In this podcast, we are joined by Lucy Jonas, a children’s well-being practitioner at Westminster CAMHS, part of the Central and North West London NHS Foundation Trust. Lucy is the first author of the JCPP Advances paper ‘A systematic review and meta-analysis investigating the impact of childhood adversities on the mental health of LGBT+ youth’ doi.org/10.1002/jcv2.12079. There is an overview of the paper, methodology, key findings, and implications for practice.
Discussion points include;
- How sexual orientation disclosure is linked with social anxiety disorder, phobia, and/or PTSD symptomatology
- Evidence that all outcomes in terms of mental health conditions were more prevalent and statistically significant in LGBT+ individuals compared to heterosexual youth
- Implications of her systematic review and meta-analysis for CAMH professionals when working with young LGBT+ patients or clients
- How schools should prepare for working with LGBT+ students
- What we should all be doing in terms of continued advocacy from communities and allies to support and empower LGBT+ youth
- Where to find resources to help
- Advice for parents or carers, CAMH professionals and policy makers.
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I am currently a passionate Children’s Wellbeing Practitioner, motivated by its impact and ability to improve the lives of young people and their parents or carers experiencing anxiety, depression and behavioural difficulties. I feel especially drawn to vulnerable young people, such as those from stigmatised or minority groups, and hope to continue research in this area in order to make a valuable contribution to their wellbeing.
[00:00:30.112] Jo Carlowe: Hello. Welcome to the In Conversation podcast series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Jo Carlowe, a freelance journalist with a specialism in psychology. And I have with me children’s well-being practitioner Lucy Jonas, who works at Central and North West London NHS Foundation Trust. Lucy is the first author of the paper ‘A systematic review and meta-analysis investigating the impact of childhood adversities on the mental health of LGBT+ youth’, published in JCPP Advances. This paper will be the focus of today’s podcast.
JCPP Advances is one of the three journals produced by the Association for Child and Adolescent Mental Health. ACAMH also produces the Journal of Child Psychology and Psychiatry and the CAMH. If you’re a fan of our In Conversation series, please subscribe on your preferred streaming platform. Let us know how we did with a rating or review. And do share with friends and colleagues. Lucy, welcome. Can you start with an introduction about yourself, including how you came to be interested in child and adolescent mental health?
[00:01:35.890] Lucy Jonas: Thank you so much, Jo. It’s really exciting for me to be talking to you today. I’m a children’s psychological well-being practitioner training at Westminster CAMHS. So, I deliver low-intensity therapy to children, adolescents, and their parents or carers who are experiencing symptoms of depression, anxiety, or behavioural difficulties using cognitive behavioural therapy techniques. I love this role because we are frequently the first level of intervention. So, we have a unique ability to improve the lives of young people before their symptoms deteriorate.
This interest in mental health came into fruition during my time at school as I studied psychology for A-level. I chose to build upon my interest in this field by studying psychology as an undergraduate degree at the University of Exeter. I graduated in 2020 during the first COVID-19 lockdown. And during lockdown, I felt particularly drawn to the news articles predicting how the restrictions would trigger a global surge of trauma exposure, physical, sexual, and psychological maltreatment, neglect, and unexpected bereavements among vulnerable children.
From my undergraduate degree, I was already aware that even before the pandemic, immense pressure was being placed on already-stretched mental health services. And too many young people were carrying the burden of mental health conditions without any support. This inspired me to do a master’s in child and adolescent mental health at King’s College London, where I was lucky enough to have the opportunity to do a placement in a psychiatric intensive care unit, which solidified my professional interest in paediatric psychology. I was supervised by Dr. Kim, an amazing clinical psychologist, who’s inspired me to follow in her footsteps of becoming a psychologist in the future.
[00:03:17.045] Jo Carlowe: Brilliant. Lucy, thank you. Let’s turn to the paper, ‘A systematic review and meta-analysis investigating the impact of childhood adversities on the mental health of LGBT+ youth’, published in JCPP Advances. Can you give us a brief overview of the paper to help set the scene?
