Pattern Constraints

"I wondered what it felt like … to see the world open up to you in all its magnificence. What did it feel like to not have to think about your every move, to not be scrutinized for everything you did, to not have to lie every day?”

So wrote Garrard Conley in his 2016 memoir, Boy Erased, which recounts his time being subjected to “conversion therapy” as a gay teenager. The continual state of hypervigilance and anxiety, the fear of rejection, and the exposure to discrimination that he describes is not unique to his experience nor is it seen only in those who have undergone tactics designed to change gender identity or sexual orientation. In fact, it’s a phenomenon that social scientists and others now term minority stress. Such chronically high levels of stress are common in stigmatized minority groups, including LGBTQ people, and are increasingly being linked to an array of harmful mental health consequences.

Indeed, recent surveys have shown that lesbian, gay, and bisexual adults are more than twice as likely to have a mental health condition as their heterosexual peers. Nearly 18 percent of LGBTQ youth have major depression, while 11 percent have post-traumatic stress disorder and 31 percent report having considered suicide at some point in their life. Such statistics stand in stark contrast to rates of these same mental health concerns in the general U.S. population: slightly more than 8 percent for depression, nearly 4 percent for PTSD, and 4 percent for suicidal ideation. In addition, although research on subjective cognitive decline (SCD) is in its infancy, some early evidence of this self-reported increase in confusion or memory loss suggests that minority stress might be tied to a higher incidence of this condition among older LGBTQ adults.

A 2019 study out of the University of California, San Franscisco, showed that for adults over the age of 45, more than 14 percent of sexual and gender minority participants reported the condition compared with just 10 percent of the cisgender participants. Other research suggested that being a person of color or having depression further increases the risk of SCD in the LGBTQ population.

Minority stress can take many forms. It can arise because of continual exposure to various microaggressions such as being unrepresented in the media or being referred to by misgendered pronouns. Or it can come from threats like being harassed or bullied. Even the expectation of rejection and discrimination that results from past experiences can contribute to persistent stress.

“All of these chronic stressors get internalized and can manifest in mental health issues such as anxiety, depression, and suicidal ideation,” explains Michal McDowell, MD ’17, an HMS clinical fellow in psychiatry at Massachusetts General Hospital, who has studied the risk of psychiatric conditions in patients who are transgender or nonbinary. “A lack of family or social support can compound minority stress and further reduce the ability to cope.”

Not Mr. Rogers’ neighborhood

Research reports leave little doubt that a hostile environment can worsen sexual and gender minority stress. Studies have identified higher rates of psychological distress and psychiatric disorders among LGBTQ adults who live in U.S. states that banned same-sex marriage or in states in which constitutional amendments to ban same-sex marriage were on election ballots. Likewise, state laws that permit the refusal of services to LGBTQ people, such as rejecting orders for wedding cakes or reservations for ceremonial venues, have had damaging psychological effects.

In one recent study, researchers looked at the potential effect of refusal-of-service laws among LGBTQ residents in Utah, North Carolina, and Michigan and found that they were associated with a 46 percent increase in LGBTQ adults experiencing mental distress when compared to peers in six states that were used as controls.

“All of these chronic stressors get internalized and can manifest in mental health issues such as anxiety, depression, and suicidal ideation. A lack of family or social support can compound minority stress and further reduce the ability to cope.”

The problem isn’t limited to adults. LGBTQ youths who reside in neighborhoods with a higher concentration of LGBTQ-targeted hate crimes or with fewer sexual orientation- and gender identity-specific antibullying policies in place have a greater likelihood of suicidal ideation and suicide attempts than their peers who live in more supportive neighborhoods.

The problem also isn’t limited to patients. For a 2018 study, Carl Streed, an assistant professor of medicine at Boston University School of Medicine and a primary care physician at Boston Medical Center, and his colleagues asked LGBTQ providers about their experiences in the workplace and found a slew of disturbing stories that ranged from fear of discrimination to actually being fired, fears and consequences that were associated with increased stress levels and unhealthy coping behaviors. An earlier study by researchers at San Francisco State University identified additional problems, such as harassment, derogatory comments, and denial of referrals from heterosexual colleagues.

Troubling times

Trauma has long-lasting consequences: Children and teenagers who experience LGBTQ-related victimization, both in person and online, have higher rates of depression, suicide attempts, substance use disorders, and psychological distress that extend well into young adulthood.

It’s a crisis that doesn’t promise to wane anytime soon. “The current administration hasn’t hidden the fact that they are attacking the LGBTQ community,” says Streed. “We’re seeing an increase in hate crimes, bullying, and homicides, particularly of transgender women of color. It’s clear that what happens at a policy level affects the health of this population.”

Indeed, research indicates that members of the LGBTQ community have been experiencing a surge in discrimination and minority stress, and an increase of anxiety and depression, since the 2016 presidential election.

Affronts to identity

This uptick in stresses from society in general is compounded by the pseudoscientific practice of “conversion therapy” in minors, which remains legal in thirty-two states. No states have banned the use of this practice in adults. More accurately described as gender identity or sexual orientation conversion efforts, the “therapy” includes any attempt to change a person’s identity from trans- to cisgender or their orientation from LGB to heterosexual. Such practices range from electroshock aversion techniques to behavioral techniques such as, in some cases, having boys spend less time with their mothers.

A pair of recent high-profile papers highlight the damage done by these gender-identity conversion efforts. In an August 2019 report in the New England Journal of Medicine, Streed and his colleagues called for an end to the practice, citing well-documented examples of the harm it causes, including higher rates of depression, suicidal thoughts, and suicide attempts and lower educational achievement, lower income, and lower work performance into young adulthood. And a study published in a September 2019 issue of JAMA Psychiatry found that lifetime and childhood exposure to gender identity conversion efforts were associated with adverse mental health outcomes.

