Albina Veltman, MD, FRCPC Assistant Professor – McMaster University

1. Queer Think for the Straight Shrink: The ABCs of Working with Individuals who Identify as LGBTTTIQQ Albina Veltman, MD, FRCPC Assistant Professor – McMaster University Department of Psychiatry & Behavioural Neurosciences aveltman@stjoes.ca

2. Conflicts of Interest • None to declare

3. Objectives • Understand the terminology related to LGBTTTIQQ communities • Gain knowledge regarding some of the specific mental health care needs of LGBTQ individuals • Understand the barriers in accessing mental health services • Gain knowledge regarding how to reduce healthcare access barriers for LGBTQ individuals • Outline outcomes of The LGBTQ Community Wellness Centre of Hamilton’s Mental Health Clinic

4. The ABCs of LGBTTTIQQ Communities • Lesbian • Gay • Bisexual • Transgender • Transsexual • Two-spirit • Intersex • Queer • Questioning

5. Other Important Terminology • MtF, M2F, transwoman • FtM, F2M, transman • Cis-gender • Genderqueer • Gender Reassignment Surgery/GRS

6. Other Important Terminology • Sexual orientation: how one identifies their sexual attraction and affection, both physical and emotional • Gender identity: a person’s deep sense of being male, female, neither or both • Ally: a person who is not a member of a specific group, but who supports that group, challenges discrimination and oppression of that group, and explores their own biases

7. Kinsey Scale Kinsey, et al., 1948

8. Other Important Terminology • Homo/bi/trans-phobia: individual, social and systemic values, beliefs, attitudes and actions that indicate hate, discrimination and “othering” of people who do not conform to socially prescribed sexual/gender identities and norms • Heterosexism: the assumption that heterosexuality is the preferred norm and that most people are heterosexual • Heterosexual privilege: Because of heterosexism, being a heterosexual in our society carries with it power and privileges

9. Heterosexism “When I went to an addiction treatment clinic, the nurse asked me, ‘What’s your husband’s name?’ I said, ‘I don’t have a husband’. ‘Okay’, she then asked, ‘Is it your boyfriend?’ I said, ‘I have a partner’. She said, ‘What’s his name?’ When it comes to these questions, it’s so uncomfortable. I don’t make it a big deal myself. I just said, ‘Her name is Sharon’. But then you can see their faces changing. Then you feel uncomfortable for the rest of the questions.” Kidd, Veltman, et al, 2011

10. Statistics • Vary widely according to definition used • Estimates of LGBTQ individuals vary from 2-14% of the population • 1 in 30,000 males at birth and 1 in 100,000 females at birth seek GRS in North America • American Psychiatric Association, 2000 • 1 in 10,000 males at birth and 1 in 30,000 females at birth seek GRS in Denmark van Kesteren, 1997

11. Lack of Education on LGBT Issues • Median number of hours of education on LGBT issues = 5 hours • 54.5% of Canadian schools reported 0 hours of clinical training in LGBT health! Obedin-Maliver, J. et. Al., 2011 • Situation at McMaster University– 3 hours in undergrad, 2 ½ hours during psychiatric residency

12. Lack of Education on LGBT Issues • Frequency of physician’s response to the statement, “Adolescent Sexual Orientation should be addressed more often in the course of training” Kitts, 2010

13. Lack of Discussion re: LGBT Status • Frequency in which physicians discuss sexual orientation while taking a sexual history from a sexually active adolescent Kitts, 2010

14. Holistic Approach • LGBTQ people have the same health concerns as anyone else, as well as some additional risk factors • Important to engage the whole person, do not treat patients like a collection of risk factors • Important to understand that life issues for people who are LGBTQ are similar to everyone else: • Work stressors • Financial issues • Long Term Relationships • Parenting • Aging

15. Special Considerations in LGBTQ Mental Health Increased vulnerability due to: • Loss of supports/rejection • Burden of keeping a secret identity • Bullying/violence • Discrimination/Heterosexism/Genderism • Coming out process • Internalized homophobia • Pathologization by the medical/psychiatric community Institute of Medicine, 2011

