Summer R. Thompson, DNP, PMHNP-BC

When the United States withdrew from Afghanistan earlier this year, clinicians noted a sharp increase in calls to veteran crisis center hotlines.

 One survey found that 90% of veterans with a history of mental illness were experiencing new or worsening symptoms since the country fell.

For veterans with posttraumatic stress disorder (PTSD), news about 

Afghanistan brought back powerful memories of traumas

 many of them were trying to forget. Nightmares invaded their sleep, intrusive thoughts distracted them from work and family, and flashbacks were so powerful there was no place to hide.

PTSD has a complicated history and neurobiology, and an array of potential comorbidities. In order to diagnose and treat it, clinicians should understand all these factors, and tailor their treatment plans accordingly.

The Prevalence of PTSD and Comorbid Disorders

Civil War General William Tecumseh Sherman put it bluntly when he said, “War is hell.” For veterans with PTSD, that hell can seem inescapable. Between the Iraq and Afghanistan wars, an estimated 500,000 US troops, about 20%, have been diagnosed with PTSD.

However, less than half of veterans in need of mental health services receive treatment. Of those who do get help, less than one-third receive evidence-based care.

 And of the 5 million service members being cared for by the US Department of Veterans Affairs (VA), only 8% have been diagnosed with PTSD. Left untreated, PTSD can lead to hospitalization, unemployment, and poverty.

There are myriad reasons for this lack of appropriate care. Veterans face unique barriers in getting treatment for 

. From the minute they enter the military, service members are trained to be tough. This, after all, is what gives them the mettle needed to survive. However, this attitude can also feed stigma, as any mental health condition might be considered a sign of weakness.

When the bullets stop flying and service members return home, the horrors they hoped to forget often follow. These unprocessed traumas bang on the door of their subconscious, demanding attention. However, talking about traumas can be an extremely uncomfortable experience, one that threatens to trigger retraumatization.

There are also societal barriers to access. Veterans who seek services from the VA must have received either an honorable or general discharge and, even then, there are usually long waits to receive services. Those living in rural areas are even less likely to get access.

Instead, many veterans turn to drugs and alcohol to dull the pain. In the 1980s, a study of Vietnam veterans with PTSD found that 74% had a comorbid substance use disorder (SUD).

 A more recent study found 76% met the criteria for both alcohol and SUDs.

Adding to the complexity, mood and anxiety 

 are high with PTSD and can complicate diagnosis and assessment. Veterans with PTSD are 3 to 5 times more likely to have major depressive disorder. Many also have anxiety disorders.

 wondering if they are irreparably broken. Between the wars in Afghanistan and Iraq, more than 30,000 veterans have died by suicide.

 It is a statistic that belies a troubling need for care.

PTSD has gone by many names over the years. During 

. During World War I, soldiers called it 

. After the Vietnam War, when almost 25% of soldiers required some kind of psychiatric care, it was known as 

The work of Charles Myers, MD, during World War I is widely credited with how PTSD is treated today. A medically trained psychologist, Myers was brought on by the British military to study and treat soldiers who were unable to function without any discernible cause.

At the time, many viewed shell shock as cowardice. Myers, on the other hand, argued that it was a psychiatric condition that caused affected soldiers to dissociate from a traumatic experience and repress its memory. The treatment, he concluded, involved connecting the traumatic memory back into one’s awareness through a series of psychotherapy sessions. These were ideally held within a military setting but away from gunfire.

 became an official diagnosis in the third edition of the DSM. Initially considered an anxiety disorder, PTSD is part of a separate group of trauma- and stressor-related disorders in DSM 5. DSM 5’s PTSD diagnosis also includes witnessing an event as a qualifying trauma.

PTSD is expressed by 4 main clusters of symptoms: reexperiencing the trauma in the form of intrusive memories, flashbacks, or nightmares; avoidance of anything that reminds an individual of the event; arousal and hyperreactivity, such as being easily startled or feeling tense; and effects on cognition and mood that include negative thoughts, feelings of guilt or blame, or a loss of interest. To receive a diagnosis of PTSD, these symptoms have to last more than a month and be functionally impairing.

Although anyone experiencing a trauma may have these reactions, symptoms usually fade over time and do not lead to PTSD. For others, however, the symptoms are severe, persist, and cause significant dysfunction.

The disorder can be diagnosed by using the Clinician-Administered PTSD Scale for DSM 5, a 30-item structured interview.

