Mental Health Practice with LGBTQ+ Children, Adolescents, and Emerging Adults in Multiple Systems of Care

Cristina L. Magalhães, PhD, LMHC, is associate director and professor of clinical psychology in the Health Emphasis of the Clinical PsyD Program, Fellow of the Rockway Institute for LGBTQ Studies, and Coordinator of the Rockway Certificate in LGBTQ Psychology at the California School of Professional Psychology at Alliant International University, Los Angeles. As a clinician, Dr. Magalhães has over 20 years of experience working with couples, families, and individuals across the life span in community mental health centers, residential settings, and independent practice. She is licensed to practice as a mental health counselor in Florida, and as a psychologist in California and Rio de Janeiro, Brazil. Her research, writing, and speaking engagements have been primarily in the areas of cross-cultural assessment, anxiety and trauma related disorders, and LGBT psychology, with an emphasis on transgender health. Richard A. Sprott, PhD, teaches in the Department of Human Development and Women's Studies at California State University, East Bay and teaches graduate level courses at various universities in the San Francisco Bay Area, including UC Berkeley, the California Institute of Integral Studies, and Holy Names University. His early work was on social and language development in early childhood. In addition, he has a long history of conducting educational program evaluations for migrant farmworker families in the Midwest, which highlight the ways in which social organizations and communities help and hinder the educational achievement of migrant farmworker children. He is currently directing research projects focused on identity development and health/well-being in people who express alternative sexualities and non-traditional relationships, and issues facing homeless LGBTQ youth. He is current president-elect of Division 44 of APA: the Society for the Psychology of Sexual Orientation and Gender Diversity. All of these efforts highlight the ways in which stigma, prejudice, minority dynamics, health, language, identity development and community development all intersect and affect each other.G. Nic Rider, PhD, is an assistant professor at the University of Minnesota Medical School’s Program in Human Sexuality and Co-Associate Director of Research for the National Center for Gender Spectrum Health. Dr. Rider is also a licensed psychologist and gender and sexuality specialist with clinical and research experience examining minority stressors, health disparities, and care utilization of LGBTQ+ individuals across the lifespan. Using an intersectionality framework, Dr. Rider is particularly interested in how interlocking systems of power and oppressive experiences related to having multiple marginalized identities influence health and wellbeing for LGBTQ+ youth of color. Dr. Rider has served as a study coordinator on a NIH-funded research project which resulted in several publications that documented barriers to care and minority stressors as well as prevalence rates of risk factors, protective factors, health concerns, and health care utilization among transgender and gender diverse youth. Dr. Rider is currently Co-Chair of the Asian American Psychological Association’s Division on LGBTQ.

