Abstract
The LBGT population is a community that still needs to be studied. It was identified as a risk population with little evidence and understand as to why. There has been increasing investigations of depression, anxiety and suicide, but not in self injury in the population. Nonsuicidal self injury among lesbian, gay, bisexual, and transgender populations: an integrative review is the research that was chosen. It investigates 26 quantitative and qualitative empirical research studies in the LGBT population and self injurious behaviors to begin to close the knowledge gap and increase understanding of risk factors and prevention, using specific keywords. It identifies subgroups that is at an increased risk within the community. The results support the hypothesis of LGBT population is at an increase, especially those in the transgendered community. This research is applicable to a specific patient that had been interviewed in a psychiatric facility. The research supports it is only even more important to specific sexual orientation and self injury screening by nurses, who are active participants in improving mental health disparities and competence of care.
Keywords: LBGT, bisexual, gay, lesbian, mental health, non suicidal self injury, sexual and gender minorities, transgender risk factors,
Databases: EBSCOhost, PubMed, PsychINFO, CINHAL
Self Injurious Behaviors in the LGBT+ Community
There hasn’t been enough understanding to a community that has been identified as a risk population by the U.S. Surgeon General in 2001. For four decades the lesbian, gay, bisexual and transgender (LGBT) population has been reported of having an elevated risk of suicidal behaviors as well as self injurious behavior. Despite these reports, there has been little information and research increasing the understanding of risk factors, prevention, intervention and health policies. The research that was chosen was on non-suicidal self injury done in the LGBT population among all ages and ethnicities. The research was relevant to a client that was encountered in a psychiatric facility presenting with self injurious behavior and suicidal intent. The research literature review was published by the Journal of Clinical Nursing by nurses with advanced degrees teaching at the School of Nursing at Columbia University. (Jackman, et al, 2016)
Background
Before beginning the research, there are concepts that need to be understood. The research needed to involve sexual minorities. Sexual minorities are as having two characteristics: sexual orientation and gender identity. Sexual orientation as either self identifying as gay/lesbian, bisexual or heterosexual or the gender of sexual partners (same, both same and opposite or just opposite). “Sexual orientation is defined as an often enduring pattern of emotional, romantic and/or sexual attractions of men to women or women to men (heterosexual), of women to women or men to men (homosexual), or by men or women to both sexes (bisexual). It also refers to an individual’s sense of personal and social identity based on those attractions, related behaviors and membership in a community of others who share those attractions and behaviors. Some people who have same-sex attractions or relationships may identify as “queer,” or, for a range of personal, social or political reasons, may choose not to self-identify with these or any labels.” (APA, 2018) Gender identity refers to a person’s internal sense of being masculine, feminine or androgynous. Transgender is an umbrella term used to describe people that don’t identifty with their own biological sex. “The "T" in LGBT stands for transgender or gender non-conforming, and is an umbrella term for people whose gender identity or gender expression does not conform to that typically associated with the sex to which they were assigned at birth. Some who do not identify as either male or female prefer the term “genderqueer.” (APA 2018) While it is important to understand that sexual orientation and gender identity are not the same thing, they do both reflect differing forms of gender norm transgression and share an intertwined social and political history.” The actual numbers of the prevalence of the LGBT community vary by how they are defined. For example, 3.2% of young adults from 18-26 described themselves as mostly or exclusively homosexual or bisexual. Sexual behavior data estimates 3.6% of adult women and 4.7% of adult men have had one same sex partner since 18, with 2.5% of men and 1.4% of women having exclusively same sex partner during the past year. A survey related to sexual orientation showed mood and anxiety disorders, risk factors for suicidal behavior were linked to gays, lesbians or bisexuals. The is no general survey to date attempting to the transgender population. (Haas, et al, 2011) According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) the criteria for non-suicidial self injury are as follows:
In the last year, the individual has, on 5 or more days, engaged in intentional self-inflicted damage to the surface of his or her body, of a sort likely to induce bleeding or bruising or pain (e.g., cutting, burning, stabbing, hitting, and excessive rubbing), for purposes not socially sanctioned (e.g., body piercing, tattooing, etc.), but performed with the expectation that the injury will lead to only minor or moderate physical harm. The behavior is not a common one, such as picking at a scab or nail biting,” with the intentional injury of two of the following:
1) psychological precipitant: interpersonal difficulties or negative feelings or thoughts, such as depression, anxiety, tension, anger, generalized distress, or self-criticism, occurring in the period immediately prior to the self-injurious act,
(2) urge: prior to engaging in the act, a period of preoccupation with the intended behavior that is difficult to resist,
(3) preoccupation: thinking about self-injury occurs frequently, even when it is not acted upon,
(4) contingent response: the activity is engaged in with the expectation that it will relieve an interpersonal difficulty, negative feeling, or cognitive state, or that it will induce a positive feeling state, during the act or shortly afterwards.
