Caring for LGBTQ+ Adolescents and Teens in Today’s Practice

Podcast Transcript

Intro: Neuro Pathways, a Cleveland Clinic podcast, exploring the latest research discoveries and clinical advances in the fields of neurology, neurosurgery, neuro rehab, and psychiatry.

Glen Stevens, DO, PhD: Child and an adolescent health care providers are increasingly caring for patients who identify as lesbian, gay, bisexual, transgender, queer or other, LGBTQ+, or who may be struggling with, or questioning their sexual orientation or gender identity. Although these patients have the same health concerns as their non-LGBTQ+ peers, LGBTQ+ adolescents and teens may face additional challenges because of the complexity of the coming out process, as well as societal discrimination and bias against sexual and gender minorities.

In today's episode of Neuro Pathways, we're discussing care for LGBTQ+ adolescents and teens in today's practice. I'm your host, Glen Stevens, neurologist, neuro-oncologist in Cleveland Clinic's Neurological Institute. I'm very pleased to have Dr. Jason Lambrese joined me for today's conversation. Dr. Lambrese is a child and an adolescent psychiatrist in the Center for Behavioral Health in Cleveland Clinic's Neurological Institute. Jason, welcome to Neuro Pathways.

Jason Lambrese, MD: Thanks so much for having me.

Glen Stevens, DO, PhD: So Jason, let's get started. Ensuring high quality care for LGBTQ+ youth requires providers to understand principles of caring for LGBTQ+ individuals. Can you start the conversation by discussing some of the primary mental health issues facing LGBTQ+ adolescents, particularly?

Jason Lambrese, MD: Absolutely. The things we really are keeping an eye on primarily, are depression and anxiety. And with depression comes the risk for suicidal thoughts or actions. And so we're really wanting to be mindful of this risk in all of our adolescents, but we do see a heightened risk for depression, suicidality in LGBTQ youth.

Glen Stevens, DO, PhD: So other issues other than the depression or suicide ideation, is there anything else?

Jason Lambrese, MD: And those are the primary ones. The other things that we do think about as well can be things like eating disorders. We do see an increased risk for eating disorders in various subsets of the LGBTQ+ youth population, and potential risk for substance use. Both using substances more regularly, in a binge pattern, as well as initiating substances at a younger age,

Glen Stevens, DO, PhD: I was listening to the clinic staff meeting this morning. They were talking about COVID and concerns about the social isolation and increase in drinking and drug use in general. Do you see that over the past year with COVID in this population or is it really not changed much?

Jason Lambrese, MD: Yeah. We're really seeing this social isolation as being really challenging for all of us over the last year, it's been hard. But particularly for youth, where such a primary goal of being a young person is those social connections. And through adolescence, it's really forming those social bonds and figuring out who we are in the world. And it's hard to figure out who we are in the world if we're stuck inside. And so we do see that isolation from peers really start to take its negative toll, and with that can lead to increased depression from being inside, increased rates of substance use. So we have seen that come up as well, and it's been a tough year for everyone.

Glen Stevens, DO, PhD: So why are we seeing higher rates of depression, suicidality in this patient population, particularly? Jason Lambrese, MD: Yeah, it's a good question because there's nothing inherent in being LGBTQ+ that leads someone to be more likely to have depression or anxiety or suicidal ideation. A lot of it really gets explained through the minority stress model. The idea being that we living as a minority of any type and in this situation, when thinking about a sexual or gender minority. Living as a minority in the world is really tough. There are constant stresses that we're facing on a day-to-day basis, whether it's at school, at home, at work or in our communities and that constant or chronic level of stress takes its toll after a while. There's a psychological as well as physiological stress that we experience. And so, these thought is that, that constant exposure to stress, without maybe a high level of support. So that imbalance of stress and supports leads to a vulnerability to depression, and then comparing that with isolation and lack of support system can lead to a lot of despair and distress that can then lead to some of the suicidal thoughts or actions.

Glen Stevens, DO, PhD: Could you comment on bullying?

