PROMOTING THE HEALTH OF MEN WHO HAVE SEX WITH MEN WORLDWIDE A training curriculum for providers

Module 5: Promoting Mental Health 2

Learning Objectives Understand factors that fuel negative mental health outcomes among gay men and other MSM Describe common mental health issues faced by gay men and other MSM Describe basic strategies for approaching mental health with gay men and other MSM

Module Overview Factors leading to poor mental health outcomes among gay men and other MSM Common mental health issues for gay men and other MSM The importance of relationships and community building Addressing mental health in the clinical setting

Pre-reading Assignment Questions for discussion: What are some of the myths that the author holds in writing about gay men and other MSM? Why do you think the author holds such beliefs? How is this similar or different to the way homosexuality is regarded where you are form? In what ways might proclaiming such negative falsehoods to a wide audience affect the mental well-being of gay men and other MSM in Uganda? How will these affect the levels of stigma and discrimination experienced by gay men and other MSM?

Factors Leading to Poor Mental Health Outcomes Criminalization Underrepresentation of gay men and other MSM in the development and implementation of policies and programs Lowered client participation and discouragement of staff from working in programs for gay men and other MSM Lack of surveillance and resources for research concerning gay men and other MSM Criminal laws in the penal code serving as justification for abuse, discrimination, stigma, and homophobia

Discrimination within Healthcare Settings In environments of discrimination: Clients less less likely to openly discuss their sexuality Clients more likely to provide incomplete or inaccurate sexual histories Makes it difficult for the provider to provide optimal care 1 2 7

Homosexuality is Not a Mental Disorder In 1973, homosexuality was declassified as a mental disorder in the Diagnostic and Statistical Manual of the American Psychiatric Association In 1992, the World Health Organization removed homosexuality as a psychiatric disorder from its International Classification of Diseases, 10 th Revision In 1995, the Japanese Psychiatric Body removed homosexuality from its list of psychiatric disorders In 2000, the Norwegian Psychiatric Association General Assembly overwhelmingly accepted homosexuality as a non-pathological understanding In 2001, a statement by the Chinese Psychiatric Association helped endorse the fact, in a non-Western context, that homosexual behavior does not signal the need for psychopathological intervention In July 2009, the Delhi High Court in India noted that “there is almost unanimous medical and psychiatric opinion that homosexuality is not a disease or a disorder and is just another expression of human sexuality” In 2013, the president of the World Psychiatric Association came out as a gay man and called for ending treatment of homosexuality as a mental illness

Reparative Therapies Any attempts to reform or “cure” sexual orientation using reparative “therapies” are likely to fail and to cause harm such as depression, anxiety, suicidality, and in some cases, a loss of sexual feeling altogether 9

Family Rejection LGBT young adults rejected by families are: 8.4 times more likely to attempt suicide 5.9 times more likely to report high levels of depression 3.4 times more likely to use drugs 3.4 times more likely to report unprotected sexual intercourse 10

Difficulty “Coming Out” Coming out refers to a period when gay men and other MSM become aware of their sexual orientation and recognize that they are sexually attracted to other men Healthcare providers must remain sensitive to the safety concerns of their gay and other MSM clients in the context of disclosure, and must uphold confidentiality agreements strictly

Group Activity Role Play 12

Maturing and Late Adulthood Aging gay men and other MSM may have less social and financial support and are at higher risk of social isolation Linked to poor mental and physical health outcomes, cognitive impairment, premature chronic disease, and death 13

Common Mental Health Issues Anxiety Depression Suicidality HIV-related stress disorder Sexual problems Eating disorders Physical and sexual violence

Group Activity Strategies for Self-care 15

Relationships and Building Community Locating a community and developing a social support system are fundamental elements in protecting against risks imposed by homophobia 16

Addressing Mental Health Issues All healthcare providers can take the necessary steps to: Provide affirmation of same-sex sexual orientation of their gay and MSM clients Recognize the factors that lead to distress in the lives of gay men and other MSM Provide accurate and scientific information regarding the normality of same- sex orientation to concerned clients and family members Become familiar with a range of coping skills and strategies that they can suggest to their clients Be prepared to provide additional tools and resources from the community so that their clients can access better mental health

Guidelines for Psychological Practice Guideline 1. Psychologists strive to understand the effects of stigma (i.e., prejudice, discrimination, and violence) and its various contextual manifestations in the lives of lesbian, gay, and bisexual people Guideline 2. Psychologists understand that lesbian, gay, and bisexual orientations are not mental illnesses Guideline 3. Psychologists understand that same-sex attractions, feelings, and behavior are normal variants of human sexuality and that efforts to change sexual orientation have not been shown to be effective or safe Guideline 4. Psychologists are encouraged to recognize how their attitudes and knowledge about lesbian, gay, and bisexual issues may be relevant to assessment and treatment and seek consultation or make appropriate referrals when indicated Guideline 5. Psychologists strive to recognize the unique experiences of bisexual individuals Guideline 6. Psychologists strive to distinguish issues of sexual orientation from those of gender identity when working with lesbian, gay, and bisexual clients 18

Guidelines for Psychological Practice Guideline 7. Psychologists strive to be knowledgeable about and respect the importance of lesbian, gay, and bisexual relationships. Guideline 8. Psychologists strive to understand the experiences and challenges faced by lesbian, gay, and bisexual parents. Guideline 9. Psychologists recognize that the families of lesbian, gay, and bisexual people may include people who are not legally or biologically related. Guideline 10. Psychologists strive to understand the ways in which a person's lesbian, gay, or bisexual orientation may have an impact on his or her family of origin and the relationship with that family of origin. Guideline 11. Psychologists strive to recognize the challenges related to multiple and often conflicting norms, values, and beliefs faced by lesbian, gay, and bisexual members of racial and ethnic minority groups. Guideline 12. Psychologists are encouraged to consider the influences of religion and spirituality in the lives of lesbian, gay, and bisexual persons. 19

Guidelines for Psychological Practice Guideline 13. Psychologists strive to recognize cohort and age differences among lesbian, gay, and bisexual individuals Guideline 14. Psychologists strive to understand the unique problems and risks that exist for lesbian, gay, and bisexual youth Guideline 15. Psychologists are encouraged to recognize the particular challenges that lesbian, gay, and bisexual individuals with physical, sensory, and cognitive- emotional disabilities experience Guideline 16. Psychologists strive to understand the impact of HIV/AIDS on the lives of lesbian, gay, and bisexual individuals and communities Guideline 17. Psychologists are encouraged to consider the impact of socioeconomic status on the psychological well being of lesbian, gay, and bisexual clients Guideline 18. Psychologists strive to understand the unique workplace issues that exist for lesbian, gay, and bisexual individuals 20

Summary Homosexuality is not a mental disorder Experiences of stigma and discrimination put gay men and other MSM at higher risk for developing a mental disorder Gay men and other MSM experience additional stress while coming out and during certain life stages such as aging Appropriate affirmation of same-sex behavior and counseling can minimize the effects of stigma and assist gay men and other MSM in their wellbeing. Support from community based organizations or groups can be protective against social isolation and harmful effects of homophobia