Learning Objectives

9:30 – 10:30 AM 1. Create a welcoming environment for LGBTQ Mental Health: LGBTQ patients.

From Closets to Communities 2. Identify unique mental health problems in LGBTQ populations. SPEAKER Petros Levounis, MD, MA 3. Provide culturally-informed and culturally- sensitive counseling to LGBTQ patients.

Outline 1. The Closets 2. 3. Terminology 4. Mental Health and Suicide 1 5. Substance Use 6. Dating and Technology 7. Families The Closets 8. Elderly 9. Our Own Sexuality 10.The Communities

1 (N=1,197) …and Most Recently (N=2,160)

• Percentage of non-LGBTQ Americans “very” or “somewhat” uncomfortable with:

A Survey of LGBT Americans, Pew Research Center, 2013. The Harris Poll, GLAAD (formerly & Alliance Against Defamation), 2018.

Clinical Tips

 Appreciate stigma against sexual and minorities both in general society and healthcare. 2  Fight discrimination against sexual and gender minorities both in general society and healthcare. Coming Out

2 Age of Coming Out Coming Out as an Iterative Process

• First thought of being “other” • Coming out to oneself • Friends • Family • Co-workers • The social network

A Survey of LGBT Americans, Pew Research Center, 2013. Levounis P, Drescher J, Barber ME, The LGBT Casebook, 2012.

Clinical Tips

 Offer validation.  Provide a safe, welcoming, and affirming environment. 3  Respect patient autonomy.  Use the magic of warmth and curiosity. Terminology

3 Alfred C. Kinsey The Kinsey Scale

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Sexual Orientation and Gender The ABCs of LGBTQ…

1. Lesbian 11.Pansexual Gender 2. Gay 12.Polyamorous 3. Bisexual 13. IDENTITY IDENTITY (e.g., gay, lesbian, bisexual, straight, (e.g., , gender fluid, ) 4. 14.MSM asexual, ) 5. 15.WSW BEHAVIOR EXPRESSION 6. Queer 16.Gender fluid (e.g., same- partners, opposite-sex (e.g., feminine, androgynous, masculine) 7. Questioning 17.Androgynous partners, both, neither) 8. Asexual 18. ATTRACTION SEX 9. Greysexual 19. (e.g., Kinsey scale 0, 1, 2, 3, 4, 5, 6, X) (e.g., , intersex, male) 10.Aromantic (Aro) 20.Ally

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The Fenway Institute, Glossary of LGBT Terms for Health Care Teams, 2016.

4 Clinical Tips

 Use gender-neutral language (e.g., partner) when asking about romantic or sexual partners. 4  Try gender-neutral pronouns (e.g., they).  Update intake forms to ask about preferred name and pronouns. Mental Health and Suicide

Minority Stress Theory Statistics

• Depression and anxiety disorders are • Discrimination 1.5 times higher in LGBTQ populations. • Expectation or Perception of • 41% of adults reported Discrimination attempted suicide. • The risk of suicide in transgender • Internalized people who served in the military is 20 times higher than that of the general veteran population.

Meyer IH, Psychological Bulletin, 2003. McNamara MC and Ng H, Cleveland Clinic Journal of Medicine 2016.

5 Clinical Tips  Screen LGBT patients for depression, anxiety, PTSD, eating disorders, body dysmorphic disorder, and suicide. 5  Treat with the same medications and psychotherapies as you would for non- LGBTQ patients. Substance Use  Consider medical aspects of LGBTQ health (PrEP and PEP, HPV and HIV screening, HPV and Hepatitis A & B vaccination, hormone therapies).

Old Thinking: Getting “High” And here is the “evidence”…

Use to “augment a hyperactive, restless lifestyle and an exaggerated need for self-sufficiency.”

Khantzian EJ, Treating Addiction as a Human Process, 1999. Khantzian EJ, Treating Addiction as a Human Process, 1999.

6 New Thinking: Excess Social Stress Sexual Attraction

Only same-sex Mostly same-sex Equally both Mostly other sex Only other sex 40 • Minority Stress Theory

• Self-medication 30 *** 24.2 25

20 17.7 18.5 *** 15.7 * 13.2 11.4 * 12.2 9.6 10 Ref 5.6

0

% reporting any % reporting any substance use disorders Women Men **p<0.01, ***p<.001 based on logistic regression analysis adjusted for race, age, educational level, personal income, employment status, relationship status, health insurance status, geographic location, MSA, age at alcohol onset, and family history of AOD problems. Reference group was “heterosexual” group.

Levounis P and Ruggiero JS, Primary Psychiatry, 2006. McCabe SE, Addiction, 2009. Courtesy of Sean McCabe, PhD.

