Belonging and grieving: Lessons from Orlando

We belong in our family, in our group, and in our community. Belonging is a basic human need, and we work throughout our lives to seek or create safe places where we can belong. For the LGBTQ+ community, the Pulse nightclub was one of those rare places where they could feel like they truly belonged. It was a place where they did not need to pretend to be someone else or to keep their guard up against insults or criticism. For survivors of the shooting, the families, and the LGBTQ+ community, that sense of belonging is now fractured.

Pulse reportedly represented every LGBTQ+’s queer bar, where a safe environment is sought – an environment in which to grow and express identity. For the LGBTQ+ community, the June 12 massacre threatened all safe havens – where few currently exist – especially in the night scene, where the increased risk of violence is a constant factor in deciding where to party. There are few gay bars.

What must psychiatrists understand about the impact of the event, besides the regular work of grieving? Some specifics pertinent to this attack must be understood: the preponderance of Latinos¹, the youthfulness of most victims, and the impact and reverberations throughout the LGBTQ+ community. This column highlights the unique aspects of this tragedy, and the complexity of the grieving that will take place in these families and communities.

Grief, illness, and resilience: What do we know?

Grieving after sudden and violent deaths, compared with natural deaths, is more likely to be associated with mental health disorders and a slower recovery (Psychiatry. 2012 Spring;75[1]:76-97). Traumatic loss can cause incapacitating grief and a search for meaning that can continue for years, especially in those who identify closely with the victims (J Trauma Stress. 2016 Feb;29[1]41-8).

The LGBTQ+ community identifies strongly with the victims of the Orlando shooting, and so is more likely to have a prolonged and difficult grieving process. Feelings of “it could have been me” or “this might happen to me or my loved ones,” can result in symptoms of anxiety and survivor guilt. The LGBTQ+ community also is grieving the loss of a safe place and that associated sense of belonging. Loss of safety and feelings of reduced control over one’s life result in a more difficult grieving process, irrespective of the cause of death (Death Stud. 2006;30[5]:403-28). It is as if the loss provides further evidence of life’s injustices and unpredictability, provoking feelings of helplessness and fear.

Being able to make sense or make meaning after a disaster is a key component of developing resilience (J Clin Psychol. 2016 Feb 22. doi: 10.1002/jclp.22270). To make meaning out of a loss, people inevitably will examine their own lives for meaning and purpose. Meaning-making also can result in post-traumatic growth, such as an increased appreciation for life, stronger connections with family and friends, or greater awareness of one’s strengths.

The meaning-making process, often facilitated by psychotherapy, plays a critical role in recovery. Meaning-making takes different forms. For some people, the record-breaking turnout at NYC Pride, in which the owner of Pulse and others rode on a float and received great support, was a significant event. Meanwhile, another person who might be scared might want to see his family, regardless of whether or not the family is fully accepting.

Grief as a social process

Coping with grief is the working out of “the meaning of the loss,” both personally and in community. Grieving is a social process, and eulogies, grief accounts in popular literature, and elegies help construct the identity of the loved one and the meaning of the event. Grieving involves reviewing the relationship to the lost loved one and establishing a sense of continuity between life before and life after the loss (Death Stud. 2014 Jul-Dec; 38[6-10]:485-98).

One challenge for the LGBTQ+ community is how to direct the meaning of the loss. What is the meaning of this loss and how will the dead be remembered? The outpouring of support across the world is heartwarming and reflects how the LGBTQ+ community has become more accepted in the world at large.

The LGBTQ+ community experiences much less stigma than 50 years ago. In 1973, after the firebombing of a club in New Orleans, some relatives reportedly refused to claim the bodies of their gay sons. However, there remains much variation in how communities/societies view LGBTQ+ individuals and relationships.

