BEHAVIORAL HEALTH CARE OF LESBIAN, GAY, AND BISEXUAL PEOPLE January 29, 2014

Kevin Kapila MD Medical Director of Behavioral Health, Primary Care Provider Fenway Health

CONTINUING MEDICAL EDUCATION DISCLOSURE

. Program Faculty: Kevin Kaplia, MD . Current Position: Medical Director of Behavioral Health, Fenway Health, Boston, MA . Disclosure: No relevant financial relationships. Content of presentation contains no use of unlabeled and/or investigational uses of products.

It is the policy of The National LGBT Health Education Center, Fenway Health that all CME planning committee/faculty/authors/editors/staff disclose relationships with commercial entities upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflicts of interest and, if identified, they are resolved prior to confirmation of participation. Only participants who have no conflict of interest or who agree to an identified resolution process prior to their participation were involved in this CME activity.

LEARNING OBJECTIVES At the end of this webinar, participants should be able to: 1. Identify the major behavioral health disparities among LGB people 2. Explain how the stresses and challenges associated with being a stigmatized sexual minority can affect behavioral health outcomes 3. Discuss ways in which to assess and address behavioral health issues in LGB people.

BEHAVIORAL HEALTH DISPARITIES: SUMMARY . There is a limited research, but some evidence suggests that LGB people may have higher rates of: . Depression . Anxiety . Suicidal attempts and ideation . Substance use (alcohol, tobacco, recreational drugs)

. Rates vary depending on life stage, gender, sexual orientation, and study methodology (IOM, 2011) CONTEXT FOR BEHAVIORAL HEALTH DISPARITIES . It can be stressful living as a stigmatized minority and yet most LBG people adapt and are resilient. . Some LGB people become depressed and anxious due to rejection, isolation and institutionalized homophobia/ heterosexism. . As a result of these stressors some develop negative coping behaviors, like heavy drinking or substance use.

HISTORY OF HOMOSEXUALITY IN PSYCHIATRY . The clinician must keep in mind that clients may approach you cautiously due to the a long history of pathologization of homosexuality by mental health providers. . It is only relatively recently in the field of psychiatry that homosexuality was removed as a pathological diagnosis. . Unfortunately, while it is considered unethical, and is banned in some states, some mental health providers still practice conversion therapy. GENERAL CONSIDERATIONS WHEN WORKING WITH LGB CLIENTS COMING OUT

. The process by which an LGB person accepts and discloses their sexual orientation. . The process is non-linear and can be life long. . Changing jobs or living situation may require the person the come out again or hide their sexual orientation . Clinician can help the client through the process by helping with the development of coping skills, support, anticipation of obstacles or discrimination. . The clinician may need to slow down the client to help them address issues around physical and emotional safety. A client may feel an urgency to come out and address potential threats to physical safety or their emotional ability to handle negative comments by friends and family.

FAMILIES OF CHOICE . LGB clients may face rejection by their families and friends when they come out. . A “family of choice” develops when clients find others with shared experiences that take on the family role. . When clinician obtains a history they should keep in mind that family structure may not include their biological family. . The clinician should also be aware that the client’s health care proxy or emergency contact may not be someone who is a biological relative. DUAL STIGMA . Having a psychiatric diagnosis while also being a LGB person creates what is called a dual stigma. . Dual stigma can also refer to a LGB person who is a member of racial/ethnic minority, has a disability or belongs to another stigmatized group. . It is important to remember that a LGB person who is a racial minority is not immune to prejudice within the LGB community. . Clinicians who are aware of and validate any of the multiple stigmas that may affect a client are better equipped to meet their needs. BISEXUALITY . Bisexuality is the capacity for emotional, romantic and/or physical attraction to more than one gender. . Bisexuality challenges the binary view of sexual orientation and may result in exclusion from the heterosexual and lesbian/gay communities. . Studies have shown bisexuals have higher rates of mental health problems including depression, anxiety, suicidal ideation and eating disorders when compared to gays and lesbians. BISEXUALITY: MYTHS . There is the belief that bisexuality is a phase that some people go through before becoming gay or lesbian. . There are negative stereotypes that bisexuals are promiscuous and are more likely to be unfaithful to their partners. . There has been the belief that bisexual men are the sources of spreading HIV from the gay to the heterosexual communities. BISEXUALITY: CLINICAL CONSIDERATIONS . The clinician should be aware of their own feelings about bisexuality and how this may be influenced by negative stereotypes. . The bisexual client may share some issues with the lesbian and gay community, but they also have unique mental health needs that should addressed. . The clinician should not assume that clinical resources for gay and lesbian people are appropriate or available for the bisexual client.

