Individuals who identify as lesbian, gay, bisexual, transgender (LGBT+) or other gender and sexual minorities can have significant mental health issues – not just as a result of their sexuality or gender identity but also because of discrimination and isolation. These individuals may find themselves seeking case management, counselling, or other social work support services and it can be helpful to have a framework for understanding their coming out process.

Coming out is the process a lesbian, gay or bisexual (LGB+) individual follows in order to disclose their sexual orientation or gender identity to those around them. It can be an intensely personal and challenging process.

Cass Identity Model

The Cass Identity Model was created by Vivian Cass in 1979 in order to better understand the coming out process for LGB+ individuals. It consists of 6 stages or phases that a person will proceed through. The six stages are:

Identity Confusion

Identity confusion is the very first stage of the model. In this stage, an individual is confused by their sexual identity and begins to become aware that sexual identities are a concept. They are possibly in early puberty and noticing individuals expressing their sexuality.

At some point though, the individual will experience thoughts or feelings regarding an individual of the same-sex that will make them wonder if they are actually LGB+. This might lead to a denial that the individual is LGB (repressing these feelings.)

Identity Comparison

In the Identity Comparison phase, the individual will ask themselves more openly if they are homosexual. They will confront the idea that they might be alone in their LGB+ experiences compared to those around them and the resulting social alienation or need to keep their LGB+ identity hidden. This is especially challenging for people living in repressive societies or communities where LGB+ identities are not tolerated.

Identity Tolerance

Once the individual has reached Identity Tolerance, they have understood that they are firmly LGB. To those around them, they may be perceived one-dimensionally – as only homosexual. This can cause these individuals to seek out other LGB+ individuals and begin to build a support network.

Some individuals may continue to deny their identity and thus experience self-hatred, which may delay their coming out process and cause much distress.

Identity Acceptance

Identity Acceptance is exactly what it sounds like. The individual has accepted themselves as an LGB+ individual. They make begin to make the LGBT+ subculture a larger part of their life. This can lead to an insulation of one’s support network as a differentiation is made between those people who are openly supportive of the individual’s LGB+ identity and those who tolerate their sexuality as long as it is not displayed openly. Limiting the role these other individuals play in the LGB+ person’s life serves to reduce distress and alienation.

Identity Pride

The Identity Pride stage is the one most associated with LGBT Pride events. The person’s sexuality continues the pendulum swing from lack of awareness to tolerance to complete pride, overtaking the other aspects of their identity. The person may even dichotomize the world into an LGB area and a second, less important heterosexual category.

The understanding of heteronormativity may appear here as well, with the individual reminding others around them that the assumption they are heterosexual is a false one.

Identity Synthesis

Finally, in Identity Synthesis the individual has come to the realization that their LGB+ identity is merely one part of them and does not dominate their life. It is one part, like their career, hobbies, ethnicity and other aspects are simply other pieces of the puzzle that makes them up. At this stage, they fully accept themselves and experience little or no distress as a result of their LGB identity.

Applying the Model

A Social Worker may apply the Cass Identity Model by noting where in the six stages their client seems to be and reading the primary literature to better understand the conflicts that may occur at each stage. This can help ensure interventions are targeted to the unique distress the client is experiencing and continue to deepen the therapeutic relationship by demonstrating a strong understanding of the client’s inner-pain.

Conclusion

The Cass Identity Model is a six-stage model that demonstrates a lot of value in understanding the coming out process as it relates to LGB individuals.

People who value following purity rules over caring for others are more likely to view gay and transgender people as less human, which leads to more prejudice and support for discriminatory public policies, according to a new study published by the American Psychological Association.

“After the Supreme Court decision affirming marriage equality and the debate over bathroom rights for transgender people, we realized that the arguments were often not about facts but about opposing moral beliefs,” said Andrew E. Monroe, PhD, of Appalachian State University and lead author of the study, published in the Journal of Experimental Psychology: General.

“Thus, we wanted to understand if moral values were an underlying cause of prejudice toward gay and transgender people.”

Monroe and his co-author, Ashby Plant, PhD, of Florida State University, focused on two specific moral values –what they called sanctity, or a strict adherence to purity rules and disgust over any acts that are considered morally contaminating, and care, which centers on disapproval of others who cause suffering without just cause – because they predicted those values might be behind the often-heated debates over LGBTQ rights.

