August 11, 2025 • 36 mins
In this episode of APA's Breaking the Silence series, Dr. Pratik Bahekar and Dr. Melvin Oatis delve into the complex and urgent issue of suicide risk among LGBTQ+ youth. Drawing from their clinical experience, they explore the impact of stigma, bullying, and systemic barriers, while also highlighting protective factors like community support, affirming clinical care, and chosen family. The conversation offers practical insights for parents, educators, clinicians, and policymakers committed to supporting LGBTQ+ youth and reducing suicide risk.
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(00:03):
within the community, you're feeling as if you're not supported, if you're feeling thatyou're being bullied, then where is the person that I go to?
Where is my voice?
Where is the person that's gonna stand up and actually understand me?
Who has demonstrated the ability to hold what I have to say and affirm what it is that Ibelieve and also to help them to know that this is going to get better.
(00:26):
that is, uh know, stigma is a huge barrier.
Welcome to the APA More Equity series, Breaking the Silence, Addressing Youth Suicide.
In this episode, Dr.
Pratik Bahekar is joined by Dr.
Melvin Otis.
Dr.
Bahekar is an assistant professor of psychiatry at Yale University and a fellow of theAmerican Psychiatric Association.
(00:51):
He completed the general psychiatry residency training program at SUNY Downstate MedicalCenter and Yale University, as well as a forensic psychiatry fellowship at the University
of Pennsylvania.
He is an acute inpatient psychiatrist at Yale Psychiatric Hospital, where he providesclinical care to young adults, adults, and geriatric patients.
(01:12):
His focus is on advancing LGBTQ plus mental health, and he has participated in advocacyand policy development efforts.
He serves as the president of the caucus of LGBTQ plus psychiatrists for the AmericanPsychiatric Association, as well as the president of the association of LGBTQ plus
psychiatrists.
So now.
(01:32):
Let's break the silence with Dr.
Behekar and Dr.
Otis.
uh
Dr.
Otis, it's a pleasure to have an opportunity to talk to you.
Thank you for taking time out from your busy schedule to talk about suicidality in LGBTQplus youth.
So Dr.
Otis is an adult child and adolescent psychiatrist in private practice in the New Yorkcity.
(01:55):
After completing his combined residency training in pediatric medicine, adult child andadolescent psychiatry at Mount Sinai uh Hospital in New York,
He joined the faculty of New York University Medical Center as an integral member of theclinical trial research team studying ADHD and comorbidities of ODD and anxiety.
(02:20):
Dr.
Otis remains a voluntary faculty at the NYU Grossman Child Study Center.
Dr.
Otis is a current co-chair of advocacy committee of the American Academy of Child andAdolescent Psychiatry.
and also serves on ACAP presidential task force.
Welcome again.
(02:40):
Thank you for having me here today.
our pleasure.
To begin, can you share what first drew you towards child and adolescent psychiatry,particularly in focusing on LGBTQ plus youth?
Sure.
So I always wanted to be in medicine and pediatrics was the first entry into it and thenchild psychiatry.
(03:00):
And at Mount Sinai, we had every type of population on demand and then that continuedwhile at NYU.
And in my private practice, I get to refer just a lot of people throughout the city andthe surrounding area.
And increasingly, I think children are more in touch with mental health care or more intouch with
(03:22):
seeking help and talk to their parents about it.
increasingly, you see anything in terms of like television, movies, have things regardingmental health in them.
So we're seeing more children in that arena.
And also, as you probably well know, that the LGBTQA community has increases in mentalhealth referrals and increase in mental health challenges as well.
(03:51):
With all that, uh it's been an honor to be able to serve the community.
I absolutely right.
What is it important to have focused conversation about suicide risk specifically withinLGBTQ plus youth populations?
Having focused conversations about suicide is extremely important in the LGBQTA community,primarily because they are at increased risk for suicidal ideation.
(04:24):
So it is not that it's so common, but it is not uncommon for children and adolescents totalk about suicidal ideation.
And oftentimes uh they're terrified at that thought, but they're also challenged with
who to tell that to, how can they trust somebody with that, what will they do with thatinformation?
(04:45):
So it's really important to have a real direct conversation in terms of uh having themunderstand what that is, having them understand that it's important for uh getting help,
for getting treatment, and that is absolutely normal to talk about it.
Why suicide rates are high amongst LGBTQ plus youth compared to their cisgenderheterosexual counterparts?
(05:10):
Well, there are a number of factors that contribute to an increase.
First, just adolescence itself is a vulnerable time, as you well know.
The brain is developing until age 25.
So with that and through puberty, you get this surge of hormones and everyone responds tothat differently.
(05:32):
They get different desires that are going on within their body because of that uh and thechallenges with that.
How often is that talked about?
Maybe they hear a little bit something about it in health, may have had one conversationabout birds and the bees with their parents, but it's pretty limited regarding what else
they talk about around uh the mental health or emotional wellbeing.
(05:57):
and not only that, bullying is common to LGBTQ uh individuals.
So, I mean, that happens in a schoolyard anyway.
but this is also another point of vulnerability.
So that increases the incidence of suicidal ideation.
Also just within a community, I'm not talking about just like your community, yourneighborhood, but your community at home, your community in your school, what is the
(06:25):
community with your friend group?
How often is uh emotional well-being talked about in that population or any kind of waywith that?
So you have vulnerability because of just development, you have vulnerability because ofbullying, and also increasingly because there is an exposure with kids having their phone,
(06:47):
there is social media, right?
So there's an element where social media can be wonderful in terms of connectivity people,but it can also be a ways in which people are bullied as well, quite broadly.
And so in a vulnerable population,
not really understanding all of these different variables that can lend itself to alsoincreases in suicidal ideation.
(07:12):
According to CDC's Youth Risk Behavioral Survey, LGBTQ plus students are more likely tomisuse substances and experience multiple forms of violence.
How are these experiences interconnected?
And what impact do they have on suicide risk?
So let's step back and say that youth in general experiment or have uh some curiosityabout various substances.
(07:39):
So just the vulnerable population of being an adolescent, children are going to thinkabout different substances and have exposure to different substances.
But when you're already having some other challenges, you're already having otherenvironmental threats and things of that nature.
that can also increase the incidence of wanting to try something or escape the way inwhich people are thinking.
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And also if you want to add to that, if people are teasing or bullying these things, thatcan also increase the susceptibility for uh this group of youth to try substances.
