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Gamache, Peter E.
Asset-based approaches for lesbian, gay, bisexual, transgender, questioning, intersex, and two-spirit (LGBTQI2-S) youth and families in systems of care
h [electronic resource] /
Peter Gamache & Katherine J. Lazear.
Llesbian, gay, bisexual, transgender, questioning, intersex, and two-spirit (LGBTQI2-S) youth and families in systems of care
Asset-based approaches for LGBTQI2-S youth and families in systems of care
[Tampa, Fla.] :
b Research & Training Center for Children's Mental Health, Louis de la Parte Florida Mental Health Institute, College of Behavioral & Community Sciences, University of South Florida,
19 p. :
FMHI publication ;
Title from cover.
"This publication was produced by the USF Research & Training Center for Children's Mental Health with partial support by the Child, Adolescent and Family Branch, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. ... The Research & Training Center for Children's Mental Health is jointly funded by the National Institute on Disability and Rehabilitation Research, U.S. Department of Education and the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration under grant number H133B040024."--P. .
Mode of access: World Wide Web.
Includes bibliographical references (p. 14-19).
[Tampa, Fla. :
University of South Florida Libraries,
Sexual minority youth.
x Mental health services.
Mental health services.
Sexual minority youth
Mental health services.
Lazear, Katherine J.
Research and Training Center for Children's Mental Health (Louis de la Parte Florida Mental Health Institute)
FMHI publication ;
Summer 2009 Peter Gamache, MBA, MLA, MPH & Katherine J. Lazear, MA The Research & Training Center for Childrens Mental Health Louis de la Parte Florida Mental Health Institute College of Behavioral & Community Sciences University of South FloridaAsset-Based Approaches forLesbian, Gay, Bisexual, Transgender, Questioning, Intersex, and Two-Spirit (LGBTQI2-S)Youth and Families in Systems of Care(LGBTQI2-S)
For more information Please contact Kathy Lazear at 202-337-2412 or Peter Gamache at 202-232-6749. Research & Training Center for Childrens Mental Health Department of Child & Family Studies College of Behavioral & Community Sciences University of South Florida 13301 Bruce B. Downs Blvd. Tampa, FL 33612 is monograph oers a public health approach for communities to meet the needs of families comprising a parent, child, or youth who is lesbian, gay, bisexual, transgender, questioning, intersex, two-spirit (LGBTQI2-S) or transitioning. is publication was produced by the USF Research & Training Center for Childrens Mental Health with partial support by the Child, Adolescent and Family Branch, Center for Mental Health Services, Substance Abuse and Mental Health Services Administration. e content of this publication does not necessarily reect the views, opinions or policies of the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration or the Department of Health and Human Services. Summer 2009 FMHI Publication 252 Research and Training Center for Childrens Mental Health Dept. of Child & Family Studies, Louis de la Parte Florida Mental Health Institute, College of Behavioral & Community Sciences, University of South Florida Recommended Citation Gamache, P., & Lazear, K. J. (2009). Asset-based approaches for lesbian, gay, bisexual, transgender, questioning, intersex, two-spirit (LGBTQI2-S) youth and families in systems of care. (FMHI pub. no. 252). Tampa, FL: University of South Florida, College of Behavioral and Community Sciences, e Louis de la Parte Florida Mental Health Institute, Research and Training Center for Childrens Mental Health. is document may be reproduced in whole or part without restriction provided the Research and Training Center for Childrens Mental Health, Louis de la Parte Florida Mental Health Institute, College of Behavioral & Community Sciences, University of South Florida is credited for the work. e Research & Training Center for Childrens Mental Health is jointly funded by the National Institute on Disability and Rehabilitation Research, U.S. Department of Education and the Center for Mental Health Services, Substance Abuse and Mental Health Services Administration under grant number H133B040024. e opinions contained in this document are those of the authors and do not necessarily reect those of the U.S. Department of Education or Substance Abuse and Mental Health Services Administration.
