Sexual and gender minorities (SGM) are those who identify as lesbian, gay, bisexual, transgender, and queer or questioning. All other affectional and sexual orientations and gender identities are represented by a “plus” (LGBTQ+). Sexual orientation refers to one’s sexual attraction, and affectional orientation refers to one’s emotional attraction towards others (Ginicola, Smith, & Filmore, 2017). Gender identity is how one feels or experiences their gender, which may or may not be congruent with their sex assigned at birth. When an individual who is assigned a sex at birth that does not match their gender identity, one may identify as transgender, non-binary, or queer (Ellis & Cook, 2017).

Disparities in exposure to violence for SGM individuals have been well-documented. SGM individuals are at a greater risk for childhood physical, sexual, and emotional abuse and also experience intimate partner violence and adult sexual assault at higher rates as compared to heterosexual individuals (Weiss, Garvert, & Cloitre, 2015). SGM individuals are also more likely to be victims of hate crimes and targets of aggression and violence in their own communities and even within their own relationships (Roberts et al., 2010). In a large-scale study assessing mental illness among SGM individuals, 83% had experienced damage to property, physical and verbal attacks, and bullying; further, 66% associated these attacks to their sexuality (Weiss et al, 2015).

SGM individuals are often exposed to discrimination and subjective feelings of being controlled by a hetero- and cis-normative society that may result in self-censorship and minority stress. Subsequently, due to the impact of minority stress and the increased vulnerability of trauma exposure, SGM individuals experience higher rates of posttraumatic stress disorder (PTSD) as compared to heterosexual individuals. The intersection of trauma and minority stress requires a nuanced treatment approach—one that addresses the mental health sequelae stemming from the trauma, and one that addresses the system of oppression and stigmatization. Indeed, social support has been proposed to be a buffer for trauma-exposed individuals in the development of posttraumatic symptoms (Evans, Steel, & DiLillo, 2013).

Prevalence Rates of Trauma Exposure and PTSD in SGM Individuals

The lifetime prevalence of PTSD for gay and bisexual men ranges from 11.5-13.4% while the prevalence for heterosexual men ranges from 3.6-5% (Weiss et al., 2015). The differences are even starker for women where lesbian women are 2.7 times more likely to report PTSD symptoms when compared to heterosexual women. Further, the overall prevalence of PTSD for women ranges from 9.7-12.5% while rates for lesbians is up to 18.04% and 25.68% for bisexual women (Weiss et al., 2015). For trans individuals, among those who experienced potentially traumatic events, 17.8% reported clinically significant PTSD symptoms (Shipherd et al., 2011). Taken together, these rates demonstrate the pervasiveness of trauma and impacting symptomatology for SGM individuals.

Edwards and colleagues (2015) conducted a study exploring the rates of physical dating violence (DV), unwanted pursuit victimization, and sexual assault victimization among college students across the northeast U.S. in a sample of 6,030 sexual-minority and heterosexual students. Results were consistent with previous findings in that sexual minority students were 2.29 times more likely than heterosexual students to report physical DV in the past six months. Sexual minority females had an increased risk and experienced significantly higher rates of physical DV compared to women in heterosexual relationships. Notably, male sexual minority students had similar rates of physical DV as compared to heterosexual males (Edwards et al., 2015), which may suggest that there is an overall underreporting of DV in men. It has been proposed that women may report higher rates of physical DV perpetration than men, which explains the findings of sexual-minority male and heterosexual male students reported similar rates of physical DV (Edwards et al., 2015).

Approximately one in four sexual-minority students were sexually assaulted, one in three were physically assaulted by a dating partner, and more than half were victims of unwanted pursuit (Edwards et al., 2015). These findings should be highlighted as a majority of studies tend to focus on heterosexual college students and their experiences rather than exploring the implication on SGM college students. Shedding light to these disparities in research is only the first step to acknowledging the prevalence of trauma in SGM and incorporating strategies into informed practices for treatment.

