LGBT Risk to Substance abuse

Concern have been expressed about the nature and extent of substance misuse or abuse in LGBT communities over the past 20 years. Studies have suggested that the rates of use are higher in comparison to the general population. The possible explanations  for substance abuse have included discrimination, minority stress and living in urban environments or no children in the household. (McCabe et al., 2010; Baiocco et al., 2010; Hoare et al.,2010). However, I believe there are various reasons that caused LGBT people to be vulnerable to substance abuse other than the aforementioned explanations.

1.      Stall and Wiley (1988) report that gay men not only use drugs more often but use a greater variety of drugs than heterosexual men. Explanation for this phenomenon include internalization of society's homophobia, nonacceptance of self, fear of coming-out, low self-esteem and lead a double life (Finnegan & McNally, 2002).

2.      Recent research also suggested that mental disorders are more common in LGBT people which they are more likely to experience psychological distress, to have thoughts of suicide and self harm (Warner et al., 2004).

3.      A UK study of gay and bisexual men identified factors associated with drug and alcohol use such as individual's sense connectedness to LGBT communities (peer pressure), mitigating social unease, alleviating loneliness or unhappiness and enabling sexual encounters (Keogh et al., 2009).

4.      Use of illicit drugs was found to be fairly common in gay and bisexual men, with half having used at least one drug in the last year. The three most common used drugs were alcohol, amyl nitrite and cannabis (Keogh et al., 2009).

5.      LGBT youth Higher rates of substance abuse and alcohol-related problems (Rivers & Noret, 2008), along with more widespread use of marijuana and cocaine than heterosexual youth and adults (Rosario et al., 2004; Ryan & Futterman, 2001). Overall, compared with heterosexual and homosexual men and women, bisexual have been found to be at higher risk for substance abuse (S. T. Russell et al., 2002).

 

References

Baiocco, R., D'Alessio, M. & Laghi, F. (2010). Binge drinking among gay and lesbian youths: the role of internalized sexual stigma, self-disclosure, and individual's sense of connectedness to the gay community. Addictive Behaviors, 35, 896-9.

Finnegan, D., & McNally, E. (2002). Counseling lesbian, gay, bisexual and transgender substance abusers: Dual identities. Binghamton, NY: The Haworth Press.

Hoare, J. and Moon, D. (Ed.) (2010) Drug Misuse Declared: Findings from the 2009/10 British Crime Survey. Home Office Statistical Bulletin 13/10. Retrieved October 17, from  http://www.homeoffice.gov.uk/rds/pdfs10/hosb1310.pdf

Keogh. P., Reid, D., Bourne, A., Weatherburn, P. Hickson, F. Jessup, K. and Hammond, G. (2009). Wasted opportunities: Problematic Alcohol and Drug Use among Gay men and Bisexual Men. London: Sigma Research.

McCabe, S.E., Bostwick, W. B., Hughes, T. L., West, B. T. and Boyd, C. J. (2010). The relationship between discrimination and substance use disorders among lesbian, gay, and bisexual adults in the United States. American Journal of Public Health, 100, 1946-52. 

Rivers, I., & Noret, N. (2008). Well-being among same-sex and opposite-sex-attracted youth at school. School Psychology Review, 37, 174-187.

Rosario, M., Schrimshaw, E., & Hunter, J. (2004). Predictors of substance use over time among gay, lesbian, and bisexual youths. An examination of three hypotheses. Addictive Behaviors, 29(8), 1623-1631.

Russell, S.T., Driscoll, A.K., & Truong, N. (2002). Adolescent same-sex romantic attractions and relationships: Implications for substance use and abuse. American Journal of Public Health, 92, 198-202.

Ryan, C., & Futterman, D. (2001). Social and developmental challenges for lesbian, gay, bisexual youth. SIECUS Report, 29(4), 5-18.

Stall, R., & Wiley, J. (1988). A comparison of alcohol and drug use patterns of homosexual and heterosexual men. Drug & Alcohol Dependence, 22, 63-73.

