Trauma, Resilience, and Health Promotion in LGBT Patients

What Every Healthcare Provider Should Know

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Preface

Prior to the preliminary definition of trauma in the Diagnostic and Statistical Manual of
Mental Disorders (DSM-III) in 1980 as a catastrophic stressor outside the range of typical
human experience, it was well understood that certain adverse experiences can cause acute
clinical manifestations. The long-term sequelae of trauma, however, were frequently
misdiagnosed as primary psychiatric disorders or unexplained physical syndromes. Trauma
research and informed care have progressed significantly since that time. For example, it is
now known that exposure to a traumatic experience can have epigenetic, neuropsychiatric, and
transgenerational effects that can persist over the course of a person’s – or their offspring’s –
lifetime. Further, what constitutes a traumatic experience is no longer narrowly defined (e.g.,
war, rape, natural disaster). Trauma is both context and person dependent, in that one
individual may experience traumatic sequelae from a specific event while another might
not. Finally, trauma may have myriad mental, physical, and behavioral effects that are not
always easily classified.
As the conceptualization of trauma diversifies, so too does the understanding of how being
identified as a member of a minority group can expose individuals to a unique set of
experiences that can be traumatic. Individuals with diverse sexual orientations, gender
identities, and expressions are more likely to experience bias, harassment, discrimination,
and violence compared to heterosexual, cisgender populations. They may also face unique
internal challenges associated with the coming out process. As suggested by the minority
stress model, the combination of these internal and external stressors can place lesbian, gay,
bisexual, and transgender (LGBT) individuals at higher risk for mental and physical health
concerns. This vulnerability may be compounded for individuals with multiple stigmatized
intersectional identities and expressions.
Fortunately, traumatic experiences are frequently paralleled by the development of coping
strategies that permit affected individuals to recover and even thrive. The ability to adapt
positively or cope with adversity – otherwise known as resilience – is difficult to measure
construct that nonetheless portends improved psychosocial function and higher quality of life.
Understanding the specific adversities experienced by different communities is a crucial first
step in the development of a resilience promotion approach. This book educates healthcare
professionals on the impact of traumas experienced by LGBT populations and outlines
strategies that can be used in the clinical encounter to facilitate recovery and resilience.
One important theme that emerges is the use of terminology. While numerous acronyms
exist to describe LGBT populations including sexual and gender minority (SGM) or sexual
and gender diverse (SGD), “LGBT” will be used throughout this text to describe individuals
with diverse sexual orientations and gender identities as this acronym is currently the most
widely used. However, at a clinical level, terminology is personal and healthcare professionals
should be well-equipped to communicate with their patients regarding sexual orientation and
gender identity using a variety of terms.
The first section of the text provides an overview of trauma in LGBT populations, followed
by a review of how resilience changes across the life span. Characteristics of resilience
development are then examined in particularly vulnerable LGBT communities, including
transgender and gender nonconforming individuals, people of color, sexual minority
v
vi Preface

women, migrant communities, and incarcerated individuals. Finally, experts in the field
present strategies clinicians can use when working with LGBT individuals to facilitate
adaptation and healthy coping.
A critical theme throughout this text is that all clinicians play a critical role in making
healthcare and the healthcare environment trauma informed. While certain specialties may
play a more specific role in treating the psychological sequelae of trauma, the myriad
manifestations of chronic stigma and trauma necessitate interdisciplinary and wide-reaching
individual, organizational, and systems changes. These changes are not arduous or cumber-
some; rather, they simply require an ongoing investment by all healthcare professionals in to
understanding, recognizing, contextualizing, and managing trauma. By addressing trauma in
LGBT communities using the strategies described in this text, we hope that not only will the
health disparities faced by LGBT communities be reduced, but that clinicians themselves can
serve as role models for the larger societal changes necessary to eliminate the stigma, violence,
and discrimination faced by LGBT individuals.
Pittsburgh, PA, USA Kristen L. Eckstrand, MD, PhD
Boston, MA, USA Jennifer Potter, MD
Contents