Cultural considerations of being LGBTQ+

Nonbinary gender identity is recognized in several cultures around the world. The word “Mahu” in Polynesian culture and the concept of being Two-Spirit in some Native American cultures describe those who do not identify as their assigned sex at birth, play out gender roles opposite their assigned sex, or are attracted to same-sex partners, according to biologist Joan Roughgarden, PhD, (“Evolution’s Rainbow: Diversity, Gender and Sexuality in Nature and People” Los Angeles: University of California Press, 2004). In Dr. Roughgarden’s 2010 book, “The Genial Gene” (Los Angeles: University of California Press), she promotes social-selection theory as an alternative to the Darwinian selfish gene theory. She lists 26 phenomena, not explained by current sexual-selection theory, that are better explained by social selection, a population-based explanation of partner selection. Those ideas are beginning to reach a wider audience in mainstream culture, although for many communities and religions, those ideas are seen as “wrong” or “blasphemous.”

For all minority groups, the importance of belonging to a safe, accepting community ranks highly. The pressure for all minority group members to conform to mainstream society is strong and persistent. A good parallel is found when thinking about race and the pressure of dark-skinned individuals to conform to white society. Skin bleaching remains a common practice; some people turn dark skin whiter in order to conform to a societal ideal. Similarly, in order to fit in and avoid discrimination or persecution, many LGBTQ+ individuals work hard to keep their gender conforming face forward. Pulse offered an opportunity for LGBTQ+ individuals and couples to feel like they could be themselves, express themselves, and forget about the societal pressures of conformity. Belonging to a safe community is, therefore, vital to maintaining a sense of self and self-worth.

The acknowledgment of LGBTQ+ status varies by culture. Ninety percent of the Pulse shooting victims reportedly were gay Latino men; a group that expresses its gender identity differently from gay white men. Verbal disclosure benefits gay white men’s well-being but doesn’t affect gay Latino men’s well-being, either positively or negatively. For gay white men, the more they verbally disclose their gay identity to others, the more they feel they are showing their true, feelings of authenticity, research shows). Additionally, LGBTQ+ members may be out in English but not in their Spanish-speaking church, according to Marianne Duddy-Burke, executive director of Dignity/USA, the largest national lay movement of LGBTQ Catholics, their families, and friends. Sadly, many of the Latino families of the Pulse shooting victims are Spanish-speaking only and reportedly had difficulty finding someone to explain what had happened.

Family considerations of being LGBTQ+.

Some families may know privately that they have an LGBTQ member but do not publicly acknowledge the fact. Family members may say things like “being married is maybe not for you, and that’s OK,” or “People should be allowed to be whoever they are.” This communication, while masked, is supportive and illustrates “an understanding” in the family. It may be some time before a family can say “we support our child, regardless” or “I know you are gay, and that’s OK.”

Gender identity can, therefore, be communicated nonverbally and behaviorally. For example, gay Puerto Rican and gay Dominican men in New York City discussed how they disclosed their gender identity by bringing their same-sex partner to family functions without the direct verbalization of a romantic relationship. This strategy, by which gay identity is implied and unspoken, is known as “tacit subjectivity,” or “tacitness.” The authors of this study postulated that for gay Latino men, their relationships in the family and Latino community are more important than the acknowledgment of individual difference and the expression of authenticity.

This perspective is consistent with the importance of community and family identity, a common aspect of non-Western cultures. At the extreme, some communities are very hostile to LGBTQ+ individuals, including in the United States. After sending “thoughts and prayers” to Orlando, the GOP House chair blocked legislation aimed at making sure that federal contractors cannot discriminate based on gender identity or sexual orientation.

Meanwhile, in Pakistani Muslim families, an LGBTQ+ member threatens the marriage prospects of the girls and may place the family in danger of being killed. Yet, 50 top Pakistani clerics recently issued a religious decree, or fatwa, declaring that transgender people have full marriage, inheritance, and funeral rights under Islamic law. The fatwa stated that a female-born transgender person having “visible signs of being a male” may marry a woman or a male-born transgender with “visible signs of being a female,” and vice versa. However, it ruled that a transgender person carrying “visible signs of both genders” – or intersex – may not marry anyone.

Currently in Pakistan, gay marriage is punishable by life imprisonment. The new fatwa also declared that any act intended to “humiliate, insult, or tease” the community was “haraam” (forbidden). The fatwa also states that transgender people should not be deprived of family inheritances, nor the right to be buried in Muslim ceremonies and that parents who deprived their transgender sons or daughters of inheritances were “inviting the wrath of God.”

