Lgbtq Mental health


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  • Lgbtq Mental health

    1. 1. Lesbian, Gay, Bisexual, Transgender, Questioning (LGBTQ) Mental Health Howard R. Hernandez, MD PGY-3 Psychiatry MetroHealth Medical Center
    3. 3. OBJECTIVES <ul><li>To understand some major events in the history of psychiatry and homosexuality </li></ul><ul><li>To identify developmental issues specific to LGBTQ youth and identify what mental health providers can do to help this subpopulation </li></ul><ul><li>To have an understanding of mental health issues unique to the LGBTQ population, with application of best care practices </li></ul>
    4. 5. DEFINITION OF TERMS <ul><li>LGBTQ: L esbian, G ay, B isexual, T ransgender and Q uestioning Individuals </li></ul><ul><li>Sexual orientation: pattern of physical and emotional arousal toward others (1) </li></ul><ul><li>Sexual behavior: men who have sex with men(MSM), or women having sex with women (WSW) (1) </li></ul><ul><li>Gender identity: one's knowledge of oneself being male or female (2) </li></ul>
    5. 6. MORE DEFINITIONS <ul><li>Gender role : one's outward expression of maleness or femaleness (3) </li></ul><ul><li>Transgender: individuals whose gender identities, expressions, or behaviors are not traditionally associated with their natal sex (4) </li></ul><ul><li>Homophobia: the unreasoning fear of homosexuals and homosexuality (2) </li></ul><ul><li>Heterosexism: a prejudiced attitude or discriminatory practices against homosexuals by heterosexuals (2) </li></ul>
    6. 7. HISTORY OF PSYCHIATRY & HOMOSEXUALITY <ul><li>Same-sex sexual activity as &quot;unnatural acts,&quot; &quot;crimes against nature,&quot; &quot;sodomy,&quot; or &quot;buggery” until the 19 th century </li></ul><ul><li>1533 – The Buggery Act by King Henry VIII </li></ul>
    7. 8. Sodom and Gomorrha (Genesis 19)
    8. 9. HISTORY OF PSYCHIATRY & HOMOSEXUALITY Havelock Ellis (1859-1939) Medical literature on homosexuality flourished in the 19th century Reason: Medico-legal experts determining if accused had mental illness “ Sexual Inversion ”
    9. 10. HISTORY OF PSYCHIATRY & HOMOSEXUALITY <ul><li>First activist for homosexual civil rights </li></ul><ul><li>Against the Prussian law criminalizing sodomy </li></ul><ul><li>“ Same-sex love is a congenital, hereditary condition ” </li></ul><ul><li>“ Urnings ” - female soul in a male body </li></ul>Heinrich Ulrichs (1825-1895)
    10. 11. HISTORY OF PSYCHIATRY & HOMOSEXUALITY <ul><li> Coined the term &quot;homosexual” </li></ul><ul><li> </li></ul><ul><li>“ Homosexual attraction was innate” </li></ul><ul><li>“ Not all homosexuals were psychologically effeminate” </li></ul>Karl Maria Kertbeny (1824-1882)
    11. 12. FOUR THEORIES OF HOMOSEXUALITY: (5) <ul><li>1 Outcome of the Oedipus conflict </li></ul><ul><li>2 Over attachment and identification with a boy’s mother </li></ul><ul><li>3 A feminine identification to seek father's love and masculine identification </li></ul><ul><li>4 Reaction formation: sadistic jealousy of brothers and father </li></ul>Sigmund Freud (1856 – 1939)
    12. 13. DECLASSIFICATION AS A MENTAL DISORDER <ul><li>The American Psychiatric Association (APA) removed homosexuality from its official Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1973. </li></ul>
    13. 14. KINSEY SCALE <ul><li>0 - Exclusively heterosexual </li></ul><ul><li>1 - Predominantly heterosexual, incidentally homosexual </li></ul><ul><li>2- Predominantly heterosexual, more than incidentally homosexual </li></ul><ul><li>3- Equally heterosexual and homosexual </li></ul><ul><li>4- Predominantly homosexual, more than incidentally heterosexual </li></ul><ul><li>5- Predominantly homosexual, incidentally heterosexual </li></ul><ul><li>6- Exclusively homosexual </li></ul>Alfred Charles Kinsey (1894-1956)
