In our Ask a Doc series, we sit down with physicians and other clinical experts across our networks, including Allegheny Health Network (AHN), for a chat on an important health topic. In this edition, we’re talking about resources and support for young people who’ve experienced trauma including those who are lesbian, gay, bisexual, transgender and questioning/queer (LGBTQ) with Dr. Judith Cohen.
The Allegheny General Hospital Center for Traumatic Stress in Children and Adolescents (CTSCA) serves children and adolescents who have experienced trauma, and their parents or other caregivers. The center is a national leader in developing and researching evidence-based, trauma-focused treatment for young people.
Amanda Changuris (AC): Dr. Cohen, let’s start by defining what trauma is, and then how the CTCSA works with young people to help them through treatment.
Dr. Judith Cohen (JC): The center’s clinical research program goes back 21 years and provides treatment to children, adolescents and families that have experienced traumatic events ranging from the death of an important person in their lives, to disasters, to domestic or community violence, to child maltreatment, including abuse. We most commonly see children or adolescents who have experienced multiple traumas, typically three or more types of traumas, often occurring chronically over many years.
First and foremost the center provides clinical treatment using the Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) model an evidence-based approach developed at the Center for children ages 3 to 18 years, their parents or primary caregivers. Parents (or caregivers) and their children begin treatment in separate sessions, with joint sessions also included in treatment over time. Treatment teaches children and their parents how to cope with trauma through skills like self-expression, processing their thoughts, and relaxation. We also stress the importance of creating a safe environment for future growth and development.
AC: I know treatment is just one aspect of the center’s mission; what other work are you doing?
JC: There are three components, really. Our clinical services are always at the forefront of what we do. Our research provides information about how to provide the best clinical services, and we have received research funding from the Substance Abuse and Mental Health Services Administration (SAMHSA), National Institute of Mental Health, National Institute of Child Health and Human Development, Department of Justice, the Pennsylvania Department of Mental Health and other entities. And there is also a strong training and dissemination component in other words, part of what we do is help other professionals to understand and use TF-CBT in their areas. The balance of these three components fluctuates somewhat depending on the funding that we have at a given time, but all three are important parts of our mission.
AC: Research from groups like the Gay, Lesbian & Straight Education Network (GLSEN) shows that the vast majority of lesbian, gay, bisexual, transgender and questioning/queer (LGBTQ) youth experience harassment. How do those experiences have an impact on their health?
JC: LGBTQ youth are at heightened risk for experiencing trauma, which contributes to poor medical and mental health outcomes. Throughout the center’s history, we have focused, and are increasingly focusing, on behavioral health disparities in certain populations, including children in foster care, children of military families, children of color, and LGBTQ youth. This is currently a primary goal through our SAMHSA-funded grant as part of the National Child Traumatic Stress Network.
LGBTQ youth experience higher rates of many types of trauma. When combined with family rejection issues, this also makes them more likely to develop physical and mental difficulties such as depression and suicide, and puts them at higher risk of becoming runaways and being homeless, of becoming victims of sexual and physical assault, of acquiring STDs and so on. At the center we are working to develop and test preventive interventions to avoid those negative outcomes.
Preventive interventions are early interventions that can prevent worse outcomes later on. In our setting, we identify youth who already have experienced some type of trauma or stressors, hopefully at an earlier stage when they may have some mental health or medical problems, but before they develop more serious ones. We provide coping and resiliency skills (typically those that are in the TF-CBT model) and also work to enhance the safety and available support for these youth in order to prevent or minimize future traumas. An example of a preventive intervention for LGBTQ youth might be providing education and prevention skills related to commercial sexual exploitation (sex trafficking), since LGBTQ youth are at elevated risk for this type of trauma.
AC: I understand the center also works to help other medical professionals to address health disparities.
JC: Yes, that’s an important part of our mission. For example, we have worked with PERSAD Center to develop materials including a video featuring five LGBT youth who talk about their own trauma experiences to help medical professionals create a more safe and welcoming environment for youth who have experienced trauma. We have developed written materials to help professionals think more carefully about creating safer environments. There are also webinars available via The National Child Traumatic Stress Network’s online learning center including one on teen sexual assault that includes the parent of one of my patients who was sexually assaulted after coming out as being LGBTQ.
AC: It’s easy to see that you’re an advocate for young LGBTQ people who are trying to overcome a traumatic experience. How did this become an area of focus for you as a doctor?
JC: I started training in pediatrics but found that what I liked best was talking to kids and parents. During my psychiatric and child psychiatric residency, two new diagnoses were introduced that hadn’t previously existed: post-traumatic stress disorder (PTSD) and AIDS. Both have significantly shaped my vision and my career.
Any of us who were there at the beginning of AIDS and saw how politics interfered with providing medical care in the 1980s couldn’t help but be affected by that. We watched a whole generation of gay individuals be decimated as much by stigma and discrimination as by a virus. My training director at Western Psych died of AIDS. He was a beloved individual and a role model for me, so that was a very important transformative experience. We all knew people who died during that generation. Everyone in health care had personal connections to at least one person who died. So this was, and is, a very personal issue.
We thought that changed over time, and it has, but when my children were going off to college, there was the Matthew Shepard murder; a young man also in college who was brutally murdered because he was gay. Just last winter a transgender child committed suicide Leelah Alcorn because of prejudice and the inability to accept her identity as a transgender person. So yes, 30-some states now allow gay marriage and there has been progress, but we need to do better.
My 3-year-old grandson said something profound while playing a game a few years ago. We were trying to divide up 20 toy cars equally between him, his sister and me, and of course you can’t do it evenly. I said, “I don’t need the same number of cars,” and he said:
That’s not what equal means, Nana. If it’s not equal for everyone, it’s not equal for anyone.
And that’s exactly it: We’re not there it’s not equal for everyone. Until we get there we all have to do the work of making things equal. That’s why I feel so strongly about LGBTQ issues. We all have to do better, to do the best we can for all of us.