Peter Gamache, MBA, MLA, MPH & Katherine J. Lazear, MA Research & Training Center for Childrens Mental Health Department of Child & Family Studies College of Behavioral & Community Sciences University of South Florida Background Families comprising a parent, child, or youth who is lesbian, gay, bisexual, transgender, questioning, intersex, two-spirit (LGBTQI2-S) or transitioning navigate varying levels of acceptance and support when accessing and utilizing needed services within the mental health system. is population shares the experience of interpersonal discovery set against social signals of exclusion in the form of negative beliefs and attitudes, stigma, stereotypes, and targeted violence such as bullying, harassment, and abuse; intrapersonal uncertainty when acknowledging, disclosing or asserting their sexual orientation and/or gender identity within new or unfamiliar settings; and multidimensional challenges related to the coming out process (DAugelli, 2002; Doueck & Maccio, 2002; Fisher, Easterly, & Lazear, 2008; Oswald, 2002; Rosario, Hunter, Maguen, Gwadz, & Smith, 2001). Non-standardized denitions and measures of sexual orientation that alternately classify participants based on self-report and/or same-sex sexual behavior obfuscate estimates of individuals who are LGBTQI2-S, including children and youth (McDaniel, Purcell, & Sell, 1997; Stacey & Biblarz, 2001). Estimates for this population range from one to greater than ten percent of the overall U.S. population (Remafedi, Resnick, Blum, & Harris, 1992). e American Community Survey (ACS) provides an estimate of 8.8 million gay, lesbian, and bisexual persons in the U.S. (Gates, 2006). Same-sex households, established as a category of interest by the 2000 U.S. Census, are found in all Congressional districts in the U.S. and total 594,391 unmarried-partner residents (i.e., a close and personal relationship that goes beyond sharing household expenses) (Congressional Budget Oce, 2004; Simmons & OConnell, 2003). While same-sex marriage, civil unions, and spousal rights form a patchwork of state recognition to same-sex spouses, the U.S. Census 2010 will continually survey same-sex partner spouses as unmarried partners as in the 2000 census (Lee, 2008). Asset-Based Approaches for Youth and Families in Systems of CareLesbian, Gay, Bisexual, Transgender, Questioning, Intersex, and Two-Spirit The following denitions illustrate the commonalities and dierences between the LGBTQI2-S population: Lesbian a woman who is physically, emotionally, and mentally attracted to other women. Gay a man or woman who is physically, emotionally, and mentally attracted to the same gender. This term is used either to only identify men or all sexual minority individuals. Bisexual a man or woman who is physically, emotionally, and mentally attracted to both genders. Transgender a person whose self-identity as male or female diers from their anatomical sex determination at birth. Questioning a person, often an adolescent, who questions his or her sexual orientation or gender identity and does not necessarily identify as denitively gay, for example. Intersex a person born with an indeterminate sexual anatomy or developmental hormone pattern that is neither male or female. The conditions that cause these variations are sometimes grouped under the terms intersex or DSD (Dierences of Sex Development). Two-Spirit a contemporary term used to describe North American Aboriginal People who possess the sacred gifts of the female-male spirit, which exist in harmony with those of female and male. Two-spirit people were respected, contributing members of traditional Aboriginal societies. Today, Aboriginal people who are two-sprit may also identify as LGBT. The term is not universally accepted among Native communities and nations; some also use terms from their own nations. Transitioning often dened as the process of ceasing to live in one gender role and starting to live in another, undertaken by transgender and transsexual people. Many people also use the term to refer to the entire transgender/ transsexual process (from living 24/7 in the beginning gender role to after sexual reassignment surgery). (Adapted from Lambda Legal, 2006; Bearse, 2007)
4 Asset-Based Approaches for LGBTQI2-S Youth and Families in Systems of Care According to the American Academy of Pediatrics (Perrin, 2002), as many as six million children are being raised by parents who are LGBT (Stacey & Biblarz, 2001; Stein, Perrin, & Potter, 2004). Patterson and Freil (2000) estimate an upper limit of more than double this gure (14 million) for children with one or two gay or lesbian parents in the U.S. Studies are showing young people become aware of sexual attraction at about age 10 on average, and teenagers are coming out as LGBTQI2-S at younger ages (Damon, Lerner, & Eisenberg, 2006; Elias, 2007; Kreiss & Patterson, 1997; Setoodeh, 2008). Racial/ethnic youth in Black and Latino communities, however, have been found to disclose their homosexuality to fewer others than their White peers (Rosario, Schrimshaw, & Hunter, 2004), indicating greater degrees of underestimation cited in the research literature. Using comparative estimates of the percentage of LGBTQI2-S individuals in the total population, an estimated number of children who are LGBTQI2-S is 1,065,858 to 5,329,292. Risk and resilience factors associated with a LGBTQI2-S identity are salient to mental health providers seeking to uphold system of care principles, improve quality of care, and increase eective outreach, engagement, treatment, and support for this population. Eective services and supports to youth and families who are LGBTQI2-S requires that both processes and structures in systems of care be addressed, including frontline practice shifts that focus on the skills, knowledge, and attitudes of service providers, evidence-based practices and promising approaches, treatment ecacy monitoring, and ongoing evaluations for continuous quality improvement (Pires, 2002; Savin-Williams, 2001). Purpose of this Monograph is monograph presents a description of the research literature related to youth and families who are LGBTQI2-S to inform future research and practices. Much of the current research literature on this population is unfortunately decit-oriented, problem-based, and focused on risk factors. While there is incremental growth of LGBTQI2-S research that is assetbased, there remains a paucity of research in this area. e monograph also discusses a conceptual model of cultural competence to develop programs to serve the LGBTQI2-S population. is model describes a framework for examining the compatibility and adaptability between the characteristics of a communitys population and the way an organizations combined policies, structures, and processes work together to impede or facilitate access, availability, and utilization of needed services and supports (Hernandez, Nesman, & Isaacs, 2008). Lastly, recommendations are suggested for next steps in a research agenda to develop an inclusive and asset-based system of care to meet the needs of youth and families who are LGBTQI2-S and to support the development and enhancement of promising approaches to serve this population. Decits and Problem-Based Approaches Much of the research on LGBTQI2-S individuals to date has been decit and problem based. Caution has been expressed that an overarching focus on problems associated with being LGBTQI2-S in the research literature and mental health eld may pathologize sexual orientation and gender identity as causing negative outcomes (Bakker & Cavender, 2003; Harper & Schneider, 2003; Meyer, 2003; NAMI, 2007). For example, transgenderism remains a gender identity disorder (i.e., a cause of distress or disability for those that experience intense, persistent gender dysphoria) within the Diagnostic and Statistical Manual of Mental Disorders (APA, 1994). In comparison, the American Psychological Association lifted its characterization of homosexuality as a mental disorder in 1975 (Conger, 1975). While a disorder/disability label increases access to services (e.g., counseling) for transgender individuals, attributing negative personal outcomes to the disorder/Young people become aware of sexual attraction at about age 10 on average, and teenagers are coming out as LGBTQI2-S at younger ages.
