1. LGBT Mental Health Odhrán Allen Odhrán Allen Director of Mental Health GLEN

2. Sexuality Four components: Four components: Biological sex Biological sex Social gender role Social gender role Sexual orientation Sexual orientation Gender identity Gender identity (American Psychological Association, 2008)

3. Sexual Orientation Sexual orientation is distinguished by an emotional, romantic, sexual or affectionate attraction to individuals of a particular sex. (APA, 2008) Sexual orientation is distinguished by an emotional, romantic, sexual or affectionate attraction to individuals of a particular sex. (APA, 2008)

4. Sexual Orientation Three sexual orientations: Three sexual orientations: Heterosexual = attraction to individuals of the opposite sex Heterosexual = attraction to individuals of the opposite sex Homosexual = attraction to individuals of one’s own sex Homosexual = attraction to individuals of one’s own sex Bisexual = attraction to members of both sexes Bisexual = attraction to members of both sexes

5. LGB = Lesbian, Gay & Bisexual Lesbian woman = a woman who is romantically, sexually and emotionally attracted to women Lesbian woman = a woman who is romantically, sexually and emotionally attracted to women Gay man = a man who is romantically, sexually and emotionally attracted to men Gay man = a man who is romantically, sexually and emotionally attracted to men Bisexual = a man or woman who is romantically, sexually and emotionally attracted to someone of either sex Bisexual = a man or woman who is romantically, sexually and emotionally attracted to someone of either sex Avoid using homosexual to refer to someone Avoid using homosexual to refer to someone 8% LGB in My World Survey (2012) 8% LGB in My World Survey (2012)

6. Gender Identity Gender identity refers to whether one feels male or female regardless of sex assigned at birth. Gender identity refers to whether one feels male or female regardless of sex assigned at birth. Gender expression refers to outwardly expressing one’s gender identity through mannerisms, grooming, physical characteristics, social interactions and speech Gender expression refers to outwardly expressing one’s gender identity through mannerisms, grooming, physical characteristics, social interactions and speech (American Psychological Association)

7. Transgender Transgender is a term used to describe people whose gender identity or gender expression, differ from the sex assigned to them at birth Transgender is a term used to describe people whose gender identity or gender expression, differ from the sex assigned to them at birth Not everyone whose feelings, appearance or behaviour is gender-atypical will identify as a transgender person Not everyone whose feelings, appearance or behaviour is gender-atypical will identify as a transgender person Gender dysphoria – gender identity opposite to sex assigned at birth (Transsexual, GID) Gender dysphoria – gender identity opposite to sex assigned at birth (Transsexual, GID)

8. Gender Dysphoria Transgender Girl/Woman Designated male sex Designated male sex Male appearance Male appearance Raised as a boy Raised as a boy Identifies as a girl/woman Identifies as a girl/woman Trans girl/woman or woman with trans history Trans girl/woman or woman with trans history (GIRES, 2013) (GIRES, 2013) Transgender Boy/Man Designated female sex Designated female sex Female appearance Female appearance Raised as a girl Raised as a girl Identifies as a boy/man Identifies as a boy/man Trans boy/man or man with a trans history Trans boy/man or man with a trans history

9. Transitioning Process of changing the way someone’s gender is lived publicly. People who wish to transition often start by expressing their gender identity in situations where they feel safe. Process of changing the way someone’s gender is lived publicly. People who wish to transition often start by expressing their gender identity in situations where they feel safe. Typically work up to living full-time in their preferred gender by making gradual changes to their gender expression. Typically work up to living full-time in their preferred gender by making gradual changes to their gender expression. Transitioning typically involves changes in clothing and grooming, a name change, change of gender on identity documents, hormonal treatment and surgery. Transitioning typically involves changes in clothing and grooming, a name change, change of gender on identity documents, hormonal treatment and surgery. (American Psychological Association)

