https://www.gap-lgbtq.org/home daily 1.0 2021-11-15 https://images.squarespace-cdn.com/content/v1/5e8757eb988faa7d6ec5ad65/1585934654229-R7XRHR1YQB0KY6JSRW4B/pexels-photo-1784278.jpg Home https://images.squarespace-cdn.com/content/v1/5e8757eb988faa7d6ec5ad65/1585934472491-2PMQTI3PD46SGFXXCKO5/pexels-photo-2430945.jpg Home https://images.squarespace-cdn.com/content/v1/5e8757eb988faa7d6ec5ad65/1585934575801-BL0NNY6S8KZAHU2MMXYR/pexels-photo-1998270.jpg Home https://images.squarespace-cdn.com/content/v1/5e8757eb988faa7d6ec5ad65/1585934236904-GH7E69RSG7VKS0KUE1XO/pexels-photo-1998456.jpeg Home https://images.squarespace-cdn.com/content/v1/5e8757eb988faa7d6ec5ad65/1585934315751-0QR2B6E83W8FB4CZV2U0/pexels-photo-1215831.jpg Home https://images.squarespace-cdn.com/content/v1/5e8757eb988faa7d6ec5ad65/1585934378621-TDHJDOGFGWQQH0AIUVYZ/pexels-photo-207129.jpg Home https://images.squarespace-cdn.com/content/v1/5e8757eb988faa7d6ec5ad65/1585934823665-GNH559ETL39DVTPPTD3M/pexels-photo-3635945.jpg Home https://images.squarespace-cdn.com/content/v1/5e8757eb988faa7d6ec5ad65/1585934908301-0KAQJRQMKWMZRDBKUN2U/pexels-photo-745045.jpg Home https://images.squarespace-cdn.com/content/v1/5e8757eb988faa7d6ec5ad65/1585934726041-2QIG49FHQA07V6ONQVUS/teddy-teddy-bear-association-ill-42230.jpg Home https://images.squarespace-cdn.com/content/v1/5e8757eb988faa7d6ec5ad65/1629756217378-9I5L478L5J8EBIYCMA5B/pexels-photo-3184398.jpeg Home https://www.gap-lgbtq.org/history daily 0.75 2022-02-21 https://images.squarespace-cdn.com/content/v1/5e8757eb988faa7d6ec5ad65/1585935385868-T47YB4QVPF6VIHE74YJP/pexels-photo-2769325.jpeg History - History of LGBTQ People and Psychiatry The pathologization of same-sex sexual activity and transgender identity in Western culture is often traced to Biblical times, specifically the explicit condemnation of male homosexual behavior in the book of Leviticus. Beginning in the sixteenth century, specific laws against homosexual sexual activity were termed alternately “sodomy,” “buggery,” or broadly “unnatural acts.” The medical field began writing extensively on same-sex sexual activity in the late 19th century; German physician Karl Westphal (1833-1890) was one of the first proponents of a “congenital” model of homosexuality to be treated psychiatrically rather than with legal means. The pathologization of homosexuality was further advanced in the works of the German writer von Krafft-Ebing’s 1886 work Psychopathia Sexualis with Especial Reference to the Antipathic Sexual Instinct: A Medico-Forensic Study, which dissected same-sex attraction as a “severe manifestation of hereditary degeneration” (see “The History of Psychiatry and Homosexuality,” cited below). Krafft-Ebing’s work also contributed to the conflation of homosexuality and transgender presentations as he made no distinction between the two in his work. Many physicians in the late 19th and early 20th century conducted studies of the bodies of homosexual and transgender individuals in an attempt to outline a physical basis for homosexuality, to no avail. Psychoanalytic theory figured heavily into early modern psychiatry’s conception and treatment of male homosexuality (there is little mention in the literature of the time of transgender identity, and only a single case report related to female homosexuality; Freud, 1920). Sigmund Freud’s theories related to the development of homosexuality began to take hold early in the 20th century as well. In essence, Freud believed that male homosexuality arose from the Oedipal realization by the over-attached boy that his mother was “castrated,” leading him to seek to love others of the same sex the same way his mother loved him (see Lewes, 2009). Rather than pathologizing it, however, Freud conceptualized homosexuality as a state of arrested sexual development that was unlikely to be modifiable. Later on in the 20th century, work by Sandor Rado and colleagues contradicted Freud’s assertion that male homosexuality was a normal variant, asserting that heterosexuality was the only nonpathological developmental outcome. This line of theory led some investigators to attempt to “cure” homosexuality using conversion therapy, an unsupported and damaging practice that continues to the present day (APA, 2009 and Drescher, 1998). Homosexuality was first listed in the DSM-1 in 1952 as a “sociopathic personality disturbance,” and was later recategorized to a “sexual deviation” with the publication of the DSM-II in 1968. During this period, however, the burgeoning civil rights movement as well as expanding interest and research in human psychology began to challenge forcefully the pathologization of homosexuality. Work by the likes of Albert Kinsey and Clellan Ford asserted that homosexuality was much more common than previously thought, and a landmark 1957 study by the psychologist Evelyn Hooker found no greater presence of psychopathology in homosexual as compared to heterosexual men (Ford et al, 1951; Kinsey et al, 1948; Kinsey et al, 1953; Hooker et al., 1957). Homosexuality was officially “de-pathologized” by the American Psychiatric Association (APA) in 1973, after years of research, advocacy, and protest at APA meetings. (This included the appearance at the 1972 APA meeting of “Dr. Anonymous” (AKA John Fryer), a psychiatrist who attended in “"a Nixon mask, a fright wig, an oversized tuxedo and used a voice-distorting microphone so as not to be recognized" when he spoke on a panel about his experiences of discrimination working as a gay psychiatrist (Bayer, 1981; Drescher et al, 2007; Drescher, 2015; Scasta et al, 2002).) De-pathologization of transgender presentations would come much later, with the ICD-11 formally removing the diagnosis of “gender incongruence” in 2019. CME Question: Under what behavioral category did the DSM-II, published in 1968, define homosexuality? Sociopathic personality disturbance Normal variant of human sexuality Sexual deviation Representation of unconscious longing for the father Answer: 3 https://www.gap-lgbtq.org/terminology daily 0.75 2022-02-21 https://images.squarespace-cdn.com/content/v1/5e8757eb988faa7d6ec5ad65/1585935339650-2F7N1MHNIUPILN6VRSEE/pexels-photo-1287194.jpeg Terminology - Terminology Language surrounding lesbian, gay, bisexual, transgender, and queer (LGBTQ) identities is constantly evolving. However, there are some basic terms that may aid in communication with patients and clients. The term sex is generally used to refer to the physical attributes of a person at birth, including their chromosomal makeup, internal and external genitalia, and reproductive organs. Most people consider sex to be binary – either male or female. However, depending on what definition is used, studies show that up to 2% of people are born intersex, meaning that their physical bodies differ in some way from stereotypical male or female bodies (Blackless et al., 2000). Examples of intersex conditions include congenital adrenal hyperplasia, where an increased level of androgens leads to masculinization of the genitals in a person with XX chromosomes, and androgen insensitivity, where the androgen receptors are partially or completely unable to respond to androgens in a person with XY chromosomes. Gender identity refers to a person’s self-identified gender, as distinct from their sex assigned at birth. While the majority of people assigned male at birth identify as men and the majority of people assigned female at birth identify as women, studies show that 0.6% of the United States population, approximately 1.4 million people, identify as transgender (Flores et al., 2016). Transgender, or trans for short, is an umbrella term that describes a diverse group of people who have in common that their gender is different than that which they were assigned. Conversely, cisgender, or cis, describes people for whom there is no discrepancy between their gender identity and sex assigned at birth. Most intersex people are assigned a gender at birth and some undergo early surgeries to match their bodies to their assigned genders, although this practice has been decreasing in frequency as intersex advocates work to convince providers and new parents to delay any non-emergency surgeries until the affected individual can participate in the decision making. . Helpful resources for intersex people and their families include InterACT: Advocates for Intersex Youth and AIS-DSD Support Group. Some intersex people come to understand their gender identities as different from those they were assigned at birth. They may transition from one gender to another in a similar fashion to transgender people. However, they may or may not consider themselves to fall under the trans umbrella. Trans men are assigned a female sex at birth and identify as male (sometimes referred to as female-to-male or FTM), whereas trans women are assigned a male sex at birth and identify as female (sometimes referred to as male-to-female or MTF). The abbreviations FTM and MTF are not generally used as self-identities, but may be helpful to include in medical charts