Complexity of grieving after Pulse

The unique cultural and family aspects of the Pulse shooting makes the process of grieving complex. The cultural aspects of LGBTQ+ identity, both within that community and within Latino culture, bring new variables to the grieving process. Many of the previously held truths about grieving may turn out to be unimportant in this tragedy, and new factors may emerge.

Previously held findings on complex grief include:

• The importance of personal risk factors, such as female gender and preexisting psychiatric difficulties, in increasing the probability for mental distress.

• Interpersonal risk factors, such as kinship and social support, especially the loss of a child.

• Low perceived social support associated with depression after disaster-related bereavement.

• Social isolation related to difficulties in adjustment after the sudden and violent loss of a child.

• Finding meaning in the loss is related to lower mental distress and grief after violent losses.

• Social support has shown nonconclusive results in the general bereavement literature. Still, some studies suggest that social support may exert a protective effect on mental health adversities after sudden and violent losses.

After the Pulse shooting, these variables need to be reanalyzed. Specific personal risk factors are likely to emerge, such as a victim’s comfort with LGBTQ+ identity and their feelings of connection with the victims. Interpersonal factors will relate to the acceptance of their families and the presence of other safe places. The social status of LGBTQ+ community vis-à-vis the mainstream culture also will have an impact. Meaning-finding is a universal need that may be more difficult to reach for the LGBTQ+ community.

An assumption that likely will be upheld is that sudden, unexpected, and violent losses, compared with losses from natural deaths, are followed by a more difficult grieving process. This has been confirmed in several empirical studies that show a heightened risk for prolonged grief disorder (PGD), major depressive disorder, and posttraumatic stress disorder (PTSD) after violent losses.

In a study measuring PGD in 1,723 college students who had experienced either sudden and violent or natural losses, Joseph Currier, PhD, and his colleagues found that the violence of the loss, not the suddenness, predicted the increased PGD risk (Death Stud. 2006;30:403-28).

Also, it was more difficult to make sense of violent losses, and those students spent more time talking about the loss. In line with studies of PGD, the violence of the loss – not the suddenness – has been shown to account for the increased PTSD risk in the bereaved (J Anxiety Disord. 2003; 17[2]131-47).

DSM-5 diagnosis of persistent complex bereavement disorder

How to make a diagnosis? There is controversy surrounding the accuracy of DSM-5 proposed criteria for persistent complex bereavement disorder (PCBD). In a study of family members of U.S. military service members who died of any cause since Sept. 11, 2001 (n = 1,732), the DSM-5 PCBD criteria accurately excluded nonclinical, normative grief, but also excluded nearly half of clinical cases (Am J Psychiatry. 2016 May 24. [doi: 10.1176/appi.ajp.2016.15111442]).

PCBD previously has been referred to in the literature as complicated grief and prolonged grief disorder. However, those three labels refer to the same syndrome of clinically impairing grief, which affects approximately 7%-15% of bereaved individuals. This syndrome is diagnosed when persistent and severe grief symptoms continue beyond 6-12 months after the death of a loved one and are associated with functional impairment.

Typical symptoms include difficulty accepting the death or a strong sense of disbelief about the death, intense yearning and longing for the deceased, anger and bitterness, distressing and intrusive thoughts related to the death, and excessive avoidance of reminders of the painful loss. In recognition of their lack of validation, PCBD criteria were included in section 3 of DSM-5 Conditions for Further Study.

In summary, the Pulse shooting highlights the importance of assessing grief from a variety of new perspectives. First, assess the patient’s own personal sense of identity and how much she identifies with the victims. Second, assess the cultural and family aspects pertinent to the patient’s expression of gender identity. Third, assess the degree of acceptance the person feels and her ability to access a safe community. Assess the degree of persecution she feels in society at large. This assessment includes identifying where the patient experiences a true sense of belonging. Lastly, the path forward is always a meaning-making endeavor.