10. Transitioning Psychosocial support during process Psychosocial support during process Connecting with other transgender people through peer support groups and transgender community organisations is also very helpful for people when they are going through the transition process. Connecting with other transgender people through peer support groups and transgender community organisations is also very helpful for people when they are going through the transition process. Professional guidelines: www.wpath.org Professional guidelines: www.wpath.orgwww.wpath.org Information & support: Information & support: TENI = Transgender Equality Network Ireland www.teni.ie www.teni.ie TransParentCI – Trans Parent Connect Ireland via TENI LOOK (Parent Support) www.lovingouroutkids.org www.lovingouroutkids.org BeLonG To Youth Service www.belongto.org www.belongto.org

12. Demographics First major Irish study on LGBT mental health First major Irish study on LGBT mental health Commissioned: GLEN & BeLonG To Youth Service Commissioned: GLEN & BeLonG To Youth Service Funded: HSE National Office for Suicide Prevention Funded: HSE National Office for Suicide Prevention Research Team: TCD & UCD - Paula Mayock, Audrey Bryan, Nicola Carr, Karl Kitching Research Team: TCD & UCD - Paula Mayock, Audrey Bryan, Nicola Carr, Karl Kitching 1,110 survey participants and 40 interviewees 1,110 survey participants and 40 interviewees Age range: 14 – 73 Age range: 14 – 73 LGB: 96%, T: 4% LGB: 96%, T: 4%

13. Mental health: Key Findings 46% had hazardous drinking (AUDIT-C) 46% had hazardous drinking (AUDIT-C) 27% had self-harmed at least once 27% had self-harmed at least once 85% more than once 85% more than once 16 years = average start age 16 years = average start age 40% female and 20% male 40% female and 20% male 17.7% had attempted suicide at least once 17.7% had attempted suicide at least once 60% more than once 60% more than once 17.5 = average start age 17.5 = average start age 24% female and 15% male 24% female and 15% male ⅓ of under 25s had seriously contemplated suicide in past year (50% ever) ⅓ of under 25s had seriously contemplated suicide in past year (50% ever) These findings strongly linked with LGBT-specific stresses. i.e. minority stress These findings strongly linked with LGBT-specific stresses. i.e. minority stress

14. Minority Stress: 3 Characteristics 1. Unique – additional to general stressors that are experienced by all people. Members of minority groups require a stress adaptation effort above that required of non-minorities 2. Chronic – related to enduring underlying social and cultural structures 3. Socially Based – stems from social processes, institutions and structures beyond the individual (Meyer, 2003)

15. COMING OUT Realising LGBT identity: Realising LGBT identity: 12 years of age = most common age 12 years of age = most common age Disclosing LGBT identity: Disclosing LGBT identity: 17 years of age = most common age 17 years of age = most common age 5 year period between people knowing they were LGBT and disclosing this to others. 5 year period between people knowing they were LGBT and disclosing this to others. This period of time coincided with participant’s school-going years – a time of critical social and emotional development This period of time coincided with participant’s school-going years – a time of critical social and emotional development Emerged as a time of particular vulnerability Emerged as a time of particular vulnerability

16. “Coming out is probably one of the most extreme and difficult things you can do. Before you come out you have to deal with it all yourself and it took me six years to. And I couldn’t be myself for those six years and it is, again, it’s called in the closet because you are in the closet. No one can see you; they see this door because no one’s ever opened up the closet to look inside”

17. COMING OUT Coming out was more positive than anticipated for majority of respondents Coming out was more positive than anticipated for majority of respondents Majority came out to a friend or other trusted individual prior to coming out to their family. Majority came out to a friend or other trusted individual prior to coming out to their family. Feelings of relief were commonly felt after coming out, particularly when respondents received a positive response from others. Feelings of relief were commonly felt after coming out, particularly when respondents received a positive response from others. Regardless of outcome of coming out, the period prior to coming out was consistently reported as a stressful one – questioning identity, afraid to tell parents/friends, secret crush on best friend, being seen as different, worries about future life Regardless of outcome of coming out, the period prior to coming out was consistently reported as a stressful one – questioning identity, afraid to tell parents/friends, secret crush on best friend, being seen as different, worries about future life For some their distress wasn’t eased by coming out For some their distress wasn’t eased by coming out