MENTAL HEALTH CASE STUDIES: CONSIDERATIONS FOR LGB CLIENTS . Adjustment disorder . Depression . Anxiety . Bipolar Disorder . Substance Abuse . Sexual Compulsivity

ADJUSTMENT DISORDER: CASE . Claire is a 23 year-old lesbian woman who present to her primary care physician with depressed mood, feeling anxious, poor sleep, and decreased appetite. The symptoms presented about three weeks ago when she came out to some close friends and family. Her announcement was met with mixed reactions and she fears she is going to lose some of the people closest to her. She is having problems functioning at work and has found herself isolating in her apartment. The physician refers her to a therapist and asks that she follow up in two weeks. When the physician is documenting the case and submitting the billing she is not sure if she should document this as an adjustment disorder with mixed anxiety and depressed mood or a major depressive episode.

ADJUSTMENT DISORDER . The diagnosis for adjustment disorder is often used when people are coming out. . The diagnosis of adjustment disorder may be less stigmatizing because it is transient. . Anxiety and depressive disorders tend to be recurrent. . Making the correct diagnosis could have multiple implications, particularly regarding the necessity for continued treatment with pharmacologic agents DEPRESSION: CASE . Mary is a 36 year-old bisexual female who present for her annual physical. She reports she is having problems with sleep. When questioned further she reports she has been depressed, waking up early in the morning, worrying, and not enjoying anything anymore. She used to be very active in her son’s afterschool program and enjoyed it, but now it feels like a chore, and she finds herself backing out of commitments. She feels guilty that her wife is taking on most of the household responsibilities and parenting of her son. She feels like people would be better off without her. Her ex-boyfriend who she is still good friends with reminded her of a similar episode she had when they were together which improved with a brief course of psychotherapy and medication. She is diagnosed with Major Depression. DEPRESSION . Studies indicate that depression and suicidal ideation rates are higher among LGB people. . Clinician should be aware of possible suicide risk and evaluate for safety. . The clinician should have awareness about how sexual orientation may impact symptoms but not assume these factors manifest the same way for all clients. . LGB clients respond to the same therapeutic and pharmacological treatments as heterosexual clients. They will respond best to a provider that understands their issues and can provide a safe environment for their treatment. ANXIETY DISORDERS: CASE

