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The Closets 2 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. Coming Out 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 Discrimination (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 Gay & Lesbian Alliance Against Defamation), 2018. Clinical Tips Appreciate stigma against sexual and gender 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 20 Sexual Orientation and Gender The ABCs of LGBTQ… 1. Lesbian 11.Pansexual Sexual Orientation Gender 2. Gay 12.Polyamorous 3. Bisexual 13.Same Gender Loving IDENTITY IDENTITY (e.g., gay, lesbian, bisexual, straight, (e.g., woman, gender fluid, man) 4. Trans man 14.MSM asexual, queer) 5. Trans woman 15.WSW BEHAVIOR EXPRESSION 6. Queer 16.Gender fluid (e.g., same-sex partners, opposite-sex (e.g., feminine, androgynous, masculine) 7. Questioning 17.Androgynous partners, both, neither) 8. Asexual 18.Intersex ATTRACTION SEX 9. Greysexual 19.Cisgender (e.g., Kinsey scale 0, 1, 2, 3, 4, 5, 6, X) (e.g., female, intersex, male) 10.Aromantic (Aro) 20.Ally 21 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 transgender adults reported Discrimination attempted suicide. • The risk of suicide in transgender • Internalized Homophobia 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 sexes 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 lesbians. Look out for stimulants, MJ, and tobacco use among gay men. 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 9 47 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 Sexual Identity 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 gender identity, 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 genders. 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.
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