LGBT Risk to Mental Disorders

 

It is no doubt that LGBT individuals encounter many steep challenges in their lives. Social stigma, prejudice, discrimination, violence and abuse against LGBT in the mainstream society is the primary challenge they face in their daily life. Furthermore, secondary challenges like rejection of friends and family, being deemed unwelcome by their faith community, bullying and harassment at school and workplace, inequitable legal rights and the risk for harm is enormous (Goldman, 2008). Ryan et al. (2009) report that family and community rejection of LGBT youth, including bullying, can have profound and long-term impacts (e.g., depression, use of illegal drugs, and suicidal behavior).

The removal of homosexuality as mental disorder from DSM II in 1973  did not significantly reduce the stigmazation, prejudice and discrimination towards LGBT, this problem we could probably contribute to the weak public education on LGBT issues. People continue to be homophobic and misunderstand LGBT  as sexually immoral and inappropriate behavior.  

LGBT studies also showed  that LGB people have higher risk, higher prevalence of mental disorders than heterosexual people with the enormous pressures of living in a society that discriminates against them, historical antigay stance and the stigmatization of LGB persons (Bailey, 1999). Some studies suggest that mood, anxiety and substance abuse disorder are likely to be influenced by the effects of oppression and stigma (Dohrenwend, 2000; Markowitz, 1998). Vulnerable and stigmatized groups in general has higher rates of mental illness often result from coping with stigma-related stress. Furthermore, homosexuals and bisexuals are particularly vulnerable to harassment and other forms of risk, further compounding their stress (Mishna et al., 2008). For person who is as both LGBT individual and mental patient, they will be considered  as "the minority within sexual minority" and this "double stigmazation" will further exacerbate his or her mental health condition.

Furthermore, several studies have been published to explain how stigma, prejudice, and discrimination create a hostile and stressful social environment for that causes mental health problems in LGBT group (Meyer, 2003).

You could refer to this link http://www.ncbi.nlm.nih.gov/pmc/articles/pmc2072932/ for more details.

In this blog, I will share findings on the prevalence and risk of mental illness in LGBT people and hope that with these findings and sharing, mainstream public could be aware of the serious consequences they have created by imposing social stress, discrimination and prejudice on LGBT individuals.

If we could embrace the diversity in human regardless of their race, ethnicity, sex and country;why couldn't we embrace the diversity of sexuality in human as well?

References

Bailey JM (1999). Homosexuality and Mental Illness. Arch Gen Psychiatry, 56(10): 883-4.

Dohrenwend, B. P. (2000). The role of adversity and stress in psychopathology: Some evidence and its implications for theory and research. Journal of Health and Social Behavior, 41(1, 1-19.

Goldman L. (2008). Coming Out, Coming In: Nurturing the Well-being and Inclusion of Gay Youth in Mainstream Society. New York: Routledge.

Markowitz, F. E. (1998). The effects of stigma on the psychological well-being and life satisfaction of persons with mental illness. Journal of Health and Social Behavior, 39(4), 335-347.

Meyer, IIan. H (2003) Prejudice, Social Stress, and Mental Health in Lesbian, Gay, and Bisexual Populations: Conceptual Issues and Research Evidence. Retrieved October 12, 2012 from http://www.ncbi.nlm.nih.gov/pmc/articles/pmc2072932.

Mishna, F., Newman, P.A., Daley, A. & Solomon, S. (2008). Bullying of lesbian and gay youth: a qualitative investigation. British Journal of Social Work, 39, 1578-1614.

Ryan C, Huebner D, Diaz RM, & Sanchez J. (2009). Family Rejection as a Predictor of Negative Health Outcomes in White and Latino Lesbian, Gay, and Bisexual Young Adults. Pediatrics, 123, 346–352.

