International Society for Traumatic Stress Studies

Gender-Related and LGBTQ Trauma

The ISTSS 34th Annual Meeting is the largest gathering of professionals dedicated to trauma treatment, education, research and prevention. There will be several workshops, symposia and expert trainings on trauma related to gender identity and sexual orientation. 


Concurrent Session One: Panel Presentation

Thursday, November 8 | 9:45 AM to 11:00 AM

Trans-Formative Change: Policy, Treatment, and Community Goals for Supporting Transgender Trauma Survivors

Minshew, Reese, PhD1; Weiss, Ben, MSW Candidate2; Gresham, Stephen, PhD3; Tobin, Harper Jean, JD4; Ruth, Richard, PhD5

1New School for Social Research, New York, New York, USA
2U. Illinois at Chicago, Chicago, Illinois, USA
3VA, Boston, Massachusetts, USA
4Case Western Reserve University, Washington, D.C., District of Columbia, USA
5George Washington University, Washington, District of Columbia, USA

Transgender and gender non-conforming (TGNC) civilian populations report among the most elevated exposure to traumatic stress of any civilian populations world-wide. Moreover, in the United States, TGNC individuals also serve in the military at three times the rate of cis-gender individuals. Thus, TGNC populations are over-represented in a variety of trauma-exposed groups, and exposure to traumatic stress is chronic and persistent in the lives of many TGNC people. However, many trauma-oriented clinicians are unfamiliar with the unique needs and challenges of TGNC people, while trauma-oriented researchers may overlook this population altogether.

This panel utilizes gender identity as a lens through which to explore issues of trauma, community, and intersectionality. Drawing on the expertise of clinicians and researchers who focus on trauma in various TGNC communities (e.g., homeless youth, veterans, immigrants, and general outpatient) as well as experts in the field of policy related to TGNC equality and health, this panel will broadly outline current understandings of those treatments and supports most relevant to TGNC populations, as well as speak to directions for future change. 

Concurrent Session Two: Symposium

Thursday, November 8 | 11:15 AM to 12:30 PM


Girls and Women in the Legal System: From Trauma Exposure to Trauma-Focused Treatment

Chair: Karlsson, Marie, PhD

Interpersonal trauma, especially sexual trauma, is a pathway to the correctional system for girls and women (Browne, et al., 1999; Kerig & Becker, 2012), which represent vulnerable populations with high rates of trauma-related disorders such as PTSD, depression, and substance use (Karlsson & Zielinski, in press). The current symposium addresses these issues by describing research on incarcerated girls and women’s trauma exposure, trauma-related pathology, and response to trauma-focused treatment. The first two presenters will discuss research on delinquent youth, with a focus on gender differences in trauma exposure and associated outcomes. More specifically, the first presenter will describe connections between specific types of trauma exposure (e.g., sexual, physical, or emotional) and posttraumatic over- and undermodulation. The second speaker will describe research on two subtypes of the callous-unemotional trait and how they relate to trauma exposure, posttraumatic stress symptoms, and emotional and self-dysregulation. The second set of presentations will focus on two different samples of incarcerated women who completed an exposure-based group treatment for sexual trauma. One presentation will describe evidence of effectiveness after implementing the group treatment at a second facility. The last presentation will focus on treatment completers’ experiences with receiving group-based exposure therapy. Implications for research, treatment, and policy will be discussed.

Associations between Types of Trauma Exposure and Posttraumatic Symptoms of Over- and Undermodulation: Gender Differences and Similarities

Kidwell, Mallory, BA (Hons); Modrowski, Crosby, MS (PhD Student); Kerig, Patricia, PhD
University of Utah, Salt Lake City, Utah, USA

Recent research has shown that posttraumatic stress symptoms (PTSS) can be distinguished by two distinct response profiles; one involving dissociation and emotional numbing, termed overmodulation, and the other characterized by overreactivity and arousal, termed undermodulation (Lanius et al., 2010). Research has yet to investigate origins of these response types, particularly whether exposure to specific types of traumatic experiences confers higher risk for over- and undermodulation, and whether these associations differ across gender. This study investigated whether sexual, physical, or emotional trauma exposure differentially predicted posttraumatic over- and undermodulation among girls and boys. A sample of detained youth (N=567;Mage=16.01) completed measures of trauma exposure and PTSS. Multigroup analysis revealed significant gender differences in associations between trauma exposure type and PTSS of undermodulation, with girls demonstrating higher undermodulation when exposed to sexual and emotional traumas (χ2=27.41,p<.001). No gender differences were found regarding overmodulation. Moreover, results indicated that the correlation between over- and undermodulation PTSS was stronger for girls than boys (χ2=3.87,p=.049). These findings suggest that girls and boys may exhibit both differences and similarities in PTSS response profiles depending on type of trauma exposure.

Testing Gender Differences in Models of Trauma-linked Acquired Callousness in a Sample of Justice-involved Youth

Kerig, Patricia, PhD; Chaplo, Shannon, Doctoral Student; Modrowski, Crosby, MS (PhD Student)
University of Utah, Salt Lake City, Utah, USA

Trauma-informed advances in the study of callous-unemotional (CU) traits confirm a distinction between primary CU, arising from an inherent lack of prosocial emotions, and acquired CU, originating in emotional numbing in the aftermath of trauma. However, few studies have elucidated the underlying processes that might account for the association between trauma and acquired CU, such as affective and self-dysregulation. Further, gender effects have emerged with differential associations between CU and trauma found for girls compared to boys. Therefore, clarification is needed regarding whether there are gender differences in the associations among CU subtypes, trauma exposures, posttraumatic stress symptoms (PTSS), and emotional and self-dysregulation. In a sample of 825 detained youth, mixture modeling in Mplus identified two groups high in CU but differing in levels of PTSS, consistent with primary (n=200) vs. acquired (n=126) CU. Girls were differentially likely to be categorized in the primary CU group, χ2=4.20, p=.04. Compared to the primary CU group, youth in the acquired CU group scored higher on measures of interpersonal trauma exposure, emotional numbing, and dysregulated functioning, including affect dysregulation, borderline personality features, and dissociation. Tests for moderation by gender indicated the results were consistent for boys and girls. 