Summary of proposed PCBD in DSM-5

• Criterion A requires that the individual has experienced the death of a loved one.

• Criterion B requires the presence of 1 of 4 symptoms related to yearning, longing, and sorrow.

• Criterion C requires 6 of 12 symptoms demonstrating reactive distress to the death or social/identity disruption.

• Criterion D requires clinically significant distress or functional impairment.

• Criterion E requires that distress or impairment is outside of sociocultural norms.

Symptoms present for at least 12 months and that are not better accounted for by major depressive disorder, generalized anxiety disorder, or posttraumatic stress disorder.

Source: Dr. Heru

Thank you to Shiona Heru, JD, for her comments.

References

1. Gender-inclusive version is to use either Latinx (the x symbol represents the absence of o/a) or Latin@ (using the @ symbol mixes the o and @).

2. For more on “The Singular Experience of the Queer Latin Nightclub”: http://www.theatlantic.com/entertainment/archive/2016/06/orlando-shooting-pulse-latin-queer-gay-nightclub-ramon-rivera-servera-intrerview/487442/

Dr. Heru is with the department of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals (New York: Routledge, 2013). She has no conflicts of interest to disclose. .

We belong in our family, in our group, and in our community. Belonging is a basic human need, and we work throughout our lives to seek or create safe places where we can belong. For the LGBTQ+ community, the Pulse nightclub was one of those rare places where they could feel like they truly belonged. It was a place where they did not need to pretend to be someone else or to keep their guard up against insults or criticism. For survivors of the shooting, the families, and the LGBTQ+ community, that sense of belonging is now fractured.

Pulse reportedly represented every LGBTQ+’s queer bar, where a safe environment is sought – an environment in which to grow and express identity. For the LGBTQ+ community, the June 12 massacre threatened all safe havens – where few currently exist – especially in the night scene, where the increased risk of violence is a constant factor in deciding where to party. There are few gay bars.

What must psychiatrists understand about the impact of the event, besides the regular work of grieving? Some specifics pertinent to this attack must be understood: the preponderance of Latinos¹, the youthfulness of most victims, and the impact and reverberations throughout the LGBTQ+ community. This column highlights the unique aspects of this tragedy, and the complexity of the grieving that will take place in these families and communities.

Grief, illness, and resilience: What do we know?

Grieving after sudden and violent deaths, compared with natural deaths, is more likely to be associated with mental health disorders and a slower recovery (Psychiatry. 2012 Spring;75[1]:76-97). Traumatic loss can cause incapacitating grief and a search for meaning that can continue for years, especially in those who identify closely with the victims (J Trauma Stress. 2016 Feb;29[1]41-8).

The LGBTQ+ community identifies strongly with the victims of the Orlando shooting, and so is more likely to have a prolonged and difficult grieving process. Feelings of “it could have been me” or “this might happen to me or my loved ones,” can result in symptoms of anxiety and survivor guilt. The LGBTQ+ community also is grieving the loss of a safe place and that associated sense of belonging. Loss of safety and feelings of reduced control over one’s life result in a more difficult grieving process, irrespective of the cause of death (Death Stud. 2006;30[5]:403-28). It is as if the loss provides further evidence of life’s injustices and unpredictability, provoking feelings of helplessness and fear.

Being able to make sense or make meaning after a disaster is a key component of developing resilience (J Clin Psychol. 2016 Feb 22. doi: 10.1002/jclp.22270). To make meaning out of a loss, people inevitably will examine their own lives for meaning and purpose. Meaning-making also can result in post-traumatic growth, such as an increased appreciation for life, stronger connections with family and friends, or greater awareness of one’s strengths.

The meaning-making process, often facilitated by psychotherapy, plays a critical role in recovery. Meaning-making takes different forms. For some people, the record-breaking turnout at NYC Pride, in which the owner of Pulse and others rode on a float and received great support, was a significant event. Meanwhile, another person who might be scared might want to see his family, regardless of whether or not the family is fully accepting.