 It is considered the gold standard for measuring PTSD in clinical trials, but it is difficult to use in a clinic setting. The PTSD Checklist for DSM 5 is a 5- to 7-minute questionnaire that may be more practical to use in the clinic. It is regularly used to establish national PTSD outcome data.

Since the 9/11 terrorist attacks in 2001, 775,000 troops have 

 on a mission to retaliate and stabilize the region. More than 2400 died, about 20,000 were wounded, and countless others have been haunted by what they have seen and experienced.

When the Taliban regained control of Afghanistan in August, texts to the Veterans Crisis Line jumped 98% compared to a year prior. Chats and phone calls rose 40% and 7%, respectively.

 While this is troubling, the VA also noted it was an encouraging sign that more veterans were seeking help for their mental health issues. One survey revealed that one-third of veterans seeking counseling were doing so for the first time.

About 70% of veterans have struggled with mental health issues since serving in the Afghanistan war.

 Since August, 90% of Afghanistan service members have experienced new or worsening mental health issues. About 75% are experiencing new or worsening symptoms of depression, 58% have started or increased drug or alcohol use, and 64% have new or worsening thoughts of suicide.

 tend to experience more severe symptoms and lower remission rates compared to noncombat-related PTSD.

 Indeed, the kind of warfare experienced in Afghanistan is likely to put anyone on edge. This includes guerrilla attacks, roadside and suicide explosives, and a wary uncertainty about safe zones and battlegrounds. When an attack can come from anywhere at any time, the amygdala will be more active, and PTSD may be more likely.

Although improvements in body armor and combat medicine protect service members who would have died from their wounds in earlier wars, it leaves them with psychological scars as well as possible PTSD, brain injury, and a host of other lifelong debilities.

Troops today are serving at younger, more impressionable ages.

 In the Vietnam War, troops mostly served a single tour. Now, more than half return to action, with some serving more than 5 tours.

 Studies have shown that morale decreased and psychiatric problems as well as the use of psychotropic medication increased during the second or third deployment. Similarly, communication with family was difficult, and separation or divorce rates increased.

Younger age, female gender, minority background, as well as lower socioeconomic status, military rank, and education all indicate a higher risk of PTSD.

 In addition to trauma from battle, sexual trauma is common in the military, with about 1 in 3 women and 1 in 50 men reporting military sexual trauma (MST).

 With fewer women in the military, 1 in 3 veterans who report MST are men.

In addition to PTSD, many Afghanistan combat veterans also suffer from moral injuries, which occur when a trauma cuts so deep it violates an individual’s moral beliefs.

 Moral injury also describes an individual’s internal conflict over things they have done to others, actions they have failed to do, and events they have witnessed others doing or failing to do. Examples of moral injury include killing others (innocent or not), dismembering bodies, torturing others, or abandoning comrades during battle.

Moral injury is highly common among service members, with at least 1 symptom appearing in 90% of veterans and 80% of active duty military.

 It is a separate and distinct syndrome from PTSD that can co-occur and be influenced by the same event. Although it shares similar symptoms with PTSD, it would be a mistake to treat it the same. In fact, the existence of unresolved moral injury can hinder the treatment of PTSD, as well as 

Shame is the underlying theme of moral injury. It is shaped by the event that caused it, and it continues to develop for years after a service member has returned home.

 Disgust also plays a major role. Studies indicate that elevated levels of disgust, whether moral or bodily, can increase intrusive thoughts and tend to be higher in those with PTSD.

Moral injury also involves feelings of guilt, betrayal, loss of meaning and trust, difficulty forgiving, self-condemnation, and inner conflict over moral implications. Moral injury can shake a patient’s spirituality and call into question their relationship with a higher power.

 It is also correlated with social anxiety isolation, depression, and 

As the understanding of PTSD has advanced, it has become clear that it is a neurobiological disorder driven by environmental trauma. It is likely a product of both nature and nurture and may be caused by a combination of biological vulnerability and 

PTSD involves the amygdala, prefrontal cortex, and hippocampus. The amygdala regulates intense emotions, particularly fear. It governs fear conditioning and contributes to symptoms of altered arousal and reactivity. The prefrontal cortex regulates conditioned fear, normally turning down the alarm signal from the amygdala. PTSD can occur when decreased activity in the prefrontal cortex prevents it from appropriately regulating heightened activity in the amygdala.

