fact that attraction to one gender is independent of attraction to another gender is highlighted. An attitude of openness to all forms of gender expression and sexual orientation constellations is encouraged to allow the patient free exploration of the several facets of their sexuality.

Various domains to explore in evaluating sexual orientation and gender as well as therapeutic avenues are proposed. Areas to enquire about include: mental, physical and social experiences of gender, eroticism and sexual fantasies towards all genders, emotional attraction towards them, sexual and romantic experiences, comfort and certainty about one’s identity and about disclosing it.

Psychoeducation can be used to teach about sexual diversity and to assess the risks and benefits of coming out to self, family, friends, co-workers or strangers. Cognitive strategies can be undertaken to debunk homophobic and transphobic myths which may fuel poor self-esteem. Psychodynamic approaches can be used to heal the narcissistic wounds of homophobia that may lead one to be mistrustful of authority figures or to suppress sexual feelings when emotional attachment becomes important. Some of these dynamic patterns are rooted in past reactions to parental homophobia and the compromises sexual minorities made as children in order to preserve their relationships with their parents. For youth coming out in present times, family support is crucial to well-being and can be enhanced through family therapy. In mixed orientation couples, couple therapy can help both spouses adapt to the coming out of one of the partners and find a new partnership. Group therapy is useful for many of the above issues particularly as it provides a sense of community which is often lacking in minority groups, especially when individuals and their families do not share the same minority status.

Conclusion With the proposed framework and an attitude of openness to sexual diversity, clinicians should feel competent to treat sexual minority patients.

Keywords:

• gender,
• sexual orientation,
• psychotherapy,
• homophobia,
• transphobia