Free Workshop “LGBTIQ+ Minority Stress as a Relational Trauma through the Lenses of Gestalt-Integrative Therapy”

“It is hard to grow up in a society in which one’s important problems are treated as non-existent. It is impossible to belong to it, it is hard to fight to change it.” — Paul Goodman

Human beings are seekers and relational beings starting from intrauterine development. First, we start to discover ourselves and then explore external world. From the beginning, movements, sensory experience, and feelings inform person of who she/he/them is/are and who she/he/they is/are becoming (Benau, 2022). Self-formation and awareness include constant learning about who we are at any moment in time. It is a process of finding our individuality and autonomy, and the ways to belong. The neuroscience proves us that human brains are also wired to be social (Brothers, 1990; Firth, 2007). We learn about ourselves through interactions with others and in relation to others. The social-emotional knowledge we gain begins in preverbal period, before we have language to describe our experience. Comparing and contrasting who we are in relationship with others and with ourselves help forge our identity. Our psychosocial identity, in part, is formed by valuing and devaluing specific qualities in ourselves and others. This valuing and devaluing lie at the heart of pride and shame. Our earliest, most important relationships with parents, caregivers and relevant others implicitly teach us to value and devalue different ways of being and relating. Shame and pride are basic to our shared humanity and central to our neurobiological, psychological, and social-emotional heritage (Benau, 2022). Human beings can be altruistic and selfish, empathic and dismissive, kind and cruel as a part of genetic heritage (Sapolsky, 2017). In ongoing existing in our proximal and more distant social circles, we help and harm others. Relational trauma refers to enduring harm caused by one or more persons overwhelming and/or underwhelming another person’s mind/body, and thus woven into experiences and intertwined in the formation of LGBTIQ+ person’s identity.

Gestalt therapy field model brings focus to how the sense that people carry of themselves, is based on their personal background influence and co- construct the relationship in the personal interactions such as psychotherapy process. The degree of fit client’s experience with therapists, is crucial in how their co- constructed mapping of their field and self-process develops. To understand someone, it is important to understand his/her/their mapping of his/her/their self and other field. Therapists’ attitudes, cultural background, previous experiences are relatively stable preferences and are plainly an organized feature of therapists’ perspective. Therefore, they can affect therapeutic process with LGBTIQ+ clients in both directions- affirmative and oppressive.

Healthy development of sexual orientation and gender identity and their integration is one obvious prerequisite for healthy psycho-sexual and psychological development. Gestalt therapists should be aware of their attitudes, cultural background and how they can influence therapeutic process when working with LGBTIQ+ clients in order to provide culturally sensitive and LGBTIQ+ affirmative practice.

LGBTIQ+ affirmative health care can include any single or combination of number of social, psychological, behavioral or medical interventions designed to support and affirm an individual’s sexual orientation and/or gender identity.

According to Meyer’s minority stress theory (2003), structural, interpersonal, and individual forms of stigma give rise to proximal stress experiences that in turn elevate health risk for LGBTIQ+ people. These stigma-related stressors experienced by LGBTIQ+ people across these levels can take a form of relational trauma, and thus compound general life stressors that represent additional risk for different stress-related outcomes. People who belong to the sexual minorities and living in countries with higher degrees of structural stigma toward sexual minorities (e.g., more discriminatory laws and policies) report more internalized homonegativity, are more likely to conceal their sexual orientation, experience greater social isolation than sexual minorities groups living in lower-structural stigma countries (Pachankis et al., 2020). Similarly, internalized transphobia can be briefly described by not having pride in one’s transgender identity, investment in passing as a cisgender person, alienation from other transgender people, and shame (Bockting et al., 2019).

Interpersonal discrimination and victimization are closely associated with proximal minority stressors. These processes include internalized homonegativity, transnegativity and sensitivity to status-based rejection, which are in turn associated with poor mental health and health-risk behaviors (Bockting et al., 2013; Feinstein et al., 2012; Frost et al., 2015; Frost and Meyer, 2009; Pachankis et al., 2015b). Anxious expectations of rejection might be particularly pronounced among transgender and gender diverse people. One study shows that two-thirds of transgender men report having experienced mistreatment in healthcare settings at some point in their lives and nearly half reported having avoided healthcare services in the past year (Hughto et al., 2018). Taken together, these data depict LGBTIQ+ populations to be of a greater risk for poor health outcomes and a scope of risk behaviors. Effects of chronic stress on the immune system are well documented. While early studies hypothesized that stress “impairs” immune function, it is now apparent that the body responds to chronic stress in a complex manner. This is known by the term immune dysregulation, with complementary up-regulation of inflammatory processes and downregulation of viral monitoring. Inflammation increases risk for a variety of chronic diseases including cardiovascular and neurodegenerative diseases, even from some types of cancer.  While reduced cellular immune function increases risk for acute illnesses via poorer responses to vaccines and reduced ability to fight viral infections.