The hippocampus can help buffer the effects of increased amygdala activity. There is evidence to suggest that the hippocampus tends to be smaller in those with PTSD, but it is not entirely clear whether that is the cause of PTSD or the result of it. Studies of identical twins have indicated that a smaller hippocampus at baseline may make people more vulnerable to developing PTSD.

Since the fall of Afghanistan, 31% of veterans have sought professional mental health services for the first time.

 It is a sign of hope that barriers to treatment are softening. 

, in particular, has become a useful way to reach patients who are either hesitant to engage in treatment or live in remote places.

A 2014 survey of 7600 veterans revealed that those who believed they needed treatment, kept a positive attitude, and had strong social networks were more likely to be successfully treated for PTSD.

 However, treating PTSD can be a challenge, and current treatment options are not always effective.

Close to 60% of those with PTSD do not achieve remission, and although treatment-resistant PTSD is hard to define, up to one-third of patients do not find relief with current therapies.

 Chronic PTSD can lead to decreased life satisfaction as well as increase suicide risk and depression rates.

Trauma-informed care seeks to tailor treatment around the unique vulnerabilities of each patient. The goal is to help a patient process their PTSD experiences without retraumatizing them in the process. To do this, clinicians need to fully understand every aspect of a patient’s traumatic event, including earlier ones. Additionally, they put a high emphasis on safety, encourage patients to rebuild control, and teach them to build upon their individual strengths.

Homeless veterans with PTSD, in particular, can benefit from trauma-informed care. While veterans comprise 7% of the total US population, they represent 12% of homeless adults.

Providing a trauma-informed approach necessitates adapting treatment to the needs of these patients. It helps earn their trust and protects them from retraumatization. PTSD is like a giant wound that many veterans will carry throughout their lives. Healing must start from the inside out. As clinicians, our job is to help them integrate the experience of trauma without being overwhelmed by it.

 used as first-line treatments of PTSD. With cognitive processing therapy, therapists teach patients coping skills and help them identify negative thoughts associated with a traumatic event and replace those thoughts with coping skills. With prolonged exposure (PE), patients revisit the trauma repeatedly in a safe, clinical setting to change how they react to the memories of the event. PE has an efficacy rate of about 60% of veterans with PTSD.

. In treating PTSD, the use of medications, specifically selective serotonin reuptake inhibitors (SSRIs), is to make therapy more effective by reducing the intensity of the overwhelming anxiety caused by PTSD. This anxiety can limit how effectively patients are able to discuss and process their trauma in therapy, which can hinder the healing process. SSRIs have a 60% rate of response in patients with PTSD, but only 20% to 30% achieve complete remission.

, such as ketamine and psilocybin mushrooms, is also currently being researched in their potential to treat PTSD, but these studies are still in the early stages of understanding how they might be useful.

Eye-movement desensitization reprocessing (EMDR).

 After ensuring a patient is prepared to process their trauma, this treatment works to replace negative images and beliefs with more positive ones. During treatment, a patient pays attention to a back-and-forth sound or movement while recalling a traumatic event. The sound or movement gives them a focus that allows them to explore and process their trauma.

 is showing potential as a possible future treatment. It works by delivering highly focused magnetic fields to modulate neural circuits in the brain. It is currently used for patients with treatment-resistant depression. Studies indicate TMS could be used to treat the poor extinction of traumatic memory by targeting the prefrontal cortex.

. Yoga and breathing-based meditation are thought to help calm the hyperactive sympathetic nervous system brought on by PTSD. In one study, veterans who practiced Sudarshan Kriya yoga showed reductions in PTSD scores, anxiety symptoms, and respiration rate.

 In another study, half of the group of veterans who practiced transcendental meditation for 3 months did not meet the criteria for PTSD at study completion, compared to a control group at 10%.

 has also been shown to indirectly reduce self-stigma felt by many veterans as well as other symptoms of PTSD.

. For veterans suffering from moral injury, programs such as 

 can help trauma survivors address a variety of spiritual concerns.

In these programs, which are administered by trained chaplains, veterans explore issues of forgiveness, their relationship with a higher power, and why that higher power allows evil to occur in the world.

 is still under investigation, it seems to have a positive effect on those with PTSD. One study found that cannabis lowered threat-related activity in the amygdala.

 A second study observed that cannabis seemed to diminish the intensity of memories associated with trauma.

 The use of cannabis to treat PTSD has not been approved by the US Food and Drug Administration and remains illegal in many states.

Articles

The US withdrawal from Afghanistan stirs memories of trauma among veterans.