Grief as a social process

Coping with grief is the working out of “the meaning of the loss,” both personally and in community. Grieving is a social process, and eulogies, grief accounts in popular literature, and elegies help construct the identity of the loved one and the meaning of the event. Grieving involves reviewing the relationship to the lost loved one and establishing a sense of continuity between life before and life after the loss (Death Stud. 2014 Jul-Dec; 38[6-10]:485-98).

One challenge for the LGBTQ+ community is how to direct the meaning of the loss. What is the meaning of this loss and how will the dead be remembered? The outpouring of support across the world is heartwarming and reflects how the LGBTQ+ community has become more accepted in the world at large.

The LGBTQ+ community experiences much less stigma than 50 years ago. In 1973, after the firebombing of a club in New Orleans, some relatives reportedly refused to claim the bodies of their gay sons. However, there remains much variation in how communities/societies view LGBTQ+ individuals and relationships.

Cultural considerations of being LGBTQ+

Nonbinary gender identity is recognized in several cultures around the world. The word “Mahu” in Polynesian culture and the concept of being Two-Spirit in some Native American cultures describe those who do not identify as their assigned sex at birth, play out gender roles opposite their assigned sex, or are attracted to same-sex partners, according to biologist Joan Roughgarden, PhD, (“Evolution’s Rainbow: Diversity, Gender and Sexuality in Nature and People” Los Angeles: University of California Press, 2004). In Dr. Roughgarden’s 2010 book, “The Genial Gene” (Los Angeles: University of California Press), she promotes social-selection theory as an alternative to the Darwinian selfish gene theory. She lists 26 phenomena, not explained by current sexual-selection theory, that are better explained by social selection, a population-based explanation of partner selection. Those ideas are beginning to reach a wider audience in mainstream culture, although for many communities and religions, those ideas are seen as “wrong” or “blasphemous.”

For all minority groups, the importance of belonging to a safe, accepting community ranks highly. The pressure for all minority group members to conform to mainstream society is strong and persistent. A good parallel is found when thinking about race and the pressure of dark-skinned individuals to conform to white society. Skin bleaching remains a common practice; some people turn dark skin whiter in order to conform to a societal ideal. Similarly, in order to fit in and avoid discrimination or persecution, many LGBTQ+ individuals work hard to keep their gender conforming face forward. Pulse offered an opportunity for LGBTQ+ individuals and couples to feel like they could be themselves, express themselves, and forget about the societal pressures of conformity. Belonging to a safe community is, therefore, vital to maintaining a sense of self and self-worth.

The acknowledgment of LGBTQ+ status varies by culture. Ninety percent of the Pulse shooting victims reportedly were gay Latino men; a group that expresses its gender identity differently from gay white men. Verbal disclosure benefits gay white men’s well-being but doesn’t affect gay Latino men’s well-being, either positively or negatively. For gay white men, the more they verbally disclose their gay identity to others, the more they feel they are showing their true, feelings of authenticity, research shows). Additionally, LGBTQ+ members may be out in English but not in their Spanish-speaking church, according to Marianne Duddy-Burke, executive director of Dignity/USA, the largest national lay movement of LGBTQ Catholics, their families, and friends. Sadly, many of the Latino families of the Pulse shooting victims are Spanish-speaking only and reportedly had difficulty finding someone to explain what had happened.

Family considerations of being LGBTQ+.

Some families may know privately that they have an LGBTQ member but do not publicly acknowledge the fact. Family members may say things like “being married is maybe not for you, and that’s OK,” or “People should be allowed to be whoever they are.” This communication, while masked, is supportive and illustrates “an understanding” in the family. It may be some time before a family can say “we support our child, regardless” or “I know you are gay, and that’s OK.”

Gender identity can, therefore, be communicated nonverbally and behaviorally. For example, gay Puerto Rican and gay Dominican men in New York City discussed how they disclosed their gender identity by bringing their same-sex partner to family functions without the direct verbalization of a romantic relationship. This strategy, by which gay identity is implied and unspoken, is known as “tacit subjectivity,” or “tacitness.” The authors of this study postulated that for gay Latino men, their relationships in the family and Latino community are more important than the acknowledgment of individual difference and the expression of authenticity.