    14. 15. PSYCHOLOGICAL DEVELOPMENT <ul><li>“ When I was 12 years old and first dealing with my gay identity, I thought I was really anxious. I tried to avoid people, I didn ’ t look at them. I tried to hide. I felt tremendous guilt. I was afraid they would know I was gay or that I was attracted to them and think I was crazy. ” </li></ul><ul><li>– at the Pride Clinic </li></ul>
    15. 16. WHAT MAKES PEOPLE GAY? <ul><li>? Pathological family dynamics (6,7,8,9) </li></ul><ul><li>? Biological studies (10) </li></ul><ul><li>Multifactorial </li></ul><ul><li>“ Born that way, ” sexual identities as a stable aspect of their essential selves </li></ul><ul><li>Unknown </li></ul>
    16. 17. IDENTITY <ul><li>Can be diverse and complex </li></ul><ul><li>Kinsey expounded upon this diversity (11) </li></ul><ul><li>Refinements of the Kinsey scale add other dimensions of sexuality (12) </li></ul><ul><li>Adds yet another dimension </li></ul>
    17. 18. Gender Identity Development <ul><li>2 or 3 years of age = a stable gender identity </li></ul><ul><li>Gender role develops during preschool years </li></ul><ul><li>Retrospective studies = Homosexuals recall feeling different from their peers </li></ul>
    18. 19. Childhood & Adolescence <ul><li>2/3 of adult gay men and women recall some gender atypical behaviors or preferences as children (Bailey & Zucker 1995) </li></ul><ul><li>75 percent of boys with extreme gender atypical behaviors reported homosexual orientation as adolescents and young adults (Green 1987) </li></ul><ul><li>Most gender atypical children face varying degrees of hostility and homophobia! </li></ul>
    19. 20. <ul><li>“ The absolute lowest insult is to be called a fag. When kids want to really put another kid down, they call them a fag, whether or not they are gay. That ’ s so gay is a remark that irks me up to this day. ” </li></ul><ul><li> – CM from Fairview Hospital CCF </li></ul>
    20. 21. HOSTILITY <ul><li>Marginalization, bullying, teasing, insults, assaults, and sexual violence </li></ul><ul><li>Effects: Internalized homophobia = self-hatred Externalized = anti-gay attitudes and aggression </li></ul><ul><li>Can lead to desperate attempts at heterosexual relations </li></ul>
    21. 22. Psychological Development and Life Cycle <ul><li>“ The presence of gender variance does not necessarily imply gender identity disturbance. Parents with a gender variant child can be encouraged to help their child feel secure about their gender identity while minimizing ostracism and isolation.” (Perrin 2004 ) </li></ul>
    22. 23. Sexual Identity Development in Adolescence <ul><li>Exploration and experimentation </li></ul><ul><li>Sexual experiences with persons of the same and/or opposite sex </li></ul><ul><li>Straight youth may be curiosity and experimentation; Lesbian and gay youth may be experiencing pressure to conform to majority behavior </li></ul>
    23. 24. LGBTQ Sexual Identity Adolescence Development <ul><li>Stage models = awareness of difference, confusion about difference, decision and action (or indecision and inaction), acceptance, pride, and integration. </li></ul><ul><li>Developmental stages = retrospective accounts </li></ul><ul><li>Young LGBTQ Adults recognized their sexual orientation during early adolescence, and awareness of same-sex erotic attraction usually predating puberty (Cohler 2000 ) </li></ul>
    24. 25. Stress Factors Influencing LGBTQ Adolescent Development <ul><li>Feel different, uncertain on how their loved ones will react </li></ul><ul><li>Lack outlets for exploring their sexual identity </li></ul><ul><li>High rates of physical and verbal abuse, resulting in homelessness (D'Augelli 1995) </li></ul><ul><li>Higher rates of dropping out of school, using tobacco, alcohol or drugs, suicide attempts, depression, and HIV (Frankowski 2004) </li></ul>
