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.