Treament of Gender Identity Disoder (GID)

Hormone therapy and psychotherapy have been used to help some people with this disorder to adopt the gender role they believe represents their true identity. For others, however, this is not enough, they might choose to undergo one of the most controversial practices in medicine : Sex Reassignment Surgery (SRS), in which the person' genitals are changed to match the gender identity.  This surgery is preceded by one to two years of hormone therapy. The operation itself involves, for men, amputation of the penis, creation of an artificial vagina, and face-changing plastic surgery. For women, surgery may include bilateral mastectomy, hysterectomy and phalloplasty. Clinicians have heatedly debated whether surgery is an appropriate treatment for GID. Some consider it a humane solution, perhaps the most satisfying one to people with the disorder (Cohen-Kettenis &Gooren, 1999). Others argue that transsexual surgery is a "drastic nonsolution" for a largely psychological problem. The long term psychological outcome of surgical sex reassignment is not clear. Some people seem to function well for years after such treatment, but others experience psychological difficulties (Lewins, 2002; Michel et al., 2002)

 

My experience with LGBT

In term of my personal experience, I have a few transman friends who have gone SRS, they  function well in their social and occupational life, some even hold managerial position in the organization.  They did admit that this was a difficult journey, however, the satisfaction  they gain from being in their true identity is indeed worth living for them.

James and Jan - Feeling like a woman trapped in a man's body, the British writer James Morris (top) underwent Sex Reassignment Surgery, described in his 1974 autobiography, Conundrum. Today Jan Morris (bottom) is a successful author and seems comfortable with her change of gender

References

Cohen-Kettenis, P. T., & Gooren, L. J. (1999). Transsexualism: A review of etiology, diagnosis and treatment. J. Psychosom. Res., 46(4), 315-333

Comer, R.J. (2007). Fundamentals of Abnormal Psychology (5th ed). New York: Worth Publisher

Lewins, F (2002). Explaining stable partnerships among FTMs and MTFs: A significant difference? J. Sociol, 38(1), 76-88

Michel, A., Ansseau, M., Legros, J.-J., Pitchot, W., & Mormont, C. (2002). The transsexual: What about the future. Eur. Psychiat., 176(6), 353-362

Gender Identity Disorder Etiology

Prevalence of Gender Identity Disorder (GID)

We discussed previously that GID is a disorder in which a person persistently feels extremely uncomfortable about his or her assigned sex and strongly wishes to be a member of the opposite sex.

These disorder are rare in comparison to most of the other mental disorders. Male-to-female transexuals are more common than female-to-male transexuals. Men with GID outnumber women by around 2 to 1. Some studies estimate the prevalence to be approximately 1:12,000 in males and 1:30,000 in females (Olsson & Moller, 2003. Overall, the prevalence of GID ranges from 0.003% to 3% in boys and 0.001% to 1.5% in girls (Bartlett, et al., 2000).

Gender Identity Disorder Etiology

 Very little is known about their etiology of GID. Cause is largely unknown, however, various theories have been proposed to explain this disorder, but research to test the ideas has been limited and generally weak. For instance, theorist have suggested that GID is the result of an absent father (Stoller, 1979), a mother being enmeshed with her son ( Loeb and Shane, 1982), the parents wishing they had had a child of the opposite sex (Green, 1974), or transsexuals had more feminised 2D:4D ratios finger length(Schneider et al. 2006). After reading several research regarding the etiology of GID, I found that the biological factors play a crucial role in this disorder. Here are some research that support the biological proposal:

1)Hormonal influences

There are some research pointed out that gender identity is strongly influenced by sex hormones , especially during the prenatal period (Diamond, 2009). Early reports suggested that plasma testosterone was lower in MtF transsexuals when compared to heterosexual men (Starká et al., 1975) and higher in FtM transsexual when compared to heterosexual women (Spiová and Starká, 1977). In addition, there is an interesting set of data comes from studies of people with a condition called pseudohermaphroditism. Individuals with this condition are genetically male, but they are unable to produce hormone that is responsible for shaping the male genital in the fetus. Therefore, the child is born with external genitalia that are ambiguous in appearance. Many of these children are raised as girls by their families , when they reach puberty, a sudden increase in testosterone leads to dramatic changes in the primary sexual characteristic of the adolescent's such as clitoris become enlarged and turns into penis, deeper voice, increasing muscle mass and etc. The child quickly begins to consider himself to be a man. The speed and apparent ease that these children adopt a masculine gender identity suggest that their brains had been prenatally programmed for this alternative (Hines, 2004)

