Mental Health Practice with LGBTQ+ Children, Adolescents, and Emerging Adults in Multiple Systems of Care

Cristina L. Magalhães, PhD, LMHC, is associate director and professor of clinical psychology in the Health Emphasis of the Clinical PsyD Program, Fellow of the Rockway Institute for LGBTQ Studies, and Coordinator of the Rockway Certificate in LGBTQ Psychology at the California School of Professional Psychology at Alliant International University, Los Angeles. As a clinician, Dr. Magalhães has over 20 years of experience working with couples, families, and individuals across the life span in community mental health centers, residential settings, and independent practice. She is licensed to practice as a mental health counselor in Florida, and as a psychologist in California and Rio de Janeiro, Brazil. Her research, writing, and speaking engagements have been primarily in the areas of cross-cultural assessment, anxiety and trauma related disorders, and LGBT psychology, with an emphasis on transgender health. Richard A. Sprott, PhD, teaches in the Department of Human Development and Women's Studies at California State University, East Bay and teaches graduate level courses at various universities in the San Francisco Bay Area, including UC Berkeley, the California Institute of Integral Studies, and Holy Names University. His early work was on social and language development in early childhood. In addition, he has a long history of conducting educational program evaluations for migrant farmworker families in the Midwest, which highlight the ways in which social organizations and communities help and hinder the educational achievement of migrant farmworker children. He is currently directing research projects focused on identity development and health/well-being in people who express alternative sexualities and non-traditional relationships, and issues facing homeless LGBTQ youth. He is current president-elect of Division 44 of APA: the Society for the Psychology of Sexual Orientation and Gender Diversity. All of these efforts highlight the ways in which stigma, prejudice, minority dynamics, health, language, identity development and community development all intersect and affect each other. G. Nic Rider, PhD, is an assistant professor at the University of Minnesota Medical School’s Program in Human Sexuality and Co-Associate Director of Research for the National Center for Gender Spectrum Health. Dr. Rider is also a licensed psychologist and gender and sexuality specialist with clinical and research experience examining minority stressors, health disparities, and care utilization of LGBTQ+ individuals across the lifespan. Using an intersectionality framework, Dr. Rider is particularly interested in how interlocking systems of power and oppressive experiences related to having multiple marginalized identities influence health and wellbeing for LGBTQ+ youth of color. Dr. Rider has served as a study coordinator on a NIH-funded research project which resulted in several publications that documented barriers to care and minority stressors as well as prevalence rates of risk factors, protective factors, health concerns, and health care utilization among transgender and gender diverse youth. Dr. Rider is currently Co-Chair of the Asian American Psychological Association’s Division on LGBTQ.

Introduction: Health Disparities, Resilience, and Interdisciplinary Care for LGBTQ+ Youth and Emerging Adults

(G. Nic Rider, PhD, LP, Cristina Magalhães, PhD, LMHC, & Richard Sprott, PhD)

Section I: Theoretical Approaches

Chapter 1: Minority Stress Theory and Resilience-Building Practice

(Eunice V. Avilés Faría, PhD, LMHC, LPC)

Author’s Note

Minority Stress Theory

Minority Stress Processes and the LGB Community

Minority Stress Processes and Transgender and Gender Nonbinary Individuals

Distal Stressors

Proximal Stressors

The Impact of Minority Stress on Mental Health

The Impact of Minority Stress on Physical Health

Resilience

Individual Resilience

Community Resilience

Resilience Building Practice: Interventions that can Enhance Resilience

Societal Level Interventions

Community and Group Level Interventions

Individual-Level Interventions (ILI)

Empirical Support for the Minority Stress Model

Gaps in the Literature and Future Directions for Clinically Relevant Research

Chapter 2: Intersectionality, Culturally Sensitive Care, and LGBTQ+ Youth

(Kayden J. Schumacher, MSc, MS, LSC, Leonardo E. Candelario-Pérez, PhD LP, Eunice V. Avilés Faría, PsyD, LMHC, LPC, & G. Nic Rider, PhD LP)

