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Working with Sexual Minority Veterans: Clinical Issues Affecting Lesbian, Gay, Bisexual and Transgendered Veterans. Katherine Hoerster Ph.D., Seattle (Postdoc) Linda R. Mona Ph.D., Long Beach Miguel Ybarra Ph.D., San Antonio Monica Roy Ph.D., Boston and the

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Working with Sexual Minority Veterans: Clinical Issues Affecting Lesbian, Gay, Bisexual and Transgendered Veterans

Katherine Hoerster Ph.D., Seattle (Postdoc)

Linda R. Mona Ph.D., Long Beach

Miguel Ybarra Ph.D., San Antonio

Monica Roy Ph.D., Boston

and the

Multicultural & Diversity Committee (2010-2011)

VA Psychology Training Council

Contact persons: 

Daryl Fujii Ph.D., Honolulu ([email protected])

Rachael Guerra Ph.D., Palo Alto ([email protected])


Multicultural diversity committee
Multicultural/Diversity Committee Affecting Lesbian, Gay, Bisexual and Transgendered Veterans

Committee 2010-2011

Loretta E. Braxton Ph.D., Durham (Co-Chair)

Linda R. Mona Ph.D., Long Beach (Co-Chair)

Angelic Chaison Ph.D., Houston

Daryl Fujii Ph.D., Honolulu

Rachael Guerra Ph.D., Palo Alto

Jamylah Jackson Ph.D., North Texas

Monica Roy Ph.D., Boston

Christina Watlington Ph.D., Perry Point

Miguel Ybarra Ph.D., San Antonio

Susana Blanco Ph.D., Bedford (Postdoc)

Nancy Cha, Honolulu (Intern)

Paul Lephuoc, Houston (Intern)

Katherine Hoerster Ph.D., Long Beach (Postdoc)


Module objective
Module Objective Affecting Lesbian, Gay, Bisexual and Transgendered Veterans

  • The purpose of this module is to review the empirical literature relevant to providing clinical care to Lesbian, Gay, Bisexual, and Transgendered (LGBT) Veterans


Agenda
Agenda Affecting Lesbian, Gay, Bisexual and Transgendered Veterans

  • APA Guidelines

  • Definition of terms

  • Demographic distribution

  • Health and mental health disparities

  • Political context

  • Clinical implications

  • Transgendered Veterans

  • General considerations

  • Experiential exercises

  • Questions

  • References and resources


American psychological association guidelines
American Psychological Association Affecting Lesbian, Gay, Bisexual and Transgendered Veterans Guidelines

  • APA Guidelines Provide:

    • “(1) a frame of reference for the treatment of lesbian, gay, and bisexual clients and

    • (2) basic information and further references in the areas of assessment, intervention, identity, relationships, diversity, education, training, and research.” 

    • Outlined in 21 guidelines

      • E.g., “Psychologists strive to understand the effects of stigma (i.e., prejudice, discrimination, and violence) and its various contextual manifestations in the lives of lesbian, gay, and bisexual people”

American Psychological Association. (2011). Guidelines for psychotherapy with lesbian,

gay, and bisexual clients. Retrieved March 28, 2011 from:

http://www.apa.org/pi/lgbt/resources/guidelines.aspx


American psychological association guidelines1
American Psychological Association Affecting Lesbian, Gay, Bisexual and Transgendered Veterans Guidelines

  • Domains include:

    • understanding that LGB orientations are not mental illnesses

    • efforts to change sexual orientation have not been shown to be effective or safe

    • recognizing how providers’ attitudes and knowledge about LGB issues may be relevant to assessment and treatment and seek consultation or make appropriate referrals when indicated

    • recognizing the unique experiences of bisexual individuals

    • distinguishing issues of sexual orientation from those of gender identity

    • understanding the ways in which a person's LGB orientation may have an impact on his/her family of origin and the relationship with that family of origin

    • recognizing the challenges related to multiple and often conflicting norms, values, and beliefs faced by LGB members of racial and ethnic minority groups

    • considering the influences of religion and spirituality in the lives of LGB persons

    • including LGB issues in professional education and training

American Psychological Association. (2011). Guidelines for psychotherapy with lesbian,

gay, and bisexual clients. Retrieved March 28, 2011 from:

http://www.apa.org/pi/lgbt/resources/guidelines.aspx


Definition of terms
Definition of Terms Affecting Lesbian, Gay, Bisexual and Transgendered Veterans

  • Gay: used to refer to a same-gender orientation, often used for men

  • Lesbian: used to refer to a same-gender orientation, often used for women

  • Bisexual: used to refer to a man or woman who is sexually attracted to members of the opposite gender and to members of the same gender

  • Transgendered: used to refer to individuals whose gender identity does not match their sex

  • Queer: a more recent and more politically-oriented self-identifier for gay men and women

  • Questioning: a term used for individuals that are seeking more insight into their sexual orientation

Haldeman, D. C., & Buhrke, R. A. (2003). Under a rainbow flag: The diversity of sexual

orientation. In Robinson, J. D. & James L. C. (Eds.) Diversity in human interactions: The

tapestry of America (145-156). New York: Oxford University Press.


