Unraveling the Depths: A Gripping Journey of a Homosexual Man Battling Adjustment Disorder and Descent into Suicide Attempt

INTRODUCTION

Suicidal thoughts and attempts are frequently reported for adjustment disorder in patients visiting hospital emergency rooms.^[1,2] Friedman et al. proposed that homosexual males have a higher lifetime risk of engaging in suicidal conduct, and this increased risk is not exclusively related to coexisting mental health issues.^[3] Social standards and a person’s homosexual orientation are in constant confrontation with one other. Clinicians should investigate the potential of Adjustment Disorder or Depressive Disorder if the degree of suffering is high enough to satisfy diagnostic criteria.^[4] Compared to heterosexual people, homosexual males are more likely to exhibit signs of social anxiety, such as tension in relationships and fear of being judged negatively.^[5–7] These symptoms become more severe if the person has a personality trait that makes them more likely to develop a personality disorder later on.^[5,8,9]

We have described the attempted suicide of a young gay man in this case study, along with potential causes and psychiatric strategies.

CASE REPORT

The Department of Psychiatry at the Assam Medical College and Hospital received a referral call from the Medicine department for a 20-year-old man with a history of alleged suicidal attempts. He was an undergraduate student from a middle-class urban nuclear family who had attempted suicide at home after being threatened by one of his ex-boyfriend’s friends. It was looking like nothing but an adjustment disorder. On further query, the rudimentary matter was revealed with regard to his difficult coping mechanism, the struggle of being a homosexual, and the family dispute where the breakup finally flourished. Unknowingly, his struggle started at 3 years of age, when he was more interested in girls’ toys and clothing and used to participate in bihu as a female dancer. He was scolded repeatedly for urinating, typically in a girl’s manner of urination. But from the age of 4 years, his likings again geared toward stereotypical male objects. Alcoholism in his father had caused disputes in the relationship between his parents right from childhood. From the age of 10, it was a difficult situation because his parents used to leave him and his brother alone for prolonged periods due to their jobs. The two kids had to stay with their maternal uncle. He was then transferred to a different school and lived in a boys’ hostel for 6 years, where he felt like an abandoned child because his parents visited infrequently. As a result, he repeatedly attempted deliberate self-harm out of loneliness and rage in the hostel. His self-gratification habit began in the eighth grade, was passed down from his dorm roommates, and was performed after watching heterosexual pornography. But, he tended to be friendlier with his female friends. Then, he was once more sent to a different school in class IX as his mother was not keeping well. Along with adjustment issues in a new school, teasing from an alcoholic father became a daily routine, which led to his suicide attempt. However, his interest in same-sex relationships began at the age of 16 years. At first, he didn’t grasp what gay orientation was, but one person on social media helped him. Following that, he dated that man for 3 months. After that, he started dating a man and he participated passively in sexual activity. For the last 1 year, their relationship was not in good shape, and it ended 2 weeks before after he caught his ex-boyfriend having relationships with multiple partners. He attempted suicide with the feeling of loneliness after the breakup, as his parents were also not supportive of his sexual orientation.

On the International Personality Disorder Examination (IPDE) scale, his personality trait was found as borderline personality trait.

He was diagnosed with Adjustment disorder (F43 according to ICD 10) with borderline personality traits.

Family therapy, cognitive behavioral therapy, and supportive therapy were started along with fluoxetine 20 mg per day. His symptoms improved with the treatment.

DISCUSSION

The power dynamics between the dominant and marginalized groups play a significant role. Mainstream society enforces a heteronormative structure, which faces resistance from marginalized groups within the sexual spectrum.^[10] Even gay individuals are typically brought up in families that follow heterosexual norms and traditions, making it challenging to escape the direct societal impact of homophobia on mental well-being.^[11] While LGBTQ+ individuals may have legal recognition, achieving genuine social acceptance remains a distant reality.^[12–15] Homosexual individuals are at a higher risk of experiencing mental health conditions such as anxiety, depression, or psychosis, with some neuroanatomical and neurophysiological variances providing additional support for these findings.^[16–19]

Likewise, our patient faced discouragement from his parents due to his sexual orientation, resulting in multiple suicide attempts. It was compounded by his emotionally unstable nature. The development of abnormal personality traits was influenced by both hereditary factors and the familial environment.^[20–23] This was evident in our patient, particularly as his mother exhibited similar traits (as she also had a history of multiple suicidal attempts and an emotionally unstable nature) and family disputes were a recurring issue.

In patients with distress about their homosexual orientation, along with pharmacotherapy, attachment-based family therapy,^[24] resolving the conflict between religion and same-sex relationships,^[25] self-empowerment,^[26] and affirmative LGBT psychotherapy^[27] have proven to be beneficial.

The therapist should recognize when LGBTQ youth focus solely on their nonconforming sexual orientation or identity as a way to avoid confronting other fears, anxieties, and fantasies, by displacing them onto a single construct.^[28]

Cognitive behavioral therapy was used as a treatment for adjustment disorder.

CONCLUSION

Male–male homosexual relationships appear to be less stable than female–female relationships. Gay male couples generally get less social support and are devoid of the capacity of childbearing. Their problem of resolving the coming out process can contribute to poor self-esteem caused by internalized homophobia due to the stigma. This causes deleterious effects on relationships. Even there can be conflict between partners on the degree of disclosure, which forms hatred toward their sexual orientation. Personality trait is a defense mechanism for an individual. Through introjection and identification, a child owns a personality trait which is ego-syntonic. So, it is difficult to change the problematic behavior. Personality traits and dysfunctional families may make a person vulnerable to adjustment disorder. This case report highlights some of the challenges faced by homosexual individuals. While there may be legal acceptance, social acceptance remains a distant goal. It is crucial to provide education starting from a young age to create an inclusive and nonstigmatized environment for the LGBTQ + community. Further research is required for the intervention in the problems of homosexual populations.