Mental Health Disparities Among Sexual Minority Youth

Transcription

1 Mental Health Disparities Among Sexual Minority Youth M ichael P. Marshal, Ph.D. m a r s h a l m u p m c. e d u A s s o c i a t e P r o f e s s o r D e p a r t m e n t s o f P s y c h i a t r y a n d P e d i a t r i c s C l i n i c a l P s y c h o l o g i s t A d o l e s c e n t M e d i c i n e C l i n i c S t e e r i n g C o m m i t t e e U n i v e r s i t y o f P i t t s b u r g h / U P M C H e a l t h S c i e n c e s L G B T Q I A l l i a n c e A n d T h a n k s t o N I H : D A , D A ( a n d A A , A A , M H , a n d T h e P i t t s b u r g h F o u n d a t i o n )

2 Presentation Topics 1) Common definitions of sexual orientation 2) Current scientific evidence for SMY mental health disparities 3) The Minority Stress Model and central mechanism of risk for mental health disparities among SMY 4) How to conceptualize problems and approaches to treatment using the Cognitive Behavioral Therapy framework

3 How do we define sexual minority youth? What determines whether or not somebody is gay/lesbian/bisexual? How do researchers define homosexuality?

4 Three common indices of sexual orientation opposite sex ATTRACTION both sexes same sex opposite sex BEHAVIOR both sexes same sex heterosexual IDENTITY bisexual gay/lesbian

5 The continuum is important! IDENTITY 100% Heterosexual Mostly Heterosexual Bisexual Mostly Gay/Lesbian 100% Gay/Lesbian

6 Traditional methods of assessing orientation IDENTITY 100% Heterosexual Mostly Heterosexual Bisexual Mostly Gay/Lesbian 100% Gay/Lesbian 3-5%

7 But what about this group? IDENTITY 100% Heterosexual Mostly Heterosexual Bisexual Mostly Gay/Lesbian 100% Gay/Lesbian

8 How many SMY are there? IDENTITY 100% Heterosexual Mostly Heterosexual Bisexual Mostly Gay/Lesbian 100% Gay/Lesbian 10% Add Health Data

9 Detecting disparities among SMY Four major domains have been studied among youth using meta-analysis* techniques: 1. Substance use and abuse 2. Risky sexual behavior 3. Depression and Suicide 4. Violence/Victimization * Inclusion criterion required a mean age <18 years old

10 Substance use disparities Overall Odds Ratio: 2.89 Marshal, M. P., Friedman, M. S., Stall, R., King, K. M., Miles, J., Gold, M. A., Bukstein, O. G., & Morse, J. Q. (2008). Sexual orientation and adolescent substance use: A meta-analysis and methodological review. Addiction, 103,

11 Substance use disparities Overall Odds Ratio: 2.89 Girls: 5.02 Marshal, M. P., Friedman, M. S., Stall, R., King, K. M., Miles, J., Gold, M. A., Bukstein, O. G., & Morse, J. Q. (2008). Sexual orientation and adolescent substance use: A meta-analysis and methodological review. Addiction, 103,

12 Substance use disparities Overall Odds Ratio: 2.89 Girls: 5.02 Bisexual Youth: 4.42 Marshal, M. P., Friedman, M. S., Stall, R., King, K. M., Miles, J., Gold, M. A., Bukstein, O. G., & Morse, J. Q. (2008). Sexual orientation and adolescent substance use: A meta-analysis and methodological review. Addiction, 103,

13 Substance use and risky sex Substance use is one of the primary risk factors for risky sexual behavior among adolescents Do the higher rates of substance use among SMY translate into higher rates of risky sexual behaviors?