PTSD’s Long Reach

In 1970, a group of gay and lesbian activists made history when they disrupted the annual meeting of the American Psychiatric Association (APA) in San Francisco. Outside the convention center, they formed a human chain to prevent visiting psychiatrists from entering. Inside, they interrupted sessions on transsexualism, laughed at a purported expert on homosexuality, and were so disruptive that a panel titled “Issues of Sexuality” it had to be adjourned.

A year later, they returned with the same demand: delist homosexuality from APA’s Diagnostic and Statistical Manual—where it had been classified as a sexual deviation.

In 1972, the APA allowed a panel of gay activists to make their case. Among them was John E. Fryer, MD, a psychiatrist who appeared in disguise, worried he might lose his license because he was gay.

In 1973, the APA put the issue to a vote, with the majority of attending psychiatrists agreeing to remove homosexuality as a mental disorder from DSM-III. However, the APA compromised by replacing the term 

. This, they argued, would allow homosexuality to be considered an illness if an individual distressed with being gay sought psychiatric help to reverse it.

The APA took the final step in 1987 and dropped this reference completely. They officially adopted what is considered a normal variant view on sexual identity. Individuals could, they acknowledged, be born gay.

 A collection of educational content for mental health providers treating LGBTQI patients.

 The terminology used within the LGBTQI community is as diverse as its individuals and is always evolving. The Human Rights Campaign, the largest LGBTQI advocacy group and political lobbying organization in the US, has a helpful glossary of terms.

 The World Professional Association for Transgender Health provides clinical guidance for health professionals to assist transgender, transsexual, and gender-nonconforming people.

 A community of psychiatrists that educates and advocates on LGBTQI mental health issues.

It is against this backdrop that the uneasy relationship between psychiatry and the 

lesbian, gay, bisexual, transgender, queer, and intersex community

 (LGBTQI) continues to evolve. While there are far more protections than there were in the 1950s, this is a group that still struggles to find acceptance, especially its 

The ideal model of health care is that patients receive unbiased care regardless of gender identity or sexuality. In reality, however, clinicians may both consciously and subconsciously discriminate against members of the LGBTQI community, causing many to forego needed care.

 associated with minority stress, or the unique experiences associated with homophobic victimization.

 Many grapple with feelings of shame, rejection, and depression. They are the target of abuse, trauma, and bullying. As a result, they experience higher rates of homelessness, substance abuse, and suicide.

As mental health professionals, it is our ethical responsibility to identify our biases as clinicians. We need to educate ourselves about the needs of this unique and ever-evolving population, to provide the best care possible, and to do so in a way that does not perpetuate the stigma and trauma many sexual minorities contend with daily.

Health Disparities in the LGBTQI Community

As of 2017, there were 9 million adults in the United States, about 3.8% of the country’s population, who 

identified as lesbian, gay, bisexual, or transgender

It takes incredible courage to come out in front of family, friends, school, work, and society at large. It can be an extremely vulnerable experience that can elicit reactions of anger, rejection, and even violence from others. Additionally, there are many subpopulations within the LGBTQI community that have their own unique risk factors that must be considered in the context of care.

, 39% said they had been rejected by a family member or friend because of their sexual orientation. About 30% said they had been attacked or threatened because of it, and 58% said they were the target of jokes or slurs.

When talking with patients, subtle word choices can make all the difference. Here are a few words and phrases to avoid as recommended by the Gay & Lesbian Alliance Against Defamation (GLAAD.)

LGBTQI individuals are more than twice as likely to experience a mental disorder compared to heterosexual men and women. They are also 2.5 times more likely to experience depression, anxiety, and substance misuse.

Almost 12% of gays, lesbians, and bisexuals have considered attempting suicide, compared to 2.3% of heterosexual individuals. With transgender individuals, this number jumps significantly to 30.8%.

Another big challenge facing the LGBTQI community is substance abuse and homelessness. 

 on drug use and health revealed that 39.1% of sexual minorities used illicit drugs, compared to 17.1% among sexual majorities.

 than non-LGBTQI youth. And black LGBTQI youth were even more at risk for homelessness. While 7% of black non-LGBTQI youth were homeless in the United States, that number jumped to 16% for black LGBTQI youth.

These statistics for youth are particularly troubling. More youth are coming out as gay or transgender at younger ages, perhaps due to the growing social acceptance for LGBTQI communities. The average age of coming out was around 14 years old, according to data collected between 2000 and 2010. A decade earlier, this age was 16. In the 1970s, it was 20. Despite this trend, concerns about the rising prevalence of adolescent LGBTQI mental health issues are increasing.

