Advocacy Mental Health as an Advocacy Priority in the Lesbian, Gay, Bisexual, and Transgender Communities This column reviews the evolution of lesbian, gay, bisexual, and transgender (LGBT) mental health advocacy in relation to modern mental health advocacy efforts. In addition to developments in organized psychiatry (e.g., American Psychiatric Association’s LGBT caucus), grassroots LGBT community initiatives are playing an important role (e.g., Trevor Project providing crisis intervention/suicide prevention services to LGBT youth, face-to-face mental health services in LGBT community centers). Studies have found that LGBT individuals are at increased risk for mental health problems (e.g., depression, anxiety, substance misuse, suicidal ideation, self-harm). Mental health advocacy in the LGBT community has been slowed by the long-standing association of the concept of homosexuality with psychopathology in mainstream psychiatry (e.g., homosexuality was only removed from the DSM in 1973, ego dystonic homosexuality still appears in the ICD-10). However, positive developments in LGBT mental health advocacy have been fostered by the proposed minority stress model (i.e., that elevated risk of mental illness in LGBT individuals is a consequence of a hostile stressful environment). A particularly encouraging initiative is the It Gets Better Project, in which thousands of videos, some by prominent individuals, have been posted online to send a message of hope to LGBT youth facing harassment and low self-esteem. (Journal of Psychiatric Practice 2014;20:225–227 KEY WORDS: lesbian, gay, bisexual, and transgender (LGBT) mental health, Trevor Project, minority stress model, It Gets Better Project
In the 45 years since the 1969 Stonewall riot, the United States has seen extraordinary social and political progress in recognition of the rights of lesbian, gay, bisexual, and transgender (LGBT) individuals. Over roughly the same period, the modern mental health advocacy movement has also developed tremendously with the formation of family organizations such as the National Alliance on Mental Illness
Journal of Psychiatric Practice Vol. 20, No. 3
ANAND PANDYA, MD
(NAMI), the evolution of the anti-psychiatry “survivor” movement into mental health consumer organizations,1 and the developing recognition of the rights of individuals with serious mental illness in landmark cases such as Jackson v. Indiana, O’Connor v. Donaldson, Rennie v. Klein, and Addington v. Texas. Given the concurrent growth of these two social and political forces, one would expect thriving progress at the intersection of the two movements. This column reviews the evolution of LGBT mental health through the lens of advocacy and grassroots organizations that have developed outside of the medical establishment. Grassroots and Community Mental Health Organizations For most psychiatrists, the most obvious manifestation of the LGBT rights movement would be the infrastructure that has developed within organized psychiatry, including the LGBT caucus of the American Psychiatric Association (APA) and the LGBT committee in the Group for the Advancement of Psychiatry. In addition, LGBT psychiatrists have formed separate professional organizations such as the Association of Gay and Lesbian Psychiatrists (AGLP) and the Lesbian and Gay Child and Adolescent Psychiatric Association (LAGCAPA). However, the organizations discussed above are less likely to be known in the larger LGBT community than grassroots LGBT mental health services provided through organizations such as the Trevor Project, which provides crisis intervention and suicide prevention services to LGBT young people 13–24 years of age.2 In addition to more traditional telephone support (a national toll-free 24/7 lifeline), the Trevor project provides support to LGBT youth using more up-to-date technology such as online chat and text messaging. Anand Pandya, MD: Associate Professor of Clinical Medicine, Department of Psychiatry and Behavioral Neurosciences, UCLA School of Medicine, Los Angeles, CA. Sources of support: Dr. Pandya works as a consultant for the National Alliance on Mental Illness. DOI: 10.1097/01.pra.0000450322.06612.a1
May 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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Advocacy Face-to-Face LGBT mental health services are often accessed through local LGBT community centers. The largest such center, the Los Angeles Gay & Lesbian Center, reports that their clients most commonly seek their mental health services for depression, anxiety, relationship issues, HIV-related issues, substance use (in particular, crystal methamphetamine), and domestic violence.3 These problems are consistent with studies showing an elevated risk for depression, anxiety, substance misuse, suicidal ideas, and deliberate self-harm in lesbian, gay, and bisexual individuals.4 Given these risks, it may be surprising to some that LGBT mental health is not a rallying cry for LGBT activists seeking additional resources to be invested in psychiatric treatment and research in the way that AIDS activism mobilized an earlier generation of the LGBT community. The Legacy Problem One reason mental health advocacy has not become a higher priority in the LGBT community may be historical. Although more than 40 years has elapsed since the APA removed homosexuality from the Diagnostic and Statistical Manual of Mental Disorders,5 the concept of homosexuality as psychopathology continues to be used as a justification for anti-LGBT laws (for example, in high-profile trials such as Hollingsworth v Perry, the U.S. Supreme Court case involving California’s Proposition 8). Even in mainstream psychiatry, vestiges of the prior categorization of homosexuality as psychopathology continued long after 1973. As recently as the early 1980s, major psychiatric textbooks continued to place reviews of homosexuality next to discussions of sexual pathology (e.g., paraphilias, disorders of sexual function) rather than in sections that reviewed normative development. Ego dystonic homosexuality remained in the DSM until 1987 and remains in the World Health Organization’s International Statistical Classification of Diseases and Related Health Problems (ICD-10).6 The public discourse concerning gender variance as psychopathology remains even less resolved. Gender identity disorder was only removed from the DSM with the recent publication of the DSM-5.7 Although the ICD Working Group on Sexual Disorders and Sexual Health has recommended that ICD-11 abandon the psychopathology model for transgender individuals, the publication of ICD11 is at least a year away8 and thus the diagnosis of