Definition of terms1
Definition of Terms Affecting Lesbian, Gay, Bisexual and Transgendered Veterans

  • Homophobia: a term used to describe an irrational fear of gay men and lesbians

  • Heterosexism: a conscious or unconscious preference for individuals who self-describe as heterosexual

  • Transphobia: a term used to describe an irrational fear of transgendered individuals

  • LGB: term used to refer to lesbian, gay, and bisexual individuals

  • LGBT: term used to refer to lesbian, gay, bisexual, and transgendered individuals

Haldeman, D. C., & Buhrke, R. A. (2003). Under a rainbow flag: The diversity of sexual

orientation. In Robinson, J. D. & James L. C. (Eds.) Diversity in human interactions: The

tapestry of America (145-156). New York: Oxford University Press.


Definition of terms2
Definition of Terms Affecting Lesbian, Gay, Bisexual and Transgendered Veterans

  • Sexual Identity: refers to how an individual interprets their own sexual and affiliative attractions and experiences

    • Everyone measures themselves on the constructs of sexual identity, sexual orientation, and gender identity

  • Coming out: a deliberate decision-making process regarding whether to disclose sexual identity and/or sexual orientation

Haldeman, D. C., & Buhrke, R. A. (2003). Under a rainbow flag: The diversity of sexual

orientation. In Robinson, J. D. & James L. C. (Eds.) Diversity in human interactions: The

tapestry of America (145-156). New York: Oxford University Press.


Definition of terms3
Definition of Terms Affecting Lesbian, Gay, Bisexual and Transgendered Veterans

  • Several terms define relationships in purely behavioral terms

    • Heterosexual and homosexual

    • Men who have sex with men (MSM); Women who have sex with women (WSW)

      • MSM grew out of HIV and sexual risk literature and WSW followed

  • Using these terms is problematic because they ignore the following:

    • A continuum of sexual desire and sexual behavior (not discrete)

    • Broad identity that goes beyond sexual behavior and desire

    • Relationships are more than sexual desire and behavior

    • Broad communities and networks beyond individual relationships

    • Labels used by gay, lesbian, and bisexual individuals

Young, R.M., & Meyer, I. (2005). The trouble with “MSM” and “WSW”: Erasure of the sexual-minority person in public health discourse. American Journal of Public Health, 95, 1144-1149.


Lgb veteran and service member demographics
LGB Veteran and Service Member Demographics Affecting Lesbian, Gay, Bisexual and Transgendered Veterans

  • 35,000 LGB Active Duty and 65,000 Guard and Reserve

    • 2.8% of military personnel

  • Rates of service higher for coupled lesbians than for straight women; the opposite is true for coupled gay men

  • Nearly one million lesbian and gay Veterans

    • Regional concentrations

Gates, G. (2004) Gay men and lesbians in the U.S. military: Estimates from Census 2000. Washington, DC: The Urban Institute.


Regional distribution of gay and lesbian veterans
Regional Distribution of Gay and Lesbian Veterans Affecting Lesbian, Gay, Bisexual and Transgendered Veterans

Gates, G. (2004) Gay men and lesbians in the U.S. military: Estimates from Census 2000. Washington, DC: The Urban Institute.


Disparities overview
Disparities Overview Affecting Lesbian, Gay, Bisexual and Transgendered Veterans

  • U.S. Department of Health and Human Services Healthy People 2010 priority

  • Called for large-scale efforts to identify and address disparities affecting LGBT populations in:

    • healthcare access

    • physical and lifestyle-related illness (e.g., tobacco use, substance use, HIV)

    • mental health and suicide

      Gay and Lesbian Medical Association and LGBT health experts. (2001). Healthy People 2010 Companion document for lesbian, gay, bisexual, and transgender (LGBT) health. San Francisco, CA: Gay and Lesbian Medical Association.


Disparities overview1
Disparities Overview Affecting Lesbian, Gay, Bisexual and Transgendered Veterans

  • 2001 – 2008 Massachusetts Behavioral Risk Factor Surveillance Survey (n=67,359)

    • LGB more likely than straight individuals to report asthma, activity limitation, smoking, drug use, tension or worry, and lifetime sexual victimization

    • Bisexual: more likely to report cardiovascular disease risk, sadness, past-year suicidal ideation, and barriers to care

      • Binge drinking and lifetime intimate partner victimization more common among bisexual women

    • Gay men: less likely to be overweight and to obtain prostate test

    • Lesbian women: more likely to be obese and report multiple risks for cardiovascular disease

      Conron, K.J., et al. (2010). A population-based study of sexual orientation identity and gender differences in adult health. American Journal of Public Health, 100, 1953-1960.


Mental health disparities
Mental Health Disparities Affecting Lesbian, Gay, Bisexual and Transgendered Veterans

  • Suicide attempts

    • Two-fold excess in lesbian, gay, and bisexual (LGB) people

    • Suicide attempt especially high in bisexual and gay men

  • 12-month or lifetime anxiety or depression

    • 1.5 x higher in LGB

  • Substance dependence > 12 mos.

    • 1.5 x higher in LGB

    • Substance dependence especially high in lesbian and bisexual women

      King, M., et al. (2008). A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay, and bisexual people. BMC Psychiatry, 8, 70.