Practice Considerations

Advocacy Considerations

Conclusion

Chapter 3: Interdisciplinary Healthcare for Transgender Youth: An Application of the Gender-Affirmative Lifespan Approach (GALA)

(Katherine G. Spencer, PhD, LP, CST & Nova Bradford, LGSW)

Introduction to Transgender Health

History of Gender-Affirmative Healthcare for Youth

Minority Stress

The Gender Affirmative Lifespan Approach (GALA)

Philosophical Foundations of GALA

Core Components of GALA

Interdisciplinary Approach

Connections to Medical Interventions

Case Studies

Case Study A: Research - Unicorn Youth

Case Study B: Advocacy & Policy - Health Insurance Advocacy in MN

Case Study C: Clinical Example - Sexuality and Agency

Case Study D: Youth Homelessness

Conclusion

Key Knowledge Points

Recommendations for Professionals

Section II: Development Issues

Chapter 4: The Youngest Part of the Rainbow: Clinical Care for Gender Diverse Children

(Dianne R. Berg, PhD, LP*, Caroline Maykut, PhD*, Rachel Becker-Warner, PsyD, LP, Catherine Schaefer, MS, & Jennifer J. Connor, PhD, LMFT - *Co-First Authors)

Social and Historical Context of Research with Gender Diverse Children

Gender Identity Development

Mental Health in Gender Diverse Children

Clinical Implications of Mental Health Research

Resilience in Gender Diverse Children

Interpersonal Contexts

Peer Group

Family

Community Contexts

Schools

Healthcare Settings



Medical Settings
Mental Health Settings

Case Study

Andi’s Gender Journey



Sessions 1-3 Assessment: Age 4.11 – 5.0
Sessions 4-5 Feedback and Collaborative Treatment Planning with Parents Only: Age 5.1 - 5.2
Sessions 6-11 Early Therapy Process: Age 5.3 – 6.1
Sessions 12-16 Ongoing Therapeutic Process: Age 6.2 – 6.7
Sessions 17 - 24 Ongoing Therapeutic Process: Age 6.8 – 7.5
Sessions 24-35 Ongoing Therapeutic Process: Age 7.6 – 9.0
Sessions 36-44 Present Therapeutic Process: Age 9.3 – 10.5

Case Reflection

Future Directions

Key Knowledge Points

Recommendations for Practitioners and Professionals

Chapter 5: Risk and Protective Factors Among LGBTQ+ Adolescents

(Amy L. Gower, PhD, Marla E. Eisenberg, ScD, MPH, & G. Nic Rider, PhD, LP)

Interpersonal Relationships

Friendships

Romantic Relationships

Parent/Family Relationships

The School Context

Community Support

Online/Internet Support

Developmental Considerations

Case Study

Practice Considerations

Conclusions

Chapter 6: Not a Teen, Not Yet an Adult: Health Risk and Protective Factors Among LGBTQ+ Emerging Adults

(Caleb Esteban, PhD, Alixida Ramos-Pibernus, PhD, Luis X. Díaz-Medero, MS, & Astrid Irizarry-Rodríguez, MS)

LGBTQ+ Emerging Adults

Institutional Challenges

Family

College

Religious Institutions

Healthcare

Government

Interpersonal Challenges

Relationships

Marriage

Peers

Religious Affiliation

Personal Challenges

Physical Health



HIV/STIs
Healthcare
Substance Abuse

Mental Health



Depression and Anxiety
Suicide

Protective Factors for LGBTQ+ Emerging Adults

Resilience

Social Support

Community Engagement and Connectedness

Gaps and Future Direction for Studies

Clinical Implications

Case Study

Case Study Discussion

Key Knowledge Points

Recommendations for Mental Health Clinicians

Section III: Systems of Care

Chapter 7: Pre-K – 12 Schools

(Molly M. Strear, PhD, NCC & Matthew J. Beck, PhD, LCPC, NCC, ACS)

