OC ACCEPT Orange County Acceptance through Compassionate Care, Empowerment and Positive Transformation

Behavioral Health Services Prevention & Early Intervention

Learning Objectives

Define common terms

Identify the mental health needs of the LGBTIQ community

Identify & describe Cass’s 6 stages of identity development model

Identify 5 ways to be an affirmative psychotherapist

Identify 3-5 behavioral interventions in working with LGBTIQ clients Why focus on LGBTIQ Community?

Protected class

Increase awareness

Decrease stigma

Increase providers confidence in providing services to LGBTIQ clients Why is it difficult to discuss sexuality? •Cultural discourse •Private issue •Medical/biological terms •Heterosexual view Barriers to discussion of sexuality: •Embarrassment & discomfort •Irrelevant vs. relevant Ethical Considerations for Professionals - Social Workers •National Association of Social Workers (NASW) Ethical Standards • (c) Social workers should obtain education about and seek to understand the nature of social diversity and oppression with respect to race, ethnicity, national origin, color, sex, sexual orientation, gender identity or expression, age, marital status, political belief, religion, immigration status and mental or physical ability. Selected History & Milestones of LGBTQ Community

Stonewall DSM-I 1st gay pride Rebellion 1952 1970 1969

Obergefell DSM-II DSM-III DSM-V v. Hodges 1973 1980 2013 2015 LGBTIQ STATISTICS

LGBTIQ identification is Gallup Poll more common among (2018) those with lower incomes.

Women are Less than $36,000 per more likely to year = 6.2% identify as $36,000-$90,000 per LGBTIQ than year = 4.7% men. >$90,000 per year = 3.9% What does LGBTIQ mean?

Lesbian A female who experiences physical, romantic and an emotional attraction to other females. Gay A male who experiences physical, romantic and an emotional attraction to other males. Bisexual A person who experiences physical, romantic and an emotional attraction to both males and females. Intersex A medical diagnosis for a person whose sexual and/or reproductive anatomy or chromosomal pattern does not seem to fit typical definitions of male or females; often referred to as disorders of sex development. What does LGBTIQ mean?

Queer Transgender An umbrella term that An umbrella term for people embraces a variety of whose gender identity differs sexual orientations and from the sex/gender they gender identities. were assigned to at birth.

Transgender Transgender Female Male Additional Terminology

Heterosexual (or straight): People whose sexual and romantic feelings are primarily for the opposite gender.

Gender Non-Conforming: A person who may identify with their assigned sex at birth, however their gender expression differs from traditional expectations for men and women. (Androgyny, “butch” female, “effeminate” males.)

Coming Out: The process of identifying as gay, lesbian or bisexual. It also refers to the process that parents go through when telling others about a gay loved one. Additional Terminology

Homophobia: Society’s misunderstanding, ignorance or fear of gay, lesbian or bisexual people.

Cisgender: A person whose gender identity and biological sex assigned at birth align (e.g., man and assigned male at birth).

Non-Binary: Identifying as either having a gender which is in-between or beyond the two categories ‘man’ and ‘woman, as fluctuating between ‘man’ and woman’, or as having no gender, either permanently or some of the time.

Men who have Sex with Men (MSM): refers to all males – of any age – who engage in sexual and/or romantic relations with other males.

Behavioral Health: Depression

Bisexual Transgender Gay Men Lesbian Women Men/Women Men/Women • 3x higher in MDD • Increased MDD • Higher incidences • MDD & anxiety are • 2x higher in anxiety • PTSD of common • Self-cutting/self • Increased anxiety depression/anxiety • Lack of support Harm • Higher levels of • Rejection from • Social rejection • Higher when intimate partner LGBTIQ community • Lack of access to remain in closet violence (IPV) medical care • Name and gender barriers

Top Health Issues for LGBTIQ Population (SAMSHA) 2012 Behavioral Health: Suicide

Bisexual Transgender Gay Men Lesbian Women Men/Women Community • Harassment •“Out” vs “not •Higher levels of •SI is widely • Negative coming out” self-harm and reported out process •Doubts suicide attempts •Issues related to • Substance use regarding sexual •Lack of transitioning • Isolation orientation understanding & pre/post • 7x higher in higher among acceptance •Issues related to suicide attempts lesbian women •Isolation “passing” •Limited social •Struggles with support/network self-acceptance

Top Health Issues for LGBT Population (SAMSHA) 2012 Behavioral Health: Suicide

Nearly half of 1 out of 6 LGBTIQ youth Suicide is the young students 2nd leading are 4x more transgender nationwide cause of death likely to attempt people have seriously among young suicide seriously considered people ages 10 to compared to thought about suicide in the 24. their straight taking their past year. peers. lives.