(American Psychiatric Association, 2013)
Nonsuicidal self injury among lesbian, gay, bisexual, and transgender populations: an integrative review.
Purpose
The purpose of this article is to analyze self injurious behavior without suicidal intention in the lesbian, gay, bisexual and transgender (LGBT) community. It is to review findings from research, summarize the statistics, develop understanding, identify knowledge gaps for the need of further research, and to push for policy changes and offer recommendations, like interventions and strategies to reduce the self injurious behavior in the LGBT community. The reason is to better understand the prevalence and identify risk factors as well. Researchers reviewed both quantitative and qualitative empirical research and conducted a review of self injurious behavior without suicidal intention, non-suicidal self injury (NSSI) amongst (LGBT) population. (Jackman, et al, 2016)
Research Design
The article is an integrative review paper to review the current state of understating on NSSI in the LGBT population. The article presents published articles and summarizes the existing literature to address gaps in knowledge and apply what is already known now to prevent suicide in the LGBT community.
Methodology
Methods. The literature review consisted of articles published with no start date to April 2015. The databases used were OvidMedline, PsycINFO, Allied and Complementary Medicin eand through the EBSCO platform: Cumulative Index toNursing and Allied Health Literature, Education ResourceInformation Center, Gender Studies Database, LGBT Lifewith Full Text, Social Sciences Full Text, Social WorkAbstracts, SocINDEX with Full Text, and Violence &Abuse Abstracts. (Jackman, 2016) The Review was conducted in three steps. See Table 1. The first step was using key words of population of interest. Second, the behavior of interest was searched used key words of behavior of interest. The third step was combining step 1 and step 2 finding articles that contained NSSI in the sexual and gender minority population. The inclusion criteria for the review were empirical studies that used an operational definition of NSSI that did not contradict the DSM-V, which included abusing substances or self harm with suicidal intent. The exclusion criteria was the use of the definition of NSSI inconsistent with the DSM-V, if there was no description of NSSI, if there weren’t sexual or gender minorities, or if the NSSI is done by someone incarcerated, developmentally delayed, or having borderline personality disorder. (Jackman, et al, 2016)
Study sample. The search ended with 1729 articles, and then further narrowed to 26 usable articles. See Table 2.
Major Findings
The review had collected findings from large-scale population findings, studies comparing LGB and heterosexual populations, and findings from exclusively LGBT samples. The findings are as follows. 11 studies show the LGBT community on a large scale, that 13-25 year olds have increased risk for NSSI compared with heterosexual populations. There is also a higher risk among the female participants. Patterns emerged where transgender males have higher rates of NSSI, compared to male sexual minorities. Research identified that harassment, discrimination and victimization, and concealing an identity are risk factors. Reports state that the NSSI behavior is from confusion of sexual identity, and those with NSSI behavior avoid seeing a health care provider. Reports state the functions of the NSSI is are coping mechanism, self punishment, communicating distress, numbing, and an effort to feel better. The literature discusses the increased NSSI behaviors amongst the LGBT community compared to the heterosexual community.
