Stress & Trauma Toolkit

for Treating LGBTQ in a Changing Political and Social Environment

Violence against the LGBTQ community has increased over recent years. In 2016, the Pulse nightclub shooting in Orlando shocked the nation—with a single gunman killing 49 people and wounding 53 others at the gay nightclub. The Pulse attack remains the most extreme assault on the gay community, but it was far from being an isolated case. When the National Coalition of Anti-Violence Programs (NCAVP) released its 2016 annual report, the data showed that it was the deadliest year on record for the LGBTQ community since NCAVP began record-keeping on anti-LGBTQ hate crimes in 1996. However, 2017 proved even worse, with anti-LGBTQ hate crimes rising 86% from 2016. LGBTQ people of color—particularly transgender people—are disproportionately affected by these hate-crimes. According to the Human Rights Campaign (HRC), at least 15 transgender women, all of whom were black, were killed in 2019.

Challenges abound on the legislative front as well. HRC reports that at least 129 anti-LGBTQ bills were introduced across 30 states during the 2017 state legislative season. Twelve of these bills—which range from adoption laws to "religious freedom" legislation—became law. The current White House administration has made repeated attempts to ban transgender soldiers from serving in the military. While these bans have not held up in court, they add to the contentious climate for LGBTQ Americans.

Clinical Vignette

John, 42 years old

John is a 42-year old gay man who receives outpatient mental health care at a local clinic. He has a history of chronic depression and reports an increase in anxiety and panic symptoms in recent months. John attributes the symptoms to various stressors, including a recent loss of part-time employment, conflicts in a romantic relationship, and his concerns about the current political climate. 3

John describes feeling restless, having increased muscle tension, moments of feeling overwhelmed, and recent insomnia. While he consistently takes his prescribed psychiatric medications, he notes depressed mood, decreased appetite, and a lack of interest in hobbies he usually enjoys.

John is currently insured through Medicaid, and recent congressional attempts to repeal the Affordable Care Act have left him anxious about losing his insurance and health care access. He also has a history of being violently assaulted and reports seeing an increase in homophobic language on his social media accounts and in public settings that makes him worried about his physical safety.

John currently shares housing with his male partner, who is living with HIV, and he worries that there may be a future cut to Ryan White-funded programs that are crucial for his partner’s housing and medical expenses. During his most recent appointment with his psychiatrist, he wonders if there are strategies that can help him cope with his worsened anxiety.

Factors that Put LGBTQ Individual at Risk for Mental Health Problems

Harassment and discrimination in education: LGBTQ students in grades K-12 experience harassment at an alarming rate. About three quarters of LGBTQ students report having been harassed at school; even worse, 35% have experienced physical assault, and 12% have been the victim of sexual violence at school. Harassment and assault, especially when it occurs in what should be a safe and supportive setting, can have serious impacts on mental health such as fear, anxiety, depression, and post-traumatic stress disorder (PTSD). A National School Climate Survey (2017) from all 50 states, the District of Columbia, and the U.S. territories reported an increase in acts of intimidation, bias, and violence against LGBTQ student at school. In the wake of the 2016 election and aftermath of the Administration's decisions against LGBTQ students, many schools have become even more hostile towards transgender and gender nonconforming youth.

Institutional discrimination: The LGBTQ population experiences institutional discrimination in a variety of situations and settings such as the workplace and places of worship. LGBTQ individuals are frequently denied career advancement or equal compensation compared with their gender-conforming peers, and their unemployment rate is double that of the general population. LGBTQ people experience the full gamut of responses from religious organizations, from unconditional support to open hostility. LGBTQ people who grow up in religious settings can be especially traumatized by their faith’s rejection or condemnation of homosexuality and non-binary gender identities. Such experiences of discrimination can lead to negative health outcomes such as hopelessness, anxiety, emotional dysregulation, social isolation, and even drug misuse and incarceration.

Health disparities: Discrimination in health care settings endangers LGBTQ people’s lives through delays or denials of medically necessary care. Transgender patients may require medical interventions such as hormone therapy and/or surgery. Despite the presence of guidelines and an advanced transgender medicine treatment paradigm, patients report a lack of providers with expertise in transgender medicine, which is the single largest factor limiting access to care for people who are transgender. Other common barriers are discrimination, lack of insurance, lack of cultural competence/sensitivity by health care providers, and socioeconomic barriers such as low income, lack of transportation, and inadequate housing. Because of the lack of access to healthcare, transgender patients are at high risk of negative health outcomes with much higher rates of HIV infection, smoking, drug and alcohol use, and suicide attempts than the general population.

Family rejection: Family rejection remains all-too common for LGBTQ individuals and may negatively affect their both mental and physical health. For example, family rejection of an LGBTQ person may lead to homelessness, which makes it difficult to stay in school or hold a job. Family rejection can also lead to long-lasting psychiatric problems later in life. Rejected individuals may develop depression and low self-esteem and may turn to alcohol, cigarettes, or drugs, smoking cigarettes to cope. People who experience familial rejection are more likely to be depressed, use illegal drugs, and attempt suicide than non-rejected young adults.

History of trauma: Many individuals in the LGBTQ population have experienced past physical assault and harassment. Past trauma compounds any current trauma, exacerbating anxiety about future safety, especially in a political climate that feels hostile.

Microtraumas/Microaggressions: People who identify as LGBTQ often experience brief, subtle expressions of hostility or discrimination. While microaggressions are often associated with racial/ethnic minorities, they can also impact LGBTQ and other marginalized populations, and cumulatively they can take a toll on mental and physical health. LGBTQ people who experience microtraumas may not meet diagnosable criteria for PTSD yet suffer tremendously from minority stressors such as from internalized phobia, rejection sensitivity, marginalization, and discrimination both in their personal life and health care settings.

