Chapter 20 Understanding Health and Mental Health Factors Impacting the LGBTQ Community Authors sarah r young phd msw Marcie fisherborne phd msw mph 1 Chapter 20 Understanding health and mental health factors impacting the ID: 935196
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Social Work Practice with the LGBTQ Community: The Intersection of History, Health, Mental Health and Policy FactorsChapter 20: Understanding Health and Mental Health Factors Impacting the LGBTQ Community
Authors: sarah r. young, phd, mswMarcie fisher-borne, phd, msw, mph
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Chapter 20: Understanding health and mental health factors impacting the
lgbtq
community Oxford University Press
Slide2Chapter 20: Key ComponentsFraming health and mental health, moving away from a pathology perspective, and examining barriers and access to care;Examining major factors that impact LGBTQ health and mental health, including: socioeconomic status, rural and urban health concerns, stress and stigma, and sub-population specific health and mental health concerns; Key policy considerations, with a focus on the ACA and demographic data;
Promising practices for reframing LGBTQ mental health;Two case scenarios with questions for consideration;Pertinent national resources with web links and a listing of all references cited2
Chapter 20: Understanding health and mental health factors impacting the lgbtq community Oxford University Press
Slide3Framing health: Understanding uniqueness and intersectionality The LGBTQ community is not homogenous.Age, socioeconomic status, race, geographic location, ability, nationality, and other factors impact health.Intersection of these experiences and identities (intersectionality) impact health care and access.
Intersections of identities and experiences may create varying healthcare needs. For example, the healthcare needs of a low-income, middle-aged white lesbian in the rural South may be distinct from the needs of a young, African American, middle-class lesbian living in an urban area of the Northeast.Chapter 20: Understanding health and mental health factors impacting the lgbtq community Oxford University Press
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Slide4Moving away from a pathology perspectiveLGBTQ health issues and research on health disparities have focused on disease, risk, and/or deviance.The focus on pathology means that well-being and resilience in the LGBTQ community has not always been recognized.Unequal burden of disease should be recognized and addressed, but should not be framed solely as a “laundry list” of illnesses and deficiencies.
Social work has also emphasized pathology within the LGBTQ community.This focus has largely ignored how the larger social environment (including stigma, discrimination, and policy) can impact LGBTQ health and wellness.Social work may be in a unique professional position to reinforce and build wellness and resilience with LGBTQ clients.Chapter 20: Understanding health and mental health factors impacting the lgbtq community Oxford University Press
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Slide5Understanding access and barriers to care and utilizationSocial and structural forces may impact LGBTQ health and mental health.For example, LGB people living in states with anti-same-sex marriage amendments had significant increases in anxiety and substance disorders compared to LGBT people living in states without these amendments (Hatzenbueler, 2010).Also, in states that enacted pro-same-sex marriage laws there were lower levels of psychological distress and reduced medical and mental health care visits (Russ et al., 2012).