Jason Lambrese, MD: Yeah. Bullying is a huge issue. So we're seeing, when folks are in a school system where they don't feel they can be themselves, they feeling they're being targeted or discriminated against. That takes its toll as well. So it's challenging. For these LGBTQ+ youth, we see that primarily at home and at school, and there's such a risk that either environment might not be supportive. So if they're in school and they're getting bullied and teased, you can start to internalize that. Because usually it's happening at the same time, as somebody is trying to figure out who they are and trying to understand themselves. They're going through a normal adolescent development, trying to figure out who they are and their identities of all sorts. And that includes a sexual and gender identity. So you're trying to figure that out, at the same time, they're being told that who they are, who they appear to be is bad.

So they're hearing the direct derogatory comments from their peers in the form of bullying. They're internalize that's saying, "I'm trying to figure who I am. Everyone else is saying I'm bad. It must be true that I am bad. That how I'm feeling is a bad thing, is negative." And that then can lead to this internalized homophobia that youth can have, where they're really starting to believe this themselves. That actually how they're feeling is wrong and is bad. And so then that can lead to, "Well, if I'm a bad person, what's the point of staying alive anymore." And then that can lead very quickly and easily to suicidal thoughts.

Glen Stevens, DO, PhD: It really hits home. When you tell me that it is not innate, because then it really makes all of us responsible for that.

Jason Lambrese, MD: That's absolutely right. I think it's something that if folks live in a society, in a world that was totally accepting of all sorts of sexual orientations, gender identities, and gender expressions, there wouldn't be a whole lot of stress. And folks can just develop and be, and express who they are comfortably. And I suspect that would lead to a much reduced rate of depression and suicidal ideation and bring a much more to the level of their peers, this level of depression in the world for lots of reasons.

But that extra piece of it is often societally based. So we see that at school with bullying, we see that in homes, a lot of these youth are not being supported by their families when they come out. And so they may be rejected through being kicked out of their homes. We're seeing LGBTQ youth overrepresented in the homeless youth population. And so that's tough again, if you have a hard home life, but school is a support environment or vice versa. A lot of bullying in school, but your home is supportive, that can sometimes help cope to get through the adolescent years. But if you're getting rejected at home and bullied at school, that's a real recipe for negative outcomes.

Glen Stevens, DO, PhD: Yeah. So lots of food for thought, and I guess we all just need to be better people.

Jason Lambrese, MD: Absolutely.

Glen Stevens, DO, PhD: So would you say that the needs of the LGBTQ adolescents are being met in today's healthcare practice or not?

Jason Lambrese, MD: I think we're getting there. I think we are, just by having these conversations. More and more of normalizing these conversations, that we're really opening the door for providers to be aware of the needs of LGBTQ youth. We're seeing that there's more and more education happening from the level of medical students, up to residents and fellows to even continuing professional development. So we're realizing as providers, there's a lot we need to know. So I think as we're increasing our education of healthcare providers, that's allowing better care, but we're sort of in the middle of it right now, where we should actively working towards, I think we're starting to see some of the fruits of that. But I think there's still a lot more we could do, including very small things that could really help us be more open and supportive of this population.

Glen Stevens, DO, PhD: So in terms of clinical management, can you discuss the current standard of care being provided in today's practice and how that differs from the non-LGBTQ+ adolescents?

Jason Lambrese, MD: Yeah, so I think it's important that a lot of it is the same, right? A lot of the care we're providing is the same care we provide to all of our patients. LGBTQ+ folks are coming in with headaches and bellyaches just like everybody else. Well, there are certain things that we do want to be mindful of. So part of it is opening up the dialogue for folks to talk about any struggles they might be having around sexuality or gender.

But the other piece of it is specifically around care for transgender or gender non-conforming youth. There are certain standards of care that we do abide by, and that's through The World Professional Association of Transgender Health publishes the standards of care, that talks about the kind of care that all of these patients, including youth or adults, may need in terms of mental health care, medical care in terms of hormone therapy or other gender-affirming therapies or surgeries. And so we really do try to use those internationally accepted and published standards to make sure that we're providing the specific care that's needed for transgender youth or youth with gender dysphoria, to help them feel more comfortable in themselves and help their bodies more align with their gender identities.

Glen Stevens, DO, PhD: So are there barriers that providers face when treating LGBTQ adolescents?

