Trauma, Resilience, and Health Promotion in LGBT Patients (eBook)

Kristen L. Eckstrand, MD, PhD Department of Psychiatry Western Psychiatric Institute and Clinic University of Pittsburgh Medical CenterJennifer Potter, MD Associate Professor of MedicineAdvisory Dean & Director, William B. Castle SocietyHarvard Medical School Director, Women's Health CenterBeth Israel Deaconess Medical Center Director, Women's Health ProgramFenway Health Center Director, Women's Health Research The Fenway Institute

Preface 5
Contents 7
Contributors 9
Part I: Overview of Trauma in LGBT Populations 12
Chapter 1: Intersection of Trauma and Identity 13
Traumatic Versus Non-traumatic Events 13
Minority Stress 15
Developmental Impact of Homophobia and Transphobia 17
PTSD Among LGBT Individuals 18
Non-traumatic Events and PTSD-Like Disorder 19
Conclusion 20
Case 20
Discussion Questions 21
Summary Practice Points 21
Resources 21
References 21
Chapter 2: Medical Intervention and LGBT People: A Brief History 25
Introduction 25
Nineteenth and Early Twentieth Century 25
WWII and Beyond: The Era of Medical Intervention 27
1960s-1990s: Civil Rights in a Changing Political Era 29
Current Issues in LGBT Medicine 30
Health Inequities 30
Sexual Orientation Change Efforts 31
Trans Issues 31
Conclusion 31
Resources 32
References 32
Chapter 3: Conceptualizing Trauma in Clinical Settings: Iatrogenic Harm and Bias 34
Defining Trauma 34
What Do We Know About Trauma and Experiences of LGBT People in Healthcare? 34
Theoretical Approaches to Understanding and Addressing Trauma with LGBT Patients 36
Trauma-Informed Care for LGBT People 37
Identifying Trauma 37
Addressing Implicit Bias 38
Reducing Reactivity 38
Preventing Harm to LGBT People in Healthcare Settings 38
Promoting Resilience 39
Advocacy on Behalf of LGBT People in Clinical Settings 39
Clinical Scenario 40
Discussion Questions 41
Summary Practice Points 41
Resources 41
References 41
Chapter 4: Impact of Stress and Strain on Current LGBT Health Disparities 43
Introduction 43
Biological Stress 44
Life Cycle Model of Stress 45
Reactive Cortisol 47
Diurnal Cortisol 47
Allostasis and Allostatic Load 48
Clinical Allostatic Load Index 49
Psychosocial Implications and Clinical Perspectives 51
Social Policy Implications 52
Case Scenario 52
Discussion Questions 53
Summary Practice Points 53
References 53
Part II: Resilience Across the Lifespan 57
Chapter 5: The Role of Resilience and Resilience Characteristics in Health Promotion 58
Introduction 58
What Is Resilience and How Does It Develop? 58
LGBT Resilience Research 59
LGBT Resilience in the Context of Health Promotion 60
Conclusions 62
References 62
Chapter 6: Childhood and Adolescence 64
Epidemiology and Healthcare Needs 64
Diverse Sexual Orientations in Childhood and Adolescence 64
Diverse Gender Identities in Childhood and Adolescence 64
The Context of Healthcare for Sexual and Gender Diverse Children and Adolescents: An Affirmative Trauma-Informed Perspective 65
Health Risks and Vulnerabilities 65
Identity-Based Stigma, Discrimination, and Victimization 67
Etiology of Health Risk: A Trauma-Informed Approach 68
Healthcare for Sexual and Gender Diverse Children and Adolescents 68
Cultivating Resilience 69
Understanding Factors that Support Resilience 69
Information and Communication Technologies 69
Affirmative Interventions and Programs 70
Affirmative Healthcare for SGD Children and Adolescents: An Emerging Framework 70
Articulate Affirmation 70
Particular Considerations for Gender Diverse Children and Adolescents 71
Consider Language 71
Orient to the Setting and Process 72
Comprehensively Assess for Discrimination and Coping Strategies 72
Support and Educate Family 73
Strengthen Organizational Capacity 73