to make a patient’s identity clear to colleagues. Others who may consider themselves as falling under the trans umbrella include people who identify as genderqueer or nonbinary. The gender binary refers to the system of classification that separates people into binary genders – male and female. Some people consider themselves to be between genders, to have aspects of both genders, or to be nongendered. The phrase gender nonconforming is sometimes used as an umbrella term to describe a diverse group that may include transgender but also genderqueer, nonbinary , or even cisgender people. As opposed to gender identity, which describes a person’s internal self-identified gender, gender nonconforming typically describes the external appearance or behaviors that may be seen as being outside the traditional norms for their assigned gender. For example, a person may identify as a cisgender male but may consider themselves as presenting as gender nonconforming due to adopting clothing or engaging in activities typically not associated with cisgender male norms. Children may also be referred to as gender nonconforming, especially when it is not yet clear how a child identifies on the gender spectrum. Other terms used to describe children include gender variant and gender creative. Whereas gender identity refers to a person’s sense of their own gender, sexual orientation refers to the gender or genders of those to whom a person is attracted. Heterosexual and homosexual are more academic terms that some find offensive when used in a personal setting. Common terms for sexual orientation in colloquial language include: gay (attracted to people of the same gender), straight (attracted to people of another gender), and bisexual (attracted to both men and women). Some women who are attracted to other women describe themselves as lesbians, while others use the more generic term gay. Researchers may use the terms androphilic (refers to a person who is attracted to men) and gynephilic (refers to a person who is attracted to women), though these terms are not commonly used colloquially. Recently, newer terms for sexual orientation identities have emerged. Pansexual refers to someone sexually attracted to people of multiple genders. People who identify as pansexual sometimes feel that the term bisexual is limiting, as it may not convey an openness to attraction to transgender or nonbinary people, although many people who identify as bisexual feel that this term can be used similarly to pansexual and can indicate attraction to multiple genders. Asexual individuals identify as not experiencing sexual attraction, though they may choose to form intimate or romantic relationships. Queer is a term often used to describe non-straight sexual orientations and non-cisgender gender identities, and those who identify as queer may vary considerably in their attractions and in their gender identities. Queer is a word that was initially derogatory and has been reclaimed by LGBTQ communities, so it may also have political connotations. Someone who identifies as queer may be expressing an anti-establishment stance toward heterosexism, the system that privileges heterosexual people, and homophobia, the system that discriminates against non-heterosexual people. It is important to note that transgender people can have any sexual orientation, and that sexual orientation terminology, when used to refer to transgender people, is based on the person’s self-identified gender. A transgender woman, for example, who is attracted to other women, may describe herself as a lesbian. Some researchers do not use self-identified gender to describe participants. Many people find it offensive when their sexual orientation is defined by researchers in reference to their sex assigned at birth. One solution for some researchers has been to use the terms androphilic or gynephilic to avoid confusion. . A distinction should be made between self-identified sexual orientation (or sexual orientation identity) and sexual behavior. Researchers studying LGBTQ health may use terms such as men who have sex with men (MSM). These terms refer to behaviors and not identities. Some men who have sex with men do not identify as gay or bisexual. Primary care providers should have open discussions with their patients about the kinds of sex they are having and which body parts are involved in order to screen for cancers and sexually transmitted diseases. Psychiatrists may want to explore with their patients how they came to identify with the terms they use to describe themselves. The terminology introduced above is basic, and there are many more nuanced ways that people describe their sexual orientations and gender identities. The most respectful way to approach understanding a person’s gender identity or sexual orientation is to ask them. This may seem daunting, especially if it is a new practice or an individual’s gender identity or sexual orientation is not accurately reflected in the electronic medical record, but most people appreciate being asked rather than assumptions being made. When meeting a transgender person for the first time, it is typical to ask about name and pronouns. Asking what name someone uses is more simple, and can be phrased, “What name would you like me to use when referring to you?” Asking about pronouns can also be straightforward, and can be phrased, “What pronouns would you like me to use when referring to you?” Most transgender people use the pronouns he/him or she/her, but nonbinary individuals may use the plural pronouns they/them, or a different pronoun altogether. While it can be hard at first to learn to use new pronouns, it becomes easier with time. An example of a sentence using the pronoun they to refer to one person is: “They called about their labs and I suggested they check back tomorrow because we hadn’t received them yet.” CME Question: Which of the following is true? 1 in 10,000 people identifies as transgender All men who have sex with men identify as gay or bisexual. Transgender men are those who are assigned male at birth and identify as female. Transgender men are those who are assigned female at birth and identify as male. Answer: 4 https://www.gap-lgbtq.org/mood-disorders daily 0.75 2022-02-21 https://images.squarespace-cdn.com/content/v1/5e8757eb988faa7d6ec5ad65/1585935419112-8NNN2FKZSOXI5O8QNJGV/pexels-photo-1666779.jpeg Mood Disorders - Mood Disorders LGBTQ people are at higher risk for mood and anxiety disorders than the general population. A 2008 systematic review of 25 studies found that LGBTQ people were 1.5 times as likely to experience depression and 2.5 times as likely to have attempted suicide as their heterosexual counterparts (King et al., 2008). There is evidence that stigmatization of minority sexual identities may contribute to the formation and propagation of mood disorders, as LGBTQ people living openly and those who are in a legally sanctioned same-sex relationship have been shown to have levels of depression and anxiety similar to their heterosexual counterparts. Concerns about disclosure and stigmatization are particularly acute in the pediatric and young adult LGBTQ population, with one study finding that that cohort is up to 4 times as likely to attempt suicide as their heterosexual counterparts (Kann et al., 2011). LGBTQ populations are also at much higher risk for trauma in the form of physical and sexual abuse, both in the form of hate crimes and intimate partner violence (Lee et al., 2016). Underlying the importance that stigmatization plays in the development and propagation of mood and trauma disorders and resultant suicidal ideation and behavior in the LGBTQ population is a 2010 study that showed that family acceptance and support of a patient’s sexual and gender identity is one of the most important protective factors for young LGBTQ adults (Ryan et al., 2010). While disclosure and acceptance have been shown to be associated with lower levels of depression and suicidality in LGBTQ patients, the situation is complicated by the fact that some patients who disclose their sexuality still face discrimination and poor treatment in social and even medical settings (Husain-Krautter et al., 2017). Indeed, disclosure of minority sexual and/or gender identities during adolescence has been associated with positive outcomes such as lower rates of mood and anxiety disorders as well as achievement of socioemotional developmental milestones earlier, but also in some studies increased incidence of trauma inflicted as a result of the person’s sexual orientation and gender identity. Central to the treatment of the LGBTQ patient presenting with a mood, anxiety, or traumatic stress disorder is asking about, and accepting, the patient’s sexual and gender identity. The knowledgeable clinician will be able to integrate what he or she knows about the rest of the patient’s history with considerations about what role sexual and/or gender identity might be playing in influencing the trajectory of the presentation. CME Question: Disclosure of