14 Sex under the influence Overall Odds Ratio: 1.91 Herrick, A., Marshal, M. P., Smith, H., & Stall, R. (2011). Sex While Intoxicated: A Meta-Analysis Comparing Heterosexual and Sexual Minority Youth. Journal of Adolescent Health, 48,

15 Depression and suicide disparities Depression and Suicidality Meta-Analysis: 1) LGB youth reported higher rates of depression symptoms, on average, than did heterosexual youth. 2)LGB youth were over three times more likely to report a history of suicidality Marshal, M. P., Dietz, L. J., Friedman, M. S., et al. (2011). Suicidality and Depression Disparities between Sexual Minority and Heterosexual Youth: A Meta-Analytic Review. Journal of Adolescent Health, 49,

16 Operationalization of suicidality Ideation Plans or intent Attempts Attempt requiring medical attention *For the meta-analysis we combined across these to obtain an overall suicidality effect Marshal, M. P., Dietz, L. J., Friedman, M. S., et al. (2011). Suicidality and Depression Disparities between Sexual Minority and Heterosexual Youth: A Meta-Analytic Review. Journal of Adolescent Health, 49,

17 Suicidality disparities Overall Odds Ratio: 2.92 Marshal, M. P., Dietz, L. J., Friedman, M. S., et al. (2011). Suicidality and Depression Disparities between Sexual Minority and Heterosexual Youth: A Meta-Analytic Review. Journal of Adolescent Health, 49,

18 Suicidality disparities Overall Odds Ratio: 2.92 Bisexual Youth: 4.92 Marshal, M. P., Dietz, L. J., Friedman, M. S., et al. (2011). Suicidality and Depression Disparities between Sexual Minority and Heterosexual Youth: A Meta-Analytic Review. Journal of Adolescent Health, 49,

19 Absolute rates of any suicidality (13/19) 30% 25% History of Suicidality 28% 20% 15% 10% 5% 12% 0% Heterosexual SMY Marshal, M. P., Dietz, L. J., Friedman, M. S., et al. (2011). Suicidality and Depression Disparities between Sexual Minority and Heterosexual Youth: A Meta-Analytic Review. Journal of Adolescent Health, 49,

20 Larger Disparities as Severity of Suicidality Increases Ideation: OR=1.96 Plans/Intent: OR=2.20 Attempts: OR=3.18 Medical Attention: OR=4.17 Marshal, M. P., Dietz, L. J., Friedman, M. S., et al. (2011). Suicidality and Depression Disparities between Sexual Minority and Heterosexual Youth: A Meta-Analytic Review. Journal of Adolescent Health, 49,

21 Results from the Pittsburgh Girls Study Sexual Minority Girls (n=173) Heterosexual Girls (n=1891) Effect size (95% CI) Cigarette Use (n) 49% 17% OR=2.42* Alcohol Use (n) 60% 37% OR=2.71*** Binge Drinking (n) 33% 16% OR=2.02** Marijuana Use (n) 50% 21% OR=3.61*** Depression (SD) d=.69*** Suicidal Ideation, 2 Weeks (n) 12.9% 3.4% OR=4.17** Suicidal Ideation, 12 Months (n) 26.0% 7.2% OR=4.43*** Self-Harm, 12 Months (n) 12.9% 2.0% OR=7.20*** Marshal, M. P., Sucato, G. S., et al. (2012). Substance use and mental health disparities among sexual minority girls: Results from the Pittsburgh Girls Study. Journal of Pediatric and Adolescent Gynecology, 5, PMID:

22 Sources of stress among SMY Rejection by church Government Potential Sources of Discrimination, Victimization, and Stress Family rejection Parent s Cultural Naïveté School apathy Internalized Homophobia Cyberbullying Peer Bullying

23 Potential stressors across the lifetime for SMY Peer Bullying School neglect Career choices: DADT Workplace Discrimination: see Williams Institute Nursing home discrimination Adolescence Young adulthood Middle adulthood Late adulthood Rejection by parents Marriage options: Higher taxes, Insurance premiums Hospital visitation rights

24 Standardized Depression Score Trajectories of Depression Bisexual Mostly Heterosexual Gay/Mostly Gay Heterosexual Trajectories across four waves from age ~14 through age ~28 Marshal, M. P., Dermody, S., Cheong, J., Hughes, T., Aranda, F., et al. (under review). Longitudinal trajectories of depression and suicidality among sexual minority youth and associations with heavy drinking over time. Journal of Abnormal Psychology.