Case Scenario 74
Case Description and Presenting Issues 74
Clinical Considerations 74
Affirmative Care Approaches 75
Questions for Learner Discussion 75
Specific Bulleted Take Home Points 75
References 75
Chapter 7: Resilience Across the Life Span: Adulthood 81
Resilience Resulting from Minority Stressors 81
General Strengths Using a Positive Psychology Framework 82
Coming Out Growth 84
Interpersonal Factors Implicated in Resilience 85
Individual Difference Factors Implicated in Resilience 86
Resilience Against Suicidality 88
Emerging Data 89
Resilience Promotion in Patient/Provider Relationships 89
Summary 90
Case Scenario 91
Discussion Questions 91
Summary Practice Points 91
Resources 92
References 92
Chapter 8: Older Adults 95
Understanding the Context and Impact of Trauma 96
Sources of External Trauma 98
Sources of Internal Trauma 98
Supporting Resilience When Working with LGBT Older Adults 100
Health Promotion 101
Case Study 104
Discussion Questions 104
Summary Practice Points 104
References 104
Part III: Resilience in Specific Populations 108
Chapter 9: Transgender and Gender Nonconforming Individuals 109
Introduction 109
Health Outcomes for Transgender People 109
Studies of Resilience in Transgender Populations 110
Summary 112
Case Scenario 112
Discussion Questions 112
Summary Practice Points 113
Resources 113
References 113
Chapter 10: Understanding Trauma and Supporting Resilience with LGBT People of Color 116
Conceptual Frameworks with LGBT People of Color 116
Trauma Prevalence Among LGBT People of Color 117
Terms Used by LGBT People of Color Communities 118
Coming Out to Others 118
Access to Services 118
LGBT People of Color and Religious/Spiritual Beliefs 118
Individual and Collective Resilience of LGBT People of Color 119
Adaptive Resilience and Coping Strategies 119
Collective and Community Resilience 119
Supporting LGBT People of Color as a Healthcare Provider 119
Clinical Scenario 120
Discussion Questions 120
Summary Practice Points 121
References to Support Case 121
References 121
Chapter 11: LGBT Forced Migrants 123
Forced Migrants 123
Terms and Definitions 123
Seeking Immigration Status in the USA 123
Forced Migrant Mental Health 124
LGBT Forced Migrants 125
Immigration Status for LGBT Forced Migrants 125
LGBT Forced Migrant Mental Health 126
Resilience Among Forced Migrants 126
Providing Services to LGBT Forced Migrants 127
General Considerations 127
Medical Assessment 128
Mental Health Assessment 129
Mental Health Interventions 130
Case Example 130
Discussion Questions 131
Summary Practice Points 131
References 131
Chapter 12: Lesbian and Bisexual Women 134
Introduction 134
Minority Stress Model 134
Development of Coping Mechanisms 135
Health Disparities in Lesbian and Bisexual Women 136
Resilience Factors in Lesbian and Bisexual Women 138
Social Ecological Model 138
Individual Level 138
Coming Out 138
Self-Acceptance 139
Interpersonal Level 140
Family of Origin Support 140
Peer Support 140
Marriage/Recognized Intimate Relationships 141
Organization/Community Level 141
Healthcare Systems 141
Employment/Workplace 141
Religion/Spirituality 142
Community Support Structures 142
Policy Level 143
Marriage Equality and Health Outcomes: Impact of Obergefell v. Hodges 143
Nondiscrimination Policies and Hate Crime Legislation 143
Bullying as a Health Risk 144
Promoting Resilience in Lesbian and Bisexual Women 144
Caring for Self 144
Caring for Others 144
Building Families 145
Bisexual Pride 145
Conclusion 145
Case Scenario 145
Discussion Questions 146
Summary Practice Points 146
Resources 146
References 146
Chapter 13: Institutionalization and Incarceration of LGBT Individuals 150
Drivers of Incarceration/Institutionalization 150
Pathologization of LGBT and GNC Status 150
