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LGBTQ+ mental health

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SciLine’s media briefing covered some of the emotional and physical stressors especially impacting members of the LGBTQ+ community, including structural disparities such as repeated policy and civil rights changes, and the intersectional experience of the Black LGBTQ+ population.

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Introduction

[0:00:00 ]

RICK WEISS: And welcome everyone to this SciLine media briefing. Very brief introduction to SciLine for those who may not be familiar with us – we are a philanthropically funded free service for reporters, editorially independent and with just one mission, which is to make it easier for you as journalists to get more evidence-based facts – science-based facts into your stories. We offer a variety of free services, including getting you connected to experts who are knowledgeable and articulate in the area that you’re writing about on a deadline or as needed and a variety of other services you can check out at our website, sciline.org. Among those services are these media briefings, which are meant to give you solid, fact-based background on various issues in the news.

And today, we’re going to take a break from the drumbeat of daily news about COVID-19 to address another important health issue that is longstanding in our society and perhaps, for that reason, too often overlooked, and that’s the mental health impacts of individuals in the LGBTQ+ community that they chronically live with as a result of discriminatory attitudes, behaviors and practices. This is an issue that crosses through personal, public health and political terrain. The good news is that there are researchers taking methodical approaches to understanding this complex landscape. So we’re not just operating on instinct or supposition as society aims to address this deeply rooted challenge.

So to describe what is known in this arena, we have two experts today who will make representations and then take your questions. Their full bios are on the SciLine landing page for this briefing. So I’m not going to go into them right now except to tell you, briefly, that we will hear first from Dr. John Pachankis, who is associate professor of public health and psychiatry at Yale School of Medicine and director of Yale’s LGBTQ mental health initiative. His research focuses on the search for effective mental health treatments for LGBTQ people and, importantly, the scientific assessment of those treatments.

Second, we will hear from Dr. Madina Agénor, who is an assistant professor of race, culture and society at Tufts University. She investigates health and health care inequities at the intersection of gender, identity, sexual orientation and race and ethnicity. That’s a particularly newsworthy intersection within the LGBTQ community today given the nation’s recent attention to the longstanding discriminatory practices against racial and ethnic minorities. A reminder – you can start asking questions through the Q&A icon that you can find by hovering your cursor over the bottom of the screen while our speakers make their opening presentations and afterwards. And with that, John, please take it away.

Presentations

Structural Disparities Affecting LGBTQ+ Mental Health

[0:03:01]

JOHN PACHANKIS: Thank you, Rick. Let me pull up my slides. Well, thank you for the opportunity to discuss the effects of structural stigma on LGBTQ people’s mental health. I’ll first present evidence that structural stigma plays an important role in LGBTQ people’s mental health then discuss the reasons that this is so, and then describe interventions that can reduce the mental health impact of structural stigma. So structural stigma is typically thought of as discriminatory laws and policies that deny equal treatment and life chances to stigmatized populations. LGBTQ populations experience many examples of structural stigma. Until two weeks ago, LGBTQ people in the U.S. – in most U.S. states – could be fired from a job because of their sexual orientation or gender identity. And what we know from past research led by Mark Hatzenbuehler at Harvard is that this type of structural stigma harms LGBTQ people’s mental health. Mark has elegantly shown this in a natural experiment that took place before and after certain U.S. states passed constitutional amendments against marriage equality in the 2004 election. The mental health of LGBT people living in those states became worse, whereas the mental health of LGBT people living in other states and the mental health of heterosexual individuals was unaffected.

To give you a sense of how powerful the association between structural stigma and mental health is, we looked across the diverse structural context of Europe, which has high structural stigma – countries like Russia – neighboring low structural stigma countries like Finland. And what we see is that the odds of mental health outcomes, including poor life satisfaction, depression and suicidality, are strongly predicted by the structural stigma of the country in which an LGBTQ person lives. For example, we find that a sexual minority person living in Poland is much less happy than a sexual minority person living in the Netherlands over and above the average happiness of all people in those countries. We find the same thing with transgender-specific structural stigma, such as whether a country allows changes of gender information on legal documents and the happiness and well-being of transgender people in those countries. Researchers are now starting to ask why structural stigma might have these associations with poor mental health.

And what we find is that living in a high-structural-stigma context is associated with taxing psychological demands like having to conceal your sexual orientation or gender identity. For instance, LGBTQ people in high-structural-stigma countries are more likely to conceal their LGBTQ status, which we know takes a toll on mental health. Emerging evidence also suggests that structural stigma might exert its effects on mental health by leading LGBTQ people to feel inferior and shameful, to be isolated from other LGBTQ people and to be lonelier overall. And while the U.S. is relatively low in structural stigma by global standards, many forms of structural stigma still exist for LGBTQ people in the U.S. For example, today, most U.S. states don’t protect against discrimination in places like restaurants and stores. In 30 U.S. states, youth can be subject to so-called conversion therapies. Seven states make it against the law to even discuss LGBT topics in schools, like in health or history education. And 29 states don’t facilitate gender marker updates on driver’s license and birth certificates, to name a few examples.