25 Operationalization of suicidality 0 = No suicidal ideation 1 = Ideation 2 = Attempt 3 = Attempt requiring medical attention Marshal, M. P., Dermody, S., Cheong, J., Hughes, T., Aranda, F., et al. (under review). Longitudinal trajectories of depression and suicidality among sexual minority youth and associations with heavy drinking over time. Journal of Abnormal Psychology.

26 Suicidality Score 0-3 Trajectories of Suicidality Bisexual Mostly Heterosexual Gay/Mostly Gay 0.2 Heterosexual Trajectories across four waves from age ~14 through age ~28 Marshal, M. P., Dermody, S., Cheong, J., Hughes, T., Aranda, F., et al. (under review). Longitudinal trajectories of depression and suicidality among sexual minority youth and associations with heavy drinking over time. Journal of Abnormal Psychology.

27 Minority Stress Model (Meyer, 2003) Coping and Social Support Minority Status sexual orientation race/ethnicity gender Minority Identity (gay, lesbian, bisexual) prominence valence integration General Stressors Minority Stress Processes (distal) prejudice events (discrimination, violence) Minority Stress Processes (proximal) expectations of rejection concealment internalized homophobia Mental health outcomes Meyer, I. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin 129(5)

28 Sources of stress among SMY Rejection by church Government Potential Sources of Discrimination, Victimization, and Stress Family rejection Parent s Cultural Naïveté School apathy Internalized Homophobia Cyberbullying Peer Bullying

29 Sources of stress among SMY Rejection by church Government Potential Sources of Discrimination, Victimization, and Stress Family rejection Parent s Cultural Naïveté School apathy Internalized Homophobia Cyberbullying Peer Bullying

30 Violence and Victimization SMY across multiple studies and methodologies are more likely to report: A. Childhood sexual abuse B. Parent physical abuse C. Assaulted at school D. Missed school due to fear Friedman, M.S., Marshal, M.P., Guadamuz, T. E., Wei, C., Wong, C., & Stall, R. (2011). A Meta-Analysis to Examine Disparities in Childhood Physical and Sexual Abuse among Sexual and Non-Sexual Minorities. American Journal of Public Health, 101,

31 Assaulted at school Overall Odds Ratio: 2.68 Friedman, M.S., Marshal, M.P., Guadamuz, T. E., Wei, C., Wong, C., & Stall, R. (2011). A Meta-Analysis to Examine Disparities in Childhood Physical and Sexual Abuse among Sexual and Non-Sexual Minorities. American Journal of Public Health, 101,

32 Assaulted at school Overall Odds Ratio: 2.68 Girls: 3.31 Friedman, M.S., Marshal, M.P., Guadamuz, T. E., Wei, C., Wong, C., & Stall, R. (2011). A Meta-Analysis to Examine Disparities in Childhood Physical and Sexual Abuse among Sexual and Non-Sexual Minorities. American Journal of Public Health, 101,

33 Higher rates of being assaulted at school 60% 50% 40% 50% 44% 43% 40% 35% 30% 20% 21% Males Females 10% 0% Gay/Lesbian Bisexual Heterosexual Friedman, M.S., Marshal, M.P., Guadamuz, T. E., Wei, C., Wong, C., & Stall, R. (2011). A Meta-Analysis to Examine Disparities in Childhood Physical and Sexual Abuse among Sexual and Non-Sexual Minorities. American Journal of Public Health, 101,

34 Overall Odds Ratio: 3.85 Missing school due to fear

35 Missing school due to fear Overall Odds Ratio: 3.85 Bisexual: 4.32

36 Missing school due to fear 25% 23% 23% 20% 16% 15% 15% Males 10% 8% 7% Females 5% 0% Gay/Lesbian Bisexual Heterosexual Friedman, M.S., Marshal, M.P., Guadamuz, T. E., Wei, C., Wong, C., & Stall, R. (2011). A Meta-Analysis to Examine Disparities in Childhood Physical and Sexual Abuse among Sexual and Non-Sexual Minorities. American Journal of Public Health, 101,

37 Understanding via mediation modeling Do victimization experiences mediate mental health outcomes among SMY? Sexual Orientation a Explanatory Variables? (Mediators) b Mental Health Outcomes