    25. 26. <ul><li>“ Many mental health providers I’ve gone to treat me like am a specimen through the lens of a microscope. When they find out you’re lesbian or gay, they focus on your sexuality as the basis of all your problems. They don’t listen to what we say that’s relevant to our problems. No matter what we tell them, they think it’s our sexuality - being gay or lesbian that is causing the problem. And we’re not getting the help we really need.” </li></ul><ul><li> – Pride Clinic Patient </li></ul>
    26. 27. Clinicans and Mental Health Providers with LGBTQ Adolescents <ul><li>Be open and inclusive </li></ul><ul><li>Confidentiality is essential </li></ul><ul><li>Question about available supports, HIV risk factors, physical and sexual abuse, drug and alcohol use, and suicidality. </li></ul><ul><li>Referrals to psychotherapy (Frankowski 2004) </li></ul>
    27. 28. Clinicians with LGBTQ Adolescents (Ng, 2010) <ul><li>Provide affirming care – </li></ul><ul><li>PRIVACY, CLEANLINESS, HONESTY, RESPECT, COMPETENCY, and NON- JUDGMENTAL STANCE </li></ul><ul><li>Include sexual orientation, gender identity, and gender expression , relationships in intake and registration process </li></ul><ul><li> </li></ul>
    28. 29. PRIDE CLINIC INTAKE FORM (please refer to sample handout) <ul><li>Medical Home for Sexual Minorities and their Families </li></ul><ul><li>Inclusive </li></ul><ul><li>Allows for self-Identification </li></ul><ul><li>Pronoun – He, She, Zhe </li></ul><ul><li>Gender identity/Expression </li></ul><ul><li>Permission to have medical student, resident or fellow participate in care </li></ul>
    29. 30. Clinicians with LGBTQ Adolescents (Ng, 2010) <ul><li>Use the language younger LGBTQ use for self-identification </li></ul><ul><li>Recognize and avoid perceived offensive actions </li></ul><ul><li>Normalize sexual health interview </li></ul><ul><li>Know your local resources and support groups </li></ul>
    30. 31. <ul><li>FAMILY BEHAVIORS THAT INCREASE RISK FOR LGBTQ YOUTH SUICIDE </li></ul><ul><li>( Caitlin Ryan, Family Acceptance Project, 2009) </li></ul><ul><li>Physically hurting a child </li></ul><ul><li>Verbal/Emotional Harassment </li></ul><ul><li>Blocking access to LGBTQ friends, events, and resources </li></ul><ul><li>Blaming a child when they are discriminated </li></ul><ul><li>Pressuring a child to be more (or less) masculine or feminine </li></ul><ul><li>Telling a child that God will punish them </li></ul><ul><li>Telling a child that that you are ashamed of them </li></ul>
    31. 32. <ul><li>FAMILY BEHAVIORS THAT REDUCE RISK FOR LGBTQ YOUTH SUICIDE </li></ul><ul><li>(Caitlin Ryan, Family Acceptance Project, 2009) </li></ul><ul><li>Talk with the child </li></ul><ul><li>Express affection </li></ul><ul><li>Support the child’s LGBTQ identity even though you may be uncomfortable </li></ul><ul><li>Advocate for the child when he or she is mistreated </li></ul><ul><li>Connect the child with an LGBTQ role model to show them options for the future </li></ul><ul><li>Believe the child can have a happy future as an LGBTQ adult </li></ul>
    32. 33. LGBTQ Resources <ul><li>Gay-straight alliances at school - Gay, Lesbian and Straight Education Network (GLSEN) </li></ul><ul><li>OUTPROUD- National Coalition for Gay, Lesbian, Bisexual and Transgender Youth </li></ul><ul><li>Parents, Families, & Friends of Lesbians and Gays(PFLAG) </li></ul>
    33. 34. COMING OUT <ul><li>“ In sixth grade, I realized I was gay and came out to my parents. It wasn ’ t total acceptance on my part or my parents for that matter. I realized I was gay and that wasn ’ t going to change. I basically dealt with it and accepted it. I didn ’ t want to go to school some day. Everyday I had stomach aches, I lived in fear everyday I got to the bus. I had to live everyday trying to avoid being  harrassed. I just want to be accepted. ” </li></ul><ul><li>- Pride Clinic Patient </li></ul>