Jason Lambrese, MD: I think the biggest barrier is even just having the conversation. Now we see that it's hard on the part of the provider and the part of the patient to maybe initiate the conversation about just even coming out to your provider, whether it's a pediatrician or child psychiatrist, letting that healthcare provider know that you are thinking about or struggling with gender and sexuality or identify as LGBTQ+. There's a study done, now it's over 10 years old, but it looked at pediatricians and asked them, how often are you talking to your youth about sexual orientation? Maybe about a third of pediatricians at that point said that they will initiate the conversation with their patients around sexual orientation and really said, I don't know how to bring it up. I don't know what to do if they say yes. I don't know the resources that are out there.

And the same thing, asked the youth, well, how often are you coming out to the provider? And same thing as about a third are coming out. Eventually, two thirds wanted to come out, but only a third did. And the number one reason that, that extra third didn't actually come out, was the doctor never asked me. So really patients see that the onus is on us as the provider to be the one starting these conversations. And so I think a huge barrier is even just provider comfort in bringing this up, like any more sensitive topic. And a psychiatrist, we see a lot of those sensitive conversations happening in our office. That can put patients in a very vulnerable position, talking about sexuality, talking about substance use, suicidal thoughts, trauma, it can fit under that umbrella. So I think we need to give providers the tools to allow them to feel more comfortable just opening the door, to allow this conversation to happen.

Glen Stevens, DO, PhD: So Jason, are there things that providers can do to make their office space more acceptable for adolescents?

Jason Lambrese, MD: Yeah, and that I think is one of the key things. So we can do whatever as much as possible from the provider standpoint to be open, to have these conversations, to be competent, supportive. But there's a lot that happens from when they pick up the phone to call our office, to actually showing up in the exam room with me. So they can, nowadays is looking at our website and searching for us and seeing, does our practice actually talk about that LGBTQ health as a specialty of theirs. And it should be something that if we're saying its specialty, we should have at least some training to be able to provide that care.

When they walk into the waiting room, are they seeing any visible signs of LGBTQ+ support that could be a little safe zone sticker, a rainbow flag, a flyer for the local LGBT community center. Folks will pick up on these small things. When they sit down and fill out the intake form, how are the questions asked there? Is there only an M and an F option for somebody's gender? Or can there be a gender with a line or multiple options to pick from. For kids, when it asks for contact info for mom and dad, instead of mom and dad, can it say parent one and parent two, to allow for folks who may have two moms, two dads or only one or the other. How can we make sure that it's more than just single, married or divorced?

We want to make sure we have our forms in our waiting rooms be visibly supportive and that all of our staff that we're working with are feeling competent in this area as well. So when the nurse comes out to the waiting room to room the patient, that they're using the patients preferred name. That there's some way in the chart or medical records, indicate a patient's preferred names. That right from the start, the first address is using their preferred name. So really visibility and just small things, like I said, a small sticker or a poster, or I have different buttons on my lanyard. That say what my pronouns are, or have a small rainbow button.

Those are little things that people will pick up on and have commented to me on, "I saw that, that button was there." "I saw that you had a sticker or a poster on your wall for the LGBT center. That's really cool that you are showing that support." So people pick up on those small visual representations of support and allow them really from the start, just to feel more comfortable walking into the office.

Glen Stevens, DO, PhD: Jason, that was really great information. So you seem an optimist to me. Are we seeing improvements in the overall care for the LGBTQ group?

Jason Lambrese, MD: I really like to think that we are, I think that we're seeing more and more providers who are seeking out this education, who are recognizing that this is a need. Especially for medical students. I'm working with a lot of medical students now and trying to just improve the educational experience from first-year med school. Seems a lot of happening at the grassroots level, but I think there's also a lot more we can do. I do hear stories of folks who are showing up at our primary care provider's office. And when they come out to that provider, they say, "Oh, you should go to the LGBT clinic." And maybe they should, and maybe that's appropriate for the care that they need, but maybe it's not necessary. Not everybody needs to go to an LGBT clinic for their medical or mental health care. Folks will to just seek care close to home.

