Out On The Couch
Telehealth offers psychotherapists a way to provide quality mental health services while still practicing and promoting extreme social distancing. This practice, instituted early, can help save lives during the COVID-19 pandemic (Pueyo, 2020; Stevens, 2020). Psychotherapists who work with queer communities should be switching to telehealth in order to decrease the risk faced by community members.
APA has created guidelines for telepsychotherapy, which can be helpful for psychotherapists who are new to providing telehealth services (APA, 2013), and numerous articles are popping up around how to do this well (APA, 2020, Palmer, 2020). This article will not focus on how to practice telehealth, but rather on why psychotherapists working with queer communities should be switching to telehealth now.
Queer communities face physical and mental health factors that may increase their risk of infection and serious illness. This is not meant to be a list to create panic, but rather to emphasize that psychotherapists who work with community members should help reduce risk by a) moving to telehealth and b) talking to their patients/clients about how to stay connected with social networks while practicing extreme social distancing. Telepsychotherapy can be viewed as an act of social justice that will save lives.
Risk factors include:
Minority stress and its impact on immune function
Minority stress describes the unique difficulties and strain on mental health and wellness experienced by racial, ethnic, cultural, sexual, and gender minorities (Meyer, 2003). LGBTQIA+ people face such stressors, which can range from unconscious microaggressions to outright violence and hatred, on a daily basis. LGBTQIA+ clients of color frequently deal with oppression that intersects across homophobia/biphobia/transphobia and racism.
Research has consistently shown that stress impacts immune function (Alessi & Bennett, 2020). It is hypothesized that the higher rate of physical health problems in LGBTQIA+ communities can be attributed to minority stress (Flentje et al., 2019).
Two resilience factors have been identified for helping to address minority stress in transgender people: community connectedness and pride (Testa et al., 2015). Telepsychotherapy can help clients find new ways of connecting with community while maintaining social distance, and may help clients find identity pride.
Telepsychotherapy can also assist LGBTQIA+ clients in addressing minority stress and the increased strain of navigating life during a pandemic while maintaining social distancing and avoiding the spread of COVID-19.
Loss of community space and its negative impact on health
Extreme social isolation may protect from COVID-19, but it can also negatively impact mental health–especially for clients who are not living in safe environments.
When LGBTQIA+ people live with others who don’t accept their identities, their mental health may decline as they lose access to queer spaces. This is especially true of children and adolescents, who have even more limited mobility and choices as minors. There are special considerations for minors and consent with telehealth that must be taken into account when providing telepsychotherapy.
LGBTQIA+ communities are more likely to experience intimate partner violence (IPV; Brown & Herman, 2015). Staying home may not be healthy for some community members; it has been hypothesized that IPV could spike as people are quarantined at home (Sherman, 2020). Since social isolation is a tool for perpetrators, COVID-19 may provide an increased risk factor (Jeltsen, 2020). IPV shelters may need to close down to avoid risk of spreading COVID-19. Telehealth when a partner is being abused can be especially tricky due to lack of privacy in the home, and is another factor that must be taken into consideration when telepsychotherapy is being offered.
That being said, in many situations, telepsychotherapy can create connection, thereby helping to minimize some of the emotional difficulties that social distancing may create.
Mental health conditions’ negative correlation with immune function
LGB people are more than twice as likely as their cisgender, heterosexual counterparts to struggle with mental health conditions (Medley et al., 2016). Both depression and anxiety have been linked to inflammatory responses and immune dysfunction in the body (Brandslet, 2019). All the links between mental health and immune function are not clear yet, but making sure that people have access to mental health services during this pandemic can help limit the negative impact of mental illness on physical health.
Some substance use disorders’ impact on the respiratory system
COVID-19 is a virus that affects the respiratory system, which could mean that it is an even bigger threat to anyone who smokes tobacco or cannabis, or to those who vape (National Institute for Drug Abuse, 2020). LGB people are more likely than their heterosexual counterparts to be smokers, with bisexual people having the highest smoking rates of the three (American Lung Association, 2010). Vaping is also higher in LGB adults (Rifai et al., 2019).
LGBT people are more likely to struggle with opioid use disorder (OUD; Girouard and LGBT Health Education Center, 2018). People struggling with opioid use disorder (OUD) may be vulnerable to COVID-19 due to the ways in which opioids affect the lungs (National Institute on Drug Abuse, 2020). Those struggling with OUD may use methadone to reduce cravings, but since methadone is a schedule-II controlled substance, many access it through clinics. The Substance Abuse and Mental Health Services Administration (SAMHSA, 2020) has introduced guidelines for those who may have been exposed to COVID-19 and need to access medication. Having a clinic follow these guidelines will help mitigate risk.