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gender identity disorder continues to be recognized by the World Health Organization. In this context, it is difficult for LGBT activists to switch from a simple message rejecting any association of LGBT identity with mental illness to the more nuanced message that, while their sexual orientation or gender identity is not itself a mental illness, LGBT individuals are at elevated risk for certain psychiatric problems. The legacy of the pathologizing of gender identity and sexual orientation by psychiatry may have hindered LGBT communities from developing a healthy dialogue about how certain aspects of their subculture can contribute to mental health problems. In the 1980s, the AIDS epidemic forced gay communities to confront the public health risks of a culture of promiscuity in bathhouses and other venues for casual sex, while at the same time the bathhouses provided a venue for safer sex education to more closeted individuals at the epidemic’s height. In contrast, without broader acknowledgment of high addiction rates in LGBT communities, it is less likely that there will be a vigorous debate about how to address increased risks of substance use disorders that may result from bars and nightclubs being some of the most commonly available gathering spaces for LGBT individuals. Grassroots Solutions These barriers to a full public dialogue about LGBT mental health should not lead to complete pessimism. Several recent developments suggest that the intersection of mental health advocacy and LGBT activism is increasingly prepared to acknowledge and address the complexities of LGBT mental health risks. Major mental health advocacy organizations, such as the National Alliance on Mental Illness (NAMI), have developed educational materials and have initiated outreach, including policy recommendations, to LGBT communities.9 The American Foundation for Suicide Prevention (AFSP) held a series of conferences on LGBT mental health and suicide, with the hope of stimulating a national LGBT suicide prevention effort. In 2010, they released a valuable resource document that reviews the literature on LGBT suicide and provides guidance based on expert consensus concerning thoughtful messaging related to this issue.10 In addition, Ilan Meyer from the Williams Institute (a think tank at the University of California at Los Angeles focused on law and public policy affect-
Journal of Psychiatric Practice Vol. 20, No. 3
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Advocacy ing LGBT individuals) has helped to develop and disseminate the minority stress model, which explains the elevated risk of mental illnesses in LGBT populations as a consequence of a hostile, stressful environment.11 This influential concept has provided a framework that acknowledges mental health problems while clearly identifying the source of these problems in social prejudice. A growing body of empirical evidence supports the minority stress model by demonstrating how greater acceptance by families of LGBT youth12 and LGBT-friendly school environments are associated with significant improvements in serious mental health outcomes such as suicidality and illicit substance use.13 Perhaps the greatest sign that grassroots LGBT mental health advocacy has come of age has been the It Gets Better Project. Begun in 2010 by the San Francisco syndicated columnist Dan Savage, this campaign has led to the posting of thousands of videos on the Internet, including videos by the Boston Red Sox, Stephen Colbert, President Obama, Hillary Clinton, Anne Hathaway, and Colin Farrell, all designed to send a message of hope to LGBT youth facing harassment and low self-esteem.14 Although many of these videos do not explicitly mention mental illness, the It Gets Better Project is best understood as a grassroots mental health advocacy campaign given its launch in the context of multiple suicides by LGBT youth,14 including the high-profile suicide of Rutgers student Tyler Clementi which was tied to anti-LGBT bullying.15 By shifting the focus away from the specifics of the suicides, these videos are consistent with the recommendations of the AFSP not to glamorize such events.10 It should not be surprising that LGBT mental health advocacy as exemplified by the It Gets Better Project looks very different from the efforts of traditional mental health advocacy organizations. Organizations such as NAMI have traditionally focused on the biological nature of mental illnesses, so that inevitably their messaging has been different than mental health advocacy that uses the minority stress model to focus on the impact of social environment. Thus LGBT mental health advocacy may serve as a valuable example of how varied the strategies and messaging can be across the broader field of mental health advocacy. In fact, the rapid progress of the LGBT movement over the last few decades suggests that we in mental health advocacy should pay close attention to how LGBT communities are over-
Journal of Psychiatric Practice Vol. 20, No. 3
coming historical barriers to acknowledging their risk for mental illness.