    34. 35. COMING OUT <ul><li>Awareness of and acknowledgment of one’s own gay identity (coming out to oneself), and disclosing that identity to others (coming out to others) </li></ul><ul><li>Two critical steps (Barry Dank 1971) : </li></ul><ul><li>being in a social context with or knowledge of homosexually identified people </li></ul><ul><li>placing oneself in a new, destigmatized cognitive category of homosexuality </li></ul>
    35. 36. COMING OUT TO SELF <ul><li>Not a single event, but a process, usually a lifelong process that parallels one’s development as a person </li></ul><ul><li>Encompasses various events </li></ul><ul><li>Can begin at any age or stage of life </li></ul><ul><li>Process of coming out is often not linear </li></ul>
    36. 37. (Drescher, 2004)
    37. 38. <ul><li>A lifelong process </li></ul><ul><li>Everyday situations offer a gay person the decision of whether or not to disclose his or her identity </li></ul><ul><li>Influenced by major life changes </li></ul>COMING OUT TO OTHERS
    38. 39. <ul><li>Suicide = 3 rd leading cause of death among 15-24 year olds (CDC 2007) </li></ul><ul><li>LGBTQ Youth - Four times (4 x) more likely to attempt suicide than their heterosexual peers (Massachusetts Youth Risk Behavior Survey 2009) </li></ul>YOUTH
    39. 40. <ul><li>LGBTQ YOUTH – Stats </li></ul><ul><li>With rejecting families, more than 8 times as likely to have attempted suicide than LGBTQ peers who reported no or low levels of family rejection (Ryan 2009) </li></ul><ul><li>More than 75 % of LGBTQ youth report verbal abuse while 15% report physical abuse at school (D’Augelli R 2002) </li></ul><ul><li>More than 1/3 will lose friends through coming out. Increased victimization and loss of friends (D’Augelli R 2002) </li></ul>
    40. 41. <ul><li>General Risk Factors for Youth Suicide </li></ul><ul><li>Family crisis </li></ul><ul><li>Academic Problems </li></ul><ul><li>Loss of a Loved one </li></ul><ul><li>Risky Sexual behavior </li></ul><ul><li>Victimization </li></ul><ul><li>History of Suicide in the Family </li></ul><ul><li>(Trevor Project Webinar, Ten Eyck, 2010) </li></ul>
    41. 42. <ul><li>LGBTQ Youth-Specific Risk Factors for Suicide </li></ul><ul><li>Gender Non-conformity </li></ul><ul><li>Coming out Issues </li></ul><ul><li>Rejection when coming out </li></ul><ul><li>Gay-related Victimization </li></ul><ul><li>Unique Developmental Stressors </li></ul><ul><li>(Trevor Project Webinar, Ten Eyck, 2010) </li></ul>
    42. 43. <ul><li>PROMOTING RESILIENCY </li></ul><ul><li>Effective Clinical Care </li></ul><ul><li>Easy Access to Care </li></ul><ul><li>Restricted Access to Highly Lethal Means of Suicide </li></ul><ul><li>Strong connections </li></ul><ul><li>Artistic, Athletic or Academic Talent </li></ul><ul><li>Medical And Mental Health care </li></ul><ul><li>Skills in Problem Solving </li></ul><ul><li>Cultural and Religious Beliefs </li></ul><ul><li>(Trevor Project Webinar, Ten Eyck, 2010) </li></ul>
    43. 44. <ul><li>PROMOTING RESILIENCY IN LGBTQ YOUTH </li></ul><ul><li>Family, Community and School Support </li></ul><ul><li>Positive Media Representations </li></ul><ul><li>Gay or Gay-friendly Social and Support Networks </li></ul><ul><li>Academic and Athletic Talents </li></ul><ul><li>Development of Coping Mechanisms </li></ul><ul><li>(Trevor Project Webinar, Ten Eyck, 2010) </li></ul>
    44. 45. LGBTQ HEALTH ISSUES AND CHALLENGES <ul><li>Same primary care issues and needs as others </li></ul><ul><li>Methodological difficulties - relatively small minority </li></ul><ul><li>Review of all MEDLINE citations in the years 1980-1999 found only 0.1% referred to LGBTQ health (Boehmer, 2002) </li></ul>