The Trevor Project (2016) Substance Use

Gay Men - Higher substance use

Lesbian Women - Higher smoking rates - Drink more than heterosexual women

Bisexual Men/Women - Significantly higher rates of binge drinking (22.6%) than their heterosexual counterparts (14.3%)

Transgender Community - Higher substance usage compared to other populations

Top Health Issues for LGBT Population (SAMSHA) 2012

STI’s and HIV/AIDS

In 2016, gay and bisexual men accounted for 67% of all HIV diagnoses & 82% among males aged 13 & older

Transmission of HIVamong Lesbian women is extremely rare

Transgender women, globally, 50 times more likely to be HIV positive

Exposure/sharing of needles with hormones and or sex work

CDC (2016) & HIV/AIDS & Youth – Fenway Health (2012) Older Adults Older Adults

When it comes to aging, Estimated range of lesbian, gay, bisexual or transgender LGBTIQ older people are Americans ages 60 and over: more concerned than 1.75 - 4 million non-LGBTIQ older adults with regard to…

SAGE (2014) Older Adults

Barriers to disclose Behavioral Health Smaller Support Medical Care Housing their sexual Concerns Systems orientation

Fear of Disclosure of Rejection by Deconstruction Major discrimination sexual children, family, of elaborate depression by nursing staff, orientation community constructs loss of housing

Negative affect Generalized on the patient- anxiety disorder provider

Suicide

SAGE (2014) Video Clip #1: Coming Out Activity: Coming Out Stars “Coming Out” The CASS Model (1979, 1984)

“Coming Out” refers to the experiences of some, but not all, LGBTIQ individuals as they explore their sexual identity

There is no specific process in coming out; some LGBTIQ persons do not come out

The coming out process is unique for each person

The Cass model outlines six stages of “Coming Out” Stage I: Identity Confusion “Who am I?”

Becomes aware that their thoughts, •What May Be Going On: feelings, or behavior •-Who am I? Am I different? conflict with their •-Feelings: Anxiety, confusion, denial heterosexual or cisgender identity

•Reassure them they are ok •Basic value-free information Clinical Guidelines: •Reflectively listen to their feelings •Be sensitive about using labels (gay, bi, etc.) with them Stage II: Identity Comparison “Where do I belong?”

Difference • What May Be Going On: between self and • Maybe I am gay. I’m alone. What are gay people like? • Feelings: Isolation, anxiety, excitement, bargaining and others starts to rationalizing magnify

• Reassure you won’t reject them and they are not alone • Allow them to learn more about themselves, at their own pace Clinical • Counter myths and stereotypes with factual information • Provide clear support for them, regardless of what their orientation/gender Guidelines: may be • Check out safety (safe-sex, suicidality, AOD use, etc.) Stage III: Identity Tolerance “I may be…”

Confusion is lessened, allowing them to acknowledge their social, sexual and emotional • What May Be Going On: needs • I accept the possibility that I may be gay. Where are other gay people? • Feelings: Social isolation, anger, excitement, reactivity Difference between how they see themselves and others grows

• Support their wish to explore their developing identity • Provide LGBTIQ community resources when available Clinical Guidelines: • Note safe places to go to and safe people to talk to • Consider safety/risk issues • Acknowledge it will take time to build networks Stage IV: Identity Acceptance “I Am….”

Fully accepts rather than • What May Be Going On: tolerates their LGBTIQ • I am gay. Am I okay? I can come out to some people Identity • Feelings: Rage, sadness, hostility towards straight culture

• Respect their right and need to be part of LGBTIQ community • Support their exploration for new friends/partner(s) Clinical Guidelines: • Explore inter-personal skills needed to meet new people/spaces • Help support the client if they want to come out to friends/family • Work out a plan of who is safe to come out to and who isn’t Stage V: Identity Pride “I am proud to be…”

Immerses him/herself • What May Be Going On: in the LGBTIQ • I am proud to be gay. I don’t (and won’t) pass for community and straight • Feelings: Excitement, focused anger, arrogant pride and culture to live out rejection of straight culture as norm their identity • Continue to be supportive • Work through any feelings the individual has about resentment toward homophobia, discrimination or other Clinical people being in the “closet” • Work through how they feel about others who experience Guidelines same-sex attraction but don’t identify or are unsure of their sexuality as the individual is of theirs • Safety around being under-age in bars/clubs, safety at events, mixing with older people on “the scene” Stage VI: Identity Synthesis “Being ….is one part of me.”