5 Asset-Based Approaches for LGBTQI2-S Youth and Families in Systems of Care disability does not explain or resolve negative social conditions. In addition, harm reduction approaches that largely center on risks associated with being LGBTQI2-S (i.e., the person-at-risk model) can ignore how individuals who are not LGBTQI2-S can mistakenly be perceived as such and experience the same types of hate crimes and hate incidents (Herek, 2003; USDOJ, 2004). e following sections examine the predominant focal points in the research literature concerning LGBTQI2-S inquiry: HIV/AIDS, homelessness, alcohol & substance abuse, and suicide (Hughes & Eliason, 2002). e identication, diagnosis, and expectation of such at-risk and high-risk pathways for the LGBTQI2-S population are well-established. Unfortunately, much less is documented on the factors that promote achievement and resilience in maintaining health and well-being. Emerging research on resilience theory discussed after these sections holds promise for an inverted approach to transform decits to assets. HIV/AIDS HIV infection disproportionally aects the population of men who have sex with men (MSM). According to the Centers for Disease Control and Prevention (CDC) (2008a), MSM comprise more than two thirds (68%) of all men living with HIV in 2005. Fifteen percent of individuals with a new HIV diagnosis in 2006 were between the ages of 13 and 24 (CDC, 2008b). Biological properties (e.g., cellular and genetic functions) among the LGBTQI2-S population do not explain or predict disproportionate risk for HIV infection, since disease transmission, resistance, and immunity are functions of individual health, susceptibility, and social determinants. For example, factors related to variant barrier protection, injection drug use, incorrect assumptions about ones own risk and the serostatus of partners, and non-consensual (i.e., forced) sexual dynamics (e.g., rape in correctional facilities) act in concert to challenge HIV risk reduction eorts (Mayo Clinic, 2009; Ratelle et al., 2005). e CDC (2008c) estimates that 30% of individuals who tested HIV positive during 2000 did not know their serostatus because they did not return to receive their HIV testing results. While the anxiety era of traditional HIV testing is over in some regions of the country and rapid (20 minute) testing has taken its place, serious disconnects remain, continue, and are given rise. Among the 246,461 women reported as HIV infected through December 2004, the CDC (2008d, p. 1) maintains that to date, there are no conrmed cases of femaleto-female sexual transmission of HIV in the United States database. Nearly three percent (7,381 / 246,461) of the women with HIV were reported to have had sex with women, of which most had other risk factors, such as injection drug use. However, Goldstein (1997, p. 86) criticizes the myth of lesbian immunity from the AIDS epidemic, fostered by an avoidance of help-seeking and outreach to identify and target this population of women. Clements-Nolle, Marx, Guzman, and Katz (2001) studied 392 maleto-female and 123 female-to-male transgender persons to assess HIV prevalence, risk behaviors, health care use, and mental health status. e authors discovered higher risk factors among the male-to-female participants, of which 35% had positive HIV test results. ese factors included lower level of education (e.g., having less than a high school degree), multiple lifetime sexual partners, and using injection drugs independent of hormone therapy. e authors illustrate that many female-to-male individuals perform sex work following severe employment discrimination, and there is also a high rate of incarceration. Among female-to-male participants, two percent had positive HIV test results. Young people are at persistent risk for HIV infection, with a higher risk for youth of minority races and ethnicities (Ford & Norris, 1993; Miller, Boyer, & Cotton, 2004). According to the CDC, an estimated 7,761 young people were living with AIDS in 2004, a 42% increase since 2000 when 5,457 young people were living with AIDS. As noted earlier, young men who have 55% of the young men (aged 15-22) did not let other people know they were sexually attracted to men, and were therefore less likely to seek HIV testing.
6 Asset-Based Approaches for LGBTQI2-S Youth and Families in Systems of Care sex with men (MSM) were at high risk for HIV infection. e CDC also found that 55% of the young men (aged 15-22) did not let other people know they were sexually attracted to men, and were therefore less likely to seek HIV testing (CDC, 2008e). Another potential risk factor among young men is the personal fable (i.e., a developmental stage in which youth believe they are invincible to problems that occur to others) (Jack, 1989). Homelessness Very few homeless shelters are specically established for LGBTQI2-S youth, and local services requests based on national research ndings can fall at in the absence of local area data (Roder, 2008). e total number of homeless LGBT youth within the homeless population is estimated between 11% to 35% (Kruks, 1991; Tenner, Trevithick, Wagner, & Burch, 1998; Wormer & McKinney, 2003), although within these estimates are several limitations some researchers say leads to underrepresentation and conservative estimates from undercounted samples. Diculties posed for data collection include visibility (i.e., locating the hidden homeless in places researchers cannot reach), willingness (i.e., disconrming homeless status or opting out of participation in studies), and timing (i.e., missed windows of short-term, periodic homeless episodes that contribute to uncounted turnover and mobility) (Link, Susser, Stueve, Phelan, Moore & Struening, 1994). e reasons underlying these diculties can include social desirability eects, stigma, and situational independence (Phelan & Link, 1999; Phelan, Link, Moore, & Stueve, 1997; Raerty, 1995). Homeless service access is also dependent on inclusive policies (e.g., identication, legal status, age, and health/mental health status requirements for qualication) and dependent on meeting denitions of homeless. e federal denition of homeless, homeless individual or homeless person (Title 42, Chapter 119, Subchapter I, 11302) is: (a) (1) an individual who lacks a xed, regular, and adequate