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Are you familiar with the concept of “gender affirming care” in medical treatment? What about the unique mental health needs of this community? Do you know what all the letters in LGBTQIA+ stand for?

Join us as today’s guest, from the Sierra Tucson Treatment Center, explains these concepts and helps us better understand — and provide better mental health care to — members of the LGBTQIA+ population.

David Cato, LCSW, TCT, SEP

David Cato, LCSW, TCT, SEP, began working at Sierra Tucson in April 2008 and has served many roles, beginning in the mailroom. He holds a Bachelor of Science in Criminal Justice from Texas A&M University and a Master of Social Work from Arizona State University. He’s a Somatic Experiencing® Therapy Practitioner (SEP), certified Transgender Care Therapist (TCT), and licensed clinical social worker (LCSW). Cato completed his master’s coursework through an internship at Sierra Tucson. He has worked with substance use disorders, mood disorders, eating disorders, codependency, grief/loss, and trauma. Cato provides individual, group sessions, and consultations for residents. He’s the clinical director at Sierra Tucson and a member of the executive leadership team. Cato enjoys presenting on topics such as trauma disorders and recovery.

Gabe Howard

Gabe Howard is an award-winning writer and speaker who lives with bipolar disorder. He is the author of the popular book, “Mental Illness is an Asshole and other Observations,” available from Amazon; signed copies are also available directly from the author.

To learn more about Gabe, please visit his website, gabehoward.com.

Producer’s Note: Please be mindful that this transcript has been computer generated and therefore may contain inaccuracies and grammar errors. Thank you.

Announcer: You’re listening to Inside Mental Health: A Psych Central Podcast where experts share experiences and the latest thinking on mental health and psychology. Here’s your host, Gabe Howard.

Gabe Howard: Hello, everyone, and welcome to this week’s episode of Inside Mental Health: A Psych Central Podcast, I’m your host, Gabe Howard, and I want to quickly thank our sponsor, Better Help. You can grab a week free by visiting BetterHelp.com/PsychCentral. Calling into the show today, we have David Cato, LCSW, TCT, SEP. Mr. Cato began working at Sierra Tucson in April of 2008 and holds a Bachelor of Science in Criminal Justice from Texas A&M University and a master of social work from Arizona State University and is currently working on his doctorate in behavioral health management. He is the clinical director at Sierra Tucson and a member of the executive team. Mr. Cato, welcome to the show.

David Cato, LCSW: Thank you for having me.

Gabe Howard: Today we are going to be discussing the mental health of transgender and other LGBTQIA+ people. Now, can you explain who is part of the LGBTQIA+ community and what do each of those letters mean?

David Cato, LCSW: Absolutely, so LGBTQIA and they use a plus sign, indicates a large array of people. The L generally stands for lesbian, the G is gay, the B is bisexual, the T it’s transgender. The Q is for queer and/or questioning. And the I is for those who are intersex and the A can be for asexual or also allies. And so the plus can indicate and mean allies as well, but plus indicates kind of anyone and everyone who’s in between any of those letters. And it could be people who don’t identify as part of any of those letters either.

Gabe Howard: Now, when we think about the topic of the show, mental health issues in LGBTQIA+ community, it sounds like we’re saying that every single member of the community struggles with their mental health or has trauma. Is that true or is that just a way over exaggeration?

David Cato, LCSW: I do believe it’s an over exaggeration as far as to say that every LGBTQIA+ person experiences mental health or mental illness issues. They are more likely to experience trauma based on their sexual identity or gender. But that doesn’t necessarily mean that they’re going to have mental health issues. They are more prone to it just because of the specifics of how they might be treated and where they come from, cultural standpoints, etc.

Gabe Howard: Are there mental health issues that the LGBTQIA+ population struggles with more than other communities?

David Cato, LCSW: There are, and the one that really comes to mind when I think about that is the increase risk and completion of suicide for those who are transgender, specifically teens.