    45. 46. LGBTQ HEALTH ISSUES <ul><li>LGBTQ - one of the 6 most underserved minority groups in America (Department of Health and Human Services, Healthy People 2010 ) </li></ul><ul><li>High rate of negative reactions and disapproval when the patient discloses their sexual orientation to their doctor (Harcourt 2006 ) </li></ul>
    46. 47. TOBACCO <ul><li>MSM have higher rates of tobacco use </li></ul><ul><li>Lesbian and bisexual women have higher rates of tobacco use, perhaps even higher than MSM </li></ul><ul><li>Increased risk for coronary and peripheral vascular disease, obstructive lung disease, lung cancer </li></ul><ul><li> (Harcourt 2006) </li></ul>
    47. 48. SUBSTANCE ABUSE <ul><li>Studies - inconsistent and has questionable validity </li></ul><ul><li>ETOH use and illicit drugs are higher in lesbians and gay men </li></ul><ul><li>Drug and ETOH use is associated with high-risk sexual behaviors and adversely affects other chronic diseases </li></ul>
    48. 49. PSYCHIATRIC ISSUES <ul><li>MSM and WSW have higher prevalence of depression, anxiety, suicidal ideation, and PTSD </li></ul>
    49. 50. INDIVIDUAL DISCRIMINATION <ul><li>Association between parental rejection and higher risk of suicide attempts (D’Augelli, Grossman; Salter et al 2005; D’Augelli, Hershberger &Pilkington, 2001; Remafedi et al, 1991; Ryan, Huebner, Diaz &Sanchez, 2009 ) </li></ul><ul><li>National Survey of Midlife development – elevated anxiety, depression and other mental health problems (Mays & Cochran, 2001) </li></ul>
    50. 51. INSTITUTIONAL DISCRIMINATION <ul><li>19 states lacking protections against hate crimes or employment discrimination- higher prevalence of psychiatric disorders (NESARC data) </li></ul><ul><li>No protective policies- 5 x more to have 2 or more mental disorders (Hatzenbuehler, Keyes and Hasin, 2009) </li></ul>
    51. 52. VIOLENCE <ul><li>MSM and WSW have higher rates of experiencing violence, including hate crimes and domestic abuse (Dean 2000) </li></ul>
    52. 53. LGBTQ SUICIDE <ul><li>Recently deceased: </li></ul><ul><li>17-year-old Eric Mohat of Ohio, March 29, 2007 </li></ul><ul><li>11-year-old Carl Walker-Hoover of Massachusetts, April 7, 2009 </li></ul><ul><li>11-year-old Jaheem Herrera from Georgia, April 16, 2009 </li></ul><ul><li>17-year-old Tyler Long from Georgia, October 17, 2009 </li></ul><ul><li>15-year-old Phoebe Prince of Massachusetts, March 28, 2010 </li></ul><ul><li>15-year-old Justin Aaberg from Minnesota, July 9, 2010 </li></ul><ul><li>15-year-old Billy Lucas from Indiana, September 9, 2010 </li></ul><ul><li>13-year-old Seth Walsh from California, September 19, 2010 </li></ul><ul><li>18-year-old Tyler Clementi of New Jersey, September 22, 2010 </li></ul><ul><li>13-year-old Texas teen Asher Brown, September 23, 2010 </li></ul><ul><li>19-year-old Raymond Chase of New York, September 29, 2010 </li></ul><ul><li>19-year-old Zach Harrington from Norman. Oklahoma, October 9, 2010 </li></ul><ul><li>19-year-old Corey Jackson of Michigan, October 19, 2010 </li></ul><ul><li>14-year-0ld Brandon Bitner of Pennsylvania, November 2010 </li></ul><ul><li>...and others </li></ul>
    53. 54. SUICIDE AND RISK - LGBTQ <ul><li>Little attention has been given to the problem in LGBTQ populations </li></ul><ul><li>The US National Strategy for Suicide Prevention and the Institute of Medicine’s Reducing Suicide: A National Imperative defined gay and bisexual youth as a risk population (US Surgeon General,2001; Goldsmith, Pellmar, Kleinman &Bunney 2002) </li></ul>
    54. 55. SUICIDE AND RISK- LGBTQ <ul><li>American Foundation for Suicide Prevention Resource Center and the Gay and Lesbian Medical Association (GLMA) Conference November 2007 </li></ul><ul><li>Relevant research and their implications for reducing suicidal behavior in the target populations, and made recommendations to address knowledge gaps </li></ul>
