Abstract
In the USA, the LGBT community has grown significantly and continues to grow. Lesbian, gay, bisexual, and transgender (LGBT) individuals encounter a range of stressors throughout their lifetime. Compared to heterosexuals the LGBT community reports higher prevalence rates of anxiety, depression, trauma, substance abuse, and suicide. Minority stress has been linked to increased psychological distress among sexual minorities, specifically prejudice and discrimination. Several evidence-based treatments have been adapted to address the specific needs of the LGBT community, including addressing minority stress, specifically cognitive behavioral therapy. In this chapter we discuss prevalence’s rates of psychological distress among the LGBT community, adapted treatments for working with LGBT, and describe several guidelines and principles to assist in working with the LGBT community.
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Keywords
Demographics
According to a national survey, in the USA an estimated 4.5% (roughly 11,343,000 people) of the adult population identifies as lesbian, gay, bisexual, or transgender (LGBT; The William’s institute, 2019). The LGBT community has grown significantly and continues to grow. In 2012 the LGBT population was estimated at 3.5% while in 2016 it was estimated to be 4.1% (Newport, 2018). The largest birth cohort that contributed to the increase in the LBGT population are millennials, individuals born between 1980 and 1999 (Newport, 2018). A 2013 survey reported that 1.7% of adults identified as gay or lesbian, 0.07 reported identified as bisexual (Ward, Dahlhamer, Galinsky, & Joestl, 2014), while roughly 700,000 individuals (0.03% of the US population) identify as transgender (Flores, Herman, Gates, & Brown, 2016). The majority of those in the LGBT community are likely to identify as Hispanic, female, have an income of less than $36,000, and have the mean age of 37 years (Newport, 2018). Although these statistics are available, the literature is lacking updated information regarding how many LGBT individuals identify as lesbian, gay, and bisexual.
Psychological Distress
Lesbian, gay, bisexual, and transgender (LGBT) individuals encounter a range of stressors throughout their lifetime (Mongelli et al., 2019). With a history of being a marginalized minority group, various mental health disparities have been associated with these stressors. Compared to heterosexuals the LGBT community reports higher prevalence rates of anxiety, depression, trauma, substance abuse, and suicide (Mongelli et al., 2019).
Anxiety and Depression
While the lifetime prevalence of depression ranges from 20% to 25% in women and 7% to 12% in men (Wang et al., 2017), among the LGBT community the prevalence rates of depression are higher. Barefoot, Warren, and Smalley (2017) conducted a national survey and reported that 43% of transgender females, 35% of transgender males, 31% of bisexual females, 24% of gay men, 22% of bisexual, and 16% of lesbians met criteria for depression. For anxiety, an estimated 10% of US adults had any anxiety disorder in the past year (Bandelow & Michaelis, 2015) while among the LGBT community 40% of transgender females, 32% of transgender males, 29% bisexual females, 27% of bisexual males, 19% of gay males, and 18% of lesbians met criteria for anxiety (findings from a national survey; Barefoot et al., 2017).
Trauma and Post-traumatic Stress Disorder
Lifetime prevalence of victimization among the LGBT community has been reported to be higher than that of non-LGBT individuals (Balsam, Rothblum, & Beauchaine, 2005). In one study by Balsam, Rothblum, and Beauchaine (2005), the lifetime victimization of LGB individuals was explored. LGB participants reported more incidents of childhood and adulthood victimization than heterosexual participants. Bisexual men and women were more likely than gay men to report an incident of nonintercourse sexual coercion and rape (Balsam et al., 2005). About 37% of participants reported experiencing physical abuse (e.g., grabbed, punched, choked, stabbed, or shot) since the age of 13. Participants reported a lifetime average of four incidents of physical attacks with half of these incidents being linked to participants gender identity or expression (Balsam et al., 2005).
Additionally, the LGBT community experiences hate crimes due to their sexual orientation and gender identity. The Federal Bureau of Investigation’s (FBI) Uniform Crime Reporting Program (UCR) reported that in 2017, 5125 adults were victims of hate crimes. For the LGB community 15.8% (1338) were targeted because of bias against sexual orientation and 1.6% (132) were victims of gender-identity bias. More specifically, 25% were victims of anti-LGBT bias, 58% were victims of anti-gay bias, 12% were victims of anti-lesbian bias, and 2% were victims of anti-bisexual bias. For individuals who identify as transgender 119 were victims of anti-transgender bias and 13 were victims of anti-gender non-conforming bias. Interestingly only two-thirds of hate crimes are reported, therefore the rates of incidents may be higher for the victims of crime particularly those in the LGBT community (Sandholtz, Langton, & Planty, 2013).