References 1. Rissmiller D, Rissmiller J. Evolution of the antipsychiatry movement into mental health consumerism. Psychiatr Serv 2006;57:863–6. 2. The Trevor Project website. About the Trevor Project (available at www.thetrevorproject.org/section/about, accessed April 20, 2014). 3. The Los Angeles Gay and Lesbian Center Website. Mental health/counseling (available at http://laglc.convio.net/site /PageServer?pagename=YH_Mental_Health_Counseling, accessed April 24, 2014). 4. King M, Semlyen J, Tai S, et al. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC Psychiatry 2008;8:70. 5. Bayer R. Homosexuality and American psychiatry: The politics of diagnosis. Princeton, NJ: Princeton University Press; 1981. 6. World Health Organization. International statistical classification of diseases and related health problems, 10th revision, online version. Geneva: World Health Organization; 2010 (available at http://apps.who.int/classifications /icd10/browse/2010/en, accessed April 20, 2014). 7. American Psychiatric Association.Diagnostic and statistical manual of mental disorders, fifth edition. Arlington, VA, American Psychiatric Association, 2013. 8. Drescher J, Cohen-Kettenis P, Winter S. Minding the body: Situating gender identity diagnoses in the ICD-11. Int Rev Psychiatry. 2012;24:568–77. 9. National Alliance on Mental Illness (NAMI). Multicultural action center. Arlington, VA: NAMI (available from: www.nami.org/Content/NavigationMenu/Find_Support /Multicultural_Support/Resources/GLBT_Resources.htm, accessed April 20, 2014). 10. Haas A, Eliason M, Mays V, et al. Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: Review and recommendations. J Homosex 2011;58:10–51. 11. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychol Bull 2003;129:674–97. 12. Ryan C, Huebner D, Diaz RM, et al. Family rejection as a predictor of negative health outcomes in white and Latino lesbian, gay, and bisexual young adults. Pediatrics 2009; 123:346–52. 13. Hatzenbuehler ML, Birkett M, Van Wagenen A, et al. Protective school climates and reduced risk for suicide ideation in sexual minority youths. Am J Public Health 2014;104:279–86. 14. It Gets Better Project website. Timeline: How it’s gotten better (available at http://www.itgetsbetter.org/timeline, accessed April 20, 2014). 15. Tyler Clementi. NY: New York Times; March 16, 2012 (available at http://topics.nytimes.com/top/reference /timestopics/people/c/tyler_clementi/index.html, accessed April 20, 2014).
May 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
227
In the 45 years since the 1969 Stonewall riot, the United States has seen extraordinary social and political progress in recognition of the rights of lesbian, gay, bisexual, and transgender (LGBT) individuals. Over roughly the same period, the modern mental health advocacy movement has also developed tremendously with the formation of family organizations such as the National Alliance on Mental Illness
Journal of Psychiatric Practice Vol. 20, No. 3
ANAND PANDYA, MD
(NAMI), the evolution of the anti-psychiatry “survivor” movement into mental health consumer organizations,1 and the developing recognition of the rights of individuals with serious mental illness in landmark cases such as Jackson v. Indiana, O’Connor v. Donaldson, Rennie v. Klein, and Addington v. Texas. Given the concurrent growth of these two social and political forces, one would expect thriving progress at the intersection of the two movements. This column reviews the evolution of LGBT mental health through the lens of advocacy and grassroots organizations that have developed outside of the medical establishment. Grassroots and Community Mental Health Organizations For most psychiatrists, the most obvious manifestation of the LGBT rights movement would be the infrastructure that has developed within organized psychiatry, including the LGBT caucus of the American Psychiatric Association (APA) and the LGBT committee in the Group for the Advancement of Psychiatry. In addition, LGBT psychiatrists have formed separate professional organizations such as the Association of Gay and Lesbian Psychiatrists (AGLP) and the Lesbian and Gay Child and Adolescent Psychiatric Association (LAGCAPA). However, the organizations discussed above are less likely to be known in the larger LGBT community than grassroots LGBT mental health services provided through organizations such as the Trevor Project, which provides crisis intervention and suicide prevention services to LGBT young people 13–24 years of age.2 In addition to more traditional telephone support (a national toll-free 24/7 lifeline), the Trevor project provides support to LGBT youth using more up-to-date technology such as online chat and text messaging. Anand Pandya, MD: Associate Professor of Clinical Medicine, Department of Psychiatry and Behavioral Neurosciences, UCLA School of Medicine, Los Angeles, CA. Sources of support: Dr. Pandya works as a consultant for the National Alliance on Mental Illness. DOI: 10.1097/01.pra.0000450322.06612.a1
May 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