• Introduction: Health Disparities, Resilience, and Interdisciplinary Care for LGBTQ+ Youth and Emerging Adults(G. Nic Rider, PhD, LP, Cristina Magalhães, PhD, LMHC, & Richard Sprott, PhD)Section I: Theoretical ApproachesChapter 1: Minority Stress Theory and Resilience-Building Practice(Eunice V. Avilés Faría, PhD, LMHC, LPC)Author’s NoteMinority Stress TheoryMinority Stress Processes and the LGB CommunityMinority Stress Processes and Transgender and Gender Nonbinary IndividualsDistal StressorsProximal StressorsThe Impact of Minority Stress on Mental HealthThe Impact of Minority Stress on Physical HealthResilienceIndividual ResilienceCommunity ResilienceResilience Building Practice: Interventions that can Enhance ResilienceSocietal Level InterventionsCommunity and Group Level InterventionsIndividual-Level Interventions (ILI)Empirical Support for the Minority Stress ModelGaps in the Literature and Future Directions for Clinically Relevant ResearchChapter 2: Intersectionality, Culturally Sensitive Care, and LGBTQ+ Youth(Kayden J. Schumacher, MSc, MS, LSC, Leonardo E. Candelario-Pérez, PhD LP, Eunice V. Avilés Faría, PsyD, LMHC, LPC, & G. Nic Rider, PhD LP)Practice ConsiderationsAdvocacy ConsiderationsConclusionChapter 3: Interdisciplinary Healthcare for Transgender Youth: An Application of the Gender-Affirmative Lifespan Approach (GALA)(Katherine G. Spencer, PhD, LP, CST & Nova Bradford, LGSW)Introduction to Transgender HealthHistory of Gender-Affirmative Healthcare for YouthMinority StressThe Gender Affirmative Lifespan Approach (GALA)Philosophical Foundations of GALACore Components of GALAInterdisciplinary ApproachConnections to Medical InterventionsCase StudiesCase Study A: Research - Unicorn YouthCase Study B: Advocacy & Policy - Health Insurance Advocacy in MNCase Study C: Clinical Example - Sexuality and AgencyCase Study D: Youth HomelessnessConclusionKey Knowledge PointsRecommendations for ProfessionalsSection II: Development IssuesChapter 4: The Youngest Part of the Rainbow: Clinical Care for Gender Diverse Children(Dianne R. Berg, PhD, LP*, Caroline Maykut, PhD*, Rachel Becker-Warner, PsyD, LP, Catherine Schaefer, MS, & Jennifer J. Connor, PhD, LMFT - *Co-First Authors)Social and Historical Context of Research with Gender Diverse ChildrenGender Identity DevelopmentMental Health in Gender Diverse ChildrenClinical Implications of Mental Health ResearchResilience in Gender Diverse ChildrenInterpersonal ContextsPeer GroupFamilyCommunity ContextsSchoolsHealthcare SettingsMedical SettingsMental Health SettingsCase StudyAndi’s Gender JourneySessions 1-3 Assessment: Age 4.11 – 5.0Sessions 4-5 Feedback and Collaborative Treatment Planning with Parents Only: Age 5.1 - 5.2Sessions 6-11 Early Therapy Process: Age 5.3 – 6.1Sessions 12-16 Ongoing Therapeutic Process: Age 6.2 – 6.7Sessions 17 - 24 Ongoing Therapeutic Process: Age 6.8 – 7.5Sessions 24-35 Ongoing Therapeutic Process: Age 7.6 – 9.0Sessions 36-44 Present Therapeutic Process: Age 9.3 – 10.5Case ReflectionFuture DirectionsKey Knowledge PointsRecommendations for Practitioners and ProfessionalsChapter 5: Risk and Protective Factors Among LGBTQ+ Adolescents(Amy L. Gower, PhD, Marla E. Eisenberg, ScD, MPH, & G. Nic Rider, PhD, LP)Interpersonal RelationshipsFriendshipsRomantic RelationshipsParent/Family RelationshipsThe School ContextCommunity SupportOnline/Internet SupportDevelopmental ConsiderationsCase StudyPractice ConsiderationsConclusionsChapter 6: Not a Teen, Not Yet an Adult: Health Risk and Protective Factors Among LGBTQ+ Emerging Adults(Caleb Esteban, PhD, Alixida Ramos-Pibernus, PhD, Luis X. Díaz-Medero, MS, & Astrid Irizarry-Rodríguez, MS)LGBTQ+ Emerging AdultsInstitutional ChallengesFamilyCollegeReligious InstitutionsHealthcareGovernmentInterpersonal ChallengesRelationshipsMarriagePeersReligious AffiliationPersonal ChallengesPhysical