Motivation to Quit Smoking Primary Prevention

N = 16,546 25%

20%

15%

10%

5%

0% M → W M → M W → M W → W

Levounis, Motivation for smoking cessation among alcohol drinkers who date on the Internet, study in progress. Courtesy of Daniel L. Carlson, Crystal Meth Working Group (HIV Forum), www.hivforumnyc.org.

7 Secondary Prevention Clinical Tips

 Look out for alcohol, MJ, and tobacco use among .  Look out for stimulants, MJ, and tobacco use among .  Consult the community!

38 Courtesy of Daniel L. Carlson, Crystal Meth Working Group (HIV Forum), www.hivforumnyc.org.

Love and Sex in Today’s World

• Sex, both virtual and real is only a click or 6 a swipe away. • Variable Intermittent Reinforcement Dating and Technology

8 GRINDR MANHUNT.NET

The Social Network Blendr

• Scruff • GROWLr • Tumblr • Adam4Adam – or just “A4A” or “Adam” • OkCupid, Plenty of Fish, and Tinder – the straight dating apps for gays

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Sex Addiction Love Addiction

A condition characterized by: • Attraction Phase 1. repetitive The craving is for the euphoria of a romantic encounter. 2. out of control, and • Attachment Phase 3. driven sexual behavior, The craving is for a sense of security and continuity in a relationship. 4. typically conducted with strangers, that leads to distress or dysfunction.

Ascher MS and Levounis P, The Behavioral Addictions, 2015. Ascher MS and Levounis P, The Behavioral Addictions, 2015.

10 Clinical Tips

 Understand and empathize with your patients by familiarizing yourself with different LGBTQ cultures. 7  It’s no longer OK not to know what Grindr is. Families

Rejection v. Support Clinical Tips

 Expect that families of LGBTQ people • Families of Origin are not always supportive. • Families of Community  Ask about support systems broadly.

Levounis P, Drescher J, Barber ME, The LGBT Casebook, 2012.

11 Identify as LGBT 8 Elderly

Caring for LGBT Older Adults, National LGBT Health Education Center, 2012.

Isolation and Lack of Support Clinical Tip

Compared to the general population,  Appreciate that a person’s sexuality may LGBTQ older adults are: not remain the same throughout their lifespan. • Significantly more likely to be isolated. • Half as likely to have a significant other. • 49% of gays and lesbians over 50 years live alone compared to 33% of heterosexuals over 50.

Caring for LGBT Older Adults, National LGBT Health Education Center, 2012.

12 Core Themes

Gay Patient Straight Patient

9 Can we Gay How similar understand Clinician are we? and trust Our Own Sexuality each other? Can we Straight understand Are we open to Clinician and trust “go there”? each other?

Levounis P and Anson AJ, Sexual identity in patient-therapist relationships, In: The LGBT Casebook, 2012.

To Disclose or Not to Disclose Clinical Tips

 Decide how public you’d like to be and • Pictures at an Exhibition. (try to) manage your social media • We are all massively googleable. accordingly.  If you are LGBTQ yourself, you are likely to be a role model for your LGBTQ patients.

Levounis P and Anson AJ, Sexual identity in patient-therapist relationships, In: The LGBT Casebook, 2012.

13 US Adults Identifying as LGBT 10 The Communities

Newport F, In US, estimate of LGBT population rises to 4.5%, Gallup.com, May 22, 2018.

Sexual Minorities and Race PrEP by Race

Newport F, In US, estimate of LGBT population rises to 4.5%, Gallup.com, May 22, 2018. Huang YA, Morbidity and Mortality Weekly Report, October 19, 2018.

14 Clinical Tip

 Celebrate the clinical and cultural uniqueness of LGBTQ people and enjoy helping everyone thrive! 10+ Bob, Helen, Steve, Bo, and Anna too

The ABCs of LGBTQ…

1. Lesbian 11.Pansexual 2. Gay 12.Polyamorous 3. Bisexual 13.Same Gender Loving 4. Trans man 14.MSM APPENDIX 5. Trans woman 15.WSW 6. Queer 16.Gender fluid 7. Questioning 17.Androgynous 8. Asexual 18.Intersex 9. Greysexual 19.Cisgender 10.Aromantic (Aro) 20.Ally

The Fenway Institute, Glossary of LGBT Terms for Health Care Teams, 2016.

15 1. Lesbian 2. Gay Lesbian (adj., noun) Gay (adj.) • A sexual orientation that describes a • A sexual orientation that describes a woman who is emotionally and person who is emotionally and sexually sexually attracted to other women. attracted to people of their own gender. It can be used regardless of , but is more commonly used to describe men.