Identity, mental health, and the DSMAlthough homosexuality was removed from the DSM in 1973, the legacy of diagnosing LGBTQ people as “ill” and “deviant” has influenced the community’s interaction and experience with mental health care.Transgender people, whose sex assigned at birth does not align with their gender identity, may still be diagnosed with gender dysphoria in the current DSM-5
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Slide6Understanding access and barriers to care and utilizationReparative therapyThis “therapy” aims to change or “fix” LGBTQ people, instead of supporting and affirming them, and has been instead shown to cause harm to mental health.This approach has been widely discredited by major professional governing bodies, including the National Association of Social Workers (NASW), the Council of Social Work Education (CSWE), the American Psychological Association (APA) among many others.The role of health care providers
Although homosexuality was removed from the DSM in 1973, the legacy of diagnosing LGBTQ people as “ill” and “deviant” has influenced the community’s interaction and experience with mental health care.Transgender people, whose sex assigned at birth does not align with their gender identity, may still be diagnosed with gender dysphoria in the current DSM-5.Chapter 20: Understanding health and mental health factors impacting the lgbtq community Oxford University Press
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Slide7Factors that impact health and mental healthIt is natural, and sometimes key, to focus on the health and mental health of the individual in social work treatment and practice.This can include examining specific health and mental health histories of clients.It can also include examining disparate health and mental health outcomes for populations, such as prevalence of disease and mental health diagnoses.The NASW Code of Ethics, however, also implores social workers to challenge
systems that oppress and undermine the well-being of minority groups.This section will examine the following macro-level factors: socioeconomic status, rural vs. urban location, and stress and stigma.This section will close with an examination of gay-, lesbian-, bisexual-, and transgender-specific health concerns.Chapter 20: Understanding health and mental health factors impacting the lgbtq community Oxford University Press
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Slide8Socioeconomic statusPoverty and income inequality are associated with poorer health outcomes in the general population.This can include higher rates of infant mortality, shorter life expectancy, and higher rates of obesity, diabetes, and heart disease (Bravemen et al., 2010).Despite the stereotype that the LGBTQ community is predominately affluent, LGBTQ people experience poverty at higher rates
than their heterosexual and cisgender peers.Gallup polling found that LGBT-identified women and men had poverty rates of 21.5% and 20.1% respectively, compared to heterosexual and cisgender women and men, who had poverty rates of 19.1% and 13.4% respectively (Gates & Newport, 2012).Children of same-sex couples are twice as likely to be living in poverty compared to married, different-sex couples, with African American children of gay male parents having the highest poverty rate of 52.3% (Badgett et al., 2013).
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Slide9Rural and urban health-related concernsLGBTQ people live in rural areas, despite the myth that they do not.Rural LGBTQ people have unique health concerns, such as lower access to primary care providers, higher risk health behaviors such as smoking and drinking, and higher rates of diabetes and asthma compared to their urban peers (Hartley, 2004).Some of these behaviors may be the result of coping with a variety of stressors such as isolation and rejection.LGBTQ people living in urban areas also have unique health and mental healthcare needs.
Some studies have found higher rates of healthcare utilization compared to rural counterparts, which corresponds to lower health risk-taking behaviors (Horvath et al., 2014).Despite the significant impact of HIV on gay, bisexual, and trans communities in cities, community support and resilience may offer support. This level of community support may not be possible in rural areas (Stall et al., 2008).Chapter 20: Understanding health and mental health factors impacting the lgbtq community Oxford University Press
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Slide10Stress and stigmaSocial workers should pay attention to people who live at the margins of multiple oppressed identities.Minority Stress Theory, detailed in Chapter XX, can help us understand the health and mental health of our clients with multiple oppressed identities.Family can be a source of stress and stigma for LGBTQ people.Youth from families that are “highly rejecting” of their LGBTQ identity have an 8.5 times higher likelihood of suicide attempts compared to youth from “highly accepting” families (Ryan, 2010).
Fostering family acceptance of their LGBTQ child is one way to reduce stress and stigma. Social workers should learn about family acceptance and how to foster it, as it can greatly improve health and mental health of LGBTQ people.Chapter 20: Understanding health and mental health factors impacting the lgbtq community Oxford University Press
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Slide11Population-specific health concernsThe LGBTQ community is not homogenous, and neither are the health and mental health experiences and needs of its sub-populations.It is important for social workers to know the specific risks and health challenges that disproportionately impact sub-populations within the LGBTQ community.At the same time, social workers should balance this knowledge with equally important information about strengths, resiliency, and macro/structural (as opposed to just individual) causes of these health challenges.
The Gay and Lesbian Medical Association has useful information about the health care concerns of gay, lesbian, bisexual, and transgender people. Chapter 20: Understanding health and mental health factors impacting the lgbtq community Oxford University Press
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Slide12Lesbian health and mental health concernsLesbians have distinct health needs.These include higher rates of tobacco use (Nyitray et al., 2006), higher rates of obesity and lower rates of exercise compared to heterosexual women (Brittain et al., 2006).Some of these needs are tied to structural issues, such as experiences of stress and stigma (
Brittain et al., 2006).Lesbians also have distinct mental health needs.In some studies, lesbians report higher rates of anxiety and depression, related to chronic stress and discrimination (Poteat, 2012).Chronic stress and discrimination is also related to heavy drinking behaviors (Poteat, 2012).More information on lesbian-specific health and mental health concerns can be found in Chapter X of this text.