The Impact of Minority Stress

Minority stress theory (MST) refers to the stigma and prejudice that is often experienced by SGMs (Meyer, 2019). Minority stress can lead to adverse outcomes including hypervigilance, expectations of being rejected, internalizing of societal biases, and often feeling compelled to hide one’s identity to escape discrimination or violence (Skinta et al., 2019). Moreover, minority stress has been shown to impact SGM individuals’ abilities to create meaningful relationships as a result of their internalized stigmatized beliefs about their identities (Skinta et al., 2019). Due to the potential lack of developed skills and comfortability in fostering meaningful, long lasting relationships, the need for a comprehensive social support system is integral for treatment with SGMs in particular. SGMs often feel a sense of rejection and to avoid being hurt by others, may inhibit or self-censor their own internal experiences (Ellis, 2020; Skinta, et al., 2019). This censorship leads to a silence within the community and promotes suppression that fosters additional stress. As a result, SGMs may avoid engaging with others to escape any uncomfortable or difficult emotions that arise from these encounters perpetuating the lack of social support that these individuals would benefit from.

Complex Traumatization in SGM Individuals

High exposure to violence and discrimination along with the impact of minority stress may lead to complex traumatization. The term complex posttraumatic stress disorder (C-PTSD) refers to a more nuanced presentation of symptoms that are distinct from PSTD symptomatology alone. C-PTSD encompasses the DSM-5’s PTSD criteria in addition to disturbances in affect regulation, identity formation, and relationships (American Psychiatric Association, 2013). C-PTSD includes exposure to repeated and prolonged totalitarian control as part of the trauma exposure. Beyond the disproportionate risk and exposure to trauma, SGM individuals are also subject to repeated exposure to discrimination and subjective feelings of being controlled by a hetero- and cis-normative society that may necessitate self-censorship.

C-PTSD also includes symptoms of affect dysregulation, identity alterations, and relational impairment (Böttche et al., 2018). When comparing the impact of minority stress to the impact of complex traumatization, there is a clear overlap in the sequelae of difficulties faced by these individuals.

Affect dysregulation could be evidenced by hypervigilance that is often experienced by SGM (Skinta et al., 2019).  According to Pachankis et al. (2019) chronic exposure to stressors faced by SGMs, which often begin at an early age, can disrupt neurobiological stress pathways resulting in rejection schemas, emotion dysregulation, and impulsivity. Additionally, chronic stressors increase the risk of emotion regulation difficulties and result in depressed and anxious mood states (Pachankis et al., 2015). Structural stigmatization denies SGMs rights and opportunities equal to heterosexual counterparts, further perpetuating the discrimination across various settings such as religious communities, schools, and workplaces. Discrimination can occur in everyday interactions and increases levels of stress on SGM that result in affect regulation difficulties (Pachankis et al., 2019). Exposure to chronic interpersonally stressful environments (e.g., bullying, subtle and overt forms of parental and peer rejection, and feeling unable to fit in) can create and maintain the difficulties related to affect regulation experienced by SGM (Pachankis et al., 2019).

Moreover, SGM individuals may have concealable identities resulting in increased anxiety and intrusive thoughts of who might know of or who might be suspicious of their hidden orientation or gender status (Pachankis, 2007). It has been suggested that individuals may adopt identities and present themselves in similar ways as their peers. Concealing one’s identity to blend in with the dominant culture helps to evade discrimination and reduce potential rejection from others. However, the costs of hiding one’s identity can lead to feelings of guilt, shame, and betrayal (Pachankis, 2007).  The noted self-censorship or lack of identity experienced by SGM is further representative of identity alterations often seen in C-PTSD (Skinta et al., 2019).

