LGBTQ Mental and Emotional Health 1 Pls note

LGBTQ Mental and Emotional Health 1

Pls. note some videos may trigger and / or be upsetting to some individuals. Contents § LGBTQ youth & adults § Using LGBTQ culturally specific analysis on cultural safety, humility § An intersectional framework and approach § Psychological impact of homo/bi/transphobia § Mental and emotional health issues § Case scenarios § Resources 2

Objectives § Learn of the health disparities and intersectional identities § Self reflection (values, attitudes, beliefs), analysis & counselling LGBTQ § Provide culturally competent healthcare and social services 3

http: //www. youtube. com/watch? v=Xq. H 6 GU 6 Trz. I ( 4 min) https: //www. youtube. com/watch? v=NUhv. Jgxg. Aac ( 10 min) 4

The whole picture: bringing all of me § Inquire about social and historical context of their lived experiences; internalized homo/bi/transphobia, selfesteem, self-acceptance, shame, discrimination, impact of & with race, culture, etc. § Syndemic: “A set of linked health problems involving two or more afflictions, interacting synergistically, and contributing to excess burden of disease in a population. Syndemics occur when health-related problems cluster by person, place, or time. ” 5

Understand LGBTQ lived experiences § An intersectional framework § LGBTQ– who have depression, anxiety, panic, phobias, bipolar, concurrent disorders § Have insight into: learn of their lived experiences, coming out (binary vs. grey zone), culture/ race/ ethnicity/ religion/ spirituality intersects with age - intergenerational differences and needs § Social issues: supported or disowned, ridiculed, lived in fear, verbal abuse, sexual assault, physical violence, microaggression, erasure of self , impact of syndemic 6

N = 704 LGBTQ and mental health needs “When you experience multiple forms of discrimination, Questions? its effects can be cumulative. Experiences of discrimination are potentially also interrelated (racist AND sexist, classist AND transphobic). While finding support that understands and appreciates one aspect of your identity can be a challenge, finding support that speaks to your whole self – all your various identities – can be much more complicated. ” The Pathway Project http: //lgbtqhealth. ca/projects/pathways. php Re: Ross et al. , (2014) The Pathways Project 7

Respondents from The Pathway Project, 2014 “ Having someone who accepts you unquestioningly for where you are, in terms of your orientation, is critical, because you don’t have to explain everything, you know? They just get it. ” § “ I always [have concerns] when coming out to a new doctor – a therapist, or psychologist. ” § “ There’s homophobia [from counsellors]. Not freaking out, but that look they get on their face when they find out you’re a dyke. ” Re: Ross et al. , (2014) The Pathways Project 8

N=460 National Canadian trans research, 2015 § Respondent “Greater sensitivity to trans issues from all health care providers. As a genderqueer, non-binary person who does not intend to use hormone therapy or surgically transition, what would help me most is a greater consciousness about gender issues, along with health care professionals making fewer assumptions and just asking what my needs are (instead of assuming). ” Trans national survey, p. 8 Re: CAS Trans Final Report 2015 9

Research on shame based trauma & LGBTQ § § From infancy- adolescence –adulthood- seniors Whole self is condemned Met with indifference or disapproval Through shame – individual learn the boundaries of socially accepted behaviors § Treated in degrading manner (humiliation, self-loathing, disgrace, dishonor) § Shame schemas- PTSD and dissociation § Higher rates of suicidal attempts, suicide ideation, current suicide plans Ref: Herman, J. L (2007) Shattered Shame States and their Repair http: //lgbtdrugrehab. com/the-development-of-dialectical-behavior-therapy/ 10

The Internalization of Oppression Psychological Symptoms Anxiety Depression Suicidal ideation Anger/Frustration Psycho-social impact of oppression Oppressive socio-cultural factors Loneliness/social isolation/loss Lack of self esteem /self respect Internalized homo/bi/transphobia Shame, guilt, hopelessness Difficulty trusting others Homo/Bi/Transphobia Heterosexism/Cisgenderism Family/friends/partner rejection Discrimination at work, church, etc. Violence, poverty, racism, stigma Diaz, (2006) HIV Stigmatization among Latino Gay Men in the US. 11

Working on Shame with LGBTQ From 1 - 9 min Re: APA 12

When working with LGBTQ clients 1. Use inclusive language, correct pronouns 2. Be comfortable in your own sexuality and gender identity and gender expression 3. Be aware of subtle signals you may be sending that are not accepting or supporting of them 4. Welcome and normalize disclosure of sexuality and gender identity and gender expression 13

