Apply lessons from tragedies to promote resilience in LGBTQ patients

Veenod Chulani, MD, MSED, FSAHM, CEDS

The 2016 attack at the Pulse Nightclub in Orlando, Florida, brought national attention to the stigma faced by the lesbian, gay, bisexual, transgender, questioning/queer (LGBTQ) community-particularly by those also in racial and ethnic minorities. Although tragic, the attack offered lessons about resilience in the LGBTQ community, and those lessons were shared at a session titled “Building LGBTQ resilience: Lessons learned from Pulse Orlando,” at the American Academy of Pediatrics (AAP) 2018 National Conference and Exhibition in Orlando, Florida, on November 5.

Led by Veenod Chulani, MD, MSED, FSAHM, CEDS, section chief of Adolescent Medicine at Phoenix Children's Hospital, Arizona, and Jennifer Foster, board chair of the One Orlando Alliance, Orlando, Florida, the session examined the stigma faced by racial and ethnic minority LGBTQ populations as marginalized groups, as well as the approaches pediatricians can use to promote resiliency in their LGBTQ patients.

Chulani discussed the importance of identity development as a fundamental task in adolescence, and the challenges LGBTQ youth face in this process.

“LGBTQ youth who are also members of racial and ethnic minority groups must develop both their gender/sexual and racial/ethnic identities as they develop their overall adult identity and must contend with gender and sexual and racial/ethnic stigma,” Chulani says. “It is important to understand the diversity in developmental processes and experiences of LGBTQ youth, including how these experiences are shaped and may vary by intersecting identities and personal characteristics such as race and ethnicity, education, socioeconomic status, and immigration status, among others.”

Pediatricians have a unique opportunity to help LGBTQ youth explore the influence of their membership in stigmatized groups and other intersecting identities on their identity development, lived experiences, and life trajectories, Chulani adds.

“We also have the opportunity to address modifiable, proximal determinants of risk and protective factors such as positive self-concept, family connectedness, school connectedness and safety, access to resources and services, and connections to prosocial peers as part of an overall strategy to promote youth development and positive outcomes for the population,” Chulani says.

Affirming the LGBTQ population

In working with LGBTQ youth, Chulani encourages pediatricians to embrace approaches that are affirmative, trauma informed, and strength based. To be affirmative, one must regard LGBTQ identity as an equally positive human experience and expression to cisgender and heterosexual identities and help youth achieve a positive identity as a racial and ethnic minority and an LGBTQ person, Chulani says. Trauma-informed practices come into play in acknowledging the discrimination, bias, and stress this population faces and their impact on physical, social, and emotional health.

“The LGBTQ populations have long endured oppression and discrimination. There is also historical trauma, from the systemic harassment of gay people leading to the Stonewall riots, the assassination of Harvey Milk, the murder of Mathew Shepherd, and the Orlando Pulse Nightclub massacre,” Chulani notes. “As such, clinicians are encouraged to apply principles of trauma-informed care in the care of LGBTQ populations.”

Strength-based approaches are essential, especially as the prevailing narrative of LGBTQ youth is one of rejection, victimization, hardship, and disparities in social, physical, and mental health outcomes, Chulani says.

“Although documenting and examining the various challenges and disparities faced by LGBTQ youth is critical to developing policy solutions and interventions to improve the life experiences and outcomes for the group, it is equally important to highlight the strength and resiliency demonstrated by many LGBTQ adolescents,” Chulani says.

Promote resilience, encourage empowerment

Chulani gives this advice. “Clinicians are encouraged to promote resiliency and positive outcomes for the population through the following promising strategies-promoting the development of positive self-concepts; fostering family, school, and community supports; encouraging and promoting physical and emotional self-care; and promoting youth empowerment, engagement, and activism,” he says.

Chulani expressed hope that the AAP discussion will inspire pediatricians to reflect on the challenges racial and ethnic minority LGBTQ youth encounter while drawing lessons from the response to the Pulse massacre.

“The Pulse Nightclub shooting cut through the intersections of gender identity, sexual orientation, race, ethnicity, national origin, immigration status, class, and religion. The Pulse shooting also reflected the intersection of various issues-homophobia, racial and ethnic bias, the subordination of immigrants, the tensions of faith and family acceptance, and the continued struggle for equality by members of the LGBTQ community,” Chulani says.

He continues: “In the face of overwhelming trauma and tragedy of what was the worst mass shooting in US history, Orlando and its LGBTQ community demonstrated remarkable resilience. The community found unity and solidarity across social divisions in its response to tragedy. The community created spaces for them to heal together and become whole. Individuals and organizations representing marginalized groups mobilized, empowered in their quest for justice and equality. Today, Orlando and its LGBTQ community are stronger for what they have endured. Provided the internal and external supports and resources they need to thrive, the same can be true of LGBTQ youth across intersecting identities.”

Foster says she hopes clinicians also will see the value in having a culturally competent staff to address the specialized and individual needs in this population.

“Our panel wants pediatricians to be mindful that more and more youth are self-identifying as LGBTQ at early stages of life,” Foster says. “The relationship between a patient and doctor, especially at a very young age, sets the tone for a lifetime of trust-or lack thereof-toward healthcare professionals. All humans need, and deserve, to feel safe and supported while also being nurtured mentally, physically, and emotionally throughout their lives.”