Exposure to the various forms of violence may account for why post-traumatic stress disorder (PTSD) is more prevalent among the LGBT community than non-sexual minorities (Roberts, Austin, Corliss, Vandermorris, & Koenen, 2010; Wawrzyniak & Sabbag, 2018). The LGB community is 1.6–3.9 times more at risk of PTSD (Roberts, Rosario, Corliss, Koenen, & Austin, 2012), while for the transgender community PTSD has a prevalence rate of 7% (Reisner et al., 2016; Wawrzyniak & Sabbag, 2018). Among LGBT veterans, PTSD is also reported at higher rates than non-sexual minorities (Brown & Jones, 2016; Cochran, Balsam, Flentje, Malte, & Simpson, 2013; Wawrzyniak & Sabbag, 2018).
Substance Abuse
According to the results of a 2015 survey, an estimated 39% of LGB adults reported using an illicit drug within the year prior to the survey, more than twice as likely than heterosexual adults (17%, Medley et al., 2016). For marijuana use it was reported that 30% of LGB individuals used within the year prior to the survey compared to 13% of heterosexual adults (Medley et al., 2016). In regard to prescription pain relievers, 10% of LGB adults used within the year prior to the survey compared to 4.5% of heterosexual adults (Medley et al., 2016). In a survey conducted in 2013 35% of LGB adults aged 18–64, who identified as gay or lesbian, 42% of bisexual adults, and 26% of heterosexuals reported past-year binge drinking (five or more drinks on a single occasion; Ward et al., 2014). Specifically, we see that bisexual men reported the most binge drinking (52%; Ward et al., 2014).
According to a 2015 survey, about 4% of transgender adults used illicit drugs within the month prior to the survey, while 29% had reported using illicit drugs in their lifetime (Ward et al., 2014). An estimated 7% of transgender adults used prescription drugs that were not prescribed to them or used them as not prescribed (Ward et al., 2014). Among transgender adults about 25% reported using marijuana within the past month of when the survey was taken (Ward et al., 2014). Finally, about 27% of transgender adults reported binge drinking within the month prior to the survey (Ward et al., 2014).
Suicide
A systematic review on the lifetime prevalence of suicide attempts among LGB adults by Hottes, Bogaert, Rhodes, Brennan, and Gesink (2016) reported that the lifetime prevalence of suicide attempts among individuals who identify as LGB was about 20% while for the general population (non-sexual minorities) it was reported to be around 11%. A literature review performed by Virupaksha, Muralidhar, and Ramakrishna (2016) found that the worldwide lifetime prevalence of suicide attempts for the transgender population to range from 32% to 50%. In the USA the lifetime prevalence rates of suicide attempts among individuals who identify as transgender were reported at 40% (National Center for Transgender Equality, 2017). For LGBT community aged 10–24, suicide is one of the leading causes of death (Center for Disease and Prevention, 2010). Currently, there are limited resources that are tracking suicide by sexual orientation for the adult population making it challenging to find current prevalence rates for LGBT adults.