When working with LGBTQ clients 5. Avoid both over and under pathologizing –provide support to explore, express resilience, courage, provide authentic feedback 6. Welcome the clients chosen connections : romantic partner (s), extended family, network of friends are all potential members of your treatment team and should be welcomed into meeting as consented by the client Re: Huygen, C. (2006). Understanding the Needs of LGBTQ people living with mental illness 14

Good Gender Therapist! Avoids stigmatising pathologising terms Normalise normalise! Expects surprises, broad variability Values ambiguity and ambivalence Advocates effectively Surfaces longed-for fantasies vs hard realities Strategize collaboratively to minimize losses Knows own vulnerabilities Finds own balance re “gate-keeper” vs “transition assistant” Knows local resources Re: Source: Hershel Russell MA, MED WWW. HERSHELTORONTO. CA

Counseling Trans clients Acceptance Witnessing and mirroring Non-judgemental listening Respectful curiosity

Counseling Trans clients Careful attention to your own inner process - counter-transference issues Everyone has such strong opinions about us. . . Co-create a quiet, safe space where both therapist and client can listen to The client’s voice

LGBTQ Youth 18

Psychological impacts of homophobia N = 63 § Bio-pyscho-social factors: the stress of living in a homophobic environment § Being rejected and victimized may disrupt hormonal response in LGB persons § Increase in LGB internalized homophobia equals cortisol levels § Increase in abnormal cortisol activity also experienced increased symptoms of depression, anxiety, suicidal ideation and attempts § Suicide rates 14 x compared to heterosexual peers Benibgui, Michael, Ph. D. , CONCORDIA UNIVERSITY , 2010 19

A Canadian picture on LGBTQ youth § In Ontario, 77 % of trans youth have admitted to contemplating suicide, and 43 % attempted suicide § In Quebec, studies have shown that gay and bisexual youth are six to 16 times more likely to attempt suicide than heterosexual teens. § In B. C. , studies have reported that 18% to 42% of the LGBTQ persons assessed described attempts on their own lives. § In Alberta, it was found that 28 % of completed suicides were carried out by LGBTQ youth (38 % of queer teens also reported being physically or emotionally affected by blatant homophobia). Carroll. M. (Ph. D Candidate), 2011 Mc. Master University 20

Top 10 Health Issues for LGBTQ Youth 1. Social Isolation 2. Bullying and victimization 3. Physical and Sexual abuse 4. Homelessness 5. Depression and anxiety 6. Risk of Suicide 7. Sexual Risk Taking 8. Smoking 9. Drug and or Alcohol addiction 10. Access to hormone blockers or hormones & ID 21

Coming Out… § § § Coming out happens continually Methods vary Managing sexual orientation and gender identity Preparing for best case and worst case Finding allies Resources

Any Given Tuesday & in NYC- LGBTQ youth https: //www. youtube. com/watch? v=1 t 3 vf. QIJ-zk (6 min) https: //www. youtube. com/watch? v=w. Nv. WGu. LRen. E (3 min) The Forsaken: A Rising Number of Homeless Gay Teens Are Being Cast Out by Religious Families. Rolling Stones Magazine, Sept. 3, 2014 23

LGBTQ homeless & coming out To 3. 49 min 24

Bullying and Victimization LGBTQ youth bullied more often then peers § Nearly 3 times more likely to report missing school because they were afraid § 1. 7 times more likely to report being threatened or injured with a weapon, or otherwise assaulted as compared to their peers The University of Pittsburgh Schools of the Health Sciences, 2011 25

Physical and Sexual Abuse § Nearly three times more likely to report childhood sexual abuse, compared with other adolescents § 1. 3 times more likely to report parental physical abuse than other adolescents § A high rate of prior sexual abuse among § bisexual female (40 percent) § lesbian (32 percent) § bisexual male (24 percent) § gay male (21 percent) § and heterosexual female (17 percent) youth § compared to 5 percent of heterosexual male adolescents. The University of Pittsburgh Schools of the Health Sciences, 2011 26

Navigating the shelters: trans youth 6 min Digital Storytelling Project - Teal's Story http: //www. ilona 6. com/artsinformed. php 27