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Slide13Gay men’s health and mental health concernsGay men have distinct health needs.This includes higher rates of HIV and Hepatitis (Centers for Disease Control and Prevention, 2015) and higher rates of cancers such as anal, prostate and colon (World Health Organization, 2010).The ability for gay men to be out about their sexual orientation and sexual behaviors is key to receiving comprehensive care. It is crucial for health care providers to be competent and affirming in order for their clients to be able to disclose their sexual orientation.
Gay men also have distinct mental health needs.This includes higher rates of some eating disorders, depression and anxiety (Carper et al., 2010; Mosher et al., 2005; Wichstrom, 2006).It is equally as important for therapists and other mental health care providers to be affirming and competent when working with gay men.More information on gay men’s health concerns can be found in Chapter X of this text.Chapter 20: Understanding health and mental health factors impacting the lgbtq community Oxford University Press
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Slide14Bisexual health and mental health concernsBisexuals have distinct health needs.Bisexual women are more likely to be uninsured compared to heterosexuals, gays, and lesbians (Diamant et al., 2000).Bisexual men who have male sexual partners report higher rates of colon cancer and HIV, similar to rates of gay men and other men who have sex with men (Winn, 2012).Bisexuals also have distinct mental health needs.
This includes intimate partner violence, which disproportionately impacts bisexual men and women (VanKim & Padilla, 2010).More information on bisexual health and mental health needs can be found in Chapter X of this text.Chapter 20: Understanding health and mental health factors impacting the lgbtq community Oxford University Press
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Slide15Transgender health and mental health concernsTransgender people have distinct health needs.Some transgender people wish to medically transition (for example, with hormones or surgeries). Not all transgender people have access to or financial means to medically transition in the ways they wish.Not all transgender or gender non-conforming people want to transition medically. Transgender people face discrimination, misunderstanding, and at times denial of health care by providers (Grant et al., 2011).
Transgender people also have distinct mental health needs.This includes higher rates of suicide attempts and ideation (Grossman & D’Augelli, 2007) and experiences of violence (Stoltzer, 2009).It is unclear how current discriminatory “bathroom bills”, which mandate that transgender people use the restroom corresponding to the sex assigned at birth, will impact the mental health of transgender people.More information on transgender-specific health and mental health concerns can be found in Chapter X of this text.
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Slide16Examining key policy considerationsThe Affordable Care Act expands health insurance and non-discrimination protection for the LGBTQ community.The LGBTQ community is less likely to be insured compared to heterosexual people, with 52% of transgender adults having health coverage (Krehely, 2009). Same sex couples with children are also less likely to have health insurance coverage compared to heterosexual couples (Buchmueller & Carpenter, 2010).
The ACA includes several LGBT non-discrimination protections, including:Protection based on gender identity for insurance purchased through the marketplace.Protection for people who are HIV+, who can no longer be denied coverage based on their status.Bans on denying visitation to partners of same-sex patients.In addition, any health care facility receiving federal funding (hospitals, primary care clinics, etc.) are banned from discriminating against the LGBTQ community.Chapter 20: Understanding health and mental health factors impacting the lgbtq community Oxford University Press
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Slide17Examining key policy considerationsDo Ask: Do Tell—Why Demographic Data MattersSeveral key reports (IOM, 2011; Healthy People 2020) suggest the standardization and increased collection of data on sexual orientation and gender identity/expression are critical for health care.Collecting such data will create a more accurate picture of LGBTQ people and highlight their unique health needs (Cahill & Makadon, 2013).
