By Cori McMahon, PsyD, NCCE
Given the societal discrimination that LGBTQIA+ individuals face, behavioral health struggles are deeply rooted in the community. Post-traumatic stress disorder (PTSD) is prevalent among gender and sexual minorities (GSM), stemming from the physical, mental, and emotional threats they too often experience. During PTSD Awareness and Pride Month, we’re examining the longstanding connection between the disorder and LGBTQIA+ identities, and how providers can help to address the community’s complex trauma.
How is the LGBTQIA+ community affected by PTSD?
The Trevor Project conducted a national survey of over 40,000 GSM youth aged 13–24 across the U.S. and found that one in three respondents reported physical threats or harm in their lifetime due to their sexual identity. Twenty-nine of those youth have run away or have been homeless and/or kicked out of their homes.
Worse still, forty percent of LGBTQIA+ and over half of nonbinary youth have seriously considered suicide. Sixty-eight percent report symptoms of generalized anxiety disorder, including more than three in four transgender youth and forty-eight percent of LGBTQIA+ youth reporting that they have engaged in self-harm.
Given these unique challenges and life experiences of the GSM population, there is a higher prevalence of PTSD than among them than heterosexual individuals. In a study by Harvard School of Public Health and Boston Children’s Hospital (Harvard Gazette), researchers found higher symptoms of PTSD in sexual minorities compared with heterosexuals in their early twenties. According to lead author Andrea Roberts, the difference in PTSD prevalence already exists by age 22 when “young adults are trying to finish college, establish careers, get jobs, maintain relationships, and establish a family.”
In prior research, Roberts and her colleagues had identified a higher rate of PTSD symptoms in a group of sexual minorities aged 40–60. Considering gender and sexual minorities across all age groups, trauma is considered intrinsically linked, with a large majority (85%) experiencing verbal harassment because of sexual orientation or gender expression. In 2015, there was a 20% increase in the number of hate-related homicides of LGBTQIA+ and HIV positive individuals. Because of the impact of trauma, the transgender or gender non-conforming community sees suicide rates reaching up to 46% (No Matter What Recovery).
What are the most common types of trauma?
There are five main categories of trauma most often referenced, all of which have been reported as issues among GSM individuals:
- Community Violence
- Childhood Trauma
- Medical Trauma
- Sexual Abuse
Bullying is very common in the U.S., with 90% of all students in grades 4–8 saying they have experienced it, and approximately 64% of students are believed to not be reporting it (Education Corner). Often identified at a young age as “different,” LGBTQIA+ children face potential difficulties with parents and peers, including abuse, neglect, and violence. A recent report revealed that 77% of gender and sexual minorities have experienced a hate crime at least once in their lifetime, while events like the 2016 shooting in an Orlando night club are examples of community violence committed based on prejudice or hatred. Even when attempting to seek care, these youth can face medical trauma through continuing issues like forced conversion therapy, insensitivity to their preferred gender identity, or refusal of medical care from providers. Finally, the Human Rights Campaign reported that LGBTQIA+ individuals are also at higher risk for sexual abuse.
What is the impact of trauma and PTSD?
Trauma’s consequences are multifaceted and often long-lasting. There is potential for social, economic, physical, behavioral, and mental impact. LGBTQIA+ youth may struggle to find healthy and safe opportunities for socialization into adulthood, resulting in challenges finding a supportive community. Unfortunately, GSM adults also report that discrimination impacts job and housing opportunities. Those who have experienced multiple lifetime traumas are more likely to suffer from chronic health conditions—PTSD is linked to diabetes, cardiovascular disease, hypertension, and digestive issues, among others. Further, trauma can influence health behaviors like smoking, overeating, sexual health, and substance use. According to SAMHSA, LGBTQIA+ adults are twice as likely to experience mental health issues like depression, anxiety/panic, and high levels of chronic stress. In this instance, the natural “fight or flight” response is no longer operational, as it was exhausted over time with repeated exposure to traumatic situations.
While symptoms of PTSD vary for individuals, the most common symptoms are negative mood and thought patterns, accompanied by feelings of hopelessness or emotional numbness. Some may also experience intrusive thoughts or nightmares of a traumatic event, finding themselves triggered by certain environments, sounds, or interpersonal scenarios. Not surprisingly, PTSD can result in sleep dysfunction, social withdrawal, ability to perform school or work tasks, or conflict in relationships. As outlined in the well-known work, The Body Keeps The Score by Bessel Van Der Kolk, MD, post-traumatic stress disorder can manifest in chronic pain that causes a reciprocal pattern of symptoms exacerbating each other.
How can we implement trauma-informed care (TIC)?
PTSD in the LGBTQIA+ community is a complex issue, but a combination of psychotherapy, very focused self-care, pharmacotherapy when warranted, and the right community connections can make a difference. The concept of trauma-informed care (TIC) has, at its foundation, the recognition that traumatic events have a significant impact on an individual’s psychological health, physical well-being, social interactions, and engagement with medical care. It is focused on creating an environment where trauma-affected individuals feel safe. SAMHSA outlines five main principles for providing TIC:
- Safety: Create an environment that is physically and psychologically safe.
- Trust: Provide care with full transparency and make sure the individual understands why a given approach, intervention, or procedure is chosen and what to expect from the process. Make sure the individual feels respected.
- Collaboration: The patient’s voice and engagement in care is paramount. Development of self-help skills and building a peer support network is important.
- Choice: Individual autonomy to make decisions is essential, as is engagement of others in the treatment process. Trusted friends or family members might lend to care.
- Empower: With respect to diversity, intersectionality, and the knowledge that factors like race or ethnicity add to one’s experience as LGBTQIA+, individuals should feel supported and encouraged to pursue a healthier life.
Additionally, routine screening for trauma symptoms has provided hope for successful treatment, especially for those who are not reporting symptoms due to fear, shame, or stigma. While depression screening in primary care has increased due to regulations, trauma screening is far from routine. Upon updating an annual mental health assessment to include a digital approach to screening, the Cooper Early Intervention Expanded Care Program in Camden, NJ, learned that approximately 56% of their HIV+ population screens positive for PTSD. This number is up from 33% on a prior screening that was done face-to-face, suggesting that individuals might be more likely to respond honestly with the anonymity provided via a digital screening. As a result, more patients in need of support for trauma-related symptoms have been connected to behavioral health services.