Part I Overview of Trauma in LGBT Populations

1 Intersection of Trauma and Identity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Edward J. Alessi and James I. Martin
2 Medical Intervention and LGBT People: A Brief History . . . . . . . . . . . . . . . 15
Sophia Shapiro and Tia Powell
3 Conceptualizing Trauma in Clinical Settings: Iatrogenic Harm
and Bias . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
Tonia C. Poteat and Anneliese A. Singh
4 Impact of Stress and Strain on Current LGBT Health Disparities . . . . . . . . . 35
Robert-Paul Juster, Jennifer A. Vencill, and Philip Jai Johnson
Part II Resilience Across the Lifespan
5 The Role of Resilience and Resilience Characteristics in Health
Promotion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
Laura Erickson-Schroth and Elizabeth Glaeser
6 Childhood and Adolescence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
Shelley L. Craig and Ashley Austin
7 Resilience Across the Life Span: Adulthood . . . . . . . . . . . . . . . . . . . . . . . . . . 75
Nathan Grant Smith
8 Older Adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89
Charles P. Hoy-Ellis
Part III Resilience in Specific Populations
9 Transgender and Gender Nonconforming Individuals . . . . . . . . . . . . . . . . . . 105
Asa E. Radix, Laura Erickson-Schroth, and Laura A. Jacobs
10 Understanding Trauma and Supporting Resilience with LGBT
People of Color . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
Anneliese A. Singh
11 LGBT Forced Migrants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121
Rebecca Hopkinson and Eva S. Keatley
12 Lesbian and Bisexual Women . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Katie Imborek, Dana van der Heide, and Shannon Phillips
13 Institutionalization and Incarceration of LGBT Individuals . . . . . . . . . . . . . . 149
Erin McCauley and Lauren Brinkley-Rubinstein

vii
viii Contents

Part IV Resilience Promotion in Clinical Practice

14 An Overview of Trauma-Informed Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . 165
Andrés Felipe Sciolla
15 Screening and Assessment of Trauma in Clinical Populations . . . . . . . . . . . . 183
Brian Hurley, Kenny Lin, Suni Niranjan Jani, and Kevin Kapila
16 Patients and Their Bodies: The Physical Exam . . . . . . . . . . . . . . . . . . . . . . . 191
Sarah M. Peitzmeier and Jennifer Potter
17 Motivational Interviewing for LGBT Patients . . . . . . . . . . . . . . . . . . . . . . . . 203
Blake E. Johnson and Matthew J. Mimiaga
18 Promoting Healthy LGBT Interpersonal Relationships . . . . . . . . . . . . . . . . . 219
Kerith J. Conron, Nathan Brewer, and Heather L. McCauley
19 Community Responses to Trauma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231
R.J. Robles and E. Kale Edmiston
20 Resilience Development Among LGBT Health Practitioners . . . . . . . . . . . . . 245
Carl G. Streed Jr. and Mickey Eliason

Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255
Contributors

Edward J. Alessi, PhD, LCSW School of Social Work, Rutgers, The State University of
New Jersey, Newark, NJ, USA
Ashley Austin, PhD, LCSW School of Social Work, Barry University, Miami Shores, FL,
USA
Nathan Brewer, MSW, LICSW Simmons College, Boston, MA, USA
Lauren Brinkley-Rubinstein, PhD Department of Social Medicine, University of North
Carolina-Chapel Hill, Chapel Hill, NC, USA
Center for Health Equity Research, University of North Carolina-Chapel Hill, Chapel Hill,
NC, USA
Kerith J. Conron, ScD, MPH Blachford-Cooper Research Director and Distinguished
Scholar, The Williams Institute, UCLA School of Law and Affiliated Investigator, The
Fenway Institute, Fenway Health, Boston, MA, USA
Shelley L. Craig, PhD, RSW, LCSW Factor-Inwentash Faculty of Social Work, University
of Toronto, Toronto, ON, Canada
E. Kale Edmiston, PhD Vanderbilt University Medical Center, Program for LGBTI Health,
Nashville, TN, USA
Mickey Eliason, PhD Faculty Development and Scholarship, College of Health and Social
Sciences, San Francisco, CA, USA
Laura Erickson-Schroth, MD, MA Mount Sinai Beth Israel, Hetrick Martin Institute,
New York, NY, USA
Elizabeth Glaeser, BS The Department of Child and Adolescent Psychiatry, NYU Langone
Medical Center, New York, NY, USA
Rebecca Hopkinson, MD Department of Psychiatry and Behavioral Medicine, University of
Washington, Seattle, WA, USA
Charles P. Hoy-Ellis, MSW, PhD, LICSW College of Social Work, University of Utah, Salt
Lake City, UT, USA
Brian Hurley, MD, MBA, DFASAM Los Angeles County Department of Mental Health,
Robert Wood Johnson Foundation Clinical Scholar, David Geffen School of Medicine of the
University of California, Los Angeles, CA, USA
Katie Imborek, MD Department of Family Medicine, University of Iowa Hospitals and
Clinics, Iowa City, IA, USA
Laura A. Jacobs, LCSW-R New York, NY, USA
Suni Niranjan Jani, MD, MPH Massachusetts General Hospital/McLean Hospital, Harvard
Medical School, Child and Adolescent Psychiatry Department, Yawkey Center for Outpatient
Care 6A, Boston, MA, USA

ix
x Contributors

Blake E. Johnson, ScM UNC School of Medicine, The University of North Carolina at
Chapel Hill, Chapel Hill, NC, USA
Philip Jai Johnson, PhD Program for the Study of LGBT Health, Division of Gender,
Sexuality, and Health, Columbia University, New York, NY, USA
Robert-Paul Juster, PhD Program for the Study of LGBT Health, Division of Gender,
Sexuality, and Health, Columbia University, New York, NY, USA
Kevin Kapila, MD Fenway Health, Fenway South End, Boston, MA, USA
Eva S. Keatley, MA Department of Psychology, University of Windsor, Windsor, ON,
Canada
Kenny Lin, MD Massachusetts General Hospital, Child and Adolescent Psychiatry Depart-
ment, Boston, MA, USA
James I. Martin, PhD, MSW Silver School of Social Work, New York University,
New York, NY, USA
Erin McCauley, MEd Department of Policy Analysis and Management, College of Human
Ecology, Cornell University, Ithaca, NY, USA
Heather L. McCauley, ScD, MS Human Development and Family Studies, Michigan State
University, Pittsburgh, PA, USA
Matthew J. Mimiaga, ScD, MPH Epidemiology and Behavioral & Social Health Sciences,
Institute for Community Health Promotion, Brown University, Providence, RI, USA
Sarah M. Peitzmeier, MSPH, PhD Johns Hopkins Bloomberg School of Public Health,
Department of Population, Family and Reproductive Health, Baltimore, MD, USA
The Fenway Institute, Boston, MA, USA
Shannon Phillips, PA-C Denver Health, Denver, CO, USA
Tonia C. Poteat, PhD, MPH, PA-C Johns Hopkins School of Public Health, Baltimore, MD,
USA
Jennifer Potter, MD William B. Castle Society, Harvard Medical School, Boston, MA, USA
Women’s Health Center, Beth Israel Deaconess Medical Center, Boston, MA, USA
Women’s Health Program, Fenway Health Center, Boston, MA, USA
Women’s Health Research, The Fenway Institute, Boston, MA, USA
Tia Powell, MD Montefiore Einstein Center for Bioethics, Bronx, NY, USA
Asa E. Radix, MD, MPH Director of Research and Education at Callen-Lorde Community
Health Center, Assistant Clinical Professor of Medicine at New York University, New York,
NY, USA
R.J. Robles, MDiv Vanderbilt University Medical Center, Program for LGBTI Health,
Nashville, TN, USA
Andrés Felipe Sciolla, MD University of California, Davis, Department of Psychiatry
& Behavioral Sciences, Sacramento, CA, USA
Sophia Shapiro, MD Emergency Medicine Department, NYUMC/Bellevue Hospital Center,
New York, NY, USA
Anneliese A. Singh, PhD Department of Counseling and Human Development Services,
The University of Georgia, Athens, GA, USA
Avondale Estates, GA, USA
Contributors xi