Mental health disparities1
Mental Health Disparities Affecting Lesbian, Gay, Bisexual and Transgendered Veterans

  • High levels of discrimination reported by lesbian, gay, and bisexual (LGB) people

    • Associated with psychiatric distress

      • Distress especially high among those who did not accept discrimination and did not discuss it with others

      • McLaughlin, K., et al. (2010). Responses to discrimination and psychiatric disorders among Black, Hispanic,

        female, and lesbian, gay, and bisexual individuals. American Journal of Public Health, 100, 1477-1484.

  • Risk of PTSD and violence exposure higher among LGB people

    • Roberts, A., et al. (2010). Pervasive trauma exposure among US sexual orientation minority adults and risk of

      posttraumatic stress disorder. American Journal of Public Health, 100, 2433-2441.


Political context stonewall riots
Political Context: Stonewall Riots Affecting Lesbian, Gay, Bisexual and Transgendered Veterans

  • June 27, 1969

  • Police raid on Stonewall Inn, a Greenwich Village gay bar: a common occurrence at that time

  • Met with great resistance from patrons, followed by several days of organized protest

  • Marks the beginning of the gay liberation movement

    Harlin, K. (2004) Stonewall and Beyond:Lesbian and gay culture. The Stonewall Riot and its aftermath. New York City: Columbia University. Retrieved March 7, 2011 from http://www.columbia.edu/cu/lweb/eresources/exhibitions/sw25/case1.html


Political context variation in state protections
Political Context: Variation in State Protections Affecting Lesbian, Gay, Bisexual and Transgendered Veterans

  • States differ in their protections for sexual minorities from (1) hate crimes and (2) employment discrimination

  • Relationship between LGB status and psychiatric distress is significantly stronger in states without those protections

  • Institutional discrimination in the form of state policy impacts psychiatric distress among LGB individuals, highlighting need for policy change

Hatzenbuehler, M., Keyes, K. & Hasin, D. (2009). State-level policies and psychiatric morbidity in lesbian, gay, and bisexual populations. American Journal of Public Health, 99, 2275-2281.


Political context don t ask don t tell dadt
Political Context: “Don’t Ask, Don’t Tell” (DADT) Affecting Lesbian, Gay, Bisexual and Transgendered Veterans

  • Consequences likely numerous during service and following separation

    • access to care

    • chronic and infectious disease management

    • financial consequences of discharge conditions

    • empirical data are limited

    • See Katz, K. (2010). Health hazards of “don’t ask, don’t tell”. New England Journal of Medicine, 363, 2380-1.; and

      Smith, D. (2008). Active duty military personnel presenting for care at a Gay Men’s Health Clinic. Journal of Homosexuality, 54, 277-279.

  • American Psychological Association has long opposed the policy

-American Psychological Association. (2011). Sexual orientation and military service. Retrieved March 28, 2011 from: http://www.apa.org/pi/lgbt/resources/military.aspx


Political context don t ask don t tell dadt1
Political Context: “Don’t Ask, Don’t Tell” (DADT) Affecting Lesbian, Gay, Bisexual and Transgendered Veterans

  • -President Barack Obama signed repeal of DADT in December of 2010, saying "For we are not a nation that says, 'don't ask, don’t tell.' We are a nation that says, 'Out of many, we are one.’”

    • Future relevant issues: Discussion Point

      • Will discrimination continue?

      • What protections will be in place for those who disclose LGB status?

      • Will partner benefits parallel military spousal benefits?

      • Will transgender Veterans be allowed to openly serve?

      • What action will be taken for those dishonorably discharged under DADT?


Clinical implications

Clinical Implications Affecting Lesbian, Gay, Bisexual and Transgendered Veterans


Reasons for seeking treatment
Reasons for Seeking Treatment Affecting Lesbian, Gay, Bisexual and Transgendered Veterans

  • Psychiatric morbidity related to exposure to stressors:

    • Prejudice, discrimination, and violence

  • Mood Disorders (e.g., MDD)

  • Anxiety Disorders (e.g., Panic attacks, PTSD)

  • Substance Use

  • Eating Disorders

  • Suicidality

Kertzner, R.M., Meyer, I.H., Frost, D.M., & Stirratt, M.J. (2009). Social and psychological

well-being in lesbians, gay men, and bisexuals: The effects of race, gender, age, and

sexual identity. American Journal of Orthopsychiatry, 79(4), 500-510.


Barriers in access to care
Barriers in Access to Care Affecting Lesbian, Gay, Bisexual and Transgendered Veterans

  • Women in same-gender relationships:

    • less likely to have insurance

    • less likely to have received medical care in the last 12 months

    • significantly more likely to have unmet medical needs than women in different-gender relationships

Buchmueller, T. & Carpenter, C.S. (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(3), 489-494.


Barriers in access to care1
Barriers in Access to Care Affecting Lesbian, Gay, Bisexual and Transgendered Veterans

  • While men in same-gender relationships are more likely to have insurance, they are more likely to report unmet medical needs, despite having a yearly physical

  • This may be because medical needs differ for men in same-gender relationships than for men in different-gender relationships, and general physical exams may not meet these needs

Buchmueller, T. & Carpenter, C.S. (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(3), 489-494.


Identity development
Identity Development Affecting Lesbian, Gay, Bisexual and Transgendered Veterans

  • Stage theories vs. emergent continuous life process

    • Identity confusion (Who am I?)