So if you want to add just the vulnerable population and then add on a use of a substance,
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you're going to increase the chances of suicidal ideation, you're going to increaseimpulsivity, you're going to increase the cloudiness of thinking.
So that also is making this population a bit more vulnerable when you add that in.
Can you speak to the intersection identity of how race, gender identity and socioeconomicstatus may compound risk for LGBTQ plus youth?
(08:54):
oh Well, that's a big question, right?
In terms of uh gender.
So just in talking about gender, I think there's uh a challenge from a perspective ofgender roles, gender identity, whether or not a child is gender conforming and
(09:14):
non-conforming and what that looks like.
And then what does that look like within their community, their community at home?
Do their parents support oh
their gender expression as it were.
What happens when the child goes to school in terms of their gender expression?
Do the students around them support that?
Does the teacher or the principal, what happens in that environment for that child?
(09:39):
So all of these things are important in terms of the intersectionality there when we startwith gender.
Then we wanna start with, I think you said social economic status.
So we're talking about social determinants in health.
Anytime you're talking about social determinants of health, vulnerable populations, LGBTQApopulation, uh communities of color, these are all added factors that are going to uh play
(10:11):
a part or play a role in emotional well-being.
So you have all of these challenges that intersect.
And then you want to think about
what are the resources for a child to then be able to discuss these types of things.
So all of these things are playing a role in their emotional being.
(10:36):
More than 60 % of LGBTQ plus students report persistent feeling of sadness orhopelessness.
What does persistent emotional distress look like in clinical terms?
And when should we be especially concerned?
So in looking at emotional well-being or looking at distress, that's going to play outvery differently.
(10:57):
We can't fool ourselves to say it only looks like this.
But notably, we look for changes, right?
If there's a change in someone's affect, a change in their mental um expression that youcan account for by, you know, they're not able to put a label on it or talk about what is
(11:18):
accounting for that.
that should arise suspicion, right, for the community, for the people that have to takecare of this youth.
So any sort of change in behavior, if there's any sort of sadness, so, you know, we allhave experienced periods of sadness, but there may be this period of sadness that you
(11:38):
exhibit that goes away a little bit and gets better, but if you have a persistent sadnessand you can't really identify a factor, that should be something that's also explored.
I think the challenge with this is that the kid doesn't know how to necessarily expressthat.
And we could uh invariably label them incorrectly and just like, that's just adolescence.
(12:02):
That's just adolescence.
They're moody.
And I want to caution parents that, OK, yes, there are adolescents that are moody.
But if there's a change from their baseline moodiness oh that you guys have established interms of thinking about them,
then there's something more that you should explore.
You should ask them about that.
Is there uh anything that they'd like to tell you about?
(12:25):
Is there anything that has happened to them?
And you really want to approach this in a very uh non-judgmental, supportive uh manner.
uh Now, parents and teachers can think that that is what they're doing, but the perceptionof that can be quite different.
And if someone is having some persistent sadness, that's also a challenge, because thenthat lends them
(12:47):
perhaps to being a little bit more sensitive to what's being said to them.
So you have a myriad of challenges, someone that's had some persistent sadness, then onthe other side is how do you explore that?
How do you get to talk about it?
How does someone avail themselves to that sort of help?
From your clinical experience, what are the long-term consequences when young people areleft to carry out the level of sadness and hopelessness without support?
(13:16):
Whoa, long-term consequences of kids not getting support is that the question in terms ofif they have a sudden sadness.
just their developmental tasks, the task of where they are of being in school and managingtheir grades in school, the task of being social and making friends is a challenge for
(13:41):
them.
Just completing their daily task and homework.
that's also going to be problematic for them in terms of showing up.
But a real challenge also is even trying to uh express what's going on.
uh If you're seeing that with your children, you really don't want to write that off,right?
(14:03):
You really don't want to just say, ah, that's typical, that's normal.
You really want to have a chance to sort of explore that a bit more, slow down a bit more,and really
try and understand what that is because that can lead to school failure.
It can also make one more susceptible to trying to escape that sort of feeling, as youmentioned before, with substances.
(14:27):
And we are talking about the topic of suicides.
uh Someone can want to escape that and have suicidal ideation and be fearful of being ableto express that or not knowing how to talk about that or feeling a bit of shame around
that.
Again, the supportive, calm way in which you approach the adolescents is extremelyimportant in talking about suicidal ideation.
(14:56):
Can you tell us more about some early warning signs to clinicians, parents or educatorsshould look for when an LGBTQ plus youth may be at risk?
So early signs, again, I go back to change.
If there's any kind of a change from their baseline, if there's a persistent, uh we thinkthat a change in behavior is gonna look like sadness, but sometimes it's irritability.
(15:20):
Sometimes it's mad.
They're just talking about they're mad and they're angry and they don't have a reason forbeing mad or angry.
Or sometimes it may be a somatic complaint.
It might be said that it have persistent headaches or persistent pain.
persistent stomach aches, or anxiety, or fears that are somewhat unfounded and they can'texplain it.
(15:44):
So there are a number of ways in which it may not just look like sadness, it might looklike anger, and it may just look like uh really low grade uh energy and inability to do
things, or persistence in saying that they're tired.
Now, we'd like for them to be able, when we go down our DSM,
(16:06):
you know, and asked about, you know, hopelessness and things of that nature.
But that may not be the word in which they're able to uh identify or talk about.
So it might just be tiredness, anger, and irritability may be something that the child isuh talking about.
Or in sort of like abdicating their responsibilities, fleeing their responsibilities, ornot wanting to be around their loved ones and really isolating.
(16:32):
So.
uh
in this day and age where children have their own phones, their own televisions and thingsin which they can be sort of uh by themselves to their rooms, we want parents and we want
caregivers to be involved and know that and not allow them to self isolate.
So besides the emotional things, self isolation could be one of the other things in whichwe're looking.
(16:58):
From a psychiatric perspective, what types of support or therapeutic approaches are mosteffective for LGBTQ plus youth in crisis?
Okay, so the support can take the form of talk, of just uh hearing someone, sort ofsupporting them and giving them information that affirms what they're feeling also.
(17:23):
There could also be a point of giving them information about what they can do to feelbetter, what sorts of activities, other ways in which they can engage.
But if that isn't enough, there are other forms of therapy.