[00:03:36.160] Lucy Jonas: So, we all know from reports, reviews, and even anecdotal evidence that the risk of exposure to a traumatic event escalates for young individuals within the LGBT+ community. Just to note, LGBT+ refers to all individuals with minority identities related to sexual orientation, gender expression, or gender identity. So, this systemic exposure is fertile ground for a number of mental health problems. However, of the existing reviews, the nature and magnitude of the impact of such adversities has only been tested in LGBT+ adult populations, impeding our understanding of the psychological repercussions in adolescents.
So, this is the first systematic review and meta-analysis to source and review all the existing literature linking multiple types of childhood adversities to mental health outcomes across the full spectrum of LGBT+ youth.
[00:04:33.922] Jo Carlowe: Great. So, it’s really timely and important. What methodology did you use for the research?
[00:04:39.900] Lucy Jonas: So, this paper is a systematic review. We conducted a keyword mapping strategy on five databases from the date of their creation until the final search in September, 2021. Based on initial scoping search, we used keywords related to LGBT+ youth, childhood adversity, and psychiatric-related health conditions to ensure the search produced all possible results. 27 studies satisfied the inclusion criteria, representing 26,505 LGBT+ youth.
And using this data, we conducted meta-analytical regressions to evaluate the association between the presence of an adverse experience and the presence of mental health outcomes. I was really lucky to be assisted by brilliant co-authors who were involved in study selection, data extraction, and bringing the meta-analysis into fruition. They were all experienced in the performance of reviews, so skilled with statistics, and possessed unparalleled knowledge of the topic being addressed.
[00:05:41.210] Jo Carlowe: I want to dig into some of the specific findings in the paper. But can you start, Lucy, with an overview just to share some of the key findings?
[00:05:50.810] Lucy Jonas: Yes. The first thing to note is that LGBT+ youth reported a higher prevalence of different forms of adversity in comparison to their heterosexual or cisgendered counterparts. The meta-analytical results revealed that 55% of LGBT+ youth were exposed to any adverse experience, with the majority reporting sexual abuse, verbal abuse, physical abuse, or cyberbullying. The upshot of this is the LGBT+ youth are at a heightened risk for mental health disorders, with 23% of LGBT+ youth reporting a mental health problem, which exceeds the worldwide estimated prevalence in the general child and adolescent population, which is 13.4%. In terms of mental health outcomes, anxiety disorders and depression were more than double reported within the LGBT+ sample when compared to the heterosexual group.
[00:06:45.875] Jo Carlowe: Gosh.
[00:06:47.647] Lucy Jonas: The formal meta-analysis also revealed that depressive symptoms were present in 36.9% of LGBT+ youth and anxiety was present in 31.5%.
[00:06:58.382] Jo Carlowe: There’s something I want to pick up on in the paper. It states, sexual orientation disclosure is linked with social anxiety disorder, phobia, or PTSD symptomatology. Can you elaborate on this link between disclosure and some mental health conditions?
[00:07:18.000] Lucy Jonas: So social anxiety, phobias and PTSD are all manifestations of anxiety. While the full answer is undoubtedly complicated as to why LGBT+ youth are more likely to struggle with mental health disorders such as anxiety, disclosing one’s sexual or gender identity to others is a unique experience, but common to LGBT+ youth, that is often marked by fear. Disclosure of a stigmatized identity unfortunately invites possible rejection from loved ones.
Seeing as family, friends, and partners might not always offer the love and support that they could, it’s not surprising that disclosing this information is anxiety-provoking. If the reaction is negative, LGBT+ youth report more physical and verbal violence. And there may also be a potential loss of social, emotional, and financial support, all of which are predictive of PTSD.
In a larger context, it’s only been 30 years since homosexuality was declassified as a psychological disorder. And there is still a lack of legal protection from laws worldwide that still criminalize the expression of LGBT+ people.
