Depression in LGBT People

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Depression in LGBT People

• Ellen Haller, MD
• Depression Center at Langley Porter
• UCSF Department of Psychiatry

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LGBT An Alphabet Soup of Labels

• Lesbian
• Gay
• Bisexual
• Transgender

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Labels ? behavior

• Erotic interests
• Sexual behavior
• Emotional attachments
• Self-identity
• label of sexual orientation

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Complexity of Labels

• Variable congruency
• Fluidity over time

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More definitions

• Sexual Orientation
• Gender Identity
• Gender Expression
• Coming out
• Being closeted
• Homophobia/Heterosexism

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Why is This Topic Important?

• Queer people are everywhere
• Patients, colleagues, faculty, family members
• Bias ? health disparities
• Imagine if the tables were turned...

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Learning Objectives

• Unique issues faced by LGBTs
• Epidemiology
• Depression
• Substance Abuse
• Treatment
• Resources

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LGBs Seek Mental Health Tx

• Survey, N1,466, all members of gay/lesbian
  oriented advocacy health organizations
• 57 response rate
• 54 male, 46 female, mostly White
• 42 had sought mental health tx in preceding 12
  mos
• 10-12 of general population
• 25 of those w/ mental health contact described
  care as poor or inappropriate
• 46 reported homophobic therapist

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Survey (cont.)

• 10 stated that therapist suggested or attempted
  reparative therapy
• none entered tx because they wished to become
  heterosexual

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Why do LGBTs enter therapy?

• Same reasons as anyone else
• Relationships, job dissatisfaction, family of
  origin tensions
• Sxs of psych d/o (i.e. depression, anxiety)

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Why else might LGBTs enter therapy?
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Coming Out

• Non-linear, individualized process
• Timing varies considerably
• Concealment has psychological burden
• Constant decision-making about disclosure
• Need for vigilance if closeted
• Lack of social support/affiliation
• Few role models

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• Discrimination faced by LGBT people is both
  similar to different from discrimination due
  to
• Ethnicity
• Gender
• Age
• Socioeconomic status or class

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Similarities

• Stereotyping assumptions
• Prejudice, discomfort hatred
• Discrimination with respect to housing, jobs
• Violence

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Differences

• Ability to pass
• implications for ones sense of an integrated
  identity
• Lack of equal rights and protections
• Lack of model in family for how to act or how to
  cope
• Potential for rejection from family, friends,
  peers, co-workers, religion
• Magnitude of discomfort and hatred from many
  different sources

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Why else might LGBTs enter therapy?

• Consequences of external homophobia transphobia
• Discrimination and hate crimes
• Relationship with family of origin
• Discrimination in health care
• Lack of equal civil and legal rights

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Inside-OUTA Report on the Experiences of LGBs in
America the Publics Views on Issues and
Policies Related to Sexual OrientationKaiser
Family Foundation, November, 2001

• Telephone survey
• Randomly selected, nationally representative
  sample
• 2,283 adults
• LGB was based on 405 telephone interviews, all
  self-identified, all 18 yo

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Why else might LGBTs enter therapy?

• Consequences of internalized homophobia
  transphobia
• Desire to change sexual orientation
• Isolation
• Limitation of career and other achievements
• Lack of relationship success
• Depression, substance abuse, anxiety, suicidal
  thoughts

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Relationship Issues

• Being at different phases of the coming out
  process
• Sameness/blending/merging
• Risk of verbal or physical violence
• Intense shame, denial

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Relationship Issues

• Legal issues
• Lack rights and responsibilities of legal
  marriage
• Lack societal and familial embracing of the
  couple and honoring of their commitment
• Separations/breakups
• No social/legal rules
• Lack of social support

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Relationship Issues

• Parenting
• Decision-making process
• Co-parenting
• Step-parenting
• Break-ups
• Infertility
• Finances/health insurance

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Epidemiology of MH in LGBs

• Very difficult research to do
• Three waves of research/publications
• Viewed as pathology
• BUT-homosexuality removed as dx in 1973
• Still viewed as pathology by NARTH
• No difference from heterosexuals
• Population-based studies since 1998

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Population-based Studies

• Surveillance of sexual behav. due to HIV epidemic
• Large data sets avail. in last decade
• Still some problems with research
• Numbers overall very small
• Studies use diff. definitions
• Almost no research on transgender people