    • Identity comparison (I am different)

    • Identity tolerance (I am probably gay)

    • Identity acceptance (I am gay)

    • Identity pride (Gay is good; heterosexuality is bad)

    • Identity synthesis (My gayness is one part of me)

Cass, V.C. (1979). Homosexual identity formation: A theoretical model. Journal of

Homosexuality, 4, 219-235.


Identity development1
Identity Development Affecting Lesbian, Gay, Bisexual and Transgendered Veterans

  • Lesbian identity development

    • Supplements information provided in traditional stage theories; addresses the unique need of females

    • Four phases: awareness, exploration, deepening/commitment, and internalization/synthesis

    • Dual identity process including personal identity and reference group orientation

    • Challenges prevailing ideology that political activism and universal disclosure is equal to synthesis

McCarn, S.R., & Fassinger, R.E. (1996). Revisioning sexual minority identity

formation: A new model of lesbian identity and its implications for counseling and

research. Counseling Psychologists ,24, 508-534.


Identity disclosure in the military
Identity Disclosure in the Military Affecting Lesbian, Gay, Bisexual and Transgendered Veterans

  • Rates of disclosure may vary across settings

  • Direct vs. Indirect Disclosure

    • Revealing sexual orientation openly

  • Indirect Disclosure

    • Mentioning same-sex partner by name

  • Studies on disclosure are not readily available for the military culture

  • Disclosure is selective

  • Supporting factors and barriers to disclosure

Beals, K.P., & Peplau, L.A. (2006). Disclosure patterns within social networks of gay men and

lesbians. Journal of Homosexuality, 51(2), 101-120.


Assessment approaches
Assessment Approaches Affecting Lesbian, Gay, Bisexual and Transgendered Veterans

  • Comprehensively Assess:

    • Behavioral Domain

      • Connectedness with LGB community

      • Unsafe sexual practices, interpersonal violence, substance use

    • Emotional & Cognitive Domain

      • Psychiatric symptoms may lead to difficulties in cognitive functioning (e.g., attention & concentration)


Intervention approaches
Intervention Approaches Affecting Lesbian, Gay, Bisexual and Transgendered Veterans

  • Cognitive Behavioral Therapy (CBT)

    • Group or individual format

    • Offers a non-judgmental, collaborative approach with an emphasis on empowerment for sexual minorities

    • Empirically supported to promote symptom reduction

    • Teaches:

      • Coping strategies for internal and external oppression; promote resilience

      • Skill building for emotional regulation

      • Attunement with internal affective states

Martell, C.R., Safren, S.A., & Prince, S.E. (2004). Cognitive behavioral therapies

with lesbian, gay, and bisexual clients. New York: The Guilford Press.


Treatment philosophy
Treatment Philosophy Affecting Lesbian, Gay, Bisexual and Transgendered Veterans

  • LGB Affirmative therapy

    • “the integration of knowledge and awareness by the therapist of the unique developmental cultural aspects of LGBT individuals, the therapist’s own self-knowledge, and the translation of this knowledge and awareness into effective and helpful therapy skills at all stages of the therapeutic process”

  • Three core conditions:

    • Therapist competence in affirmative therapy

    • Therapist affirmation of LBGT culture

    • Therapist openness in addressing sexual orientaion and identity issues

  • Perez, R. M. (2007). The “boring” state of research and psychotherapy with lesbian, gay, bisexual,

    and transgender clients: Revisiting Baron (1991). In K. J. Bieschke, R. M. Perez, & K. A. DeBord

    (Eds.) Handbook of counseling and psychotherapy with lesbian, gay, bisexual, and transgender

    clients (2nd ed.; pp. 399-418). Washington, DC: American Psychological Association.


    Transgendered Veterans Affecting Lesbian, Gay, Bisexual and Transgendered Veterans


    Disparities transgendered people
    Disparities: Transgendered People Affecting Lesbian, Gay, Bisexual and Transgendered Veterans

    • The National Transgender Discrimination Survey (n=6,450 transgender or gender non-conforming people) documented:

    • Significant discrimination, especially for ethnic and racial minorities (i.e., Black, Latino, Asian, Native American, and Multiracial/Other)

    • 4x more likely than general population to have annual income of <$10,000; 2x higher unemployment

    • 41% had attempted suicide (1.6%, general population)

    • Higher rates of HIV infection, smoking, and drug and alcohol use than the general population

    • 19% report being denied care due to status

    Grant, J.M., et al., J. (2011). Injustice at every turn: A report of the National Transgender Discrimination Survey. Washington, D.C.: National Center for Transgender Equality and National Gay and Lesbian Task Force.


    Mental health professionals treatment for transgendered veterans
    Mental Health Professionals & Affecting Lesbian, Gay, Bisexual and Transgendered Veterans Treatment for Transgendered Veterans

    • As recent research has demonstrated that sexual orientation disclosure is related to positive military unit cohesion, while sexual orientation-based harassment is related to negative military unit cohesion, it is reasonable to expect that more veterans may be inclined to divulge that information to mental health professionals in the VA system.

    • Based on this information, it appears important to consider that disclosure of gender identity issues might also increase within the VA system, requiring a thoughtful preparation for the needed appropriate assessments, treatments, and other interventions before a critical need exists.