SGM individuals experience difficulties in forming close and meaningful relationships which is evidence of relational impairment (Skinta et al., 2019). Sullivan and colleagues (2017) conducted a longitudinal study examining the impact of discrimination in SGM on alterations in relational functioning. Trauma exposure was also assessed as a potential moderator of the associations for the three constructs of relationship functioning being measured (e.g., relationship satisfaction, commitment, and trust). Participants included 86 LGBT youth from the Chicago area between the ages 16 to 20 at the start of the study. For participants who reported low trauma exposure, experienced discrimination was associated with increased relational satisfaction and commitment (Sullivan et al., 2017). The authors theorized that SGM individuals who reported high rates of trauma exposure may not benefit from or engage in coping strategies that promote resilience as compared to those with reported low trauma exposure (Sullivan et al., 2017). While such a study is unique in its longitudinal design, it should be taken into consideration that authors observed at two time points with only one-year separation and may not be representative of change across the lifespan. Moreover, the relationship constructs being assessed should not be assumed to represent healthy relationships (Sullivan et al., 2017).

While C-PTSD is nuanced and requires the criteria necessary for a PTSD diagnosis, it may prove more beneficial to conceptualize the minority stress experienced by SGM as complex traumatization—chronic, repeated, and prolonged control by a society that is often traumatizing. By identifying the factors that potentially mitigate the resiliency towards trauma and discrimination of SGM, will allow for more informed and efficacious treatment to this underserved population. However, it is also important to caution against pathologizing adaptive and protective behaviors. A key feature of PTSD is overgeneralization of the fear response outside of what is proportionate or expected. For example, a soldier who is currently oversees and in active duty warfare and who endorses nightmares or numbing of emotions, does not have PTSD for two reasons: the trauma is still enduring, therefore there is no “post-trauma” response; and their response is a normal reaction to the situation. However, if the veteran returns to the U.S. and several years later has nightmares and is numbing emotions around anger or fear, this is a maladaptive reaction and not in response to a current or present stressor. Therefore, individuals who identify as SGM who are hypervigilant, numb their emotions, and experience other forms of PTSD, are not overreacting, but appropriately reacting to a society that is nonaccepting and acts more violently towards them. The beneficial aspect of a C-PTSD diagnosis is that it characterizes individuals’ behaviors as appropriate reactions to an abusive environment, rather than taking a presumptive pathology-based framework.

Social Support as a Protective Factor

The minority stress model further suggests that social support is a potential protective factor to mitigate psychiatric symptoms and suicidal ideation in transgender and non-transgender populations (Carter et al., 2019). Social support may also play a role in a survivor’s ability to reexamine the event more adaptively. Notably, the perception of social support or one’s ability to access it, may be more salient than actual support received following a stressful event (Evans et al., 2013).

While studies have found mixed support in the role of social support mitigating effects in cisgender samples, findings have been consistent when exploring these associations in transgender individuals (Carter et al., 2019). Having strong social connections with individuals who share similar identities can facilitate a non-stigmatizing environment and allows one to compare themselves to the community rather than the majority culture (Carter et al., 2019).

Weiss and colleagues (2015) examined a subset of archival data collected from self-referred women for the study in New York City between 1995-2007. Social support moderated the relationship between sexual minority status and PTSD symptoms. Results were consistent with previous literature suggesting that SGM women with lower reported social support may indicate greater functional impairment and somatic symptoms. Additionally, low social support was associated with more severe PTSD symptomatology in SGM women (Weiss, Garvert, & Cloitre, 2015). Overall, SGM women endorsed higher levels of social support as compared to heterosexual women which fits the minority stress model and the buffering role of social support or inclination to seek out connection with those experiencing similar discrimination and prejudice. This implies that treatment interventions should be individualized to address these deficits particularly for SGM individuals who may feel more isolated (Weiss, Garvert, & Cloitre, 2015).

In sum, while social support and connectedness generally lead to positive mitigating effects, the support being from those who have a shared identity may prove especially protective against negative outcomes for individuals in marginalized groups (Carter et al., 2019). Social support, friendships, and a sense of community have been shown to aid in SGM individuals’ ability to cope with hostility and stigma (Paceley, Hwu, & Arizpe, 2017).