Research shows that these forms of structural stigma harm LGBTQ people’s mental health. In fact, LGBTQ people experience among the highest risk of mental health problems of any mental health risk group. And transgender and gender nonbinary people, LGBTQ persons of color and LGBTQ people without higher education and incomes are likely particularly impacted by these mental health effects of structural stigma. So while I’ve shown that the mental health correlates of structural stigma operate at the country level, structural stigma also operates at the level of states, counties, cities and even institutions like schools, hospitals and workplaces, with there being wide variation in the degree of institutional acceptance or stigma in those places and parallel variation in LGBTQ people’s mental health. Research identifies two points of intervention.

First, we can change structural stigma, which would be preferable and most just ’cause its effects would be pervasive and place the onus of change on structural factors rather than on LGBTQ people themselves and, also, another important source of support in the meantime – namely, empowering LGBTQ people to cope with the mental health impact of structural stigma. So our research shows that LGBTQ people’s – that LGBTQ-affirmative mental health treatments can improve LGBTQ people’s mental health by empowering them to express their true selves, find their authentic voice and identify a supportive community where those expressions are safe and validating. These treatments have the power to reduce the shame and loneliness through which structural stigma jeopardizes mental health. We’ve seen this, for example, in a 10-session identity-affirming cognitive behavior therapy that we’ve delivered to young LGBTQ people in person in various U.S. cities, online across the U.S. and internationally. And it’d be a group counseling to young LGBT people of color in conjunction with local community-based organizations.

Comparing the line in gray here, which shows the effect of those receiving no treatment, to the line in blue, which shows the effect for people who have received the treatment, we find that the treatment reduces depression, anxiety, substance use and sexual risk across clinical trials with LGBTQ young people. The treatment has these powerful effects through exercises that raise awareness of the emotional pain of stigma in LGBTQ young people, helping LGBTQ young people build healthier patterns of responding to that pain, enhancing their coping skills, such as through self-affirmation exercises and assertiveness practice, and fostering LGBTQ community-building. The COVID-19 pandemic has provided us an opportunity to scale up our delivery of this treatment through efficient online delivery and the opportunity to train mental health providers across the U.S. to deliver this treatment.

So in conclusion, in the past 10 years, researchers have shown clear associations between LGBTQ people’s exposure to structural stigma and their poor mental health compared to the rest of the population, the mechanisms through which structural stigma generates these disparities – and now, potential solutions to alleviate these disparities through both structural change and personal and community empowerment. This research suggests that further reductions in structural stigma are the surest route to improving LGBTQ people’s mental health. And then greater access to identity-affirming mental health services can also have a powerful and needed impact. Thank you.

[0:09:40]

RICK WEISS: Thank you, John – great overview and a lot of potential there for local and regional reporters to check out, given your noting that it makes a difference even at the local and state level just to see what’s going on there and what impact that’s having. Wonderful. Let’s move over to Madina.

Intersectionality and Black LGBTQ+ Health

[0:10:16]

MADINA AGÉNOR: All right. Good afternoon, everyone. Thank you so much for having me. And it’s really a pleasure to be here to speak with you today about a critically important yet understudied topic – namely, intersectionality and the health of Black LGBTQ-plus people in the United States. So first things first – LGBTQ people are a racially and ethnically diverse population, with about a third of LGBTQ-plus individuals identifying as Black, Indigenous or a person of color. It’s important that we consider this heterogeneity when we talk about LGBTQ plus people. Because intersectionality tells us that, for example, Black LGBTQ plus individuals have unique and specific concerns, needs and lived experiences as a result of being exposed to not only structural discrimination related to sexual orientation and/or gender identity like their other LGBTQ plus counterparts, but, also, anti-Black structural racism which refers to the ways in which societies both explicitly and also implicitly foster the marginalization and oppression of Black individuals and communities through mutually reinforcing systems of housing, education, employment, earnings, health care and criminal justice among others.

And you can see, here, the 1977 statement by the Combahee River Collective which clearly illustrates the central idea of intersectionality – namely, that the lives and, in turn, the health of multiply marginalized groups including Black LGBTQ plus people are shaped by multiple interlocking systems of oppression including racism, sexism, heterosexism – that is discrimination based on sexual orientation – and cissexism or discrimination based on gender identity. So a few years ago, we used nationally representative data to examine health disparities in relation to both sexual orientation and race ethnicity among both US women and men. In this analysis, we found that Black lesbian and bisexual women were significantly more likely than Black heterosexual women to report smoking, heavy drinking, stroke, sadness and depression and significantly more likely than white heterosexual women to report short sleep, overweight and obesity, hypertension, stroke, sadness and depression.

We also found that Black gay and bisexual men were significantly more likely than both Black heterosexual men and white heterosexual men to report drinking and sadness. In 2017, the National Center for Transgender Equality released a report showing that the burden of various health outcomes, including HIV, psychological distress, suicidal thoughts and behaviors and sexual victimization, was considerably higher among Black transgender and non-binary individuals compared to both their white counterparts and, also, to the US population overall. In addition, research shows that Black LGBTQ plus youth in particular have specific health needs and concerns especially in relation to mental health and health care.