LGBTQ sexual identity is associated with: Lower rates of inflicted trauma Lower rates of mood and anxiety disorders Decreased rates of discrimination by the medical establishment All of the above Answer: 2 https://www.gap-lgbtq.org/substance-use daily 0.75 2022-02-21 https://images.squarespace-cdn.com/content/v1/5e8757eb988faa7d6ec5ad65/1585935469345-17JBS41Z6E0RL9OV0UFE/pexels-photo-1028637.jpeg Substance Use - Substance Use Anecdotal evidence and research findings have long pointed to an increased rate of substance use disorders in LGBTQ populations. A large population-level study in 2015 found that those who self-defined as sexual minorities (4.1% of the surveyed population) were more than twice as likely to have used any illicit substance in the last year as compared to their sexual majority counterparts (Medley et al., 2016). They were also more likely to have smoked cigarettes (though less likely to have smoked daily) and more likely to have used alcohol and to have engaged in binge drinking over the past year. The issue of substance use disorders is especially acute in the LGBTQ adolescent population, with a 2008 meta-analysis of available studies showing an odds ratio of 2.89 for substance abuse in the LGBTQ adolescent population as compared to their heterosexual counterparts (Marshall et al., 2008). The reasons behind increased rates of substance use disorders in LGBTQ populations are not fully understood, but minority stress is thought to play a large role in the onset and continuation of problematic substance use in these populations. One meta-analysis of substance use in LGBTQ youth found that the largest risk factors for unhealthy substance use patterns in the populations studied were victimization, lack of supportive environments, psychological stress, internalizing/externalizing problem behavior, negative disclosure reactions, and unstable housing status (Goldbach et al., 2014). As discussed elsewhere in this review, LGBTQ populations also experience higher rates of certain mental illnesses, including depression and trauma-related disorders, than non-minority populations. Mood disorders and eating disorders are often comorbid with substance abuse (SAMHSA, 2012). In essence, LGBTQ people face the same challenges and stressors throughout development as everyone else but additionally navigate stigma, shame, and isolation, which further increase the risk of substance abuse (SAMHSA, 2012). Numerous studies and national surveys have also illustrated high rates of trauma among LGBTQ populations. For example, national data from the CDC’s Youth Risk Behavior Survey showed much higher rates of experiencing physical violence, sexual violence, and harassment among sexual minority (LGB) youth as compared to heterosexual-identified peers (Kann et al., 2016). Lesbian, gay, and bisexual-identified teenagers also reported much higher rates of tobacco, alcohol, and drug use as compared with heterosexual peers, and they also reported using alcohol and/or drugs before sex much more frequently than non-minority peers (Kann et al., 2016). Gender non-conforming and transgender youth similarly face high rates of violence, victimization, and discrimination (Institute of Medicine, 2011). LGBTQ youth are also known to experience alarmingly high rates of homelessness, which may further increase exposure to additional trauma and substance use. Forty percent of homeless youth served by national agencies report LGBTQ identities (Durso, 2012). Prevention strategies and treatment options are essential to curb the high levels of substance abuse in LGBTQ communities. Unfortunately, targeted substance abuse programs are few and far between. In one study, approximately 12% of substance abuse treatment programs reported to the Substance Abuse and Mental Health Services Administration (SAMHSA) that they offered LGBTQ-specific programming, but when the researchers reached out to the programs, only 7.4% of those that claimed to have specific programming could identify a service tailored to the needs of LGBTQ clients (Cochran, Peavy, & Robohm, 2007). Those seeking treatment for substance abuse issues are often in a vulnerable state, vacillating between a desire to wrestle some control over their addiction and being pulled back to the addictive behaviors. LGBTQ people in programs that do not recognize their unique struggles may feel misunderstood or unable to approach the work honestly. They may be the targets of discrimination and even violence in treatment settings. A study of transgender people with substance abuse issues revealed that 60% were required to sleep and shower in facilities inconsistent with their gender identities. Many were prohibited by staff from talking about trans issues in the treatment setting. In fact, participants reported experiencing more transphobic events involving staff than other clients (Lombardi, 2008). Nevertheless, programs specifically designed for LGBTQ populations do exist. An example is the Crystal Clear Project at the Addiction Institute in New York City, which focuses on crystal meth abuse in MSM. The program provides an environment where it is explicitly acknowledged that crystal meth and sex are often overlapping in MSM communities (Mount Sinai West). Self-help 12-step programs such as Crystal Meth Anonymous also focus on MSMs, and provide similar spaces where LGBTQ people can be open about their reasons for substance use within a supportive community. CME Question: Which of the following does not contribute to substance use disorders in LGBTQ patients? Higher rates of trauma Robust access to substance treatment programs Higher rates of psychological stress Fear of violence and discrimination in treatment settings Answer: 2 https://www.gap-lgbtq.org/child-and-adolescent daily 0.75 2022-02-21 https://images.squarespace-cdn.com/content/v1/5e8757eb988faa7d6ec5ad65/1585935499122-KN40AC5UE9J3NSTGAWUN/pexels-photo-3727647.jpeg Child and Adolescent - Child and Adolescent An increasing number of youths identify as LGBTQ. Estimates vary but are as high as 27% in a 2017 survey of California teenagers (William’s Institute, 2017). It is increasingly important for child and adolescent clinicians to understand the unique characteristics and needs of gender and sexual minority youth. LGBTQ youths, like adults, display notable health disparities compared to their heterosexual and cisgender counterparts. Numerous studies have documented increased rates of suicidal thoughts, suicide attempts, and depressive symptoms among sexual minority youth. Transgender youth populations have not been studied to the same degree, though existing data also suggest significant disparities in negative mental health outcomes. In one large study, investigators found that teenagers who identified as sexual minorities experienced more than two times the odds of suicidal ideation and suicide attempts compared to heterosexual peers (Zhao et al., 2010). In the most recent Youth Risk Behavior Survey (YRBS), a survey conducted annually among 9th to 12th grade students by the Centers for Disease Control and Prevention (CDC), LGB youths reported high rates of suicidal thoughts (40%), and 60% of LGB youths surveyed reported feeling sad or hopeless enough to stop doing some of their usual activities (Kann et al., 2016). The overall prevalence of suicide attempts resulting in contact with a medical professional was 9.4% for LGB students, versus 2.0% for heterosexual students (Kann et al., 2016). Though fewer studies exist on transgender youth, national survey data are very alarming: a stunning 40% of adult respondents in the 2015 US Transgender Survey (USTS) reported at least one lifetime suicide attempt – 9 times the rate of the general US population – with 92% reporting that the attempt(s) occurred prior to age 25 (James et al., 2016). Community studies reflect similar mental health outcomes for transgender youth (see, for example, Reisner et al., 2015). It is no surprise that LGBTQ youths experience elevated rates of depression and suicidality given the well-documented adversity they face, including high rates of emotional, physical, and sexual trauma (Kosciw et al., 2012; Friedman et al., 2011). Almost 18% of LGB student responders in the YRBS reported at least one incident of being physically forced to have non-consensual sexual intercourse, and a similar number reported physical violence within the last year (Kann et al., 2016). Of note, students who identified as “questioning,” or unsure of their sexuality, also reported higher rates of rape and physical violence than heterosexual peers (Kann et al., 2016). A well-known Institute of Medicine report also noted that gender non-conforming youth experienced elevated levels of violence, victimization, and harassment, as well as high levels of discrimination (Institute of Medicine, 2011). LGBTQ youths also face much higher rates of homelessness and substance use. A study by the Williams Institute revealed that 40% of homeless youth served in national agencies identified as LGBTQ (Durso, 2012). These