[00:08:28.190] Jo Carlowe: Yeah, that’s a really helpful explanation as to why it’s so provoking. As you’ve already stated, your review found that all outcomes in terms of mental health conditions were more prevalent and statistically significant in LGBT+ individuals compared to heterosexual youth. What are the implications of this for CAMH professionals when working with young LGBT+ patients or clients?
[00:08:53.462] Lucy Jonas: Yeah. So, it’s interesting that– well, historically LGBT+ people have been found to report more concerns with care and communication provided by CAMHS clinicians. Due to this long-standing history of poor patient care, fostering inclusive and safe environments in which youth can disclose sensitive histories is crucial. To make key but achievable changes, clinicians should aspire to support young people to feel comfortable disclosing and discussing their identities, establishing confidentiality and educating parents.
I think another important takeaway for service professionals assessing and treating children and adolescents is that they may wish to pay particular attention to patients who endorse a sexual or gender minority status, and consider the etiological role of trauma in their practice. Due to the over-presentation of adverse childhood experiences within the LGBT+ population, it may be helpful to incorporate assessment of patient’s childhood history and to adopt a trauma-informed approach.
This approach places a strong emphasis on enhancing support systems, mitigating trauma reminders, and fostering safety in a patient-centred way. Having said this, as clinicians approach trauma treatment among LGBT+ individuals, it’s important to mitigate running the risk of a one-size-fits-all method, as it’s essential to contextualize their current presentation within their respective environmental histories in a patient-centred way, rather than making assumptions based on their sexual or gender identity.
[00:10:32.428] Jo Carlowe: Lucy, I want to turn to schools. Your paper highlights the strong evidence that school-based victimization is causative of mental illness, and conversely, that the impact can be lessened through relationships with supportive peers. Given these findings, how should schools prepare for working with LGBT+ students?
[00:10:53.310] Lucy Jonas: So, all students, no matter their background, sexual orientation, or gender identity, deserve to feel safe and welcomed in schools. No student should experience discrimination or harassment in the classroom. The lack of support in the fabric of many school institutions limits LGBT+ students’ rights and leaves them more vulnerable to experiences that may compromise their mental health. With most of the studies in this systematic review taking place in school settings, we found strong evidence that school-based victimization is causative of mental illness.
Therefore, there is an urgent need for establishing inclusive programming in schools to support young LGBT+ mental health. The first method is to provide a compassionate and safe school environment for sexual and gender minority youth. It’s so well documented that the impact of childhood diversity on LGBT+ youth can be lessened through relationships with supportive peers, such as peer-based support groups. A peer-led program to raise the awareness to students about cyberbullying towards LGBT+ youth was piloted and successful, allying students, reducing prejudice and harassment in the school environment.
Similarly, key adults around school must be vigilant in recognizing victimization efforts, and offer a safe space where minority feel valued in their choices. To adhere to a welcoming and inclusive ethos, it’s crucial that all school personnel utilize correct terminology and implement protection and provision policies for vulnerable students. Teachers should strive to establish rapport with LGBT+ students by, for example, always ensuring they’re using transgender-youth-preferred pronouns and to allow gender nonconforming children to wear the uniform in a way which is comfortable for them.
[00:12:42.625] Jo Carlowe: Do you think that happens at the moment?
[00:12:44.750] Lucy Jonas: I think there’s definitely a change going forward at the moment. What we found in our paper, actually, is that victimization efforts in schools is reducing when we compared studies to decades ago and to now. So, I think that’s an indication of the policies that are being put in place in schools at the moment.
[00:13:04.310] Jo Carlowe: Mm-hmm, great. In the paper, you call for continued advocacy from communities and allies to support and empower LGBT+ youth in the face of adversity. How do you envisage this happening? What should we all be doing?
[00:13:20.600] Lucy Jonas: Continued advocacy is definitely required to modify the hostility and violence that has historically been perpetrated towards the community. In terms of what we should all be doing, I think we should all be vocal in our support for LGBT equality. Studies repeatedly identify social support as an important element of countering the possible negative effects of childhood adversities on LGBT+ youth.