Minority Stress
Meyer (2003) created a model that recognizes that marginalized groups, such as the LGBT community, experience stressors unique to their group in the form of prejudice and discrimination. Meyer theorized that such stressors significantly impact the mental health of the LGBT community. Such stressors include experiencing prejudice events, expectations of rejection, internalized stigma, and internalized homophobia (Meyer & Frost, 2013). A systematic review by Mongelli et al. (2019) examined the relationship between minority stress and mental health among LGBT population. The findings from the review indicate that the stressors experienced by the LGBT community predict their mental health outcomes. For example, among individuals who identified as LGBT stigma (internalized, enacted, and anticipated) was associated with increased depression scores (Marsack & Stephenson, 2017). Specifically, individuals who identified as bisexual or queer reported higher stigma and depression scores than gay and lesbians’ participants (Marsack & Stephenson, 2017). Minority stress has also been linked to increased suicidality thoughts and attempts among the LGBT community, specifically when experiencing internalized homophobia (Lea, de Wit, & Reynolds, 2014) and transphobia (Perez-Brumer, Hatzenbuehler, Oldenburg, & Bockting, 2015; Timmins, Rimes, & Rahman, 2017). Additionally, we see similar trends with alcohol consumption. Heaving drinking days are reported more often among gay men who experienced internalized heterosexism (Kuerbis et al., 2017). Finally, another group within the LGBT community that experiences minority stress are individuals who are HIV positive. Rendina et al. (2017), examined HIV-related stressors among gay and bisexual men. Internalized stigma was significantly associated with negative mental health and sexual behavior outcomes. A path analyses revealed that emotion dysregulation mediated internalized stigma on symptoms of depression/anxiety (Rendina et al., 2017). The authors from this study implicate that cognitive restructuring and emotion regulation may be particularly useful in targeting the negative self-schemas and difficulty with emotion regulation problems reported by the participants in the study.
Summary
The LGBT community experiences high levels of anxiety, depression, trauma, substance abuse, and suicidal ideation. There are notable prevalence differences among each sexual minority sub-group, for example, individuals who identify as transgender experience higher rates of psychological distress than other sexual minority sub-group. Minority stress has been linked to increased psychological distress among sexual minorities, specifically prejudice and discrimination. Several evidence-based treatments have been adapted to address the specific needs of the LGBT community, including addressing minority stress.
Evidence-Based Treatments for Mental Health Among LGBT Clients
There are various evidence-based treatments that are recommended to be used with the LGBT community. One treatment that will be briefly discussed is cognitive behavioral therapy for LGB.
Cognitive Behavioral Therapy (CBT)
Cognitive behavior therapy has been effective in reducing psychological distress among a range of populations with various disorders (Coull & Morris, 2011). CBT is effective in addressing presenting maladaptive behaviors and motivates clients to cope with adverse circumstances by promoting coping self-efficacy (Pachankis, Hatzenbuehler, Rendina, Safren, & Parsons, 2015). CBT encourages the development of adaptive cognitive, affective, and behavioral stress responses (Pachankis et al., 2015). CBT can be used to improve psychological distress among the LGBT population since it can target cognitive, affective, and behavioral minority stress processes (Balsam, Martell, & Safren, 2006; Pachankis, 2014; Pachankis et al., 2015). CBT has been adapted to address stressors that the LGB community may face in addition to addressing psychological distress.
Pachankis et al. (2015) created a study to assess the efficacy of a CBT adaptation to improve young gay and bisexual men’s mental health. They adapted the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (Unified Protocol; Barlow et al., 2017) intervention to target both minority stress processes (i.e., rejection sensitivity, internalized homophobia, concealment) and universal risk factors (i.e., hopelessness, rumination, social isolation, unassertiveness). The Unified Protocol (UP) promotes changes through modules that focus on motivation enhancement, exposure, cognitive restructuring, mindfulness, self-monitoring techniques, and techniques of behavior change across psychosocial problems and disorders (Barlow et al., 2017).
Pachankis et al. (2015) specifically adapted the intervention to help participants identify minority stress experiences; track cognitive, affective, and behavioral reactions to minority stress, address avoidance reactions (i.e., substance use and condomless anal sex), attribute distress to minority stress rather than to personal failure; and assertiveness training for coping with minority stress in safe situations. The Unified Protocol Modules were described in detail in Pachankis (2014) and briefly described below as in Pachankis et al. (2015):
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Session 1 focused on discussing primary mental, behavioral, and sexual health issues; building motivation to address those issues; and reviewing participants’ unique strengths as gay or bisexual men.
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Session 2 reviewed the impact of minority stress on health, specific manifestations of minority stress, and current coping strategies.
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Session 3 raised awareness of the emotional impact of early and ongoing forms of minority stress.
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Session 4 raised awareness of the behavioral impact of minority stress and taught mindful, present-focused reactions to minority stress.
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Session 5 raised awareness of the cognitive impact of minority stress and posed cognitive restructuring activities.
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Session 6 engaged participants in a review of the impact of emotions on mental, behavioral, and sexual health and personal emotion avoidance tendencies driven by minority stress.