Perhaps because they are already grappling with identity development, adolescents are already at increased risk for suicide; it is a 

 LGBTQI youth, however, tend to have higher rates of mental health issues, with 18% meeting the criteria for depression, 11.3% experiencing posttraumatic stress disorder, and 31% reporting suicidal behavior at some point during their lives. This compared to national youth rates of 8.2%, 3.9%, and 4.1%, respectively.

The reason behind these rates may have to do with increased peer pressure experienced during these ages. One 2012 study pointed to stronger prejudicial attitudes and homophobic behaviors among youth 12 to 18 years old, especially among boys.

 revealed that 86% of LGBTQI students experienced harassment or assault at school, according to the Gay, Lesbian, & Straight Education Network (GLSEN), a national organization that supports the LGBTQI community in K-12 schools.

When LGBTQI people turn to mental health providers for help, they are often let down. Almost one-sixth of LGBTQI adults have felt discriminated against at a doctor’s office, while one-fifth say they avoid medical care altogether due to their fear of discrimination, 

 conducted by Harvard University, National Public Radio, and the Robert Wood Johnson Foundation.

A 2018 Harvard panel said health care providers were woefully unprepared to address the needs of the LGBTQI community. Panelists said providers needed to do a better job gathering data about these patients, even if it meant asking them direct questions about their sexual health.

 For many providers, improvements in mental health care must be based on increased education and understanding of how different people experience and express gender identity.

Understanding Gender Identity and Expression

Today, there are increasing efforts being made to explore what, exactly, gender is and how it should be defined. In Eurocentric models rooted in colonialism, gender has been identified as a 

that distinctly categorizes individuals as either male or female based on their sex.

 It operates on the idea that gender can be visually seen as a bodily characteristic, with males having penises and females having vaginas. Gender-identity research is shifting away from this binary approach and acknowledging that the idea of gender exists on a spectrum. It is not defined by simplistic biological characteristics and is 

While our understanding of the concept of gender is evolving, gender has been postulated to encompass 4 parts: anatomical sex, gender identity, legal gender, and gender expression. Anatomical sex generally refers to genitalia, chromosomes, and bodily attributes. Gender identity refers to one’s sense of self, which can be fluid and change over time and within context. Legal gender is tied to an individual’s assigned gender at birth and is used as a way to measure differences between genders, such as health and wage disparities. Gender expression is how a particular individual presents their gender identity to society, usually through appearance, dress, and behavior. Cisgender refers to those whose self-defined gender identity matches their assigned gender at birth. Transgender refers to others whose assigned gender at birth does not match their self-identified gender.

The problem with a simple binary description of gender identity tends to be with its limitations. In research studies, for example, most demographics include gender responses with very little reflection on why it is included or 

 This standard fails to consider findings related to other gender identities, which can provide results that are inaccurate or misrepresented. Additionally, by only giving male or female as gender options, it immediately discriminates against anyone who does not identify as either.

This discrimination continues in other areas. Even though APA’s recognition of gender dysphoria as a diagnosis is not necessarily stigmatizing, it is the gatekeeping of care that perpetuates the stigma. In addition to a gender dysphoria diagnosis, transgender individuals, for example, need to jump through significant hoops to access gender-affirming care—including psychological evaluations, letters of support, and therapy.

These are just some examples of how the mental health community needs to shift awareness to treat a population desperately in need of treatment and acceptance.

For decades, psychiatry viewed being gay as a degenerative disorder. It created a deep scar that the mental health industry must now work to mend by setting aside biases, broadening our understanding, and earning the trust of LGBTQI patients. To do so, it is vitally important to refrain from making assumptions about a patient’s gender, sexuality, or sexual identity. It is always necessary to ask about an individual’s pronouns. Do not refer to them as preferred pronouns; they are simply pronouns.

Clinicians are obligated to be aware of their own biases, both conscious and subconscious, that can potentially negatively influence the care provided to their clients. This will help avoid any countertransference of opinion from provider to client.

Creating a therapeutic container is essential for holding patients in a safe place that allows them to express any feelings of pain and shame.

