The relationship between paranoia and sexual orientation has a long and controversial history in psychoanalytic thinking. It has shifted from a position of early linkage and pathologisation, a subsequent rejection of that link citing societal homophobia, followed by more recent attempts at possible conceptual synthesis. Through the process of a hermeneutic literature review, I explore the different ways this linkage has been thought about over time. I then present my understandings and new insights into how best to work with paranoid LGBTQ+ clients and explore the ethical challenges involved in theorising about and working with marginalised and vulnerable client groups.