Homelessness 28

LGBTQ youth who experience rejection: § 3 times more likely to use illegal drugs § 3 times more likely to engage in unprotected sex, putting them at risk for HIV and other STI’s § 6 times more likely to have depression § 8 times more likely to have attempted suicide Ryan C, Huebner D, Diaz RM, Sanchez J. (2009) Family rejection as a predictor of negative health outcomes in white and Latino lesbian, gay, and bisexual young adults. Pediatrics Vol. 123, pp. 346– 352. 29

Tobacco and Smoking § Toronto Rainbow Tobacco Survey (2006) § LGBT youth are more likely to have ever smoked and to be current smokers § 57% from 15 -19 age group § 44% of 20 -24 age group were smokers § Toronto Rainbow Tobacco Survey (2006) – 36% vs. 19% (n= 3, 140) adult § Highest in bi men and lowest in bi women § Smoking increases the risk of blood clots in trans women who take estrogen Clear the Air campaign http: //clear-the-air. ca/about 30

N= 405 Mental health & substance use among bisexual youth in ON § Poorer health outcomes vs. heterosexuals, gays and lesbians § Severe depression (4. 5%) § Anxiety disorder ( 30. 9%) § PTSD (10. 8%) § Past yr. suicide attempts (1. 9%) § Problem drinking (31. 2%) § Polydrug use (30. 5 %) Re: Ross et. al. (2014) http: //journals. plos. org/plosone/article? id=10. 1371/journal. pone. 0101604 31

What helps For LGBTQ youth § Safe environments – at home and at school § Supportive environments – at home, school and institutions Institutional Support § Schools § Confidential Medical Care § Confidential Counseling § Culturally Competent Mental Health Services § Culturally Competent Drug and Addictions Services § Clear & Accurate Sexual Health Information § Trans Competent Clinicians 32

Sexual orientation and gender identity microaggressions in clinical settings § APA To 5. 36 https: //www. youtube. com/watch? v=FY 6 SBs. Opjck 33

Mental Health § Higher rates of mood disorders § Depression (31% Gay Bi vs. 10. 2% hetero men) § Anxiety (15% Lesbian Bi vs. 4% hetero women) § Panic attacks (18% Gay Bi vs. 4% hetero men; Cochran and Mays, 2003) § Depression/Anxiety-higher rates directly related to stress and the expectation and experience of discrimination (Dean 2000/Meyer 2003) 34

Alcohol and Drug Use Lesbian/bisexual women (Compared to heterosexual women): § More alcohol-related problems (Mc. Kirnan, 1989; Wilsnack 2008) § Heavier alcohol use (Aaron, 2001) § Greater lifetime rates of marijuana (24 -36%) (Skinner 1994, 1996), cocaine (39%) and other illicit drugs (Cochran, 2004) Gay and bisexual men (Compared to heterosexual men): § Greater lifetime use rates of cocaine (37%) (Cochran 2004), marijuana (18 -37%) (Skinner 1994), MDMA (ecstasy), methamphetamine, poppers (Stall 2005; Cochran 2004) § Alcohol use rates similar to heterosexual men (Drabble 2005) Stress of coming out, transition, depression, isolation 35

Violence and Trauma § § § Feeling personally targeted Crisis of identity/ feelings of vulnerability Self-blame; internalized homo/bi/transphobia Loss of trust (including in medical providers) Depression, stress, anxiety Community members may have internalized trauma responses § Compared with heterosexuals, the odds of being victimized for violent crimes were nearly 2 times greater for gays and lesbians and 4. 5 times greater for bisexuals (Statistics Canada, 2008) 36

Domestic Violence § In same-sex relationships, May also include: § Threats of “outing” partner § Persuading victim that leaving relationship is akin to admitting same-sex relationships are deviant § Asserting women can’t be violent (denying abuse) § Asserting men are violent and therefore domestic violence expected § Male victims may feel ashamed about fearing partner 37

Body Image, Fitness & Weight § Lesbians are twice as likely than heterosexual women to be overweight or obese (Boehmer, Bowen & Bauer, 2007) § Gay & bi men have higher prevalence of eating disorders compared to heterosexual men (Feldman, 2007); higher body dissatisfaction (Kaminski 2005) § For trans people, body image concerns relate to discomfort with gender and physical characteristics; dieting, over-exercising or self-harming may be present. RHO factsheet: Critical analysis of BMI, fat phobia, SDOH, HAES 38