nighttime residence; and (2) an individual who has a primary nighttime residence that is (1) a supervised publicly or privately operated shelter designed to provide temporary living accommodations (including welfare hotels, congregate shelters, and transitional housing for the mentally ill); (2) an institution that provides a temporary residence for individuals intended to be institutionalized; or (3) a public or private place not designed for, or ordinarily used as, a regular sleeping accommodation for human beings. Homeless individuals excluded from this denition include any individual imprisoned or otherwise detained pursuant to an Act of the Congress or a State law and those that fall outside income eligibility requirements of specic programs (HUD, 2007). Additional excluded individuals include those that double up or share housing, reside in motels, live in permanent housing designated for the homeless, reside temporarily in hospitals, institutions, treatment facilities, or correctional facilities, or are at-risk of a homeless event (FDCF, 2007, p. 1). According to a study by Rew, Whittaker, Taylor-Seehafter, & Smith (2005), leaving home as a result of parental conict about sexual orientation was more likely for gay and lesbian youth than bisexual youth. When compared with heterosexual and bisexual youth, more gay and lesbian youth left home as a result of sexual abuse. Health disparities by sexual orientation among youth who are homeless are supported by data indicating a higher incidence of HIV diagnosis and treatment coupled with lower immunization rates for hepatitis B among LGB youth when compared with their heterosexual peers. Multivariate analyses investigating factors that contribute to high-risk street behaviors among LGB youth by Whitbeck, Chen, Hoyt, Tyler, & Johnson (2004) similarly indicate LGB adolescents (ages 16-19) are more likely than heterosexual adolescents to have been kicked out or to have run away because of conict over their sexual orientation. In addition, gay males were LGB adolescents (ages 16-19) are more likely than heterosexual adolescents to have been kicked out or to have run away because of conict over their sexual orientation.
7 Asset-Based Approaches for LGBTQI2-S Youth and Families in Systems of Care more likely than heterosexual peers to have engaged in survival sex [dened by Greene, Ennett, and Ringwalt (1999, p. 1406) as selling sex to meet subsistence needs such as shelter, food, drugs, or money.] A matched sample of LGBT homeless adolescents (ages 13-21) found this group was more likely to report victimization, engage in substance abuse, leave home more frequently, have more sexual partners, and have higher rates of psychopathology when compared with heterosexual adolescents (Cochran, Stewart, Ginzler, & Cauce, 2002). One study found that 65% of 400 homeless youth in their sample reported having been in a child welfare placement at some point in their life (Berberet, 2006). Whitbeck et al. (2004, p. 340) suggest a clustering of risk factors and a cumulative continuity for homeless and runaway LGB adolescents that makes disengaging from homelessness increasingly dicult. Alcohol & Substance Abuse A number of studies nd that lesbian and gay individuals experience higher rates of substance abuse than heterosexuals (Gruskin, Hart, Gordon, & Ackerson, 2001; Hughes & Eliason, 2002; Skinner, 1994). Researchers point out several underlying factors, including younger lesbian and bisexual womens participation in the lesbian bar culture, coping with the stress of homophobia and heterosexism by smoking, drinking heavily, or both, and negative stress responses that include depression and anxiety. A meta-analysis by Marshall et al. (2008) of 18 studies from 1994 to 2006 revealed that gay youth reported higher rates of cigarette, alcohol and marijuana use, as well as other illicit drugs, including cocaine, methamphetamines and injection drugs (Marshall et al., 2008). Transgender people are also at higher risk of substance abuse than the general population (Reback & Lombardi, 2001). e research points to a lack of sensitivity and respect on the part of health care providers and a lack of help-seeking among transgender persons due to reports of discriminatory treatment by other transgender individuals (Lombardi, 2001; Lombardi & van Servellen, 2000; Nemoto, Operario, Keatley, Nguyen, & Sugano, 2005). Suicide McDaniel, Purcell, and DAugelli (2001) discuss the methodological and substantive limitations of conducting LGB suicide research. ese include denitional dierences of LGB, as well as suicide attempt (which may or may not correlate with self-harm). Another prominent limitation is that most researchers have examined risk factors but have ignored factors that promote resilience (McDaniel, Purcell, & DAugelli, 2001, p. 86). Reviewed are ve studies that utilized heterosexual comparison groups, where all found higher rates of suicide attempts among LGB people. Identied risk factors include stress, lack of social support, and ineective coping (Safren & Heimberg, 1999), in addition to psychiatric and substance abuse disorders, discrimination and homophobia, and a HIV/AIDS diagnosis (McDaniel, Purcell, & DAugelli, 2001; Moscicki, 1997). Studies have found that LGBT youth were more likely than their heterosexual peers to report suicidal ideation, intent, and attempts (Goodenow, 2004; Remafedi, French, Story, Resnick, & Blum, 1998). In an earlier study, Remafedi, Farrow, and Deisher (1991) found that sexual orientation for gay and bisexual youth was tangential to self harm. Of particular note is the nding that one third of rst attempts occurred within the same year of self-identication as gay or bisexual. With minority youth more likely to express feelings of alienation, cultural and societal conicts, academic anxieties, and feelings of victimization, it is clear that careful attention must be paid to the needs of minority youth and their families within the context of their culture. For sexual minority students, research has shown sexual orientation to be correlated with identied risk factors for suicide and is less a factor after controlling for these risks (Lazear, Doan, & Roggenbaum, 2003).One third of suicide rst attempts (of LGB youth) occurred within the same year of self-identication as gay or bisexual.