38 Pittsburgh Pilot Study (n=197) Mediation* of depression/anxiety symptoms (p<.05): Sexual Orientation Gay-related Victimization Depression and Anxiety Burton, C. M., Marshal, M. P., Chisolm, D. J., Sucato, G. S., & Friedman, M. S. (2013). Sexual minority-related victimization as a mediator of mental health disparities in sexual minority youth: A longitudinal analysis. Journal of Youth and Adolescence, 42,

39 Stress & Negative Affect Pathway Sexual Orientation Gay-related Victimization Depression Drug and Alcohol Use Marshal, M. P., Burton, C. M., Chisolm, D. J, Sucato, G. S, & Friedman, M. S. (in press). Cross-sectional evidence for a stress-negative affect pathway to substance use among sexual minority girls. Clinical and Translational Science.

40 Reasons for hope 5) StopBullying.gov Homepage

41 General Conclusions 1) There are large disparities in several psychosocial health domains 2)For some SMY, disparities appear to last well into young adulthood. 3)There is heterogeneity within the SMY group and variability with regards to risk (e.g., bisexuality and gender). 4)SMY may have higher rates of comorbidity between mental health outcomes over time 5) We don t know enough about what s driving the disparities, but minority stress is a reasonable candidate

42 Situation or Event Basic CBT Model Automatic Thoughts Emotion or Behavior Intermediate Thoughts Core Beliefs Beck, J.S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford

43 Situation or Event Basic CBT Model Automatic Thoughts Emotion or Behavior Most fundamental beliefs about the self and the world that are: 1. Global 2. Rigid 3. Over-generalized Intermediate Thoughts Core Beliefs Beck, J.S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford

44 Situation or Event Basic CBT Model Automatic Thoughts Emotion or Behavior Intermediate Thoughts 1. Attitudes 2. Rules and Expectation 3. Assumptions Core Beliefs Beck, J.S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford

45 Situation or Event Basic CBT Model Automatic Thoughts Emotion or Behavior Intermediate Thoughts Words or images that come to one s mind in response to a situation Core Beliefs Beck, J.S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford

46 Situation or Event Basic CBT Model Automatic Thoughts Emotion or Behavior Intermediate Thoughts Core Beliefs Beck, J.S. (1995). Cognitive therapy: Basics and beyond. New York: Guilford

47 5. Conceptualizing LGB Youth Experience Using the CBT Framework Situation or Event Automatic Thoughts Emotion or Behavior Intermediate Thoughts Core Beliefs

48 5. Conceptualizing LGB Youth Experience Situation or Event Early experiences w/ homophobic culture: Automatic Thoughts Emotion or Behavior 1.Parent attitudes and beliefs 2.Church doctrine and anti-gay messages 3.Peers teasing others for being gay or gender-role nonconforming 4.Predominant heterosexual norms Intermediate Thoughts Core Beliefs

49 5. Conceptualizing LGB Youth Experience Situation or Event Early experiences w/ homophobic culture: 1.Parent attitudes and beliefs 2.Church doctrine and anti-gay messages 3.Peers teasing others for being gay or gender-role non-conforming Automatic Thoughts Intermediate Thoughts Core Beliefs Emotion or Behavior In response, some youth may develop a negative self image: Because I am gay 1.I am not as good as others 2. I am not lovable 3. I am not normal 4. I am a sinner

50 5. Conceptualizing LGB Youth Experience Situation or Event Automatic Thoughts Emotion or Behavior If I tell people that I m gay 1.My parents won t love me 2. My friends will reject me 3. I will go to hell 4. I will never have a normal life 5. I will always be an outcast Intermediate Thoughts Core Beliefs Because I am gay 1.I am not as good as others 2. I am not lovable 3. I am not normal 4. I am a sinner

51 5. Conceptualizing LGB Youth Experience Situation or Event Automatic Thoughts Emotion or Behavior If I tell others 1.My parents won t love me 2. My friends will reject me 3. I will go to hell 4. I will never have a normal life 5. I will always be an outcast Intermediate Thoughts Core Beliefs Maladaptive automatic thoughts that are due to: 1.Fundamental beliefs about selfworth as a person 2. Rules, attitudes, and assumptions about self and the world

