Dr Umar Toseeb Hello, welcome to the Podcast Series for the Association for Child and Adolescent Mental Health, or ACAMH for short. I’m Umar Toseeb, Professor of Psychology. My research focuses on special educational needs and mental health in childhood and adolescence. All listeners to this, and indeed any of ACAMH’s podcasts, are eligible for a free CPD certificate. Do please visit acamhlearn.org for details of this, together with information on how you can access hundreds of hours of free talks, lectures, interviews, all of which you can also get free CPD certificates for. The web address is acamhlearn.org, that’s a-c-a-m-h-l-e-a-r-n.org. Today, I’ll be speaking to Dr Olakunle Oginni, Clinical Academic Fellow, and Speciality Trainee in Child and Adolescent Psychiatry, University of Cardiff and NHS Wales. Kunle completed his medical training in Nigeria before undertaking a PhD in Behavioural Genetics at the Institute of Psychiatry, Psychology and Neuroscience, King’s College London. Kunle’s research has investigated the mental health of sexual minority individuals, including young people, using genetic research designs. This will be the focus of today’s podcast. Kunle, thank you so much for joining me. Dr Olakunle (Kunle) Oginni Thank you for having me as well. Dr Umar Toseeb And let’s start with some motivations. What got you into this line of research? Dr Olakunle (Kunle) Oginni I think broadly there are two things, or there are two main influences. One was curiosity. I attended a boarding school in Nigeria and there was a boys’ section, there was a girls’ section, there were often remarks or comments or instances of same sex sexual acts, they were boys and boys would experiment. But what was striking to me was the attitude, we tended to disparage such activities. It struck me at some point that people wouldn’t deliberately choose to be gay, for example, and I became curious about why people were gay, and so on, and that curiosity stayed with me through medical school, and then after finishing medical school, I had an opportunity to choose what I would specialise in. I thought, okay, let’s focus clinically on psychiatry, because of the likelihood of doing more research. So, while I was doing adult psychiatry in Nigeria, I was interested in the research of mental health in lesbian, gay and bisexual individuals. And then after finishing that training, I got the scholarship to do a Master’s at the IoPPN, the Institute of Psychiatry, Psychology and Neuroscience, and specifically at the Social, Genetic and Developmental Psychiatric Centre. And that was where I got exposed to the twin method, it’s a type of genetic research which compares identical and non-identical twins. And I became fascinated with what it could potentially do and blended that interest with my curiosity about sexual orientation and mental health, and that led to my PhD. Dr Umar Toseeb Excellent, and before we go on, I think it would be helpful just to think about and define some of the terms that you're going to be using. So, you’ve already used one of them, “sexual minority,” and then I think we’re going to talk a bit about “gender non-conforming,” and also “mental health.” What do those terms mean in the context of the conversation that we’re going to have? Dr Olakunle (Kunle) Oginni Okay. So, I’ll start with sexual orientation. Sexual orientation is a description of who a person is sexually attracted to, in terms of whether they are the same sex as the person, or opposite sex to the person, or both sexes. So, if a person is attracted sexually to persons of the same sex, we say they are “gay,” if it’s a woman, we may say they are “lesbian.” If they’re attracted predominantly to those of the opposite sex, then we say they are “heterosexual” or “straight.” And then if it’s to persons of both sexes, either males or females, then we say they are “bisexual.” And statistically, depending on how you define it, you can define completely based on sexual attraction, you could define based on who a person has had sex with actually, and when you use either of those, typically find that between one and 10% of the population will identify as being somewhere on that spectrum, and then because 10% is obviously smaller than 90%, it’s a minority of the population. And because it’s based on their sexual attraction and behaviour, we define them as a group as “sexual minority.” So, I think it’s more of a statistical term or descriptive at the very least. So, I’ve talked about “sexual orientation,” I’ve talked about “sexual minorities.” And then you mentioned about “gender conforming” or “non-conforming.” So, the idea of that is if a person is born, typically we would say, based on their external genitalia, they are “male” or “female,” at least where that is as clear as possible, so that is more biology. But beyond the biology of it, there’s also the social components, which is what we often describe as “gender,” that’s what society expects of a person based on their biological sex. So, a person can be male biologically, and often they would identify as being – as having masculine interests, want to do things that are typical of what we define as a “male,” that’s the gender bit of it. There’s also the psychological component of that, which is gender identity, which is how an individual feels inside of themselves as being either male or female. Often, we find that the gender would match the biological sex, but in some cases, that doesn’t happen, and then that’s where we talk about the – what used to be called “gender identity disorders,” or is now called the “gender dysphoria,” and