Effect of Pathologization 150
Events Over Time 151
The Shift from Mental Health Hospitals to Incarceration 153
Cost for Families and Communities 153
Dual Diagnosis with Substance Use Disorders 153
The Current State of Mental Healthcare 153
Community-Based Mental Health Services 154
Institutions for the Mentally Ill 154
Criminal Justice System 154
Incarceration and Mental Health 155
Prevalence and Impact of Incarceration on LGBT People 155
Prevalence of Incarceration Among LGBT Individuals 156
Arrest and Incarceration of LGBT Adults 156
Juveniles 156
Specific Health-Related Concerns Relevant to LGBT Inmates 156
Provision of Medication 157
Hormone Therapies 157
Treatment of HIV/AIDS 157
Housing Policies 157
Treatment by Correction Staff and Fellow Inmates 158
Access to Support Systems 159
Specific Mental Health Issues Among Justice-Involved LGBT Individuals 159
Increased Levels of Anxiety and Stress 159
Issues of Self-Esteem 159
Post-traumatic Stress Disorder 159
Mental Deterioration 159
The Future of LGBT Justice-Involved Individuals: Returning to a Public Health Paradigm 160
Decriminalization of Substance Use and Mental Illness 160
References 160
Part IV: Resilience Promotion in Clinical Practice 163
Chapter 14: An Overview of Trauma-Informed Care 164
Definitions of TIC 164
The Origins of Trauma-Informed Care 165
Toward a Synthesis: Raja´s Pyramid Model of Trauma-Informed Care 167
The Relationship Between the Neurobiology of Trauma and TIC 169
TIC and Trauma-Informed Approaches Outside Healthcare 171
TIC for LGBT Healthcare and the Promotion of Wellness Among LGBT Individuals and Communities 172
Evidence of the Effectiveness of TIC 174
Knowledge and Practice Gaps in TIC 175
TIC, Resilience, and the Limitations of Resilience 176
Conclusions 176
References 176
Chapter 15: Screening and Assessment of Trauma in Clinical Populations 181
Introduction 181
Contextualizing Trauma Assessment Based on Sexual Orientation and Gender Identity 181
Assessment for Trauma 182
Screening for Trauma 182
Transition from Screening to Assessment 182
Detailed Assessment of Trauma Symptoms 183
Diagnosis of Trauma-Associated Sequelae 183
Contextualizing Screening and Assessment of Trauma in LGBT Populations 183
Rationale for Contextualizing 183
How Is the Assessment of LGBT Patients Similar and Different from Assessment of Their Heterosexual/Cisgender Counterparts? 183
What Specialized Screening and Assessment Considerations Are Relevant for LGBT People of Color? 184
What Specialized Screening and Assessment Considerations Are Relevant for LGBT Youth? 185
What Specialized Screening and Assessment Considerations Are Relevant for LGBT Adults? 185
Assessment of Posttraumatic Growth and Resilience 186
Conclusion 186
Key Clinical Recommendations 187
References 187
Chapter 16: Patients and Their Bodies: The Physical Exam 189
Introduction 189
Performing a Trauma-Informed Physical Exam That Is LGBT-Inclusive 189
Screen for Trauma 189
Consider if You Actually Need to Perform the Exam 190
Consider if There May Be Alternative Procedures to Recommend to or Offer the Patient 190
Make No Assumptions About Patients´ Preferences and Discuss the Benefits, Potential Harms, and Limitations of the Examination,... 190
Before Proceeding with the Exam, Discuss Whether the Patient Desires Any Modifications to the Exam to Reduce the Potential for... 191
Always Obtain Assent Before You Physically Touch or Examine a Patient 192
During the Exam, Be particularly Mindful of Your Tone and Reactions 192
Additional Considerations for Patients Who Have Experienced Trauma 192
Validate the Patient 192
Be Patient and Focus on Building a Relationship 192
Brainstorm Additional Ways to Support the Patient 193