      Moradi, B. (2009). Sexual orientation disclosure, concealment, harassment, and military cohesion: Perceptions of LGBT military veterans. Military Psychology, 21, 513-533.


    Treatment for transgendered veterans
    Treatment for Transgendered Veterans Affecting Lesbian, Gay, Bisexual and Transgendered Veterans

    10 tasks for mental health gender specialists

    • Create a supportive environment and determine purpose of visit: perhaps more important with this group/community as treatment planning continues

    • Assessment of gender identity concerns: explore gender identity issues, self definition, and related history

    • Assessment of mental stability: explore the possibility of any co-morbid mental health issues that may impact the process of hormonal treatment or recommendations for surgery

    • Education regarding treatment options and advocating for support: Some patients/clients may be overwhelmed by their struggle, options for treatment, and implications of hormone treatment and reassignment surgery

    • Responsibility for integrated services for family members: consider services for spouses, significant others, and other family members

    • Lev, A. (2009). The ten tasks of the mental health provider: Recommendations for revision of the World Professional Association for Transgender Health standards of care. International Journal of Transgenderism, 11, 74-99.


    Treatment for transgendered veterans1
    Treatment for Transgendered Veterans Affecting Lesbian, Gay, Bisexual and Transgendered Veterans

    10 tasks for mental health gender specialists (Cont)

    • Determine eligibility and readiness for referral to medical treatment: a determination that the client/patient is psychologically, emotionally, and physically ready for medical treatment

    • Completion of psychosocial assessment

    • Documentation letter for hormone therapy or surgery: typically a referral letter that provides support for medical treatment and is not an “identity document”

    • Provision of collaborative services: the MH professional should be prepared to work with physicians, surgeons, and other providers

    • Be available to educate or train employers, school, and institutions: provide support and education to human resources, managers, employers, deans, heads of departments to address transition issues

    • Lev, A. (2009). The ten tasks of the mental health provider: Recommendations for revision of the World Professional Association for Transgender Health standards of care. International Journal of Transgenderism, 11, 74-99.


    Treatment for transgendered veterans2
    Treatment for Transgendered Veterans Affecting Lesbian, Gay, Bisexual and Transgendered Veterans

    • The psychosocial assessment, as introduced in the previous slide, includes various elements; Coolhart, Provancer, Hager, and Wang (2008) have created a suggested assessment to gather information regarding the following domains:

      • Family/childhood context

      • Current gender expression

      • Sexual/relationship development

      • Current intimate relationship(s)

      • Physical and mental health

      • Support

      • Future plans and expectations

        Coolhart, D., Provancher, N., Hager, A., & Wang, M., (2008). Recommending transsexual clients for gender transition: A therapeutic tool for assessing readiness. Journal of GLBT Family Studies, 4, 301-324.


    Mental health professionals and treatment for transgendered veterans
    Mental Health Professionals and Treatment for Transgendered Veterans

    • The Resolution on Transgender, Gender Identity, and Gender Expression Non-Discrimination calls on APA to:

      • Support legal and social recognition of transgender individuals consistent with their gender identity and expression

      • Support the provision of adequate and medically necessary treatment for transgender and gender-variant people

      • Recognize the benefit and necessity of gender transition treatments for appropriately evaluated individuals

      • Call on public and private insurers to cover these treatments

    • Furthermore, the APA Task Force on Gender Identity and Gender Variance has submitted its full report to APA and can be accessed at http://www.apa.org/pi/lgbt/resources/policy/gender-identity-report.pdf

    American Psychological Association. (2011). Transgender identity issues in psychology. Retrieved March 28, 2011 from: http://www.apa.org/pi/lgbt/programs/transgender/index.aspx


    Apa and future directions
    APA and Future Directions Veterans

    • The American Psychological Association has agreed to support a joint project between the Committee on Lesbian, Gay, Bisexual, Transgender Concerns and APA Division 44 to create new guidelines on working with transgendered clients.

    • The call for general membership and positions of leadership for this group should be posted by the end of April 2011.

    American Psychological Association. (2011). Transgender identity issues in psychology. Retrieved March 28, 2011 from: http://www.apa.org/pi/lgbt/programs/transgender/index.aspx


    Boston va policy on working with transgendered veterans
    Boston VA Policy on Working with Transgendered Veterans Veterans

    • “Transgender individuals prefer to live outside the traditional boundaries of gender which may not necessitate surgical interventions or other elements of transition. Thus..care for transgender patients provided for those who may present at multiple points on this transition continuum, including individuals who are not seeking Genital Reassignment Surgery.”

    Department of Veterans Affairs. (2008) Management of transgender veteran patients. Patient Care Memorandum-11-046-LM. Boston, MA: VA Boston Healthcare System.


    Boston va policy on working with transgendered veterans1
    Boston VA Policy on Working with Transgendered Veterans Veterans

    • “Health care should be delivered to that veteran, based upon that veteran’s self-identified gender, recognizing that unique health issues are associated with some transgender patients.”

      • “As an example, a male-to-female transsexual should be referred to as “she” in all contacts and documents irrespective of appearance and/or surgical history. This is included in documentation in the medical chart as well as on all correspondence.”