Nathan Grant Smith, PhD Department of Psychological, Health, and Learning Sciences,
University of Houston, Houston, TX, USA
Carl G. Streed Jr., MD General Internal Medicine & Primary Care, Brigham & Women’s
Hospital, Boston, MA, USA
Dana van der Heide, MD, MPH Carver College of Medicine, University of Iowa,
Iowa City, IA, USA
Jennifer A. Vencill, PhD Program in Human Sexuality, Department of Family Medicine &
Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
 Part I
Overview of Trauma in LGBT Populations
 Intersection of Trauma and Identity
1
Edward J. Alessi and James I. Martin

In the last four decades, lesbian, gay, bisexual, and transgender LGBT people. We will follow this discussion with the
(LGBT) people have made significant progress in gaining developmental impact of homophobia and transphobia and
social acceptance and securing legal rights in many parts of then focus on the connection between PTSD and traumatic
the world. Same-sex sexual and gender-nonconforming and non-traumatic events. Finally, we will conclude with a
behavior used to be considered morally, pathologically, and clinical case to illustrate the concepts discussed in this
legally aberrant throughout the world, but LGBT identities chapter.
are now increasingly affirmed and celebrated in many Any discussion about LGBT people must acknowledge
countries. However, the trauma that LGBT people have their extraordinary diversity. Although LGBT people are
experienced throughout history remains part of their shared often discussed as if they comprise a single population, we
identity. Moreover, even in relatively accepting parts of the understand that the experiences and identities of lesbians
world (e.g., North America, Western Europe), LGBT people may be quite different from those of gay men; those of
continue to encounter verbal abuse, physical and sexual bisexual and transgender people are likely to differ from
victimization, and structural oppression [1]. The increased lesbians and gay men even more [3]. Additionally, there
risk of experiencing such events results in a “fundamental are LGBT people in every part of the world [4], and they
ecological threat,” forcing sexual and gender minorities to have a broad spectrum of life experiences influenced not
choose between expressing their authentic selves or the only by their sexual orientation and gender identity
identities validated by society [2, p246]. Constant exposure but also by other intersecting identities, including race,
to marginalization and the frequent fear of victimization ethnicity, social class, culture, religion, age, and ability
contribute to unrelenting vigilance that may ultimately status [5–10]. The intersection of these sociocultural
become integrally linked to identity. characteristics results in highly diverse identities [11], life
The primary aim of this chapter is to describe the course trajectories [12], and experiences of privilege or
intersection of trauma and identity among LGBT people. marginalization and discrimination [4, 13]. Furthermore,
First, we will review diagnostic criteria for posttraumatic all of these identities must be taken into consideration
stress disorder (PTSD) and then discuss how current when attempting to understand how trauma impacts the
conceptualizations of trauma overlook associations between mental health of LGBT individuals.
non-traumatic events and PTSD-like disorder. Next, we will
discuss minority stress among sexual and gender minorities
and draw upon microsociological theories to understand the Traumatic Versus Non-traumatic Events
impact of the social environment on the mental health of
The term trauma is widely used in vernacular language and
commonly refers to an experience “that is emotionally pain-
E.J. Alessi (*)
School of Social Work, Rutgers, The State University of New Jersey, ful, distressful, or shocking” [14]. Traumatic experiences can
360 Martin Luther King Jr. Blvd, Hill Hall, Room 401, Newark, precipitate a myriad of psychiatric disorders including depres-
NJ 07102, USA sive and anxiety disorders, and, of course, PTSD. PTSD is a
e-mail: [email protected] commonly occurring disorder that can seriously impair an
J.I. Martin individual’s psychosocial functioning, resulting in mood
Silver School of Social Work, New York University, 1 Washington vacillations, disorganized thinking, dissociation, impaired
Square North, New York, NY 10003-6654, USA
e-mail: [email protected] judgment, hyperarousal, and the use of maladaptive coping