HealthHIV/STIsHealthcareSubstance AbuseMental HealthDepression and AnxietySuicideProtective Factors for LGBTQ+ Emerging AdultsResilienceSocial SupportCommunity Engagement and ConnectednessGaps and Future Direction for StudiesClinical ImplicationsCase StudyCase Study DiscussionKey Knowledge PointsRecommendations for Mental Health CliniciansSection III: Systems of CareChapter 7: Pre-K – 12 Schools(Molly M. Strear, PhD, NCC & Matthew J. Beck, PhD, LCPC, NCC, ACS)SBMHPs Working with LGBTQ+ Youth: Review of LiteratureSchool CounselorsSchool Social WorkersSchool PsychologistsSBMHP CollaborationRecommendations for SBMHPsCoordination of Services Through MTSSTier 1 - Universal SupportTier 2 - Supplemental SupportTier 3 - Intensified SupportFamily/Community EngagementImplications & Future DirectionsConclusionKey Knowledge for StudentsRecommendations for Practitioners and ProfessionalsChapter 8: Serving LGBTQ+ Students at University and College Campuses(Jan E. Estrellado, PhD & Saromi Kim, PhD)Challenges Facing LGBTQ+ College StudentsMental Health DisparitiesIdentity Development as a Major Task of Late Adolescence and Emerging AdulthoodAcceptance and Visibility of LGBTQ+ Students on CampusIntersectionality and Marginalized IdentitiesThe Need for Affirming LGBTQ+ College Student ServicesStudent Support ServicesRelationships with FacultyRelationships with PeersHealth Services on CampusGaps in ResearchFirst-Generation StudentsBisexual and Fluid StudentsTransgender, Nonbinary, and Gender Expansive (TNBGE) StudentsSTEM StudentsImmigration StatusInternational StudentsClinical and Policy Recommendations When Working with LGBTQ+ College Students University or College Counseling CentersComing OutLanguageComplexity of IdentitiesDepathologizing SymptomsAdvocacyPolicy RecommendationsData CollectionInstitutional PoliciesFeedback LoopsInclusivityDialogue SpacesIntersectionalityCommunity LGBTQ+ ServicesCommunity CollegesProtective FactorsHealth ProvidersCounseling CentersAcademic and Career AdvisorsConclusionKey Knowledge PointsRecommendations for PractitionersChapter 9: Medical Care Centers as Beacons of Hope for LGBTQ+ Youth(Hiram Rivera-Mercado, PsyD, Kevin Carrion, PsyD, & Taymy J. Caso, PhD)Role of Hospitals in Serving LGBTQ+ Youth and Emerging AdultsServices IncludedPrimary CarePediatric EndocrinologistBehavioral Health and Mental Health ServicesPolicies and Their FunctionTraining of PersonnelCommunity Partnerships and ResourcesCreating a Welcoming EnvironmentPhysical EnvironmentRegistration and Documentation ProcessesLanguage and CommunicationConclusionChapter 10: Improving Child Welfare and Foster Care Outcomes for LGBTQ+ Youth(Kellen Grayson, PsyD, LMFT & Mira Jourdan, PhD, ABPP)Family Rejection, Abuse, and HomophobiaLGBTQ+ Youth and PolyvictimizationPoverty and LGBTQ+ Youth VulnerabilityOver-Representation of LGBTQ+ Youth in Child Welfare ServicesThe State of Foster Care and Child Welfare SystemsPolicies and Practices in Child Welfare ServicesTraining and Oversight of Foster Parents and Child Welfare WorkersGaps in CareTransition-Age YouthThe Landscape for ChangeReligious Freedom Restoration Acts and Child WelfareConsiderations for CliniciansConclusionChapter 11: LGBTQ+ Youth Experiencing Homelessness(Catherine Forbes, PhD, Carrie Mounier, LCSW, & Kaitlin Venema, PhD)Literature Review and Gaps in Research: LGBTQ+ Youth Experiencing HomelessnessClinical Considerations and Recommendations for Practice in Mental Health and Substance Abuse TreatmentTrauma Informed CareInterdisciplinary Programs for LGBTQ+ YEHEvidenced-Based LGBTQ+ Affirming Therapeutic ServicesGroup Therapy