This perspective is consistent with the importance of community and family identity, a common aspect of non-Western cultures. At the extreme, some communities are very hostile to LGBTQ+ individuals, including in the United States. After sending “thoughts and prayers” to Orlando, the GOP House chair blocked legislation aimed at making sure that federal contractors cannot discriminate based on gender identity or sexual orientation.

Meanwhile, in Pakistani Muslim families, an LGBTQ+ member threatens the marriage prospects of the girls and may place the family in danger of being killed. Yet, 50 top Pakistani clerics recently issued a religious decree, or fatwa, declaring that transgender people have full marriage, inheritance, and funeral rights under Islamic law. The fatwa stated that a female-born transgender person having “visible signs of being a male” may marry a woman or a male-born transgender with “visible signs of being a female,” and vice versa. However, it ruled that a transgender person carrying “visible signs of both genders” – or intersex – may not marry anyone.

Currently in Pakistan, gay marriage is punishable by life imprisonment. The new fatwa also declared that any act intended to “humiliate, insult, or tease” the community was “haraam” (forbidden). The fatwa also states that transgender people should not be deprived of family inheritances, nor the right to be buried in Muslim ceremonies and that parents who deprived their transgender sons or daughters of inheritances were “inviting the wrath of God.”

Complexity of grieving after Pulse

The unique cultural and family aspects of the Pulse shooting makes the process of grieving complex. The cultural aspects of LGBTQ+ identity, both within that community and within Latino culture, bring new variables to the grieving process. Many of the previously held truths about grieving may turn out to be unimportant in this tragedy, and new factors may emerge.

Previously held findings on complex grief include:

• The importance of personal risk factors, such as female gender and preexisting psychiatric difficulties, in increasing the probability for mental distress.

• Interpersonal risk factors, such as kinship and social support, especially the loss of a child.

• Low perceived social support associated with depression after disaster-related bereavement.

• Social isolation related to difficulties in adjustment after the sudden and violent loss of a child.

• Finding meaning in the loss is related to lower mental distress and grief after violent losses.

• Social support has shown nonconclusive results in the general bereavement literature. Still, some studies suggest that social support may exert a protective effect on mental health adversities after sudden and violent losses.

After the Pulse shooting, these variables need to be reanalyzed. Specific personal risk factors are likely to emerge, such as a victim’s comfort with LGBTQ+ identity and their feelings of connection with the victims. Interpersonal factors will relate to the acceptance of their families and the presence of other safe places. The social status of LGBTQ+ community vis-à-vis the mainstream culture also will have an impact. Meaning-finding is a universal need that may be more difficult to reach for the LGBTQ+ community.

An assumption that likely will be upheld is that sudden, unexpected, and violent losses, compared with losses from natural deaths, are followed by a more difficult grieving process. This has been confirmed in several empirical studies that show a heightened risk for prolonged grief disorder (PGD), major depressive disorder, and posttraumatic stress disorder (PTSD) after violent losses.

In a study measuring PGD in 1,723 college students who had experienced either sudden and violent or natural losses, Joseph Currier, PhD, and his colleagues found that the violence of the loss, not the suddenness, predicted the increased PGD risk (Death Stud. 2006;30:403-28).

Also, it was more difficult to make sense of violent losses, and those students spent more time talking about the loss. In line with studies of PGD, the violence of the loss – not the suddenness – has been shown to account for the increased PTSD risk in the bereaved (J Anxiety Disord. 2003; 17[2]131-47).

DSM-5 diagnosis of persistent complex bereavement disorder

How to make a diagnosis? There is controversy surrounding the accuracy of DSM-5 proposed criteria for persistent complex bereavement disorder (PCBD). In a study of family members of U.S. military service members who died of any cause since Sept. 11, 2001 (n = 1,732), the DSM-5 PCBD criteria accurately excluded nonclinical, normative grief, but also excluded nearly half of clinical cases (Am J Psychiatry. 2016 May 24. [doi: 10.1176/appi.ajp.2016.15111442]).