52 5. Conceptualizing LGB Youth Experience Situation or Event Automatic Thoughts Emotion or Behavior 1.Parents asking about opposite sex dating 2.School dances or parties 3.Having a secret crush on someone 4. Church sermon Intermediate Thoughts Core Beliefs

53 Margaret: 17 Years Old Situation or Event Automatic Thoughts Emotion or Behavior Senior in H.S. Honors Student Chemistry Major Applying to colleges Intermediate Thoughts Family: Two Bio Parents Two Bio Siblings Core Beliefs Father is a minister Mother violin teacher Parents are progressive Conceptualizing LGB Youth Experience: A Case Study

54 Psychiatric History: Family history of anxiety Situation or Event Automatic Thoughts Emotion or Behavior Reason for seeking treatment: Suicidality Moderate MDD & GAD Intermediate Thoughts Suicidal thoughts but no plans or intent, and no history of attempts Average mood is 4/10 Core Beliefs Difficulties concentrating Low Energy Moderate Insomnia Conceptualizing LGB Youth Experience: A Case Study

55 Psychosocial History: Has experienced same-sex attraction for several years Situation or Event Automatic Thoughts Emotion or Behavior Is out to parents and they are supportive Intermediate Thoughts Never been in a romantic or sexual relationship No kissing, no handholding, no love letters (with same-sex teen) Core Beliefs Conceptualizing LGB Youth Experience: A Case Study

56 Traditional CBT Interpretation Focused on Surface-Level Automatic Thoughts Situation or Event Mother nags patient about getting her college applications submitted Automatic Thoughts I am a constant disappointment to her and always letting her down Emotion or Behavior Sadness and hopelessness

57 Deeper Meaning Related to Sexual Orientation Situation or Event Automatic Thoughts Emotion or Behavior Mother nags patient about getting her college applications submitted I am a constant disappointment to her and always letting her down I have to prove to people that I am as good or better than everybody else Sadness and hopelessness Intermediate Thought

58 Deeper Meaning Related to Sexual Orientation Situation or Event Automatic Thoughts Emotion or Behavior Mother nags patient about getting her college applications submitted I am a constant disappointment to her and always letting her down I have to prove to people that I am as good or better than everybody else Sadness and hopelessness about being accepted unconditionally Intermediate Thought I am not as good as other people because I am gay Core Belief

59 6. Suggestions for navigating therapy w/ LGB teens For LGB teenagers in which gay-related issues are influential: 1) Gay-related stressors and influences may not be obvious 2) Core beliefs may be unconscious and deeply entrenched 3) Automatic thoughts may not appear to be gay-related 4) Using the vertical arrow technique can help identify core beliefs that are feeding into automatic thoughts 5) Identifying, challenging, and changing core beliefs may the key to success!

60 6. Suggestions for navigating therapy w/ LGB teens Nondiscrimination policies Inclusive forms and assessment questions Visible signs of diversity Training for all staff positions Confront discrimination when displayed Include diverse examples and stories Don t assume youth want to discuss Emphasize privacy policies Know community resources

61 Reasons to be hopeful! 1) Most gay youth are resilient and do not report histories of depression symptoms or suicidality 2) Strength-based approaches to protecting teens 3) Some evidence for the power of positive parent relationships 4) Most gay youth do not report mental health problems 5) Society and acceptance of homosexuality is changing

62 Reasons for hope! 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% History of Suicidality 72%! 28% 12% Heterosexual SMY Marshal, M. P., Dietz, L. J., Friedman, M. S., et al. (2011). Suicidality and Depression Disparities between Sexual Minority and Heterosexual Youth: A Meta-Analytic Review. Journal of Adolescent Health, 49,

63 Resources for Youth and Families National PFLAG GLSEN GLMA The Trevor Project- Local Persad Center GLCC Dreams of Hope

64 This presentation may not be reproduced without written permission from: STAR-Center Outreach, Western Psychiatric Institute and Clinic, 3811 O Hara Street, Pittsburgh, PA (412) All rights reserved, 2013