So, every single one of us can play a role in instilling hope in the hearts and minds of the young people, particularly during uncertain and unsettling times. So, another idea is to take action at a local level to create safe spaces. I urge you to consider your community and some of the places where the youth might spend their time and wonder, are they safe for LGBT+ youth? And if you work with youth as a teacher, therapist, social worker, or other professional, learn the best practice in creating safe spaces.
[00:14:16.055] Jo Carlowe: Are there any particular resources for professionals? If they don’t feel confident about doing this properly, where can they go?
[00:14:23.180] Lucy Jonas: There’s definitely an increasing number of services online. The resources that are available just on the internet are growing, and they’re so incredible, often made by LGBT+ youth themselves. However, I would really encourage any workers to go to their managers and ask for specific training because there are lots of different training courses available.
[00:14:45.590] Jo Carlowe: Let’s turn to policymakers. What’s your message to them?
[00:14:49.620] Lucy Jonas: Well, despite clear and persistent evidence that LGBT+ populations are among the most vulnerable groups for mental health problems, stigma has driven this long-standing shortage of funding devoted to LGBT health. I would strongly encourage policymakers and stakeholders to garner adequate funding to address the prevalence of ACEs and to create successful early interventions. It’s so important that LGBT+-specific work is continuously reviewed and updated in light of rapid developments in public discourse and academic knowledge. Similarly, the UK government should continue to consult with LGBT+ people and their organizations to ensure work is inclusive of the community’s needs.
[00:15:32.793] Jo Carlowe: Are you optimistic that that’s happening?
[00:15:34.960] Lucy Jonas: Yes. Well, as I said, society is changing. And there does seem to be this shift in public thought and in major legal reforms. So, I continue to be optimistic, yes.
[00:15:46.915] Jo Carlowe: OK, good. Lucy, what follow-up research or other projects are in the pipeline for you that you’d like to mention?
[00:15:55.157] Lucy Jonas: Well, although there’s nothing specific just yet, a limitation of this review, which bears emphasis, is that we were unable to conduct meta-analysis using subpopulations of the LGBT+ community. Where there was once a single well-known rainbow pride flag, today, a wide array of colourful flags fly to showcase sexual and gender diversity. And I think this suggests exciting avenues for future study. To extend the research presented here and to conduct a more comprehensive meta-analysis, it would be really interesting to examine ACEs and the mental health outcomes of lesser-known gender and sexual minorities because by combining them into a collective group, it can strip the differences in experiences that distinguishes each individual. So, I think this would be a really interesting piece of follow-up research.
[00:16:43.882] Jo Carlowe: Great. Is it something you plan to take on?
[00:16:46.600] Lucy Jonas: I would love to, if anyone wants to join up with me.
[00:16:50.380] Jo Carlowe: Finally, Lucy, what is your take-home message for those listening to our conversation?
[00:16:56.420] Lucy Jonas: So, in summary, young LGBT+ people endure disproportionate trauma exposure. They’re more likely to experience the profound effects in adolescence. But it’s often not noticed during this period, and instead, the psychological wounds linger into adulthood. If help is available, it’s often provided too late. And this needs to urgently change. So, the paper is a wake-up call to reach out and be vocal in your support for LGBT equality.
If any of your family and friends hear this, they’re more likely to feel confident to be open about their sexual orientation or gender identity. As I said, society is changing. And this is largely as a response to burgeoning global activism, denouncing the systemic human right violations responsible for victimizing the LGBT+ population in the past. This means that many more people can be themselves with people who matter, which is critical for confidence and well-being. So, I would tell the person that you love them and appreciate them just the way that they are.
[00:17:57.808] Jo Carlowe: What an important message. Lucy, thank you so much. For more details on Lucy Jones, please visit the ACAMH website, www.acamh.org, and Twitter @acamh. ACAMH is spelled A-C-A-M-H. And don’t forget to follow us on your preferred streaming platform. Let us know if you enjoyed the podcast with a rating or review. And do share with friends and colleagues.