Cognitive behavioral therapy is quite useful in terms of having them reframe theirthoughts, what's going on with them.
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Also, DBT, dialectable behavioral therapy, is also useful.
You know, when kids are having some of these challenges, sometimes they feel as if no onecan understand them, or sometimes because of their personalities, they can get really
locked in on a way in which they're...
a feeling about something and again saying no one understands it.
(18:05):
But by these methods of both supportive therapies, behavioral therapy, dialecticalbehavioral therapy, DBT kinds of things are ways in which we can help the individual.
Sometimes those things aren't enough.
in crisis, some children may have to be brought to the hospital, some children may have tobe hospitalized for a while.
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uh That's going to vary depending upon the person.
Sometimes if we get before that and we're doing therapy, sometimes therapy along withmedication is something that is needed.
But the challenge with all that is seeking a mental health provider and also ideas aboutmedication.
And then that opens up a whole other uh arena of discussions for family when we're talkingabout therapy and medications.
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How can psychiatrists or health professionals in general make their practices moreaffirming and safer for LGBTQ plus young people?
The, you're doing your initial assessment and when you're talking with your families, youwant to be as general and open as possible.
When we're asking things about attractions, we really want to allow people to understandthat we are able to hear anything that they're able to say to to tell us about attraction,
(19:26):
male, female, both.
And in the most
non-judgmental, even way possible.
If we have to practice that for a while to be able to do it every time, then that's whatwe need to do in order to let the youth that come into our office know that we are
welcoming to them.
We should also be able to talk with their parents, talk with the child and the parenttogether, but also talk to the parent and the child separately because in that...
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we can get a sense of whether or not this child feels supported or what the real ideasthat their parents and their community have about perhaps their gender expression or their
sexuality.
And then when we're talking with the parents doing the same and try and understand howhave they tried to be supportive or understand their child.
uh When you were talking about some of the intersectionality and challenges before, what Ididn't mention is in different communities, uh different
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communities of color and LGBTQA, there are certain people may share a faith or not sharetheir parents' faith or people may have attitudes around that.
That may be something that we really have to talk about.
Or that may be a challenge for the parent and child to be able to have a conversationbased upon uh whatever their uh faith or religious upbringing are.
(20:53):
Sometimes that's a challenge and that has to be talked about quite directly.
Sometimes there may be some differences and that may not mean very much to them.
So we have to understand what does it mean for the child?
What does it mean for the parent?
And have those very direct conversations.
But also really affirm in your first meeting that you are there for support, that you canhear anything that they have to say, that it's rare that anyone's gonna say something that
(21:20):
you haven't heard before.
and that you're going to do your best to be both supportive and to keep them safe.
Talking about families, what role does a family acceptance or rejection play in suiciderisk?
And what can families do to do better, even if they are struggling to understand?
Now, so that's going to vary from child to child, you know, because you have a parent thatthinks that they're being very supportive, but the parent, the child doesn't perceive it
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that way, right, in terms of what that parent is offering.
So the level of support is critical.
It is absolutely essential.
A big fear that still exists is if the child tells their parent and caregiver that they'requestioning or that they feel that they're gay or
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sexual, anything that isn't quote unquote heteronormative, that that might be a challengefor them and a reason for them to leave their household.
And that may be the fear.
And maybe that isn't actually accurate, but that is a fear that can prevent children fromactually having a conversation with their parents.
So it's absolutely essential for
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you as the clinician, as the physician, as the provider to have conversations with theirparents and have an understanding.
If it's in their culture, if it's in their background that this is a challenge, explorewhy that is a challenge.
But also, I don't think there's a family that doesn't love their child even if they havedifferences or don't understand their development.
I think there are times where the parents really just does not understand their lack ofsupport or their
(22:58):
a parent rejection, how strong an impact that can have upon a child.
So that requires some individual work for the clinician to really explain that.
Support is essential.
uh And while you're trying to build up the parents in order to be supportive, on the otherside of that is talking with a child to have them have other adults in their life that can
(23:24):
be supported.
Maybe they don't feel that they can have this conversation with their
with their parent, we always want to encourage them to do so.
But maybe it's going to be enough, an uncle, a grandparent, a godparent, uh or some otheradult that is a part of the caregiving circle, a village of that child that the child can
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feel a level of support and understanding and go to.
So that's going to be extremely important.
uh If it's not the parent, if it's not the grandparent, if it's not the uncle, what is theadult?
Where is the community?
What is uplifting, surrounding, and a safety net for that child?
You mentioned community.
(24:05):
Are there any evidence-based school or community programs that have shown to reducesuicide risk for LGBTQ plus youth?
Yes, is, yes, support uh for youth is tantamount for their survival, for their ability toget help.
There are a number, as you mentioned at the beginning of this, there are surveys, there'sthe Trevor Project, there is uh Dan Savage had, It Gets Better, there is the American
(24:36):
Foundation for Suicide Prevention, there is the
NIH uh websites, their government websites that all uh give a number of resources andorder and also show that these source of interventions are helpful and protective of
youth.
(24:56):
Not only do you have those broad ones that I just mentioned, but you also have communityorganizations like NAMI, the National Association of Mental uh Health, that help.
you have NAMI.
you have uh PFLAG as well as another uh resource within the community.
Increasingly, even the faith-based organizations have mental health counselors.
(25:22):
You have some pastors, rabbi, ministers that also uh have some background in counseling orsome background in helping people with emotional wellbeing.
So increasingly, there are other ways in which people can receive assistance.
rather than just getting to a psychiatrist because most people aren't gonna run right outto the adult or child psychiatrist.
(25:47):
Even their uh pediatrician or their family uh GP might be also a source of support.
So everyone at this point needs to have some sort of training and understanding in termsof mental health and wellbeing and talking about this and really talking directly
(26:09):
about suicidal ideation and taking sort of that sting out of it, trying to decrease thestigma so you can talk about this.
uh So I'm talking about a support, but as I'm thinking about this, I'm also thinking aboutthe barriers that stigma still exists.
As much as I said earlier that
(26:32):
Children are coming into the office a lot more savvy and a lot more welcome tointerventions and able to talk to their parents about that.
There's still stigma involved depending upon the community.
wealthier, educated communities get a lot more exposure to mental health and emotionalwellbeing than other communities, but it is possible.