SBMHPs Working with LGBTQ+ Youth: Review of Literature

School Counselors

School Social Workers

School Psychologists

SBMHP Collaboration

Recommendations for SBMHPs

Coordination of Services Through MTSS

Tier 1 - Universal Support

Tier 2 - Supplemental Support

Tier 3 - Intensified Support

Family/Community Engagement

Implications & Future Directions

Conclusion

Key Knowledge for Students

Recommendations for Practitioners and Professionals

Chapter 8: Serving LGBTQ+ Students at University and College Campuses

(Jan E. Estrellado, PhD & Saromi Kim, PhD)

Challenges Facing LGBTQ+ College Students

Mental Health Disparities

Identity Development as a Major Task of Late Adolescence and Emerging Adulthood

Acceptance and Visibility of LGBTQ+ Students on Campus

Intersectionality and Marginalized Identities

The Need for Affirming LGBTQ+ College Student Services

Student Support Services

Relationships with Faculty

Relationships with Peers

Health Services on Campus

Gaps in Research

First-Generation Students

Bisexual and Fluid Students

Transgender, Nonbinary, and Gender Expansive (TNBGE) Students

STEM Students

Immigration Status

International Students

Clinical and Policy Recommendations When Working with LGBTQ+ College Students

University or College Counseling Centers

Coming Out

Language

Complexity of Identities

Depathologizing Symptoms

Advocacy

Policy Recommendations



Data Collection
Institutional Policies
Feedback Loops
Inclusivity
Dialogue Spaces
Intersectionality
Community LGBTQ+ Services
Community Colleges
Protective Factors
Health Providers
Counseling Centers
Academic and Career Advisors

Conclusion

Key Knowledge Points

Recommendations for Practitioners

Chapter 9: Medical Care Centers as Beacons of Hope for LGBTQ+ Youth

(Hiram Rivera-Mercado, PsyD, Kevin Carrion, PsyD, & Taymy J. Caso, PhD)

Role of Hospitals in Serving LGBTQ+ Youth and Emerging Adults

Services Included

Primary Care

Pediatric Endocrinologist

Behavioral Health and Mental Health Services

Policies and Their Function

Training of Personnel

Community Partnerships and Resources

Creating a Welcoming Environment

Physical Environment

Registration and Documentation Processes

Language and Communication

Conclusion

Chapter 10: Improving Child Welfare and Foster Care Outcomes for LGBTQ+ Youth

(Kellen Grayson, PsyD, LMFT & Mira Jourdan, PhD, ABPP)

Family Rejection, Abuse, and Homophobia

LGBTQ+ Youth and Polyvictimization

Poverty and LGBTQ+ Youth Vulnerability

Over-Representation of LGBTQ+ Youth in Child Welfare Services

The State of Foster Care and Child Welfare Systems

Policies and Practices in Child Welfare Services

Training and Oversight of Foster Parents and Child Welfare Workers

Gaps in Care

Transition-Age Youth

The Landscape for Change

Religious Freedom Restoration Acts and Child Welfare

Considerations for Clinicians

Conclusion

Chapter 11: LGBTQ+ Youth Experiencing Homelessness

(Catherine Forbes, PhD, Carrie Mounier, LCSW, & Kaitlin Venema, PhD)

Literature Review and Gaps in Research: LGBTQ+ Youth Experiencing Homelessness

Clinical Considerations and Recommendations for Practice in Mental Health and Substance Abuse Treatment