Develops a fully internalized and • What May Be Going On: • I am a person who happens to be gay integrated LGBTIQ • Feelings: Excitement, happiness, grief identity

• Coming out is a life-long journey • The individual may experience homophobia/transphobia on Clinical Guidelines many different levels, support around this may be needed • Affirm to individual that it has been a long journey to get to this stage and a lot of courage and strength has been needed Disclaimer

Do not make Thorough Information assumptions assessment is presented is (not all X necessary to help means Y/not with your conceptualize all Y means X) client(s) Coming Out

“It’s not a decision to come out but a realization.” (Bigner & Wetchler, 2012) According to Valory Michell, “People come out at every age. They come out to their parents, children, siblings, spouses, extended families, colleagues and friends. They come out in the context of their culture, their communities and their values.” (Bigner & Wetchler, 2012, Chapter 9, pg. 132) Coming Out

Different agendas between family and client

Stereotypes of LGBTIQ relationship: sex vs. family Coming Out: Assessment

Whom the client wants to tell and why?

Who is the most important and most difficult to tell?

Who accepts vs. who rejects Coming Out: Assessment

Assess for dependency status

Assess for barriers (e.g., religions, traditional, cultural issues) Coming Out: Early Interventions

Encourage family members to understand Prepare the that coming out Use reframe to Planning for client to is a recognition decrease disclosure answer for the LGBTIQ conflicts* questions* person rather than a sudden unexpected change** Coming Out: Early Interventions

Explore w/family The members to Explore “solution” remember each Explore the to coming the history person positives of out is not to w/the about coming go back LGBTIQ his/her out** into the person to hopes * closet help create continuity Coming Out: Middle Phase of Therapy

Provide resources Process the such as idea that Clarify assumptions PFLAG, Psychoeducation* LGBTIQ on LGBTIQ identity** straight identity is bad alliance, to or sinful family members Coming Out: Middle Phase of Therapy

Work on coping Consider individual Process any loss or strategies for client session to decrease grieve and love ones blame & guilt Coming Out: Middle Phase of Therapy

Encourage Encourage family to welcoming & Plans for disclosure be empathetic respectful to others toward the client environment Coming Out: Concluding the Therapy

Accepting that not Understanding the Accepting that everyone will accept coming out is a dynamics will change you lifelong process LGBTIQ Affirmative Therapy

Alan Malyon: Gay affirmative therapy is not an independent system of psychotherapy. Rather, it represents a special range of psychological knowledge which challenges the traditional view that homosexual desire and fixed homosexual orientations are pathological (1982)

AAMFT definition: “An approach to psychotherapy that embraces a positive view of the LGBTQ identities & relationships and addresses the negative influences that homophobia, transphobia & heterosexism have on the lives of LGBTQ clients.”

Bigner & Wetchler (2012): The basis of the concept of affirmative therapy is the understanding that the difficulties LGBTIQ people face are culturally conferred. This means that the problems people have concerning their sexual orientations are not consequences of homosexuality but of homophobia. These problems result from intolerance of difference and from ignorance. Affirmative Therapist

Create an affirmative & safe Being “gay friendly” or knowing space “gay friends” aren’t enough

Know thyself

Taking an affirmative stance and Get involved challenge the status quo Affirmative Therapist

Do not assume Every story is unique Use nonjudgmental language

Acknowledge family of choice

Know generational differences

Seek appropriate supervision if you cannot refer out Gay Male Couple Therapy

Tunnel & Greenan (2004) Marital Tasks:

• (1) Creating a boundary around them • (2) Dealing w/individual differences and conflicts • (3) Regulating closeness & distance Each is much more complicated for male couples than for married heterosexual couples Gay Male Couple Therapy

