Mental Health in LGBTQ+ Young People

Mental Health in LGBTQ+ Young People

• LGBTQ-affirmative psychotherapy addresses higher rates of mental health issues in SGM individuals, compared to heterosexual and cisgender people
• Over the past two decades, the field has evolved from pathologizing perspectives to affirmative approaches
• Current evidence supports the efficacy of LGBTQ-affirmative psychotherapy across different SGM populations, delivery modalities, and settings
• Treatment moderators and potential mechanisms are discussed, including:
  • Race/ethnicity
  • Stigma exposure
  • Hypervigilance
  • Shame
  • Negative self-schemas
• Implementation and dissemination efforts, including therapist training and various treatment delivery modalities, are also covered
• Future research should focus on:
  • Identifying treatment mechanisms to better understand how LGBTQ-affirmative psychotherapy works
  • Exploring therapy orientations beyond cognitive-behavioral therapy (CBT) with diverse populations
  • Determining which contexts and client characteristics require adaptations to current protocols
  • Investigating how LGBTQ-affirmative psychotherapy can interact with structural and systemic conditions to maximize impact on SGM mental health
  • Focussing on successful treatment protocols
  • Embedding therapy within structural interventions to address broader societal factors affecting SGM mental health
• LGBTQ-affirmative psychotherapy effectiveness and accessibility for diverse SGM populations needs improvement

Minority Stress Model

• The minority stress model has roots in psychology, sociology, public health, and social welfare, articulated by Meyer in 2003
• The theory explains mental health inequalities in sexual minority populations by considering social, psychological, and structural factors
• Focuses on:
  • Critiques of the model
  • Applications in research and practice
  • Reflections on its continued relevance
• Considers the model's applicability in light of changing social and policy contexts affecting sexual and gender minorities
• The minority stress model has shaped research across various social and health sciences related to SGM well-being
• Provides insights into the ongoing relevance and adaptations of the minority stress theory

Historical Context

• For around 100 years, sexual and gender diversity was considered abnormal/an illness, leading to pathologization without a known cause
• Therapy focused on change efforts
• Efforts were made in the 1960s/70s to normalize homosexuality and show mental health disparity due to stressors
• More methodologically sound methods were used in the 2000s (population cohorts)
• Theories were developed to explain health disparities, with an increasing focus on gender minorities in the 2010s/20s

LGBTQ+ Awareness

• 57% consistently identify as gay/lesbian, 18% transition from bisexual to gay/lesbian, and 15% are consistently bisexual (N = 156; Rosario et al., 2006)
• 12% change in identity over time (N = 11,727; Everett, 2015)
• 13% report a history of detransition (N = 27,725; Turban et al., 2021)
• Sexual attractions tend to develop first (Mage = 12.70; CI:10.10-15.30)
• Followed by questioning orientation (Mage = 13.20; CI: 12.80-13.60)
• Self-identification (Mage = 17.80, CI: 11.60-24.00)
• Sexual activity (Mage = 18.10; CI: 17.60-18.60)
• Coming out (Mage = 19.60; CI: 17.20-22.00)
• Then romantic relationships (Mage = 20.90; CI:13.20-28.60)
• Considerable heterogeneity exists within and between groups
• Older cohorts reach milestones later, and not linear
• Depression & Anxiety Disorders (1.5-4.7x higher)
• Suicidal ideation and attempts (2.47-6.5x higher)
• Non-suicidal self-injury (1.95-3.61x higher)
• Alcohol and substance use (1.45-9.7x higher)
• Post-Traumatic Stress Disorder (2.20x higher)
• Borderline/Emotionally Unstable Personality Disorder
• Eating Disorders
• LGBT+ youth have a higher prevalence of:
  • Sexual abuse (29.70%)
  • Verbal abuse (28.70%)
  • Physical abuse (26.50%)
  • Cyber-bullying (19.10%)
• Childhood sexual abuse and intimate partner violence
• Sexual assault and harassment, rape
• Risky sexual behaviours
• Violence and hate crimes
  • 1/5 LGBTQ+ experience in the last 12 months
  • 4/5 are unreported to the police (Stonewall, 2017)
• Homelessness

Methodology and Theories

• Research uses observational and correlational methodology
• Theories include:
  • Biological theories for biological explanations of health disparities
  • Minority Stress Theory
  • Distinct Lifeways Theory
  • Narrative Possibilities Theory
  • Social Safety Theory
  • Fast Life History Theory

Minority Stress Theory

• Distal Minority Stressors:
  • Originate from the environment or outside the person
  • Discrimination
  • Harassment
  • Micro-aggression
• Proximal Minority Stressors:
  • Are a response to distal stressors, from inside the person
  • Expectations of rejection
  • Concealment of identity
  • Prejudice
  • Violence
  • Rumination about distal stressors
  • Internalised stigma