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And for that matter, whatever culture you find yourself in,
whatever that institution, maybe in the black community, that might be a church, thatmight be a community center, that might be the barbershop, it might be the nail salon,
where people are talking about this.
uh there are studies that help within the community is very, very uh useful oh in terms ofprevention and really surrounding the child with a safety net.
(27:27):
Talking about barriers, what are the biggest systemic barriers that prevent LGBTQ plusyouth from assessing timely and affirming mental health care?
Well, a lot of it is fear, fear and uh a mistrust.
And if within the community, if you're feeling as if you're not supported, if you'refeeling that you're being bullied, then where is the person that I go to?
(27:51):
Where is my voice?
Where is the person that's gonna stand up and actually understand me?
Who has demonstrated the ability to hold what I have to say and affirm what it is that Ibelieve?
and also to help them to know that this is going to get better.
that is, uh know, stigma is a huge barrier.
(28:12):
Even cost, right?
In terms of, you know, you have kids that feel as if what they're going through, that theyare a burden to their parents, that they were a cost to their parents, that their parents
are having some financial challenges.
That could be something else that's within this child's mind.
(28:32):
where they're not really thinking so much about themselves, well, they are feeling badlyabout themselves, but also feeling burdened that they have these challenges.
And so we really want uh people to understand that, to give the message that you are not aburden in any way to your family.
You're not a burden to your community.
Your community can be helpful to you because with time you are going to be an asset andyou're an asset right now to your community.
(28:57):
So mistrust, stigma, cost,
are all challenges.
uh Fear is a huge challenge and a huge barrier to having that.
Also within the healthcare environment, having people that look like them, having peoplethat they feel were going to understand them for culture.
(29:22):
We've spoke of cultural competence, cultural humility, and all of these things areimportant.
That's not to say that someone can't help.
an individual that doesn't look like them, but they have to be able to listen and holdwhat it is that the person is telling them in order to be able to help them.
So increasingly, we need more people within the community that looks like the diversitythat is within the community.
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need caregivers that equal that as well so that we can give people the care that theyneed.
How do peers support and chosen family factor into building protective networks for LGBTQmental health?
uh
So happy to ask that.
So that's a wonderful support.
If you can't get what it is, if the child is not getting what they need or feel that theycan get it from their parents, their peers, a peer that's the same age, that has supports
(30:20):
in other arenas can help them in terms of support.
Peers that might be older or younger can also provide support.
And the notion of chosen family is a...
very, a very uh strong one and something that has really shown to be effective.
when a kid is feeling bad and they're feeling uh suicidal or just feeling really hopeless,it's really hard for them to reach out to that community or reach out to someone else.
(30:50):
So it's incumbent upon us all to uh be able to circle around and help all the children.
within the American Academy of and Psychiatry where I am, uh the presidential uh theme isone of uh bringing the village to the children.
So when we are seeing people that are in need or hurting, we need to get to them.
(31:15):
Because sometimes it's hard for them to come to us.
So that might look like the physicians, it might look like the neighbor next door, it maybe the principal of the school, it might be a counselor.
what what have you may not be the direct blood relative that is the person that isproviding the most support we want to get them and that's crucial as i mentioned earlier
(31:37):
but it might be other people outside the family that are providing that support
In your opinion, what policy or funding changes would make the greatest difference insuicide prevention efforts in the community?
Well, that's about cutting Medicaid, not cutting Medicaid, uh having students, paying backstudent grants, student loans so that people can remain uh within the educational system
(32:08):
in order to spend enough time to become fully trained to take care of people.
uh Also, so
prioritizing mental health along with physical health, parity laws, the enforcement ofparity laws so that people can receive care and it's paid for.
(32:28):
So many people have to go out of pocket for both adult and child mental health care, butit should be right up there with everything else because mental health care is health
care.
It is for you to be completely sound and well and to be able to do everything.
Everything needs to be functioning.
So the laws,
that enforce parity, the laws that uh help to have a diverse workforce, the laws that donot cut Medicaid and things of that nature, and also funding to community organizations.
(32:59):
uh Oftentimes there's a dearth of resources where they're needed the most.
Our large institutions are fine, that's wonderful if you can get there to get your care,but more often than not, LGBTQA and uh
Patients of uh various uh ethnic minorities are not necessarily in those areas.
(33:21):
So care, laws, money, resources that go to the community will help to make a bigdifference here.
What gives you hope when working with LGBTQ plus youth even in face of such heartbreakingstatistics?
Oh, hope is actually having them in office and seeing that change, having them feelsupported, really when they say that they feel supported, when they are able to talk about
(33:49):
uh a difference uh and that the power of them feeling different, that they also want to goout and help their community.
They want to help others that feel like they do.
So the help is uh when you see that change, it gives me hope.
The fact that children and youth are resilient also gives me uh hope.
(34:13):
But we have to normalize being able to talk about this very directly.
We also have to have the youth understand that they're not alone.
We have to have to let them understand that it does get better, that this is part ofdevelopment, and that it's not a one size fits all.
(34:36):
This may take longer than they want to just like spring out of it, but the thing thatgives me hope is seeing that change and then being able to verbalize that and then wanting
to then help others to get better too.
Dr.
Otis, thank you for your informative conversation and your contribution towardsadvancement of LGBTQ mental health.
It's been pleasure talking to you.
(34:58):
Before we go, can you tell us the one message you wish every LGBTQ plus individual,especially youth struggling with their mental health should hear right now?
They are not alone in their struggles.
They are not alone in getting better, that there is a community around them.
If they haven't felt that community at their home, knock on another door, knock on anotherdoor at school, knock on and talk to another friend, tell people how you're feeling and
(35:29):
know that this can change for the better and not to have any sort of...
uh fear or care around stigma, around this, normalize, uh knowing that it's okay not tofeel so great and that you can get to help to feel better.
Can't agree with you more.
(35:50):
Thank you, Dr.
Ortiz.
Hope to speak with you again very soon.
Thank you.
Thank you for joining us on Breaking the Silence, Addressing Youth Suicide.
Please visit the Medical Minds podcast homepage at psychiatry.org for more information anda resource document related to this episode.
We also invite you to visit psychiatry.org slash more equity, M-O-O-R-E-E-Q-U-I-T-Y formore information on the APA More Equity in Mental Health Initiative.
(36:21):
Take care.
The views and opinions expressed in this podcast are those of the individual speakers onlyand do not necessarily represent the views of the American Psychiatric Association.