Transgender and gender diverse (TGD) people most often perceive available healthcare to be of inadequate quality and potentially unsafe (European Union Agency for Fundamental Rights. EU-LGBTI II: A long way to go for LGBTI equality, 2020). However, up to now healthcare systems across Europe fail to provide equal access for TGD compared to cisgender people It has been estimated that at least 27% of TGD people in Europe fail to access TGD care (Smiley et al., 2017). Compared to cisgender people and compared to lesbian, gay, bisexual or intersex people, TGD people are most affected by not having access to appropriate care and are among those reporting the highest rates of experiencing bad health (European Union Agency for Fundamental Rights. EU-LGBTI II: A long way to go for LGBTI equality, 2020; Gonzales et al., 2022; Jackson et al., 2023; Kachen et al., 2020; Reisner et al., 2016; Transgender Europe. Trans Health Map, 2022). Country-specific inequalities may be compounded by other socio-demographic variables, such as young age or non-binary gender identity, which may negatively affect access to TGD interventions (non-binary gender diverse people are significantly less likely to access TGD services than binary transgender men or women), (Burgwal et al., 2019; Burgwal et al., 2021). Other intersecting oppressions such as low education and socio-economic status, ethnic minority and disability status, migrant background or involvement in sex work can potentiate these inequalities.

Also a global anti-gender movement has emerged that is pushing back on women’s and LGBTIQ+ people’s rights. In Europe we also find traditional and conservative societal groups, organizations and parties that are increasingly vocal in opposition women’s reproductive rights, same-sex marriage, adoption, and comprehensive sex education (Gallo, 2019; Graff & Korolczuk, 2017; Graff & Korolczuk, 2018; Graff & Korolczuk, 2022). A 2023 study coauthored by Dhanani and Totton, found all trans people are at risk of experiencing negative outcomes, including increased risk of suicide, because anti-transgender laws are being called for implementation and shared around the USA. In response, members marginalized LGBTIQ+ communities and their families are finding ways to build connections and advocate for their rights. Szymanski and colleagues (2023) show that sexual minorities who participate in LGBTIQ+ activism tend to have enhanced psychological well-being. The study indicates that meaning in life, problem-solving coping strategies, and community connection play a key role in this relationship.

Access to the highest standard of LGBTIQ+ affirmative health care, including LGBTIQ+ affirmative approach within psychotherapeutic practice, that respects dignity and right of self-determination, personal, physical, and psychological integrity, autonomy and wellbeing of LGBTIQ+ people, and that relies on evidence-based practice, clinical guidelines and standards of care should be a priority across European health care systems and psychotherapeutic modalities. Education and sensitization of medical, mental health professionals, psychotherapists and other health care professionals on sexuality, sexual orientations, gender identities and diversities should be implemented through a lifespan and in the obligatory curriculum courses of health and mental health professionals.

This interactive workshop will provide experiential insight of the minority stress and relational trauma on identity formation and mental health of LGBTIQ+ individuals through the lenses of the gestalt-integrative concepts.

Iva Žegura was born on 14th of February 1979 in Zagreb. She attended the 1st gymnasium in Zagreb. She graduated and specialized in clinical psychology at the Department of Psychology at the Faculty of Humanities and Social Sciences in Zagreb. She is currently attending doctoral studies. She has the status of a licensed clinical psychologist by Croatian Psychological Chamber. She received education in gestalt integrative therapy, cybernetic psychotherapy, and sexual therapy. Since 2004, she works at the University Psychiatric Hospital Vrapče in Zagreb, currently at the Department for psychotic disorders and has huge outpatient ambulance for LGBTQ+ affirmative mental health care.