Several tested questions can assist social work providers in gathering clinically relevant information (from Cahill et al., 2014), such as:Do you think of yourself as: lesbian, gay or homosexual?; Straight or heterosexual? Bisexual? Something else (please specify)? Don’t know?What sex were you assigned at birth on your original birth certificate? Male? Female? Decline to answer?Additional relevant questions can be found in Table 1 from this chapter.Chapter 20: Understanding health and mental health factors impacting the lgbtq community Oxford University Press
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Slide18Reconceptualizing mental healthPublic discourse and media attention often focus on the most challenging or violent aspects of LGBTQ mental health, such as suicide and victimization.This skewed focus means that inherent strengths and resiliency may not get recognized.This link between pathology and minority sexual orientation and gender identity may be harmful to LGBTQ people’s mental well-being and may skew the treatment they receive from social work professionals.
A reconceptualization in mental healthcare for the LGBTQ community is needed.This could focus, in part, on fostering resilience, family acceptance, and connection with faith/spiritual communities.Chapter 20: Understanding health and mental health factors impacting the lgbtq community Oxford University Press
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Slide19Identifying and building resilienceLGBTQ people often demonstrate resilience in the face of discrimination.Older LGBTQ people have come of age during a time when discrimination and prejudice were more pronounced or legally sanctioned, and have often demonstrated great resilience (Dentato et al., 2014). LGBTQ people of all ages may be demonstrating resilience, but research tell us less about resilience and predicting what can build health for LGBTQ youth and adults (Russell, 2005).
Social workers should understand and build resilience with LGBTQ clients, and not simply focus on challenges or deficits.LGBTQ clients with multiple intersecting identities should be supported in developing resilience against multiple oppressions and –isms.Russell (2005) reminds us that “the majority of sexual minority young people grow up to be health and contributing members of society despite widespread heterosexism and homophobia.” (p. 8).Chapter 20: Understanding health and mental health factors impacting the lgbtq community Oxford University Press
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Slide20Promoting family acceptance for mental wellnessFamily acceptance of their LGBTQ child or family member should be viewed as a spectrum, from highly accepting to highly rejecting (Ryan, 2010).Ryan (2010) has demonstrated a range of behaviors that can cause harm (such as forcing an LGBTQ child to hide their identity) and can be helpful in showing acceptance (such as the parent learning more about the LGBTQ community and their child’s needs).Family acceptance has been associated with more positive mental health outcomes.
The Family Acceptance Project is a resource for families and practitioners alike.Social workers should work with families to foster acceptance, even in families that may be highly rejecting.Referrals to community-based support groups, like Parents Families and Friends of Lesbians and Gays (PFLAG) may be helpful for families that could benefit from peer-to-peer support.Chapter 20: Understanding health and mental health factors impacting the lgbtq community Oxford University Press
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Slide21Connecting with faith and spiritual communitiesFor those who choose to participate, faith/religious communities and traditions can have a positive influence on a person’s mental health.LGBTQ people have not always been welcomed in religious communities, and according to Pew Research Center most LGBTQ people surveyed felt that most major religions have negative views of LGBT people (Murphy, 2015).Despite discrimination, LGBTQ people identify as people of faith at similar rates to the general population, although they may face unique barriers to full inclusion within their faith (Murphy, 2015).
Social workers should assess the role that faith/spirituality, whenever appropriate, plays in the life of the client.Not all LGBTQ people are religious/spiritual, but social workers should not assume that no LGBTQ people are religious/spiritual due to the public exclusion of LGBTQ people from some major religions and denominations.Social workers can assess the desired role a client wishes to have with a faith community, and can refer the client to LGBTQ-affirming places of worship whenever appropriate.
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Slide22ConclusionsThe LGBTQ community is NOT homogenous, and neither are the health and mental health needs of this community.Social work practitioners are well-positioned to refocus the conversation and subsequent interventions on more than just pathology and disease.