Gabe Howard: Now, I know you work for Sierra Tucson and you have LGBTQIA+ patients. Does that manifest differently because of their sexual orientation versus than a non LGBTQIA+ person?

David Cato, LCSW: I don’t necessarily see the differences between that. I mean, there are people who come here who are across the LGBTQIA+ spectrum and we do have specific programing for them. We do have various different secondary programs, and that’s one of the ones we offer. So they do receive additional support. But they’re LGBTQIA+ people who come in here and to treatment and they say, oh, I don’t want the group or I don’t want the additional support because things are good just the way they are. That’s kind of where they’re coming from. And so not everyone needs that additional support.

Gabe Howard: Now, more than 30 states have introduced laws that are anti-trans, including laws that would criminalize parents for providing gender affirming medical care. What is the impact of laws like that on treatment centers like yours and on practitioners?

David Cato, LCSW: Hmm, it most definitely impacts the eligibility of care and how providers would approach work with someone. I do end up feeling sad when this topic comes up just because it’s such a big deal to be able to help people be who they are. And these laws get in the way of people’s ability to become who they are and be seen as who they are. And when certain laws say, hey, the state can practice a certain way or, hey, these providers can only practice a certain way, then that gets in the way of not only people being seen for who they are, but will increase things such as depression, anxiety, suicidal ideation, etc.

Gabe Howard: Now, gender affirming care is a phrase and a concept that I myself am not familiar with, and I imagine a good many of our listeners aren’t either. Could you define what gender affirming care means?

David Cato, LCSW: Gender affirming care is basically seeing people as they are and who they want to be. And so there are terms out there like people who use preferred pronouns or people who present as a certain way. And so I like to stay away from words like presenting as or preferred pronouns, etc., just because we want to be more specific about who they are and saying these are their pronouns and they are this gender, as opposed to saying they prefer this gender or they prefer this pronoun, it’s really more it needs to be more succinct by using those affirming terms for them. So gender affirming care also means that we’re providing a safe environment. It’s also known as trauma informed care, at least how we perceive things here. Gender affirming care can mean something as simple as having gender neutral bathrooms. It can mean having additional support or knowledge around people who are LGBTQIA+. It’s about having a team or staff members who can be able to use the correct pronouns for someone who identifies as something other than the gender they appear to be. For example, if somebody is non binary, they might use pronouns like they/them or somebody who might be transgender, who is beginning a transition process, and we want to avoid the gendering piece. And so it’s really about providing training to staff and also providing education to our residents who might not know much about the LGBTQIA+ community and how to help see people as who they are.

Gabe Howard: Now, in addition to being a licensed clinical social worker, you’re also a transgender care therapist, can you explain exactly what that is and how you become a transgender care therapist?

David Cato, LCSW: Of course, yes, several years back, our previous chief executive officer, Jaime Vinck, had found a training that was a transgender specific training when she was at a conference in Florida, and she’d come back and she’d given me the flier. And the training is through a company called the ITCA or International Transgender Care Association. And so they basically helped get people certified in working specifically with transgender people. I was able to learn about what it’s like to be trans and coming from somebody who is self-identified as an LGBTQIA+ person, but not self-identified as transgender. I was able to learn so much about what it’s like to be trans and what their culture is like.

Gabe Howard: I know that there’s a lot of misinformation in our society and there’s a lot of misunderstanding by well-intentioned people. This is more of an open ended question to sort of gain your experience of what you’ve seen. But what are some common misunderstandings that society has about transgender individuals?

David Cato, LCSW: One of the most common misconceptions is that everyone who is trans will go through full surgeries in order to appear as the other gender. What I’ve seen over the years is I’ve worked with so many trans people who do not pursue surgery, they’re not interested in pursuing surgery. There are people who will get top surgery and not bottom surgery, as they call it. Bottom surgery would mean that they have reconstructive surgery on their genitals. We don’t necessarily see people wanting to do that. And it’s actually pretty uncommon as far as I’ve known and working with transgender individuals here that people go through that process.