PCBD previously has been referred to in the literature as complicated grief and prolonged grief disorder. However, those three labels refer to the same syndrome of clinically impairing grief, which affects approximately 7%-15% of bereaved individuals. This syndrome is diagnosed when persistent and severe grief symptoms continue beyond 6-12 months after the death of a loved one and are associated with functional impairment.

Typical symptoms include difficulty accepting the death or a strong sense of disbelief about the death, intense yearning and longing for the deceased, anger and bitterness, distressing and intrusive thoughts related to the death, and excessive avoidance of reminders of the painful loss. In recognition of their lack of validation, PCBD criteria were included in section 3 of DSM-5 Conditions for Further Study.

In summary, the Pulse shooting highlights the importance of assessing grief from a variety of new perspectives. First, assess the patient’s own personal sense of identity and how much she identifies with the victims. Second, assess the cultural and family aspects pertinent to the patient’s expression of gender identity. Third, assess the degree of acceptance the person feels and her ability to access a safe community. Assess the degree of persecution she feels in society at large. This assessment includes identifying where the patient experiences a true sense of belonging. Lastly, the path forward is always a meaning-making endeavor.

Summary of proposed PCBD in DSM-5

• Criterion A requires that the individual has experienced the death of a loved one.

• Criterion B requires the presence of 1 of 4 symptoms related to yearning, longing, and sorrow.

• Criterion C requires 6 of 12 symptoms demonstrating reactive distress to the death or social/identity disruption.

• Criterion D requires clinically significant distress or functional impairment.

• Criterion E requires that distress or impairment is outside of sociocultural norms.

Symptoms present for at least 12 months and that are not better accounted for by major depressive disorder, generalized anxiety disorder, or posttraumatic stress disorder.

Source: Dr. Heru

Thank you to Shiona Heru, JD, for her comments.

References

1. Gender-inclusive version is to use either Latinx (the x symbol represents the absence of o/a) or Latin@ (using the @ symbol mixes the o and @).

2. For more on “The Singular Experience of the Queer Latin Nightclub”: http://www.theatlantic.com/entertainment/archive/2016/06/orlando-shooting-pulse-latin-queer-gay-nightclub-ramon-rivera-servera-intrerview/487442/

Dr. Heru is with the department of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals (New York: Routledge, 2013). She has no conflicts of interest to disclose. .

We belong in our family, in our group, and in our community. Belonging is a basic human need, and we work throughout our lives to seek or create safe places where we can belong. For the LGBTQ+ community, the Pulse nightclub was one of those rare places where they could feel like they truly belonged. It was a place where they did not need to pretend to be someone else or to keep their guard up against insults or criticism. For survivors of the shooting, the families, and the LGBTQ+ community, that sense of belonging is now fractured.

Pulse reportedly represented every LGBTQ+’s queer bar, where a safe environment is sought – an environment in which to grow and express identity. For the LGBTQ+ community, the June 12 massacre threatened all safe havens – where few currently exist – especially in the night scene, where the increased risk of violence is a constant factor in deciding where to party. There are few gay bars.

What must psychiatrists understand about the impact of the event, besides the regular work of grieving? Some specifics pertinent to this attack must be understood: the preponderance of Latinos¹, the youthfulness of most victims, and the impact and reverberations throughout the LGBTQ+ community. This column highlights the unique aspects of this tragedy, and the complexity of the grieving that will take place in these families and communities.

Grief, illness, and resilience: What do we know?

Grieving after sudden and violent deaths, compared with natural deaths, is more likely to be associated with mental health disorders and a slower recovery (Psychiatry. 2012 Spring;75[1]:76-97). Traumatic loss can cause incapacitating grief and a search for meaning that can continue for years, especially in those who identify closely with the victims (J Trauma Stress. 2016 Feb;29[1]41-8).

The LGBTQ+ community identifies strongly with the victims of the Orlando shooting, and so is more likely to have a prolonged and difficult grieving process. Feelings of “it could have been me” or “this might happen to me or my loved ones,” can result in symptoms of anxiety and survivor guilt. The LGBTQ+ community also is grieving the loss of a safe place and that associated sense of belonging. Loss of safety and feelings of reduced control over one’s life result in a more difficult grieving process, irrespective of the cause of death (Death Stud. 2006;30[5]:403-28). It is as if the loss provides further evidence of life’s injustices and unpredictability, provoking feelings of helplessness and fear.