Effectiveness of a brief Exposure-based Group Treatment with Incarcerated Women

Karlsson, Marie, PhD1; Zielinski, Melissa, PhD2; Bridges, Ana, PhD3

1Murray State University, Murray, Kentucky, USA
2University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
3University of Arkansas, Fayetteville, Fayetteville, Arkansas, USA

Incarcerated women, a vulnerable population with high rates of sexual trauma exposure and associated symptoms, could benefit from receiving evidence-based trauma-focused treatment (Karlsson & Zielinski, in press). Our team’s exposure-based group treatment, Survivors Healing from Abuse: Recovery through Exposure (SHARE group; 8 weekly 1.5 hour-sessions), was developed to fit the needs of incarcerated women with sexual abuse histories. Treatment completion was associated with statistically and clinically significant reductions in symptoms from pre- to post-treatment that were maintained during a follow-up period from multiple cohorts at the women’s prison that launched the program (Karlsson et al., 2014; 2015; 2016). This presentation will focus on evidence of effectiveness from implementing the SHARE group at a different women’s prison. Preliminary findings from six SHARE groups (N = 24; 83.3% White) showed statistically significant reductions in PTSD (p < .001), depression (p = .02), and generalized anxiety symptoms (p = .01) from pre- to post-treatment with large effect sizes. Thirteen participants (54.2%) were above the clinical cutoff at pre-treatment on one or more of the three measures; 69.2% of those women had recovered (i.e., below clinical cutoff) and/or improved (i.e., reliable change index; Jacobson & Truax, 1991) by post-treatment. Implications will be discussed.

“I’m Not Alone, My Story Matters”: Re-evaluating Assumptions about the Acceptability of Group-based Exposure Therapies in Prisons

Zielinski, Melissa, PhD1; Karlsson, Marie, PhD2; Bridges, Ana, PhD3

1University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
2 Murray State University, Murray, Kentucky, USA
3University of Arkansas, Fayetteville, Fayetteville, Arkansas, USA

Although it is clear that incarcerated women are in desperate need of trauma therapies (Karlsson & Zielinski, In Press; Harner et al., 2015), some have argued that our most effective trauma treatments – exposure-based therapies – are not safe to provide in the prison setting (e.g., Miller & Najavits, 2012; Wolff et al., 2009). This presentation will provide both qualitative and quantitative indices of women’s experiences of completing an exposure-based group therapy while incarcerated which challenge common assumptions about the appropriateness of (1) prison as a context for evidence-based trauma treatments, including exposure, and (2) sharing trauma narratives in a group setting. Data were drawn from women (current n = 21, with data collection ongoing) who completed the SHARE (Survivors Healing From Abuse: Recovery through Exposure) group protocol and who completed follow-up measures indexing both symptom change (presented elsewhere; c.f. Karlsson et al. 2014, 2015) and treatment feedback. We will present information regarding women’s self-reported reasons for enrolling in the group, satisfaction with various therapy components (e.g., exposure, skill-building) and the treatment overall, and experience of both sharing and listening to trauma narratives.

Concurrent Session Three: Workshop Presentation

Thursday, November 8 | 3:00 PM to 4:15 PM

Emotion Focused Therapy Intervention and Prolonged Exposure Therapy or Cognitive Processing Therapy for Veterans with PTSD and Complex Childhood Trauma

Powch, Irene, PhD
PTSD Clinical Team, VA Heathcare Center, Portland, Oregon, USA

Although Cognitive Processing Therapy (CPT) and Prolonged Exposure Therapy (PE) are highly effective evidence based therapies for PTSD, the most vulnerable veterans with deeply entrenched self-critical processes and dissociative coping related to complex childhood trauma can fail to fully engage or benefit from these therapies. Emotion Focused Therapy (EFT) is an evidence based therapy for sequelae of complex developmental trauma. Case studies of two female veterans will be used to illustrate the utility of an EFT intervention before or after an EBT for PTSD. In the first case, PTSD is resolved with PE, but global self-blame with debilitating perfectionism remain. The case illustrates how a self-critical process is identified and resolved with EFT two-chair interventions over 2 additional sessions. In the second case a veteran previously treated with DBT and CPT, laments that she knows how she is “supposed” to think, but deeply feels that she is worthless and deserving of abuse. This case illustrates how EFT intervention can be used to access healthy anger to stand up to a self-critical internalized parent and transform that internalized relationship. EFT interventions will be discussed in the context of theory and research behind EFT, PE, and CPT; two chair interventions will be demonstrated; and participants will have an opportunity to practice two chair interventions.

Concurrent Session Five: Panel Presentation

Friday, November 9 | 9:45 AM to 11:00 AM


Seeing Beyond Scars: Reframing Acid Violence Burn Trauma as a Public Health Issue

Sharma, Samata, MD, MPh1; Shah, Jaf2; Guarino, Kathleen, LMHC3; Nath, Shampa, MA4; Levy-Carrick, Nomi, MD5

1Brigham and Women's Hospital, Boston, Massachusetts, USA
2Acid Survivor Trust International, London, London E2 7EY, United Kingdom
3American Institutes for Research, Waltham, Massachusetts, USA
4Healthlink Worldwide, London, London, United Kingdom
5Bellevue Hospital Center, New York, New York, USA

Acid violence is a rarely discussed, often gender-specific, global form of violence used to facially disfigure and socially shame its victims. Incidences are rising, from the UK to Uganda. In this panel, we will reframe acid violence as a gender-specific public health issue: exploring not only its physiological and psychological consequences, but also its impact on communities, and economic cost to society. We will: provide an cross-cultural overview of acid violence; reveal how facial recognition is fundamental to self-identification and why disfigurement can create particularly severe suffering (Wright 2017); review the psychiatric comorbidities unique to deliberate burn injury (McAleavey 2018), and introduce a trauma-informed framework for addressing acid violence (DeCandia & Guarino, 2015). We will discuss the creation of our pilot program in Colombia to systematically enhance mental health services: drawing upon our early findings and a survivor’s narrative to demonstrate why an intersectoral trauma informed approach best reflects the expressed needs of this population. We believe our proposed model will also carry clinical significance beyond acid violence to inform treatment practices in larger burn/disfigurement injury populations as well as broader significance in ultimately revealing universal aspects of optimal gender-specific trauma treatment.  