16. Barriers to Accessing Health Services for LGBTQ Individuals • Discomfort/fear of disclosing LGBTQ status due to real or perceived Homo/Bi/Transphobia • Patient’s own internalized Homo/Bi/Transphobia • Provider ambivalence/discomfort related to inadequate education re: LGBTQ issues • Heterosexist assumptions on forms/interviews Sears, 2009

17. Barriers to Accessing Health Services for LGBTQ Individuals • “Dual alienation” • Pathologization of LGBTQ status • Previous experiences or stories of “corrective or reparative” therapies • No opportunity for disclosure – providers not asking the right questions Sears, 2009

18. Dual Alienation “I’m not really all that accepted in the mental health patient community because I’m a lesbian and I’m not accepted in the lesbian community because I’m a mental health patient. I don’t feel like I belong anywhere.’’ Kidd, Veltman et al, 2011

19. Dual Alienation “The LGBTQ community is already marginalized. The mental health community is already marginalized. When you belong to two marginalized groups, you become that much further marginalized.” Kidd, Veltman et al, 2011

20. Pathologization of the LGB Community • History of homosexuality in the DSM Bayer, 1987 • Consideration of sexuality/gender status as part of illness • Aversive/reparative therapies (eg.“Pray away the gay”) • Expectation of increased rates of psychiatric diagnoses Biaggio et al, 2000

21. Gender Identity Disorder in the DSM: The Controversy Continues • Many transgender activists/individuals want GID to be removed from the DSM • WPATH and CPATH (World/Canadian Professional Association for Transgender Health) support the removal of GID from the DSM • If not under psychiatry’s umbrella, who will diagnose/treat? How will individuals receive treatment they need and want without a diagnosis? Allison, 2010; Winters & Ehrbar, 2010

22. Pathologization “I’ve had several doctors and nurses tell me that I must be depressed because I’m a lesbian and I haven’t dealt with that. That’s bull****. I was a happy, out-and-proud,-in-a-relationship, lesbian before I got depressed for the first time. I don’t think it has anything to do with my being gay.” Kidd, Veltman et al, 2011

23. Dismissiveness/“Neutrality” • Dismisses the potential importance of sexuality as a part of the client’s identity • Doesn’t take into account the experience of the individual Willging et al, 2006

24. Asking the Right Questions • Are you currently dating, sexually active or in a relationship(s)? Yes □ No □ • If yes, is (are) your partner(s): female □ male □ intersex □ transsexual □ transgender □ two-spirit □ other □ ________ • How would you identify your sexual orientation? straight/heterosexual □ lesbian □ gay □ bisexual □ woman who has sex with women (WSW) □ man who has sex with men (MSM) □ transensual □ polysexual □ two-spirit □ questioning □ asexual □ autosexual □ unsure □ other □ ________ • Do you have concerns related to your sexual orientation, or do you ever feel awkward about your sexual orientation? Not at all □ a little □ somewhat □ a lot □ unsure □ ARQ2, 2007

25. Asking the Right Questions • How would you identify your gender identity? female □ male □ transsexual □ transgender □ genderqueer □ two-spirit □ FTM □ MTF □ intersex □ questioning □ other □ ________ • Do you have concerns related to your gender identity or do you ever feel awkward about your gender identity? Not at all □ a little □ somewhat □ a lot □ unsure □ • Is your reason for getting help related to any issues around your sexual orientation or gender identity? • Can you tell me about any particular problems you have faced because of discrimination based on your sexual orientation/gender identity?ARQ2, 2007

26. Asking the Right Questions • At about what age did you first realize your were _____? What has it been like for you after coming out/transitioning to yourself and to others? • How open are you about your sexual orientation/gender identity? At work? At school? At home? With new acquaintances? • Tell me about your family. How has your sexual orientation/gender identity affected your relationship with your family? Do you have support from your family? • How involved are you in the LGBTTTIQQ communities? ARQ2, 2007

27. Mental Health Disparities • 2-6 times greater lifetime risk of suicide attempt and/or depression • Social stigma, prejudice and discrimination associated with minority sexual orientation accounts for a significant portion of the increased risks King et al, 2008; Haas et al, 2011