      • “Room assignments and access to any facilities for which gender is normally a consideration (e.g., restrooms) should give preference to the veteran’s self-identified gender, irrespective of appearance and/or surgical history, in a manner that respects the privacy needs of transgender and non-transgender patients alike.”

    Department of Veterans Affairs. (2008) Management of transgender veteran patients. Patient Care Memorandum-11-046-LM. Boston, MA: VA Boston Healthcare System.



    Facilitating lgbt mental health care
    Facilitating LGBT Mental Health Care Veterans

    • Provide a safe and supportive environment

    • Be aware of own counter transference

    • Reflect client’s language

    • Be mindful of using heterocentric language

    • Discuss sexuality openly

    • Treat the presenting problem, not sexual orientation

    • Assess:

      • How “out” clients are to social network

      • Social support, or lack thereof

      • Presenting problem in the context of the individual


    Facilitating lgbt mental health care1
    Facilitating LGBT Mental Health Care Veterans

    • Assume that staff, clients, and other people associating with the program are from diverse sexual orientations and gender identities

      • When completing biopsychosocial assessments ask about sexual orientation rather than making assumptions

    • Do not tolerate LGBT clients being harassed or belittled by other program clients, nor staff

      • Address discriminatory comments in a timely and non-judgmental manner

      • Provide education to both program clients and staff as needed

    Lucksted, A. (2004). Raising issues: Lesbian, gay, bisexual, & transgender people receiving services in the public mental health system. Baltimore, Maryland: University of Maryland, Center for Mental Health Services Research, Department of Psychiatry.


    Recommendations for clinicians
    Recommendations For Clinicians Veterans

    • Examine one’s own information, attitudes, and beliefs about LGBT issues and consumers

    • Seek out self-education opportunities and resources

    • Consult with professional mental health organizations that have committees on LGBT issues and community organizations, especially those with mental health components

    Lucksted, A. (2004). Raising issues: Lesbian, gay, bisexual, & transgender people receiving services in the public mental health system. Baltimore, Maryland: University of Maryland, Center for Mental Health Services Research, Department of Psychiatry.


    Recommendations for mental health programs services and agencies
    Recommendations For Mental Health Programs, Services, and Agencies

    • Assess and improve programs operations, climate, and quality of care regarding LGBTQ consumers

    • Facilitate the development of staff and organizational competence through trainings, supervision, feedback, and expectations

    • Reflect the diversity of people and lives in the program’s physical space, including artwork, literature, flyers

    • Know which local mental health and human service resources are LGBTQ-affirmative and which are not

    Lucksted, A. (2004). Raising issues: Lesbian, gay, bisexual, & transgender people receiving services in the public mental health system. Baltimore, Maryland: University of Maryland, Center for Mental Health Services Research, Department of Psychiatry.


    Diverse belief systems
    Diverse Belief Systems Agencies

    • Importance of intersectionality of belief systems and identities among LGB individuals

      • Clinical providers are called to assess broad array of identities in addition to LGB orientation

      • Researchers and educators are called to be inclusive of the potential effects of intersecting identities in all levels of research process and teaching methods


    Within community diversity
    Within Community Diversity Agencies

    • Race and ethnicity: consider that some ethnic/cultural groups are more embracing of differences in sexual orientation, while other are less so

    • Disability: People with disabilities may not be seen as sexual beings, thus sexual orientation can be invisible

    Haldeman, D. C., & Buhrke, R. A. (2003). Under a rainbow flag: The diversity of sexual

    orientation. In Robinson, J. D. & James L. C. (Eds.) Diversity in human interactions: The

    tapestry of America (145-156). New York: Oxford University Press.


    Within community diversity1
    Within Community Diversity Agencies

    • Bisexuality: may find themselves ostracized from the heterosexual community because of same-gender attraction, and alienated from the LGBT community for their other-gender relationships

    • Generational Differences: individuals are coming to terms with their sexual identity earlier in life; individuals are living more openly later in life; both groups are creating new and vibrant communities

    Haldeman, D. C., & Buhrke, R. A. (2003). Under a rainbow flag: The diversity of sexual

    orientation. In Robinson, J. D. & James L. C. (Eds.) Diversity in human interactions: The

    tapestry of America (145-156). New York: Oxford University Press.


    Exercises Agencies


    Lgbt exercises
    LGBT Exercises Agencies

    • Considering this advice provided by the Diversity Builder’s Training Staff, is where you work gay friendly? How true are each of these five steps at your site? Why, or why not? Please discuss.

      Is Your Business Gay-Friendly?The Top 5 Steps in Making Your Business GLBT-Friendly

      1. Hire a diverse working staff2 Convert your company's forms to a "gay-friendly version.”3. Offer diversity training to staff, to include "gay sensitivity training."4. Offer domestic partner benefits with a nondiscrimination policy.5. Support gay-related organizations within your charitable work.

      by Diversity Builder's Diversity Training Staff (http://www.diversitybuilder.com/supplier_diversity.php)


    Experiential exercises
    Experiential Exercises Agencies

    • Coming Out Exercise (Modified)

      • Barry A. Schreier, Ph.D.Purdue University

      • http://ccvillage.buffalo.edu/Village/WC/wsc/outlines_and_handouts/sexual_coming_out.html

        Introduction

        This exercise is used to assist individuals understand loss that is often associated with Coming Out.