Concurrent Session Six: Panel Presentation

Friday, November 9 | 11:15 AM to 12:30 PM

Have Women ‘Made It’? Challenges and Possibilities for Future Female Scientists, Policy-Makers, and Practitioners in Traumatic Stress Studies

Street, Amy, PhD1; Hobfoll, Ivonne, PhD2; Newman, Elana, PhD3; Teng, Ellen, PhD4; Bufka, Lynn, PhD5; Cogan, Chelsea, PhD Student6; Patel, Anushka, PhD Student3

1National Center for PTSD, VA Boston Healthcare System, Boston University School of Medicine, Boston, Massachusetts, USA
2Rush University Medical Center, Chicago, Illinois, USA
3The University of Tulsa, Tulsa, Oklahoma, USA
4Michael E. DeBakey VA Medical Center, Houston, Texas, USA
5American Psychological Association, DC, District of Columbia, USA
6University of Tulsa, Tulsa, Oklahoma, USA

The field of traumatic stress threads together law, economics, policy, social work, along with health and behavioral sciences. How conducive is our multidisciplinary field for women? Are women’s ideas supported and recognized? Have pressures and expectations changed? This panel will spark lively dialogue among five women in diverse roles and settings. Panelists will interact with the audience to examine similarities and differences in these issues across disciplines, settings, geographical locations and generations of female scientists, policy-makers, and practitioners. 

Panelists include a past ISTSS president and academic who has worked in various applied research and clinical roles (Elana Newman), two psychologists from VAs who have conducted research on gender differences in PTSD (Amy Street) and treating  PTSD and comorbid anxiety disorders (Ellen Teng) respectively, a senior staff member at APA who led coordination and publication of the PTSD treatment guidelines (Lynn Bufka), and a psychologist in an academic medical center who has treated trauma-exposed people in rural America and Ethiopian refugees in Israel (Ivonne Hobfoll).

Concurrent Session Seven: Symposium

Friday, November 9 | 3:00 PM to 04:15 PM


Trauma, PTSD, and Eating Disorders: Understanding Prevalence, Mechanisms of Association, and Implications for Treatment

Chair: Holmes, Samantha, MA;
Discussant: Maguen, Shira, PhD

Trauma exposure, particularly childhood sexual abuse, is considered to be a non-specific risk factor for eating disorders (EDs), and a substantial minority of women and men with EDs have lifetime histories of PTSD. Comorbid EDs and PTSD (ED-PTSD) confer incremental risk from either disorder alone making it critical to understand the prevalence and underlying mechanisms. The existing literature is growing, but there remain significant gaps that need to be addressed. Specifically, many studies are limited by employing too narrow a lens with regards to trauma type (i.e., child sexual abuse), ED diagnosis (i.e., bulimia), and sample (i.e., undergraduate students, clinical populations). Additionally, few previous studies have explored integrated treatments for treating comorbid ED-PTSD. This symposium presents a series of studies which build upon the current understanding of trauma, PTSD, and EDs by examining the prevalence, theoretical underpinnings, and treatment implications.

First, Dr. Hebenstreit will  present the results of employing mental health screening tools with female Veterans in Veterans Affairs mental health and primary care settings, by examining the prevalence of positive screens for various psychological disorders (e.g., PTSD, depression, EDs) and associations among these psychiatric conditions. Understanding these comorbidities is an important step in developing and tailoring screening, triage, and treatment.

Dr. Mitchell will present on the relationship between intimate partner violence (IPV) and ED symptoms in a sample of female Veterans. Relative to other forms of trauma, IPV has been understudied in its association with ED symptoms; however, this issue is particularly salient among female Veterans, who report high rates of IPV.

Ms. Holmes will explore an extension of the Model of Psychological Adaptation to ED symptoms. The Model of Psychological Adaptation posits that trauma results in core schema disruptions which are associated with psychological symptoms. It serves as the theoretical underpinning of Cognitive Processing Therapy, a frontline treatment for PTSD, and has successfully been used to predict symptoms of other psychological disorders (e.g., PTSD, depression). However, its application to ED symptoms has not yet been tested.

Finally, Dr. Liebman will present preliminary results on the acceptability and efficacy of novel integrated group treatment for comorbid ED-PTSD that hypothesizes a mutually reciprocal and reinforcing relationship between these two disorders. Results will highlight implications for timing of interventions based on trajectory of symptom change.

Dr. Maguen will discuss the empirical and clinical implications of these findings as they relate to the larger literature on trauma, PTSD, and EDs.

PTSD, Depression, and Disordered Eating among Female Veterans

Hebenstreit, Claire, PhD1; Dinh, Julie, BA2; Donalson, Rosemary, MPH2; Maguen, Shira, PhD3

1Palo Alto VA Medical Center, Livermore, California, USA
2San Francisco VA Medical Center (VAMC-SF), San Francisco, California, USA
3San Francisco VA Medical Center and UCSF, San Francisco, California, USA

Identifying associations between eating disorders, PTSD, and other psychiatric conditions will enhance our understanding of the service needs of female Veterans, and can help to guide the development of standardized eating disorder assessment and treatment protocols. A sample of female Veterans (N = 407) were recruited from one VA medical center to complete several mental health screening tools designed for use in mental health or primary care settings. Female Veterans ranged in age from 24-70 years and represented multiple military service eras. Over one quarter (27.3%) of the sample met PTSD screening criteria, 28.1% met depression screening criteria, 8.4% met alcohol misuse criteria, 26.6% met anorexia/bulimia screening criteria, and 8.8% met binge eating screening criteria. Regression models were conducted to determine which common psychiatric conditions (PTSD, depression, and/or alcohol misuse) were most strongly associated with probable binge eating disorder as well as probable anorexia/bulimia. While women with probable depression were more likely to screen positive for binge eating disorder, women with probable PTSD were more likely to screen positive for anorexia/bulimia. Additional research is needed to establish effective screening tools, referral processes, and treatment approaches for disordered eating among female VA users with comorbid conditions such as PTSD. 