youth most frequently lost their homes due to family rejection of their sexual orientation and/or gender identity (Durso, 2012). Though accurate statistics are difficult to determine due to the overall lack of data, LGBTQ youths have typically reported higher rates of alcohol, tobacco, and other substance use, especially among urban youth (Broderick and Clark, 2013). The marked disparities in mental health outcomes seen in LGBTQ populations are often explained in academic literature by the minority stress theory, which asserts that they are the result of chronic stress related to experiences of stigma and discrimination on the basis of identity (Cochran, 2001). The minority stress framework stems from social stress theory and reflects earlier research on psychological outcomes associated with discrimination and stigma (e.g., Markowitz, 1998). Numerous well-known studies also examine the impact of childhood traumatic stress more broadly, showing clear associations between early adverse events and worse mental and physical health outcomes in adulthood (e.g., Felitti et al., 1998). There is great interest among mental health clinicians in mitigating stressors to improve mental health outcomes. However, specific treatment protocols around gender-related care for youths presenting with gender-related stressors and/or mental health symptoms are limited. Numerous reputable medical societies, including the American Psychiatric Association, the American Academy of Pediatrics, and the American Psychological Association, recommend nondiscriminatory, supportive interventions that recognize variations in gender identity and sexuality as natural outcomes in human development. No credible scientific evidence has demonstrated that individuals with diverse sexual and gender identities have an inherent predisposition for psychopathology (Bailey, Vasey, Diamond, & Breedlove, 2016). Child and adolescent clinicians play an increasing role in guiding families through gender exploration and identity consolidation. Psychoeducation about gender and sexuality development across human life stages can help families better understand a youth’s feelings and behaviors. Very young children generally do not have the cognitive ability to understand gender, but they still pick up cues from their parents and environment that may shape their later understanding about gender. It is generally accepted that around ages 3-4 children begin to better understand gender identity (Kuhn, Nash, & Brucken, 1978; Martin, Ruble, & Szkrybalo, 2004; Halim & Ruble, 2010). Reasoning at this age usually remains quite rigid and rule-bound. According to psychologist Lawrence Kohlberg, who generally based his theories of cognitive development upon the earlier work of Jean Piaget, children develop “gender constancy” through a series of stages. Preschool children can “gender label,” or identify a gender based on concrete attributes. Children then achieve “gender stability,” where they begin to understand that gender is stable over time. Around ages 5-6 years old (school age), most children achieve “gender consistency,” the ability to understand that gender identity is fixed despite changes in appearance or activities (American Psychological Association). Rigidity about gender typically declines in later childhood and, especially, in adolescence. Parents’ responses to youths’ gender identities and sexualities vary widely, with some highly accepting, some highly rejecting, and many expressing ambivalence (Ryan, 2004; Ryan & Chen-Hayes, 2013). Clinicians can help family members identify their beliefs about gender and sexuality and develop insight into how they influence their thinking about the youth’s identity. In working with families, it is also helpful to teach parents and caregivers ways to express acceptance for their child as they are. Numerous studies have shown that family rejection is a significant risk factor for adverse mental health outcomes in LGBTQ youth, including depression, suicidality, substance use, and other risk behaviors (Ryan, Huebner, Diaz, & Sanchez, 2009). On the other hand, family support has been shown to be protective against suicidal behaviors in LGBTQ youth (Eisenberg & Resnick, 2006; Mustanski & Liu, 2013; Ryan et al., 2010). As a clinician, it is important to understand that most families are motivated to provide care and support to their child. Some families are not deliberately rejecting but rather do not understand gender diversity or how to communicate about this topic. Research has shown that even rejecting families can become less rejecting over time and that providing resources and accurate information can help families better support their children (Mustanki, 2013; Ryan et al., 2010). It is worth noting that conversion therapy — a treatment aimed at changing LGBTQ individuals’ gender identity and/or sexuality — is still legal in most states across the US and continues to be practiced. The Williams Institute estimates that almost 700,000 US adults have received conversion therapy, with half of them receiving it before age 18 (Mallory, Brown, and Conron, 2018). Currently, 20 states and the District of Columbia have laws banning conversion therapy for minors (Movement Advancement Project, 2020). There is no credible or mainstream medical or mental health association that supports the use of conversion therapy. Conversion therapy has been repeatedly associated with poor mental health outcomes, including suicidality (Flentje et al, 2013; Weiss et al., 2010; Shidlo & Schroeder, 2002; James et al., 2016). Numerous mental health associations, representing thousands of providers, oppose the use of conversion therapy; these include the American Psychological Association (2009), the American Psychiatric Association (2018), the American Academy of Child and Adolescent Psychiatry (2018), and the LGBT Committee of the Group for Advancement of Psychiatry (Drescher, 2016). CME Question: Which of the following is not a risk factor for suicide among LGBTQ youth? (a) family rejection (b) identification as transgender or gender non-conforming (c) traumatic experiences (d) exploration of gender at a young age Answer: D https://www.gap-lgbtq.org/medical-treatments daily 0.75 2022-02-21 https://images.squarespace-cdn.com/content/v1/5e8757eb988faa7d6ec5ad65/1585935550571-QGA411VPJZHJKVOB8VT5/pexels-photo-1882309.jpeg Medical Treatments - Medical Treatments Though psychiatrists are not primary medical providers, there are some medical topics with which they should be familiar to have a complete picture of the health of LGBTQ populations. Discussions of health-related topics in men who have sex with men (MSM) and transgender women typically emphasize the prevention and treatment of sexually transmitted infections (STIs) such as HIV and Hepatitis B. While MSMs face a number of other health issues, including increased mental health symptoms and unique patterns of substance abuse, STIs do play a large role in primary health care for this population, and psychiatrists should be aware of advances in this field. In addition, STIs can affect cancer risk, and MSM are at increased risk of penile and anal cancers caused by the human papilloma virus (HPV) (Van Aar et al., 2013). Health providers have typically learned about post-exposure prophylaxis (PEP) as it pertains to needle sticks, sexual assaults, or unprotected sex, but may be less familiar with pre-exposure prophylaxis (PrEP). A once daily pill (brand name: Truvada, generic name: tenofovir/emtricitabine) is now being used as HIV prevention in at-risk populations. Truvada is well tolerated and highly effective in preventing HIV seroconversion (Spinner et al., 2016). In one study of targeted PrEP introduction into a population of 3700 high risk MSM, the incidence rate of new HIV infection in the year following PrEP use was lowered by 25% compared to the year prior to PrEP introduction (Grulich, 2018). HIV itself can have neuropsychiatric effects. The term used to describe these is HIV-Associated neurocognitive disorder (HAND). While access to anti-retroviral medications can prevent AIDS dementia and AIDS mania, even those with decreased viral loads and higher CD4 counts may, over time, experience neurocognitive impairment, likely due to the inability of current HIV medications to successfully protect the nervous system from the effects of the virus (Clifford & Ances, 2013). Psychiatrists treating people on HIV medications should research the side effects and possible drug interactions. Some HIV medications have psychiatric side effects (Treisman & Soudry, 2016) and some are well-known to interact with other medications, including psychotropic medications. Ritonavir, for example, is specifically used for the purpose of boosting the efficacy of other HIV treatments through inhibition of CYP3A4 (Larson et al., 2014). However, psychiatric medications such as benzodiazepines, sertraline, venlafaxine, mirtazapine, and haloperidol are also broken down by CYP3A4, and concurrent use with ritonavir should be monitored closely (English et al., 2012). The health concerns of self-identified lesbians, bisexual women, and queer women (also sometimes called sexual minority women) are often overlooked. However, sexual minority women experience unique health challenges. They are more likely than heterosexual women to be overweight or obese, which can lead to other health problems (GLMA, 2001). They also drink more heavily than other women and engage less with the health care system, undergoing fewer routine physical exams, pap smears for cervical cancer, and mammograms for breast cancer (Roberts et al., 2004). Discrimination in health care settings contributes to these disparities in health care utilization, suggesting that improved health provider competency in LGBTQ care could improve outcomes (Johnson et al., 2016). Trans people may interact with the health care system as part of the physical transition process. Not all trans people desire physical transition (hormones, surgeries), although many do. Interventions can be expensive, and even those who are interested in physical transition may not be able to afford it. Nonbinary or genderqueer people may be interested in interventions that create a more androgynous look. Many health insurance companies explicitly exclude transition-related care. Some even make it difficult for trans people to obtain routine care. Trans men, for example, may not be covered for pap smears despite retaining a cervix. In terms of private insurance, on a federal level, the Patient Protection and Affordable Care Act, often called the Affordable Care Act (ACA) or “Obamacare” prohibits discrimination based on gender identity by health plans receiving federal funding or that are part of exchanges. Some private insurance companies can continue to discriminate, but many cannot (NCTE, Healthcare). On a state level, 19 states and the District of Columbia outlaw the exclusion of transition-related care by private insurance companies, but this leaves 31 states that do permit exclusion (MAP, Healthcare laws and policies). Government-sponsored health care programs differ somewhat from private insurance. As of 2014, Medicare now covers both hormone therapy and some surgeries for transgender people (NCTE, Medicare). However, many surgeons do not accept Medicare because it does not pay well. Medicaid, which generally pays even less, has separate rules because it is a state/federal partnership. Thirteen states and the District of Columbia have Medicaid programs that cover at least some transition-related care, 22 states have no specific policy, and 15 explicitly exclude transition-related care (MAP, Healthcare laws and policies). A Federal Lawsuit has been lodged against a managed care company accusing it of not following Federal parity guidelines. (https://www.nytimes.com/2019/03/05/health/unitedhealth-mental-health-parity.html) Hormone treatment for transgender people is generally very straightforward and can be done by primary care providers without the assistance of endocrinology unless there are complicating medical issues. The Endocrine Society publishes guidelines for hormone therapy in trans people, and these are freely available online (Hembree et al., 2017). Trans men typically take testosterone, usually injected approximately every two weeks. Many transgender men, within 2 years or so of starting testosterone, are read as male in social settings. Testosterone increases muscle mass, as well as body and facial hair, deepens the voice, leads to cessation of menses, and causes the clitoris/phallus to grow. Many of these changes are irreversible. There are also often unwanted side effects of testosterone, such as acne and male pattern baldness. Additionally, the vaginal lining can atrophy, causing pain if the man chooses to use this body part for sex. (Of note: It can be helpful to ask trans people how they would like you to refer to their body parts, as some prefer other terms to traditional anatomical terms. For example, some trans men call the vagina their “front hole.”) Lab monitoring while on testosterone is relatively basic, and includes hemoglobin/hemtocrit (for polycythemia), liver function tests (for transaminitis), and testosterone level (can be helpful to ensure it is within normal range if a client is not experiencing desired effects). There are very few absolute contraindications to testosterone use, and few drug interactions (Gorton & Erickson-Schroth, 2017). Trans women typically take estrogen (injected, patch, or pill), often alongside an androgen-blocker such as spironolactone. Physical changes from estrogen and spironolactone include skin softening, female-typical fat distribution, and loss of muscle mass. Unlike testosterone, feminizing regimens do not typically, by themselves, allow a person to be read as their desired gender in social situations. An already deep voice does not change, and masculine features such as the adam’s apple and facial hair remain. Lab monitoring of feminizing hormones includes estrogen level, liver function tests (for transaminitis from estrogen), and potassium (for hyperkalemia from spironolactone). Estrogen should be used with caution in those who are at increased risk for blood clots. However, a history of a DVT or PE does not necessarily preclude the possibility of taking estrogen as long as the person is engaged in regular medical care (Wesp & Deutsch, 2017). Two important drug interactions for psychiatrists to be aware of in their patients taking feminizing hormones are between lithium and spironolactone (spironolactone can cause an increase in lithium levels, leading to toxicity) and between lamotrigine and estrogen (estrogen can decrease lamotrigine levels, so lamotrigine dose may need to be increased). Psychiatrists are often interested in the mental health effects of hormones. Outpatient practitioners may wonder whether estrogen is causing a client to be more depressed or tearful, or inpatient/ER practitioners may wonder if testosterone is contributing to mania or psychosis. There is no evidence that hormones, when taken in prescribed doses, lead to depression, mania, or psychosis. There are some people who use “street hormones” (obtained outside of prescriptions) who may experience side effects. They may use street hormones because they cannot afford to see health providers, or because they have had bad experiences in the health care setting. Clients on prescribed hormone regimens prior to entering an inpatient unit should be continued on these medications, as it can affect both emotional and physical health to stop them abruptly, and can damage the therapeutic alliance. One well-known effect of testosterone is an increase in libido. Not all trans men experience this change, but many do (Gorton & Erickson-Schroth, 2017). Feminizing hormones have more complicated effects on libido and sexuality. Some trans women report a decrease in libido when starting these medications, while others say that beginning their transition makes them more comfortable with themselves and more interested in sexual relationships (Schulman & Erickson-Schroth, 2017). Most importantly, research from multiple studies shows that hormone treatment increases quality of life and decreases depression and anxiety (White Hughto & Reisner, 2016). The details of surgeries for transgender clients are beyond the scope of this review, but important to note is that surgery is a very individual choice, and is often based on expected outcome and financial access. The most common surgery for transgender men is “top surgery” (mastectomy). Many trans men do not have genital surgery (options include the very expensive, multi-step phalloplasty, as well as metoidioplasty, which is an extension of the clitoris/phallus by cutting the suspensory ligament). Feminizing surgeries include breast augmentations, bottom surgery (vaginoplasty), and facial feminization surgeries. Psychiatrists are more likely to be involved in the surgery process than the hormone therapy process, as hormones are now commonly prescribed by primary care through an informed consent model, while surgeons generally require at least one letter from a mental health provider and sometimes two. This can put psychiatrists in the role of “gatekeepers” and disrupt the therapeutic relationship. Psychiatrists working with trans clients who desire surgeries may want to do further reading about how to balance their conflicting roles and support their clients. In general, an evaluation for surgery closely approximates any other informed consent process, and psychiatrists should focus on determining decision-making capacity. There are numerous other interventions trans people may undergo as part of the physical transition process aside from hormones and surgeries. For example, trans women may have electrolysis to remove facial hair. This process is expensive and not covered by insurance but can be extremely helpful in allowing a person to be read as their desired gender. Some trans people, most commonly trans women without access to surgeries, may also use silicone