In 2019, the Human Rights Campaign released a report focusing on the experiences of Black LGBTQ youth which showed that the vast majority experienced pervasive problems with sleep as well as high levels of stress, depression, hopelessness and anxiety. However, the researchers also found that only 35% of Black LGBTQ youth had received mental health counseling in the past year. So we’ve seen that Black LGBTQ plus people face notable physical and mental health challenges but the question remains – why? One thing that I’ve noticed in both research and the media is that scientists and journalists alike will describe health disparities but won’t always look at what is behind those disparities. When, in fact, the health disparities that we see between Black LGBTQ plus people and other social groups are driven by a whole host of upstream societal factors including the social determinants of health, the structural determinants of health, and the social and political and economic and historical context in which we live.

So I will spend the next couple of minutes talking about two key social determinants of health – namely income and housing, that impact the health of Black LGBTQ plus people. But I’ve included information on all of these social determinants of health at the end of this presentation for your future reference. So let’s start by looking at poverty among Black LGBTQ plus people. So this graph shows that the poverty rate was higher among Black LGBT people compared to both Black cisgender – that is non-transgender heterosexual people – and white LGBT people. What this graph doesn’t show, though, is the pronounced heterogeneity that exists among Black LGBTQ people with the highest poverty rates occurring among Black cisgender bisexual women and Black transgender people and the lowest rate occurring among Black, gay, cisgender men.

So turning our attention now to housing – you can see from the graph on the left that Black same-sex sexual couples were considerably less likely to own a home compared to both white same-sex couples and Black different-sex couples – married different-sex couples. Additionally, the graph on the right shows you data from a 2015 national survey of transgender and non-binary people which found that 40% of all Black respondents had experienced housing discrimination or instability in the past year with the highest prevalence occurring among Black transgender women. So we’ve talked a little bit about the health challenges experienced by Black LGBTQ plus people and – as well as the pronounced barriers that this population experiences in relation to health promoting – social determinants of health, including income and housing.

And this, in turn, negatively impacts the health of Black LGBTQ+ people in communities through a whole range of pathways, including a lack of access to social and economic resources, stress and trauma and exposure to toxic or hazardous living or working conditions. However – so we spent some time talking about that, but we shouldn’t stop there. We should also be thinking about the structural inequities that affect these social determinants in the first place. And these are laws, policies, rules and practices that perpetuate structural inequity. So my conclusion here is that in thinking about the health of Black LGBTQ people and also in seeking solutions to the disproportionate burden of poor mental and physical health among Black LGBTQ+ communities, we should really be thinking about addressing both the social determinants of health and the structural determinants of health and really seek to implement and – develop and implement laws, policies, rules, practices and institutions that promote equity and justice at the intersection of not only sexual orientation and gender identity but also race/ethnicity and social class. So I’ll stop there, and I’m happy to answer questions.

[0:18:28]

RICK WEISS: Fantastic. Very interesting and clear approach to understanding what’s at the root of these things. Obviously, some of the roots – historical roots – too late to address. But other things – still room to take some action. So great overview, thank you. I want to remind reporters who are logged in now that you can go and hover over the Q&A icon at the bottom of your screen to type in your questions.

Q&A


What are the most pervasive barriers to mental health care that transgender individuals face?


[0:18:28]

RICK WEISS: Fantastic. Very interesting and clear approach to understanding what’s at the root of these things. Obviously, some of the roots – historical roots – too late to address. But other things – still room to take some action. So great overview, thank you. I want to remind reporters who are logged in now that you can go and hover over the Q&A icon at the bottom of your screen to type in your questions. While you’re doing that, we have a few already in the pipeline here that I will start with. This first question is from Emerson Grey, a freelancer based in Colorado – asks, what are the most pervasive barriers to mental health care that transgender individuals face? And what are some practical steps to dismantle those barriers? I suspect that’s something that both of you could weigh in on. One of you want to start? John, I see you nodding – you want to start?

[0:19:32]

JOHN PACHANKIS: I’m happy to start. The barriers that LGBTQ people face to mental health care are of two parts. One, they’re largely – the first part is that they’re largely the same that all people in the U.S. face to receiving high-quality mental health care – lack of money, lack of insurance. LGBTQ people also face some distinct barriers to health care, including past discrimination in mental health care settings that’s both historic in terms of, you know, the mental health profession promoting pathologizing views of LGBTQ people – promoting conversion therapy still today – as well as past experiences of discrimination they, themselves, might have had in health care settings.

Many trans people will note that the mental health care profession – many mental health care professionals adopt a gatekeeping stance towards their well-being and their gender affirmation, which could be seen as paternalizing and ineffective. Other barriers that LGBTQ people face to mental health care include lack of LGBTQ-affirmative therapists and that there may be therapists in your community who are, you know, competent mental health professionals, but many LGBTQ people are asking, are they competent in treating people like me? And for too many LGBTQ people, the answer is either not obvious, or it’s no.

[0:21:01]

MADINA AGÉNOR: Yes. So I agree with what John said. Thinking about the social determinants of health around transgender people, especially transgender people of color – face really pronounced barriers to employment, to income, as we’ve discussed. And all of those are tied to health insurance and access to health care. Additionally, to the interaction between patients and providers, there’s also organizational contexts that disproportionately undermine the well-being of transgender folks from everything from, you know, the way that the services are being offered – how they’re being offered, when they’re being offered – also the kind of messages that are around the clinic – or lack thereof – in terms of affirming the presence of transgender and nonbinary people in that space. And then the last thing I’ll say is – in some of the research that I’ve been doing around health care access among transgender and nonbinary youth of color, a major issue has been kind of these institutions that weren’t set up for them to begin with, right? And so there have been efforts to try to reform those institutions and change them and make them more accessible.