more recently, “gender non-conformity.” So, when we talk about being “gender non-conforming,” it’s that a person’s biological sex does not go along with their internal sense of gender, their gender identity, on – or that their behaviours, their interests, are not characteristic of what is expected for their biological sex. So, we can talk about a child, a boy, being “gender non-conforming” because he likes to play games that are typical of girls, he likes things that are typical of females, like makeup, and so on, so we would describe that young person as being “gender non-conforming.” Dr Umar Toseeb Excellent. Thank you so much, and then to move onto the relationship between being a sexual minority adolescent and mental health, what do we know about the mental health of sexual minority adolescents? Dr Olakunle (Kunle) Oginni We often talk about “mental disorders,” “mental difficulty,” and mental health can be a bit difficult to describe. But generally it refers to a state where a person is able to cope well with the environment, maximise their potential, perform optimally and maximise their potential, and it’s not that they don’t feel any distress, but they are able to cope well with any distress that they experience. So, it’s more a sense of being well, psychologically, and because psychological wellbeing is linked to social and biological wellbeing, we often describe it as an overall state of “wellbeing” psychologically. I think that’s the simplest I can bring it. Now, in terms of the mental health of sexual minority adolescents or young people, and from research, among adult and among young people, the evidence is consistent that they tend to experience higher rates of mental health difficulties, compared to those who are not sexual minority, that’s compared to straight individuals. And when we say they experience difficulties, we are talking about things like anxiety symptoms, symptoms of depression, higher rates of substance use, suicidal thoughts, which indicate that there’s some level of psychological distress that they are experiencing. Dr Umar Toseeb And is that different for the different groups within sexual minority adolescents? So, for example, is it different for gay adolescents and lesbian adolescents and, for example, trans adolescents? Like, is there, within the sexual minority group, is there a difference? Dr Olakunle (Kunle) Oginni To point out – so a slight difference, so when people say “sexual minority,” they often distinguish that from gender minority. So, what I said about the gender identity or being gender non-conforming, or gender dysphoria, in research, that would be categorised as “gender minority,” while lesbian, gay, bisexuals would be “sexual minorities.” And, of course, in general language, lay terms and general discourse, we talk about “queer” and “LGBTQ individuals,” and lump those together. And even as a group, the rates of mental health difficulties are higher when they are put together. My research has been more among lesbian, gay and bisexual individuals, but from research, among trans identified individuals, the rates of mental health difficulties are higher, compared to sexual minorities. And because I’m more familiar with the literature of sexual minorities, I will talk a bit more on that. For sexual minorities, yes, when we look at the different subgroups within sexual minorities, that’s lesbian, gay, bisexual, and we can introduce the element of sex into it. So lesbian will be referring to sexual or – yeah, same sex attracted women or female young people, and gay will be referring usually to men, and then bisexual to men and women. The evidence is that the rates of mental health difficulties appear to be higher among bisexual individuals compared to those who are mostly or exclusively gay or lesbian. And then it also theories – I’m extrapolating from adult data now, so from adult research the evidence is that even among the disorders there also appears to be a difference, so, overall, bisexual individuals experience more mental health difficulties. And then it also appears that for – among lesbian and gay individuals now, it appears that rates of depressive symptoms, anxiety symptoms, appear to be slightly higher among gay men compared to lesbian women, and then for substance use problems, it appears to be a bit higher among lesbian women compared to gay men. But the difficulty in extrapolating that to adolescents is that in the general population the dif – there’s a sex difference in depression and depressive symptoms, where females have higher rates of depression, and that emerges during adolescence, between nine and 12. I’m sure that’s been looked at specifically among sexual minorities – sexual minority adolescents, I’m just not familiar with that, so that can be difficult to extrapolate. Dr Umar Toseeb Thank you, and why might sexual minority adolescents have poorer mental health compared to sexual majority adolescents? Dr Olakunle (Kunle) Oginni That’s a big question, many possible answers. So, one of the leading theories about why they might experience mental health difficulties is what’s been summarised as the “minority stress theory.” And put very simply, it’s that members of the minority group tend to ex – have some negative experiences because they are a member – they are members of that minority group, and those experiences can be stressful, and that can directly increase their risk of mental health difficulties. And the minority stress factors we are talking about here are things like experiences of discrimination, and for young people, one experience of discrimination