injections (“pumping”), often performed by unlicensed providers, to shape their bodies. Silicone injection carries with it serious risks such as cellulitis, necrosis, migration of silicone, and pulmonary embolus (Murariu et al., 2015). As part of the informed consent process when starting hormones or having surgeries, medical providers should also discuss with trans clients the effects these interventions may have on their fertility. The effects of surgeries on fertility depends on the anatomy. Hormones can be more complicated. Although not guaranteed, trans men may be able to stop testosterone and restart ovulation. There are numerous cases of trans men who have previously been on testosterone giving birth (Light, A., 2014). Testosterone is known to cause birth defects, so trans men engaging in sex where they have the possibility of becoming pregnant should be advised to use effective birth control (Gorton & Erickson-Schroth, 2017). Trans women starting feminizing hormones are generally advised to bank sperm first if they have any desire to have biological children. This is because feminizing hormones can lead to irreversible infertility. CME Question: Which of the following is true about the physical health of LGBTQ people? Sexual minority women are more likely than heterosexual women to engage in routine primary health care. Hormones prescribed to transgender people for transition can lead to psychosis and mania. Pre-exposure prophylaxis (PrEP) is well tolerated and highly effective in preventing HIV seroconversion Insurance companies typically cover all transition-related health care as long as the patient has a diagnosis of gender dysphoria. Answer: 3 https://www.gap-lgbtq.org/trauma daily 0.75 2022-02-21 https://images.squarespace-cdn.com/content/v1/5e8757eb988faa7d6ec5ad65/1585935583028-UDI6Q61KCMECJ7L5O0V1/pexels-photo-3040493.jpeg Trauma - Trauma and Resilience Resilience is generally defined as the process of “adapting well in the face of trauma, tragedy, threats, or significant sources or stress” (American Psychological Association, 2018). In simpler terms, resilience describes bouncing back from stressful and/or traumatic experiences. There is ongoing debate about the utility of resilience as a scientific construct, variations in different domains of functioning involved in resilience, and the stability of resilience over time (Luthar, Cicchetti, and Becker, 2000). Furthermore, resilience is a challenging concept to operationalize in research, and the approach varies by investigator, though most focus on protective factors and processes. Resilience researchers have examined numerous populations and sources of adversity and traumas, though research focused specifically on LGBTQ populations remains relatively limited. Early on, investigators noticed that some people maintain good mental health despite facing severe adversity, while others do not. This pattern of mental health outcomes has been observed across many populations and with many types of adversity (Bonanno, Westphal & Mancini, 2011; Boden & McLeod, 2015; Chang et al., 2015). Resilience researchers have generally focused on children thought to have a high risk of psychopathology due to their genes or life experiences, including those with serious medical conditions and disabilities and children from urban school settings. Psychologists Norman Garmezy and Ann Masten showed that youths who demonstrate resilience turn out much like their successful peers who have faced less adversity over time (2012). In their studies, high-quality relationships with parents and other adults, as well as good cognitive and social-emotional skills, were protective. Other studies have similarly suggested that close relationships with supportive adults—family members and others in the community—as well as effective schooling increase resilience (Luthar, Cicchetti, and Becker, 2000). Current health research focuses on ways to improve the mechanisms that protect people against stress (Kalisch et al, 2017). Masten’s model of resilience is particularly helpful in conceptualizing stressors and trauma experienced by LGBTQ populations, which are known to be at high risk of violence, stigma, and other forms of severe adversity, in addition to the usual challenges faced throughout life. Numerous studies and surveys have established that LGBTQ youth experience elevated levels of violence, victimization, and harassment, as well as high levels of discrimination (Institute of Medicine, 2011). Traumatic exposures can increase the risk of poor mental health outcomes, as well as health, academic performance, and coping issues (Bethell et al. 2014). As clinicians, it is important to identify and address trauma and stressors affecting our patients, while also providing guidance for improving social relationships and supportive activities. Studies on LGBTQ youth have shown that family support is protective against suicidal behaviors (Eisenburg & Resnick, 2006, Mustanski & Liu, 2013, Ryan et al., 2010), while family rejection is a strong risk factor for depression, suicidality, substance use, and other risk behaviors (Ryan, 2009). Gender diverse youth with support have better mental health outcomes (SAMHSA, 2014). As clinicians, we may wish to engage families in care, with the goal of helping families become more accepting and validating over time. Helping patients connect with a positive role model and positive activities through school or the community is also advisable, especially if families do not foster a supportive environment. CME Question: Resilience researchers have shown that which of the following factors mitigate experienced adversity? (a) strong cognitive skills (b) quality relationships with parent(s) (c) experiencing stress early in life (d) both a and b Answer: D https://www.gap-lgbtq.org/psychotherapy daily 0.75 2022-02-21 https://images.squarespace-cdn.com/content/v1/5e8757eb988faa7d6ec5ad65/1585935634230-AAYLQPETTD4OODSG43V9/pexels-photo-236215.jpeg Psychotherapy - Psychotherapy In many ways, conducting effective psychotherapy with an LGBTQ patient requires skills that a psychiatric practitioner uses with every patient: empathic listening, reflection on the patient’s words, affect, and the transference/countertransference, as well as the appropriate psychotherapeutic intervention. In other ways, the therapist must adapt his or her approach to tailor it to the needs of the LGBTQ identity of the patient. One overarching approach to psychotherapy with LGBTQ patients is called LGBT Affirmative therapy. This therapeutic approach advocates creating an open, welcoming, and non-judgmental environment as a basic frame for therapy. An LGBT affirmative therapist is expected to actively examine the internalized biases that he/she/they hold regarding minority sexual orientations and gender identities so that they can be more aware of unconscious countertransferential reactions (Stevenson, n.d.). Affirmative psychotherapy also calls for ensuring that the office space is a welcoming environment, with LGBTQ-friendly reading materials and forms that allow the patient to specify their preferred gender and pronouns. Maintaining a welcoming and affirming stance should not lead to the therapist encouraging the patient to prematurely come out. Many sources note a risk of the therapist assuming a blanket “gay is OK” stance and in so doing not acknowledging the very real risks that LGBTQ patients face as a result of a public coming out about their gender or sexual identity (Lev et al., 2014). Instead, most important is taking an open and empathetic therapeutic stance that recognizes the complexity of the issues surrounding identity and disclosure that this patient population faces. Obviously, therapy with an LGBTQ patient will follow the needs of that particular patient. All forms of established therapy are theoretically adaptable to the care of the LGBTQ patient depending upon the context, including the psychoanalytic framework (Drescher, 2001). The therapist should expect to encounter, however, a higher frequency of many of the issues mentioned previously in this review, given the higher prevalence of mood, anxiety, and substance use disorders in LGBTQ people as compared to the general population. Review of the topics covered in this curriculum should prepare any therapist, regardless of experience level or sexual orientation, to address the myriad issues faced by the LGBTQ population with care, compassion, and effectiveness. CME Question: Which of the following is NOT a component of LGBTQ affirmative therapy? Encouraging self-disclosure of sexual and gender identity (coming out) in most or all cases Forming awareness of the therapist’s countertransference to the patient Providing LGBTQ-specific literature and brochures in the office space Modifying forms to allow for accurate representation of patient gender identity Answer: 1 https://www.gap-lgbtq.org/introduction daily 0.75 2022-02-21 https://images.squarespace-cdn.com/content/v1/5e8757eb988faa7d6ec5ad65/1585935300450-BIL7RQPI7EU3BFF7BIO3/pexels-photo-1149363.jpeg