Medical Trauma in LGBTQIA Youth: Adapting Trauma-Informed Affirming Clinical Practices

Abstract

Lesbian, gay, bisexual, transgender, queer and/or questioning, intersex, and asexual (LGBTQIA) youth are more likely than cisgender heterosexual youth to experience traumatic stress across all social systems, including within family, school, and health care settings. LGBTQIA youth may be particularly susceptible to traumatic stressors associated with medical illness or injury and health care, due to both to higher baseline levels of stress and adversity and unique identity-linked stressors pervasive across systems of care. Pediatric providers can greatly impact mental health in their LGBTQIA patients by providing trauma-informed care that is affirming of gender and sexual identities. This article presents foundational concepts pertaining to medical trauma and practice priorities for pediatric providers, who are uniquely positioned to mitigate medical traumatic stress experienced by LGBTQIA youth.

Lesbian, gay, bisexual, transgender, queer and/or questioning, intersex, and asexual (LGBTQIA) youth experience elevated rates of trauma related to discrimination, harassment, and victimization across social settings.¹ Youth who experience multiple forms of severe psychosocial stress, as well as those who experience chronic and/or pervasive social stressors (eg, unsupportive or dangerous home environments), are especially susceptible to trauma sequalae across the lifespan.² Although stressful for many youth, medical settings present unique and more severe stressors for LGBTQIA youth, in comparison to their cisgender heterosexual peers.

PEDIATRIC MEDICAL TRAUMA AND TRAUMATIC STRESS

Trauma refers to a harmful, threatening experience with lasting adverse effects on functioning and mental, physical, social, or emotional wellbeing.³ Traumatic stress describes adverse experiences that outweigh a person’s ability to cope or adapt. Medical trauma and medical traumatic stress occur when a youth experiences a painful, invasive, or frightening event in the setting of injury, illness, pain, or medical care. Like other severely stressful events, traumatic stress in medical settings activates a cascade of physiological and psychological responses.⁴ It is important to note that, though we focus primarily on experiences of pediatric patients in this article, every involved family member has a unique experience of the same events and can experience traumatic stress in health care and medical settings.

Each person has a different threshold for stress. Stress becomes “toxic” or harmful when it overwhelms a person’s available supports and/or coping abilities.⁵ Biologically, exposures to highly stressful experiences cause the release of stress hormones, including cortisol and norepinephrine, which impact all organ systems. Some brain structures are more susceptible to stress, including the hippocampus, amygdala, and prefrontal cortex, areas associated with episodic and spatial memory and mood regulation, emotional response and memories, and planning and decision making, respectively.⁵ Stress hormones also impact Circadian rhythms and sleep,⁶ motor learning,⁷ and metabolic functions⁸—all key functions for growing and developing youth.

It is important to note that medical traumatic stress results from the subjective experiences of the patient (or family member), not the objective severity of the injury, illness, or pain. For example, a pediatric patient’s internal emotional experience of receiving a diagnosis or enduring a procedure is more impactful on mental health than data-driven facts about medical severity, prognosis, or risk. LGBTQIA youth may be especially susceptible to medical trauma due to higher levels of stress at baseline, prior traumatic experiences, and the long-term effects of minoritization, discrimination, and stigma, which are explored further below. In addition to facing unique identity-linked stressors in medical settings, LGBTQIA youth are also more likely than cisgender heterosexual peers to lack key protective factors that build resilience and mitigate traumatic stress, including social support networks,⁹ stable housing,¹⁰ and family support.^11,12 Furthermore, for Black and Latinx LGBTQIA youth, minoritized sexual and/or gender identities intersect with racial marginalization and discrimination, further compounding the inequities faced.

Some children who experience medical traumatic stress eventually meet diagnostic criteria for post-traumatic stress disorder (PTSD) as outlined by the Diagnostic and Statistical Manual of Mental Disorders, fifth edition,¹³ whereas others do not. PTSD is characterized by difficulty with physical, affective, behavioral, cognitive, and/or interpersonal functioning.¹⁴ Children without clinical PTSD may still experience changes in their mood or thinking, intrusive memories or nightmares, avoidance of specific trauma reminders, and/or changes in arousal and reactivity. Young children, in particular, may manifest trauma symptoms in subtle ways, such as through changes in play, nervousness, or social withdrawal. These core trauma symptoms ultimately map onto the brain structures vulnerable to stress, which are described above. There is no single symptom or presentation that characterizes pediatric medical trauma. Thus, pediatricians must engage in thoughtful screening for trauma-related symptoms and traumatic events in routine clinical practice to identify those at higher risk for trauma symptomatology.