28. Mental Health Disparities Meta-analysis of 25 international studies • 4 times risk of suicide attempt in LGB people • 1.5 times risk of depression or anxiety disorder in LGB people • 3 times greater risk of substance use disorder in lesbian/bisexual women • 2 times greater risk of depression and panic disorder in gay/bisexual menKing et al, 2008

29. Suicide in Transgender People • 77% have seriously considered suicide • 50% have seriously considered suicide because of trans status • 43% have attempted suicide at some point TransPULSE, 2010

30. LGBTQ Youth • One in seven Canadian high school students self-identify as LGBTQ (14%) • 70% of all high school students reported hearing homophobic remarks every day in school • Almost 10% of LGBTQ students reported having heard homophobic comments from teachers daily or weekly Egale Canada, 2011

31. LGBTQ Youth • >40% of LGBTQ students report having experienced sexual harassment in school in the last year • Three-quarters of LGBTQ students and 95% of trans students feel unsafe at school (compared to 20% of heterosexual students) • Approximately 28% of LGBT youth drop out of high school because of discomfort or fear in the school environment Egale Canada, 2011

32. Suicide in LGBTQ Youth • 42% of LGBTQ youth reported thoughts of suicide at some time, 25% in the past year • 1/3 of LGBTQ youth report having made a suicide attempt at some time • LGBTQ youth are 3-4 times more likely to make a suicide attempt Russell & Joyner, 2001 • LGB youth who come from highly rejecting families are more than 8 times as likely to have attempted suicide than LGB peers who reported no or low levels of family rejection D’Augeillet al, 2005; Ryan et al, 2009

33. LGBTQ Youth Homelessness • 22-35% of homeless youth identify as LGBTQ • Many of these youth have been kicked out of their home and/or do not feel safe at home Van Leeuwen et al, 2006

34. Defining Care LGBT Affirmative • LGBT-tolerant • Aware that LGBT people exist and use services • LGBT-sensitive • Aware of, knowledgeable about, and accepting of LGBT people • LGBT-affirmative • Actively promote self-acceptance of an LGBT identity as a key part of health and recovery

35. Positive Experiences with Providers • Can facilitate recovery in general • Can facilitate process of coming out • Greatly increases sense of connection and self-worth • Can be extremely helpful when provider is queer, but not a necessity • Importance of linkages with community “When a nurse shared that she was a lesbian: It made me feel less ashamed. It was because she is a nurse and she is gay and there is nothing wrong with that. I didn’t have to be ashamed for being gay.”

36. Negative Experiences with Providers • Negative impacts of stigma and lack of understanding on clinical work: • Overemphasis on LGBT identity • Lack of understanding > irrelevant lines of inquiry and focus • Regarding LGBT as a result of mental illness • Hinders establishment of rapport/trust • “There was one doctor who asked me ‘If you have children, how can you be a lesbian?’” • Bottom line: Lack of client-centred care

37. Allies • If you’re not LGBTQ yourself, become an ally!

38. LGBT Affirmative Care • Evaluate your belief system • Understand risk factors associated with LGBT patients • Advocate for policy changes that are LGBT-affirmative • Create and maintain a positive office space Coren, JS et al., 2011; Haas, AP et al., 2011

39. What constitutes a positive space? • Inclusive language • Lack of assumptions • LGBT posters/pamphlets/signs • Respect • Acceptance and celebration of diversity

40. Ask all clients about their sexual orientation and gender identity. Be guided by your LGBTQ clients. Listen to what they say is comfortable for them. Acknowledge clients’ significant others and encourage their participation in treatment. Require all clients and staff members to create and maintain a safe environment for all LGBTQ clients. Post a non-discrimination policy in the waiting room that explicitly includes sexual orientation and gender identity. Treatment Do’s

41. Use the proper pronouns based on patient’s self-identity when talking to/about transgender individuals. Allow transgender clients to continue the use of hormones when they are prescribed. Advocate for the transgender patient using “street” hormones to be able to access medically prescribed hormones. Allow transgender patients to use bathrooms and showers based on their gender self-identities. Treatment Do’s