Introduction - Introduction Although there have been some positive changes in social attitudes and legal protections in the last few decades, lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) individuals continue to live and work in environments that are heterosexist, homophobic, and transphobic. LGBTQ youth remain much more likely to be kicked out of their homes than their cisgender heterosexual peers, and 40% of homeless youth identify as LGBTQ (Durso & Gates, 2012). Transgender and gender diverse individuals face even higher rates of discrimination than their LGB peers. In the 2015 National Transgender Discrimination Survey, 27% of those who held or applied for a job during the past year reported being fired, denied a promotion, or not being hired for a job they applied for because of their gender identity or expression (James et al., 2016). Some states and municipalities have enacted nondiscrimination laws that protect individuals on the basis of gender identity and expression in various settings. Federally, the legal landscape has been murky and largely unsupportive, though in June 2020 the Supreme Court of the United States ruled that Title VII of the Civil Rights Act of 1964 - which prohibits employment discrimination on the basis of sex - applies to sexual orientation and gender identity. This is a promising decision, though it remains unclear exactly how it will be interpreted by other courts. Transgender women may be at especially elevated risk of discrimination and violence, as male-assigned children are generally afforded less flexibility in gender roles, and adults who are assigned male can have more trouble being viewed as female than their trans male counterparts. The trans author Julia Serano argues that a unique form of discrimination affects trans women, who face both transphobia and misogyny. She calls this transmisogyny (Serano, 2007). LGBTQ people of color, especially trans women of color, are most vulnerable. For example, the 2013 Anti-Violence Project report showed that 67% of LGBTQ homicide victims were transgender women of color (Anti-Violence Project). Due to their environments and experiences, LGTBQ people are more likely to develop mental disorders than the general public. The Minority Stress Model is a theory that explains the connection between discrimination and increased mental health burden (Meyer, 1995). The Minority Stress Model is supported by findings that conditions such as depression, anxiety, and substance use are more common among LGBTQ individuals. These conditions are more strongly influenced by social and environmental factors, as compared to biologically-based disorders such as bipolar disorder or schizophrenia, which are not necessarily more common among LGBTQ individuals (Carmel & Erickson-Schroth, 2016; Schulman & Erickson-Schroth, 2017). While LGBTQ people have higher documented rates of depression, suicidality, and substance use disorders than the general population, there are no studies to date that demonstrate higher prevalence of post-traumatic stress disorder or personality disorders. However, given the nature of the environment in which LGBTQ people live, it is likely that trauma-related disorders are more prevalent in LGBTQ patients. Hospital and clinic settings are not immune from both implicit and explicit biases which may negatively impact patient care (Sharman, 2016). Although medical training institutions are working to improve education about LGBTQ issues, the educational experiences that students and residents receive is not standardized and varies greatly between institutions. A Stanford study showed that medical students, on average, receive only 5 hours of LGBTQ-related content over their entire 4 years of medical school (Obedin-Maliver et al., 2011). In a Lambda Legal survey, 89.4% of transgender people felt there were not enough health professionals adequately trained to care for them, and 26% said they had been refused health care because they were transgender (Lambda Legal, 2010). Psychiatry, in particular, has had a fraught relationship with LGBTQ patients given the historical pathologization of LGBTQ identities and the ongoing perception of gatekeeping related to hormones and surgeries for transgender individuals. CME Question: Lesbian, gay, bisexual, transgender, and queer (LGBTQ) people have elevated rates of all of the following EXCEPT: Substance use disorders Bipolar disorder and schizophrenia Depression Suicidal thoughts and attempts Answer: 2 https://www.gap-lgbtq.org/references daily 0.75 2021-08-23 https://www.gap-lgbtq.org/diversity daily 0.75 2022-02-21 https://images.squarespace-cdn.com/content/v1/5e8757eb988faa7d6ec5ad65/1629756505152-W5HZTDR16Y6I9J3MU98S/pexels-photo-9255748.jpeg Diversity - Diversity Goal After completing this module the participant will understand how social and cultural factors influence psychosocial development and identity formation. Objectives Participants will: Appreciate how men and women can have different psychosexual life paths and understandings of their LGBTQ+ identity; Understand how racial, ethnic and class groups may conceptualize sexual identities in radically different ways; Appreciate how religious upbringing and beliefs can affect an individual's adjustment to his/her sexuality. Pre-Test LGBTQ+ identity: Can interact with other aspects of cultural identity in complex ways. Does not describe an aspect of cultural identity. Always takes on more importance than ethnic identity. All of the above. Members of a racial or ethnic minority who are gay: May face mulitple forms of discrimination by the majority community. May have difficulty finding possible role models. May feel they have to resolve conflict by choosing a primary identity. All of the above. Religious LGBTQ+ people: Must remain celibate to retain their faith. May experience conflicts between their faith and their LGBTQ+ identity. Must abandon their faith in order to successfully come out. ANSWERS 1. a 2. d 3. b Introduction When thinking about diversity within the LGBTQ+ community, there are broad factors that affect identity. These may include diverse cultural ideas about gender roles, conceptions about the role of family, family structure and family expectations, geographical location, and the influence of religion (Garnets & Kimmel 2003). The term intersectionality refers to the overlap of multiple identities, which may include race, ethnicity, religion, socioeconomic status, age, sexual identity and gender identity (to name a few). While it is important for psychiatrists to have knowledge about issues within each major community (Cabaj and Stein 1996) a categorical approach may be limiting, and paradoxically may reinforce cultural stereotypes. It is difficult, after all, to speak of specific commonalities between disparate members of the same ethnic group— for example, a married Mexican migrant farm worker who secretly has sex with men on the side and a third-generation Latina graduate student planning a gay wedding ceremony in Toronto. When formulating research questions, a common mistake is to assume that the category of “gay” represents a homogeneous group, overlooking not only race and ethnicity as mediating variables, but also age, gender, socioeconomic status, etc. (Herek et al. 2003). All to frequently, "the gay community" being studied consists of gay, white men. This fact not only leads to conclusions that are difficult to generalize or cannot be generalized beyond gay white men, but also limits the scope of research questions. One reason for a paucity of literature on gay people of color, for example, is researchers' lack of recognition of diversity within the gay community. This is not only a problem in research on gay populations, but in research on racial and ethnic minorities. For example, researchers, looking at alcohol dependence in the Native American population, may omit questions about sexual orientation, thereby not only contributing to the invisibility of gay and lesbian people of color, but also missing possible confounding factors and complex interactions. In addition, terms like "gay" or "lesbian" are culture-bound. Most models of sexual identity formation with stages of coming out are a largely white, western phenomenon (Cass 1996). Ethnic minorities who research studies may categorize as "gay," "homosexual" or "bisexual" may not necessarily identify themselves as such. For some LGBTQ+ individuals, identification with another group may be a more important determinant of their identity than their sexual identity. It is helpful for the clinician to understand the diverse meanings of sexual orientation within these groups. With these caveats in mind, this module draws attention to some of the issues related to race, gender, ethnicity, religion, socioeconomic status, disability and geography. Race & Ethnicity An individual's racial or ethnic identity plays a powerful role in social belonging and group affiliation (Chan 1995). LGBTQ+ individuals who are Black, Latino, Asian, Pacific Islander