Limitations
The lack of a standardized measure for NSSI limited the literature review. The studies used either the behavior is present or not. Some research didn’t assess the aspects of the self injury such as frequency, type, severity, duration, motivations and functions. Some studies limited it to cutting, despite there being more than one method. Another limitation is the lack of representative sample due to snowball or convenience sampling.
Conclusions
The conclusion made from the research is that there is a high prevalence of NSSI among sexual and gender minority populations compared with heterosexual and cisgender populations. Groups at a higher risk for NSSI are those who identify are those who are bisexual, gender non-comforming or transgender. Factors contributing to risk include victimization, discrimination and harassment, stress due to hiding identity; invalidation by others, even healthcare providers, and homophobia. There needs to be more research done on screening NSSI to develop evidence based interventions to broaden patient-specific nursing care.
Client Description
The client that was worked with was Patient D. I had spent time with him at my clinical rotation in the fall of 2018. I met Patient D on the acute floor of a psychiatric facility, and he was stilling struggling to speak with the hospital staff and was still acclimating to his new environment. He is relevant to the study because he identifies as a transgendered male and has both suicidal ideations and self injurious behavior. Patient D was a single white 21 year old transgendered male. His chief complaint was “I have not been thinking safe and I have been cutting a lot. If I don’t come in, I’m not going to be alive.” Patient D reported increased depressed mood and reported chronic depression increasing. His medications, he reported were not helping as well as he liked, so he stoped taking them. He’s had self injurious behavior since 16 and he felt hopeless about life circumstances. His past psychiatric diagnoses are depression, anxiety, Borderline Personality Disorder and Obsessive Compulsive disorder, anorexia and bulimia. He was diagnosed after his walk in at the psychariatic facility with Borderline Personality disorder, Major Depressive disorder with suicidal ideations and self injurious behavior and body dysmorphia.
Implications for Nursing Practice
Implications for further nursing research is to engage NSSI in all different kinds of clinical settings. Nurses are the people on the healthcare that is more likely to meet LGBT patients and those with NSSI. Nurses provide patient centered care for each individual, and this includes those amongst minority populations, like the LGBT community. Nurses should screen for NSSI, and ask sexual orientation and gender identity, and acknowledge that LGBT community is at a higher risk due to specific stressors to the community. The use of screenings like psychosocial screening as well as a screening on sexual orientation is important in both youth and adults. It is important to identify risk factors during a comprehensive assessment. Using universal screening tools, nurses will be able to gather information that can intervene or reduce NSSI, increase coping mechanisms and promote safe environments. (Jackman, et al, 2016) Little is known about psychological problems amongst the LGBT community, so it is important to expand knowledge and understanding of all mental health risks in that population. It is important to continually research, and test new screening tools and encourage more funding for longer studies. It is important to include all ages and ethnicities to have a broader understanding. As nurses, there should be advocacy for the LGBT community, and destigmatize mental disorders, educate, encourage seeking help and develop appropriate, accessible services for everyone. It is important to make sure that professionals should be culturally and socially competent in treatment and standards of care. This research is applicable to Patient D simply because it could have possible changed his outcomes if the self injurious behavior was screened at 16, and would have been able to access more social support systems and he could have received more help before it developed into suicidal behavior.
Conclusion
In conclusion, the literature research review analyzed 26 articles that all had similar results. Until recently, there hasn’t been adequate research regarding the sexual minority popularion and mental health risk factors. The literature review focused specifically on non-suicidal self injurious behavior and its prevalence in the LGBT community. The results presented as those that identify in the LGBT community are at higher risk of NSSI due to minority specific stressors as well as life’s normal stressors. Those among the female and nonbinary subgroups are more prevalent to the behavior. By being nonjudgement and screening properly, nurses can intervene with competent resources and identify factors that lead to the behavior and develop coping skills.