People and systems that were once thought of as “dead ends” of support, such as faith and family systems, may hold possibilities to build physical and mental health for LGBTQ clients.A number of new policies and trends (such as the Affordable Care Act and more consistent data collection) may mean better health and wellness outcomes for future LGBTQ people.Chapter 20: Understanding health and mental health factors impacting the lgbtq community Oxford University Press
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Slide23Case ScenariosThe following case scenarios will highlight some potential practice challenges when working with LGBTQ clients on health and mental health issues.The cases may be used as in-class group assignments or for homework based on the needs of the course.Each case is followed by several questions for consideration.
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Slide24Case Scenario 1: AngelAngel is a social work student who has an internship in an LGBTQ health clinic. She is very motivated to work with LGBTQ clients, and has learned as much as she can from textbooks about the specific health and mental health needs of this population. She is assigned her first client, Jada, who is a 32 year old African American transgender woman who is experiencing temporary homelessness. Angel’s job is to provide a routine intake assessment to see what health and mental health needs Angel may have that the clinic can assist with. Angel knows that transgender women often experience violence and discrimination. She also knows that transgender women may be at risk for HIV and also will want to explore hormone replacement in order to physically transition. To prepare for her first meeting with Jada, Angel has a number of brochures (on HIV prevention, medical transitions for transgender women, and violence prevention) that she will give to Jada right away and discreetly, in hopes that it helps Jada and shows that Angel understands her needs.
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Slide25Case Scenario 1: Questions for ConsiderationConsider the following questions with regard to Angel’s work with Jada:What are your impressions of Angel’s initial approach to joining with Jada? Are there strengths that you noticed in Angel’s approach? Are there challenges or weaknesses in Angel’s approach? Imagine you are Angel. How might you approach Jada differently?
Does Angel’s approach assume pathology or resilience in her client? Explain your answer.Are there resources that Angel may want to consider linking Jada to? Chapter 20: Understanding health and mental health factors impacting the lgbtq community Oxford University Press
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Slide26Case Scenario 2: GeraldGerald is a 24 year old white, bisexual, cisgender male who lives in a rural area of your state. He is recently divorced from his wife of six years whom he married right out of high school. He recently disclosed to his ex-wife that he identifies as bisexual and although she was supportive of his identity she no longer wanted to be married to him and initiated the divorce. His ex-mother-in-law disclosed to his church members that he identifies as bisexual and he has been shunned from his church, which was an important social support for him. Gerald is experiencing panic attacks because he is afraid he may be fired for being bisexual. To ease the symptoms of his anxiety, he has begun to drink heavily after work. He would like to explore dating men, but he expresses that he never received sexual health education in school and he is afraid of HIV and other STIs. He has no idea how to meet a boyfriend, and the closest gay bars and community centers are about an hour’s drive from his hometown. He feels as though his life is spinning out of control and he asks for your help as a social worker.
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Slide27Case Scenario 2:Questions for ConsiderationConsider the following questions with regard to your work in therapy: How would you attempt to build a therapeutic alliance with Gerald? In what ways is the macro or structural environment impacting Gerald’s health and mental health?
What are some immediate health and mental health needs that you notice from Gerald’s case scenario? How might you begin to address these needs with Gerald?Are there examples of resilience or support that you notice in Gerald’s case? How might you assess for additional resilience or support with Gerald in order to build health and wellness?Chapter 20: Understanding health and mental health factors impacting the lgbtq community Oxford University Press
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Slide28National Resources and Web LinksInstitute of Medicine: Health of Lesbian, Gay, Bisexual, and Transgender Peoplehttp://thefenwayinstitute.org/research/iom-report/Gay and Lesbian Medical Association (GLMA)http://www.glma.org/
The Family Acceptance Projecthttp://familyproject.sfsu.edu/The Fenway Institute at Fenway Health: Advancing Lesbian, Gay, Bisexual, and Transgender Healthhttp://fenwayhealth.org/the-fenway-institute/Chapter 20: Understanding health and mental health factors impacting the lgbtq community Oxford University Press
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Slide29ReferencesBadgett, M.V., Durso, L.E., & Sheneebaum, A. (2013). New patterns of poverty in the lesbian, gay, and bisexual community. Los Angeles: The Williams Institute. Braverman
, P.A., Cubbin, C., Egerter, S., Williams, D.R., & Pamuk, E (2010). Socioeconomic disparities in health in the United States: What the patterns tell us. American Journal of Public Health (S1) 100. S186-S196.Brittain, D.R., Baillargeon, T., McElroy, M., Aaron, D.J., & Gyurcsik, N.C. (2006). Barriers to moderate physical activity in adult lesbians. Women Health, 43(1), 75–92.
