Sexual and gender minorities (SGM) encompass members of the LGBTQ+ community as well as any individuals whose sexual orientation, gender identity, and reproductive development is considered to be outside physio-socio-cultural norms (NIH, 2019). SGM individuals are a population that is disproportionately affected by trauma, more specifically hate violence (acts of discrimination or violence based on gender, sexual orientation, race, etc.), intimate partner violence (IPV), and sexual assault.
A 2019 report by the Office for Victims of Crime found that bisexual men and women report more instances of IPV than do heterosexual and gay/lesbian individuals. Staggeringly, the lifetime prevalence of IPV for transgender individuals ranges somewhere between 24-47%. Rape and sexual assault also occur at higher rates for SGM individuals. Notably, 40% of gay men and 47% of bisexual men report sexual violence, as compared to 21% of heterosexual men. Trans individuals and bisexual women face the most alarming rates of sexual violence. Among both of these populations, sexual violence begins early, often during childhood (Human Rights Campaign, n.d.). A startling high percentage of transgender people, that is 47%, are sexually assaulted at some point across their lifespan (National Center for Transgender Equality, 2015).
Beyond these direct and overt forms of trauma, SGM individuals are disproportionately exposed to day-to-day discrimination, peer and parental rejection, unsupportive or hostile work or social environments, and unequal access to opportunities afforded to heterosexuals, including marriage, adoption and employment non-discrimination (Balsam, Rothblum, & Beauchaine, 2005). Chronic expectations of rejection, internalized homophobia, alienation, and lack of integration with the community can understandably lead to problems with self-acceptance (Hatzenbuehler, 2009; Meyer, 2003). As a result, SGM male-identifying individuals are significantly more likely than heterosexual males to report experiencing mental health problems, like depression and anxiety, as well as several behavioral health risks, such as alcohol use and sex-risk behavior (Hequembourg, Bimbi, & Parsons, 2011).
SGM male-identifying sexual abuse survivors have unique health care needs that require a trauma-informed approach. Such an approach would integrate gender- and SGM-based principles, alongside a comprehensive understanding of the adverse consequences of trauma on emotional, and physical well-being. Hopton and Huta (2013) evaluated the treatment effects of a male-centered curriculum focused on gender role issues and abuse. Of the 114 men who received the treatment, there was overall improvement in depression and PTSD symptoms. The authors of this important study called for future research and programming to address treatment ambivalence in this population, promoting in particular the use of Motivational Interviewing (MI; Miller & Rollnick, 2013).
MI could help in assisting SGM men to reduce ambivalence around emotional and behavioral challenges, and to enter mental health treatment. MI is an evidence-based, patient-centered approach that explores and develops patients’ motivation and commitment to change within a collaborative, highly empathic patient-clinician relationship. Clinicians blend a combination of fundamental patient-centered counseling techniques (e.g., reflective listening) with advanced strategic methods (e.g., developing discrepancies between important life goals and current behavior) to elicit patient statements that favor change, called “change talk,” and diminish those that argue against change, called “sustain talk.”
Peer-based support might be another way of reducing ambivalence towards mental health support. The use of mutual self-help groups (e.g., 12-step groups) have been widespread for many years. Peer specialists, individuals who identify as members of the community and have a shared connection, are those individuals who are recruited and trained to deliver psychological treatments and act as paraprofessionals, Research indicates the utilization of peer specialists in formally delivering mental health interventions within service systems can improve client engagement in treatment (Davidson, Bellamy, Guy, & Miller, 2013) along with numerous other advantageous outcomes, such as increased feelings of acceptance by others and decreased stigma (Repper & Carter, 2011). While there is a great increase in the use and role of peer specialists in delivering mental health interventions, it is still not standard treatment for trauma-related disorders.There is some work showing that peer support can also facilitate positive outcomes for trauma-specific evidence-based treatment (Leamy, Bird, Le Boutillier, Williams, & Slade, 2011).
Applying MI When Working with SGM Trauma-Survivor Clients
Miller and Rollnick (2013, p. 29), define MI as “a collaborative, goal-oriented style of communication with particular attention to the language of change. It is designed to strengthen personal motivation for and commitment to a specific goal by eliciting and exploring the person’s own reasons for change within an atmosphere of acceptance and compassion.”