2) Brain correlational studies

One biological has received considerable attention (Zhou et al., 1995). This research was to examine the sex difference in the human brain and its relation to transsexuality. Dutch investigators autopsied the brains of six people who had changed their sex  from male to female (MtF). They found that the transsexuals' bed nucleus of stria terminalis of the hypothalamus (BST) was only half as large in these subjects as it was in a control group of normal men (generally, woman's BST is much smaller than a man's). Scientist do not know the function of BST in humans but they know that it helps control sexual behaviour in male rats. This research proposed that men who develop GID have a key biological difference that leaves them very uncomfortable with their assigned sex characteristics.

3) Bruce/Brenda and David Reimer  (A case of a Boy being raised as a Girl)

In 1967, a Canadian couple brought their two identical twin boy (8 months old) to the hospital for routine circumcisions. A surgical mistake during one of the twin's circumcisions resulted in the destruction of his penis. The couple met with Dr.John Money, a well-known medical psychologist who believed that gender was learned and could be changed through child rearing. After meeting with Dr.Money and discussing their options, the couple decided to have their son, Bruce, undergo castration and have surgery to transform his genitals into those of an anatomically correct female. Bruce became Brenda and was raised as a girl. She was put on hormone treatment beginning in adolescence to maintain her feminine appearance.

For many years, this Brenda/Bruce case stood as "proof" that children were psychosexually "neutral" at birth and that gender could be assigned , no matter what the genetic or biology indicated. However, no one paid much attention to the fact that Brenda was struggling against her girlhood and  gender identity from the beginning. Once Brenda reached puberty, despite her hormone treatments, her misery increased. She became depressed and suicidal. She never felt that she was a girl, and she was relentlessly teased by peers. Her parents finally told her the truth, and at 15 years old, she stopped hormonal treatment and changed her name to David.

Soon afterward, David went public with this medical story in hopes of discouraging similar sex assignment (especially nonconsenting minors) and published his real-life story in a book called As nature Made Him: The Boy Who Raised as a Girl. This book, in conjunction with interview with David, influenced medical understanding about the biology of gender.

Although David eventually married and adopted children, his struggles with depression continued. In 2004, at age 38, David committed suicide.

These are the links of YouTube video where you could watch the interview with David Reimer (Part 1 to Part 5)

1) http://www.youtube.com/watch?v=3GhbVFjIaN0

2)http://www.youtube.com/watch?v=noqRhuE8_XA&feature=related

3) http://www.youtube.com/watch?v=5ctg3poxT9g&feature=relmfu

4) http://www.youtube.com/watch?v=Fnb3EwJtsDs&feature=relmfu

5) http://www.youtube.com/watch?v=2OeITsQgKns&feature=relmfu

I always feel downhearted whenever I read through David's story. His life became a tragedy because of our poor medical understanding about the biology of gender and gender identity. From his case, we might conclude that gender is innate and cannot be overridden by nurture or social learning. Indeed, more research should be done to find out the biology of gender as well as etiology of GID  to prevent another tragedy from happening. Research could also benefit psychology clinical practice in terms of the diagnostic assessment and treatment plan.

References

Carroll JL. (2010). Sexuality Now: Embracing diversity (3rd ed). Belmont: Wadsworth Cengage Learning.

Bartlett, N.H., Vasey, P.L., Bukowski, W. (2000). Is gender identity disorder in children a mental disorder. Sex Roles, 43(11-12), 753-785.

Diamond, M. (2009). Clinical implications of the organizational and activational effects of hormones. Hormones and Behavior, 55, 621-632

Green R (1974). Sexual Identity Conflict in Children and Adults. New York: Basic Books.

Hines, M. (2004). Psychosexual development in individuals who have female pseudohermaphroditism. Child and Adolescent Psychiatric Clinics of North America, 13, 641-656

Loeb L and Shane M (1982). The resolution of a transsexual wish in a five-year-old boy. Journal of the American Psychoanalytic Association 30: 419-434.