Intimate Partner Violence and Eating Disorder Symptoms in Female Veterans: The Mediating Role of PTSD and Depression

Mitchell, Karen, PhD1; Huston, Julia, MA2; Iverson, Katherine, PhD3

1National Center for PTSD, VA Boston Healthcare System, Boston University School of Medicine, Boston, Massachusetts, USA
2VA Boston Healthcare System, Boston, Massachusetts, USA
3National Center for PTSD, Women's Health Sciences Division, VA Boston Healthcare System and Boston University School of Medicine, Jamaica Plain, Massachusetts, USA

Many women with eating disorders (EDs) report high rates of interpersonal trauma and posttraumatic stress disorder (PTSD), but few studies have investigated associations between intimate partner violence (IPV) and ED symptoms (Mitchell et al., 2012). There are several potential mechanisms for the IPV-ED relation: IPV may directly impact one’s body image, ED symptoms may serve as maladaptive coping strategies, or PTSD and depression symptoms may account for this association (Wong & Chang, 2016). We examined IPV and ED symptoms, with PTSD and depression symptoms as mediators, in three waves of data from a national sample of female veterans (N = 190). Participants were recruited via e-mail from the GfK Knowledge Networks panel to complete online surveys. Measures included the HARK IPV screener, the PTSD Checklist-5, the Center for Epidemiologic Studies-Depression scale, and the Eating Disorder Diagnostic Scale. Using path analysis, with bootstrapping for indirect effects, we found that lifetime IPV at time 1 was directly associated with ED symptoms at time 3 (B=3.87, T=5.87, p<.001); in addition, this association was mediated by both PTSD (B=3.36, 95%CI: 1.78, 4.94) and depression symptoms (B=2.37, 95%CI: .90, 3.83) at time 2. These results emphasize the importance of assessing for and treating ED symptoms in women with IPV histories and related PTSD and depression symptoms.

Understanding the Relationship between Interpersonal Trauma and Eating Disorder Symptoms: An Extension of the Model of Psychological Adaptation

Holmes, Samantha, MA1; Johnson, Nicole, PhD2; Johnson, Dawn, PhD1

1University of Akron, Akron, Ohio, USA
2Lehigh University, Bethlehem, Pennsylvania, USA

There is considerable evidence that demonstrates that trauma is a non-specific risk factor for eating disorder symptoms (ED). A growing body of literature has begun to examine mechanisms that may explain the relationship; however few studies have tested comprehensive theoretical models. The Model of Psychological Adaptation (McCann, Sakheim, & Abrahamson, 1988) posits that trauma exposure results in core schema disruptions and that these schema disruptions are associated with various psychological symptoms that are also established predictors of ED (e.g., interpersonal problems, overcontrol). The model has found support through its ability to predict symptoms of other psychological disorders (i.e., PTSD, depression) and is the theoretical underpinnings for Cognitive Processing Therapy, a frontline treatment for PTSD; however it has not previously been extended to predict ED. Utilizing structural equation modeling (SEM) in a sample of 341 undergraduate women, preliminary analyses suggest excellent fit, χ2/df = 1.83, RMSEA = .05, CFI = .99, SRMR = .02, for a model that extends the framework of the Model of Psychological Adaptation to predict ED. These results provide a preliminary theoretical clinical conceptualization with which to interpret the relationship between trauma and ED symptoms. 
Acceptability and Efficacy of a Novel Group Intervention for Adults with Co-occurring Eating Disorders and PTSD: An Integrated Treatment Approach

Liebman, Rachel, PhD; Van Buren, Brian, MA; Ani, Keshishian, BA/BS; Kendra, Becker, PhD; Eddy, Kamryn, PhD; Thomas, Jennifer, PhD
Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA

Eating disorders (EDs) and PTSD are highly comorbid and may have a mutually reinforcing relationship that impedes recovery. Integrated group treatments represent “best buy” interventions that are cost effective and easily disseminated. Integrated treatments for ED-PTSD are lacking but are critically needed. This pilot study presents preliminary acceptability and efficacy of a novel 15-session group intervention for ED-PTSD that addresses the overlapping (emotion regulation, avoidance) and unique (eating behaviors, traumatic intrusions) features of ED-PTSD. Participants (n = 8) with co-occurring transdiagnostic EDs (i.e., binge eating disorder, atypical anorexia, or bulimia nervosa) and PTSD have completed six of 15 weekly 90-minute sessions to date. At each session, participants complete the PTSD Checklist for DSM 5 (PCL-5), Eating Disorder-15 (ED-15), and Difficulties in Emotion Regulation Scale (DERS). Retention and attendance have been excellent. Paired sample t-tests show a significant decrease in PTSD and emotion dysregulation and no change in ED symptoms over the first six weeks. The pattern of ED-PTSD symptom change has implications for the conceptualization of EDs as an avoidance behavior for PTSD that may require longer course of treatment. Results of this initial pilot study are promising and provide preliminary support for an integrated group ED-PTSD treatment.