        Preparing Stage

    • Step 1: Create four columns on one sheet of paper


    Step two
    Step Two Agencies

    • Personalizing Stage

      In the first column, participants are to write down the names of four people who are very special, important, and central to their current lives. One name to one piece of paper.


    Step three
    Step Three Agencies

    In the second column, participants are to write down four important roles central to their current lives. Roles can be sister, father, student, banker, and so on. Use this prompt only if asked.


    Step four
    Step Four Agencies

    In the third column, participants are to write down four objects which they possess which are very special, important, and central to their current lives.


    Step five
    Step Five Agencies

    In the final group, participants are to write down four activities in which they engage which are most important to them.


    Step six
    Step Six Agencies

    Experiencing Loss Stage

    Explain now that loss can come in many forms. The first form is the form of loss that can be predicted. As one is coming out one can often guess that loss is going to occur and can even say that the first set of losses will be here, here, and here, and so on. Ask participants to now look at their columns and pick one from each that they could do without. Allow sufficient time for participants to do this.


    Step seven
    Step Seven Agencies

    Explain that another form that loss can come in is the form that can be predicted in that loss is going to occur, but in which areas of life the loss will happen can be unpredictable because how people act on their beliefs and attitudes about people who are Gay, Lesbian, or Bisexual is often unpredictable. Ask participants to turn their papers over so they cannot see what is written on them and to pick one from each group (first line, second role, etc.) and to scratch it off their list. Ask participants to not turn the sheet over yet.


    Step eight
    Step Eight Agencies

    Explain that loss can also be completely unpredictable and that as one feels one is safe, one can quite easily become unsafe. That as one feels that they have sustained all the loss they can there comes more loss. Some people get lucky and have little to no loss and others are terribly unfortunate and lose everything. People act on their homophobic/biphobic attitudes and heterosexist beliefs in a manner quite often that is blind to the devastation they create. As you are explaining this to participants begin to move among them and take from participants some of their remaining roles/persons/objects. From some take all, from some take only a few, from some take nothing. With one individual who you might let alone, return to them later and take everything. From those from you take everything, take their papers, crumple them, and haphazardly throw them aside onto the floor.


    Step nine
    Step Nine Agencies

    Processing Stage

    Process the reactions individuals have to this exercise and provide understanding to participants’ experiences in terms of how their emotional experiences easily match the emotional experiences that people who are Gay, Lesbian, or Bisexual often have in their own Coming Out processes.


    Step ten
    Step Ten Agencies

    Questions and end.



    References
    References Agencies

    American Psychological Association. (2011). Guidelines for psychotherapy with lesbian, gay, and bisexual clients. Retrieved March 28, 2011 from: http://www.apa.org/pi/lgbt/resources/guidelines.aspx

    American Psychological Association. (2011). Sexual orientation and military service. Retrieved March 28, 2011 from: http://www.apa.org/pi/lgbt/resources/military.aspx

    American Psychological Association. (2011). Transgender identity issues in psychology. Retrieved March 28, 2011 from: http://www.apa.org/pi/lgbt/programs/transgender/index.aspx

    Beals, K.P., & Peplau, L.A. (2006). Disclosure patterns within social networks of gay men and lesbians. Journal of Homosexuality, 51(2), 101-120.

    Buchmueller, T. & Carpenter, C.S. (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(3), 489-494.

    Cass, V.C. (1979). Homosexual identity formation: A theoretical model. Journal ofHomosexuality, 4, 219-235.

    Conron, K.J., et al. (2010). A population-based study of sexual orientation identity and gender differences in adult health. American Journal of Public Health, 100, 1953-1960.

    Coolhart, D., Provancher, N., Hager, A., & Wang, M., (2008). Recommending transsexual clients for gender transition: A therapeutic tool for assessing readiness. Journal of GLBT Family Studies, 4, 301-324.

    Department of Veterans Affairs. (2008) Management of transgender veteran patients. Patient Care Memorandum-11-046-LM. Boston, MA: VA Boston Healthcare System.

    Eliason, M.J., & Schope, R. (2001). Does ‘Don’t Ask Don’t Tell’ apply to health care? Lesbian, gay, and bisexual people’s disclosure to health care providers. Journal of the Gay and Lesbian Medical Association, 5,125–134.

    Gates, G. (2004) Gay men and lesbians in the U.S. military: Estimates from Census 2000. Washington, DC: The Urban Institute.

    Gay and Lesbian Medical Association and LGBT health experts. (2001). Healthy People 2010 Companion document for lesbian, gay, bisexual, and transgender (LGBT) health. San Francisco, CA: Gay and Lesbian Medical Association.

    Grant, J.M., et al., J. (2011). Injustice at every turn: A report of the National Transgender Discrimination Survey. Washington, D.C.: National Center for Transgender Equality and National Gay and Lesbian Task Force.

    Haldeman, D. C., & Buhrke, R. A. (2003). Under a rainbow flag: The diversity of sexual orientation. In Robinson, J. D. & James L. C. (Eds.) Diversity in human interactions: The tapestry of America (145-156). New York: Oxford University Press.