can be through bullying, where peers bully them because of their perceived sexual minority status. Another component of sexual minority stress is concealment of sexual identity. So if I was gay, for example, I would be reluctant for people to know that I am gay because of the discrimination I expect. And that concealment can be stressful, because it means one needs to be vigilant about oneself and about reactions from other people, and then the expectation of that discrimination is another layer of stress. And then the most internal component of it is what’s been described as “internalised stigma.” In the past, it used to be called “internalised homophobia,” and then they said it wasn’t a proper phobia, and then it’s been called “internalised heterosexism,” but I think it’s easier to just describe it as “internalised stigma.” And it’s a type of stigma in which the individual has negative views or thoughts towards themselves as a person, and that can be a very stressful thing for someone to have consistently. So, that’s one possible explanation for higher rates of mental health difficulties. One other possibility that’s been suggested from some lines of research is the possibility that there’s a shared genetic component and by this it’s that the same genetic factors that make an individual likely to be sexual minority can also predispose them to a higher rate of de – higher likelihood of having depression or anxiety. However, it’s like walking along the bridge and stopping midway without going further, that’s my take on the methods that have been used to examine those relationships. And the reason is, it’s one way of looking at it, but it’s also possible to probe those relationships a bit further, using more advanced genetic research designs, and this was something I did during my PhD. And when I did that, what emerged was that rather than stop at saying that there’s a genetic link between them, it’s actually that there is a non-genetic link that if we don’t recognise appropriately, we might mislabel as representing a common genetic influence. So, what I’m saying is, yes, there’s evidence for minority stress, there appear to be evidence for a genetic link, but my research suggests that it’s not a genetic link, that we can understand it as being non-genetic. Would that make some sense? Dr Umar Toseeb It does. Let’s unpack the gene environment stuff a bit more. So, you said that the reason why sexual minority individuals might have higher rates of mental health difficulties is that the genetic influences on one are the sim – are similar to the genetic influences on the other. What are some of the explanations in terms of theory for why that might be? And I’m thinking things like pleiotropy. Dr Olakunle (Kunle) Oginni So the idea of pleiotropy and you have some experience, correct me if I’m not so accurate, it’s that, yes, we identify some specific genetic variants that are associated with the trait of interest, but because of the way genes act, it’s very unlikely that one gene affects only one trait that you are interested in. So, while we are invest – interested in sexual orientation as an example, some genetic variants associate – can be associated with sexual orientation, but can also be associated with depressive symptoms, anxiety symptoms, and this is from statistics, okay? There are two ways people have looked at pleiotropy. One way is that, indeed, that genetic variant is causing or influencing sexual orientation and, at the same time, actually influencing depressive symptoms, what’s been called “horizontal pleiotropy,” so there is a true effect on both outcomes. However, the other way it can happen is what’s been described as “vertical pleiotropy,” in which sexual orientation has a relationship with depressive symptoms, for any reason that we know, so there is that relationship. However, if we do find some genetic variants that are associated with sexual orientation, if we did not look at sexual orientation and just looked at depression, we would find that some of those genetic variants are also associated with depression. But it’s not because they are truly associated with depression, it is because they are indirectly associated with depression through sexual orientation. And what we expect is that if you bring sexual orientation into the equation, then what we thought was an association between this genetic variant and depression, if we bring sexual orientation into it, then that association should disappear. Dr Umar Toseeb Okay, and then, I know that as part of some of your work, you looked at gender non-conformity, and then how that is related to sexual minority status and mental health, using a genetics and a twin design. Tell us about that. Dr Olakunle (Kunle) Oginni So, gender non-conformity sp – more specifically, I was interested in childhood gender non-conformity, and it’s that there is evidence that suggests that when children are gender non-conforming, boys are feminine in their behaviours, in their interests, and vice versa for girls. It tends to be that when they grow older they are more likely to identify as being sexual minority. It’s not a 100% association where if somebody is gender non-conforming in childhood, they would definitely be sexual minority. It’s not one – the correlation is not one, but there is that association, and many studies have replicated it. But we also know that when children are gender non-conforming, it can be a trigger for bullying from other children, they can get teased by other children, they can be bullied and have other negative experiences, because they are gender