18. HARASSMENT HARASSMENT in daily life: 80% had been verbally abused because of their LGBT identity 80% had been verbally abused because of their LGBT identity 40% were threatened with physical violence 40% were threatened with physical violence 25% had been punched, kicked or beaten 25% had been punched, kicked or beaten

19. “I’m sure people knew I was gay you know, I’d walk up through the village and people would be calling faggot and stuff like that. It did kill me a lot hearing the words and stuff and I was afraid as well. I felt very alone inside and the drink was my best friend”

20. HOMOPHOBIA IN SCHOOLS 58% reported homophobic bullying in their school 58% reported homophobic bullying in their school 40% verbally threatened by fellow students 40% verbally threatened by fellow students 25% physically threatened by fellow students 25% physically threatened by fellow students 20% missed or skipped school because they felt threatened or were afraid of getting hurt at school 20% missed or skipped school because they felt threatened or were afraid of getting hurt at school 34% reported homophobic comments by teachers 34% reported homophobic comments by teachers 8% were called homophobic names by teachers 8% were called homophobic names by teachers 5% left school early because of homophobic bullying 5% left school early because of homophobic bullying

21. “I left school because of the hurt and suffering I got in school, and the teachers didn’t care, as I think it was a case of "well they call him gay and he probably is gay, so why should we step in, cos they aren’t saying anything wrong" attitude towards gay people... even though I wasn’t out at school. I was forced to leave at my junior cert, due to the abuse I got … jumped on, called puff, queer etc”

22. SUICIDALITY/SELF-HARM linked to: Younger age Younger age Victimisation experiences Victimisation experiences Fear of rejection or actual rejection by family & friends Fear of rejection or actual rejection by family & friends Homophobic bullying in school Homophobic bullying in school Higher alcohol consumption Higher alcohol consumption

23. Key Findings Comparison: LGB & T Lesbian, Gay, Bisexual Now comfortable: 81% Now comfortable: 81% Physically attacked: 24.4% Physically attacked: 24.4% Contemplated suicide: 26% Contemplated suicide: 26% Self-harm: 27% Self-harm: 27% Attempted suicide: 17.7% Attempted suicide: 17.7%Transgender Now comfortable: 61% Now comfortable: 61% Physically attacked: 39.1% Physically attacked: 39.1% Contemplated suicide: 80% Contemplated suicide: 80% Self-harm: 43.5% Self-harm: 43.5% Attempted suicide: 26.1% Attempted suicide: 26.1%

24. “My mother doesn’t get my body yet and she was very shocked at first. She tried to convince herself that it was just a phase and then she was trying to tell me that there are some women who are feeling masculine but they are fine with it. When I told her I was actually going through hormone therapy, she was like, if you’re doing that then you’re not living here anymore” (Female-to-Male Trans, 20).

25. SOCIAL SOURCES OF RESILIENCE 1. Supportive friends 2. Accepting family 3. Belonging to LGBT community group or organisation 4. Positive school or work experiences

26. PERSONAL SOURCES OF RESILIENCE 1. Forming a positive LGBT identity 2. Developing good self-esteem 3. Positive turning points 4. Developing positive coping strategies

27. “I am happy to conclude by saying that I am now a very content, confident, well- adjusted gay man, fully out and very happy to be gay. I have grown and thrived with the love and support of my friends and two of my sisters … being gay was never my problem but how people reacted to me being gay was certainly part of what made life very hard in the past”

28. Available at: http://www.glen.ie/news- post.aspx?contentid=15493&name=new_l gbt_guide_for_mental_health_services http://www.glen.ie/news- post.aspx?contentid=15493&name=new_l gbt_guide_for_mental_health_serviceshttp://www.glen.ie/news- post.aspx?contentid=15493&name=new_l gbt_guide_for_mental_health_services