. Matt is a 26 year- old gay male who presents to the clinic for HIV testing. When reviewing the chart the physician notices he has been tested eight times in the past three months for very low risk and no risk sexual activity. He went out to a gay bar with some friends and kissed a man he met. When he woke up this morning he was overcome with anxiety that he contracted HIV. He spent most of the morning on the computer looking up information about HIV transmission. He went to a HIV testing clinic earlier in the day and had a rapid HIV test that was negative. This provided momentary relief but he then worried the rapid test was not reliable and came to the clinic to get a serum HIV test. Patient understands on a “logical” level that he is at very low risk but feels compelled to get tested. He does admit when he was younger he had some problems with pulling his hair and need to count things. ANXIETY DISORDERS . Acquiring HIV is common fear among gay men, especially when coming out. . Studies have shown higher rates of anxiety disorders in the LGB community. it is generally accepted that emotional stress is a trigger for anxiety among LGB clients who are at unique risk from societal homophobia. . For Matt, he is educated about the risk for HIV and aware it is low. The clinician should be aware of his sexual orientation, his coming out experience and if there is a correlation between this and his fear of HIV. BIPOLAR DISORDER: CASE . Rob is a 33 year-old gay male who was sent in by his psychiatrist for medical evaluation prior to having a trial of lithium for bipolar disorder. He had been having symptoms of depression after the loss of his job and a recent break up. The medical provider asked about manic behavior and how the diagnosis of bipolar disorder was made. Matt grew up in a conservative family and had always repressed his sexual orientation and he described himself as “exploding” out of the closet at 25. He was not educated about safer sex and that first year was very sexually active and not always safe. He was active in the club scene and would sometime stay up for days with little sleep, using crystal meth to help keep up his energy. BIPOLAR DISORDER: CASE . He also had some financial problems related to his spending money at the clubs. This behavior lasted about a year and he sought out counseling to help with his own internalized homophobia and accepting his sexual orientation. He met his partner stopped using drugs, maintained a monogamous relationship. There have been no symptoms for six years until recently when his relationship ended and he was laid off. The psychiatrist believed this period in his life was consistent with manic episode, and his current episode was related to bipolar depression BIPOLAR DISORDER . One needs to be careful of the misdiagnosis of Bipolar Disorder in the LGB client. . When someone comes out they may feel euphoric over understanding and acting on their sexual feelings and this may be coupled with guilt and sadness due to the stigma that comes with acting on these feelings. . People may experiment with drugs that mimic manic behaviors. . Some LGB people may chose to have many sexual partners, we need to be aware of own bias and not label this as hypersexual behavior. . LGB people can be bipolar; clinician needs to assess for physical and sexual safety when client is manic. SUBSTANCE USE: CASE

. Colin is a 34- year- old gay male lawyer who presents with increasing symptoms of depression. As part of the evaluation, the clinician asks Colin about alcohol and drug use. Colin reports he had a brief period of weekend binge drinking when he started college. Then, when he came out in law school and started to go out with friends to bars and clubs, he experimented with Ecstasy a few times. He tried crystal methamphetamine once and, realizing he liked it very much, was scared to use it again. The clinician asked Colin what he liked so much about crystal methamphetamine. Colin remembers when he used the drug his troubles seemed less relevant, and his mood improved. Since he has been depressed lately, he sometimes thinks about using it again. The clinician questions Colin further about his desire to use drugs and his ability to access them. Colin admits it would not be difficult to obtain drugs, but he has seen what they have done to several friends. SUBSTANCE USE

. The psychiatric history should include a detailed substance abuse history. . Clinicians should assess what drugs the client uses/has used, the degree of their use, and the potential reasons behind the use. . Drugs and alcohol are sometimes used as a way of fitting into the bar or club scene, or to alleviate anxiety around going to an openly LGBT venue. . It is very important to ask what the person liked about using drugs. Clients can often confess about the bad things drugs do to them, but then go out and use again. People would not continue to use drugs that made them horribly ill or that did not produce any positive effect. When the benefits of the drugs are understood, it provides an opportunity to deal with the root causes of drug use.

SUBSTANCE USE

. When obtaining the substance use history, the clinician should assess the client’s readiness to change. IF they are not willing to stop are they willing to reduce their use. . Harm reduction is the practice of meeting clients where they are at with their substance use and trying to reduce the impact. . A clinician can simply asking the client, “How will you know when you have a problem?” . For example, if the client says he knows he has a problem if he uses drugs and misses work, and later tells the clinician he has missed work due to drug use, the clinician may then reflect back to the client, “You mentioned before that you would consider your substance use a problem if you missed work, and now that it has happened, let’s put our heads together and think of some ways we can prevent this from happening again.”