Early life traumatic stressors like serious injury or illness may impact social, emotional, and cognitive development across the lifespan. Traumatic events in childhood, often referred to as Adverse Childhood Experiences (ACEs) in research and clinical practice, are associated with numerous risk factors for the leading causes of morbidity and mortality among adults – including ischemic heart disease, cancer, lung disease, and liver disease.¹⁵ ACEs are associated with adverse health outcomes in a dose-response pattern, and studies clearly demonstrate that youth exposed to one form of traumatic stress are more likely to experience additional forms of traumatic stress as well.¹⁵ LGBTQIA youth, for example, experience more adversity across both social and health care settings based on their marginalized gender and sexual identities.

Traumatic exposures increase the risk of poor mental health, physical health, academic performance, and coping.¹⁶ Exposure to traumatic events in childhood also increases the risk of psychiatric conditions, including substance use disorders, depression, suicide, anxiety, PTSD, and psychosis in adulthood.¹⁵ Relatedly, childhood trauma is associated with health care compliance variables like decreased adherence to medications and lower frequency of checkups.¹⁷ All of these outcomes result from complex, interconnected pathways in which early life adversity cascades into risk behaviors and lifetime poor health outcomes.

MINORITY STRESS IN HEALTH CARE SETTINGS

The minority social stress framework helps explain the impacts of pervasive discrimination and other unique identity-linked social stressors on LGBTQIA youth.¹⁸ In general, LGBTQIA youth face numerous recognizable social stressors in home, school, and community systems. Examples of such social stressors include family rejection and neglect, harsh discipline and bullying, and sociopolitical anti-LGBTQIA messaging such as bans on military service for transgender people and bans on gender health care, to name a few. LGBTQIA youth also face unique stressors within health care settings, including fears around identity disclosure to caregivers and providers, discriminatory practices at all levels of health systems, a lack of insurance coverage for LGBTQIA-specific services, legal and structural barriers to LGBTQIA-related care, and unprepared and/or biased providers.¹⁹ Surveys of medical providers also demonstrate that providers in primary care settings feel unprepared to treat LGBTQIA patients.²⁰

Experiences of discrimination, prejudice, stigma, and rejection alter internal beliefs and self-image, increasing internalized stigma, stress related to concealment of identity, and anticipation of discrimination.²¹ Within the health care setting, these internal processes may manifest as avoidance of care, non-disclosure of identity and/or health behaviors to providers, and a lack of health promoting behaviors. Negative self-image or self-regard may also correspond with higher rates of risk-taking behaviors among LGBTQIA adolescents, including escalating substance use,²² earlier substance use,²³ and higher risk sexual behaviors.^24,25

LGBTQIA youth—particularly transgender and gender diverse youth—face identity-linked stressors within medical systems that promote cissexism and heterosexism across all layers of care. First, youth experience negative and stressful interactions with people within healthcare institutions, namely through encounters with providers and staff who are not affirming and/or overtly reject or stigmatize LGBTQIA identities. Person-level, or interpersonal, discrimination ranges from microaggressions to overt experiences of rejection, discrimination, and refusal of care. About one-half of LGBTQIA patients report being mistreated by a health care provider, whereas more than 70% of transgender patients have experienced overt discrimination at least once.²⁶ Second, structural discrimination greatly affects LGBTQIA youth. For example, LGBTQIA youth may lack insurance coverage for gender-affirming care, or insurance coverage at all. Furthermore, pediatric residency programs often lack adequate training on LGBTQIA health and affirming practices. For some youth, medical traumatic stress derives from discrete experiences in health care settings with care teams or procedures. For others, low grade, insidious discrimination contributes to non-engagement in health practices for disease prevention and health maintenance. All iterations of minority stress in health care push LGBTQIA youth away from preventive care measures toward worse health outcomes across the lifespan.

TRAUMA-INFORMED LGBTQIA-AFFIRMING PRACTICES

Pediatric providers can play a pivotal role in mitigating the risk of medical and minority traumatic stress among LGBTQIA youth. The provision of care that is trauma-informed and affirming of gender and sexual identities is the best practice for working with LGBTQIA youth across care settings.