The researchers conducted five experiments with nearly 1,100 participants. Overall, they found that people who prioritized sanctity over care were more likely to believe that gay and transgender people, people with AIDS and prostitutes were more impulsive, less rational and, therefore, something less than human. These attitudes increased prejudice and acceptance of discriminatory public policies, according to Monroe.

Conversely, people who endorsed care over sanctity were more likely to show compassion for those populations, as well as support public policies that would help them.

“The belief that a person is no better than an animal can become a justification for tolerating and causing harm,” said Plant. “When we believe that someone lacks self-control and discipline, we may make moral judgments about their life choices and behaviors, which can lead down a dark path of discrimination and hate.”

The first experiment involved people who were generally moderate politically and religiously. They rated their agreement with five moral values (care, fairness, sanctity, loyalty and authority) and then read short descriptions of five different men: a gay man, a man with AIDS, an African-American man, an obese man and a white man. Afterward, the participants filled out questionnaires about their thoughts on each man’s state of mind (e.g., “John is rational and logical”) and emotions (e.g., “John is rigid and cold”) and their attitudes and feelings of warmth toward each man.

“We found that people who placed more value on sanctity were more likely to believe that the gay man and man with AIDS had less rational minds than the obese, African-American or white men,” said Monroe.

Experiment two focused on how political affiliation might affect responses. The researchers recruited an equal number of self-identified liberal and conservative participants and used the same morality survey as in the first experiment, but this time, participants rated their thoughts on the state of mind for only four men: a gay man, a man with AIDS, an African-American man and a white man.  The liberals and conservatives then assessed their feelings of prejudice for each man (e.g., “I would rather not have a black person/gay person/person with AIDS in the same apartment building I live in”), their attitudes about public policies that would help or harm gay people (e.g., conversion therapy) and people with AIDS and their willingness to help them by being involved with pro-gay/AIDS awareness activities.

Liberals tended to value care and fairness more while conservatives were more focused on loyalty, authority and sanctity. And the people who valued sanctity were more likely to discriminate against the gay man and man with AIDS but not the African-American or white men, according to the study.

Experiment three focused on perceptions of transgender people and found that participants who endorsed sanctity were more likely to hold prejudiced attitudes about transgender people and to support discriminatory public policies.

The fourth experiment tested whether temporarily increasing sanctity values, relative to care, increased dehumanization and prejudice. Experimenters collected survey responses on a college campus on two separate days –Ash Wednesday—a day associated with sanctity and spiritual cleansing in the Christian faith—and a non-religious day. Participants filled out a survey intended to assess their moral beliefs and attitudes toward a woman described as a prostitute.

Participants surveyed on Ash Wednesday reported much higher concerns about sanctity compared to care and this caused participants to become more likely to dehumanize and express negative feelings towards the prostitute, according to the study.

The final study explored whether heightening concern about care was an effective method of reducing prejudice about gay and transgender people. To prime care values, participants listened to a radio news clip about the importance of safe spaces for people of color, while in the control condition participants listened to a clip about Brexit. Afterward, the participants rated their moral values, made judgments of a transgender woman, a gay man and a white man and indicated their support or disapproval of three public policies that would either help or harm gay and transgender people (e.g., national legislation for marriage equality, banning transgender people from the military).

Participants who listened to the clip about safe spaces emphasized caring as an important moral value over those who listened to the clip about Brexit. Caring individuals showed less prejudice toward gay and transgender people and less acceptance of discriminatory policies against them.

“Our study suggests that a person’s moral values can be altered, at least temporarily, and that highlighting certain values, like caring, can be an effective way to combat prejudice,” said Monroe. “We hope that by showing the moral roots of bias and discrimination against sexual and gender minorities we encourage others to conduct further research to increase equity and inclusion.”

A while ago I posted a meme which said, “Better to have lost in love than to live with a psycho for the rest of your life.”

I liked it, of course, otherwise, I wouldn’t have posted it. Eleven others did too, some commenting on Facebook, “Amen to that,” and “Definitely!!”

Then this: “Hate it. It’s beat up on people with mental illness time again. Ever had the amazing person you love tell you that they just can’t deal with your mental illness anymore? Our society is totally phobic about people with mental illness having intimate relationships.”

Woah, that came a bit out of the blue. I hadn’t made the link between “person with a mental illness” and “psycho”, otherwise I wouldn’t have posted it. It didn’t say, “Better to have lost in love than to live with a person with a mental illness for the rest of your life.” I had linked “psycho” with the often weird, unspoken assumptions people make when in relationships, which have kept me out of long-term relationships all my life.