ApproachesAlternative Programming for LGBTQ+ YEHMedical InterventionsStructural Competency and Service Systems for LGBTQ+ YEHImpact of Structures on Patient HealthInfluence of Structures on the Clinical EncounterRespond to Structures in the ClinicRespond to Structures Beyond the ClinicStructural HumilityPractice and Policy RecommendationsHealing Centered Engagement and Structural ViolenceRestorative Justice and Structural ViolencePositive Youth Development and Structural ViolenceHarm Reduction and Structural ViolenceGaps and Future DirectionsChapter 12: Gender Expansive and Sexual Minority Youth and the (In)Justice System(Macy Wilson, PsyD, Jessica Ward, MA, & Roberto L. Abreu, PhD)Incidence and PrevalenceRisk FactorsSchool to Prison Pipeline“No Promo Homo” Laws and a Heterosexual-Cisgender School-Based CurriculumA Failed Welfare SystemThe (Il)legal SystemDisproportionate RepresentationUnequal InjusticeGender DifferencesYouth of ColorMicroaggressionsMediating FactorsMental Health Behaviors While IncarceratedSelf-Harming BehaviorsAggression Toward OthersToward a Socially-Just System: Ensuring Safety for LGBTQ+ YouthIncorporating a Holistic Approach to CareConstitutional RightsLegal Rights of LGBTQ+ Youth in the Justice SystemRecommendationsKey Knowledge PointsChapter 13: Services for Youth and Emerging Adults at LGBTQ+ Centers and Other Community-Based Organizations(Tangela Roberts, PhD, Zari Carpenter, MA, and Kat Schuette, MA)Author’s NoteLGBTQ+ Youth and Emerging Adults of ColorTransgender and Gender Non-Conforming (TGNC) Youth and Emerging AdultsChallenges for LGBTQ+ Youth and Emerging AdultsHealthcare ChallengesMental HealthSexual HealthInterpersonal ChallengesComing OutBuilding CommunityDating and RelationshipsIntimate Partner ViolenceVocational ChallengesCareer DevelopmentEmployment DiscriminationWorkplace Identity ManagementMethodSample of LGBTQ+ Community CentersResultsPhysical Health ServicesMental Health ServicesServices for Queer Youth and Emerging Adults of Color (QYAOC)Services for Transgender and Gender-Non-Conforming (TGNC) Youth and Emerging AdultsEmotional SupportSocial SupportServices Related to the Provision of Basic NeedsHousing StabilityFood InsecurityServices Related to Educational and Vocational AssistanceAuxiliary ServicesDiscussionAreas of Improvement in Serving LGBTQ+ Youth and Emerging AdultsAvailability of Services by Geographical RegionAccess to LGBTQ+ Community CentersLGBTQ+ Youth and Emerging Adults of ColorConsiderations for Clinical PracticePolicy RecommendationsChapter 14: Independent Practice(Gary Howell, PsyD, Arlene Noriega, PhD, Julie Williams, MSEd)Independent PracticeSolo PracticesGroup PracticesIntegrated PracticesNuances with LGBTQ+ Affirmative PracticesConsultative RolesBarriers to CareHealthcare DisparitiesSociopolitical FactorsSocial Determinants of CareEliminating Barriers to CareCultural CompetenceIntersectional ApproachCentering Marginalized VoicesAdvocacyIntegrated ApproachImpact of the Affordable Care ActImpact of COVIDSuccessesChallengesResearch Gaps and Future DirectionsConsiderations for PracticeKey Knowledge Points Recommendations for PractitionersConclusion: Increasing Health and Well-Being of LGBTQ+ Youth and Emerging Adults: Lessons Learned, Questions Unanswered(Richard Sprott, PhD, G. Nic Rider, PhD, & Cristina L. Magalhães, PhD, LMHC)Summary of Findings and LessonsA Possible Agenda for Research, Clinical Treatment, and PolicyMore Resources and FundingTrain Mental Health ProvidersSystems-Based Approach RefinementSummaryAppendix A: List of ResourcesAbout the ContributorsReferencesIndex