“The practice can lead to deep feelings of shame and internalized transphobia that in turn may lead to depression and even suicidal ideation,” says Jack Turban, an HMS clinical fellow in psychiatry at Mass General and McLean Hospital, who led the study, which involved The Fenway Institute in Boston.

Attempts to change gender identity may be especially damaging to young children. “We found that for those exposed to gender identity conversion efforts before age 10, the odds of attempting suicide were four times higher than for those who spoke with a professional about their gender identity but were not exposed to conversion efforts,” Turban adds.

Unwelcome ramifications

When it comes to LGBTQ health, clinicians have the opportunity—and obligation, argues Streed—to affect change at a policy level. But change must also come from within. The field of medicine has a history of caring for sexual and gender minorities that many consider checkered at best. The American Psychiatric Association, for example, took decades before deciding to excise homosexuality from the Diagnostic and Statistical Manual of Mental Disorders; today, some physicians remain reluctant to treat LGBTQ patients. In one recent survey by the Center for American Progress, a public policy research and advocacy organization based in Washington, DC, 8 percent of LGBQ respondents and 29 percent of transgender respondents said that a doctor or other health care provider refused to see them because of their actual or perceived sexual orientation or gender identity.

Of course, most health care discrimination is far less overt and is often unwitting. Yet the effect of such discrimination on the mental health of a patient can be as troubling as that of intentional refusal to treat.

“Providers may use the wrong name or pronouns for trans patients, or there may be limited options for gender on intake forms and in electronic medical records,” says McDowell. Even an OB/GYN’s waiting room that’s decorated in stereotypical feminine colors and contains magazines that appeal only to some cisgender women can contribute to gender minority stress, since transgender males and patients with nonbinary bodies often require gynecologic services.

“All of this can make patients feel like they don’t belong,” she adds.

Intentional or not, fear of discrimination contributes to minority stress and can keep LGBTQ patients away from the doctor altogether. Surveys by the Center for American Progress have found that more than 6 percent of LGBTQ people said they avoided physicians’ offices within the past year due to concerns about discrimination. Moreover, the survey indicated that more than 18 percent of LGBTQ patients who had already experienced discrimination avoided their doctor’s office in the past year, a percentage that was nearly seven times greater than that for peers who had not experienced such discrimination.

“The most pernicious effect of perceived discrimination is that people don’t want to see their physician for any reason,” says Streed. “If they don’t come in, we can’t provide them with even the most basic care.”

“We’re seeing an increase in hate crimes, bullying, and homicides, particularly of transgender women of color. It’s clear that what happens at a policy level affects the health of this population.”

Along with leading to higher rates of mental health concerns, internalized minority stress has been linked to an increased risk of cardiovascular disease and other conditions, all of which remain untreated when patients avoid medical care.

According to Streed, physicians have a responsibility to provide care for LGBTQ patients that is both welcoming and affirming. It’s an approach that allows patients to feel safe and willing to share personal information with their doctors.

“As physicians, we need to be open with our patients,” he says. “Introduce yourself, tell patients your pronouns, and ask them what pronouns they use. Include questions about pronouns, gender, and orientation on your intake forms and electronic medical records.”

Data support this type of gender- and sexual orientation-affirming care. Studies suggest that support of sexual orientation and gender identity can act as a buffer against the negative effects of minority stress and is associated with higher self-esteem and lower rates of depression and suicidal ideation and suicide attempts.

“There’s new evidence that trans youths who are supported in their identities have mental health similar to cisgender controls,” says Turban. That’s a big difference from past studies, which found that unsupported trans youths have high rates of anxiety and depression.

The care-filled approach

Although it’s important to understand the distinct needs of LGBTQ patients, clinicians emphasize that there are more similarities in caring for this population than differences. Chief among them: the need for physicians to provide trauma-informed care to every patient. A large proportion of this nation’s population has experienced some form of trauma. An estimated one in four children have experienced some form of abuse; the same ratio of women have experienced domestic violence. One in five women and one in seventy-one men have been raped.

For these reasons, providers should refrain from making assumptions about their patients. “We shouldn’t presume to know a patient’s gender, orientation, whether they’ve experienced trauma, or anything else,” says McDowell. “As providers, it’s our responsibility to take a complete medical history and to ask all patients how they want to be walked through an exam.”

The same approach applies to mental health. “It’s really important to screen all patients for mental health concerns,” she adds. “Yes, LGBTQ people are at risk for depression and other conditions, but so are many people in other vulnerable populations, and we often don’t know who those patients are until we ask.”

Indeed, LGBTQ patients have the same wish for their medical care as anyone else would. “At the end of the day, they want to know that you’re on their team,” says Turban, who recently asked a focus group of gender-diverse youths what they wanted their physicians to understand. “Telling them that you accept them for who they are lets them know that you aren’t rejecting them, too.”

For many providers, the greatest challenge may be getting out of their own way. “As physicians, we tend to get uncomfortable when we aren’t an expert in something. We worry that we aren’t competent and that we’ll make a mistake,” says McDowell. “Providers can take continuing medical education courses to increase their comfort and competence.

“There are so many layers to identity—culture, gender, sexual orientation, race, ethnicity, or religion—that we’ll never know everything about our patients. The most important thing isn’t to be perfect, but to be humble, curious, and willing to learn.”

Jessica Cerretani is a Boston-based writer.

Images: Gwoeii/Shutterstock (top); John Soares