But a lot of folks are finding that alternative spaces actually provide better, more affirming care. So things like LGBTQ youth organizations that were, from the beginning, organized and structured to meet the needs of LGBTQ people of color. For example, there’s one in Boston that I work with. And so they’re finding that they can get much better mental health care and also other kinds of care through those settings. So I think it’s important to think about the various ways that folks can receive health care in this country that meets their needs.


How can the specific needs of LGBTQ+ people be met through widespread, standardized therapeutic practice?


[0:22:53]

RICK WEISS: Interesting. Thank you. Our next question here is directed to Dr. Pachankis. I was in a Facebook thread this week – I’m sorry, this is from Benjamin Ryan, who is a reporter based in New York. He says he was in a Facebook thread this week with someone who doubted that researchers could ever develop an LGBTQ-specific therapeutic modality that could be standardized, taught widely, and, ultimately, help reduce mental health problems specific to this population. Could you address this skepticism and tell us what you know from your research – essentially expanding on that chart you just showed us – providing more specifics about just how the specific needs of LGBTQ people can be met through widespread therapeutic practice?

[0:23:39]

JOHN PACHANKIS: You know, that’s a great question. The challenges to standardizing mental health care for any population are also the challenges that apply to standardizing mental health care for the whole population. Mental health care needs to be personalized to address the specific issues that people present to treatment with. At the same time, we know through lots of research that the psychological mechanisms that explain why LGBTQ people so consistently experience poor mental health, in addition to all the structural factors that Dr. Agénor addressed, are relatively clear.

And those are kind of chronic feelings of shame or inferiority, anxious expectations of rejection, internalized forms of stigma and pressures related to concealing one’s sexual orientation or gender identity. And to the extent that we can train – and mental professionals can be trained to recognize and address, systematically, those type of presenting concerns. At the same time, all treatments have to be addressed to people’s structural context and personal context. And all mental health professionals should know how to take on that challenge of personalized treatment while also understanding these group-specific mechanisms that elevate risk.


Are there particular mental health issues that Black LGBTQ+ people face as a cumulative effect of being both Black and queer? Or do these individuals experience particular interactions of their race and gender identity or sexual orientation that affect their mental health?


[0:25:11]

RICK WEISS: OK. Our next question is from Grace Huckins at WIRED Magazine. For Dr. Agénor – do you see the particular mental health issues that Black LGBTQ folks face as a cumulative effect of being both Black and queer? Or do these individuals experience particular interactions of their race and gender identity or sexual orientation that affect their mental health?

[0:25:36]

MADINA AGÉNOR: That’s a really good question. And I think that’s a question that folks try to understand when looking at intersectionality and its effect on population health. So my response is twofold – one, that that’s an empirical question, so that’s something that you can actually look at in your data and test in your data. And it will vary based on your outcome and based on your population. So there are specific settings in which – and specific outcomes for which it will be compounding risk of exposure to both racism and then heterosexism and/or cissexism. And there are instances where it is more of an interaction effect. So, really, you can see both. And in various areas of my research, I’ve seen both. My sense is that both are happening, so you have the compounding effect of multiple forms of both structural and interpersonal discrimination that negatively impact the mental health and other health outcomes among Black LGBTQ+ folks and also unique intersections.

So I’ll give you one example. There is a research study that found that, actually, LGBTQ+ people of color are more likely to experience LGBTQ-related discrimination. And so that would be kind of a magnifying of a single strand of discrimination – right? – sexual orientation or gender identity-based – but that gets magnified per the specific lived experiences and social and economic and political context of Black LGBTQ people in particular. So that’s how I try to think about it.

RICK WEISS: Interesting – anything to add there, John?

JOHN PACHANKIS: No, that’s fantastic (inaudible).


Is there a network of accessible LGBTQ+- affirmative mental health professionals in the U.S.?


[0:27:35]

RICK WEISS: Next question from Camalot Todd at Spectrum News based in Buffalo, N.Y. – are you aware of any network of LGBTQ+-affirmative mental health professionals that are accessible in the U.S.?

[0:27:53]

JOHN PACHANKIS: Yeah, I’m happy to answer this. Many people probably know about the services of the Trevor Project, which provides crisis services – suicide intervention services – for LGBTQ people in immediate distress. Finding an – finding longer-term mental health support is more of a challenge for LGBTQ people living in the U.S. At the same time, there are over 250 LGBT centers across the U.S. in urban areas and less urban areas that have, historically, made part of their mission to provide health services and mental health services distinct – that distinctly address the needs of the LGBTQ population. So the first step for many LGBTQ people might be to check out the services at those centers. Those centers also often provide financial – relatively financially accessible services.

The current COVID-19 pandemic may actually – one benefit of moving mental health services – including those centers – online is that they might be more accessible to people who otherwise wouldn’t be in the geographic proximity of those places to receive them. Otherwise, organizations like the American Psychological Association maintain lists of psychologists – members who are given the option to select whether they provide LGBT-affirmed health care. So I think those are some of the options that people might turn to who are looking for professional help.


Are there data on whether access to care has decreased during this administration, which has encouraged health care providers to claim religious exemptions?