Concurrent Session Eight: Symposium

Friday, November 9 | 4:30 PM to 05:45 PM


Understanding the Experience of Trauma and Minority Stress in Lesbian, Gay, Bisexual, and Transgender Populations: Implications for Conceptualization, Practice, and Policy

Chair: Scholl, James, MA PhD Student;
Discussant: Shipherd, Jillian, PhD

Research has consistently demonstrated that in the United States, minority populations bear a disproportionate burden of mental and physical illness. Striking health disparities have been identified in lesbian, gay, bisexual, and transgender populations (LGBT), including higher rates of suicide, depression, and substance use.  Minority stress theory has provided insight into these disparities proposing that individuals with marginalized identities experience unique stressors which place them at risk for adverse health outcomes. Research has converged to support the minority stress model by providing evidence that increased exposure to unique, stressful events are associated with chronic stress and increased rates of psychological distress (e.g., mood disorders, social anxiety).

In addition to these unique stressors, preliminary research suggests that LGBT individuals experience violence and victimization at higher rates than the general population both nationally and internationally. While data has been collected on the prevalence of trauma, violence, and victimization in the TGNC population, few studies have explored the impact they have on psychopathology, specifically PTSD. Scholars have asserted that sexual and gender minorities are repeatedly exposed to stress, and such exposure can, in turn, heighten their vulnerability to PTSD. Furthermore, some have argued that experiencing events which are non-life threatening (e.g., prejudice, discrimination) and associated with an individual’s minority identification can precipitate PTSD, as they are a threat to both the security and well-being of individuals.

The purpose of this symposium to provide clinicians and researchers an in-depth examination of trauma and minority stress in lesbian, gay, bisexual, and transgender populations. Four clinician researchers will present findings from studies examining the relationship between trauma, minority stress theory, and psychopathology. The first two presenters will examine the specific theoretical mechanisms of minority stress theory in relation to PTSD symptom severity in two different transgender samples. One presenter will report on data collected from an online study examining the relationships between trauma exposure, sexual minority stressors, and posttraumatic stress symptoms, in a sample of sexual minority military service members. The last presenter will report findings from a study examining the relationship between trauma, minority stressors, and suicidality. Results indicate that each component of minority stress theory has a unique relationship with trauma-related pathology. Implications for conceptualization, practice, and policy will be discussed by the LGBT Program Director at the U.S. Department of Veterans Affairs.

Non-Affirmation and Exposure to Anti-transgender Bias Related to Increased Severity of PTSD Symptoms: Evaluating a Model of Partial Mediation by Internalized Transphobia

Barr, Sebastian, PhD
Cambridge Health Alliance | Harvard Medical School, Cambridge, Massachusetts, USA

Prevalence rates for PTSD are higher in the transgender population; this has often been understood to be the result of transgender people’s increased exposure to Criterion-A single-event traumas. Reisner et al. (2014), however, found that after controlling for Criterion-A trauma exposure, experiences of discrimination predicted PTSD symptoms in a sample of transgender adults. The current study expands previous work by integrating theories of complex and non-complex PTSD, insidious trauma, and minority stress to explore the possible traumatic nature/impact of gender minority stressors. SEM was used to evaluate the relationships between distal stressors (i.e., anti-transgender bias and non-affirmation of gender identity), internalized transphobia (a proximal stressor), and PTSD symptoms in 572 trans-identified participants. After controlling for exposure to non-bias-related potentially traumatic events, distal gender minority stressors significantly predicted severity of posttraumatic stress. These relationships were partially mediated by internalized transphobia. Findings indicate that anti-transgender bias, non-affirmation experiences, and internalized transphobia are related to transgender people's increased risk for PTSD and may be implicated in the development of trauma responses and/or recovery from said responses. Research and clinical implications will be discussed.

Predicting Suicidal Ideation and Behaviors in Transgender Individuals: An Examination of Traumatic Experiences, Distal Stressors and Proximal Stressors

Cogan, Chelsea, PhD Student; Scholl, James, MA PhD Student; Lee, Jenny, BS; Davis, Joanne, PhD
University of Tulsa, Tulsa, Oklahoma, USA

Transgender and gender non-conforming (TGNC) individuals face a myriad of unique stressors related to their gender identity. Minority stress theory suggests these stressors may increase the likelihood of poor physical and mental health outcomes. Prior research has found a relationship between these stressors and various forms of psychopathology, such as posttraumatic stress disorder, depression, and substance use. Additionally, research has indicated that TGNC individuals are at an increased risk for experiencing suicidal ideation, behaviors, attempts, and completions. Research suggests these behaviors are related to experiences of trauma as well as distal stressors. The present study aims to examine the frequency of traumatic experiences and distal and proximal stressors as predictors for suicidal ideation and behaviors in a TGNC sample (n = 155). We found traumatic experiences and both distal and proximal stressors significantly predicted suicidal ideation and behaviors F(3, 151) = 17.482, p < .001, with each variable significantly contributing at p < .05 or less. This is one of the first studies to suggest proximal stressors, in addition to experiencing trauma and distal stressors, may predict suicidal ideation and behaviors in TGNC individuals. These results and the implication of these findings will be discussed in depth.

Predicting Posttraumatic Stress Symptoms in a Sample of Sexual Minority Service Members

Micol, Rachel, MA PhD Student1; Scholl, James, MA PhD Student2; Davis, Joanne, PhD2

1Boston VA Healthcare System, Boston, Massachusetts, USA
2University of Tulsa, Tulsa, Oklahoma, USA

Sexual minority individuals are at increased risk for trauma exposure and mental and physical health diagnoses compared to their heterosexual counterparts. Minority stress theory postulates sexual minority individuals may experience unique stressors that may help to partly explain the increased propensity for these mental and physical health diagnoses, but application of this theory to understand PTSD symptoms in sexual minority military service members is limited. Examination of sexual minority stressors in military service members appears warranted, given the long history of policies prohibiting open service for sexual minorities. The present study sought to examine the relationships between trauma exposure, sexual minority stressors, and posttraumatic stress symptoms, in a sample of sexual minority military service members (N = 95). Results provided support for several minority stressors, including discrimination, internalized heterosexism, and institutional betrayal, as unique predictors of PTSD symptom severity [F(4,90) = 11.11, p < .001]. These sexual minority stressors emerged as significant predictors of PTSD symptoms even after controlling for the effects observed for trauma exposure [F(4,90) = 9.34, p < .001]. The findings obtained from this study may have important implications regarding outreach and treatment efforts with sexual minority military service members.