8 Asset-Based Approaches for LGBTQI2-S Youth and Families in Systems of Care Assets-Based Approaches Resiliency Development Resilience theory, emergent from the health sciences and developmental psychology in particular, supports an assets-based approach by: (1) identifying qualities of individuals and support systems that explain or predict success, (2) describing the process of coping with negative stressors, and (3) creating experiences that move individuals toward reintegration (Masten & Powell, 2003; Richardson, 2002; Zimmerman & Arunkumar, 1994). An evolving fourth wave of inquiry particularly applicable for cultural competence program evaluation is how organizational infrastructure and direct service domains interact to promote compatibility (Macro International CLC Study Team, 2008). e concept of resilience has been dened as a risk factor that has been averted or unrealized (Keyes, 2004, p. 224), a phenomenon that some individuals have a relatively good outcome despite suering risk experiences (Rutter, 2007, p. 205), and a class of phenomena characterized by patterns of positive adaptation in the context of signicant adversity or risk (Masten & Reed, 2002, p. 75). Resilience research has found that 1. early and continuous attachment positively shapes relationship development in later years among all young children, adolescents, and adults (Rutter & Rutter, 1993), 2. self-ecacy is impingent upon an internal locus of control (Anderson, 1998), and 3. protective factors in one setting can compensate for risks in multiple settings (Bernard, 2004). Studies of resilience applicable for LGBTQI2-S youth have demonstrated: (1) positive social relationships moderate the relationship between stress and distress (Rosario, Schrimshaw, & Hunter, 2005), (2) arming faith experiences contribute to less internalized homonegativity, more spirituality, and psychological health (Lease, Horne, & Nofsinger-Frazier, 2005), and (3) family support and acceptance explains adolescent comfort and resilience in later life (Glicken, 2006). Consistent with these ndings, a longitudinal study comparing Black, Latino, and White LGB youth found that cultural factors do not impede sexual identity formation; however, identity integration involving internal and external acceptance and comfort being known as LGB, in addition to positive engagement in LGB social activities, is delayed by negative cultural factors (Rosario, Schrimshaw, & Hunter, 2004). ese cultural factors aect internalized anxiety and avoidance as they relate to LGBTQI2-S individuals experiences with attachment gures. For example, secure attachment during the coming out process functions to enhance coping with antigay prejudice, self-acceptance, and self-esteem (Grin & Bartholomew, 1994; Mohr & Fassinger, 2003). e development of resiliency interventions for the LGBTQI2-S population is at a nascent stage as the knowledge base for developmental psychology parallels the coming out process for this population with life stage development. Family dynamics among a network of support (e.g., friends as family, building community) are particularly indicative of promoting resilience (Oswald, 2002; Russell & Richards, 2003). For example, a study of baby boomers (born between 1946 and 1964) conducted by the MetLife Mature Market Institute in 2006 found approximately 40% of LGBT respondents cited being LGBT helped them to develop positive character traits, resilience, and support networks (MetLife Mature Market Institute, Lesbian and Gay Aging Issues Network of the American Society on Aging, & Zogby International, 2006). With studies showing that young people become aware of sexual attraction, on average, at about age 10, the impact of the family environment cannot be underestimated (Damon, Lerner, & Eisenberg, 2006). Compelling new research on LGB young adults and their families from the San Francisco-based Family Acceptance Project establishes a clear link between family rejecting reactions to sexual orientation and gender expression during adolescence to negative health and mental health outcomes in LGB young adults (Ryan, Huebner, Diaz, & Sanchez, 2009).Family support and acceptance explains adolescent comfort and resilience in later life.
9 Asset-Based Approaches for LGBTQI2-S Youth and Families in Systems of Care e social support literature throughout the last thirty years has identied natural helping networks as support systems (Gottlieb, 1983; Pancoast, 1980). For example, surveys and studies repeatedly show that individuals rst go to friends, relatives, neighbors, and lay helpers such as bartenders and beauticians for information and help (Cohen & Wills, 1985; Germain & Patterson, 1988; Gottlieb, 1988). is is especially true of racially and culturally diverse populations (Lazear, Pires, Issacs, Chaulk, & Huang, 2008). A review of randomized trials of community-based family support programs for children with chronic health conditions indicates that social support from other families can reduce anxiety in parents (Ireys, Sills, Kolodner, & Walsh, 1996). PFLAG (Parents, Families and Friends of Lesbians and Gays) is an example of the power of family and social support, and a successful grassroots organization. PFLAG grew from an organization of parents supporting each other and their GLBT children to an organization of more than 500 chapters nationwide with 200,000 members, supporters, and aliates representing the largest chapter network in the struggle for GLBT rights. e national organization was launched after receiving 7,000 letters requesting information following a mention of PFLAG in Dear Abby (PFLAG, 2008). In addition, a growing number of youth-run organizations also provide peer-to-peer support, information and education. Numerous challenges best met by a peer-to-peer approach include addressing the tensions regarding age appropriateness for childrens education programs regarding same sex relationships, religiosity and intergenerational divisions, and antagonistic environments beset with misinformation about sexuality. ese issues necessitate dialogue rather than avoidance and silence. LGBT programs that emphasize dialogue demonstrate eective ways to begin to dissolve fear and produce actions without fear of controversy or confrontation to protect all youth (YES Institute, 2008). A limitation of utilizing resilience theory to explain, observe, or predict LGBTQI2-S resistance to adversity, however, is its dependency on complex and interdependent relationships among physical, mental, emotional, and social states. Since resilience is upheld by the dual constructs of nature and nurture, proponents that are polarized may not accept such a dual view. For example, the belief that existing as LGBTQI2-S is a choice rather than a state of personal being that includes physical, mental, and emotional attraction takes a side between nature and nurture rather than a combined perspective. Asking whether identity is xed or variable provides a point of reection on identity choice and determination. Community-Focused Cultural Competency e concept of community-focused cultural competence provides a framework for an assets-based approach for the LGBTQI2-S population. Cross, Bazron, Dennis and Issacs (1989) propose a denition of cultural competence as a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals and enable that system, agency or those professionals to work eectively in cross-cultural situations. ey maintain it is essential that cultural competence eorts of any organization or system must include working in partnership with the community. While the authors work focuses on delivering culturally relevant services to children and youth of color, the philosophical framework is equally relevant to meeting the needs of youth and families who are LGBTQI2-S. For example, the Family Organization of Burlington County, New Jersey, introduced the idea of a book club because of some uneasiness about issues associated with the LGBT population. ey began with a book about the American Indian experience, as a way to engage the sta and community. e success of their rst meeting empowered them to take on a book about the LGBT experience (Dunne & Goode, 2004). A second premise of communityfocused cultural competence is found in Pires (2002), which LGBT programs that emphasize dialogue demonstrate eective ways to begin to dissolve fear and produce actions without fear of controversy or confrontation.