Implications for Treatment

Trauma-informed affirmative care is paramount to treating the intersection of traumas that SGM individuals face, including the role of life-threatening experiences as well as daily and cumulative minority stressors (Ellis, 2020). In regard to the treatment of C-PTSD, a collaborative therapeutic relationship should function as a model for developing skills and practices needed to foster a social support system (Ellis, 2020; Gold & Ellis, 2018).

While social support is recognized as a protective factor for SGM individuals exposed to trauma, those with more complex traumatization may lack the skills to initiate the process of building and maintaining friendships or participating in community functions. These skills are an integral component for building upon in treatment. The collaborative therapeutic relationship should aim to model appropriate social conventions, role-play, or the direct teaching of skills. It is important to remain supportive and genuine with clients, and the therapist should continue to facilitate cognitive flexibility in an effort to enhance social interactions (Ellis, 2020).

Characteristics of complex traumatization such as emotional reactivity, avoidance, feelings of detachment, and affective numbing, may further complicate one’s ability to initiate and maintain adaptive relationships (Kern et al., 2018). Indeed, treatment recommendations for C-PTSD include a phase-based model that begins with stabilization and a strengthening of skills (Cloitre et al., 2012).

Russell and Hawkey (2013) propose a treatment approach that is specific to working with survivors of hate crimes. The initial phases generally begin with psychoeducation and addresses the client’s safety and strengthening of one’s capacities for emotional awareness, self-concept, and increasing interpersonal and social competencies (Cloitre et al., 2012; Russell & Hawkey, 2013). Moreover, it is important for the therapist to consider the perception of social support available to the client as this may be an area to strengthen prior to encouraging a client to rely on social support as coping mechanisms. The therapist and client should collaborate to strengthen support seeking behaviors and feel safe enough to invite support from others prior to translating skills to the real world (Evans et al., 2013). Such mechanisms are even more essential when working with SGM individuals. Russell and Hawkey (2013) further emphasize social support-based interventions and suggest that hate crimes are by definition social events that may lead to a trauma response resulting in avoidant behaviors (Russell & Hawkey, 2013).

Pachankis (2007) proposed a model that describes how specific parts of situations can activate a set of internal reactions that occurs both cognitively and affectively for SGM individuals who often attempt to conceal their identity to avoid discrimination. In turn, various person and environmental variables can then shape our behaviors (Pachankis, 2007). In other words, cognitive and affective responses to a traumatic event related to one’s minority status and can result in preoccupation, vigilance, guilt, and shame. Responses are bidirectional in that negative cognitive patterns (e.g., misattribution of problems, feelings of being unsafe) can lead to problematic affective states (e.g., anxiety and depression), while negative affective states can in turn lead to problematic cognitive processing (Pachankis, 2007).

The bidirectional relationship further influences the behavior displayed by the individual facing a threatening situation. For example, the individual may avoid social situations, experience impaired relationship functioning, and lack assertiveness skills. The model also accounts for the negative self-evaluation that often occurs as a result of the interactions between cognition, affect, and behavior. One’s self concept is threatened leading to experiencing of identity ambivalence, lack of self-efficacy, and low self-esteem (Pachankis, 2007). This is particularly relevant for SGM as research has consistently found that concealing one’s identity in certain situations can lead to cognitive burdens resulting in emotional difficulties. This feedback loop of maladaptive strategies that aid in SGM ability to function in a cisgender society both fosters and maintains consequences of minority stress (Pachankis, 2007). Similarly, Russell and Hawkey (2013) highlight the importance of addressing the impact the hate crime or event had on the survivor’s sense of self as a member of their particular identity group. Author’s suggest assessing for levels of positive contact individuals have with their ingroup community as well as the relationships with members of the outgroup to determine the impact on identity development (Russell & Hawkey, 2013). Those with a stronger preexisting sense of self may have a potential advantage in working through their identity. However, those who may not have reflected on the meaning behind being a member of a stigmatized group may need more time for exploration into these areas (Russell & Hawkey, 2013). Acknowledging the client’s individual needs is crucial when utilizing such approaches.