225
Advocacy Face-to-Face LGBT mental health services are often accessed through local LGBT community centers. The largest such center, the Los Angeles Gay & Lesbian Center, reports that their clients most commonly seek their mental health services for depression, anxiety, relationship issues, HIV-related issues, substance use (in particular, crystal methamphetamine), and domestic violence.3 These problems are consistent with studies showing an elevated risk for depression, anxiety, substance misuse, suicidal ideas, and deliberate self-harm in lesbian, gay, and bisexual individuals.4 Given these risks, it may be surprising to some that LGBT mental health is not a rallying cry for LGBT activists seeking additional resources to be invested in psychiatric treatment and research in the way that AIDS activism mobilized an earlier generation of the LGBT community. The Legacy Problem One reason mental health advocacy has not become a higher priority in the LGBT community may be historical. Although more than 40 years has elapsed since the APA removed homosexuality from the Diagnostic and Statistical Manual of Mental Disorders,5 the concept of homosexuality as psychopathology continues to be used as a justification for anti-LGBT laws (for example, in high-profile trials such as Hollingsworth v Perry, the U.S. Supreme Court case involving California’s Proposition 8). Even in mainstream psychiatry, vestiges of the prior categorization of homosexuality as psychopathology continued long after 1973. As recently as the early 1980s, major psychiatric textbooks continued to place reviews of homosexuality next to discussions of sexual pathology (e.g., paraphilias, disorders of sexual function) rather than in sections that reviewed normative development. Ego dystonic homosexuality remained in the DSM until 1987 and remains in the World Health Organization’s International Statistical Classification of Diseases and Related Health Problems (ICD-10).6 The public discourse concerning gender variance as psychopathology remains even less resolved. Gender identity disorder was only removed from the DSM with the recent publication of the DSM-5.7 Although the ICD Working Group on Sexual Disorders and Sexual Health has recommended that ICD-11 abandon the psychopathology model for transgender individuals, the publication of ICD11 is at least a year away8 and thus the diagnosis of
226
May 2014
gender identity disorder continues to be recognized by the World Health Organization. In this context, it is difficult for LGBT activists to switch from a simple message rejecting any association of LGBT identity with mental illness to the more nuanced message that, while their sexual orientation or gender identity is not itself a mental illness, LGBT individuals are at elevated risk for certain psychiatric problems. The legacy of the pathologizing of gender identity and sexual orientation by psychiatry may have hindered LGBT communities from developing a healthy dialogue about how certain aspects of their subculture can contribute to mental health problems. In the 1980s, the AIDS epidemic forced gay communities to confront the public health risks of a culture of promiscuity in bathhouses and other venues for casual sex, while at the same time the bathhouses provided a venue for safer sex education to more closeted individuals at the epidemic’s height. In contrast, without broader acknowledgment of high addiction rates in LGBT communities, it is less likely that there will be a vigorous debate about how to address increased risks of substance use disorders that may result from bars and nightclubs being some of the most commonly available gathering spaces for LGBT individuals. Grassroots Solutions These barriers to a full public dialogue about LGBT mental health should not lead to complete pessimism. Several recent developments suggest that the intersection of mental health advocacy and LGBT activism is increasingly prepared to acknowledge and address the complexities of LGBT mental health risks. Major mental health advocacy organizations, such as the National Alliance on Mental Illness (NAMI), have developed educational materials and have initiated outreach, including policy recommendations, to LGBT communities.9 The American Foundation for Suicide Prevention (AFSP) held a series of conferences on LGBT mental health and suicide, with the hope of stimulating a national LGBT suicide prevention effort. In 2010, they released a valuable resource document that reviews the literature on LGBT suicide and provides guidance based on expert consensus concerning thoughtful messaging related to this issue.10 In addition, Ilan Meyer from the Williams Institute (a think tank at the University of California at Los Angeles focused on law and public policy affect-
Journal of Psychiatric Practice Vol. 20, No. 3
