Creating Connections: Training Competencies for Practitioners Supporting Traumatized LGBTQ+ Youth

Stephany Pinales & Mariah Montgomery Stickley

In 2020, approximately 9% of adolescents between 13 and 17 years of age identified themselves as lesbian, gay, or bisexual, while nearly one percent of the population surveyed (.73%) identified as transgender (Bowleg, 2020). Considering the social, cultural, and spiritual influences placed upon youth in their development, these numbers should be used as an approximation. Lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+) adolescents experience higher rates of mental health disorders in comparison to their heterosexual peers (Russell & Fish, 2016). Literature indicates LGBTQ+ individuals also report higher adverse childhood experiences (ACEs) than their heterosexual peers (McCormick et al., 2018; Merrick et al., 2018) and experience higher lifetime rates of posttraumatic stress disorder (PTSD) as a result of their sexual or gender minority status (Alessi, 2013; National Resource Center for Mental Health Promotion and Youth Violence Prevention, 2019). Historically, the field of psychology has contributed to such stressors by pathologizing sexual and gender minority-identifying persons, increasing the importance of our commitment to affirming and culturally competent psychological services. In support of this aim, this article briefly reviews the available literature and future considerations for trainees and practitioners providing trauma care to LGBTQ+ youth.

A documented declining age of “coming out” among LGBTQ+ youth now overlaps with adolescence (Fish, 2020). Russell & Fish (2016) pose that coming out is associated with positive adjustment in adults but is a risk factor for youth. When considering contributions and unique challenges for youth, the 2015 National School Climate Survey report by the Gay, Lesbian & Straight Education Network (GLSEN) reported approximately 85% of LGBTQ+ adolescents have experienced verbal abuse, 27% were physically harassed, and 13% were physically assaulted while in high school (Pizmony-Levy & Kosciw, 2016). Sexual minorities are recognized as experiencing higher exposure to traumatization; LGBTQ+ people are exposed to traumatic life events such as hate crimes, violence, and sexual assaults at higher rates (Marchi et al., 2023). Similarly, internalized homophobia has been identified as predictive of PTSD symptom severity in LGBTQ+ persons with a trauma history (Gold et al., 2011). These findings are supported by foundational frameworks such as the minority stress theory (Meyer 1995, 2003), which posits that sexual minorities experience distinct chronic stressors related to their stigmatized identities.

In addition to interpersonal challenges, LGBTQ+ youth also navigate systemic barriers that exacerbate their vulnerability to potentially traumatic events as well as exposure to chronic stressors. Manifestations of these barriers are observed at national and state policy levels for sexual and gender diverse youth across cultures. This is evident through laws prohibiting same-sex marriage as well as the criminalization of same-sex acts, practices, and gender expression. Structural stigma can also be observed through policies prohibiting change of gender or sex on identification cards and legal requirements (Earnshaw et al., 2024). As such, pediatric providers must acknowledge the potential impact of increased opportunities for youth to experience rejection, stigmatization, and discrimination, in addition to other potentially traumatic events. These systemic and structural barriers to safety should also be considered in case conceptualization and treatment planning.

Recent studies have applied Meyer’s minority-stress theory (2003) to investigate the risk of developing PTSD in LGBTQ+ individuals, attributing increased risk to unique stressors linked to their minority identity (Binion & Gray, 2020). Constructs linked to minority stress, including rumination, perceived burdensomeness, and rejection sensitivity, are especially relevant in cases of trauma related to abandonment (Russel et al., 2016; Baams et al., 2015). Studies also highlight the mediating role of internalized heterosexism (IH) in this relationship, aligning with contemporary PTSD models emphasizing the significance of emotions like guilt and shame in the development and maintenance of the disorder (Budden, 2009; Straub et al., 2018; Stickley et al., 2023). While the majority of these studies were conducted with adult populations, they shed light on the minority stress process and potential points of intervention for pediatric providers.