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Session 7 focused on the impact of minority stress on behavioral avoidance with a focus on creating an emotional and behavioral avoidance hierarchy.
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Session 8 engaged participants in behavioral experiments in which previously avoided experiences were gradually confronted.
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Session 9 continued the graduated behavioral experiments with a focus on assertiveness training as a skill for coping with minority stress.
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Session 10 reviewed new cognitive, affective, and behavioral coping strategies and their application to future minority stress experiences (Pachankis, 2014). Therapists assigned homework between-session homework after sessions to promote skill generalization.
The adapted UP protocol above was compared to a waitlist condition. The participants in the UP condition reported reduced depressive symptoms, alcohol use problems, sexual compulsivity, and condomless anal sex with casual partners, and improved condom use self-efficacy. The UP did not significantly reduce the cognitive, affective, or behavioral minority stress processes or universal mental health risk factors. Although other sexual minorities were excluded from the study, the intervention addresses material that can be used with lesbian, bisexual women, and transgender men and women. As noted by Weir and Piquette (2018) the transgender community experience violence, discrimination, along with other stressors that impact psychological well-being. Therefore, exploring treatments that aim at targeting minority stress in addition to psychological distress may be beneficial for individuals who identify as transgender especially since they also experience hopelessness and rumination which is targeted by the Unified Protocol.
Guidelines for Working for with LGBT Clients
The American Psychological Association (2012) has 20 guidelines for working with LGB clients. The guidelines cover an array of important issues including therapists understanding the effects of stigma (Guideline 1), understanding the impact of HIV/AIDS on the lives of lesbian, gay, and bisexual individuals and communities (Guidelines 16), and encouraging psychologists to consider the impact of socioeconomic status on the psychological well-being of lesbian, gay, and bisexual clients (Guideline 18). The entire list of guidelines can be found at: https://www.apa.org/pubs/journals/features/amp-a0024659.pdf. Although these guidelines are helpful, they are not as detailed as the clinical principles and techniques suggested by Pachankis (2014). The principles include:
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Normalize the adverse impact of minority stress.
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Facilitate emotion awareness, regulation, and acceptance.
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Reduce avoidance.
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Empower assertive communication.
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Restructure minority stress cognitions.
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Validate sexual minority individuals’ unique strengths.
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Build supportive relationships.
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Affirm healthy, rewarding expressions of sexuality.
These principles assist therapists and psychologists to better work with clients who are LGB. A more detailed list can be found in Pachankis (2014). The guidelines from the APA (2012) and the principles by Pachankis (2014) are very important but have been limited to only LGB. Weir and Piquette (2018) describe some considerations for therapists to take when working with transgender clients. The most important consideration is being supportive and knowledgeable about the transgender community. A therapist who has knowledge of sexual orientation, issues faced by LGBT individuals, community resources, as well as the barriers that may be present with a school or larger community can be a powerful support (Weir & Piquette, 2018). Advocating for transgender individuals, using transgender affirmative language, awareness and discussion of historical marginalization, pathology descriptions within the assessment and diagnosis stage, and promotion of social justice are other forms of support a therapist can provide (Weir & Piquette, 2018). Knowledge of the environment that transgender clients live in is encouraged. Being aware of the violence and discrimination the community faces, the loss of family and friends that can occur can be better understood by reading material such a biography of transgender authors.
Summary
If a therapist, psychologist, or researcher is interested in working with the LGBT community, knowledge of the diverse stressors being faced by the community is important. The therapist needs to be aware of their limitations and own biases. Seeking additional resources from the community and other therapists is always recommended by guidelines and principles. Finally asking the clients directly about how to address certain issues is crucial such as asking the client their appropriate name and pronouns. Since the LGBT community continues to grow, particularly the transgender community, therapists should become more familiar with the rates of psychological distress, minority stress, and begin or continue to explore interventions and the guidelines and principles in working with the LGBT community.
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Gonzalez, F.R. (2020). Cultural Considerations in Behavioral Health Service Delivery with LGBT Populations. In: Benuto, L.T., Gonzalez, F.R., Singer, J. (eds) Handbook of Cultural Factors in Behavioral Health. Springer, Cham. https://doi.org/10.1007/978-3-030-32229-8_13
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