MI actively works against a hierarchical relationship and power imbalances. More specifically, it means asking open-ended questions that are free of bias or microaggressions. For example, “What has your transition been like?” as compared to a question with biased judgment, “Your transition must have been hard especially since you’re a daycare provider working with young children, no?” The latter connotes a judgment that it is less acceptable for daycare providers to transition, as well as implies that he might be part of the vampire myth and likely to abuse the children he is caring for, although that may not be the clinician’s intent. Asking open-ended questions that allow for the client to fill in their experiences is paramount to building a collaborative relationship. Affirming the person’s positive aspects and the full intersectionality of their many identities is essential to helping the client feel seen, understand, and cared for in the therapy room. Statements like, “As a parent, you’re working hard to protect your children from being bullied” are more affirming than “As a lesbian, you’re working hard to protect your children from being bullied”.
Additionally, MI focuses on the client’s motivations, which also means clients define their problems, issues, or difficulties without the judgment from a practitioner. Therapists can be mindful to not superimpose their own belief system on clients, focusing on open-ended questions of “what brings you here today?” versus something akin to “you noted that you were gay on the intake form, is that what brings you to therapy?” The former question allows for the client to share the intersectionality of their identities in a way that is self-defined, initiated, and expressed.
MI is also a strengths-based perspective that focuses on empowerment and resiliency. Practitioners employing this style reflects back what clients are doing, have done successfully, and what clients believe they are capable of accomplishing, rather than focusing on what they have not yet done, have been unsuccessful in doing, or believe they cannot accomplish. Further, the model emphasizes core strengths and values inherent in the person, rather than deficits. This is particularly important from an affirmative care standpoint, focusing on resiliency in the face of SGM minority stress, lack of access to and inadequate resources, and stigmatization/discrimination.
Moving Forward: A Community-Based Partnership
Given what we know about the need for trauma-specific, gender-based services for SGM male-identifying individuals, and the power of MI and peer-delivered services, we have partnered with MaleSurvivor, a non-profit organization that is focused on helping men with sexual abuse/assault histories heal, to refine MI to meet the unique needs of this population.
We are conducting a randomized controlled trial comparing two versions of MI to enhance treatment engagement, and reduce depression and anxiety, in SGM male-identifying sexual abuse survivors. Groups are 1.5 hours, meet for 6 consecutive weeks, and are facilitated by 20 peer leaders who were extensively trained in peer-based work, trauma-informed principles, and MI.
To read more about this innovative study please see https://peersformenshealthstudy.com
Given the prevalence of sexual trauma in the lives of men and more specifically sexual and gender minority male-identifying individuals, and its well-documented connection to mental and physical health disorders, facilitating their entry into formal mental health services is imperative. Because of the high level of poly-victimization among male survivor populations, this research is also expected to generate insights generalizable across multiple forms of trauma. In addition, given the significant increase in risk for many medical and psychiatric diagnoses for trauma survivors, this research has potential to improve understanding of barriers to trauma survivor engagement across all areas of heath care.Information garnered may also help underscore additional innovative targets for preventive interventions directed at further reducing health disparities in SGM populations.
Balsam, K. F., Rothblum, E. D., & Beauchaine, T. P. (2005). Victimization over the life span: A comparison of lesbian, gay, bisexual, and heterosexual siblings. Journal of Consulting & Clinical Psychology, 73(3), 477-87.
Cicchetti, D., & Lynch, M. (1993). Toward an ecological/transactional model of community violence and child maltreatment: Consequences for children’s development. Psychiatry, 56(1), 96-118.
Davidson, L., Bellamy, C., Guy, K., & Miller, R. (2013). Peer support among persons with severe mental illnesses: A review of evidence and experience. World Psychiatry, 11(2),123-8.
Elhai, J. D., North, T. C., & Frueh, B. C. (2005). Health service use predictors among trauma survivors: A critical review. Psychological Services, 2, 3-19.