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Treatment Recommendations

  1. Please see Suggested Assessment and Treatment Recommendations for Marginalized Populations
  2. Provide trauma-informed care. LGBTQ people often experience trauma as gender minorities. Common clinical concerns specific to LGBTQ individuals can be addressed by implementing the following principles:
    • Understand the impact of identity-based trauma on cognition, emotion, behavior, and perception.
    • Provide physical and emotional safety by meeting patient needs, clearly establishing and communicating safety procedures, creating a predictable environment, and fostering respectful relationships.
  3. Create an inclusive environment. Providers should ensure an inclusive environment by collaborating with LGBTQ clients in program design, individual service planning, and the creation of policies and procedures. Policies, procedures, forms, and regulations should be inclusive of LGBTQ patients while minimizing re-traumatization. Anti-discrimination and hiring policies as well as policies concerning client services should include sexual orientation and gender identity. Employee and client forms should allow LGBTQ individuals to answer honestly and thoroughly.
  4. Screen for trauma. Providers should consider specific stressful life experiences when assessing trauma in gender-diverse people. For LGBTQ people who also identify as racial/ethnic minorities, providers should use the LGBT People of Color Microaggressions Scale (an 18-item self-reported microaggressions scale). Screening for trauma is also appropriate for primary care, behavioral health settings, emergency rooms, and tertiary care settings.
  5. Plan for continuity of care. Given the high risk of HIV, suicide attempts, drug and alcohol abuse, and tobacco use among LGBTQ people, providers must determine appropriate levels of care. Providers should consider treatment within their scope of practice; make necessary referrals to integrated clinics; provide a continuum of care referrals for services; and offer services the patient will receive after discharge such as follow-up and monitoring activities, outreach, recruitment, and retention.
  6. Understand and promote understanding. Providers should be aware of the effects of stigma such as prejudice, harassment, discrimination, and violence in the lives of LGBTQ individuals. Providers can help reduce stigma by educating the public about LGBTQ health issues and policies and by advocating for equal care.
    • Educate the public with culturally relevant materials from organizations such as LGBTQ-advocacy organizations and provide information through media channels, newspapers, social networking, schools, hospitals, offices, and private companies.
    • Educate the medical community by providing instruction to medical students and residents as well as peer supervision to colleagues.
  7. Given that LGBTQ populations have unique lived experiences partly defined by adversity and discrimination, they have developed resilience. Despite harassment, mistreatment, discrimination, and violence, LGBTQ individuals demonstrate determination, resourcefulness, and perseverance. They have advocated for basic civil liberties such as marriage and parental rights. Gender-diverse people have sought out hormone treatments and gender-affirming procedures despite a lack of competent and even hostile providers. Despite high levels of harassment, bullying, and violence in school, most LGBTQ youth return to or stay in school and obtain an education. Even with harassment and discrimination at work, more than 75% of gender-diverse people report being comfortable at work and improve their performance after transitioning. Despite barriers to work and success, the LGBTQ community continues to thrive, and many serve as leaders in the workforce.

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Resources

The Family Acceptance Project is a research, intervention, education, and policy initiative that works to prevent health and mental health risks for lesbian, gay, bisexual, and transgender (LGBT) children and youth, including suicide, homelessness and HIV – in the context of their families, cultures, and faith communities. www.Familyproject.sfsu.edu

Parents and Friends of Lesbians and Gays (PFLAG) is a national organization for education, advocacy and support for families and friends of LGBTQ persons. More than 400 chapter networks provide confidential peer support, education, and advocacy in communities in nearly every state, the District of Columbia, and Puerto Rico. https://www.pflag.org/

LGBT National Help Center provides peer support, community connections, and information about resources for LGBT people. The Help Center operates three national hotlines: the LGBT National Hotline, the LGBT National Youth Talkline, and the SAGE LGBT Elder Hotline. They have 15,000 local resources for cities and towns across the country. http://www.glnh.org/

The Gay and Lesbian Medical Association (GLMA) works to ensure equality in health care for lesbian, gay, bisexual, and transgender individuals and health care professionals. www.glma.org

National Coalition of Anti-Violence Programs (NCAVP) is a national network of service organizations working with LGBTQ people who have been victims of domestic violence. http://www.avp.org

National Immigrant Justice Center’s LGBTQ Immigrant Rights Initiative provides legal services to low-income immigrants who identify as LGBT and those who are living with HIV. http://www.immigrantjustice.org/index.php/services/lgbtq-immigrants

Ryan White HIV/AIDS Program https://hab.hrsa.gov/about-ryan-white-hivaids-program/about-ryan-white-hivaids-program

References

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Authors

  • Saeed Ahmed, MBBS, M.D.
  • Matthew Dominguez, M.D.
  • Marshall Forstein, M.D.
  • Keith Hermanstyne, M.D.
  • Liz Garcia, M.D.
  • Ubaldo Leli, M.D.
  • Eric Yarbrough, M.D.

About the Toolkit

Disclaimer: This toolkit is intended to provide general medical advice or recommendations. Each clinician is responsible for using his or her own medical judgement as to how to best diagnose and treat patients.

This introductory guide offers an array of topics that will be essential in understanding how to work with special populations experiencing stress and trauma in today's changing political environment. It provides basic information to raise awareness of the needs of special population patients and strategies to incorporate in care in psychiatric practices. This toolkit does not represent official APA policy, but offers a perspective from physicians that work with this community on a regular basis. The objective of this toolkit is to help a broader range of psychiatrists become familiar with best practices for treating special populations experiencing stress and trauma. Psychiatrists can consult Resources & References section on each page for further reading.