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Depression
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NCS (National Comorbidity Survey)

• Completed between 1990-92
• Household survey of people 15-54 yo
• Behaviorally defined
• Gender of sexual partners in preceding 5 years
• Psychiatric substance use d/o assessed with
  standardized diagnostic interview
• 82 response rate

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NCS (National Comorbidity Survey)

• Numbers
• 2,475 women with male partners
• 51 women with female partners
• 2,310 men with female partners
• 74 men with male partners

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NCS FindingsCochran, 2001

• 12 mo. prev. of Major Depression
• 13 of women with male partners
• 35 of women with female partners
• 10 of men with female partners
• 7 of men with male partners

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MIDUS (MacArthur National Survey of Midlife
Development in the US)

• Conducted in 1995, ages 25-74
• Used random-digit-dial telephone-sampling
• Defined by sexual orientation
• Standardized dx interview
• Overall, 3,032 individuals completed both
  telephone interview and written survey tool
• 2,917 answered ? about orientation
• 2,844 heterosexual
• 41 homosexual, 32 bisexual
• Cochran, Sullivan Mays, 2003

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MH in the MIDUS survey-Women12 mo prev. rates
p 39
MH in the MIDUS survey-Men
p 40
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Depression in Transgender People

• Survey done of 392 MTF and 123 FTM
• Recruited through targeted sampling and agency
  referrals
• Depression found in
• 62 of MTF
• 55 of FTM
• 32 had h/o suicide attempts
• (Clements-Nolle, Marx et al, 2001)

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Substance Use
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MH in the MIDUS survey-Women
p 44
MH in the MIDUS survey-Men
p 45
NHSDA (National Household Survey of Drug Abuse)

• Population-based survey conducted in 1996 to
  estimate prev of substance use in US pop.
• Defined by gender of sexual partners in preceding
  12 mos
• Numbers
• hetero only 9,714
• same gender only 135
• bisexual 59

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NHSDA Findings

• Etoh dep. L-B 7 Het Women 2
• G-B 11 Het Men 8
• Differences for women not men
• ? 1-year prev rates of alcohol dependency for
  women
• Alcohol used more frequently in greater amts
• Similar patterns of alcohol use to all men
• Cochran, Keenan, Schober Mays, 2000

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Substance Abuse in Transgenders

• 332 MTF transgenders completed interviews
• 112 African Americans
• 110 APIs
• 110 Latinas
• 18 - 60 yo avg age 34 yo
• 58 foreign-born

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Substance Abuse in Transgenders

• Nemoto, Keatley et al. Center for AIDS
  Prevention Studies, UCSF (www.caps.ucsf.edu/TRANS/
  )

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Treatment Issues
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Pts Expectations of Therapists

• May fear that therapy will be unsafe place
• May have had past negative experiences
• 10 stated that therapist suggested or attempted
  reparative therapy
• Worry txist may be disgusted by them
• May present false self to txist as to family and
  peers

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What you can do

• Dont assume heterosexuality
• Use open-ended, gender neutral questions to
  gather family or social hx
• Dont push indiv to accelerate the coming out
  process
• Assess if indivs sexual orientation/gender
  identity is the FOCUS or the CONTEXT of their
  presentation

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Conduct Violence Screening

• Ask gender neutral questions
• Are you currently being hurt by someone you
  love?
• Have you ever experienced violence or abuse?

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Therapeutic Style May Vary

• Active for education, role modeling, encouraging
  of socialization
• Supportive during early coming out, identity
  development phases
• Reflective to aid pt in understanding own beliefs
  about homosexuality
• Cognitive to combat automatic schemas

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What you can do

• Be open to own assumptions, prejudices, biases,
  feelings
• Know about resources
• Seek supervision/consultation!!

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Conclusions

• Prev. of some MH d/o ? in LGBTs
• Most likely causes are heterosexism, homophobia,
  transphobia
• Differences arent large
• Most do NOT have MH disorders
• Population has significant resiliency

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Resources

• Association of Gay and Lesbian Psychiatrists
• www.aglp.org
• Center for Lesbian Health Research at UCSF
• www.lesbianhealthinfo.org
• UCSF Transgender Resources Neighborhood Space
• www.caps.ucsf.edu/TRANS/
• Queer Blues The Lesbian and Gay Guide to
  Overcoming Depression by Hall and Hardin