10 Asset-Based Approaches for LGBTQI2-S Youth and Families in Systems of Care recognizes the importance of developing a population of focus, that is, being clear about the children, youth, and families for whom a system of care exists and serves. Pires (2002, p. 172) states, system builders must be thoughtful about the characteristics, strengths, and needs of subpopulations within the population [of focus] so that relevant strategies will be pursued and responsive structures built. Following these premises, a conceptual model developed by Hernandez and Nesman (2006) illustrates the importance of understanding community context in the development of compatibility between mental health organizations and the populations they serve. Since contextual factors can facilitate or limit help-seeking and pathways through which LGBTQI2-S individuals enter into care and develop resilience, assets-based approaches for this population must incorporate specic competencies or social /environmental conditions (Hernandez, Nesman, Mowery, & Gamache, 2006; Hughes & Eliason, 2002; Masten & Reed, 2002). Figure 1 indicates the compatibility between an organizations/ systems structures and processes and the communitys characteristics. Outreach to and engagement of the LGBTQI2-S population, for example, would include an awareness of both their struggles and achievements to be eective. Specic practices, such as those that employ messaging (e.g., risk awareness messages, health maintenance messages) would also incorporate an understanding of labeling and self-identication within a regional context. e expected outcome of organizational cultural competence is reduced mental health disparities for children and their families. e model illustrates that this outcome is the product of joint organizational and community eorts. Diverse community representation thus mirrors organizational capacity. Organization-Focused Cultural Competency Figure 2 illustrates a derivative or break-out model of cultural competence that details an organizations/ systems combined policies, structures, and processes (Hernandez, Nesman, Mowery, & Gamache, 2006). e infrastructure domain on the left supports sta conducting outreach and engagement, while the direct services domain to the right functions to enable community access, availability, and utilization of mental health services. Access encompasses the mechanisms that facilitate entering, navigating, and exiting appropriate services and supports as needed. Availability includes having services and supports in sucient range and capacity to meet population needs. Utilization is the rate of the use of services or their usability by a population. Compatibility is enhanced through Denition: Within a framework of addressing mental health disparities within a community, the level of a human service organizations/systems cultural competence can be described as the degree of compatibility and adaptability between the cultural/linguistic characteristics of a communitys population AND the way the organizations combined policies and structures/processes work together to impede and/or facilitate access, availability and utilization of needed services/supports. Community Context Outcomes: Reducing mental health disparities Cultural/Linguistic characteristics of a communitys population Compatibility An organizations/systems combined policies, structures and processes Degree of compatibility denes level of organizational/systemic cultural competence Figure 1. Conceptual model for adaptability of mental health services to culturally/linguistically diverse populations.