Summary § § § Treat the whole person Use correct pronouns, inclusive language Learn about clients social and historical experience(s) Pay attention to your own inner process: counter-transference Be comfortable in your own sexuality, gender identity and gender expression § Understand the dynamics of oppressions and heteronormative impact on LGBTQ sense of self and validation § Do not use pathologizing or stigmatizing terms & language § Have a rainbow sticker at door, desk, room, etc. , opens communications, signifies safer space for LGBTQ discussions 39

Questions? 40

LGBTQ counselling resources including 6 languages Source: http: //www. algbtic. org/competencies. html 41

6 Training videos for clinicians on LGBTQ § Navigating Self-Disclosure of Sexual Orientation and Gender Identity with Clients § Sexual Orientation and Gender Identity Microaggressions in Clinical Settings § Working on Shame with Sexual Minority Clients § http: //www. apa. org/apags/governance/subcommittees/lgbttraining. aspx 42

The B Side http: //lgbtqhealth. ca/projects/riskresiliencebisexual. php https: //www. youtube. com/watch? v=d. DD 1 -VTC 80 w 7. 5 min 43

Resources for LGBTQ & mental health § CMHA where multiple margins intersect http: //ontario. cmha. ca/news/spring-2010 -focus-onequity/#. U_yxm_ld. WGc § BC Mental Health and Addiction ( 2010). vol. 6 (2) § Huygen, C. (2006). Understanding the Needs of Lesbian, Gay, Bisexual, and Transgender People Living With Mental Illness § Boehmer et al. (2014). Health Conditions in Younger, Middle, and Older Ages: Are There Differences by Sexual Orientation? § Meyer (2003). Prejudice, Social Stress, and Mental Health in Lesbian, Gay, and Bisexual Populations: Conceptual Issues and Research Evidence § Barbara & Chaim (2011). Asking About Sexual Orientation During Assessment for Drug and Alcohol Concerns: A Pilot Study 44

Resources for LGBTQ & mental health § Chamberland & Saewyc(2011). Stigma, Vulnerability, and Resilience: The Psychosocial Health of Sexual Minority and Gender Diverse People in Canada § CAMH –ARQ 2 (resource for working with LGBTQ and mental health and addiction) ttps: //knowledgex. camh. net/amhspecialists/Screening_Ass essment/assessment/ARQ 2/Documents/arq 2. pdf § http: //lgbtdrugrehab. com/the-development-of-dialecticalbehavior-therapy/ 45

Resources for LGBTQ & mental health § http: //www. pflagnyc. org/safeschools/tips § http: //www. familyservicetoronto. org/programs/dks/tips. html § http: //www. familyservicetoronto. org/programs/dks/selfestee m. html § http: //allpsych. com/journal/counselinggay. html § http: //www. algbtical. org/2 A%20 COUNSELING. htm § http: //www. thegenderbook. com/ § Alan Downs –shame based trauma http: //www. youtube. com/watch? v=Aj 33 c 40 f 0 -c 46

Griffin Centre for LGBTQ youth 47

LGBTQ Youth Resources § LGBT Youth Line: http: //youthline. ca/ 1 -800 -268 -9688 § Associated Youth Services of Peel: 1 -800 - 762 -8377 § Dufferin Family Services: 519 -941 -1530 x 418 § Family Services of Peel, LGBT Counselling 905 -453 -5775 § PFLAG Canada: www. pflagcanada. com § EGALE: Safe Schools Report http: //egale. ca/ § Gender Independent Children www. rainbowhealthontario. ca/lgbt. Health/about. Lgbt. Health/factsheet s. cfm#section 2 48

Supporting Our Youth (Toronto) Extensive Expertise with Diverse Communities of LGBT Youth Current Programs § Alphabet Soup § Bill 7 Award § BQY § Essence § Express/FOB § Fluid § § § Fruit Loopz Pink Ink Pride Prom Shift Trans_Fusion Crew CLICK Mentoring Program 49

Suicide prevention § http: //egale. ca/wp-content/uploads/2012/12/LGBTQ-YSPSConference-Paper. pdf § Report on Outcomes and Recommendations: LGBTQ Youth Suicide Prevention Summit http: //egale. ca/all/ysps 2012/ § KIDS Help Phoneline 1 -800 - 668 -6868 § LGBT youthline -1 -800 - 268 -YOUTH 50

Lesbian Gay Bi Trans Youth Line § Peer Help Line § Youth will turn to their peers before they come out to an adult 51

http: //www. pflagcanada. ca/en/ 52