Creating a Boundary

• The act of marriage makes the boundary* • Gay couples do not assume sexual exclusivity, separation between sex and emotional fidelity • Long-term vs. short-term vs. open-relationships Creating a Welcoming Environment

Avoid Continually closed Confidentiality assess risks ended questions

Rapport and Don’t trust building assume Terminology Consideration: Client-Centered Strategies

Consider Ask individuals Individual’s barriers to self- how they choice of disclosure by would like to language(s) LGBTIQ be addressed individuals

Avoid Get clinical Be aware of overgeneralizing supervision/ask community with the use of questions resources the term “gay”

http://nicic.gov/library/029681

Thoughtful Considerations: Culture

Integrating multiple Ethnic and religious Assess level of identities, some may factors related to acculturation be stigmatized acceptance

Assess level of Assess for history of acceptance from bullying and peer Age of coming out family acceptance members/community

Historical significance Generational of early LGBTIQ Gaps/Differences movements Issues Underlying Discrimination

The Gender Binary Misogyny Heteronormativity Gender Policing

Noting or relating The imposition or enforcement of to behavior or normative gender attitudes expressions on an A concept or Hatred, dislike, or consistent with individual who is belief that there mistrust of traditional male perceived as not are only two women, or or female adequately genders, male prejudice gender roles and performing, and female against women the assumption through of appearance or behavior, the sex heterosexuality that was assigned as the norm to them at birth Most Important Issues for LGBTIQ People of Color

• 58% reported their community views them as “sinful” Higher prevalence of • 50% also feel discriminated against prejudice within racial and • 45% felt excluded ethnic communities • 50% feel they received doubts over their LGBTIQ identity • 45% were teased or made fun of

Those who come from a more •Feeling condemned as sinful for being traditional background are the most likely to feel LGBTIQ is particularly strong among negative reactions from their African-Americans and Latinos/Latinas racial or ethnic communities

Human Rights Campaign (2009) Video Clip #8: Diversity Inclusion Community Resources

OC ACCEPT http://www.ochealthinfo.com/bhs/about/pi/early/ oc_accept

LGBTIQ Resources http://www.ochealthinfo.com/bhs/about/pi/early/ oc_accept/resources

LGTBIQ Links http://www.ochealthinfo.com/bhs/about/pi/early/ oc_accept/links

PFLAG https://pflag.org/

What is OC ACCEPT?

• Short-term Individual/Family Behavioral • Mild-Moderate Participants • Case Management Health • Peer Mentorship Services to • Community-based Supportive Services • Referrals & Linkage Services the LGBTIQ • Support & Discussion Groups • Health and Wellness Activities Community • Educational & Vocational Support

OC ACCEPT Team

Master Peer level specialists clinicians

For more information or to refer a client: OC ACCEPT 2035 E. Ball Road, Suite 100 – C Anaheim, CA 92806 (714) 517-6100 http://www.ochealthinfo.com/bhs/about/pi/early/oc_accept (Services available in English & Spanish) References

 American Institutes for Research. (2013). Standards of Care for LGBT Youth [Data File]. Retrieved from http://www.air.org/resource/standards-care-lgbt-youth.  Bigner, J. J., & Wetchler, J. L., (2012). Handbook of LGBT-Affirmative Couple and Family Therapy. New York, NY: Taylor & Francis Group.  Browning, C. (2008). Multicultural competency with lesbian, gay, bisexual, transgender, and intersex clients and staff. Presented at the Orange County Health Care Agency, Orange County, CA.  Centers for Disease Control. (2015). HIV Among Incarcerated Population. Retrieved from http://www.cdc.gov/hiv/group/correctional.html.  Centers for Disease Control. (2015). HIV Among Transgender People. Retrieved from http://www.cdc.gov/hiv/group/gender/transgender/index.html.  Centers for Disease Control. (2015). HIV Among Gay and Bisexual Men. Retrieved from http://www.cdc.gov/hiv/group/msm/index.html.  Centers for Disease Control. (2016). HIV and Gay and Bisexual Men. Retrieved from https://www.cdc.gov/hiv/group/msm/index.html.  CDC. (2010). National Intimate Partner and Sexual Violence Survey. Re-release (2013). Department of Health and Human Services.  Coulter, R.W.S., Bersamin, M., Russell, S.T., Mair, C. The Effects of Gender-and Sexuality Based Harassment on Lesbian Gay, Bisexual, and Transgender Substance Use Disparities. Journal of Adolescent Health, 62, pp. 688- 700.