[0:29:32]

RICK WEISS: Great. Next question is from Kathleen O’Neil, a freelancer based in Maryland. Are there data on whether access to care has decreased during this administration, which has encouraged health care providers to claim religious exemptions? Sounds like no data are coming to mind, anecdotal or otherwise.

[0:30:08]

MADINA AGÉNOR: Yeah. I haven’t seen any data on that. I think, certainly, that would be a really important study to do. I’m not sure if we have enough data to necessarily do that quite yet, though, absolutely, we’ve seen a whole host of policies that have undermined access to various social and health care resources among LGBTQ populations and communities of color, as well. And I – and through some of the qualitative research that I’ve been doing with, again, trans and nonbinary youth of color, I have gotten a sense through that research, which is still ongoing – and I’m still analyzing the data – but I have gotten a sense that people may be feeling more reluctant to maybe seek out services at this time. Some folks brought up issues related to immigration and issues around, you know, pervasive, racially biased discriminatory attitudes, as well. So that’s kind of a sense that there’s a social climate that might be undermining people’s ability to seek out the resources they need, as well as a policy climate. But I think to be able to give you a definitive answer, hopefully, someone will do that research soon.


What has research shown about why some people seem more resilient in the face of microaggressions and other attacks on individuals’ identity?


[0:31:47]

RICK WEISS: Question here about resilience. What has research shown about why some people seem more resilient in the face of microaggressions and other attacks on individuals’ identity? There are protective factors.

[0:32:07]

JOHN PACHANKIS: I think one tendency when we think of resilience is to locate that as a factor within individuals to think that, you know, some people who don’t succumb to mental health problems have something within them that prevents that from happening. But, in fact, it might be more useful to think of resilience as the presence or absence of structural and institutional factors. So we know, for example, that family support plays a very big role in protecting LGBT people, especially LGBT young people, from the harms of discrimination and microaggressions. We also note that for some LGBTQ people, religious organizations, churches can be protective. And for others, especially those who are members of homophobic, transphobic religions, contact with religious organizations can actually be – can actually jeopardize their mental health. So I would just encourage the media to think of resilience in terms of the presence or absence of structural things, factors outside of the individual as opposed to questioning whether some people have deficits in resilience, and other people possess a gift for resilience.

RICK WEISS: Interesting. Anything to add there, Dr. Agénor?

[0:33:36]

MADINA AGÉNOR: Just to agree and just to say that we know that discrimination and stigma harm mental health and also physical health and that I’m thinking of a study that was done among Black sexual minority women in particular which did find a compounding effect of multiple forms of discrimination – so of discrimination based on race, ethnicity and on sexual orientation. And so that that is – points to a great place to start in terms of addressing the role of the pervasive discrimination and stigma that LGBTQ+ people face, especially LGBTQ+ people of color. And instead of – like John said, instead of thinking about, what can we do to change the individual? – but really thinking about changing the discriminatory context in which people live.


What research is there on mental health issues in LGBTQ+ seniors? What resources are being directed to assist them?


[0:34:28]

RICK WEISS: That’s a great point. Thank you. Question here from John Selig. He’s a reporter based in Dallas, Texas. A large percent of resources are targeted to assist the needs of LGBTQ+ youth, which makes sense. However, LGBTQ+ seniors are another group faced with unique challenges, often causing major impacts involving income, overall health and mental health. For example, they are much less likely to have children and supportive family members than the general population. What information do you have on research on mental health issues on LGBTQ+ seniors and also resources being directed to assist them?

JOHN PACHANKIS: I think you’re right that most – there’s been a disproportionate focus in the world of mental health interventions for LGBTQ people on LGBTQ young people because we know that the mental health disparities by sexual orientation and gender identity tend to be highest among adolescents and young adults. At the same time, we also know that a lifetime of compounded, accumulating stressors can also take their toll on stigmatized populations. I know that there are certainly local organizations across the U.S. – going back to that earlier question of other kind of national networks of care providers. One of those, SAGE, is directed towards – specifically to older LGBTQ individuals. We know that living alone and not having kids are two of the major predictors of suicidality, and we know that LGBTQ older people are greater – experience both of those things more than the general population.

To the extent that researchers and community members can think of ways to foster intergenerational support between older LGBT people and younger LGBT people, it would be a great – it would fill a great two-way need for younger LGBT people who are typically born into families that don’t – that aren’t also LGBTQ to receive the wisdom and mentorship of older LGBTQ people at the same time that it provides an outlet for the generativity of the older LGBTQ community.


Are clinicians trained to assess and treat LGBTQ+ related mental health issues?


[0:37:04]

RICK WEISS: Question here on training programs. Are clinicians trained to assess and treat LGBTQ+ related mental health issues? And, specifically, are there medical training programs out there specific to meeting this need?

MADINA AGÉNOR: I can speak more generally to programs that are emerging around medical schools around the country related to training in LGBTQ+ health in particular. My sense with that is that, you know, mental health is covered, as are other aspects of LGBTQ+ health, but it’s – there – it’s limited time to address all of the various topics that need to be addressed. And my understanding as well is that a lot of these training programs or courses are electives, and so they’re not being required of all students going through medical school or nursing school or getting training in psychology. So it’s kind of a self-selection of the folks who are choosing to engage in this training, and that’s a major barrier around being able to ensure that all clinicians are competent in providing LGBTQ+ care.