 This is based on Carl Jung’s concept that compares the therapeutic container to an alchemical container that safely holds the feelings and thoughts of patient and analyst alike.

 authors Caroline Shahbaz, BBSc(Hons), MPsych, MA; and Peter Chirinos, MA, LPC, NCC, DCC; offer the following guidelines to create a therapeutic container:

- Validate the sociopolitical issues confronting a patient’s marginalized community

- Do not assume their psychological problems are a function of their sexuality

- Connect patients with appropriate communities and networks

LGBTQI patients may engage in sexual activities that a provider may find disturbing and uncomfortable, which is indicative of a clinician’s own conscious and unconscious biases that can impede a patient’s progress in care. As with any patient population, when treating sexual minorities, competent care as it relates to this population must be the standard of practice and directly translates into making patients feel accepted and validated.

By providing competent care as clinicians, we can continue to bridge the gap of trust and open new appropriately informed ways to treat and support the LGBTQI community. In a sign of hope for the future, the American Psychoanalytic Association issued what it called an “

” in 2019 to members of the LGBTQI community for its “role in the discrimination and trauma caused by our profession.”

 Moving past apologies, the mental health community needs to focus on restorative justice on both the macro and micro levels. This can include educating themselves and their peers, centering learning from LGBTQI individuals, using cultural safety and trauma-informed frameworks for care, and reducing gatekeeping to gender-affirming care.

Additionally, it is vitally important to advocate for policy changes both in the mental health field and with broader causes that disproportionately impact LGBTQI individuals, such as fair housing, harm reduction, and antidiscrimination legislation. Only a multi-pronged approach will ensure members of the LGBTQI community receive the mental health services many of them so desperately need.

is an Adolescent and Adult Psychiatric Mental Health Nurse Practitioner with 

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https://www.nami.org/Your-Journey/Identity-and-Cultural-Dimensions/LGBTQI

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https://www.pewresearch.org/social-trends/2013/06/13/a-survey-of-lgbt-americans

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https://www.samhsa.gov/data/sites/default/files/NSDUH-SexualOrientation-2015/NSDUH-SexualOrientation-2015/NSDUH-SexualOrientation-2015.htm

5. Chapin Hall at the University of Chicago, Voices of Youth Count. Missed opportunities: LGBTQ youth homelessness in America. April 2018. 

https://voicesofyouthcount.org/wp-content/uploads/2018/05/VoYC-LGBTQ-Brief-Chapin-Hall-2018.pdf

6. Russell ST, Fish JN. Mental health in lesbian, gay, bisexual, and transgender (LGBT) youth. 

7. Centers for Disease Control and Prevention. Adolescent health. Updated April 14, 2021. Accessed June 3, 2021. 

https://www.cdc.gov/nchs/fastats/adolescent-health.htm

8. Poteat VP, Anderson CJ. Developmental changes in sexual prejudice from early to late adolescence: the effects of gender, race, and ideology on different patterns of change. 

9. GLSEN. The 2019 National School Climate Survey. 2019. Accessed June 3, 2021. 

https://www.glsen.org/sites/default/files/2020-10/NSCS-2019-Executive-Summary-English_1.pdf

10. Powell A. The problems with LGBTQ health care. 

https://news.harvard.edu/gazette/story/2018/03/health-care-providers-need-better-understanding-of-lgbtq-patients-harvard-forum-says/

11. Lugones M. The Coloniality of gender. 

https://globalstudies.trinity.duke.edu/sites/globalstudies.trinity.duke.edu/files/file-attachments/v2d2_Lugones.pdf

12. Ainsworth C. Sex redefined: the idea of 2 sexes is overly simplistic. 

https://www.scientificamerican.com/article/sex-redefined-the-idea-of-2-sexes-is-overly-simplistic1/

13. Lindqvist A, Sendén MG, Renström EA. What is gender, anyway: a review of the options for operationalising gender.

https://www.tandfonline.com/doi/full/10.1080/19419899.2020.1729844?scroll=top&needAccess=true

14. White Hughto JM, Reisner SL, Pachankis JE. Transgender stigma and health: A critical review of stigma determinants, mechanisms, and interventions. 

15. Finlay L. Holding, containing and boundarying. In: 

Relational Integrative Psychotherapy: Engaging Process and Theory in Practice

The uneasy relationship between psychiatry and the LGBTQI continues to evolve. How can it be influenced for the better? 

Bridging the LGBTQI Gap in Care: Why Psychiatrists Need To Do More To Treat These At-Risk Communities

Videos

Suicide is the third leading cause of death in people aged 15-24. Review how you can assess adolescents for suicidal ideation. 

Summer R. Thompson, DNP, PMHNP-BC

Articles

PTSD’s Long Reach

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