So I think that there is still a bit of a discomfort in the part of providers and it's, in some ways, easy to be able to send folks to LGBT clinic and not own some of that themselves. And to me, that's kind of the pro and con of having some of these extra services. So how do we make sure we provide really good care in LGBT clinic, but then allow that to permeate to all the practices and all the providers in an area to make sure everyone has a basic level of competence and comfort. So I think we're getting there. I'd like to believe that we're getting there. Maybe I need to believe that we're on that path, but I do think we've got some room to go.

Glen Stevens, DO, PhD: Can you share some insights on how your team has evolved LGBTQ Care at the Cleveland Clinic, specifically?

Jason Lambrese, MD: Yeah, so we have the Center for LGBT Care. That's mostly based at the Lakewood Family Health Center and within the center, we're providing care for youth and adults. So I primarily work on the pediatric team. And we have services for all LGBTQ+ youth, but we have really developed and expanded our team for transgender and gender non-conforming youth. So that's our GUIDE team, which is our acronym for Gender Understanding, Identity and Expression. And it's a team that includes pediatric mental health providers, including psychiatrists and psychologists, as well as medical providers, including adolescent medicine and endocrinology. So we've really over the last few years, have really built up a care path that allows for folks coming in to get support around coming out. And I'll say the support is often around, for the youth and for the families who may be in the midst of this process and this journey, how we're making sure we're providing early on in the journey.

Folks going to be at the point of wanting to explore gender-affirming hormone therapy. And so they'll often meet with the mental health provider to have that conversation and really explore what that means for them. And then we will link them up with our different medical providers who can provide that care. And then as folks become adults, we do have a really good relationship with the adult gender team where we can make sure care transfers really smoothly from pediatric to adult care. So I think it's great that the Cleveland Clinic has such a robust array of services for pediatric and adults in terms of mental health, medical care, and for adult surgical care.

Glen Stevens, DO, PhD: So Jason, are there instances where a provider should be referring a patient to an LGBTQ+ provider, or are there instances where they can manage the patient themselves?

Jason Lambrese, MD: Yeah. I think for me, the biggest part of it is, how comfortable does that provider feel in providing that care. And that may just be having that conversation. It may just be learning more about what that concerns or questions that the youth has. And then they may be that they do need mental health services or they do have questions about gender-affirming hormone therapy, that may be out of the realm of the comfort zone of that provider. Or maybe that they need services for sexual health and they don't feel comfortable providing it. So I think a lot of LGBT care is primary care, but it takes the provider knowing where their line is to say, this I feel comfortable and competent to provide this tier. And this feels a little bit beyond me.

It shouldn't always be an automatic referral. There should be some level of comfort that every provider should have in starting these conversations, but they may feel like the needs that they have are just more than I can provide. I think oftentimes, a lot of it comes around treatment for gender dysphoria. And so linking up with the more specialized gender team, I think is really helpful. Because they can often provide some of the medical and mental health wraparound care that the youth could benefit from.

Glen Stevens, DO, PhD: So I'd like to go back to the family support. I think if I just think about my life and friends that I know that have gone through this. It's very tough on the families and it's very tough on parents. And I think that the parents don't quite understand how to deal with it. What can we offer to the families?

Jason Lambrese, MD: I think it really is just that it's a recognition that this is a process for everyone, and that can sometimes be hard for the young person, who often... When I'm working with families for the first time, oftentimes the young person after they come out, they're usually a few steps ahead of their parents in terms of understanding where they're at on this journey. And I call that out and I want to recognize that because I always tell the young person, when you made the decision to come out, you've been thinking about this for a while for yourself, to really know for sure this is who I am. And I'm confident enough in who I am to be able to tell other people. And so it's a lot of mental energy and thought that you put into this. So you're already a few steps ahead of the game by the point of coming out, you've been thinking about this for a while.

Your parents may have had this on their mind and they may not have. Take me very well back at step one, and so what can we do to help make sure that we're supporting both the youth and the parents in this journey along the way? So it's allowing parents to have a reaction. It's allowing them to be able to say what some of their concerns are. Parents have had a conceptualization of their kid from before they were born, in terms of what they were going to be doing in their lives. Their planning their weddings out. I mean, we have this image and when that image shifts because of what we know about our child, really can fundamentally change. That can be hard for parents.