# Springer International Publishing AG 2017 3

K.L. Eckstrand, J. Potter (eds.), Trauma, Resilience, and Health Promotion in LGBT Patients,
DOI 10.1007/978-3-319-54509-7_1
4 E.J. Alessi and J.I. Martin

strategies [14]. In the United States, the lifetime prevalence of and importance; however, focusing solely on such events
PTSD ranges from about 6% to 9% [15–19]. Although tends to ignore the psychological impact of so-called “non-
initially categorized as an anxiety disorder, PTSD was traumatic” events [22]. The use of the term non-traumatic is
removed from the chapter on anxiety disorders and included not intended to minimize the psychological impact of these
in a new chapter on Trauma- and Stressor-Related disorders in events, but to clearly demonstrate how they differ from
the 5th edition of the Diagnostic and Statistical Manual of events considered traumatic by the DSM. Non-traumatic
Mental Disorders (DSM-5; [20]). All of the disorders in the events include major life events such as ending a marriage/
Trauma- and Stressor-Related disorders chapter account for relationship, psychological or emotional abuse, employment
the various clinical presentations that can emerge following issues, homelessness, financial concerns, nonlife-threatening
exposure to a traumatic or stressful event [21]. See Table 1.1 medical problems, and the expected death of a loved one.
for a list of Trauma- and Stressor-Related disorders in DSM-5. Ignoring the connection between non-traumatic events and
According to DSM-5, traumatic events involve “exposure symptoms that look very much like PTSD may overlook the
to actual or threatened death, serious injury, or sexual vio- suffering of many individuals and result in the use of inap-
lence” [20, p271]. Exposure to traumatic events can occur in propriate or ineffective treatment interventions [23].
one or more of the following ways: (a) directly experiencing The debate over whether events must involve threat to life
the event, (b) witnessing the event as it happened to others, or physical integrity to qualify as traumatic has existed since
(c) learning that the event occurred to a loved one, or PTSD was first introduced as a psychiatric disorder in 1980
(d) experiencing repeated or extreme exposure to aversive [24]. In our study of PTSD [23], we joined that debate by
details of the event [20]. To be diagnosed with PTSD, investigating the stressor criterion, which sets the threshold
individuals are required to have at least one intrusion symp- for the types of events qualifying as traumatic [25]. Referred
tom (spontaneous memories, nightmares, flashbacks), one to as Criterion A1 in DSM-IV, the stressor criterion defined
avoidance symptom (avoidance of distressing memories or traumatic events as those that involve “actual or threatened
external reminders of the event), two symptoms of negative death or serious injury, or a threat to the physical integrity of
alteration in cognition and mood (estrangement from others, oneself or others” [25, p427]. Although the stressor criterion
distorted sense of blame, diminished interest in activities), originated from the concept of PTSD as an expectable
and two symptoms of marked alterations in arousal and response following exposure to extraordinary events [26],
activity (difficultly sleeping or concentrating, hypervigi- it is still unclear why events that do not pose threat to life or
lance, self-destructive behavior). These symptoms must be physical integrity are excluded from the stressor criterion
present for a least 1 month following the traumatic event and [27]. Excluding these events is contradictory to what is
cause significant impairment in social and/or occupational already well established in the trauma literature—that
functioning (Fig. 1.1). reactions to stressful events are inherently subjective. More-
Studying the mental health consequences of life- over, studies consistently show that non-traumatic events
threatening events and sexual violence has obvious value can be associated with symptoms suggestive of PTSD