11 Asset-Based Approaches for LGBTQI2-S Youth and Families in Systems of Care acceptance, ally development, and the institutionalization of armative policies for LGBTQI2-S individuals. ese components function to increase access, availability, and utilization. For example, LGBTQI2-S diversity training curricula, used within programs such as SafeZone, center on recognition and awareness of their particular needs, challenges, and experiences of dierence. Participants are presented with the choice to become an ally and display a sticker on their oce door or other location indicating a safe zone for dialogue with LGBTQI2-S individuals. Since the sticker functions to increase access, recognition and awareness, capacity and availability, LGBTQI2-S individuals are more likely to engage with and utilize services. Taken together, these domains contribute to cultural competence when they provide LGBTQI2-S youth shared decision-making along heightened levels of a ladder of participation (see Figure 3). Rethinking Interventions Prevention, treatment, and care interventions for LGBTQI2-S individuals ideally incorporates awareness of the social determinants of health as well as individual behaviors to reduce disease, illness, injury, and disability across communities (Marmot, 2005; World Health Organization, 2003). Social inequality among the LGBTQI2-S population weakens health systems ability to engage communities in a common dialogue if race, gender, Direct Service Domain/Function AccessThe ability to enter, navigate, and exit appropriate services and supports as needed AvailabilityHaving services and supports in sucient range and capacity to meet the needs of the populations they serve UtilizationThe rate of use or usability of appropriate mental health services Compatibility between the infrastructure and direct service functions of an organization Infrastructure Domain/Function Governance Evaluation Development Community & Consumer Service Array structure/ SupportsFigure 2. Organizational/system implementation domains for improving cultural competence. (Hart, 2002)8. Youth-initiated, shared decisions with adults is when projects or programs are initiated by youth and decisionmaking is shared among youth and adults. These projects empower youth while at the same time enabling them to access and learn from the life experience and expertise of adults. 7. Youth-initiated and directed is when young people initiate and direct a project or program adults are involved only in a supportive role. 6. Adult-initiated, shared decisions with youth is when projects or programs are initiated by adults, but decisionmaking is shared with the young people. 5. Consulted and informed is when youth give advice on projects or programs designed and run by adults. The youth are informed about how their input will be used and the outcomes of the decisions made by adults. 4. Assigned but informed is where youth are assigned a specic role and informed about how and why they are being involved. 3. Tokenism is where young people appear to be given a voice, but in fact have little or no choice about what they do or how they participate. 2. Decoration is where young people are used to help or bolster a cause in a relatively indirect way, although adults do not pretend that the cause is inspired by youth. 1. Manipulation is where adults use youth to support causes and pretend that the causes are inspired by youth.Figure 3. Ladder of participation model. 8. Youth-initiated, shared decisions with adults7. Youth-initiated and directed 6. Adult-initiated, shared decisions with youth 5. Consulted and informed 4. Assigned but informed 3. Tokenism 2. Decoration 1. Manipulation
12 Asset-Based Approaches for LGBTQI2-S Youth and Families in Systems of Care sexual orientation, ethnicity, and culture are perceived as mutually exclusive and non-interactive across groups (Halperin et al., 2004). With respect to HIV in particular, this unbalanced social equation is marked by poverty and disparities that conate structural barriers and functions to perpetuate minority status for all those with a viral load of > 400 copies/ml and < 200 CD4 CD4+ T-lymphocytes/uL (CDC, 1992). Reecting on missed opportunities to cross social boundaries and carry light for others is too late when realized at an AIDS candlelight vigil. Interventions that utilize resiliency provide a framework for not only risk reduction, but also community development of behavior change expectations. e eory of Change that drives this framework is illustrated in Figure 4. e theory of change progresses along focal points that originate with the needs and opportunities of LGBTQI2-S individuals and their families, communities, LGBTQI2-S inclusive service providers, and LGBTQI2-S inclusive service system administrators. A need for prevention and treatment of adverse conditions for LGBTQI2-S individuals will be met by determining the degree of resiliency barriers and facilitators and then tailoring program activities (on-site trainings, technical assistance, and curricula) to identied needs. At the community level, reducing and eliminating stigma and culturally-dened barriers associated with individuals who identify as being LGBTQI2-S and their families will be addressed through an informed process of identifying, developing, implementing, and evaluating community and resiliencybased approaches. e opportunity for systematic understanding of LGBTQI2-S inclusive service provider innovations for achieving cross-group resiliency will be met with a Provider Support Network (LGBTQI2-S individuals, service personnel, family members) that will share service adaptation lessons learned, common teaching methods, and opportunities for improvement. Finally, LGBTQI2-S inclusive services organizations seeking to enhance cross-group resiliency outcomes and resources will gain from this Provider Support Network of experts (inclusive of LGBTQI2-S individuals and family members) who will formulate work plans in partnership with organizational stakeholders. Assets-Based Research and Recommendations Miceli (2002) wrote, Despite the increase in visibility, gay, lesbian and bisexual youth are still one of the most under-researched groups of children and adolescents (p. 199). Due to this invisibility, there is limited systematic information about disparities in treatment outcomes for this population. is monograph proposes a framework for LGBTQI2-S research that focuses on assets for a number of Figure 4. LGBTQI2-S theory of change. LGBTQI2-S individuals and their families have limited opportunities for resiliency education and a need for prevention and treatment of adverse conditions LGBTQI2-S individuals and their families receive a Resiliency Collaborative Readiness Assessment (RCRA), and identied resiliency barriers/facilitators inform the tailoring of all education curricula, on-site trainings, and technical assistance Communities have an important role in addressing stigma associated with LGBTQI2-S and crossing culturallydened barriers with a resiliency approach Communities will identify, develop, implement, and evaluate crosscultural opportunities for resiliency approaches for LGBTQI2-S individuals and their families LGBTQI2-S inclusive service provider innovations for achieving cross-group resiliency are not systematically understood A Provider Support Network is formed to share LGBTQI2-S service adaptations, common teaching methods, and opportunities for improvement LGBTQI2-S inclusive service system administrators are seeking to enhance cross-group resiliency outcomes and resources The Provider Support Network team of experts rene and monitor resiliency program work plans in partnership with organizational stakeholders