The content of this podcast is provided for general information purposes only and does notoffer medical or any other type of professional advice.
(36:46):
If you are having a medical emergency, please contact your local emergency responsenumber.
within the community, you're feeling as if you're not supported, if you're feeling thatyou're being bullied, then where is the person that I go to?
Where is my voice?
Where is the person that's gonna stand up and actually understand me?
Who has demonstrated the ability to hold what I have to say and affirm what it is that Ibelieve and also to help them to know that this is going to get better.
(00:26):
that is, uh know, stigma is a huge barrier.
Welcome to the APA More Equity series, Breaking the Silence, Addressing Youth Suicide.
In this episode, Dr.
Pratik Bahekar is joined by Dr.
Melvin Otis.
Dr.
Bahekar is an assistant professor of psychiatry at Yale University and a fellow of theAmerican Psychiatric Association.
(00:51):
He completed the general psychiatry residency training program at SUNY Downstate MedicalCenter and Yale University, as well as a forensic psychiatry fellowship at the University
of Pennsylvania.
He is an acute inpatient psychiatrist at Yale Psychiatric Hospital, where he providesclinical care to young adults, adults, and geriatric patients.
(01:12):
His focus is on advancing LGBTQ plus mental health, and he has participated in advocacyand policy development efforts.
He serves as the president of the caucus of LGBTQ plus psychiatrists for the AmericanPsychiatric Association, as well as the president of the association of LGBTQ plus
psychiatrists.
So now.
(01:32):
Let's break the silence with Dr.
Behekar and Dr.
Otis.
uh
Dr.
Otis, it's a pleasure to have an opportunity to talk to you.
Thank you for taking time out from your busy schedule to talk about suicidality in LGBTQplus youth.
So Dr.
Otis is an adult child and adolescent psychiatrist in private practice in the New Yorkcity.
(01:55):
After completing his combined residency training in pediatric medicine, adult child andadolescent psychiatry at Mount Sinai uh Hospital in New York,
He joined the faculty of New York University Medical Center as an integral member of theclinical trial research team studying ADHD and comorbidities of ODD and anxiety.
(02:20):
Dr.
Otis remains a voluntary faculty at the NYU Grossman Child Study Center.
Dr.
Otis is a current co-chair of advocacy committee of the American Academy of Child andAdolescent Psychiatry.
and also serves on ACAP presidential task force.
Welcome again.
(02:40):
Thank you for having me here today.
our pleasure.
To begin, can you share what first drew you towards child and adolescent psychiatry,particularly in focusing on LGBTQ plus youth?
Sure.
So I always wanted to be in medicine and pediatrics was the first entry into it and thenchild psychiatry.
(03:00):
And at Mount Sinai, we had every type of population on demand and then that continuedwhile at NYU.
And in my private practice, I get to refer just a lot of people throughout the city andthe surrounding area.
And increasingly, I think children are more in touch with mental health care or more intouch with
(03:22):
seeking help and talk to their parents about it.
increasingly, you see anything in terms of like television, movies, have things regardingmental health in them.
So we're seeing more children in that arena.
And also, as you probably well know, that the LGBTQA community has increases in mentalhealth referrals and increase in mental health challenges as well.
(03:51):
With all that, uh it's been an honor to be able to serve the community.
I absolutely right.
What is it important to have focused conversation about suicide risk specifically withinLGBTQ plus youth populations?
Having focused conversations about suicide is extremely important in the LGBQTA community,primarily because they are at increased risk for suicidal ideation.
(04:24):
So it is not that it's so common, but it is not uncommon for children and adolescents totalk about suicidal ideation.
And oftentimes uh they're terrified at that thought, but they're also challenged with
who to tell that to, how can they trust somebody with that, what will they do with thatinformation?
(04:45):
So it's really important to have a real direct conversation in terms of uh having themunderstand what that is, having them understand that it's important for uh getting help,
for getting treatment, and that is absolutely normal to talk about it.
Why suicide rates are high amongst LGBTQ plus youth compared to their cisgenderheterosexual counterparts?
(05:10):
Well, there are a number of factors that contribute to an increase.
First, just adolescence itself is a vulnerable time, as you well know.
The brain is developing until age 25.
So with that and through puberty, you get this surge of hormones and everyone responds tothat differently.
(05:32):
They get different desires that are going on within their body because of that uh and thechallenges with that.
How often is that talked about?
Maybe they hear a little bit something about it in health, may have had one conversationabout birds and the bees with their parents, but it's pretty limited regarding what else
they talk about around uh the mental health or emotional wellbeing.
(05:57):
and not only that, bullying is common to LGBTQ uh individuals.
So, I mean, that happens in a schoolyard anyway.
but this is also another point of vulnerability.
So that increases the incidence of suicidal ideation.
Also just within a community, I'm not talking about just like your community, yourneighborhood, but your community at home, your community in your school, what is the
(06:25):
community with your friend group?
How often is uh emotional well-being talked about in that population or any kind of waywith that?
So you have vulnerability because of just development, you have vulnerability because ofbullying, and also increasingly because there is an exposure with kids having their phone,
(06:47):
there is social media, right?
So there's an element where social media can be wonderful in terms of connectivity people,but it can also be a ways in which people are bullied as well, quite broadly.
And so in a vulnerable population,
not really understanding all of these different variables that can lend itself to alsoincreases in suicidal ideation.
(07:12):
According to CDC's Youth Risk Behavioral Survey, LGBTQ plus students are more likely tomisuse substances and experience multiple forms of violence.
How are these experiences interconnected?
And what impact do they have on suicide risk?
So let's step back and say that youth in general experiment or have uh some curiosityabout various substances.
(07:39):
So just the vulnerable population of being an adolescent, children are going to thinkabout different substances and have exposure to different substances.
But when you're already having some other challenges, you're already having otherenvironmental threats and things of that nature.
that can also increase the incidence of wanting to try something or escape the way inwhich people are thinking.
(08:06):
And also if you want to add to that, if people are teasing or bullying these things, thatcan also increase the susceptibility for uh this group of youth to try substances.
So if you want to add just the vulnerable population and then add on a use of a substance,
(08:27):
you're going to increase the chances of suicidal ideation, you're going to increaseimpulsivity, you're going to increase the cloudiness of thinking.
So that also is making this population a bit more vulnerable when you add that in.