42. The LGBTQ Community Wellness Centre of Hamilton (The Well) • Community organization started in 2004 • Response to a hate crime against a well-known gay man in the community • Mostly volunteer-run • Small amount of Trillium Grant funding • Several groups running, including: Lesbian and Bi Women’s Support, Same-sex partners Planning Parenting, Trans Peer Support, Queer Youth Group, and Running Group

43. The Well Mental Health Clinic Types of patients seen at the clinic

44. The Well Mental Health Clinic Types of patients seen at the clinic

45. The Well Mental Health Clinic The Role of Advocacy in Trans Health Care

46. LGBTQ Youth Resources www.youthline.ca - 1-800-268-6888 – LGBT Youth line – Toll-free by youth for youth – Sun-Fri 4:00 – 9:30 pm www.pflagcanada.ca - Parents and Friends of Lesbians and Gays – Organization that supports families and friends of LGBTQ individuals. www.hifyhamilton.com - 905-528-3009 - Health Initiatives for Youth Hamilton www.niagarapride.ca - Rainbow Youth Niagara – 905-380-4576 www.rainbowhealthontario.ca – Ontario-wide resource for LGBTQ health www.thetrevorproject.org– The Trevor Project – Suicide Prevention for the LGBTQ community www.itgetsbetter.org - It Gets Better Project – Suicide Prevention Online Project

47. Other Web Resources http://www.MyGSA.ca/OntarioKit - Curriculum, how to start/continue a GSA/Positive Space group www.opsta.com - Ontario Positive Space Teachers Association – great resources available for downloading re: curriculum www.egale.ca - Every Class in Every School Report, other resources http://www.camh.net/Publications/Resources_for_Professionals/ARQ2/arq2.pdf - Asking the Right Questions Manual - helpful resource for knowing how to ask questions regarding sexuality and gender identity www.glsen.org – Gay Lesbian and Straight Education Network

48. Other Web Resources http://www.gender.org - Gender Education and Advocacy is a U.S. National organization focused on the needs, issues, and concerns of gender variant people in human society. www.2spirits.com - Information about and for Aboriginal two-spirit individuals. http://www.wpath.org - The World Professional Association for Transgender Health is a professional organization devoted to the understanding and treatment of gender identity disorders. http://www.isna.org - The Intersex Society of North America is devoted to systemic change to end shame, secrecy, and unwanted genital surgeries for people born with an anatomy that someone decided is not standard for male or female.

49. Other Web Resources www.fenwayhealth.org - The Fenway Institute works to make life healthier for those who identify as LGBTQ, people living with HIV/AIDS, and the larger community. http://www.glma.org - The Gay and Lesbian Medical Association exists to maximize health care for LGBTI individuals. www.transpulse.ca - The Transpulse Project website contains information regarding a recent study of health care disparities within the transgender community. http://www.sherbourne.on.ca/ - The Sherbourne Health Centre provides health care to over 500 trans-identified patients. Guidelines regarding treatment of trans patients are available.

50. References Allison, R. (2010). Aligning bodies with minds: The case for medical and surgical treatment of gender dysphoria. Journal of Gay & Lesbian Mental Health, 14(2), 139–144. Bayer, R. (1987). Homosexuality and American Psychiatry: The politics of Diagnosis (revised edition). Princeton, NJ: Princeton University Press. Bolton, S-L., & Sareen, J.(2011). Sexual Orientation and it relation to mental disorders and suicide attempts: Findings from a nationally representative sample. The Canadian Journal of Psychiatry, 56 (1), 35-43. Coren, JS et al., (2011). Assessing your office for care of lesbian, gay, bisexual, and transgender patients. The Health Care Manager 30 (1), 66-70. D’Augelli, A.R., et al., (2005). Predicting the suicide attempts of lesbian, gay, and bisexual youth. Suicide and Life Threatening Behavior, 35(6), 646–660. Drescher, J. (2010). Transsexualism, gender identity disorder and the DSM. Journal of Gay & Lesbian Mental Health, 14(2), 109–122.