RICK WEISS: John, you’re affiliated with a medical school. Any insights from that situation?

[0:38:41]

JOHN PACHANKIS: I would say that – right. I mean, the average medical student in the U.S. receives something like four hours of training or coverage on LGBTQ-related topics. To the extent that medical and mental health education can be embedded within, you know, a larger focus on social determinants of health and mental health, I think that would be outstanding. I mean, competence is probably not something that can be gained in four hours or maybe even, you know, in a class. Competence takes, you know, questioning your position, critically, within the local context that you live and the local communities that you live. And I do think that some med schools take that part of education seriously. And I think that to the extent that others don’t, their patients could certainly benefit from more of that approach.


What is the history of mutual support between activist communities for LGBTQ+ rights and those focused on racial and ethnic inclusivity?


[0:39:41]

RICK WEISS: Question here for Dr. Agénor. What is the history of mutual support between activist communities for LGBTQ rights and those focused on racial and ethnic inclusivity? Do you see evidence of greater collaboration among discriminated populations within the civil rights arena, or is it a fragmented movement?

MADINA AGÉNOR: That’s an excellent question, and I think it goes back to – yes, I have seen kind of collaboration among different groups. And I was going to say that it goes back to kind of a shared worldview. Different groups that share this worldview that the kind of institutions that we’re living with, the social structures that we have are unjust and unfair and discriminate against marginalized people and really want that to change. There’s been quite a bit of conversation among folks who have that kind of perspective of the world. And you’ve seen, you know, for example, the Black Lives Matter movement was started and led and is continuing to be fostered by queer Black women in particular who have been at the forefront of this movement and, really, kind of pushing people to think about the intersections that exist and kind of the relationship between the different forms of discrimination and marginalization and how they negatively impact multiply marginalized people to a disproportionate extent.

So absolutely, and I think that as researchers, there’s certainly a lot that we can learn from community organizers and activists and advocates who are kind of pushing for systemic and structural change. And so that’s something that I’ve tried to kind of think about in my own work beyond just the research. But also, how can we translate what we know into concrete structural change? I think we’re – a lot of us are hoping to work towards that moving forward. And it will require collaboration across movements, across sectors and across settings.


Can individual policy decisions such as Supreme Court rulings affect the mental health of members of the LGBTQ community?


[0:41:56]

RICK WEISS: Couple more questions here. One for you, Dr. Pachankis. Can individual policy decisions such as Supreme Court rulings affect the mental health of members of the LGBTQ community, or is it the cumulative impact of repeated changes and overall uncertainty about policies that has the greater impact?

JOHN PACHANKIS: That’s an excellent question that really begs for sophisticated, nuanced research approaches to looking at these structural changes. The research suggests that both are true. When you look at distinct policy changes, like constitutional amendments against same-sex marriage that happened in the early 2000s, you see that that single event alone produced noticeable negative impacts on LGBT people’s mental health. At the same time, a lot of the research on structural stigma looks more at its – looks more in aggregate at all of the laws, policies, population attitudes that characterize a state or country or municipality. What some of our latest research shows is that early exposure to structural stigma – so growing up LGBTQ in a place that’s particularly unaccepting or stigmatizing for LGBTQ people – can carry effects for several years after that along the life span. It can lead to more dysregulated stress physiology. It can lead to greater risk of mental health problems, things like depression, suicide just because of that early exposure, suggesting that we do carry structural stigma with us at least for several years into development after early exposure.


Are there data on the intersection of ethnic discrimination, immigration status and LGBTQ stigma and the impact this particular intersection has on those affected?


[0:43:58]

RICK WEISS: We have a question here from Barbara Jungwirth, freelancer based in New York. Are there data on the intersection of ethnic discrimination, immigration status and LGBTQ stigma and the impact this particular intersection has on those affected? I’m thinking in particular of LGBTQ Latinx people seeking asylum in the U.S. That has your name all over it, Dr. Agénor.

MADINA AGÉNOR:(Laughter) That’s an excellent question and a really kind of important area that needs further study. My – from my familiarity with the research, I’ve seen people addressing different bits and pieces of that. And part of it is because our data, our national data aren’t as comprehensive as they could be, I should say. And subgroups like LGBTQ+ Latinx folks are not, you know, represented in large numbers in those datasets, which is certainly something that we should think about addressing around oversampling not just only people of color but also LGBTQ+ people in our national data sets so that we can look at these intersections. So I haven’t seen any research that has specifically addressed that unique intersection, and a really important one. But I know that there are community organizations across the country who are working on these issues. And that’s something that I try to think about, too. You know, the research often is a couple years behind some of the work that people on the ground are already doing.

So you saw in my presentation I cited a lot of reports because the community organizations and community organizers are kind of already doing this work, and a lot of times, researchers are kind of trying to play catch up on the work that people are dealing with and experiencing every day. So I haven’t seen research, but I urge you to look at the work of community organizations who do this work day in and day out. I’m sure they have reports on this important topic.


What are some common issues you see with journalism related to LGBTQ+ mental health?


[0:46:13]

RICK WEISS: Maybe a penultimate question here, and this is really about reporting methods. So what are some common issues you each see with reporting related to LGBTQ+ mental health? Are there particular narratives or stereotypes that reporters should avoid? Here’s your chance.