Can you speak to the intersection identity of how race, gender identity and socioeconomicstatus may compound risk for LGBTQ plus youth?
(08:54):
oh Well, that's a big question, right?
In terms of uh gender.
So just in talking about gender, I think there's uh a challenge from a perspective ofgender roles, gender identity, whether or not a child is gender conforming and
(09:14):
non-conforming and what that looks like.
And then what does that look like within their community, their community at home?
Do their parents support oh
their gender expression as it were.
What happens when the child goes to school in terms of their gender expression?
Do the students around them support that?
Does the teacher or the principal, what happens in that environment for that child?
(09:39):
So all of these things are important in terms of the intersectionality there when we startwith gender.
Then we wanna start with, I think you said social economic status.
So we're talking about social determinants in health.
Anytime you're talking about social determinants of health, vulnerable populations, LGBTQApopulation, uh communities of color, these are all added factors that are going to uh play
(10:11):
a part or play a role in emotional well-being.
So you have all of these challenges that intersect.
And then you want to think about
what are the resources for a child to then be able to discuss these types of things.
So all of these things are playing a role in their emotional being.
(10:36):
More than 60 % of LGBTQ plus students report persistent feeling of sadness orhopelessness.
What does persistent emotional distress look like in clinical terms?
And when should we be especially concerned?
So in looking at emotional well-being or looking at distress, that's going to play outvery differently.
(10:57):
We can't fool ourselves to say it only looks like this.
But notably, we look for changes, right?
If there's a change in someone's affect, a change in their mental um expression that youcan account for by, you know, they're not able to put a label on it or talk about what is
(11:18):
accounting for that.
that should arise suspicion, right, for the community, for the people that have to takecare of this youth.
So any sort of change in behavior, if there's any sort of sadness, so, you know, we allhave experienced periods of sadness, but there may be this period of sadness that you
(11:38):
exhibit that goes away a little bit and gets better, but if you have a persistent sadnessand you can't really identify a factor, that should be something that's also explored.
I think the challenge with this is that the kid doesn't know how to necessarily expressthat.
And we could uh invariably label them incorrectly and just like, that's just adolescence.
(12:02):
That's just adolescence.
They're moody.
And I want to caution parents that, OK, yes, there are adolescents that are moody.
But if there's a change from their baseline moodiness oh that you guys have established interms of thinking about them,
then there's something more that you should explore.
You should ask them about that.
Is there uh anything that they'd like to tell you about?
(12:25):
Is there anything that has happened to them?
And you really want to approach this in a very uh non-judgmental, supportive uh manner.
uh Now, parents and teachers can think that that is what they're doing, but the perceptionof that can be quite different.
And if someone is having some persistent sadness, that's also a challenge, because thenthat lends them
(12:47):
perhaps to being a little bit more sensitive to what's being said to them.
So you have a myriad of challenges, someone that's had some persistent sadness, then onthe other side is how do you explore that?
How do you get to talk about it?
How does someone avail themselves to that sort of help?
From your clinical experience, what are the long-term consequences when young people areleft to carry out the level of sadness and hopelessness without support?
(13:16):
Whoa, long-term consequences of kids not getting support is that the question in terms ofif they have a sudden sadness.
just their developmental tasks, the task of where they are of being in school and managingtheir grades in school, the task of being social and making friends is a challenge for
(13:41):
them.
Just completing their daily task and homework.
that's also going to be problematic for them in terms of showing up.
But a real challenge also is even trying to uh express what's going on.
uh If you're seeing that with your children, you really don't want to write that off,right?
(14:03):
You really don't want to just say, ah, that's typical, that's normal.
You really want to have a chance to sort of explore that a bit more, slow down a bit more,and really
try and understand what that is because that can lead to school failure.
It can also make one more susceptible to trying to escape that sort of feeling, as youmentioned before, with substances.
(14:27):
And we are talking about the topic of suicides.
uh Someone can want to escape that and have suicidal ideation and be fearful of being ableto express that or not knowing how to talk about that or feeling a bit of shame around
that.
Again, the supportive, calm way in which you approach the adolescents is extremelyimportant in talking about suicidal ideation.
(14:56):
Can you tell us more about some early warning signs to clinicians, parents or educatorsshould look for when an LGBTQ plus youth may be at risk?
So early signs, again, I go back to change.
If there's any kind of a change from their baseline, if there's a persistent, uh we thinkthat a change in behavior is gonna look like sadness, but sometimes it's irritability.
(15:20):
Sometimes it's mad.
They're just talking about they're mad and they're angry and they don't have a reason forbeing mad or angry.
Or sometimes it may be a somatic complaint.
It might be said that it have persistent headaches or persistent pain.
persistent stomach aches, or anxiety, or fears that are somewhat unfounded and they can'texplain it.
(15:44):
So there are a number of ways in which it may not just look like sadness, it might looklike anger, and it may just look like uh really low grade uh energy and inability to do
things, or persistence in saying that they're tired.
Now, we'd like for them to be able, when we go down our DSM,
(16:06):
you know, and asked about, you know, hopelessness and things of that nature.
But that may not be the word in which they're able to uh identify or talk about.
So it might just be tiredness, anger, and irritability may be something that the child isuh talking about.
Or in sort of like abdicating their responsibilities, fleeing their responsibilities, ornot wanting to be around their loved ones and really isolating.
(16:32):
So.
uh
in this day and age where children have their own phones, their own televisions and thingsin which they can be sort of uh by themselves to their rooms, we want parents and we want
caregivers to be involved and know that and not allow them to self isolate.
So besides the emotional things, self isolation could be one of the other things in whichwe're looking.
(16:58):
From a psychiatric perspective, what types of support or therapeutic approaches are mosteffective for LGBTQ plus youth in crisis?
Okay, so the support can take the form of talk, of just uh hearing someone, sort ofsupporting them and giving them information that affirms what they're feeling also.
(17:23):
There could also be a point of giving them information about what they can do to feelbetter, what sorts of activities, other ways in which they can engage.
But if that isn't enough, there are other forms of therapy.
Cognitive behavioral therapy is quite useful in terms of having them reframe theirthoughts, what's going on with them.
(17:44):
Also, DBT, dialectable behavioral therapy, is also useful.
You know, when kids are having some of these challenges, sometimes they feel as if no onecan understand them, or sometimes because of their personalities, they can get really
locked in on a way in which they're...
a feeling about something and again saying no one understands it.