I think we need to allow them that space to process that and to potentially even mourn the loss of what they imagined their child's future life to be. But I always tell parents, you made be losing the son that you had, but now you have this daughter. And so it's a mourning, but it's mourning of an idea, more than mourning of a person, because that person is still here. And they're actually more open with you now that they've come out. You're actually seeing more and more of who they really are. So allowing that space, but then allowing them to be open to hear from their child's really, who they are. And I think those conversations can be tough, but making sure that we really try to facilitate a space where there's an open dialogue between the young person and the parent, and often with a counselor.

I think it's really beneficial for kids to be in longer-term psychotherapy or counseling with someone who is knowledgeable about LGBTQ+ issues. So they can provide support to the young person as they explore who they are in this journey, but also provide support to the parents and provide a space for these conversations to happen. A lot of parents find it helpful to talk to other parents or families going through a similar process to maybe link them up with community services who may be able to talk with them. And they can hear that perspective from other parents who are going through this, that can often be super helpful and powerful.

Glen Stevens, DO, PhD: So what percentage of patients get actively involved in some type of therapy with their child and what percent should?

Jason Lambrese, MD: I would say, I think for most people, I would say most or all, I think there's a benefit to counseling. To me, the counseling is certainly not to change who the young person is, but to provide them the support and tools they need to really grow and blossom as who they are and as comfortable way as possible. So I think to me, there's very little downside or side effect to counseling. It's such a helpless space to provide that exploration. And I think more and more people are doing that. But people who are seeing me are already started taking that step to come into the office to talk about it. I think there are probably a lot more people who are not yet at the point of coming into the psychiatrist's office or coming into the gender team to be having these conversations.

Think there's a lot of folks who are just maybe so uncomfortable with this idea, they're shutting the conversation down from the start. So I do think that there probably are many folks who don't have access to services either because they live in a place where maybe there are few counselors in general, let alone anybody who is maybe knowledgeable about LGBTQ health. They may not have the health insurance that allows them to access the counseling. They may not have the transportation to get there. Their parents may not think it's important or relevant. Or the young person not feel comfortable talking to their parents about it, to even let them know they need the counseling.

So it can be a lot of barriers, both psychologically as well as logistically to make that happen. But I think if there are ways of we can creatively get someone linked with the counselor. And nowadays, with everything being so virtual, that's been a real positive for me, that folks who I work with who are not living in and around the Cleveland area have access to counselors. Or access even to our team that may be further away, but that can engage with us virtually. So taking down that geographical barrier, I think really will open up services for a lot of these families.

Glen Stevens, DO, PhD: But it seems like the driver needs to be the adolescent, is that right?

Jason Lambrese, MD: Yeah. The adolescents needs to start the conversation to let the parent know. But the parent needs to be there ready to hear that and ready to provide support from the start. And I often tell parents, you don't need to know the answer. We don't even know what your child's final destination is going to be on this journey. All you need is to be supportive, let your kid know that you love them, that you can be able to support them on this journey. Those really small, basic things are actually so important. When an adolescent comes out as they're lesbian or as transgender, there is such a fear of what the reaction's going to be.

Unfortunately, there are many youth who do at that point, get rejected by their families. So if a parent doesn't know and doesn't know the right answer, and doesn't know what the next steps are, and they're just pressing it themselves, just saying, "I'm here for you. I'm figuring this out with you. And I love you." That's an important step right then and there because that kid needs to hear that because they question that in that moment because that fear and anxiety can really take over.

Glen Stevens, DO, PhD: So Jason, before we sound off, would you like to provide any additional insights for providers treating LGBTQ patients?

Jason Lambrese, MD: To me, I think the most important things for providers are, start the conversation, figure out a way that you feel comfortable bringing up these topics and do it universally. The more we do it in a regular basis, the more comfortable we feel having these conversations. And know what the resources are. So if a person does tell you that they're struggling with gender identity or sexual orientation, you can provide them some support in the moment, whether it's a conversation in your office, information about the local counseling center, information about the local LGBT community center. So figure out a way to start the conversation and have some resources available for when a youth does come out to you.

Glen Stevens, DO, PhD: All right. Well, thank you very much, Jason.

Jason Lambrese, MD: Yeah. Thanks so much.

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