Gabe Howard: Now, swinging back to Sierra Tucson for a moment, what do you all do to make your mental health treatment facility a welcoming place for LGBTQIA+ patients?

David Cato, LCSW: The first thing that we have here is that we have a zero tolerance policy for any kind of hate speech, not just towards LGBTQIA+ individuals, but towards any people. Any time that something is reported from a resident where something inappropriate has been said, such as that, we address their behavior immediately. We also provide gender neutral restrooms for our residents. So we do have non binary and all gender restrooms here in addition to bathrooms for men and women as well. This is the only

Gabe Howard: If I understand you correctly, it seems so simple. It’s the golden rule, right? Treat other people how you yourself want to be treated. I mean, you mentioned a zero tolerance for hate speech. That just seems like common sense to me. Make sure there’s bathroom facilities. I understand that this has become a complicated issue in our society, but I’m struggling to understand why it’s a complicated issue. What are you seeing from your perspective and how do we move past that and just allow people to understand that it really is just a matter of dignity and respect? Nobody’s asking for anything more than that, at least from my perspective. And I’m, I know that there’s a controversy, but I do struggle with trying to figure out exactly what it is.

David Cato, LCSW: Yeah, I most definitely agree with you, it’s definitely golden rule, treat others as you want to be treated. And I feel like as a society, we’re getting closer to that. And I feel like we have come a long way as far as helping to support and love more of one another and also LGBTQIA+ individuals, people across all cultures and races. And I think that’s one of the big parts of it, is that there are people still in cultures where hate is something that they live every day and they’re taught how to hate. And I think that over the years what we see is those cultures tend to dissipate. I don’t want to use the term die out just because I don’t know that those things will ever completely leave our world. But I do see that more and more things are being brought to light as far as hate goes. And what I see and what I seem to experience, at least from the LGBTQIA+ perspective, is that there’s so much more knowledge and there’s so much more information and acceptance than there used to be.

David Cato, LCSW: Yes, there is a lot more to learn and there’s a long way to go. Still, I remember hearing years back in regard to the term, it gets better, when talking initially about gay marriage, when those laws were happening. And I do feel like it is getting better even still. And that phrase still rings back in my mind when I see something about hate on the news or when I see something about legislation being passed that is anti this or anti that I do see in my head, it gets better. And I just keep telling myself, and that’s what helps me kind of bring this message across to the people that I work with or my staff and through the LGBTQIA+ community, that things do get better. And we have here at Sierra Tucson the ability and the capacity to help people see it does get better, and not just with the LGBTQIA+ piece, but with mental illness and with addiction and with all the things that come along with that.

Gabe Howard: And we’ll be right back after a word from our sponsors.

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Gabe Howard: And we’re back discussing the mental health needs of the LGBTQIA+ community with Sierra Tucson’s David Cato. What can the mental health community as a whole, from psychiatrists, psychologists to therapists, do to support LGBTQIA+ patients?

David Cato, LCSW: So I have two thoughts around this, and the first one is see more LGBTQIA+ individuals, see them in your practice, bring them in. I know briefly, when I had a private practice for a couple of years, there were people who would call me and say, hey, I have this LGBTQIA+ person and you’re the therapist to work with them. And I thought, well, you’re also a therapist that can work with them. And I’m not sure how my work would be very different. And yet, not that they don’t feel comfortable with it, but they’re just like, I don’t, I feel like somebody else could be better. And that’s kind of the message that they give themselves. And I think that the more we experience and the more that we connect to people who are unlike what we are used to, that we can learn to help them more. The second piece is to continue to get education. Medical providers and therapists and practitioners with licenses need to get CEU’s, or continuing education as part of maintaining their license. To seek out culturally supportive CEU’s, attend an LGBTQIA+ training. Attend cultural competency training that brings awareness to something other than what you know and what you’re used to. I know that historically people tend to go where their comfort zone or their safety net is, and to be able to push out of that is going to really help round out practitioners and round out people who are able to get more experience across all different spectrums and cultures.