Olsson, S., & Moller, A. R. (2003). On the incidence and sex ratio of transsexualism in Sweden, 1972-2002. Archives of sexual behaviour, 32, 381-386.

Schneider HJ, Pickel J, & Stalla GK (2006). Typical female 2nd-4th finger length (2D:4D) ratios in male-to-female transsexuals - possible implications for prenatal androgen exposure. Psychoneuroendocrinology 31: 265-269.

Spiová L,  Starká L (1977). Plasma testosterone values in transsexual women. Archieves of Sexual Behaviour 6:477-481.

Starká L, Spiová L, & Hynie J (1975). Plasma testosterone in male transsexuals and homosexuals. Journal of Sex Research 11: 134-138.
Stoller RJ (1979). Fathers of transsexual children. Journal of the American Psychoanalytic Association 27: 837-866.

Zhou JH, Hofman MA, Gooren LJ, and Swaab DF (1995). A sex difference in the human brain and its relation to transsexuality. Nature 378: 68-70

Gender Identity Disorder (GID) and Trangender

One of the most fascinating disorder related to sexuality is gender identity disorder (GID), a disorder in which a person persistently feels extremely uncomfortable about his or her assigned sex and strongly wishes to be a member of the opposite sex. Also known as transexualism or gender dysphoria.  Based on DSM IV-TR, the diagnostic criterion are as following:

1. Characterized by a strong, persistent cross gender identification and discomfort with one’s biological sex.
2. Persistent discomfort with one’s sex or a sense of inappropriateness in the gender role of that sex (preoccupation with getting rid of primary and secondary sex characteristic or belief one was born the wrong sex
3. Significant distress and impairment

However, we should distinguish GID from transvestic fetishism(transvestism) and sexual orientation. Transvestism is a form of paraphilia in which heterosexual man dresses in the clothing of the other gender in order to become sexually aroused.  In contrast, GID individuals dress in opposite sex clothing as an expression of gender identity, and they are not sexually aroused by cross-dressing.

Furthermore, the relation between gender identity disorder and sexual orientation has been controversial. Some clinicians suggested that transexuals are homosexuals who claim to be member of the other gender as a way to avoid criticism and stigmatization from the  community that discourage sexual relationship with members of their own sex. However, this proposal doesn't make sense for two reasons.

First, lesbian, gay and bisexual are not uncomfortable with their own identity.

Second, laboratory studies suggest that transsexual and homosexual subjects exhibit different patterns of sexual arousal in response to erotic stimuli.

For the first reason, this issue is rather complex to discuss. The research on relation of GID and LGB group is rather scarce. From my opinion, self-identified transgender individuals are most likely related to  GID.  Reason being transgender individuals are uncomfortable with their own gender identity (they might or might not want to go through the sex reassignment surgery (SRS)), whereas most LGB individuals are comfortable with their identity.

Let me share two real life examples  with you and I hope that through this two examples you could better appreciate the complexity of transgender identity.

1) One of my gay couple friends informed me that they are going to get married next year and invited me to their wedding celebration.  One of my heterosexual friends *David was invited to their wedding as well. David and I had a discussion one time regards this good news. However, I was surprised with a question asked by David and I found the question really hilarious. He asked me "Will either one of them wear gown in their wedding day?". People always assume a female and male relationship in LGB couple and either one of the parties would like to change their gender identity,  but it is definitely not true for all LGB couples. This gay couple friends of mine are comfortable with their identity and sexual orientation, and they would dress in their best suit (maybe tuxedo as what he told me) in their wedding day.