SEXUAL COMPULSIVITY . Not a formal DSM diagnosis. . Lack of control over one’s sexual behavior despite negative impact on relationships, work, health or self esteem. . More common in gay and bisexual men. . The behavior may manifest as sexual encounters and/or looking for sex on the internet or looking at internet pornography. . Unsuccessful attempts are made to limit, control or stop the behaviors. SEXUAL COMPULSIVITY . The actual sexual encounter and achievement of orgasm is often not the goal. The reinforcing aspects are the rituals and heightened emotional state around looking for sex. . There are some gay and bisexual men who have multiple sexual partners and function well in society and are not distressed by their behaviors. They would not be considered sexually compulsive. . Clinicians should help clients identify and understand behaviors and triggers for behaviors. There are also 12 step groups like Sex and Love Addicts Anonymous and Sexual Compulsivity Anonymous. CLINICIAN’S SELF-ASSESSMENT . The most important thing a clinician must do in order to provide affirming therapy is to honestly evaluate your own feelings about the LGBT community. . Clinicians who are not aware of their personal feelings and biases can have a negative impact on patient care. This can manifest in their body language, questions asked or avoided, or even care options offered. . Awareness of one’s bias may not change someone’s beliefs, but can help in understanding how it may impact a clinical interaction. This understanding can help one adjust his/her behavior accordingly, so that the ethical obligation to provide optimal health care can be fulfilled.

QUESTIONS A CLINICIAN MAY CONSIDER ASKING THEMSELVES . Do I feel same-sex relationship are as valid as heterosexual relationships? . Do I feel nervous when a client talks about their same- sex relationship? . How do I feel about gay marriage? . Do I think all gay men are promiscuous? . Do I think all lesbians dislike men? . How do I feel about clients that identify as bisexual? . Do I feel sorry for people that identify as LGB?

MENTAL HEALTH ASSESSMENT . Structurally the interview is the same as as regular mental health interview. . Be aware of heterosexist assumptions. Imagine asking a married lesbian woman what her husband does. Just changing husband to spouse would be more appropriate. . The client may ask about the sexual orientation of the clinician. . Evaluate how sexual orientation influences the presenting problem and past psychiatric history yet at the same time not assume or put too much emphasis on sexual orientation. . Evaluate for any prior trauma history which may include bullying or anti-gay violence. MENTAL HEALTH ASSESSMENT . Evaluate for current violence/domestic violence. Myth persists that women cannot be perpetrators of violence or that men can not be victims of violence. . In the social history, evaluate how the client’s sexual orientation impacted their education, vocation, family and social relationships. . When obtaining a sexual history, evaluate if the client is comfortable giving the information. They may need to see the clinician as a safer person before they give this information, so you may have to come back to it when there is more of a therapeutic alliance. Assess knowledge of safer sex. TREATMENT . The treatment of LGB people uses the same modalities that are used with heterosexual clients including psychotherapy, medication or a combination of both. . There is no specific medication or type of therapy that works better with LGB clients than non-LGB clients. . The clinician should incorporate knowledge of LGB health into the therapeutic process. . Conversion therapy by its natures assumes same-sex attraction is pathological and needs to be repaired. It is unethical to perform this type of therapy. TREATMENT . LGB affirming therapy assumes that LGB identities are normal and the focus of treatment is to gain comfort with their sexual orientation. . Affirming therapy should not imply there are real challenges that may face the client. . There is no psychiatric medication or type of therapy that works better with LGB clients. Psychodynamic therapy, cognitive behavioral therapy and relational therapy all work. . Have LGB-friendly referrals on hand. This may include LGB friendly therapist and or support groups. CONCLUSION . Despite societal homophobia and stigmatization, most LGB people are resilient and adapt well. . There is some evidence to suggest that LGB people have higher rates of anxiety, depression, and substance abuse issues when compared to the heterosexual population. . Clinicians, regardless of their sexual orientation, should be aware of their own beliefs about the LGB community. . Conversion therapy is not effective and is an unethical treatment modality. . A clinician who is well informed about issues facing the LGB community and is able to provide a safe and affirming practice is well equipped to treat any LGB client.

RESOURCES . APA Lesbian, Gay, Bisexual and Transgender Concerns Office . www.apa.org/pi/lgbt/ . Association of Gay and Lesbian Psychiatrists . www.aglp.org/ . Gay and Lesbian Medical Association . www.glma.org