Table 1.1 Trauma-spectrum disorders in DSM-5

Trauma and stressor-related disorders in DSM-5 include disorders in which exposure to a traumatic or stressful event is necessary to make a
diagnosis
Reactive attachment disorder
Disinhibited social engagement disorder
Posttraumatic stress disorder
Specifiers:
With dissociative systems (depersonalization or derealization)
With delayed expression (full diagnostic criteria are not met until at least 6 months after the event)
Acute stress disorder
Adjustment disorders
With depressed mood
With anxiety
With mixed anxiety and depressed mood
With disturbance of conduct
With mixed disturbance of emotions and conduct
Unspecified
Other specified trauma and stressor-related disorder
Unspecified trauma and stressor-related disorder
1 Intersection of Trauma and Identity 5

traumatic events also emerge following non-traumatic events

[23]. Ultimately, the adjustment disorder specifier with PTSD-
like symptoms was not included, although the DSM-5 does
indicate that an adjustment disorder is “diagnosed when the
symptom pattern of PTSD occurs in response to a stressor that
does not meet PTSD Criterion A (e.g., spouse leaving, being
fired)” [20, p279]. While the adjustment disorder specifiers
account for symptoms of anxiety and depression, they do not
the capture the core symptoms of PTSD (re-experiencing,
avoidance, and hyperarousal; for a comparison of diagnostic
criteria between PTSD and adjustment disorder see
Table 1.2). Furthermore, adjustment disorders must be
diagnosed within 3 months of the onset of the stressor, and
symptoms cannot persist longer than 6 months following the
termination of the stressor [20]. In contrast, symptoms do not
have to emerge within a specific time frame to diagnose
PTSD, although a delayed expression subtype is used when
individuals do not manifest the full set of PTSD symptoms
until 6 months after the trauma [20]. Therefore, clinicians may
overlook the symptoms suggestive of PTSD following expo-
sure to a non-traumatic event, particularly if those symptoms
Fig. 1.1 Abbreviated DSM-5 diagnostic criteria for posttraumatic emerge more than 3 months following exposure to the
stress disorder stressor.

[23, 28–31]. Specifically, in these studies individuals Minority Stress

presented with the requisite number of symptoms from
each DSM-IV cluster (re-experiencing, avoidance, and The marginalized status of sexual and gender minorities
hyperarousal) to meet criteria for PTSD, although they increases their vulnerability to traumatic and non-traumatic
were exposed to a non-traumatic event. stressors; therefore, understanding the effects of PTSD and
Given the potential pitfalls of using the stressor criterion, trauma-related disorders among LGBT people is critical for
some suggested removing it from PTSD diagnostic criteria providing culturally sensitive health and mental health care.
in DSM-5 [32]. Doing so would have allowed clinicians and Prejudice related to homophobia and transphobia character-
researchers to focus on the symptoms following a stressful ize the social environment for LGBT people and precipitate
event rather than whether the event met Criterion A1. How- stressful events, commonly referred to as minority stress.
ever, others were concerned that removing the stressor crite- Meyer [35] proposed a model of minority stress in which
rion would increase PTSD prevalence and diffuse the sexual minorities encounter stress “along a continuum from
suffering of those exposed to catastrophic events such as distal stressors, which are typically defined as objective
war, natural disasters, concentration camp imprisonment, events and conditions, to proximal personal processes,
and extreme violence [33]. Arguing in favor of retaining which are by definition subjective because they rely on
the stressor criterion, Friedman [24] explained that traumatic individual perceptions and appraisals” (p676). Four specific
events are distinct from non-traumatic events because expo- minority stress processes provide the framework for Meyer’s
sure to a traumatic stressor results in discontinuity between [35] minority stress model: (a) external, objective stressful
the way individuals view themselves before and after the events, (b) the expectation of minority stress and the vigi-
event. However, exposure to non-traumatic events may also lance this expectation requires (stigma), (c) the internaliza-
result in a similar process [34]. tion of negative societal attitudes (internalized
To address the validity issues related to Criterion A1, the homophobia), and (d) sexual orientation concealment.
DSM-5 work group initially proposed adding a new adjust- Scholars initially used minority stress-based hypotheses to
ment disorder specifier that could be used when PTSD explain the higher prevalence of mental health problems
symptoms were present following exposure to non-traumatic among sexual minorities as compared to heterosexuals; in
events [23]. However, adding this specifier would not have recent years, however, minority stress theory has also been
resolved the ongoing conceptual problems because it still used to explain negative mental health outcomes among
does not explain why symptoms considered unique to gender minorities [36, 37].
6 E.J. Alessi and J.I. Martin