non-conforming. So, I was curious about whether people who are sexual minority, who had been gender non-conforming in childhood, were more likely to experience mental health difficulties, compared to those who were sexual minority, who were not gender non-conforming, and those who were heterosexual, a sexual majority, and not gender non-conforming in childhood. Then look at if there was an association, was it due to genetic influences or non-genetic influences? What I found was if you looked at it on the surface, it would feel as if childhood gender non-conformity did not make a strong difference, in terms of whether sexual minority individuals would experience mental health difficulties. But when we then broke it down and looked at the impacts of genetic and environmental influences on that relationship, it appeared that impact of environmental influences on that association tends to be increased when someone has been gender non-conforming in childhood, whereas not so much effect on the genetic influences. Dr Umar Toseeb Thank you, and I think one of the great things about your background in terms of your training and the research that you’ve done is that you can talk to the cross-cultural aspect of mental health in sexual minority individuals, and so let’s talk about that a bit more. So, how is the relationship between sexual minority status and mental health different, depending on the cultural context? Do we know? Is there lots of work out there? Is there a limited amount of work, and what does the research show? Dr Olakunle (Kunle) Oginni So, specifically looking at different cultural contexts, not very much. There is some work, but not massive compared to what we find from the US, from the UK, as examples. However, what limited work is available does suggest that there is also that disparity where sexual minorities experience more mental health difficulties. But in terms of why this is so, in one paper we did among university students in Nigeria, mostly male, we found when we applied a very strict definition, gay and bisexual male students were more likely – were three to four times more likely to have significant depressive symptoms, compared to those who were straight. And that’s consistent with what’s been found in research from the US, from the UK, high income countries. But my – what intrigued me was considering the context of settings like Nigeria, it was that, why were the rates not higher than that? Where I don’t have an answer for that yet. Another comparative study looked at elements of minority stress, and, here, they looked at mostly from Western countries and they stratified the countries into those that were high stigma versus low stigma. High stigma settings did not have policies to protect the rights of LGBTQ individuals, while low stigma settings were more protecting. And they found that even though we describe things like concealment of sexual orientation as a “stressful factor,” in places that were high stigma, it tended to be protective for their wellbeing. So, it suggests that, yes, minority stress may be a factor, but it may behave differently across settings, depending on the context. And it stands to reason, if I was living in Nigeria as an openly gay person, I would expose myself to more discrimination compared to if I kept it – kept things quiet and stayed in the closet, which makes some sense. From my own research, I’ve looked at coping strategies or resilience factors, and found that some of it may be that gay people in these environments may use adaptive coping strategies, and that can serve as a buffer against mental health difficulties. And one other research that came from South Africa was interesting in that, while I looked at childhood gender non-conformity as a risk factor, they looked at gender non-conformity in adulthood, and tried to look at its effect. And what they found was that if you look – when they looked at it, it was that being gender non-conforming in adulthood was, kind of, protective against mental health difficulties. And their reasoning was that if a gay person is gender non-conforming, then they don’t have to do as much work coming out, so it reduces the stress of keeping their sexual identity secret. Whereas, if someone was masculine presenting was gay, then it’s more stressful for them to hide it, for people not to discover, and then they associated stress with that, but that was interesting. I don’t think it’s been replicated yet, but those are some nuances. Dr Umar Toseeb Okay, and I suppose this is not necessarily a cross-cultural question anymore, but, broadly, in your experience, in your clinical practice and your understanding of the research literature, as certain societies have become more tolerant and inclusive and accepting of sexual minority individuals and adolescents, has there been a corresponding improvement in the mental health of those individuals, in sexual minority individuals? ‘Cause you would think that that would be the case, is that the case? Dr Olakunle (Kunle) Oginni Unfortunately, it’s not the case, and it’s a bit surprising that I had thought about it before. I’d had discussions around this, and there are a few papers that have looked at this specifically, like, comparing cohorts of people, gay, lesbian, bisexual individuals, born at different times, and this was more in the US. And what they found is that really the mental health difficulties, the rates have not really changed and, if anything, it sounded as if it had increased slightly in the younger cohort. And the questions for me were then, why is that so – just as you mentioned, with things