Gabe Howard: Obviously, LGBTQIA+ people know other people, what can their friends and family members do to support their mental health?

David Cato, LCSW: This is going to sound simple, love them and accept them and see them for who they are. One of the biggest things and as I hear it here at Sierra Tucson and from LGBTQIA+ individuals I know currently and have known in my personal life over the years, is that there is a lot of unacceptance out there from loved ones, family, friends, people who use the word disowned. My family disowned me. My grandparents won’t talk to me and that or I was kicked out of the church or rejected from the church. And those are things that people experience every day as LGBTQIA+ individuals. And my belief is that the more love and acceptance they get from friends and family, it’s going to be able to help them feel safer, not just, you know, in their home or at the school they’re going to or anywhere they go. It’s more about how they feel internally. And if they feel loved and accepted from external people who are important in their lives, they’re going to feel safer and more loved on the inside as well.

Gabe Howard: You had mentioned earlier that things will get better. Are we seeing that? Are things getting better?

David Cato, LCSW: I’ll just say that when I first kind of got into this field, I had talked with practitioners who would say things like and this is not at Sierra Tucson, but people I was going to school with. What they would say, things like, oh, well, they’re gay. And isn’t that why they’re depressed. Or, oh, they’re trans? Isn’t that why they’re suicidal? And I’d hear statements like that. And I’m thinking no, that’s really not the, not the connectivity. And I don’t hear statements like that anymore. I don’t hear people having that much of an uneducated connection to this piece. I think it’s what continues to get better, too, is that we have legislators now and people in office who are LGBTQIA+ affirming. And I had actually seen a video yesterday where President Joe Biden had reported that he sees LGBTQIA+ Americans and he sees transgender Americans. And it was something that really meant a lot to me, not only as an LGBTQIA+ person, but also as a therapist and a leader myself, is to see that there is still hope out there. And that we have leadership who model what love and acceptance looks like, and we’re going to be better able to model that ourselves.

Gabe Howard: As a therapist, how would you recommend somebody respond to insensitive comments like you just mentioned? Because while it may not be happening on the professional level anymore, I know that a lot of members of the LGBTQIA+ community report that people say insensitive things to them all the time. And what are they supposed to do? They want to advocate, but they also don’t want to get in a fight at work or cause stress in their families.

David Cato, LCSW: Mm-hmm.

Gabe Howard: What would you recommend that they do to stay true to themselves, their cause, effect positive change, but also not be seen as the quote unquote problem?

David Cato, LCSW: Absolutely, I say do it with intention. So if somebody comes up to you and makes a statement such as, oh, this is their issue, it’s because they’re gay. If somebody says that to you, instead of shaming them and tearing them down because of what they said, you can ask them where they get that information from and say, hey, what where did you get that perspective? I’m curious to learn about that. And then when they tell you, you can say, oh, OK, that’s interesting. And take into account maybe it’s something cultural, maybe it’s something that they taught or learned from childhood, then you could take the opportunity to step in and say, well, this is what my experience tells me, or this is what I see can be most helpful for people and to just kind of have a conversation instead of having us versus them. That’s a lot of what we see us versus them. And we’ve definitely seen it within the last six months plus. Is it’s us against them, us versus them. And I just see it over and over and over again. And if we join together and say, yes, I see that your experience or what you’ve learned is different from what I learned, let’s share information and be able to trade instead of saying you’re wrong.

Gabe Howard: Mr. Cato, thank you so much for being so open and honest with us. What myths and misconceptions about the mental health issues facing LGBTQIA+ people would you like to just immediately clear up for our listeners?