(18:05):
But by these methods of both supportive therapies, behavioral therapy, dialecticalbehavioral therapy, DBT kinds of things are ways in which we can help the individual.
Sometimes those things aren't enough.
in crisis, some children may have to be brought to the hospital, some children may have tobe hospitalized for a while.
(18:27):
uh That's going to vary depending upon the person.
Sometimes if we get before that and we're doing therapy, sometimes therapy along withmedication is something that is needed.
But the challenge with all that is seeking a mental health provider and also ideas aboutmedication.
And then that opens up a whole other uh arena of discussions for family when we're talkingabout therapy and medications.
(18:54):
How can psychiatrists or health professionals in general make their practices moreaffirming and safer for LGBTQ plus young people?
The, you're doing your initial assessment and when you're talking with your families, youwant to be as general and open as possible.
When we're asking things about attractions, we really want to allow people to understandthat we are able to hear anything that they're able to say to to tell us about attraction,
(19:26):
male, female, both.
And in the most
non-judgmental, even way possible.
If we have to practice that for a while to be able to do it every time, then that's whatwe need to do in order to let the youth that come into our office know that we are
welcoming to them.
We should also be able to talk with their parents, talk with the child and the parenttogether, but also talk to the parent and the child separately because in that...
(19:55):
we can get a sense of whether or not this child feels supported or what the real ideasthat their parents and their community have about perhaps their gender expression or their
sexuality.
And then when we're talking with the parents doing the same and try and understand howhave they tried to be supportive or understand their child.
uh When you were talking about some of the intersectionality and challenges before, what Ididn't mention is in different communities, uh different
(20:26):
communities of color and LGBTQA, there are certain people may share a faith or not sharetheir parents' faith or people may have attitudes around that.
That may be something that we really have to talk about.
Or that may be a challenge for the parent and child to be able to have a conversationbased upon uh whatever their uh faith or religious upbringing are.
(20:53):
Sometimes that's a challenge and that has to be talked about quite directly.
Sometimes there may be some differences and that may not mean very much to them.
So we have to understand what does it mean for the child?
What does it mean for the parent?
And have those very direct conversations.
But also really affirm in your first meeting that you are there for support, that you canhear anything that they have to say, that it's rare that anyone's gonna say something that
(21:20):
you haven't heard before.
and that you're going to do your best to be both supportive and to keep them safe.
Talking about families, what role does a family acceptance or rejection play in suiciderisk?
And what can families do to do better, even if they are struggling to understand?
Now, so that's going to vary from child to child, you know, because you have a parent thatthinks that they're being very supportive, but the parent, the child doesn't perceive it
(21:47):
that way, right, in terms of what that parent is offering.
So the level of support is critical.
It is absolutely essential.
A big fear that still exists is if the child tells their parent and caregiver that they'requestioning or that they feel that they're gay or
(22:09):
sexual, anything that isn't quote unquote heteronormative, that that might be a challengefor them and a reason for them to leave their household.
And that may be the fear.
And maybe that isn't actually accurate, but that is a fear that can prevent children fromactually having a conversation with their parents.
So it's absolutely essential for
(22:30):
you as the clinician, as the physician, as the provider to have conversations with theirparents and have an understanding.
If it's in their culture, if it's in their background that this is a challenge, explorewhy that is a challenge.
But also, I don't think there's a family that doesn't love their child even if they havedifferences or don't understand their development.
I think there are times where the parents really just does not understand their lack ofsupport or their
(22:58):
a parent rejection, how strong an impact that can have upon a child.
So that requires some individual work for the clinician to really explain that.
Support is essential.
uh And while you're trying to build up the parents in order to be supportive, on the otherside of that is talking with a child to have them have other adults in their life that can
(23:24):
be supported.
Maybe they don't feel that they can have this conversation with their
with their parent, we always want to encourage them to do so.
But maybe it's going to be enough, an uncle, a grandparent, a godparent, uh or some otheradult that is a part of the caregiving circle, a village of that child that the child can
(23:44):
feel a level of support and understanding and go to.
So that's going to be extremely important.
uh If it's not the parent, if it's not the grandparent, if it's not the uncle, what is theadult?
Where is the community?
What is uplifting, surrounding, and a safety net for that child?
You mentioned community.
(24:05):
Are there any evidence-based school or community programs that have shown to reducesuicide risk for LGBTQ plus youth?
Yes, is, yes, support uh for youth is tantamount for their survival, for their ability toget help.
There are a number, as you mentioned at the beginning of this, there are surveys, there'sthe Trevor Project, there is uh Dan Savage had, It Gets Better, there is the American
(24:36):
Foundation for Suicide Prevention, there is the
NIH uh websites, their government websites that all uh give a number of resources andorder and also show that these source of interventions are helpful and protective of
youth.
(24:56):
Not only do you have those broad ones that I just mentioned, but you also have communityorganizations like NAMI, the National Association of Mental uh Health, that help.
you have NAMI.
you have uh PFLAG as well as another uh resource within the community.
Increasingly, even the faith-based organizations have mental health counselors.
(25:22):
You have some pastors, rabbi, ministers that also uh have some background in counseling orsome background in helping people with emotional wellbeing.
So increasingly, there are other ways in which people can receive assistance.
rather than just getting to a psychiatrist because most people aren't gonna run right outto the adult or child psychiatrist.
(25:47):
Even their uh pediatrician or their family uh GP might be also a source of support.
So everyone at this point needs to have some sort of training and understanding in termsof mental health and wellbeing and talking about this and really talking directly
(26:09):
about suicidal ideation and taking sort of that sting out of it, trying to decrease thestigma so you can talk about this.
uh So I'm talking about a support, but as I'm thinking about this, I'm also thinking aboutthe barriers that stigma still exists.
As much as I said earlier that
(26:32):
Children are coming into the office a lot more savvy and a lot more welcome tointerventions and able to talk to their parents about that.
There's still stigma involved depending upon the community.
wealthier, educated communities get a lot more exposure to mental health and emotionalwellbeing than other communities, but it is possible.
(26:55):
And for that matter, whatever culture you find yourself in,
whatever that institution, maybe in the black community, that might be a church, thatmight be a community center, that might be the barbershop, it might be the nail salon,
where people are talking about this.
uh there are studies that help within the community is very, very uh useful oh in terms ofprevention and really surrounding the child with a safety net.