getting better we would expect that things improved generally. So, some of the things I’ve talked about are that generally we are seeing that the rates of mental health difficulties among young people is increasing, whether they are a sexual minority or not. But the other thing those papers found was that there are things called “sexual identity milestones,” and these are things about when a person first becomes aware of being attracted to the same sex as themselves, when they first have sex with someone of the same sex as themselves, when they first recognise that they have an identity as a sexual minority, when they come out to people, their friends, their families. And then for older people, these are people born in the 50s, 60s, and this was in the US, what they found was that the ages were later, so people were coming out in their late teens, early 20s, and then there were gaps between those experiences. Whereas, compared to young people born in the 90s, they are more likely to recognise the same sex attraction earlier, more likely to have sex earlier, and more likely to come out to their friends, to their families, earlier. The other intriguing thing was that the space between coming out and having sex and recognising same sex identity was close together, so this was happening between 15, 16, for the younger cohort, while this was spaced with two, three years between some of these events. So, one, my thoughts are it’s possible that there is some stress with coming out and navigating all these milestones. There is some stress with dealing with all of it together, and while things are better, yes, there are increased reports of people having positive experiences. If they experience negative feedback from disclosing their sexual orientation, I wonder if it’s that the young person or at that age they may not yet have developed enough resources to cope with things like that, and it can make the impact more stressful for them, and that can maintain the rates of mental health difficulties, despite the improving context. Dr Umar Toseeb Yeah, really interesting, I suppose, yeah, the younger people who come out in their mid-teens might still be – adolescent development is a critical period, so, like, they’re still going through that process. Whereas, the older generation, who were coming out in their – a few years later, might have developed in – cognitively and in other ways as well, to help them cope with whatever those negative impacts might be or might not be, or negative reactions. It’s really fascinating. So, we probably have listeners who are working in clinical practice, we might have people who are working in education, other Researchers, but also maybe parents, what might your recommendations be around how people can support sexual minority youth with their mental health? Dr Olakunle (Kunle) Oginni Okay, so I think the first is to be aware that there can be difficulties linked to being sexual minority. Yes, things are better, and in my practice I find more young people are able to discuss some of this with their parents or caregivers, but we should remember the landscape is not uniform. And for the ones we are seeing, there are potentially many other people who are unable to have these discussions, not because the environment around them is not supportive, but, somehow, there is still a lot of negative messaging. And it’s not messages that people give directly, it’s things we give subtly and we imply in our communication, and that can go a long way in determining how comfortable people feel to discuss things. So, what people can do, want to be aware that people still struggle, and then to be curious about it, so to see people in clinic, make it part of our practice to ask about their sexual identity, who they are sexually attracted to. And if it’s not heterosexual, to keep in mind it could be a source of stress, and to find ways to broach this with the young person, within limits, that are acceptable or comfortable to them. Dr Umar Toseeb Thank you, and, finally, what’s your take home message for our listeners? Dr Olakunle (Kunle) Oginni What’s difficult for me is that I like to say something positive, but, at the same time, I like to be specific. And it’s difficult to see that – so, one is that, yes, lesbian and gay, bisexual young people still experience higher rates of mental health difficulties, compared to those who are not sexual minority. And for parents, Teachers, adults who work with young people, yes, we often say to be supportive generally, but I’m wondering if the support doesn’t necessarily have to be direct. Some of it should also be indirect, in terms of ensuring that the environment is accepting and non-discriminatory. So, this was me wondering about where the notion of internalised stigma comes from. Nobody would deliberately tell somebody, “You are bad,” or, “You don’t deserve to be alive,” it’s from the messages we get, the things people imply, and the way we talk to other people, that people, young people, get the message of what’s acceptable and not acceptable. So, I think in our spaces of influence, it’s to ensure that we don’t allow messages like that to pass unfiltered to young people, to enable them develop an optimal sense of self. Dr Umar Toseeb Thank you so much, that was a fantastic conversation, and learnt lots there. So, thank you so much for taking the time to share your research, other people’s research, and also your experiences with us. Thank you. For more details, please visit the ACAMH website, www.acamh.org, and Twitter @ACAMH. 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