Helpful influences

• Coping resources
• Social support
• Parental non-acceptance
• Peer bullying
• Identity concealment and coming out
• Peer non-acceptance
• Victimisation
• Gender non-conformity
• Normative stressors
• Minority stress correlated to self-compassion (r = .29)
• Self-compassion correlated to psychological distress (r = -.59) and wellbeing (r = -.50)
• Self-acceptance correlated to mental health outcomes
• Self-esteem significantly correlates with mental distress

Evidence-Based Interventions for LGBTQ+

Intervention History

• In the 1960/70s, early treatment research focused on eradicating sexual attractions and behaviors, but had weak evidence
• In the 1980/90s, oppositional parties launched a parallel affirmative movement
• The HIV/AIDS epidemic in the 1980/90s increased public attention to physical and mental health
• In the 2000s, intervention models began to be informed by minority stress theory
• In the 2000/10s, specialized interventions were developed, and universal interventions were optimized

Universalised Interventions

• Culturally relevant and responsive to LGBTQ+ clients
• Addresses social inequities on LGBTQ+ peoples lives
• Fosters autonomy
• Enhances resilience
• Advocacy to reduce systemic barriers
• Leverages LGBTQ+ client strengths
• Important aspects of the intervention:
  • Clinicians knowledgeable of impact of stigma & minority stress
  • No identity matching
  • Forming respectful positive client therapist dynamics
  • Knowing how to integrate sexual and gender identity into clinical work
• 232 past RCT anx/dep interventions, only 1 reported sexual orientation
• Often there is low recording of sexual orientation and gender identity

Experienes

• Significant barriers to accessing care
• Restricted treatment pathways
• There is a reliance on a charitable sector
• NHS LGBT+ Action plan aims to develop & improve services
• Need for culturally sensitive care and clinician competency building
• Summary of other findings:
  • Not trying to change identity
  • Educate and work on yourself
  • Creating supportive environements
  • Use pronouns
  • Watch for pathologising statements
  • Use more validation than usual
• Utilise self-disclosure when appropriate
• Ask and invite space for it
• Build safety and context
• Clear about confidentiality
• Laws that protect against hate crimes
• Interaction and connection with other LGBTQ+ people
• Family, friends, and staff who support, stand up for, accept, support and advocate for LGBTQ+ people
• Seeing LGBTQ+ people portrayed realistically in the media and in public
• Do not assume heterosexual or cisgender
• Do not assume identity is stable
• Do not conflate or play down the interrelationship between sexual orientation and gender
• Introduce pronouns
• Gender neutral language and less reference to gender

Key Practice Points

• Therapists must:
  • Be aware of support needs of GSM youth
  • Balance supporting GSM youth in cis-heterosexism
  • Ask early about gender identity and sexual orientation, consulting on how to intergrate
  • Create a relaxed and inclusive therapeutic atmosphere for GSM individuals

Guidelines

• Respect diverse backgrounds and responsibilities
• Support self-determination of clients
• Should reflect limits of practice when working with LGBTQ+
• Should reflect limits of practice when working with LGBTQ+, consider refeerals
• NHS talking provides
  • Improves visibility and access
  • Collect socio-demo info
  • Disclose pronouns
  • Secure client data
  • Provides reasonable adaptions - Creates safe private space
    • Utilise supervision
• Themes for intervention include:
  • Improving minority stress
  • Promoting resilience - Fostering supportive discussions
    • Focus on identity formation
    • Acceptance

Specialised Interventions

• LGBTQ-Affirmative CBT (Adults; Pachankis et al., 2020) 3 modules with 10 sessions: Intro of minority stress
• There are various efficacy studies
• Works great with clients experiencing high minority stress • -Efficacious online (Yi et al., 2024) Implementation research (Pachankis et al., 2022)
• AFFIRM (Affirmative CBT for youth; Austin et al., 2018; Craig et al., 2021; 2018) 8 modules: Intro to CBT Learning to manage with transphobic attitudes; learning skills for managing feelings; development starts with paper studies
• Rainbow SPARX (gamified CBT; Lucassen et al., 2021; Lucassen et al., 2023) • 7 modules (30 mins per individual session) • Relaxation training • Behavioural activation • Recognising or naming cognitive distortions • Problem solving and • Cognitive restructuring

Therapies

• Third-Wave CBT Approaches and Similar Dialectical Behaviour Therapy (DBT) (Camp et al., 2023; Camp et al., 2024; Cohen et al., 2021; Skerven et al., 2021; Stock, Lea, & Camp, in prep; Tilley et al., 2022) • Other Mindfulness-Based Interventions (Sun et al., 2022; Tan, 2008) LGBTQ - Affirmative DBT:
• Utilise DBT skills to manage minority stres
• Ensure the environment validates the client
• Balance coping with current methods

Health Care Surrounding Gender Diverse/Expansive and Questioning Youth

• Models of Gender-Related Care: Traditional Affirmative Approaches Conversion Approaches Exploratory Approaches
• Potential known and unknown negative consequences of physical interventions. Cass Review/Report (2014) Recommendation:
• Provide adequate support channels
• MDT assessments required
• Provide holistic/individual care plans
• Increase research