Table 1.2 Comparision of trauma- and stressor-related disorders in DSM-5

Acute
Posttraumatic stress stress Adjustment
Criteria for trauma and stress-related disorders in DSM-5a disorder (PTSD)b disorder disorders
Time frame
Duration of disturbance is more than 1 month ✓
Symptom duration of 3 days to 1 month after traumatic event ✓
Symptoms develop within 3 months of onset of stressor(s); when stressor and consequences ✓
cease, symptoms do not persist for more than an additional 6 months
Symptoms
Exposure to actual or threatened death, serious injury, or sexual violence (i.e., traumatic ✓ ✓
event)
Development of emotional or behavioral symptoms (e.g., anxiety, depression) in response ✓
to stressor of any severity
Intrusion symptoms associated with traumatic event ✓ ✓
Persistent avoidance of stimuli associated with traumatic event ✓ ✓
Negative alterations in cognitions and mood associated with traumatic event ✓ ✓
Alterations in arousal and reactivity associated with traumatic event (i.e., angry outbursts, ✓ ✓
reckless behavior, sleep disturbance)
Symptoms persist more than 1 month after traumatic event ✓
Significant distress or impairment in major areas of functioning ✓ ✓ ✓
Disturbance is not due to medication, substance use, developmental disability, or other ✓ ✓ ✓
disorder
a
All criteria are further specified in DSM-5; this figure is not all-inclusive, but highlights important features of each disorder
b
Separate diagnostic criteria for children and adolescents and for children age 6 or younger

To explain how particular minority stress processes influ-

ence the well-being of LGBT identities, we draw from
microsociological theorists such as Charles Horton Cooley
and Erving Goffman. Their theories were critical to the
development of Meyer’s minority stress model
[35]. Cooley’s [38] concept of the looking-glass self
suggests that the way in which individuals see themselves
is determined by how others view them. Cooley questioned
the concept of the self, since one’s feelings are always
connected to the ways in which others think about him or
her. According to Cooley, the self is really a social self
consisting of three principal components: how we imagine
our appearance to another person, the way we imagine
another person judges our appearance, and the specific
self-feeling that results from this judgment such as pride or
mortification (Fig. 1.2). Thus, the formulation of our self-
concept is dependent on the ways in which others perceive
us. Since LGBT people are likely to face discrimination
based on their sexual orientation and/or gender identity,
Cooley’s theory may help to explain why these experiences
contribute to hypervigilance, insecurity, shame, avoidance, Fig. 1.2 Visual representation of Cooley’s looking-glass self which
and self-loathing. For instance, homophobic and transphobic proposes that an individual’s sense of self develops from interpersonal
attitudes are constantly being communicated to sexual and actions with and perceptions of others
gender minority individuals. These negative societal
attitudes are then reflected onto sexual and gender minority Goffman [39], stigmatized individuals are likely to interpret
people, which in turn influence how they feel about their interactions as being undermined by the dominant
themselves. group, as they may justifiably anticipate rejection based on
Goffman’s work also increases our understanding of how their marginalized status. Consequently, they must continu-
stigma affects the lives of LGBT people. According to ally discern what others think about them [22]. Those who
1 Intersection of Trauma and Identity 7