In clinical application, practitioners are encouraged to consider the individual needs and experiences of traumatized LGBTQ+ youth when using manualized treatments. Providers can also leverage the constructs outlined in theories such as minority stress theory to bolster therapeutic outcomes (e.g., perceived burdensomeness and IH). For example, attempts to decrease perceived burdensomeness may include encouraging clients to increase their social involvement (e.g., joining clubs, sports, or other groups with peers that are a safe and affirming environment). Addressing IH may entail the integration of the patient’s unique socio-cultural values and beliefs (e.g., spirituality) into the provider’s conceptualization of trauma-related cognitive distortions (see Stickley et al., 2023 for an overview). The role of caretakers also plays a vital role in minority stress; a positive and supportive adolescent-parent relationship can significantly contribute to decreasing symptoms of depression and suicidality (Diamond et al., 2011). Practitioners must also caution against pathologizing or attempting to change clients of sex and gender minorities. McCormick and colleagues (2018) pose that the perception of physical and emotional safety is compromised when considering the trauma and secondary challenges (financial, social, and emotional) that often accompany traumatic experiences.

The use of trauma-informed practices can vary depending on the setting, structure, and organization. However, recommendations include protecting privacy and confidentiality, being aware of the client’s body language, considering the identity of adults interacting with youth, and considering cultural norms when greeting and questioning youth and their families (National Resource Center for Mental Health Promotion and Youth Violence Prevention, 2019). Practitioners should remain current with professional guidelines to minimize potentially traumatizing or re-traumatizing practices and ensure quality care. Practices and considerations within this realm include trauma around coming out or difficulty disclosing the traumatic event for those who have not yet disclosed their LGBTQ+ status (Stickley et al., 2023). Trauma-informed clinicians are encouraged to make use of banners, books, or other observable markers of support toward gender and sexual minority populations as a symbol of allegiance. Additionally, inquiring about preferred pronouns may allow youth to disclose and set a precedent for an accepting and affirming approach. Additional clinical techniques and considerations can be found through the National Resource Center for Mental Health Promotion and Youth Violence Prevention (2019).

The American Psychological Association (APA) has supported movements for treating clients with equity and respect. Specifically, gender and sexual minority topics in workshops and conventions have been included, and relevant resources and guidelines are available for APA members. To become accredited by APA, psychology doctoral programs must adopt a curriculum that fosters the development of the nine profession-wide competencies. Within these competencies, individual and cultural diversity, as well as legal and ethical standards, are especially relevant. However, it is essential to note that implementations of these standards are individual and subjective to each program. Additionally, students seeking a mental and behavioral health career may not be enrolled in an APA-accredited graduate program. These factors contribute to considerable variability in quality, preparedness, and understanding of appropriate services by providers.

In conclusion, the multifaceted challenges faced by traumatized LGBTQ+ youth underscore the critical need for tailored, comprehensive interventions and robust training in cultural competence. This article represents only a brief overview of the existing literature exploring mental health outcomes and treatment recommendations for LGBTQ+ youth. Practitioners are encouraged to adopt trauma-informed practices, protect privacy and confidentiality, and be mindful of cultural norms when interacting with LGBTQ+ youth and their families. By creating affirming environments and actively engaging with clients’ unique socio-cultural values and beliefs, practitioners can foster healing and resilience among traumatized LGBTQ+ youth.

STEPHANY PINALES (she/her/hers) is a bilingual master’s level school psychologist and doctoral student in the school psychology program at Texas A&M University. In her academic and professional career, Stephany has collaborated with multidisciplinary teams in schools, clinics, and behavioral health centers to provide culturally and linguistically diverse interventions to youth and their families. As a student, Stephany’s research and clinical interests include providing diverse trauma-based interventions to youth of minority backgrounds.

MARIAH MONTGOMERY STICKLEY, PhD (she/her/hers) is a licensed psychologist and assistant professor at Texas A&M University. Dr. Stickley specializes in the treatment of PTSD in adolescent populations. Her current research focuses on refining evidence-based PTSD treatments for greater accessibility, including the use of intensive/massed treatment models. In both her clinical and academic work, Dr. Stickley strives to provide culturally competent care that honors the unique experiences and stories of her patients and participants.

Citation: Pinales, S., & Montgomery Stickley, M. (2024). Creating connections: Training competencies for practitioners supporting traumatized LGBTQ+ youth. Trauma Psychology News, 19(1), 34-37. https://traumapsychnews.com