MADINA AGÉNOR: I mean, I think we’ve been kind of talking about this for the last hour, which is a great opportunity – thank you – that we really need to think about mental health, physical health and well-being as being contextualized and as being shaped by the social and economic resources and environments that people interact with and live in and that that is really a key piece here because what ends up often happening – and we see it with not just mental health, but we see it with COVID-19. You hear – you know, it’s very easy to draw conclusions that it’s something wrong with that group or there’s something wrong with that person, right? So we’ve heard genetic explanations. We’ve heard, quote-unquote, “cultural” explanations. And COVID-19 is just on my mind, so I’m thinking about it around, you know, genetic risk factors or, you know – this group doesn’t wash their hands as much.

So it’s very easy to reach for biology and kind of these cultural explanations, and that tends to happen when we don’t contextualize our data. So when we don’t give the full context of how these disparities emerge and what are the factors that are driving the health and well-being of populations, we end up falling short and kind of leaving the door open to these simplistic and erroneous conclusions about individuals and communities as inherently being problematic or less worthy or, you know, having deficiencies. And so that would be my cry, to please, please, please, in the stories about LGBTQ+ mental health and any health issue about any marginalized group, to really go beyond just describing the health outcomes but, really, to contextualize them within the social determinants of health and the structural determinants of health so that it’s clear how they’re driving them.

[0:48:45]

RICK WEISS: That’s wonderful advice, and it seems to me to speak both to the need for research to be multidisciplinary. You need scientists who study lots of different things to get at this. And at the same time, it means, as a reporter, maybe we need to be reaching out to a wider array of sources than we thought we needed to. It may not just be a medical person or a health person, but it may be a political science person or an economist who needs to get on the phone with a reporter in a case like that. Doctor Pachankis, anything to add there?

[0:49:20]

JOHN PACHANKIS: Yeah. I mean, there’s a common narrative in the media that’s – it’s almost a singular narrative in the media, and that’s that stigma drives poor mental health among LGBT people. As was just said, like, obviously, the mental health of LGBT people is multidetermined, and stigma is a root cause of that. At the same time, most LGBTQ people are thriving, and most of them continue to embody the LGBTQ’s historic courage and creativity in carving out the paths that, you know, the rest of the world, you know, might follow.

We see this with, like, emerging identities that LGBTQ youth have, creative ways of challenging and affirming gender, creative ways and courageous ways of kind of stepping outside the singular narrative that LGBT – all LGBTQ people’s whole experience can be defined in terms of stigma and, instead, suggesting that the story’s much more complex within how people occupy a sexuality and gender but also how people’s health might be influenced by those things. So I would just suggest to the media, to the extent that singular narrative could be made more nuanced by talking to LGBTQ people about the things that matter in their lives, I think the story would probably be more nuanced than that.


What does the research tell us about disparate police treatment of Black LGBTQ+ people?


[0:50:58]

RICK WEISS: About at the end of our questions, but an interesting one here about law enforcement for Dr. Agénor. A lot of attention is currently being focused on how Black people are treated by law enforcement. What does the research tell us about disparate police treatment of Black LGBTQ+ people?

MADINA AGÉNOR: Excellent question. The reason you probably haven’t seen much about this is because the data are really sparse. There is currently very limited data collection around sexual orientation and policing in particular. You might have seen there’s a report that just came out around police killings by Justin Feldman, where he looked at the intersection of race and social class. So that is already an advancement in kind of looking at intersections. He used area-level measures of social class and then individual race, ethnicities and social classes that recorded in police killings, and same goes for sexual orientation, gender identity not recorded in that kind of nuanced way that we would need to look at intersections with race, ethnicity, sexual orientation, gender identity and class. So all this to say that the data are really missing. We do have the survey that I mentioned among transgender and nonbinary folks, the one where it pulled out the data for Black people in particular, does have a section on policing. And I have included some data in a backup slide that will be made available to you.

Short – long story short is that Black, transgender and nonbinary people are extremely, much more likely, compared to white transgender or nonbinary people and also their heterosexual counter – heterosexual and cisgender counterparts, to be victims of physical and sexual harassment by law enforcement officers, so not just police but also immigration enforcement officers. So that report includes information on that. And then there are organization – again, I keep going back to this because the community-based organizations are really kind of doing the work of looking at the health of Black LGBTQ+ folks. And there are organizations around the country like Black & Pink that look at incarceration and policing and precisely what you’re asking about among LGBTQ+ people of color. So I encourage you to look there while the research catches up.


How might social distancing due to COVID-19 be impacting LGBTQ+ youth?


[0:53:37]

RICK WEISS: Going to get one more question in before we wrap up. And this has to do with COVID-19. How might social distancing due to COVID-19 be impacting LGBTQ+ youth? Being stuck at home may mean living without the support and resources one might typically get at school, for instance. Is there evidence of an effect there? John.