David Cato, LCSW: The biggest myth I want to clear up is that it is not because of someone’s sexuality or gender as the reason why they’re struggling with something. It is not because they’re gay, it is not because they’re trans. And people who are bisexual are not just confused. There’s so many misconceptions out there and so many myths. It would probably take me a while to debunk all of the ones that I could think of, but I will say stop assuming myths are true. That’s probably the biggest thing is if you have a question about something, ask someone, ask an LGBTQIA+ person. One of the things that I as an LGBTQIA+ person and others as the same, have said, ask me the question. The reason people who are trans or non-binary say ask me my pronouns means that they want people to be educated. They want to be able to provide the information to them instead of just having people assume. And I think the biggest part is, and the reason myths can be so hurtful is, because they’re just assumptions.

Gabe Howard: Along those same lines, what’s one thing that you wish the broader health care community understood about the LGBTQIA+ community?

David Cato, LCSW: This comes along the same lines in asking people questions and getting the information from them and getting educated from them directly instead of saying, oh, this last LGBTQIA+ person I worked with had this issue and so will this person. That can be one of the biggest pieces of how people get put in a box and say, this is what the culture says. And so that means that it’s true for everyone. And so to avoid, for example, a young gay man will not be the same as every young gay man you come across. And I have seen providers over the years that have assumed that certain things are true as far as people who are across the LGBTQIA+ spectrum and how they kind of relate, like all gay people are like this, or all transgender people are like that. And so we really differentiate individuality and treating people as individuals versus grouping them together.

Gabe Howard: Thank you so much for your candor. Now we’re almost out of time, but I sort of want to give an open mic because as a cis-gendered, middle aged male, there’s probably just a lot of questions that I don’t even know to ask that

Gabe Howard: Are incredibly relevant to your community. So I don’t normally turn my podcast over to guests. But what is the world missing? What would you like us to know if you had your own show, Mr. Cato? What would you tell people listening right now?

David Cato, LCSW: If I had my own show, one of the biggest things that I would say to everyone who would listen, all two or three listeners, probably what I would tell them is that we’re human. It doesn’t matter for LGBTQIA+ or black or Asian or from Montana. What matters is that we are human. We are all inherently the same as far as we’re created inside. If we are all to treat each other as human beings versus whatever box we’re put in or whatever culture we have. There are people who are LGBTQIA+ who do not identify with anything on that spectrum. They don’t share the same views or the same beliefs that people who do in that group. You know, we have people who come in here and, you know, we say you’re an LGBTQIA+ person. Would you like to participate in programming? Not you are an LGBTQIA+ person. We’re going to go ahead and put you in the groups. We want to make sure that everybody has the right to make their own decisions and be able to be a part of their own culture. You might have an LGBTQIA+ person who identifies with a totally different kind of culture. It’s not just about being gay. Maybe they’re a musician or maybe they play video games or maybe they are yoga instructors or something like that, like we have these different cultures that we’re part of. But in the end, we’re all human. And so the humanistic piece of connecting to other people, regardless of gender, sexuality, race. We’re all one people.

Gabe Howard: Mr. Cato, thank you so much for helping us better understand and for educating our audience.

David Cato, LCSW: Thank you so much for having me. It’s been an honor to be here.

Gabe Howard: And a big thank you to all of our listeners as well. Wherever you downloaded this podcast, please follow or subscribe to the show. It’s absolutely free. Take a moment to review the show and tell other people why they should listen. My name is Gabe Howard and I’m the author of “Mental Illness Is an Asshole,” as well as a nationally recognized public speaker who thinks it would be awesome to be at your next event. You can grab a signed copy of my book or you can learn more about me just by heading to my website, gabehoward.com. I will see everybody next Thursday on Inside Mental Health.

Announcer: You’ve been listening to Inside Mental Health: A Psych Central Podcast from Healthline Media. Have a topic or guest suggestion? E-mail us at show@PsychCentral.com. Previous episodes can be found at PsychCentral.com/Show or on your favorite podcast player. Thank you for listening.