Be Prepared to Handle Dissociation or Distress During the Exam 193
Debrief After the Exam and Make Sure the Patient Has a Plan for Self-Care After Leaving the Office 194
Case Example 194
Discussion Questions 194
Example Introductory Language to the Physical Exam 194
Performing a Physical Exam in the Immediate Posttrauma Setting 195
Special Considerations: Data, Disparities, and Context 195
Special Considerations: Administrative Issues, Forms, and Interacting with Others Besides the Patient 196
Special Considerations: Clinical Considerations for Trans Patients 196
Special Considerations: Patient-Provider Interaction 198
Conclusion 198
References 199
Chapter 17: Motivational Interviewing for LGBT Patients 201
Origins of Motivation Interviewing in Theories of Behavior Change 202
Following 202
Directing 202
Guiding 203
Fundamentals of Motivational Interviewing 203
R: Resist the Righting Reflex 204
U: Understand the Motivations of Your Patient 204
L: Listen to Your Patient 205
E: Empower, Engage, and Encourage Your Patient 205
Incorporating Motivational Interviewing into Patient-Provider Interactions 205
Asking 205
Open vs. Closed Questions 205
Agenda Setting 206
Key Techniques to Asking the Right Questions 207
Listening 208
Silence 210
Reflective Listening and Summarizing 210
Informing 210
Balancing Asking, Listening, and Informing 212
Applications of Motivational Interviewing in LGBT Health 212
Case Study #1 213
Instructions for Provider (Actor 1) 213
Instructions for Patient (Actor 2) 213
Provider Follow-Up Questions 213
Patient Follow-Up Questions 214
Case Study #2 214
Instructions for Provider (Actor 1) 214
Instructions for Patient (Actor 2) 214
Provider Follow-Up Questions 214
Patient Follow-Up Questions 215
Additional Resources 215
References 215
Chapter 18: Promoting Healthy LGBT Interpersonal Relationships 216
Background 216
Trauma-Informed Violence Screening and Assessment in Primary Care 217
Strategies for IPV Screening in Primary Care 217
IPV Assessment in Primary Care: Universal Education, Routine Inquiry, and Brief Counseling 218
Behavioral Health 220
Assessment of IPV 220
Treatment of Individuals Following IPV 220
Ongoing Violence 222
Stabilization of Trauma Symptoms 223
Metabolizing Trauma 223
Integrating Trauma 223
The Violence Recovery Program, Fenway Health 224
Case Study 224
References 225
Chapter 19: Community Responses to Trauma 228
Purpose 228
Learning Objectives 228
Introduction: Linking Interpersonal and Structural Violence in LGBT Communities 228
Trauma and Resilience in Vulnerable LGBT Populations 229
Adolescents and Youth 229
Elders 230
Members of Faith-Based Communities 231
Geographically Marginalized Communities 232
Historical Community-Based Responses to Trauma 232
Limitations of Community-Led Responses 233
Innovations in Community-Led Responses to Trauma 234
Provider Engagement in Existing Community Support Structures 235
Advocacy Solutions: Ensuring Sustainable Models to Oppose Structural Violence 235
Conclusion 236
References 236
Chapter 20: Resilience Development Among LGBT Health Practitioners 241
Objectives 241
Introduction 241
Case Scenario, Part 1 241
Trauma and Discrimination Experienced by LGBT Health Practitioners 242
Case Scenario, Part 2 242
Physicians, Medical Students, and Physician Trainees 242
Case Scenario, Part 3 243
Nurses and Nursing Students 243
Other Healthcare Practitioners and Trainees 244
Case Scenario, Part 4 244
Resilience Among LGBT Health Practitioners 245
Societal/Public Policy Level 245
Organizational and Professional Factors of Resilience 245
Case Scenario, Part 5 247
Community Factors of Resilience 247
Individual Factors of Resilience 248
Conclusions 248
Case Conclusion 248
Discussion Questions 248
Summary Practice Points 248
References 248
Index 251