Buchmueller T, Carpenter CS. (2010). Disparities in health insurance coverage, access, and outcomes for individuals in same-sex versus different-sex relationships, 2000-2007. American Journal of Public Health. 100
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Slide30ReferencesDentato, M.P., Orwat, J., Spira, M., & Walker, B. (2014). Examining cohort differences and resilience among the aging LGBT community: Implications for education and practice among an expansively diverse population. Journal of Human Behavior in the Social Environment, 24
. 316-238.Diamant, A.L., Wold, C., Spritzer, K., & Gelberg, L. (2000). Health behaviors, health status, and access to and use of health care: A population-based study of lesbian, bisexual, and heterosexual women. Archives of Family Medicine, 9(10), 1043-1051.Gates, G.J. & Newport, F. (2012). Special report: 3.4% of U.S. Adults Identify as LGBT. Gallup Polling. Accessed from:
www.gallup.com/poll/158066/special-report-adults-identify-lgbt-aspx.Grant, J.M., Mottet
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Slide31ReferencesHorvath, K.J., Iantaffi, A., Swinburne-Romine, R., & Bockting, W. (2014). A comparison of mental health, substance use, and sexual risk behaviors between rural and non-rural transgender persons. Journal of Homosexuality, 61. 1117-1130.
Institute of Medicine. (2011). The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: The National Academies Press.Krehely, J. (December 21, 2009). The Center for American Progress, “How to Close the LGBT Health Disparities Gap,” Retrieved from https://www.americanprogress.org/issues/lgbt/report/2009/12/21/7048/how-to-close-the-lgbt-health-disparities-gap/Mosher, W.D., Chandra, A., Jones, J., 2005. Sexual behavior and selected health measures: men and women 15–44 years of age, United States, 2002. : Advance Data from Vital and Health Statistics, 362. National Center for Health Statistics, Hyattsville, MD.Murphy, C. (2015). Lesbian, gay and bisexual Americans differ from general public in their religious affiliations. Pew Research Center. Retrieved from http://www.pewresearch.org/fact-tank/2015/05/26/lesbian-gay-and-bisexual-americans-differ-from-general-public-in-their-religious-affiliations/
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, T. (2012). Top 10 things lesbians should discuss with their healthcare provider. Gay and Lesbian Medical Association. Accessed from:
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Slide32ReferencesRyan, C., Russell, S.T., Huebner, D., Diaz, R., & Sanchez, J. (2010). Family acceptance in adolescence and the health of LGBT young adults. Journal of child and adolescent psychiatric nursing,23(4), 205-213. doi: 10.1111/j.1744-6171.2010.00246xStall, R., Friedman, M., & Catania, J. A. (2008). Interacting epidemics and gay men’s health: a theory of
syndemic production among urban gay men.Unequal opportunity: Health disparities affecting gay and bisexual men in the United States, 1, 251-274.Stotzer, R. L. (2009). Violence against transgender people: A review of United States data. Aggression and Violent Behavior, 14
(3), 170-179.VanKim, N.A. & Padilla, J.L. (2010). New Mexico’s progress in collecting lesbian, gay, bisexual, and transgender health data and its implications for addressing health disparities. Albuquerque, NM: New Mexico Department of Health, Chronic Disease Prevention and Control Bureau.
Wichstrom
, L., 2006. Sexual orientation as a risk factor for bulimic symptoms. International Journal of Eating Disorders 39, 448–453.
Winn, R.J. (2012).
Ten things bisexuals should discuss with their healthcare provider.
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World Health Organization. (2010). Hepatitis: frequently asked questions. Retrieved from:
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