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Advocacy ing LGBT individuals) has helped to develop and disseminate the minority stress model, which explains the elevated risk of mental illnesses in LGBT populations as a consequence of a hostile, stressful environment.11 This influential concept has provided a framework that acknowledges mental health problems while clearly identifying the source of these problems in social prejudice. A growing body of empirical evidence supports the minority stress model by demonstrating how greater acceptance by families of LGBT youth12 and LGBT-friendly school environments are associated with significant improvements in serious mental health outcomes such as suicidality and illicit substance use.13 Perhaps the greatest sign that grassroots LGBT mental health advocacy has come of age has been the It Gets Better Project. Begun in 2010 by the San Francisco syndicated columnist Dan Savage, this campaign has led to the posting of thousands of videos on the Internet, including videos by the Boston Red Sox, Stephen Colbert, President Obama, Hillary Clinton, Anne Hathaway, and Colin Farrell, all designed to send a message of hope to LGBT youth facing harassment and low self-esteem.14 Although many of these videos do not explicitly mention mental illness, the It Gets Better Project is best understood as a grassroots mental health advocacy campaign given its launch in the context of multiple suicides by LGBT youth,14 including the high-profile suicide of Rutgers student Tyler Clementi which was tied to anti-LGBT bullying.15 By shifting the focus away from the specifics of the suicides, these videos are consistent with the recommendations of the AFSP not to glamorize such events.10 It should not be surprising that LGBT mental health advocacy as exemplified by the It Gets Better Project looks very different from the efforts of traditional mental health advocacy organizations. Organizations such as NAMI have traditionally focused on the biological nature of mental illnesses, so that inevitably their messaging has been different than mental health advocacy that uses the minority stress model to focus on the impact of social environment. Thus LGBT mental health advocacy may serve as a valuable example of how varied the strategies and messaging can be across the broader field of mental health advocacy. In fact, the rapid progress of the LGBT movement over the last few decades suggests that we in mental health advocacy should pay close attention to how LGBT communities are over-
Journal of Psychiatric Practice Vol. 20, No. 3
coming historical barriers to acknowledging their risk for mental illness.
References 1. Rissmiller D, Rissmiller J. Evolution of the antipsychiatry movement into mental health consumerism. Psychiatr Serv 2006;57:863–6. 2. The Trevor Project website. About the Trevor Project (available at www.thetrevorproject.org/section/about, accessed April 20, 2014). 3. The Los Angeles Gay and Lesbian Center Website. Mental health/counseling (available at http://laglc.convio.net/site /PageServer?pagename=YH_Mental_Health_Counseling, accessed April 24, 2014). 4. King M, Semlyen J, Tai S, et al. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC Psychiatry 2008;8:70. 5. Bayer R. Homosexuality and American psychiatry: The politics of diagnosis. Princeton, NJ: Princeton University Press; 1981. 6. World Health Organization. International statistical classification of diseases and related health problems, 10th revision, online version. Geneva: World Health Organization; 2010 (available at http://apps.who.int/classifications /icd10/browse/2010/en, accessed April 20, 2014). 7. American Psychiatric Association.Diagnostic and statistical manual of mental disorders, fifth edition. Arlington, VA, American Psychiatric Association, 2013. 8. Drescher J, Cohen-Kettenis P, Winter S. Minding the body: Situating gender identity diagnoses in the ICD-11. Int Rev Psychiatry. 2012;24:568–77. 9. National Alliance on Mental Illness (NAMI). Multicultural action center. Arlington, VA: NAMI (available from: www.nami.org/Content/NavigationMenu/Find_Support /Multicultural_Support/Resources/GLBT_Resources.htm, accessed April 20, 2014). 10. Haas A, Eliason M, Mays V, et al. Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: Review and recommendations. J Homosex 2011;58:10–51. 11. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychol Bull 2003;129:674–97. 12. Ryan C, Huebner D, Diaz RM, et al. Family rejection as a predictor of negative health outcomes in white and Latino lesbian, gay, and bisexual young adults. Pediatrics 2009; 123:346–52. 13. Hatzenbuehler ML, Birkett M, Van Wagenen A, et al. Protective school climates and reduced risk for suicide ideation in sexual minority youths. Am J Public Health 2014;104:279–86. 14. It Gets Better Project website. Timeline: How it’s gotten better (available at http://www.itgetsbetter.org/timeline, accessed April 20, 2014). 15. Tyler Clementi. NY: New York Times; March 16, 2012 (available at http://topics.nytimes.com/top/reference /timestopics/people/c/tyler_clementi/index.html, accessed April 20, 2014).
May 2014
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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