Posttraumatic Stress Symptoms in the Transgender Population: An Examination of Minority Stress Theory

Scholl, James, MA PhD Student1; Micol, Rachel, MA PhD Student2; Cole, Hannah, Undergraduate1; Davis, Joanne, PhD1

1University of Tulsa, Tulsa, Oklahoma, USA
2Boston VA Healthcare System, Boston, Massachusetts, USA

Research suggests individuals who identify as transgender are at increased risk for victimization and subsequent elevated rates of distress and psychopathology compared to cisgendered individuals. Existing research attempts to explain these health disparities utilizing a minority stress theory framework, which posits that individuals with a marginalized identity may experience unique stressors that increase the risk for psychopathology. The theory proposes that distal stressors (e.g., discrimination, victimization) lead to poor physical and mental health outcomes and proximal stressors (e.g., internalized transphobia) partially mediate this relationship. Further, the theory suggests community-level resilience (e.g., pride, community connectedness) moderates the development of psychopathology. The present study investigated the theoretical mechanisms of minority stress theory in relation to PTSD symptoms in a sample of 199 transgender individuals. Results provided support for the minority stress framework as distal stressors predicted PTSD symptom severity [R2 = .33, F(2,196) = 47.17, p < .001]  and this relationship was partially mediated by proximal stressors. Additionally, community resilience partially moderated the relationship between stressors and PTSD symptom severity. Implications for theory, treatment, and policy will be discussed.


Concurrent Session Nine: Workshop Presentation

Saturday, November 10 | 9:45 AM to 11:00 AM


Treating Stress and PTSD with CB-ART: an Integrative Intervention combining Cognitive Behaviour Interventions and Art Therapy

Cwikel, Julie, PhD
Ben Gurion University of the Negev, Beer Sheva, Israel
Cwikel, J. & Huss, E.

CB-ART is an innovative published model of treatment that integrates cognitive behavioural interventions with guided imagery and art therapy. The CB-ART protocol integrates art making and cognitive behavioral interventions to transform distressing images, symptoms and memories, thus changing the structural components of the image, and through this,  altering affect  and enabling the reduction of symptoms.  In this workshop, I will present the rationale for the combination of the two treatment methods that adds a focus on visual non-verbal elements to CBT, as a way to address symptoms of stress and PTSD.    Examples will be drawn from published, empirical evaluations of the method, specifically with young people who have been exposed to stressful or traumatic experiences during their army service. The learning will be experiential, and interactive, together with theoretical foundations of the method.  Using published protocols of CB-ART, we will learn how to apply the methodology in a variety of treatment settings.


Concurrent Session Ten: Symposium

Saturday, November 10 | 11:15 AM to 12:30 PM


Sexual Assault among Individuals who Identify as Sexual Minorities: Predictors of Severity and Mental Health Outcomes

Co-Chairs: Newins, Amie, PhD; Wilson, Laura, PhD

While rates of sexual assault in the general population are alarming, individuals who identify as sexual minorities (e.g., individuals who identify as lesbian, gay, bisexual, or questioning [LGBQ+]) are more likely to experience sexual violence than individuals who identify as heterosexual. Furthermore, individuals who identify as LGBQ+ report high rates of stigma due to heteronormativity. This series of presentations will include four studies examining sexual assault among individuals who identify as LGBQ+. First, Ms. Salim will describe how internalized heteronormativity and "outness" affect the relationship between experiences of stigma and sexual coercion severity among women who identify as bisexual. Second, Dr. Wilson will present findings examining how rape myth acceptance may contribute to rape acknowledgment among individuals who identify as LGBQ+. Third, Dr. Newins will explain differences between individuals who identify as LGBQ+ and individuals who identify as heterosexual in mental health outcomes following sexual assault and how posttraumatic cognitions may affect these outcomes. Fourth, Ms. Lopez will describe factors that predict resiliency and mental health problems following a sexual assault among women who identify as LGBQ+. Together, these presentations will address gaps in the literature related to the experience of sexual assault among individuals who identify as LGBQ+. Furthermore, they will provide researchers with questions that remain. Finally, they will provide clinical recommendations regarding specific treatment considerations (e.g., discussing heteronormativity, considering rape acknowledgment status, addressing posttraumatic cognitions, and considering the compounding effects of other minority statuses).

Bisexual Women’s Experiences of Stigma and Sexual Coercion: The Role of Internalized Heterosexism and Outness

Salim, Selime, Doctoral Student; McConnell, Amy, MA; Messman-Moore, Terri, PhD
Miami University, Oxford, Ohio, USA

Bisexual women report higher rates of sexual victimization compared to heterosexual and lesbian women (Rothman et al., 2011; Hequembourg et al., 2013), including double the rates of lifetime sexual coercion (Walters et al., 2013). These documented disparities in sexual violence experiences deserve additional examination to identify specific risk factors. The current study investigated how anti-bisexual stigma from heterosexual and lesbian/gay individuals impact severity of sexual coercion among a sample of 350 bisexual community women. Two moderated-mediation models tested whether internalized heterosexism (IH) would mediate the relation between anti-bisexual experiences (from heterosexual individuals in model 1 and from lesbian/gay individuals in model 2) and sexual coercion severity, and whether outness would moderate the relation between anti-bisexual experiences and IH. Analyses indicated that IH mediated the relation between anti-bisexual experiences and sexual coercion severity. Further, outness moderated the relation between anti-bisexual experiences and IH. Probing of conditional indirect effects revealed a significant indirect effect between anti-bisexual experiences and sexual coercion through IH for individuals who were out. These results point to specific targets for violence prevention programs that may help reduce the disparity experienced by bisexual women.

