First, Do No Harm: Reducing Disparities for Lesbian, Gay, Bisexual, Transgender, Queer and Questioning Populations in California The California LGBTQ Reducing Mental Health Disparities Population Report First, Do No Harm: Reducing Disparities for Lesbian, Gay, Bisexual, Transgender, Queer and Questioning Populations in California The California LGBTQ Reducing Mental Health Disparities Population Report Table of Contents Acknowledgements . 4 Executive Summary . 11 Part 1: Introduction and Background Information . 18 What We Know, What We Don’t Know and What We Need to Know About LGBTQ . 20 Research Issues: Who Counts, What Counts, How to Count . 20 History - The Sexologists . 22 The Diagnostic and Statistical Manual of Mental Disorders . 25 Gender Identity Disorder (GID) . 27 Etiology: The “Choice” Debate . 32 The Many Forms of Stigma . 35 Minority Stress . 37 Majority Rules - Anti-LGBTQ Initiatives . 39 Coming Out / Staying In . 44 HIV and AIDS . 45 Alcohol and Other Drugs (AOD) . 46 Domestic Violence . 47 Suicide . 52 Resiliency . 52 Mental Health Services: The Good, the Bad, and the Harmful . 54 First Do No Harm . 56 Lack of Training . 58 Seeking Cultural Competence . 60 Intersecting Identities . 64 Lesbians . 64 Gay Men . 67 Bisexual Individuals . 70 Transgender Individuals . 77 People of Color Who Are LGBTQ . 83 Asian American, Native Hawaiians and Pacific Islanders . 84 Black/African American/African Descent . 87 Latino/Hispanic/Mexican American/Chicano . 92 Native American—Two-Spirit . 95 Couples . 101 Parents, Children and Families . 103 Youth . 106 Older Adults . 124 Part 2: Research Methodology . 128 Community Engagement . 128 Information Gathering: A Multi Method Approach . 128 Strategic Planning Workgroup . 128 Community Dialogue Meetings . 130 Advisory Groups . 131 Community and Provider Surveys . 132 Data Analysis and Preparation of Findings . 134 Study Limitations . 136 Part 3: Findings and Recommendations . 139 Community Survey . 139 General Demographics . 140 Sexual Orientation . 145 Gender Identity . 147 Intersex . 148 Mental Health and Minority Stressors . 149 Social Supports - Rejection and Outness . 152 Service Providers - Outness, Rejection and Difficult to Find . 156 Access to Services . 157 Mental Health Services - Barriers, Problems and Satisfaction . 159 Provider Survey . 162 Workplace Environment . 163 Disparities for LGBTQ-Identified Providers . 163 Barriers to Providing Services . 164 Comfort Matters . 165 Training Matters . 167 Summary . 169 Recommendations . 171 Focus 1: Data Collection, Research and Evaluation . 172 Focus 2: Policy . 173 Focus 3: Workforce Training . 176 Focus 4: Funding and Services . 178 Part 4: Community Defined & Promising Practices . 181 Index By Practice Focus . 182 Description of Practices . 185 Glossary . 206 References . 210 Appendix A: Additional Population & Subject Specific Recommendations . 237 Policy . 237 Workforce Training . 237 Funding and Services . 238 Appendix B: Additional Resources . 240 Acknowledgements Writers Pasha Mikalson, MSW Seth Pardo, PhD Jamison Green, PhD Project Staff Pasha “Poshi” Mikalson, MSW Project Director Mental Health America of Northern California Nicole Scanlan Project Coordinator Mental Health America of Northern California Seth Pardo, PhD Data Analyst Executive Director, Professional Education & Research Consulting Daniel Gould, LCSW* LGBT Health and Human Services Network Deputy Director Equality California Institute * Former Staff Member Laurie Hasencamp Interim Executive Director Equality California Institute Susan Gallagher, MMPA Executive Director Mental Health American of Northern California Contributors Asian American & Native Hawaiian/Pacific Islander section R . Anthony Sanders-Pfeifer, PhD—Alameda County Behavioral Health Services and Contra Costa County Behavioral Health Services Black/African American/African Ancestry section Gil Gerald, President/CFO—Gil Gerald and Associates, Inc . Parents, Children and Families section Judy Appel, JD—Executive Director, Our Family Coalition Renata Moreira, MA—Our Family Coalition 4 Domestic Violence section Susan Holt, PsyD, CCDVC—LA Gay and Lesbian Center HIV and AIDS section Brian D. Lew, MA—HIV Prevention Services Branch, Office of AIDS Majority Rules—Anti-LGBTQ Initiatives section Nicole Scanlan—Mental Health America of Northern California Native American section Nazbah Tom, MFTI—Native American Health Center Older Adults section Dan Ashbrook—Director, Lavender Seniors of the East Bay Michelle Eliason, PhD—San Francisco State University Dan Parker, PhD Youth section Bernadette Brown, JD—National Council on Crime & Delinquency Hilary Burdge, MA—Gay-Straight Alliance (GSA) Network Karyl E . Ketchum, PhD—California State University, Fullerton Carolyn Laub—Executive