or Native American are members of a “double minority” or even a "multiple minority." Such individuals can have interpersonal and familial issues, as well as intrapsychic conflicts, that affect the successful development of an affirmative identity and self esteem. Disclosure of one's homosexual or bisexual orientation can sometimes leads to a negation of one's racial or ethnic identity, either from one's racial or ethnic group (e.g. "There are no gays in our community, therefore you are not Black, Asian, Arab, etc.") or from the larger gay community (e.g. "Your race does not matter, you are gay, you are one of us"), or both. Consequently, LGBTQ+ people of color can face alienation, discrimination, or both from the LGBTQ+ community and from their ethnic community of origin. Some members of LGBTQ+ racial minorities may feel forced to choose one identity over the other. In addition, LGBTQ+ people of color may not necessarily derive the same psychological benefits from "the gay community" as white people, e.g. social support, visible role models, acceptance for "who you are," and may even experience racism within the gay community (Garnets and Kimmel 2003) . Gender Men and women, as well as transgender and gender non-binary people, will have very different experiences of being gay or bisexual because sex and gender are profound determinants of identity. Prejudice against women can also have an impact on a lesbian's development. While lesbians and gay men may share common psychological qualities and interests, this assumption must be qualified by the recognition that lesbian psychology and development may relate as much to female psychology and development as it does to the psychology of being gay. Gender may influence the development of sexuality and sexual orientation differently in men, women and those who are gender non-binary. For example, there are differing expectations for men and women that may limit women's choices or lead to sex discrimination. Gender socialization of boys and girls profoundly influences the quality of their social interactions, and as a result, men and women generally behave in different ways. This can be even more complicated for those who are transgender. One’s gender identity may or may not correlate with the expected gender socialization in the cases of transgender and gender non-binary people. Further, the impact of gender socialization on male to female transgender individuals (transwomen) is not the same as on female to male individuals (transmen) nor for those who are gender non-binary. Consequently, a variety of features of same-sex relationships will be influenced by the gender characteristics of the partners. [See also the Child and Adolescent unit.] Religion Many religious institutions are passionately debating the meanings of homosexuality and its impact on the individual, the family and society at large. A growing number of religions are moving toward theological positions that tolerate and even actively embrace LGBTQ+ individuals. Some religious groups are ordaining LGBTQ+ priests, ministers and rabbis. Others have reaffirmed their traditional opposition to open expressions of homosexuality. Regardless of an LGBTQ+ individual's personal relationship to religion or his/her involvement with a specific religious group, s/he will be profoundly affected by religious teachings and beliefs about homosexuality. LGBTQ+ individuals have had exposure to a wide range of religious attitudes toward homosexuality. Some may maintain ties to their original communities of faith while others may have changed or even abandoned their religion. Many LGBTQ+ individuals have left religious communities with disapproving or condemnatory teachings about homosexuality. Some have abandoned religious practices altogether. Others may work within their religious groups to try and change traditional, unaccepting attitudes about homosexuality. Many LGBTQ+ individuals have sought reconciliation between their sexual identity and their spirituality within traditional religious groups; some have been successful in doing so. Others have moved to create new churches and spiritual settings that affirm their sexual identities and their relationships. LGBTQ+ individuals often internalize the antihomosexual attitudes with which they have been raised or to which they have been exposed since childhood. In some cases, this may inhibit their sexual identity development and their ability to develop relationships. LGBTQ+ individuals from communities where social and religious activities are deeply intertwined may stop participating in religious activities altogether and become estranged from their families, or may identify with their religious identity and avoid any involvement with the LGBTQ+T community. Conflicts between religious beliefs and homosexual feelings are usually an important focus of the clinical work with religious LGBTQ+ individuals. Clinical Example Javier is a 17-year-old, first generation Mexican-American young man born in San Diego, CA. He has been aware of his same sex attraction since fifth grade. Although he dated girls in junior high school, since then, he has become more certain of his gay sexual orientation. However, these feelings conflict with his Roman Catholic upbringing. He is very close to his mother and is afraid she will be heartbroken if he does not marry a woman and have children. He asks you if he will go to hell if he pursues his gay inclinations. As with any patient, the clinician has to be respectful of Javier's religious and cultural values. However, it is not the role of psychiatrists to get patients to conform to religious dogma. The clinician might explore what Javier's core moral values are and if and how they actually conflict with his sexual orientation. Javier may not be aware that increasing numbers of gay couples are choosing to start families by adopting children. He could also be referred to Dignity, a gay Catholic community organization, where he might meet others who have managed to reconcile their religious and sexual identities. Socioeconomic Status, Disability, Geography All these are additional factors that may influence a person's LGBTQ+ identity and connection to the wider community. For example, coming out as gay in rural Montana is markedly different from coming out in Manhattan. On the other hand, the internet may be blurring geographic boundaries and lessening social isolation for rural LGBTQ+ people. Physical disabilities may limit LGBTQ+ people's access to the larger gay community as well. Subcommunities of support may exist, e.g., the gay deaf community. Socioeconomic status interacts with other cultural factors as well. For example, being a poor Black gay man from the inner city poses much different challenges than being an upper middle class, Harvard-educated Black man from the suburbs. For these groups as well as other cultural groups discussed above, it may be much harder to find or recognize positive role models in one's neighborhood or the media. Clinical Vignette Betty is a 64 year old white woman living on social security. For twenty years she lived with her female partner in a trailer in rural, upstate New York. The couple had met on the job and developed their relationship. To Betty's surprise, she had never considered herself a lesbian prior to meeting her partner. Five years ago, Betty's partner suddenly died. Betty now comes to treatment complaining of depression. She has no connection to the gay community and no family members are aware of the relationship she lost. In the past year, her diabetes has resulted in loss of vision and Betty cannot drive. She feels increasingly isolated, helpless, and unable to move on from her grief. The clinician can help Betty by identifying bereavement as a primary diagnosis, which will frame her feelings of depression and validate the importance of the relationship with her partner. The clinician can help Betty explore whether disclosing her loss and therefore her same sex relationship to her family might provide her with additional support. The clinician can also point Betty in the direction of resources in the gay community, such as a local gay bookstore or SAGE, an organization that provides advocacy and support for LGBTQ+ elders, so that she can begin to find a social network. Post-Test Gay identity: is the same for men and women does not exist for African-Americans may vary in different countries is well accepted by middle class white families Homosexuality: is condemned by all religions is incompatible with spiritual beliefs is more common among agnostics None of the above LGBTQ+ people in rural areas must go to large cities to pursue their sexuality must repress their sexuality may use the internet to find community only marry and secretly have gay relationships Religion is an aspect of diversity important to consider in evaluating LGBTQ+T people True False ANSWERS 1. c 2. d 3. c 4. true Links Google Directory of ethnic LGBTQ+T support groups Google Directory of LGBTQ+T religious support groups Gay Latino Links