Interventions that acknowledge such feedback loops and provide skills to reduce consequent outcomes of those feedback loops (e.g., avoidance, impaired relationships, affect dysregulation, identity disturbances) may be an important first step in working with SGM individuals. Russell and Hawkey’s (2013) approach for working with survivors of hate crimes propose that as a result of such maladaptive cognitions experienced by SGM, cognitive therapy would aid in identifying distorted thoughts. Similar to the treatment for C-PTSD, utilizing Socratic questioning aims to guide the client and generate more adaptive thinking patterns. In addition, Pachankis et al. (2019) offers a Cognitive Behavioral Therapy (CBT) intervention called Effective Skills to Empower Effective Men (ESTEEM). ESTEEM combines CBT principles with LGBTQ-affirmative principles and targets the pathways involved in minority stress and the subsequent mental and physical health outcomes. Consistent with the aforementioned approaches, ESTEEM is a protocol targeting skills related to emotion regulation, avoidance patterns, and self-efficacy (Pachankis et al., 2019). The protocol also enhances coping strategies to reduce the impact of minority stress in young gay and bisexual men (Pachankis et al., 2019). Although this intervention is specific for gay and bisexual men, the implications of skill learning are congruent to treatment of C-PTSD and survivors of hate crimes.

The second phase of C-PTSD treatment typically includes the review and reappraisal of traumatic experiences through a variety of strategies in a safe environment (e.g., Eye Movement Desensitization and Reprocessing (EMDR), Narrative therapy, Cognitive Processing Therapy). The approaches may vary however the commonality between interventions is the emphasis of an organized recounting of events through reexamining the trauma experiences (Cloitre et al., 2012). A similar approach is noted by Russell and Hawkey (2013) who suggest that survivors must work through their feelings about the individual perpetrator and consider their thoughts and feelings towards the perpetrator and perpetrator’s group(s). Trust is another key component and the therapist must work with the client in recognizing the capacity to trust oneself both as an individual and as a member of a stigmatized group. This phase is particularly necessary to tailor to the client’s needs, and the therapist should collaborate with the client to assess the most appropriate approach for the individual (Ellis, in press; Russell & Hawkey, 2013).

The final phase of treatment for C-PTSD comprises of transitioning out of therapy into the community environment. The therapist works with the client to apply and strengthen skills to engage in safe and supportive social networks and foster more intimate relationships (Cloitre et al., 2012). Developing functional skills such as education, employment, and meaningful hobbies should also be discussed to promote overall well-being. The goal is for the client to feel equipped to manage symptoms that arise while working to enhance newly acquired skills moving forward. For SGM, it may not be enough to focus on the individual and one’s capacity to be equipped in managing symptoms or challenges that are faced on a daily basis. As noted by Pachankis et al. (2015), interventions targeting minority stress should begin at the structural level to alleviate the burden placed on SGM individuals given that the source of discrimination starts with social structures. Interventions that focus on stigmatizing social structures will set the platform for SGM to begin integrating and practice their newly acquired skills without the fear of discrimination or rejection.

Community-level interventions might include SGM-allied educators, mental health practitioners, and other advocates engaging in more professional development or training opportunities aimed to increase SGM-issue competencies to promote acceptance and safety for SGM individuals in the community. In addition, incorporating resources to provide support groups to introduce SGM youth peers who may share marginalized identities or experiences can connect them to additional supportive resources (Paceley et al., 2018). Resources can be implemented in schools, community mental health centers, or even supportive churches. Implementing workshops or accessible resources to facilitate discussion amongst SGM peers and psychoeducation could benefit both SGM and non-SGM individuals within a community. For example, specific topics such as same-gender violence being highlighted may mitigate the stigma and misconceptions of SGM dating violence (Murchison, Boyd, & Pachankis, 2017). In addition, SGM organizations might look to incorporate events such as movie nights or outings for SGM youths to promote SGM visibility and safe places (Paceley et al., 2017). Lastly, SGM-inclusive policies are instrumental in contributing to a supportive community climate. Anti-discrimination policies and bathroom legislature that protects transgender and gender-nonconforming individuals will support the capacity for a supportive community environment that may mitigate the minority stress experienced by SGM individuals (Paceley et al., 2017).