It made me think, though. Suppose it had read, “Better to have lost in love than to live with an idiot for the rest of your life.” Would that have been a slight against people experiencing unique learning function?

Probably a more accurate meme would have been, “Better to have lost in love than to live with an arsehole for the rest of your life.” But that’s not what the image said.

For the record, I have had someone I loved tell me he couldn’t cope with my unique physical function anymore. It was hard to hear, but ultimately he was the one who lost out. And I know intuitively many would-be lovers haven’t even gone there — again, their loss and my gain, because why would I want to be with anyone so closed-minded?

The power we let labels have over us can be overwhelming. If I had a dollar for every time a person called someone a “spaz” in my presence, I’d be wealthy. If I got offended because “spaz” is a shortened version of “spastic”, which is one of my diagnoses, and I got another dollar for that, well — I’d be angrily living in the Bahamas.

I think the evolution of language — and the generalization of words like, “gay,” “spaz,” “idiot” and “psycho” — creates the opportunity for them to lose their charge and liberate us from their stigma. By allowing them to continue having power over us, though, we re-traumatize ourselves every time we hear them. Words are symbols and they change meaning over time and in different contexts.

I celebrate that “gay” means “not for me” rather than “fag”; that “spaz” means “over-reacting”, not “crippled”; that “idiot” means “unthinking”, not “retarded”; and that “psycho” means “someone with weird, unspoken assumptions”, not “a crazy person”.

By letting words change meaning for us, we are redefining diversity and creating social change. It’s not a case of, “Sticks and stones will break my bones but words will never hurt me.” It’s recognizing that, unless someone is looking directly at us menacingly, calling us gay, spaz, idiot or psycho, we’re not in their minds — they’ve moved on.

Maybe it’s useful for us to move on with them?

It is widely accepted the earliest months and years of a child’s existence have the most profound impact on the rest of the lives. Attachment theorists believe the early bonds and relationships a child forms with his/her carer(s) or parent(s), informs that child’s ability or inability to form successful and healthy relationships in the future.

Alan Sinclair’s ‘Right from the Start’ is the latest in the Postcards from Scotland series of short books, which aim to stimulate new and fresh thinking about why us Scots are the way we are.

In my previous book review in the Scottish Journal of Residential Child Care, I commended the author of ‘Hiding in Plain Sight’ (another book in the same series) Carol Craig for her ability to write succinctly and accessibly about a complex subject matter. I feel the same way about Alan Sinclair’s writing in this book.

The premise of this book, put simply, is laying out the bare truths of how good and bad us Scots are at parenting as well as having the appropriate supporting systems in place for parents and carers of our most vulnerable children.

A consistent thread throughout the book is the author arguing that by investing in parents and babies ‘from the start’, governments and the surrounding systems who support children and families can relieve the heartache of tomorrow in the form of poorer outcomes in education, employment and in health.
The book begins by acknowledging the UK’s position on the UNICEF global league table of child well-being, ranking 29 of the world’s richest countries against each other. The UK is placed 16th, our particular challenge being a high proportion of young people not in work, training or education. Although the league table did not single out the devolved nation of Scotland, the author describes the UK as a ‘decent proxy for Scotland’.

The first 1,000 days

The author goes on to explore the theory of the first 1,000 days of a child’s life. This theory suggests this is the most significant indicator of what the future holds for them. He touches on child poverty, which we know from well-cited research can lead to adversities in life, but he also mentions too much money can be an issue as well.

This point is explored more deeply later in the book’s in a chapter titled: ‘Is social class a factor?’. The author is effective at challenging the popular rhetoric that it’s the least educated and most poverty-stricken parents in society who are most likely to neglect their children. He talks about the longitudinal study, Growing Up in Scotland, which tracks the lives of thousands of children and families from birth to teens. Amongst many other findings, the survey shows 20% of children from the top income bracket have below average vocabulary; it also finds problem-solving capabilities are below average for 29% of this group. This proposes child poverty is only a small indicator of the child’s developmental prospects.

Where the Dutch Get it Right

The most intriguing part of the book from my point of view is the comparison the author makes between raising a child in Scotland versus the Netherlands (which ranked first in the UNICEF league table). In Holland, pregnant women have visits from a Kraamzorg, an omnipresent healthcare professional who identifies the type of support required. Post-birth the Kraamzorg plays a very active role and can typically spend up to eight hours a day supporting the new mother in her first week of childcare. The Kraamzorg also becomes involved in household chores including shopping and cooking. And it doesn’t stop there. The Dutch system includes Mother and Baby Wellbeing Clinics, which support families from birth to school age and have been doing so effectively for the last century.