    55. 56. Suicide and Suicide Risk in LGBT Populations Review & Recs <ul><li>Summarized what is currently known about suicide, suicide attempts and suicide risk across the lifespan </li></ul><ul><li>2. Identified knowledge gaps most in need of future research, and make recommendations for how these can be addressed </li></ul><ul><li>3. Recommendations for applying what is already known to reduce suicidal behavior and suicide risk in sexual minority populations </li></ul>(Journal of Homosexuality, 2011)
    56. 57. RECENT FINDINGS <ul><li>Suicidal behavior significant higher in youth who identify as LGBTQ compared to those who identifed as heterosexual (Zhao, Montoro, Igartua & Thombs, 2010) </li></ul><ul><li>Rates of mood and anxiety disorders were strongly linked to LGBTQ identity than to sexual behavior or attraction , particularly in women (Bostwick, Boyd, Hughes, McCabe, 2010) </li></ul>
    57. 58. SUICIDE DEATHS FINDINGS <ul><li>Denmark: extensive registries – death records include deceased person’s sexual orientation </li></ul><ul><li>Same-sex registered domestic partners were 3-4 times more likely than heterosexual married persons to die by suicide (Qin, Agerbo &Mortenson, 2003) </li></ul>
    58. 59. STATS – COMPLETED SUICIDES <ul><li>Men who were currently or formerly in same-sex domestic partnerships were 8 x more likely to die by suicide compared to men with histories of heterosexual marriage and twice likely as men who never married </li></ul><ul><li>(Mathy, Cochran, Olsen & Mays, 2009) </li></ul>
    59. 60. ATTEMPTED SUICIDES RECENT FINDINGS <ul><li>Meta- analysis of 25 international population-based studies –Suicide attempts was about 4 x that of comparable heterosexual males (King et al, 2008) </li></ul><ul><li>Lifetime suicide attempt rates to be higher on gay/bisexual men that in lesbian/bisexual women (King et al, 2008) </li></ul>
    60. 61. Race and Ethnicity Suicidal Behavior <ul><li>LGB adolescents to be especially high among African-American males (Ramafedi, 2002) </li></ul><ul><li>Adults- SA rates have been highest among gay/bisexual men of lower socioeconomic status (Paul et al, 2002) and among LGB Latinos (Meyer, Dietrich & Schwartz, 2007) </li></ul><ul><li>Latino and Asian-American adults –gay and bisexual men were more likely than heterosexual men to report a recent SA (Cochran, Mays, Alegria, Ortega &Takeuchi, 2007) </li></ul>
    61. 62. Race and Ethnicity Suicidal Behavior <ul><li>LGB Caucasian participants had significantly higher rates of mood disorders than Black or Hispanic Individuals </li></ul><ul><li>Black and especially Latino individuals however reported significantly higher rates of lifetime suicide attempts than did whites, with most attempts before age 20 (Meyer et al, 2007) </li></ul>
    62. 63. Race and Ethnicity Suicidal Behavior <ul><li>NESARC data – After adjusting from mental disorders, suicide attempt rates in LGB respondents overall remained 2-3 times higher than among heterosexual respondents ( Belik& Sareen, 2010) </li></ul>
    63. 64. TAKE HOME POINTS <ul><li>Don't assume patients are heterosexual just because they haven't said otherwise </li></ul><ul><li>Don't assume LGBTQ patients do not have children </li></ul><ul><li>Don't assume that self-identified gay men do not have sex with women or that lesbians never have sex with men </li></ul><ul><li>Don't assume that early same-sex erotic feelings are merely a passing phase, and therefore not to be taken seriously </li></ul>
    64. 65. TAKE HOME POINTS <ul><li>Provide affirming care </li></ul><ul><li>Use the language younger LGBTQ use for self-identification </li></ul><ul><li>Recognize and avoid perceived offensive actions </li></ul><ul><li>Normalize sexual health interview </li></ul><ul><li>Know your local resources and support groups </li></ul><ul><li> </li></ul>
    65. 66. Thank You!