[0:54:00]

JOHN PACHANKIS: A paper by researchers at UCSF came out a few days ago that showed that the odds of depression and anxiety among LGBTQ people has increased since before the pandemic. Everything else, to my knowledge, about the mental health of LGBTQ people during the pandemic is anecdotal and somewhat speculative because the data – we don’t have the data fast enough yet. But sure. I mean, like, as was suggested by the reporter, there are stories to be told about how LGBT people have to choose between health and homophobia or transphobia, you know, choosing to live at home with maybe homophobic or transphobic family versus, you know – versus being in more precarious living situations – even more precarious living situations that might put them at greater risk of infection. I think those decisions are probably – have been – are made all the time by LGBTQ people. We also know that LGBTQ people are – for several reasons might be at greater risk of COVID in the first place. Their choices, likely, to smoke, their economic disparities, et cetera, that might make the pandemic particularly severe among this population.


What is one key take-home message for journalists covering LGBTQ+ mental health?


[0:55:28]

RICK WEISS: We are just about at the top of the hour here, so I want to give each of our speakers just a half a minute or so to make a final wrap up, a take-home message, something you’ve already said or something new that you want to make sure reporters walk away with today. And I will start with you, John. Oh, you’re on mute.

[0:55:57]

JOHN PACHANKIS: Sorry. I think one take-home point that our research that we talked about has shown is that historically we’ve tended to locate the root of mental health problems within the individual, such as, like, problems with brain functioning and chemistry – where in the case of LGBTQ people, like, inherent weaknesses. But when you see such wide variation in mental health, depending on one’s group membership or identity or where they live, it really points to the fact that the root of mental health problems has strong societal determinants. And research shows that the sooner we can make our society more just, from institutional commitments to equality to our day-to-day interactions with each other, the sooner we can expect that no one population will bear a disproportionate burden of mental illness.

RICK WEISS: Madina?

[0:56:45]

MADINA AGÉNOR: I agree. And also, I think that we have a tendency to think about LGBTQ+ health – when we look at the structural determinants, to think about LGBTQ+ specific policies, right? So we see that most of the stories and most of the research is around things like same sex-marriage laws, for example – but that, really, when you’re thinking about LGBTQ+ people of color in particular, as one of the reporters mentioned, laws and policies that affect and relate to structural racism and also xenophobia and marginalization based on other kind of social characteristics are important. We can’t just kind of segment out the LGBTQ+ policies. We really need to look at policies and laws related to structural racism and xenophobia and social class in order to really get a comprehensive understanding of these structural determinants of – specifically for LGBTQ+ people of color. So I would urge folks to think about, you know, the laws and policies, like DACA, for example. The recent Supreme Court, you know, ruling is relevant to LGBTQ+ health. So thinking about making those connections explicitly in ways that you might not initially think are relevant but really speak to the intersectionality of these issues.

[0:58:23]

RICK WEISS: All right. I want to give a big thanks for our two speakers today. Your presentations and answers were so clear and really helpful, I think, for this population of reporters who are working on these issues. And, especially, I appreciate your attention to sort of research and methodology. Obviously, from some of your answers, there’s a lot more research to be done. We really appreciate that you are among those who are doing that work and trying to get real answers to these difficult questions. I want to remind reporters online as we wrap up that this video and transcript will be available over the next day or two on the sciline.org website. We encourage you to follow us on social media at @RealSciLine. And there is a brief survey that we really encourage you to take as you log off today. It’s just three questions. It can help us greatly as we plan future briefings to help you on your job. So thank you for taking the minute to do that. Thanks again to our guests. And we’ll see you all at the next SciLine media briefing.


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Dr. Madina Agenor

Tufts University

Madina Agénor, ScD, MPH, is the inaugural Gerald R. Gill Assistant Professor of Race, Culture, and Society in the Department of Community Health at Tufts University. As a social epidemiologist and health services researcher, Dr. Agénor investigates health and health care inequities in relation to various dimensions of social inequality – especially sexual orientation, gender identity, and race/ethnicity – using an intersectional lens. Specifically, she uses quantitative and qualitative research methods to elucidate the patient-, provider-, and policy-level social determinants of sexual and reproductive health and cancer screening and prevention among marginalized U.S. populations, especially sexual minority women and girls, transgender and non-binary individuals, and lesbian, gay, bisexual, transgender, and queer people of color. Dr. Agénor holds a Doctor of Science in social and behavioral sciences with a concentration in women, gender, and health from Harvard T.H. Chan School of Public Health, a Master of Public Health in sociomedical sciences from Columbia University Mailman School of Public Health, and a bachelor’s degree in community health and gender studies from Brown University.

Dr. John Pachankis

Yale School of Medicine

John Pachankis, Ph.D., is the Susan Dwight Bliss Associate Professor of Public Health and Psychiatry at Yale. As Director of Yale’s LGBTQ Mental Health Initiative, his goal is to bring effective mental health treatments to LGBTQ people around the world and to identify strategies to getting such treatment to LGBTQ people in greatest need. His NIH-funded studies examine the efficacy of LGBTQ-affirmative interventions delivered via diverse technologies, settings, and community members. These treatments have shown sustained reductions in depression, anxiety, suicidality, substance use disorders, and HIV risk across several randomized controlled trials. Dr. Pachankis has published 100+ scientific papers on LGBTQ mental health and stigma and recently co-edited the Handbook of Evidence-Based Mental Health Practice with Sexual and Gender Minorities published by Oxford University Press. He has received several awards for his research, including APA’s Distinguished Contribution to Psychology in the Public Interest award, Distinguished Contribution to the Advancement of Psychotherapy award, and awards for Distinguished Book and Distinguished Scientific Contribution to LGBTQ scholarship.

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