29. Thank you odhran@glen.ie @odhranallen www.glen.ie

30. Other Information & Resources

31. INCLUSIVE PRACTICE Inclusive practice means: Expecting diversity among your clients, colleagues, service users, etc. and respecting this diversity. Expecting diversity among your clients, colleagues, service users, etc. and respecting this diversity. Understanding the issues facing diverse groups (such as LGBT people) and being able to respond to their specific needs. Understanding the issues facing diverse groups (such as LGBT people) and being able to respond to their specific needs. Providing an accessible and appropriate service within your area of competence. Providing an accessible and appropriate service within your area of competence. (Psychological Society of Ireland, 2008)

32. UNHELPFUL SERVICES Unhelpful services had 5 characteristics: Presumption of heterosexuality Presumption of heterosexuality Lack of understanding of LGBT issues Lack of understanding of LGBT issues A lack of meaningful connection between the person and the practitioner A lack of meaningful connection between the person and the practitioner A lack of willingness or ability on the part of the practitioner to engage with or respond to LGBT people’s specific concerns or needs A lack of willingness or ability on the part of the practitioner to engage with or respond to LGBT people’s specific concerns or needs Anti-LGBT bias among professionals Anti-LGBT bias among professionals (Mayock et al 2009) (Mayock et al 2009)

33. HELPFUL SERVICES Helpful Services had 4 characteristics: Acceptance and open-mindedness of practitioners towards the LGBT people Acceptance and open-mindedness of practitioners towards the LGBT people Unbiased, sensitive practice Unbiased, sensitive practice The provision of constructive and meaningful support The provision of constructive and meaningful support Confidence of the LGBT person that they were understood by the professional Confidence of the LGBT person that they were understood by the professional (Mayock et al 2009)

34. General Guidelines Adapted from Lesbian, Gay and Bisexual Patients: The Issues for Mental Health Practice (2010) 1. Be aware of LGBT mental health issues/LGBT-specific stressors and assess for/respond to same 2. Don’t assume everyone is heterosexual/not transgender 3. Respond supportively when service users disclose they are LGBT 4. Challenge anti-LGBT bias if it exists and take a ‘gay- affirmative’ approach (see CPsychI Guide & APA) 5. Demonstrate that your practice is inclusive of LGBT people (see guide for more detail on these)

35. Professional Anti-Gay Bias Professional anti-gay bias results in lesbian, gay and bisexual people receiving sub-optimal care and experiencing direct or indirect discrimination or exclusion when they use health services. The characteristics of professional anti-gay bias are: Professional anti-gay bias results in lesbian, gay and bisexual people receiving sub-optimal care and experiencing direct or indirect discrimination or exclusion when they use health services. The characteristics of professional anti-gay bias are: Presuming service users are heterosexual Presuming service users are heterosexual Pathologising, stereotyping and stigmatising LGB service users Pathologising, stereotyping and stigmatising LGB service users Failing to empathise with or recognise LGB service users ‟ health concerns Failing to empathise with or recognise LGB service users ‟ health concerns Denigrating any non-heterosexual form of behaviour, identity, relationship, family or community Denigrating any non-heterosexual form of behaviour, identity, relationship, family or community Attempts to change a person’s sexual orientation Attempts to change a person’s sexual orientation (Irish Institute of Mental Health Nursing, 2010) (Irish Institute of Mental Health Nursing, 2010)

36. Reparative Therapy As the name suggests, reparative (or conversion) therapy is based on the belief that homosexuality is an illness and aims to cure LGB people by converting them to heterosexuality. As the name suggests, reparative (or conversion) therapy is based on the belief that homosexuality is an illness and aims to cure LGB people by converting them to heterosexuality. Extensive empirical research has been carried out on the use of reparative therapy with LGB people and this research has demonstrated that reparative therapy does not work and can be damaging to the mental health of LGB people who undergo it. Extensive empirical research has been carried out on the use of reparative therapy with LGB people and this research has demonstrated that reparative therapy does not work and can be damaging to the mental health of LGB people who undergo it. The CPsychI, ICGP, IASW and IIMHN do not support referral to or the practice of reparative therapy or any approach aiming to change a person’s sexual orientation and instead promote inclusive practice that is gay- affirmative. The CPsychI, ICGP, IASW and IIMHN do not support referral to or the practice of reparative therapy or any approach aiming to change a person’s sexual orientation and instead promote inclusive practice that is gay- affirmative.