In her extensive clinical practice, she collaborates with several university departments of psychology in Croatia; on the Psychology of Nursing course at the Nursing Study of the Faculty of Medicine in Zagreb; lectures and mentors the propaedeutics of psychotherapy classes at the Edward Bernays College of Communication Management. Also, she collaborates as external expert with various governmental and non-governmental organizations, as well as institutes and institutions in Croatia and the region (IGW Centre Zagreb, Office of the Ombudsman for Gender Equality, Directorate for the Prison System and Probation – Training Centre of the Ministry of Justice and Administration, LORI, KolekTIRV, Sarajevo Open Centre, etc.).

She is a mentor to psychology students who do regular student internships and a mentor to trainee psychologists in clinical psychology. She is a member of the National List of Experts for the Health Care of Transgender People by the Ministry of Health of the Republic of Croatia. She is the president of the Section for Clinical Psychology and Section for psychology and human rights by Croatian Psychological Society – CPA and vice-president of the Section for Psychology of Sexuality and Psychology of Gender. She served as a member of the Board of Directors of the Croatian Psychological Chamber – CPC for two mandates. She was a member of the Board of Directors of the Zagreb Psychological Society and a member of the Supervisory Board of the Croatian Psychological Chamber. She is currently president of Committee for trainee psychologist, an active member of the Division of Clinical Psychology by CPC and Committee for professional concerns. Currently she actively participates in the Working Group for developing a new version of Psychological Code of Ethics by CPC.

She is the representative of CPA in the Board on Cultural and Ethnic Diversity at the European Federation of Psychologists’ Associations – EFPA. From 2021, she was elected as a member of the Board of Directors of the European Professional Association for Transgender Health – EPATH, and in 2023 serves as president elect. Since 2021 she participates in WPATH’s GEI Diversity, Inclusion, and Community Engagement Committee and become WPATH GEI Institute lecturer in 2023. Since 2022, she has been a representative of the Croatian Psychological Society in APA’s Ipsy Net. From the October 2022, she is national representative of The Global Network of Psychologists for Human Rights. She regularly participates in domestic and foreign psychological symposia, congresses and conferences covering various topics in the fields of clinical psychology, psychological diagnostics, psychotherapy, gestalt psychotherapy, psychiatry, sexual medicine, sexual health, sexual orientations, gender identities, transgender mental health care, human rights, and social justice, interculturality, scientific research in psychotherapy.

She is the author of several scientific papers, review articles and books: “Psychological aspects of coronary heart disease” and “Coming out: To Understand vs./feat. to Accept” and the chapter “Different partnerships – psychological aspects of LGBT partnerships and parenthood” in the university textbook “Psychological aspects of the modern family, marriage and partnerships” and the chapters “Transition process of gender non-normative, transgender and transsexual people – perspective of clinical psychology” in the handbook “Medical aspects of gender affirmation”. She is the editor of the first handbook in the Croatian language on sexual medicine, “Fundamentals of Sexual Medicine”, for which she also wrote the chapter on gender dysphoria. She participated in the translation of several books from the English language: J.F. Masterson “In Search of the Real Self – Unmasking the Personality Disorders of Our Age”, “An Oral History of Gestalt Therapy”, for which she wrote the foreword and afterword, and “50 Great Myths of Psychology”. She also collaborates with the Journal of Sexual Medicine as peer reviewer and is a member of editorial board of Clinical Psychology- Journal of clinical and health psychology, clinical neuropsychology, counselling, psychotherapy, and related disciplines.

She is a member of several national and foreign professional societies and associations: Croatian Psychological Association, Croatian Psychological Chamber, Society of Gestalt and Integrative Therapists of Croatia, Croatian Society for Sexual Therapy, Zagreb Psychological Society, European Federation of Psychologists’ Associations, World Professional Association for Transgender Health- WPATH, European Professional Association for Transgender Health – EPATH, European Society for Sexual Medicine- ESSM, European Association of Clinical Psychology and Psychological Treatment, European Psychiatric Association. She is the recipient of several professional certificates of appreciation and awards, including the Marulić Social Award: “Fiat Psychologia” for special contribution to Croatian applied psychology (2011) and the Certificate of Distinguished Contribution to the Croatian Psychological Chamber (2020), and the APA Division 52- International Psychology Global Citizen Psychologist Citation 2022 Award for exceptional volunteer professional engagement and contribution to increasing visibility and strengthening the availability of psychological scientific and practical knowledge both in the local and international community related to LGBTQ+ mental health.

In 2024, she was awarded the Ramiro Bujas award by the Croatian Psychological Association for a particularly valuable achievement in the social affirmation of psychology.