do not adhere to heterosexual and cisgender norms are also are associated with PTSD, indicating that concealing a
therefore ascribed deviant status. The deviant is “cleanly stigmatized identity may in and of itself be traumatic
stripped of many of his [sic] accustomed affirmations, [22]. Researchers have begun to use population-based stud-
satisfactions, and defenses, and is subjected to a rather full ies to investigate the effects of concealing a stigmatized
set of mortifying experiences” [39, p365]. For LGBT people, identity, with one study revealing that women who were
mortifying experiences can include harassment and hate recently out were less likely to be depressed than closeted
crimes, alienation from family and friends, termination women, although this was not the case for men who were out
from certain types of employment, and exposure to propa- when compared to closeted men [54]. Men who were
ganda portraying LGBT persons as sick or mentally ill recently out were more likely to have major depressive
[22]. As a result of these mortifying experiences, LGBT disorder or generalized anxiety than men who were closeted,
people may have difficulty sustaining any of their previously suggesting that because of strict gender norms, men who are
assumed roles, such as student, worker, friend, spouse, or out may experience greater minority stress than women who
partner. The only role society acknowledges is the deviant are out, which in turn negatively impacts their mental health
one [40]. Essentially, mortifying experiences result in a [54]. There is limited research on the effects of concealing a
withdrawal of environmental support for LGBT people, stigma among transgender individuals, though one study of
and to cope, they may use avoidance, isolation, and/or con- transgender adults aged 50 and older showed that identity
ceal their identities, to protect themselves from further concealment explained the effect of gender identity on per-
experiences of prejudice. Although these strategies serve ceived stress, with concealment being related to higher
an adaptive function by fostering a greater sense of control, levels of stress [52].
their use may also result in feelings of disconnection, or lead
LGBT people to overestimate danger in contexts in which
they are free to express their authentic selves [41, 42]. Developmental Impact of Homophobia
Empirical research has demonstrated the relationship and Transphobia
between social stigma and negative health and mental health
outcomes among sexual minorities [43–45] as well as gender To gain a comprehensive understanding of trauma among
minorities [36, 46]. Because sexual and gender minority LGBT people we must consider the impact of minority stress
people grow up in homophobic and transphobic on childhood and adolescent development. Growing up in an
environments, they inevitably internalize these negative environment where one’s experiences of gender and sexual-
attitudes or direct them inward. When applied to lesbian, ity do not conform to societal standards contributes to
gay, and bisexual (LGB) people, these internalizations have conditions in which there is a high potential for trauma and
commonly been called internalized homophobia [47]; other identity to intersect. Studies demonstrate that sexual and
terms include internalized heterosexism and internalized gender minority youth experience high numbers of victimi-
sexual stigma (see [48]). Internalized homophobia has been zation events and that these events are associated with nega-
connected to psychological distress in this population and tive mental health outcomes such as depression [55, 56] and
has been shown to predict PTSD symptom severity in les- PTSD [57, 58]. Given the increased levels of stress encoun-
bian and gay survivors of child abuse [49] as well as sexual tered by sexual and gender minority youth, it is not
assault [50, 51]. More research is needed to understand the surprising that they have a higher prevalence of mood and
influence of internalized transphobia among transgender anxiety disorders [59] – as well as depressive symptoms and
populations [37], though emerging evidence suggests that suicidality [60, 61] – than heterosexual youth. Even sexual
internalized stigma mediates the relationship between gen- and gender minority children and adolescents who grow up
der identity and a host of negative health outcomes as well as in supportive environments must deal with structural forces
depression among transgender older adults [52]. that marginalize those who do not conform to heterosexual
Even sexual minority individuals who “pass” as hetero- or cisgender identities. Therefore, they too may be at greater
sexual must contend with the consequences of concealing risk for negative mental and physical health outcomes. In
their stigmatized status [22]. Pachankis [53] contends that fact, evidence suggests that age may be an important modi-
those who conceal their stigmatized identity must cope with fier of physical health disparities among sexual minority
the constant threat of being discovered, which leads to four individuals. A study using a general population sample in
psychological responses: cognitive (vigilance, suspicious- Sweden revealed that LGB individuals had more physical
ness, preoccupation), affective (shame, guilt, anxiety, health symptoms and conditions as compared to heterosex-
depression), behavioral (social avoidance, the need for feed- ual individuals and that these disparities differed by age,
back, impaired relationships), and self-evaluation (identity with adolescents and young adults reporting worse self-
ambivalence, negative view of self, diminished self- rated health than older individuals, indicating that minority
efficacy). Interestingly, these psychological consequences stress may be exacerbated for youth [62].