2) A lesbian couple, *Janet and *Crystal  came for couple therapy and counselling. Their relationship was doomed for months due to the fact that Janet has gone for SRS [female-to-male (FTM)] , and Crystal was struggling with how to continue and sustain their relationship with Janet's new gender identity. Crystal explained that she was extremely uncomfortable with Janet's male identity and she feel disgusted with the new "male" body. Moreover, Janet was glad that she finally could get her sex reassigned but she was upset that Crystal was not happy of her new identity. From this example, we could understand that Crystal only would like to have a relationship with female, NOT a male. Janet's new male identity has placed their relationship at risk. Thus, we could see that not all lesbian relationship has femme and butch dynamics as what the stereotype suggested. From my opinion, I would agree that Janet had GID and she was relieved from the distress by being a male. However, Crystal did not has issue with her female identity and sexual orientation as a lesbian, and most importantly she has no desire to be the member of opposite sex.

*not their real name for confidentiality purpose

I hope that this two examples could illustrate and support my view that not all LGB individuals are related to GID. However, there could be co-occurrence between GID and homosexuality but we shouldn't  generalize that all LGBT individuals have GID.

According to Browne & Lim (2008), transpeople felt strongly that their mental health problems were not caused by their gender identity, but by the lack of social support, isolation and transphobic responses in everyday life. We have to note that society (or heterosexual authority figure I guess) might medicalising or pathologizing trans identities with diagnosis of GID for social control. Labelling them as mentally ill could effectively reduce their autonomy and human /legal rights.

Transgender identity is rather more complex than LGB group, the table below show the details of how transgender identify themselves regards of  their sexual orientation and gender identity.

Sexual Preferences		Sexual Orientation
		Homosexual	Heterosexual	Bisexual
Gender Identity	MTF (Male to Female)	Women (lesbian)	Men	Men and Women
	FTM (Female to Male)	Man (Gay)	Women	Men and Women

 For example, a MTF transwoman would identify her as heterosexual when she has a relationship with man, whereas she would identify herself as lesbian if she is in love with women.
 

Is being transgender a mental disorder?

Though I mentioned that transgender individual could be more related GID, but I have to emphasize that NOT all transgender individuals experience their transgender feelings and traits to be distressing or disabling( a very important criteria in DSM IV) If some transgender individual do find their transgender feelings to be distressing and impair their social functioning, and they also meet other DSM diagnostic criterion as mentioned above as well as they have reached puberty, a GID diagnosis might be given. However, this diagnosis is again highly controversial among mental health professionals and transgender people. Some contend that the diagnosis inappropriately pathologies gender variance and should be eliminated. Some LGBT activist also argue that GID is used as a stigmatizing and pathologizing diagnosis by the authority to control and dictate the live of gender-different person. On the other hand, because the health care system in the United States requires a diagnosis to justify medical or psychological treatment (for example, transgender people will only be allowed to do SRS if they are diagnosed GID),it is essential to retain the diagnosis to ensure access to care.  So what is your stand on this?

What kind of mental health problems do transgender people face?
In general, LGBT group has increased risk for certain mental health problems such as substance abuse, mood disorder and suicidal attempts and etc. However, the stigma, discrimination, and internal conflict that many transgender people experience could be  more intense than other LGB people. For example, many transgender people are the targets of hate crimes, and many of them can be denied employment due to their "uncommon" gender identity or gender expression. One of my previous transgender clients has been unemployed for the last 5 years because the employer could not accept her MTF appearance while most of my LGB friends and clients could still be employed and hold  high job position in the organization. So transgender is the "minority within the minority group", the discrimination and lack of social support can exacerbate mental health problems in transgender people

I also attached two videos that illustrate transgender employment discrimination in US for your reference. A lawsuit might be filed if you discriminate transgender people, beware if you are employer!

Transgender Employment Discrimination 1

Transgender Employment Discrimination 2

I will continue with the causes, prevalence and treatment for Gender Identity Disorder tomorrow.

References

APA (American Psychiatric Association). (1994). Diagnostic and statistical manual of mental disorders (4th ed). Washington, DC:  Author.

 

APA (American Psychiatric Association). (2006). Answers to your questions about transgender individuals and gender identity. Washington, DC: Author.

Browne, K & Lim, J. (2008a). Count me in Too: Mental Health. Brighton: Spectrum.

Choong B. (2011). Handling sexuality issues. Singapore: Oogachaga.