13 Asset-Based Approaches for LGBTQI2-S Youth and Families in Systems of Care reasons: (1) the assets-based research on this population is minimal, necessitating an adaptation of assets-based research from other populations, and (2) the focus of LGBT research for so long has been on the problem/harm approach that it creates a sense of inevitability that existing as LGBTQI2-S will lead to being in harms way. All of the assets-based approaches presented in this monograph can be structured within a population-based approach, that is, a public health approach concerned with the health of all people, including their relationship to the physical, psychological, cultural, and social environments in which people live, work and go to school. A growing body of literature is moving in this direction. For example, research by Riggle, Whitman, Olson, Rostosky, and Strong (2008) found that the positive aspects of gay or lesbian identity were belonging to a community; creating families of choice; forging strong connections with others; serving as positive role models; developing empathy and compassion; living authentically and honestly; gaining personal insight and sense of self; involvement in social justice and activism; freedom from gender-specic roles; and exploring sexual relationships. It is especially encouraging to see the larger systems involved with policy and the provision of services addressing the issues and needs of the estimated 2.7 million youth who are LGBTQI2-S. For example, the Center for Mental Health Services (CMHS) Child, Adolescent and Family Branch of the Substance Abuse and Mental Health Services Administration (SAMHSA) recently established a LGBTQI2-S National Workgroup to: policies, programs, and materials such as cultural competency practice briefs in partnership with the National Center for Cultural and Linguistic Competence to address the needs of children and youth who are LGBTQ2-S and their families in the Community Mental Health Initiative (Poirier, Francis, Fisher, WilliamsWashington, Goode, & Jackson, 2008); Child Traumatic Stress Network brief focused on trauma among youth who are LGBTQ; League of America on best practice guidelines for serving LGBT youth in out-of-home care (Wilber, Ryan, & Marksamer, 2006); and a toolkit to support LGBTQ youth in care (CWLA/Lambda Legal, 2007). Using an assets-based approach to examine the complex biological, psychological and sociological dynamics of sexual orientation and gender identity can inform policy makers, front line service providers, parents, other caregivers, youth, and the community who are concerned with the LGBTQI2-S population (Espinoza, 2008; Lazear & Gamache, 2008; NIH, 2007; SAMHSA, 2008, 2001; Stroul, 2006). An asset-based approach is also consistent with the values and principles of a child and family team approach to service provision, such as Wraparound (Walker & Bruns, 2007). Research methodologies must be planned and funded that examine assets-based approaches, such as the impact of positive development programs; stigma reduction strategies; positive role models and adult connections; and supportive family settings. We especially need to better understand how peer-to-peer support organizations reduce stigma, social withdrawal and isolation. By taking a strengths-based approach and focusing on how to infuse inclusionary and asset-based approaches that are responsive to this population into existing systems of care and professional training, research can identify the critical variables in promising practices that can be adapted to programs and communities.
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19 Asset-Based Approaches for LGBTQI2-S Youth and Families in Systems of Care Tenner, A. D., Trevithick, L. A., Wagner, V., & Burch, R. (1998). Seattle YouthCares prevention, intervention and education program: A model of care for HIV-positive, homeless, and at-risk youth. Journal of Adolescent Health, 23(suppl. 1), 96-106. U.S. Department of Housing and Urban Development [HUD]. (2007, August). Federal denition of homeless. Retrieved April 10, 2009, from http://www.hud.gov/ homeless/denition.cfm U.S. Department of Justice [USDOJ]. (2004). Crime in the United States: 2004. Retrieved April 10, 2009, from http://www.fbi.gov/ucr/cius_04/oenses_reported/ hate_crime/index.html Walker, J., & Bruns, E. (2007). Wraparound-key information, evidence, and endorsements. Retrieved March 16, 2009, from http://www.rtc.pdx.edu/PDF/pbWraparoundEvidenceRecognition.pdf Whitbeck, L. B., Chen, X., Hoyt, D. R., Tyler, K. A., & Johnson, K. D. (2004). Mental disorder, subsistence strategies, and victimization among gay, lesbian, and bisexual homeless and runaway adolescents. e Journal of Sex Research, 41(4), 329-342. Wilber, S., Ryan, C., & Marksamer, J. (2006). CWLA best practice guidelines: Serving LGBT youth in out-ofhome care. Washington, DC: Child Welfare League of America. World Health Organization. (2003). e world health report 2003: Shaping the future. Retrieved April 10, 2009, from http://www.who.int/whr/2003/en/whr03_en.pdf Wormer, K. V., & McKinney, R. (2003). What schools can do to help gay/lesbian/bisexual youth: A harm reduction approach. Adolescence, 38(151), 409-420. YES Institute. (2008). Communication solutions. Retrieved April 10, 2009, from http://www.yesinstitute.org/education/courses/communication_solutions.php Zimmerman, M. A., & Arunkumar, R. (1994). Resiliency research: Implications for schools and policy. Social Policy Report, 8(4), 1-20.Acknowledgements ReviewersLinda Callejas, MA, Ph.D. candidate Project Director & Faculty Department of Child & Family Studies College of Behavioral & Community Sciences University of South Florida Mario Hernandez, Ph.D. Chair, Department of Child & Family Studies College of Behavioral & Community Sciences University of South Florida Rohan Jeremiah, MPH, Ph.D. candidate Department of Public Health and Preventive Medicine School of Medicine St. Georges University Grenada, West Indies Lynn McBrien, Ph.D. College of Education University of South Florida Marlene Penn, MSW National Family Technical Assistance Consultant, Medford, New Jersey Sheila A. Pires, MPA Partner, Human Service Collaborative Washington, D.C. Tony Tan, Ph.D. College of Education University of South Florida Antonio Wilson Youth MOVE National Houston, Texas
For more information Please contact Kathy Lazear at 202-337-2412 or Peter Gamache at 202-232-6749. Research & Training Center for Childrens Mental Health Department of Child & Family Studies College of Behavioral & Community Sciences University of South Florida 13301 Bruce B. Downs Blvd. Tampa, FL 33612