References

• Gay, Lesbian & Straight Education Network. (2017). The 2011 National School Climate Survey; The experiences of Lesbian, Gay, Bisexual and Transgender Youth in Our Nation’s Schools [Data File]. Retrieved from https://www.glsen.org/article/2017-national-school-climate-survey-1. • Grossman, A.H. & D’Augelli, A.R. (2007). Transgender Youth and Life-Threatening Behaviors. Suicide and Life- Threatening Behaviors. • Healthline. (2016). Depression in the LGBT Population [Data File]. Retrieved from http://www.healthline.com/health/depression/gay#Overview1.  Kort J. (2018). LGBTQ Clients in Therapy: Clinical Issues and Treatment Strategies. New York, NY: W. W. Norton & Company, Inc.  Marshal MP, Friedman MS, Stall R, et al. Sexual orientation and adolescent substance use: a meta-analysis and methodological review. Addict Abingdon Engl. (2008) 103(4):546-556.  Malyon, A.K. (1982). Psychotherapeutic implications of internalized homophobia in gay men. In J. C. Gonsiorek (Ed.), Homosexuality and Psychotherapy: A practitioner’s handbook of affirmative models (pp. 59-70). New York, NY: Haworth Press.  National Alliance of Mental Illness. (2016). How Do Mental Health Conditions Affect the LGBTQ Community [Data File]. Retrieved from https://www.nami.org/Find-Support/LGBTQ.

References

 National Eating Disorder Association. (2016). Eating Disorders in LGBT Populations [Data File]. Retrieved from https://www.nationaleatingdisorders.org/eating-disorders-lgbt-populations.  National Center for Transgender Equality. (2016). National Transgender Discrimination Survey: Executive Summary [Data File]. Retrieved from http://www.transequality.org/issues/resources/national-transgender-discrimination-survey-executive- summary. • NIDA. (2017, September 5). Substance Use and SUDs in LGBT Populations. Retrieved from https://www.drugabuse.gov/related-topics/substance-use-suds-in-lgbt-populations on 2019, February 14.

• Reis, B. (1997). Report of the Anti-Violence Documentation Project from the Safe Schools Coalition of Washington,” Retrieved from http://www.eric.ed.gov/PDFS/ED418175.pdf.

• Robert W.S. C., Melina B., Stephen T. R., Christina M. (2016). The Effects of Gender and Sexuality-Based Harassment on Lesbian, Gay, Bisexual, and Transgender Substance Use Disparities. Journal of Adolescent Health, 62, pp 688-700.

• Services and Advocacy for Gay, Lesbian, Bisexual & Transgender Elders (SAGE). (2016). Out and Visible, The experiences and attitudes of Lesbian, Gay, Bisexual and Transgender Older Adults, Ages 45-75 [Data File]. Retrieved from http://www.sageusa.org/resources/publications.cfm?ID=221.

• Substance Abuse and Mental Health Services Administration . (2012). Top Health Issues for LGBT Population [Data file]. Retrieved from http://store.samhsa.gov/shin/content//SMA12-4684/SMA12-4684.pdf.

References

•U.S. Department of Justice National Institute of Corrections. (2015). LGBTI: Lesbian, Gay, Bisexual, Transgender, and Intersex Offenders [Data File]. Retrieved from http://nicic.gov/library/026518. •Substance Abuse and Mental Health Services Administration . (2008). Providing Services and Supports for Youth who are Lesbian, Gay, Bisexual, Transgender, Questioning, Intersex or Two-Spirit. [Data File]. Retrieved from http://www.samhsa.gov/sites/default/files/lgbtqi2-s-practice-brief.pdf. •The Trevor Project. (2016). Facts About Suicide [Data File]. Retrieved from http://www.thetrevorproject.org/pages/facts-about-suicide. •True Colors Fund. (2015). Serving Our Youth 2015: The Needs and Experiences of Lesbian, Gay, Bisexual, Transgender, and Questioning Youth Experiencing Homelessness [Data File]. Retrieved from https://truecolorsfund.org/wp-content/uploads/2015/05/Serving-Our-Youth-June-2015.pdf. •Tunnell, G., & Greenan, D.E. (2004). Clinical issues with gay male couples. Journal of Couple & Relationship Therapy, 3, 13-26.