    References1
    References Agencies

    Harlin, K. (2004) Stonewall and Beyond:Lesbian and gay culture. The Stonewall Riot and its aftermath. New York City: Columbia University. Retrieved March 7, 2011 from http://www.columbia.edu/cu/lweb/eresources/exhibitions/sw25/case1.html

    Hatzenbuehler, M., Keyes, K. & Hasin, D. (2009). State-level policies and psychiatric morbidity in lesbian, gay, and bisexual populations. American Journal of Public Health, 99, 2275-2281.

    Katz, K. (2010). Health hazards of “don’t ask, don’t tell”. New England Journal of Medicine, 363, 2380-1.

    Kertzner, R.M., Meyer, I.H., Frost, D.M., & Stirratt, M.J. (2009). Social and psychological well-being in lesbians, gay men, and bisexuals: The effects of race, gender, age, and sexual identity. American Journal of Orthopsychiatry, 79(4), 500-510.

    King, M., et al. (2008). A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay, and bisexual people. BMC Psychiatry, 8, 70.

    Lev, A. (2009). The ten tasks of the mental health provider: Recommendations for revision of the World Professional Association for Transgender Health standards of care. International Journal of Transgenderism, 11, 74-99.

    Lucksted, A. (2004). Raising issues: Lesbian, gay, bisexual, & transgender people receiving services in the public mental health system. Baltimore, Maryland: University of Maryland, Center for Mental Health Services Research, Department of Psychiatry.

    Martell, C.R., Safren, S.A., & Prince, S.E. (2004). Cognitive behavioral therapies with lesbian, gay, and bisexual clients. New York: The Guilford Press.

    McCarn, S.R., & Fassinger, R.E. (1996). Revisioning sexual minority identity formation: A new model of lesbian identity and its implications for counseling and research. Counseling Psychologists ,24, 508-534.

    McLaughlin, K., et al. (2010). Responses to discrimination and psychiatric disorders among Black, Hispanic, female, and lesbian, gay, and bisexual individuals. American Journal of Public Health, 100, 1477-1484.

    Moradi, B. (2009). Sexual orientation disclosure, concealment, harassment, and military cohesion: Perceptions of LGBT military veterans. Military Psychology, 21, 513-533.

    Pachankis, J.E., & Goldfried, M.R. (2010). Expressive writing for gay-related stress: Psychosocial benefits and mechanisms underlying improvement. Journal of Consulting and Clinical Psychology, 78(1), 98-110.

    Perez, R. M. (2007). The “boring” state of research and psychotherapy with lesbian, gay, bisexual, and transgender clients: Revisiting Baron (1991). In K. J. Bieschke, R. M. Perez, & K. A. DeBord (Eds.) Handbook of counseling and psychotherapy with lesbian, gay, bisexual, and transgender clients (2nd ed.; pp. 399-418). Washington, DC: American Psychological Association.

    Roberts, A., et al. (2010). Pervasive trauma exposure among US sexual orientation minority adults and risk of posttraumatic stress disorder. American Journal of Public Health, 100, 2433-2441.

    Smith, D. (2008). Active duty military personnel presenting for care at a Gay Men’s Health Clinic. Journal of Homosexuality, 54, 277-279.

    Young, R.M., & Meyer, I. (2005). The trouble with “MSM” and “WSW”: Erasure of the sexual-minority person in public Health discourse. American Journal of Public Health, 95, 1144-1149.


    Resources advocacy
    Resources: Advocacy Agencies

    • Advocacy groups have been developed

      • Service Members Legal Defense Network: http://www.sldn.org/ (focused on DADT)

      • American Veterans for Equal Rights: http://aver.us/aver/

      • Vets Do Ask Do Tell, Inc: http://www.vetsdoaskdotell.org/(focused on promoting access to VA Care)

    • Legislation to end LGBT disparities initiated

      • H.R.3001 - Ending LGBT Health Disparities Act: http://www.opencongress.org/bill/111-h3001/show


    Resources helpful links for working with transgender veterans
    Resources: Helpful Links for Working with Transgender Veterans

    • www.wpath.org (World Professional Association for Transgender Health, Inc.). WPATH is a “professional organization devoted to the understanding and treatment of gender identity disorders.” Members are spread worldwide in diverse fields (e.g.medicine, psychology, law, social work, counseling, psychotherapy, family studies, sociology, anthropology, and sexology. WPATH provides Referral Source lists.

    • www.gender.org(Gender Education and Advocacy; GEA) is a national 501(c) (3) non-profit organization focused on the needs, issues and concerns of gender variant people in human society. GEA seeks to “educate and advocate, not only for ourselves and others like us, but for all human beings who suffer from gender-based oppression in all of its many forms”.

    • www.tavausa.org (Transgender American Veterans Association). The Transgender American Veterans Association (TAVA) is a 501(c) 3 non-profit organization “formed to address the growing concerns of fair and equal treatment of transgender veterans and active duty service members…TAVA serves as an educational organization that will help the Veterans Administration and the Department of Defense to better understand the individuals they encounter who identify as being gender-different”.

    • www.tsroadmap.com (Transsexual Road Map). A private individual provides information that is specific for transsexual transition process. It describes many of the medical issues in terms laypeople can understand. In addition, there are links to more in-depth overviews of issues such as surgeries and hormone therapy.


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