Methamphetamine also impacts pulmonary health (National Institute on Drug Abuse, 2020). Gay men are dying at an alarming rate from meth abuse (Mangia, 2020). Chemsex, which involves combining drugs (like crystal meth, cocaine, and MDMA) with sexual activity, is on the rise due to hookup apps like Grindr (Branson-Potts, 2020). Chemsex is associated with higher risk of HIV infection due to unsafe sexual behaviors (Washton, 2019). To make matters worse, those who are HIV-positive are less likely to stay medication compliant (Washton, 2019).
Social distancing could increase a person’s desire to use drugs or alcohol. If a client is participating in 12-step meetings to help, loss of ability to attend in-person meetings can be especially detrimental. Luckily, there are online 12-step groups that allow people to continue to work the steps and stay safe from COVID-19.
Telepsychotherapy can also help our clients not only reduce risk of harm from substances, but also from COVID-19.
Some HIV-positive clients’ reluctance to come in
There is no evidence that HIV-positive clients who are on stable antiviral medications will face a higher risk with COVID-19 at this time (Highleyman, 2020; Gustav, 2020). If HIV has impacted the immune system, there may be a different story. Luckily, HIV medications have come a long way; HIV is not the death sentence it once was. Helping clients navigate the sea of information (and misinformation) can help alleviate panic for HIV-positive clients.
There may be heightened anxiety and stress around having HIV during this pandemic due to the nature of HIV affecting the immune system. Some of this anxiety may be heightened around possible shortages of medications due to many pharmaceuticals coming from China (Highleyman, 2020). Working with clients to strategize about how to access medication and get a larger supply (to last a month or longer) to avoid interruption can be helpful.
Our HIV population is aging, and some of our older LGBT community members may still remember the horror of the AIDS crisis (Rostovsky, 2019). COVID-19 may bring up some of those difficult and traumatizing memories. Telepsychotherapy can help provide safety from COVID-19 while providing space to process these traumatic events.
Affirmative psychotherapists are hard to find
Affirmative therapists are in a unique position to help LGBTQIA+ community members due to the training and experience they have in working with these communities. As an invaluable resource to the community, there is not only the risk of you spreading COVID-19 to the community, but you getting COVID-19 yourself if you continue seeing clients in person. In the best case, you need to take some time off. In the worst case, you are the next victim of the virus. If this happens, your LGBTQIA+ clients may struggle to find another affirmative therapist due to the lack of competent providers. Keeping yourself healthy is a great way to continue to provide services to the community.
In order to keep yourself, your clients, and everyone safe, please consider switching to telepsychotherapy now. LGBTQIA+ clients face unique risk factors that may impact how COVID-19 affects them. This pandemic is already wreaking havoc in China, Italy, and Iran; let’s not have it wreak havoc here.
Learn more about working with LGBTQIA+ Clients
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American Lung Association. (2010). Smoking Out a Deadly Threat Tobacco Use in the LGBT Community. Retrieved March 15, 2020, from https://www.lung.org/assets/documents/research/lgbt-report.pdf
American Psychological Association. (2013). Guidelines for the practice of telepsychology. Retrieved March 15, 2020, from https://www.apa.org/practice/guidelines/telepsychology
American Psychological Association. (2020). COVID-19 and psychology services: How to protect your patients and your practice. Retrieved March 15, 2020, from https://www.apaservices.org/practice/news/covid19-psychology-services-protection
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Brandson-Potts, H. (2020). Fighting meth-fueled ‘chemsex’ in the LGBTQ community, West Hollywood takes a stand. Retrieved March 15, 2020, from https://www.latimes.com/california/story/2020-02-13/weho-chemsex-methamphetamine-lgbtq
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Girouard, P. and National LGBT Health Education Center. Addressing opioid use disorder among LGBTQ Populations. Retrieved March 15, 2020, from https://www.lgbthealtheducation.org/wp-content/uploads/2018/06/OpioidUseAmongLGBTQPopulations.pdf
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Washton, A. (2019). A Vicious Cycle: Stimulant Drugs and Compulsive Sex. Retrieved March 15, 2020, from https://www.rehabs.com/pro-talk/stimulant-drugs-and-compulsive-sex-how-to-break-the-cycle/