The Fenway Institute, Glossary of LGBT Terms for Health Care Teams, 2016. The Fenway Institute, Glossary of LGBT Terms for Health Care Teams, 2016.

3. Bisexual 4. Trans man Bisexual (adj.) Trans man/transgender man/ • A sexual orientation that describes a female-to-male (FTM) (noun) person who is emotionally and sexually • A transgender person whose gender attracted to people of their own gender identity is male may use these terms to and people of other . describe themselves. Some will just use the term man.

The Fenway Institute, Glossary of LGBT Terms for Health Care Teams, 2016. The Fenway Institute, Glossary of LGBT Terms for Health Care Teams, 2016.

16 5. Trans woman 6. Queer Trans woman/transgender woman/ Queer (adj.) male-to-female (MTF) (noun) • An umbrella term used by some to describe people who think of their sexual orientation or • A transgender person whose gender gender identity as outside of societal norms. identity is female may use these terms to Some people view the term queer as more describe themselves. Some will just use fluid and inclusive than traditional categories for sexual orientation and gender identity. Due the term woman. to its history as a derogatory term, the term queer is not embraced or used by all members of the LGBT community.

The Fenway Institute, Glossary of LGBT Terms for Health Care Teams, 2016. The Fenway Institute, Glossary of LGBT Terms for Health Care Teams, 2016.

7. Questioning 8. Asexual Questioning (adj.) Asexual (adj.) • Describes an individual who is unsure • Describes a person who experiences about or is exploring their own sexual little or no sexual attraction to others. orientation and/or gender identity. is not the same as .

The Fenway Institute, Glossary of LGBT Terms for Health Care Teams, 2016. The Fenway Institute, Glossary of LGBT Terms for Health Care Teams, 2016.

17 9. Greysexual 10. Aromantic (Aro) Greysexual (adj.) Aromantic (adj.) • Describes a person who experiences • An orientation that describes a person occasional and/or mild sexual who experiences little or no romantic attraction. They may act on it, they attraction to others and/or a lack of may not. interest in forming romantic relationships.

Adapted from: The Telegraph, A guide to the brave new world of sexuality, 2016. The Fenway Institute, Glossary of LGBT Terms for Health Care Teams, 2016.

11. Pansexual 12. Polyamorous Pansexual (adj.) Polyamorous (adj.) • A sexual orientation that describes a • Describes a person who has or is open person who is emotionally and sexually to having more than one romantic or attracted to people regardless of sexual relationship at a time, with the gender. knowledge and consent of all their partners. Sometimes abbreviated as poly.

The Fenway Institute, Glossary of LGBT Terms for Health Care Teams, 2016. The Fenway Institute, Glossary of LGBT Terms for Health Care Teams, 2016.

18 13. Same Gender Loving 14. MSM Same Gender Loving (SGL) Men who have sex with men (adj.) (MSM) (noun) • A term used as an alternative to the • Term often used in research and public terms gay and lesbian. SGL is more health settings to collectively describe commonly but not exclusively used by those who engage in same-sex sexual members of the African American/ behavior, regardless of their sexual Black community. orientation. However, people rarely use the term MSM to describe themselves.

The Fenway Institute, Glossary of LGBT Terms for Health Care Teams, 2016. The Fenway Institute, Glossary of LGBT Terms for Health Care Teams, 2016.

15. WSW 16. Gender fluid Women who have sex with Gender fluid (adj.) women (WSW) (noun) • Describes a person whose gender • Term often used in research and public identity is not fixed. A person who is health settings to collectively describe gender fluid may always feel like a mix those who engage in same-sex sexual of the two traditional genders, but may behavior, regardless of their sexual feel more one gender some days, and orientation. However, people rarely another gender other days. use the term WSW to describe themselves.

The Fenway Institute, Glossary of LGBT Terms for Health Care Teams, 2016. The Fenway Institute, Glossary of LGBT Terms for Health Care Teams, 2016.

19 17. Androgynous 18. Intersex Androgynous (adj.) Intersex (noun) • Describes a person who is neither • Group of rare conditions where the clearly masculine nor clearly feminine reproductive organs and genitals do in appearance. not develop as expected. Some prefer to use the term disorders (or differences) of sex development. Intersex is also used as an identity term by some community members and advocacy groups.

Adapted from: Dictionary.com. The Fenway Institute, Glossary of LGBT Terms for Health Care Teams, 2016.

19. Cisgender 20. Ally Cisgender (adj.) Ally (noun) • A person whose gender identity and • A person who supports and stands up assigned sex at birth correspond, i.e., for the rights of LGBTQ people. a person who is not transgender.

The Fenway Institute, Glossary of LGBT Terms for Health Care Teams, 2016. The Fenway Institute, Glossary of LGBT Terms for Health Care Teams, 2016.

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