(27:27):
Talking about barriers, what are the biggest systemic barriers that prevent LGBTQ plusyouth from assessing timely and affirming mental health care?
Well, a lot of it is fear, fear and uh a mistrust.
And if within the community, if you're feeling as if you're not supported, if you'refeeling that you're being bullied, then where is the person that I go to?
(27:51):
Where is my voice?
Where is the person that's gonna stand up and actually understand me?
Who has demonstrated the ability to hold what I have to say and affirm what it is that Ibelieve?
and also to help them to know that this is going to get better.
that is, uh know, stigma is a huge barrier.
(28:12):
Even cost, right?
In terms of, you know, you have kids that feel as if what they're going through, that theyare a burden to their parents, that they were a cost to their parents, that their parents
are having some financial challenges.
That could be something else that's within this child's mind.
(28:32):
where they're not really thinking so much about themselves, well, they are feeling badlyabout themselves, but also feeling burdened that they have these challenges.
And so we really want uh people to understand that, to give the message that you are not aburden in any way to your family.
You're not a burden to your community.
Your community can be helpful to you because with time you are going to be an asset andyou're an asset right now to your community.
(28:57):
So mistrust, stigma, cost,
are all challenges.
uh Fear is a huge challenge and a huge barrier to having that.
Also within the healthcare environment, having people that look like them, having peoplethat they feel were going to understand them for culture.
(29:22):
We've spoke of cultural competence, cultural humility, and all of these things areimportant.
That's not to say that someone can't help.
an individual that doesn't look like them, but they have to be able to listen and holdwhat it is that the person is telling them in order to be able to help them.
So increasingly, we need more people within the community that looks like the diversitythat is within the community.
(29:46):
need caregivers that equal that as well so that we can give people the care that theyneed.
How do peers support and chosen family factor into building protective networks for LGBTQmental health?
uh
So happy to ask that.
So that's a wonderful support.
If you can't get what it is, if the child is not getting what they need or feel that theycan get it from their parents, their peers, a peer that's the same age, that has supports
(30:20):
in other arenas can help them in terms of support.
Peers that might be older or younger can also provide support.
And the notion of chosen family is a...
very, a very uh strong one and something that has really shown to be effective.
when a kid is feeling bad and they're feeling uh suicidal or just feeling really hopeless,it's really hard for them to reach out to that community or reach out to someone else.
(30:50):
So it's incumbent upon us all to uh be able to circle around and help all the children.
within the American Academy of and Psychiatry where I am, uh the presidential uh theme isone of uh bringing the village to the children.
So when we are seeing people that are in need or hurting, we need to get to them.
(31:15):
Because sometimes it's hard for them to come to us.
So that might look like the physicians, it might look like the neighbor next door, it maybe the principal of the school, it might be a counselor.
what what have you may not be the direct blood relative that is the person that isproviding the most support we want to get them and that's crucial as i mentioned earlier
(31:37):
but it might be other people outside the family that are providing that support
In your opinion, what policy or funding changes would make the greatest difference insuicide prevention efforts in the community?
Well, that's about cutting Medicaid, not cutting Medicaid, uh having students, paying backstudent grants, student loans so that people can remain uh within the educational system
(32:08):
in order to spend enough time to become fully trained to take care of people.
uh Also, so
prioritizing mental health along with physical health, parity laws, the enforcement ofparity laws so that people can receive care and it's paid for.
(32:28):
So many people have to go out of pocket for both adult and child mental health care, butit should be right up there with everything else because mental health care is health
care.
It is for you to be completely sound and well and to be able to do everything.
Everything needs to be functioning.
So the laws,
that enforce parity, the laws that uh help to have a diverse workforce, the laws that donot cut Medicaid and things of that nature, and also funding to community organizations.
(32:59):
uh Oftentimes there's a dearth of resources where they're needed the most.
Our large institutions are fine, that's wonderful if you can get there to get your care,but more often than not, LGBTQA and uh
Patients of uh various uh ethnic minorities are not necessarily in those areas.
(33:21):
So care, laws, money, resources that go to the community will help to make a bigdifference here.
What gives you hope when working with LGBTQ plus youth even in face of such heartbreakingstatistics?
Oh, hope is actually having them in office and seeing that change, having them feelsupported, really when they say that they feel supported, when they are able to talk about
(33:49):
uh a difference uh and that the power of them feeling different, that they also want to goout and help their community.
They want to help others that feel like they do.
So the help is uh when you see that change, it gives me hope.
The fact that children and youth are resilient also gives me uh hope.
(34:13):
But we have to normalize being able to talk about this very directly.
We also have to have the youth understand that they're not alone.
We have to have to let them understand that it does get better, that this is part ofdevelopment, and that it's not a one size fits all.
(34:36):
This may take longer than they want to just like spring out of it, but the thing thatgives me hope is seeing that change and then being able to verbalize that and then wanting
to then help others to get better too.
Dr.
Otis, thank you for your informative conversation and your contribution towardsadvancement of LGBTQ mental health.
It's been pleasure talking to you.
(34:58):
Before we go, can you tell us the one message you wish every LGBTQ plus individual,especially youth struggling with their mental health should hear right now?
They are not alone in their struggles.
They are not alone in getting better, that there is a community around them.
If they haven't felt that community at their home, knock on another door, knock on anotherdoor at school, knock on and talk to another friend, tell people how you're feeling and
(35:29):
know that this can change for the better and not to have any sort of...
uh fear or care around stigma, around this, normalize, uh knowing that it's okay not tofeel so great and that you can get to help to feel better.
Can't agree with you more.
(35:50):
Thank you, Dr.
Ortiz.
Hope to speak with you again very soon.
Thank you.
Thank you for joining us on Breaking the Silence, Addressing Youth Suicide.
Please visit the Medical Minds podcast homepage at psychiatry.org for more information anda resource document related to this episode.
We also invite you to visit psychiatry.org slash more equity, M-O-O-R-E-E-Q-U-I-T-Y formore information on the APA More Equity in Mental Health Initiative.
(36:21):
Take care.
The views and opinions expressed in this podcast are those of the individual speakers onlyand do not necessarily represent the views of the American Psychiatric Association.
The content of this podcast is provided for general information purposes only and does notoffer medical or any other type of professional advice.
(36:46):
If you are having a medical emergency, please contact your local emergency responsenumber.
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