Trauma Informed Care

Interdisciplinary Programs for LGBTQ+ YEH

Evidenced-Based LGBTQ+ Affirming Therapeutic Services

Group Therapy Approaches

Alternative Programming for LGBTQ+ YEH

Medical Interventions

Structural Competency and Service Systems for LGBTQ+ YEH

Impact of Structures on Patient Health

Influence of Structures on the Clinical Encounter

Respond to Structures in the Clinic

Respond to Structures Beyond the Clinic

Structural Humility

Practice and Policy Recommendations

Healing Centered Engagement and Structural Violence

Restorative Justice and Structural Violence

Positive Youth Development and Structural Violence

Harm Reduction and Structural Violence

Gaps and Future Directions

Chapter 12: Gender Expansive and Sexual Minority Youth and the (In)Justice System

(Macy Wilson, PsyD, Jessica Ward, MA, & Roberto L. Abreu, PhD)

Incidence and Prevalence

Risk Factors

School to Prison Pipeline

“No Promo Homo” Laws and a Heterosexual-Cisgender School-Based Curriculum

A Failed Welfare System

The (Il)legal System

Disproportionate Representation

Unequal Injustice

Gender Differences

Youth of Color

Microaggressions

Mediating Factors

Mental Health Behaviors While Incarcerated

Self-Harming Behaviors

Aggression Toward Others

Toward a Socially-Just System: Ensuring Safety for LGBTQ+ Youth

Incorporating a Holistic Approach to Care

Constitutional Rights

Legal Rights of LGBTQ+ Youth in the Justice System

Recommendations

Key Knowledge Points

Chapter 13: Services for Youth and Emerging Adults at LGBTQ+ Centers and Other Community-Based Organizations

(Tangela Roberts, PhD, Zari Carpenter, MA, and Kat Schuette, MA)

Author’s Note

LGBTQ+ Youth and Emerging Adults of Color

Transgender and Gender Non-Conforming (TGNC) Youth and Emerging Adults

Challenges for LGBTQ+ Youth and Emerging Adults

Healthcare Challenges



Mental Health
Sexual Health

Interpersonal Challenges



Coming Out
Building Community
Dating and Relationships
Intimate Partner Violence

Vocational Challenges



Career Development
Employment Discrimination
Workplace Identity Management

Method

Sample of LGBTQ+ Community Centers

Results

Physical Health Services

Mental Health Services

Services for Queer Youth and Emerging Adults of Color (QYAOC)

Services for Transgender and Gender-Non-Conforming (TGNC) Youth and Emerging Adults



Emotional Support
Social Support

Services Related to the Provision of Basic Needs



Housing Stability
Food Insecurity

Services Related to Educational and Vocational Assistance

Auxiliary Services

Discussion

Areas of Improvement in Serving LGBTQ+ Youth and Emerging Adults



Availability of Services by Geographical Region
Access to LGBTQ+ Community Centers
LGBTQ+ Youth and Emerging Adults of Color

Considerations for Clinical Practice

Policy Recommendations

Chapter 14: Independent Practice

(Gary Howell, PsyD, Arlene Noriega, PhD, Julie Williams, MSEd)

Independent Practice

Solo Practices

Group Practices

Integrated Practices

Nuances with LGBTQ+ Affirmative Practices

Consultative Roles

Barriers to Care

Healthcare Disparities

Sociopolitical Factors

Social Determinants of Care

Eliminating Barriers to Care

Cultural Competence

Intersectional Approach

Centering Marginalized Voices

Advocacy

Integrated Approach

Impact of the Affordable Care Act

Impact of COVID

Successes

Challenges

Research Gaps and Future Directions

Considerations for Practice

Key Knowledge Points

Recommendations for Practitioners

Conclusion: Increasing Health and Well-Being of LGBTQ+ Youth and Emerging Adults: Lessons Learned, Questions Unanswered

(Richard Sprott, PhD, G. Nic Rider, PhD, & Cristina L. Magalhães, PhD, LMHC)

Summary of Findings and Lessons

A Possible Agenda for Research, Clinical Treatment, and Policy

More Resources and Funding

Train Mental Health Providers

Systems-Based Approach Refinement

Summary

Appendix A: List of Resources

About the Contributors

References

Index