Faller, K. C. (1989). Characteristics of a clinical sample of sexually abused children: How boy and girl victims differ. Child Abuse & Neglect, 13(2), 281-91.
Galdas, P. M., Cheater, F., Marshall, P. (2005). Men and health-seeking behavior: Literature review. Journal of Advanced Nursing, 49, 616-623.
Hatzenbuehler, M. L. (2009). How does sexual minority stigma “get under the skin”? A psychological mediation framework. Psychological Bulletin, 135(5), 707-30.
Hequembourg, A. L., Bimbi, D., & Parsons, J. T. (2011). Sexual victimization and health-related indicators among sexual minority men. Journal of LGBT Issues in Counseling, 5(1), 2-20.
Hopton, J. L., & Huta, V. (2013). Evaluation of an intervention designed for men who were abused in childhood and are experiencing symptoms of posttraumatic stress disorder. Psychology of Men & Masculinities, 14(3), 300-13.
Human Rights Campaign. (n.d.). Retrieved from https://www.hrc.org/resources/sexual-assault-and-the-lgbt-community
Leamy, M., Bird, V., Le Boutillier, C., Williams, J., & Slade, M. (2011). Conceptual framework for personal recovery in mental health: Systematic review and narrative synthesis. British Journal of Psychiatry, 199(6), 445–452.
Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674-97.
Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). New York, NY: Guilford Press.
Monk-Turner, E., & Light, D. (2010). Male sexual assault and rape: Who seeks counseling? Sex Abuse, 22(3), 255-65.
National Center for Transgender Equality. (2015). The report of the 2015 U.S. Transgender Survey. Retrieved from https://www.transequality.org/sites/default/files/docs/USTS-Full-Report-FINAL.PDF
National Institutes of Health. (n.d.). Sexual & gender minority. Retrieved from https://www.edi.nih.gov/people/sep/lgbti/about
Office for Victims of Crime. (2019). Intimate partner violence. Retrieved from https://ovc.ncjrs.gov/ncvrw2018/info_flyers/fact_sheets/2018NCVRW_IPV_508_QC.pdf
Repper, J., & Carter, T. (2011). A review of the literature on peer support in mental health services. Journal of Mental Health, 20(4), 392-411.
Turchik, J. A., Pavao, J., Hyun, J., Mark, H., & Kimerling, R. (2012). Utilization and intensity of outpatient care related to military sexual trauma for veterans from Afghanistan and Iraq. Journal of Behavioral Health Services & Research, 39(3), 220-233.
Dr. Joan Cook is a clinical psychologist and Associate Professor in the Yale School of Medicine, Department of Psychiatry. She has over 150 scientific publications in the areas of traumatic stress, geriatric mental health and implementation science fields. Dr. Cook has worked clinically with a range of trauma survivors, including combat veterans and former prisoners of war, men and women who have been physically and sexually assaulted in childhood and adulthood, and survivors of the 2001 terrorist attack on the former World Trade Center. She has served as the principal investigator on seven federally funded grants, was a member of the American Psychological Association (APA) Guideline Development Panel for the Treatment of PTSD and was the 2016 President of APA’s Division of Trauma Psychology. Since October 2015, she has published over 80 op-eds in places like CNN, TIME Ideas, The Washington Post and The Hill.
Dr. Amy Ellis is a licensed clinical psychologist and the Assistant Director of the Trauma Resolution and Integration Program (TRIP) at Nova Southeastern University. TRIP is a university-based community mental health center that provides specialized psychological services to individuals age 18 and above who have been exposed to a traumatic situation and are currently experiencing problems in functioning as a result of the traumatic experience. Dr. Ellis has also developed specific clinical programming focusing on trauma-informed affirmative care for sexual and gender minorities as well as gender-based services focusing on male-identifying individuals at TRIP. Dr. Ellis is involved in a variety of leadership activities within the American Psychological Association (APA), including service as a Consulting Editor for three peer-reviewed journals, and Guest Editor for Practice Innovations on a special issue dedicated to the role of evidence-based relationship variables in working with sexual and gender minorities. She is also the Editor for APA’s Division 29 (Psychotherapy) website.