Rape Acknowledgment in the LGBQ+ Community: The Indirect Effect of Rape Myth Acceptance

Wilson, Laura, PhD1; Newins, Amie, PhD2

1University of Mary Washington, Fredericksburg, Virginia, USA
2University of Central Florida, Orlando, Florida, USA

Unacknowledged rape occurs when a survivor does not label a rape as such. Although the prevalence of unacknowledged rape is estimated to be 60%, little existing literature has examined whether rates of rape acknowledgment differ in individuals who identify as lesbian, gay, bisexual, or questioning (LGBQ+). This study examined whether rates of rape acknowledgement differ between individuals who identify as LGBQ+ and those who identify as heterosexual, and whether differences in rape myth acceptance account for this difference. A total of 2,440 college students (59% female) completed an online survey of history of sexual assault and rape myth acceptance. Among the 264 participants who experienced a rape since the age of 14, the 58 participants who identified as LGBQ+ (65.5% acknowledged) were significantly more likely to be acknowledged survivors than individuals who identified as heterosexual (42.9% acknowledged; c2 = 9.25, p < .05). The indirect effect of sexual orientation on likelihood of rape acknowledgment through rape myth acceptance was statistically significant (ab = 0.26, p < .05), such that individuals who identified as LGBQ+ reported greater rejection of rape myths, which in turn was associated with increased likelihood of acknowledged rape. These findings suggest that beliefs about rape may account for the lower rates of unacknowledged rape among LGBQ+ individuals. 


Depression and Posttraumatic Stress Symptoms following Sexual Assault: The Role of Posttraumatic Cognitions in Differences Based on Sexual Orientation

Newins, Amie, PhD1; Wilson, Laura, PhD2

1University of Central Florida, Orlando, Florida, USA
2University of Mary Washington, Fredericksburg, Virginia, USA

Individuals who identify as a sexual minority (e.g., lesbian, gay, bisexual, questioning [LGBQ]) are more likely to experience sexual assault than individuals who identify as heterosexual. The purpose of this study was to examine whether individuals who identify as LGBQ experience higher levels of mental health symptoms following sexual assault and, if so, potential mediators of that relationship. A total of 2,440 college students (59% female) completed an online survey assessing history of sexual assault and current mental health symptoms. Individuals who identified as LGBQ were more likely than individuals who identified as heterosexual to have experienced a sexual assault and to have experienced a rape in the past year and since the age of 14 (ps < .001). Among the 304 individuals who reported experiencing a sexual assault since the age of 14, individuals who identified as LGBQ reported higher levels of depression, posttraumatic stress symptoms (PTSS) secondary to their worst sexual trauma, and multiple posttraumatic cognitions (PTCs; ps < .02). PTCs did not mediate the relationship between sexual orientation and PTSS, but they did mediate the relationship between sexual orientation and depression symptoms. Based on these finding, addressing PTCs may be particularly indicated for reducing symptoms of depression following sexual trauma among individuals who identify as LGBQ.

Sexual Victimization among Lesbian and Bisexual Women: Protective Factors and Mental Health

López, Gabriela, MS1; Yeater, Elizabeth, PhD1; Hughes, Tonda, RN, PhD2

1University of New Mexico, Albuquerque, New Mexico, USA
2University of Illinois Chicago, Chicago, Illinois, USA

Minority stress (Meyer, 2003) posits that sexual victimization experienced by women who are sexual and/or ethnic minorities can lead to more negative mental health consequences relative to heterosexual or Caucasian women (Balsam et al., 2011). This study will use structural equation modeling to examine associations among sexual identity (e.g., lesbian bisexual), ethnicity (e.g., Latina, African American, Caucasian), lifetime sexual victimization, mental health symptoms (e.g., depression, anxiety, PTSD symptoms, hazardous drinking), and resiliency (e.g., coping, spirituality, social support). Resiliency hypothesis suggests LGB people of color have a greater capacity to cope with stress relative LGB whites (Meyer, 2010). Participants were 660 lesbian/gay, mostly lesbian/gay and bisexual women who completed measures about health and life experiences. The sample is ethnically diverse and 35% of the participants reported sexual assault in their lifetime. It is hypothesized that LGB women of color will have higher levels of resiliency and fewer mental health symptoms compared to LGB Caucasian women. With respect to victimization, women with higher levels of resilience, relative to women with lower levels of resilience, will report lower mental health symptoms. Differences in resiliency and mental health among ethnic and sexual minority groups will be exploratory in nature. 


Concurrent Session Eleven: Symposium

Saturday, November 10 | 2:00 PM to 03:15 PM

Sexual and Gender Minorities’ Elevated Vulnerability for Interpersonal Trauma: Patterns, Risk Factors, and Outcomes

Chair: McConnell, Amy, MA

Research repeatedly demonstrates elevated risk for interpersonal trauma exposure and negative trauma-related outcomes among sexual and gender minorities (Roberts, Austin, Corliss, Vandemorris, & Koenen, 2010), yet little research has examined risk factors for and outcomes of interpersonal trauma within these populations. Drawing on the theme for this year’s meeting, four studies will explore sexual and gender minorities’ vulnerability for interpersonal trauma. The goal of this symposium is to increase understanding of the trauma faced by sexual and gender minorities broadly, as well as the unique experiences of underrepresented groups within the community. Dr. Charak will report on five latent classes of interpersonal victimization among lesbian, gay, and bisexual people currently in relationships and their associations with emotion dysregulation, anxiety, and depression. Mx. McConnell will demonstrate how minority stress and hazardous drinking contribute to high risk for sexual revictimization among bisexual women. Using a mixed methods approach, Dr. Hequembourg will compare post-sexual victimization coping and disclosure among bisexual, lesbian, and heterosexual women. Last, Dr. Valentine will share selected results from a systematic literature review of mental health among transgender and gender non-conforming people, focusing on exposure to traumatic life events, negative mental health outcomes, and protective factors within this population.