Trauma-informed care is characterized by a resilience-promoting perspective, wherein providers recognize and support a person’s strengths rather than pathologize symptoms or difficulty with functioning. One simple question that guides this practice is, “What have you been through?” instead of “What’s wrong with you?”²⁷ Ample research has shown that social support and positive coping strategies mitigate social stress experienced by LGBTQIA youth. In clinical practice, providers who practice from a trauma-informed perspective engage patients in collaborative decision-making and actively work to avoid re-traumatization in clinical settings. Examples of such actions include presenting developmentally tailored information to a patient, discussing confidentiality, and engaging the patient in decision-making whenever possible. Trauma-informed care also necessitates empathy and awareness about intersecting positions of privilege and oppression, including gender identity and sexual orientation, as well as race, ethnicity, class, and physical ability.

LGBTQIA-affirming care fundamentally presumes that no gender identity or expression or sexual orientation is pathological. Rather, gender can be fixed or fluid, binary (male/female) or nonbinary, and may evolve or change over the life course for some people. Similarly, sexual orientation exists on a spectrum where no specific identity is normal or pathological. LGBTQIA-affirming care recognizes that gender and sexuality vary across cultures.²⁸ In practicing LGBTQIA-affirming care, providers fundamentally recognize that impairing psychological symptoms are the result of sociocultural stressors and discrimination facing the LGBTQIA youth, rather than any intrinsic traits associated with LGBTQIA identities.

In clinical practice, affirming care can occur in any clinical care setting. Pediatricians can improve care for LGBTQIA youth by supporting healthy exploration of identities, providing safe medical interventions when appropriate, and working with families and caregivers to promote family support.²⁹ Some gender-diverse and transgender youth rely on pediatricians and other medical providers for gender-related care like puberty suppression and hormone therapies, placing them in a particularly vulnerable position within a medical system that may not feel welcoming or safe. Physical examinations and clinical interviews may be especially stressful, and potentially traumatic, for a young LGBTQIA person.

PRIORITIES FOR PEDIATRIC PROVIDERS

LGBTQIA youth are particularly vulnerable to medical trauma due to their pervasive experiences of discrimination and marginalization, including prior negative and/or unsupportive experiences with health care providers and systems of care. Pediatricians who tailor their clinical practice to provide trauma-informed affirming care³ can greatly impact the health of LGBTQIA youth. Providers and care teams can improve care delivered to LGBTQIA youth patients through the following steps: (1) screening for signs of stress and trauma and attunement to LGBTQIA patients’ needs; (2) preparation in trauma-informed practices, affirming practices, and LGBTQIA-focused knowledge; and (3) understanding the effects of trauma on youths’ behavior and development and taking well-informed steps to prevent traumatic events in medical encounters. Table 1 summarizes specific clinical strategies for pediatricians to provide trauma-informed affirming care and thereby mitigate traumatic stress experienced by young LGBTQIA patients.

TABLE 1.

Key Priorities for Pediatricians to Decrease Traumatic Stress for LGBTQIA Youth in Health Care Settings

Trauma-informed approach	Specific clinical practices
Recognize traumatic stress	• Review confidentiality and privacy practices with youth, including limitations • Discuss gender and sexuality with patients, recognizing that all genders and sexual orientations are normal and not pathological • Enact evidence-based,culturally responsive screening and assessment
Realize the impact of traumatic stress on health and well-being	• Foster collaboration and create opportunities for choice and control where possible • Offer clear,developmentally tailored information and answers about medical conditions • Be attuned to the patient’s emotional reactions during interviews,examinations,and procedures • Be mindful of the potential to cause re-traumatization and/or activate trauma responses
Respond by integrating trauma-informed and LGBTQIA-affirming practices into care	• Create treatment spaces that are safe and private • Use LGBTQIA-affirming language with all youth • Foster resilience and recognize people’s strengths • Discuss procedures and examinations in a developmentally tailored fashion and encourage the patient to ask questions and/or express their concerns • Advocate for LGBTQIA patients to access resources and affirming providers • Provide resources to patients and caregivers about pediatric trauma, family,and social support

Abbreviation: LGBTQIA, lesbian, gay, bisexual, transgender, queer and/or questioning, intersex, and asexual.

Adapted from Substance Abuse and Mental Health Services Administration.³

CONCLUSION

In working with LGBTQIA youth, attention should be paid to the unique psychosocial stressors and experiences of discrimination and marginalization that compound risk for medical traumatic stress. Providers can promote resilience and mitigate medical traumatic stress by integrating specific trauma-informed and affirming care practices into routine care.