Summary

The disparities in exposure to violence over the life course has been well documented in SGM populations. These individuals are at a greater risk for various types of abuse and discrimination and is demonstrated in the higher prevalence rates of PTSD symptoms as compared to cisgender and heterosexual individuals (Weiss, Garvert, & Cloitre, 2015). Due to the compounding impact of minority stress, a conceptualization and treatment formulation that falls in line with C-PTSD can better capture the experiences of SGM individuals. The literature demonstrated the importance of integrating social support in C-PTSD treatment. It is essential for SGM individuals with a history of complex traumatization to feel empowered and capable of managing challenges of stigma and discrimination. While the client should work to promote resilience towards a stigmatizing environment, it should be emphasized that the change should also occur at institutional levels. Rather than solely focusing on changing the individual, it is also the therapist’s job to advocate and work to make change through policies and community level engagements. Utilizing this multi-faceted approach to interventions, may provide the necessary buffer for the challenges experienced by SGM individuals with a history of complex traumatization.

Some online available resources for clinicians include:

1. GLBT Near Me:

An online database for finding LGBTQ+ resources and support in your local area. https://www.glbtnearme.org

2. PFLAG Chapter Network:

Provides confidential peer support, education, and advocacy to LGBTQ+ people, their families, and allies. PFLAG has over 400 chapters across the country.

https://pflag.org

3. TheTribe Wellness Community:

A forum to connect individuals to online peer to peer support groups for those in the LGBTQ+ community as well as those facing a variety of mental health challenges. https://support.therapytribe.com

4. The Trevor Project:

• “Coming Out: A Handbook for LGBTQ Young People”: Includes tools and provides information to help navigating what it might be like to share their identity with others. Includes a crisis intervention service for LGBTQ+ youth (Call 866-488-7386).

https://www.thetrevorproject.org/wp-content/uploads/2019/10/Coming-Out-Handbook.pdf

• TrevorSpace aims to connect LGBTQ individuals (ages 13-24) to peer support and communities through online forums. https://www.trevorspace.org

5. Trauma Psychology (American Psychological Association):

Provides a fact sheet and video on working with LGBTQ+ trauma survivors. https://www.apatraumadivision.org/633/resources-on-underserved-populations.html

6. Society for the Psychology of Sexual Orientation and Gender Diversity (American Psychological Association):

Provides resources, empirical studies, and advocacy opportunities https://www.apadivisions.org/division-44/

7. Society for Sexual, Affectional, Intersex, and Gender Expressive Identities (American Counseling Association):

Provides educational materials, policy information, clinical and counseling resources for working with LGBTQ+ individuals.

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Korey Abbriano, M.A., M.S.

Korey Abbriano is currently pursuing her PsyD in Clinical Psychology at Nova Southeastern University. She is originally from Long Island, New York and completed her bachelor's degree in Psychology and Sociology at Stony Brook University. She also completed her master's degree in General Psychology at Stony Brook University. Ms. Abbriano has completed practicum experiences in community mental health settings including the Faulk Center for Counseling and the Psychological Services for the Emotionally Distressed clinic. She is currently an elective practicum student at the Pediatric Psychology Associates, treating children with Autism Spectrum Disorder and ADHD. Ms. Abbriano served on the board of Mental Illness New Directions (MIND), a student led organization, for two years where she worked with the community to advocate for reducing stigma surrounding mental illness. She also volunteers on a weekly basis for the Crisis Text Line, which provides crisis services across the United States to individuals via text message. Ms. Abbriano's clinical interests include trauma, advocacy, and working with underserved populations.