Director, GSA Network Caitlin Ryan, PhD, ACSW—Family Acceptance Project Dave Reynolds, MPH—GSA Network Geoffrey Winder—GSA Network Report Design Aimee Yllanes Design Strategic Planning Workgroup John Aguirre National Alliance on Mental Illness (NAMI) California Delphine Brody California Network of Mental Health Clients Hilary Burdge, MA GSA Network Gil Gerald Gil Gerald & Associates/LGBT Tri-Star Betsy Gowan, MFT Butte County Department of Behavioral Health Jamison Green, PhD Center of Excellence for Transgender Health, UCSF 5 Joanne Keatley, MSW* Center of Excellence for Transgender Health, UCSF Danny Kirchoff Transgender Law Center Carolyn Laub* GSA Network Justin Lock* Mental Health America of Northern California Dennis Mallillin, MFTI Asian and Pacific Islander Wellness Center Hector Martinez Mental Health America of San Diego Sheila Moore, LCSW Gay and Lesbian Elder Housing (former) Jewish Family Services of Los Angeles (current) Dan Parker, PhD* The LGBT Community Center of the Desert—Palm Springs Denise Penn, MSW American Institute of Bisexuality Jessica Pettitt I Am Social Justice Rev . Benita Ramsey Riverside County Department of Mental Health Dave Reynolds, MPH* Trevor Project & GSA Network Nazbah Tom, MFTI Native American Health Center Michael Weiss Humboldt County Department of Health and Human Services * Former SPW Member 6 Advisory Groups African American/Black/African Ancestry Gil Gerald—facilitator Bartholomew T . Casimir, MFTI Linda Hobbs Jabari Ahmed Malik Morgan Larry Saxxon 4 anonymous members Asian American & Native Hawaiian/Pacific Islander Dennis Mallillin, MFTI—facilitator Eddie Alvarez Ben Cabangun, MA Stephanie Goss Justin Lock Patrick Ma Hieu Nguyen Lina Sheth Lance Toma, LCSW 1 anonymous member Bisexual/Pansexual/Fluid Denise Penn, MSW—facilitator Heidi Bruins Green, MBA James Walker 6 anonymous members Consumer/Clients/Survivors and Family Members Delphine Brody—SPW Liaison Justin Lock—(former facilitator) Eden Anderson Karin Fresnel Abby Lubowe Kathryn (Kate) White Stephen Zollman 7 anonymous members County Staff Betsy Gowan, MFT—facilitator Sharon Jones Stephanie Perron Victoria Valencia R . Anthony Sanders-Pfeifer, PhD Nicola Simmersbach, PsyD, MFT Noel Silva 3 anonymous members 7 Latino John Aguirre—co-facilitator Hector Martinez—co-facilitator Joanne Keatley, MSW—(former facilitator) Angelica Balderas Jorge Fernandez 5 anonymous members Native American Two-Spirit/LGBTQ Nazbah Tom, MFTI—facilitator Carolyn Kraus Karen Vigneault 3 anonymous members Older Adult Sheila Moore, LCSW—facilitator Dan Parker, PhD—(former SPW liaison) David Cameron Rick Khamsi Richard Levin, MFT Glenne McElhinney Nora Parker Patty Woodward, EdD Paul D . Zak, LCSW 3 anonymous members Research and Data Analysis Pasha Mikalson, MSW—facilitator Heidi Bruins Green, MBA Sue Hall, MD, PhD, MPH Jamison Green, PhD Rose Lovell Shelley Osborn, PhD Seth Pardo, PhD Nicole Scanlan 3 anonymous members Rural Michael Weiss—Facilitator Slade Childers Eden Joseph Rick Khamsi Pat Rose Kathryn “Kate” White 3 anonymous members 8 School-Based Lawrence Shweky, LCSW—facilitator Hilary Burdge, MA—SPW liaison Carolyn Laub—(former SPW liaison) Dave Reynolds, MPH—(former SPW liaison) Kate Mayeda Jabari Ahmed Malik Morgan 9 anonymous members Transgender Danny Kirchoff—facilitator Rachel Bowman Delphine Brody Porter Gilberg Jamison Green, PhD Zander Keig, MSW Aydin Kennedy Connor Maddox Asher Moody-Davis 9 anonymous members Youth Justin Lock—facilitator Dave Reynolds, MPH—(former facilitator) Eden Joseph Patrick Ma Hieu Nguyen 7 anonymous members Women’s Issues Jessica Pettitt—facilitator Antonia Broccoli, LCSW Porter Gilberg Carol Hinzman Kristen Kavanaugh Kyree Kilmist Victoria Valencia 9 Special Thank You We are grateful to Rachel Guerrero, members of the former Office of Multicultural Services (OMS), and all others who were involved in the creation of the California Reducing Disparities Project (CRDP)—as well as recognizing that LGBTQ communities need to be included when addressing mental health disparities . We are extremely appreciative of all the support we have received from both the staff of the former OMS and staff from the Office of Health Equity (OHE), including Autumn Valerio, Claire Sallee, Kimberly Knifong and Shayn Anderson . We would particularly like to thank Marina Augusto for her leadership at the former OMS and during the transition to the OHE and California Department of Public Health . We would like to thank the California LGBT Health and Human Services Network for their support in launching this project . We would like to gratefully acknowledge the California MHSA Multicultural Coalition, the African American, Asian and Pacific Islander, Latino, and Native American Strategic Planning Workgroups for their support and