LGBTQ+ Terminology: Minority Stressors

• Terminology for LGBTQ+ topics is available at Stonewall.org.uk.

Minority Stress Model

• Explains stress due to stigmatized social status affecting mental health outcomes.
• General stressors impact mental health, both positively through resilience and negatively through depression, anxiety, self-harm, substance use, and suicidal tendencies.
• Research includes observational, correlational, mediation, moderation, and longitudinal studies to understand causality.

Distal Minority Stressors

• Environmental factors from outside the individual.
• Includes discrimination, harassment, microaggressions, prejudice, and violence.

Proximal Minority Stressors

• Internal responses to distal stressors.
• Includes expectations of rejection, concealment of identity, rumination about distal stressors, and internalized stigma.

Minority Stressors in Early Development

• Parental non-acceptance, peer bullying, identity concealment, peer non-acceptance, victimization, and gender non-conformity.
• These stressors occur alongside normative stressors.
• Helps explain the link between sexual and gender minority stress events and mental health symptoms, providing avenues for intervention.
• Resilience is a key factor, with self-compassion mitigating minority stress and psychological distress.
• Self-acceptance is associated with better mental health outcomes, while low self-esteem correlates with mental distress.

Theories Addressing Sexual and Gender Diversity

• Biological theories offer biological explanations.
• Minority stress theory explains stress related to stigma.
• Distinct lifeways theory, narrative possibilities theory, and social safety theory offer alternative perspectives.
• Fast Life history.

History of Understanding Diversity

• For 100 years, sexual and gender diversity was considered abnormal, with therapies focused on change efforts.
• The 1960s and 70s saw efforts to normalize homosexuality and highlight mental health disparities.
• In the 2000s, more robust methods and theories emerged to explain disparities.
• Focus on gender minorities increased in the 2010s and 2020s.

Identity Trends

• 57% of individuals consistently identify as gay/lesbian.
• 18% transition from bisexual to gay/lesbian.
• 15% consistently identify as bisexual.
• 12% experience changes in identity over time.
• 13% reported detransition.

Sexual Identity in Young People

• Sexual attractions typically develop around age 12.
• Questioning of orientation begins around age 13.
• Self-identification occurs around age 17.
• Sexual activity starts around age 18.
• Coming out happens around age 19.
• Romantic relationships begin around age 20.
• Experiences vary significantly within and between groups, with older cohorts reaching milestones later and development is not always linear.

Intersectionality

• Wheel of power/privilege and Social GRACES used for comprehensive understanding.

Health Inequalities

• LGBTQ+ individuals face a higher risk of depression and anxiety (1.5-4.7 times), suicidal ideation and attempts (2.47-6.5 times), non-suicidal self-injury (1.95-3.61 times), alcohol and substance use (1.45-9.7 times), PTSD (2x), borderline personality disorder, and eating disorders.
• Higher prevalence of sexual, verbal, and physical abuse (29%, 28%, 26.5% respectively), cyber-bullying (19%), childhood sexual abuse, intimate partner violence, sexual assault, rape, risky sexual behaviors, violence and hate crimes (1 in 5), and homelessness.

Interventions

• LGBTQ+ affirmative therapy is culturally relevant and responsive, addressing social inequality, fostering autonomy, enhancing resilience and coping skills, building community, and reducing barriers.
• Clinicians should be knowledgeable about the impact of stigma and minority stress.
• Identity matching is not necessary for therapists.
• Therapists should understand when and how to integrate sexual and gender identity into clinical work.

Inclusion in Trials and Service Experiences

• Only 1 out of 200 RCTs reported sexual orientation.
• LGBTQ+ individuals often experience poorer outcomes, significant barriers to accessing care.
• There are restricted treatment pathways and over-reliance on the charitable sector.
• The NHS action plan (2018) aims to improve services.

Microaggressions in Therapy

• Sexual orientation-based microaggressions include assuming sexual orientation, avoidance, minimizing, over-identifying, making stereotypical assumptions, heteronormative bias, and warnings about the dangers of identifying as LGBTQ+.
• Gender identity-based microaggressions include lack of respect for identity, lack of competency, and over or under-emphasizing gender identity.

Helpful Aspects in Therapy

• Not trying to change identity.
• Therapist education and self-awareness.
• Open, supportive, and non-judgmental environment.
• Creating a sense of safety.

Safety Signals

• Laws protecting against hate crimes.
• Interaction and connection with other LGBTQ+ people.
• Positive media portrayal.
• Use of correct pronouns and inclusive language.

Inclusive Language

• Avoid assumptions and use gender-neutral language.

Practice Points for Gender and Sexuality Minoritised Adolescents (GSM)

• Therapists should be aware of support needs for GSM young people in DBT, including identity confusion, non-acceptance, and hostility.
• Therapists should balance supporting GSM young people to cope with cis-heterosexism.
• Ask about gender and sexual identity early in treatment and create a safe relational space.

LGBTQ Affirmative CBT for Adults

• It consists of 3 modules over 10 sessions covering the impact of minority stress, cognitive restructuring, and building behavioral skills.

AFFIRM - CBT for Youth

• Involves 8 modules focused on understanding the impact of homophobic/transphobic attitudes, managing thoughts and feelings, and developing safe, supportive social networks.

Rainbow SPARX - Gamified CBT

• Includes relaxation training, behavioral activation, recognizing cognitive distortions, problem-solving, and cognitive restructuring.