37. Gay-affirmative approach A gay-affirmative approach is based on the following key principles derived from research: Same-sex sexual attractions, behaviour, and orientations per se are normal and positive variants of human sexuality and are not indicators of either mental or developmental disorders Same-sex sexual attractions, behaviour, and orientations per se are normal and positive variants of human sexuality and are not indicators of either mental or developmental disorders Lesbians, gay men, and bisexual people can live satisfying lives and form stable, committed relationships and families that are equivalent to heterosexuals’ relationships and families in essential respects Lesbians, gay men, and bisexual people can live satisfying lives and form stable, committed relationships and families that are equivalent to heterosexuals’ relationships and families in essential respects Same-sex sexual orientation is not linked to family background, problems or trauma Same-sex sexual orientation is not linked to family background, problems or trauma

38. Sexual orientation cannot be changed and attempts to change a person’s sexual orientation do not work and can be damaging to the mental health of those who undergo it Sexual orientation cannot be changed and attempts to change a person’s sexual orientation do not work and can be damaging to the mental health of those who undergo it The historical stigmatisation of lesbian, gay and bisexual people can have a variety of negative consequences throughout the life span for LGB people and social workers need to be proactive in challenging this stigmatisation among professional peers, society and service users. The historical stigmatisation of lesbian, gay and bisexual people can have a variety of negative consequences throughout the life span for LGB people and social workers need to be proactive in challenging this stigmatisation among professional peers, society and service users. (Irish Association of Social Workers, 2011)

39. Resources for Professionals: Sexual Orientation Lesbian, Gay & Bisexual Patients: The Issues for Mental Health Practice College of Psychiatry of Ireland, 2011.Available at: www.glen.ie/attachments/CPsychI_LGB_Mental_Health_Guide.PDF Gay, Lesbian &Bisexual People: Guide to Good Practice for Mental Health Nurses Irish Institute of Mental Health Nursing, 2010. Available at: www.glen.ie/attachments/IIMHN_LGB_Mental_Health_Guide.PDF Lesbian, Gay & Bisexual People: A Guide to Good Practice for Social Workers Irish Association of Social Workers, 2011.Available at: www.glen.ie/attachments/IASW_LGB_Mental_Health_Guide.PDF Appropriate Therapeutic Responses to Sexual Orientation American Psychological Association, 2009.Available at: www.glen.ie/attachments/APA_Therapeutic_Responses.PDF

40. Resources for Professionals: Gender Identity Standards of Care for the Health of Transsexual, Transgender and Gender Nonconforming People The World Professional Association for Transgender Health, 2012. Available at: www.glen.ie/attachments/WPATHstandards.PDF Guidance for GPs, Other Clinicians and Health Professionals on the Care of Gender Variant People: Transgender Wellbeing and Healthcare National Health Service, 2008. Available at: www.gires.org.uk/assets/DOH-Assets/pdf/doh-guidelines-for-clinicians.pdf GIRES: Gender Identity Research and Education Society www.gires.org.uk/index.php

41. Irish LGBT Reports LGBT Health: Towards Meeting the Healthcare Needs of Lesbian, Gay, Bisexual and Transgender People Health Service Executive, 2009.Available at: www.glen.ie/attachments/HSE_LGBT_Health_Report.PDF Supporting LGBT Lives: A Study of the Mental Health and Wellbeing of Lesbian, Gay, Bisexual and Transgender People Mayock, Bryan, Carr & Kitching, 2009. Available at: www.glen.ie/attachments/Supporting_LGBT_Lives_Report.PDF Visible Lives: Identifying the Experiences and Needs of Older Lesbian, Gay, Bisexual and Transgender people in Ireland Higgins, Sharek, McCann, Sheerin, Glacken, Breen & McCarron, 2011. Available at: www.glen.ie/attachments/Visible_Lives_Report.PDF