Three-step Latent Class Approach on Childhood Maltreatment and Intimate Partner Aggression among Gay, Lesbian, and Bisexual Individuals: Differences in Emotion Dysregulation, Anxiety, and Depression

Charak, Ruby, PhD1; Villarreal, Lillianne, BSc1; Cantu, Jorge, MA Student1; Erwin, Meredith, MA PhD Student2

1The University of Texas Rio Grande Valley , Edinburg, Texas, USA
2University of Toledo, Department of Psychology, Toledo, Ohio, USA

The aims of the present study were three-fold. First, to identify patterns of childhood maltreatment and intimate partner aggression (in-person and via cyberspace), among gay, lesbian, bisexual (GLB) people currently in a romantic relationship. Second, to examine if biological sex, sexual orientation, and race/ethnicity predicted class-membership; third, if there were differences in the latent classes on emotion dysregulation (ER), depressive and anxiety symptoms. Participants were 288 emerging adults in the age range of 18- 29 years (M = 25.4, 41.7% gay/lesbian; 26% Hispanic) recruited via Amazon Mturk. Victimization ranged from 14% of physical partner-aggression to 69% of childhood emotional neglect. Using the 3-step approach for latent class analysis, five classes, namely, high victimization (HV), moderate victimization (MV), cyberaggression (CYB), in-person intimate partner aggression (IPA), and low victimization (LV) were obtained. Lesbian and bisexual women were more likely to be in the MV and Hispanic individuals were more likely to be in the HV versus the LV. Further, HV and MV were higher on ER, depression symptoms, and anxiety than the other less severe classes. Findings suggest a cumulative and detrimental effect of lifetime victimization on the mental health of GLB adults, with lesbian and bisexual women, and Hispanic individuals at heightened risk of victimization.

A Mixed Methods Investigation of Lifetime Sexual Trauma and Coping among Sexual Minority Women and Exclusively Heterosexual Women

Hequembourg, Amy, PhD1; Livingston, Jennifer, PhD1; Bostwick, Wendy, PhD2; Blayney, Jessica, Doctoral Student1

1State University of New York at Buffalo, Buffalo, New York, USA
2University of Illinois Chicago, Chicago, Illinois, USA

Introduction: Sexual minority women (SMW) report higher rates of sexual victimization (SV) than heterosexual women (HW), yet relatively little is known about SMW’s post-SV outcomes. The current study provides mixed methods insights into post-SV adaptation and disclosure among bisexual women (BW), lesbian women (LW), and HW.

Methods: A community sample of 246 women (88 LW, 84 BW, 74 HW) were recruited using Respondent-Driven Sampling and surveyed about SV-related symptoms, disclosure, and coping via interview and self-report.

Results: Nearly ¼ of the sample reported childhood sexual abuse and over half reported adult SV, with the highest rates found in BW. BW reported greater trauma symptoms, but no differences were found in women’s reporting of SV disclosure response quality. Despite quantitative findings regarding poorer post-SV outcomes among BW, qualitative interview (n = 176) results revealed more similarities than differences in women’s post-SV outcomes.

Conclusions: Mixed methods findings indicate a high prevalence of lifetime SV among SMW, with BW at greatest risk. Narratives suggest similarities in disclosure and coping regardless of sexual identity. Understanding the short- and long-term impact of SV on SMW is critical to inform culturally-competent clinical care that is sensitive to the needs of diverse SV survivors.


Hazardous Drinking, Anti-bisexual Prejudice, and Sexual Revictimization among Bisexual Women: A Moderated Mediation Model

McConnell, Amy, MA; Messman-Moore, Terri, PhD
Miami University, Oxford, Ohio, USA

Bisexual women report higher rates of sexual revictimization than their heterosexual and lesbian peers, and limited research has examined risk factors for sexual revictimization among this population. The current study examined hazardous drinking as a mediator of the relation between childhood sexual abuse (CSA) and adult rape among bisexual women. Further, anti-bisexual prejudice was tested as a moderator of the indirect effect to better understand the context of hazardous drinking. Data were collected online from 343 bisexual women. Participants completed measures of CSA, anti-bisexual prejudice, hazardous drinking, and adult rape. The PROCESS macro was used to test the conditional indirect effect of CSA on adult rape via hazardous drinking, moderated by anti-bisexual prejudice. The rate of revictimization in the current sample was 38.6%. The hypothesized conditional indirect effect was supported; CSA was indirectly related to adult rape through hazardous drinking only at mean and high levels of anti-bisexual prejudice. Findings highlight the need for interventions at multiple levels. Policies aimed at reducing bisexual stigma may be useful in addressing high rates of revictimization. Clinical interventions focused on helping bisexual CSA survivors cope adaptively with the added stress of anti-bisexual prejudice may be useful in reducing risk for sexual revictimization.

A Systematic Review of the Literature on Mental Health Outcomes among Transgender and Gender Non-nonconforming (TGNC) People: Applying the Minority Stress Model to Clinical Research Study Design

Valentine, Sarah, PhD1; Shipherd, Jillian, PhD2

1Boston University School of Medicine, Boston, Massachusetts, USA
2National Center for PTSD, Boston VA Medical Center and Boston University School of Medicine, Boston, Massachusetts, USA

Transgender and gender non-conforming (TGNC) populations are increasingly recognized in health care settings. Research on the health of TGNC people is growing. Disparities are often noted, yet adequate prevalence data is not available. In this review, we examine 77 studies published between 1997 and 2017 which reported mental health outcomes in TGNC populations to (a) characterize what is known about mental health outcomes and (b) characterize the gaps in this literature and methodological concerns. We used Meyer’s (2003) minority stress model as a framework for summarizing existing literature. Findings suggest that TGNC people are exposed to a variety of social stressors, including stigma, discrimination, and bias events that contribute to risk for exposure to interpersonal trauma and a range of mental health sequelae. In general, depressive symptoms, suicidality, posttraumatic stress symptoms, substance use, anxiety, and general distress have been consistently elevated among TGNC adults. Social support, community connectedness, and effective coping strategies may buffer the relations between trauma and discrimination exposure and mental health sequelae. The presentation will provide a critique of the extant literature and detailed recommendations on how to address key theoretical and methodological issues related to conduct of TGNC health research.