On reading how the Dutch system operates, it’s hard to not make comparisons to the system here in Scotland (and the wider UK) within our NHS where mothers are wheeled in to give birth and very quickly wheeled out again to free up bed space. I exaggerate slightly here and I do not want to discredit the incredible job hard-working NHS staff do, but I’m sure I’m not alone in feeling envious of the Dutch system and thinking they’ve got something right, in comparison with Scotland. This was neatly summarised at the start of the book in a quote from a Dutch woman who had spent time living in both Holland and Scotland when she said: ‘In Holland we love children. In Scotland you tolerate children.’

But it’s not all bad. As the author remarks himself: ‘Scottish parenting is not universally awful: if we were we would not be almost halfway up the global table of child well-being’ (p. 12).

The penultimate chapter explores some real-life examples of parents who are struggling and striving to succeed in bringing up children with some success despite the odds stacked against them. I found the author’s injection of such human stories among the explanation of evidence useful as it allowed a chance for the reader to reflect on how all this is applicable in everyday life in Scotland.

To me, there was, however, a glaring omission in these stories: a voice from the LGBT community. Gay adoption in Scotland was legalised almost 10 years ago in 2009, and at the same time the Looked After Children (Scotland) Regulation 2009 came into force allowing same-sex couples to be considered as foster parents. It would have been interesting to hear from this historically marginalised part of our society what the experience has been like and how different, or similar, this was from the other stories included in this chapter. Are they arguably better equipped as carers of Scotland’s most vulnerable children given their own life experiences of being marginalised?

The book ends with the author setting out his vision for a better future for Scotland’s children where they have better life chances and are fully nurtured. It’s clear we have some way to go but reading this book makes you feel a glimmer of hope that could, one day, become a reality.

Even though the overall number of people with HIV and AIDS has fallen, it is still a disease which predominately affects gay males. An estimated 67% of new HIV cases are transmitted via male-to-male sexual contact, with heterosexual contact accounting for 24%, and 6% due to drug use. Young people are also more likely to be infected. Young people ages 13-24 account for 21% of new AIDS cases. The most at risk individuals are young gay and bisexual men which “accounted for 81% of all new HIV diagnoses in people aged 13 to 24 in 2016, and young African American gay and bisexual men are even more severely affected,” according to the CDC.

Since 1987, the first year Human Immunodeficiency Virus (HIV)/Acquired Immune Deficiency Syndrome (AIDS) was listed on death certificates, over 500,000 people have died in the United States from HIV/AIDS. That’s more than the number of people who have died in the Syrian War. Currently, in the United States, AIDS is the 9^th leading cause of death in people 25-44 years old.

The AIDS epidemic reached its peak in 1992, with an estimated 78,000 cases diagnosed annually. Since then, AIDS diagnosis began to steadily decline until stabilizing in the late 1990s at approximately 40,000 cases diagnosed annually. The latest statistics from the Center for Disease Control and Prevention (CDC) show between 2010 and 2015 the estimated number of annual infections declined 8% from 41,800 to 38,500.

Victims of intimate partner violence (IPV) are also at a greater risk for contracting HIV. People who report a history of being a victim of IPV are more likely to engage in risky behaviors – intravenous drug use, prostitution, unprotected anal sex – increasing their risk of contracting HIV. HIV-positive women also report higher rates of IPV than the general population.

The opioid epidemic is responsible for the first uptick of HIV diagnosis attributed to intravenous drug use in two decades. In 2015, opioid use led to 181 individuals being diagnosed with HIV in Scott County, Indiana. Lowell, Massachusetts has also seen a recent spike in HIV cases attributed to opioid use.

One of the biggest obstacles faced by HIV/AIDS patients is a healthcare system which is less than perfect. A recent Times article stated, “no class of medicines is more scandalously expensive than for H.I.V.” In the U.S., HIV medication can cost $39,000 a year, while countries in Africa the same medication costs $75 a year.

The U.S. healthcare system may not be perfect, but HIV treatments are getting better. Experts think it’s possible HIV transmission can be stopped in the United States within 3-7 years. The most current and powerful antiretroviral drugs on the market can lower the amount HIV in a person’s system to a level so low it cannot be transmitted.