Being able to make sense or make meaning after a disaster is a key component of developing resilience (J Clin Psychol. 2016 Feb 22. doi: 10.1002/jclp.22270). To make meaning out of a loss, people inevitably will examine their own lives for meaning and purpose. Meaning-making also can result in post-traumatic growth, such as an increased appreciation for life, stronger connections with family and friends, or greater awareness of one’s strengths.

The meaning-making process, often facilitated by psychotherapy, plays a critical role in recovery. Meaning-making takes different forms. For some people, the record-breaking turnout at NYC Pride, in which the owner of Pulse and others rode on a float and received great support, was a significant event. Meanwhile, another person who might be scared might want to see his family, regardless of whether or not the family is fully accepting.

Grief as a social process

Coping with grief is the working out of “the meaning of the loss,” both personally and in community. Grieving is a social process, and eulogies, grief accounts in popular literature, and elegies help construct the identity of the loved one and the meaning of the event. Grieving involves reviewing the relationship to the lost loved one and establishing a sense of continuity between life before and life after the loss (Death Stud. 2014 Jul-Dec; 38[6-10]:485-98).

One challenge for the LGBTQ+ community is how to direct the meaning of the loss. What is the meaning of this loss and how will the dead be remembered? The outpouring of support across the world is heartwarming and reflects how the LGBTQ+ community has become more accepted in the world at large.

The LGBTQ+ community experiences much less stigma than 50 years ago. In 1973, after the firebombing of a club in New Orleans, some relatives reportedly refused to claim the bodies of their gay sons. However, there remains much variation in how communities/societies view LGBTQ+ individuals and relationships.

Cultural considerations of being LGBTQ+

Nonbinary gender identity is recognized in several cultures around the world. The word “Mahu” in Polynesian culture and the concept of being Two-Spirit in some Native American cultures describe those who do not identify as their assigned sex at birth, play out gender roles opposite their assigned sex, or are attracted to same-sex partners, according to biologist Joan Roughgarden, PhD, (“Evolution’s Rainbow: Diversity, Gender and Sexuality in Nature and People” Los Angeles: University of California Press, 2004). In Dr. Roughgarden’s 2010 book, “The Genial Gene” (Los Angeles: University of California Press), she promotes social-selection theory as an alternative to the Darwinian selfish gene theory. She lists 26 phenomena, not explained by current sexual-selection theory, that are better explained by social selection, a population-based explanation of partner selection. Those ideas are beginning to reach a wider audience in mainstream culture, although for many communities and religions, those ideas are seen as “wrong” or “blasphemous.”

For all minority groups, the importance of belonging to a safe, accepting community ranks highly. The pressure for all minority group members to conform to mainstream society is strong and persistent. A good parallel is found when thinking about race and the pressure of dark-skinned individuals to conform to white society. Skin bleaching remains a common practice; some people turn dark skin whiter in order to conform to a societal ideal. Similarly, in order to fit in and avoid discrimination or persecution, many LGBTQ+ individuals work hard to keep their gender conforming face forward. Pulse offered an opportunity for LGBTQ+ individuals and couples to feel like they could be themselves, express themselves, and forget about the societal pressures of conformity. Belonging to a safe community is, therefore, vital to maintaining a sense of self and self-worth.

The acknowledgment of LGBTQ+ status varies by culture. Ninety percent of the Pulse shooting victims reportedly were gay Latino men; a group that expresses its gender identity differently from gay white men. Verbal disclosure benefits gay white men’s well-being but doesn’t affect gay Latino men’s well-being, either positively or negatively. For gay white men, the more they verbally disclose their gay identity to others, the more they feel they are showing their true, feelings of authenticity, research shows). Additionally, LGBTQ+ members may be out in English but not in their Spanish-speaking church, according to Marianne Duddy-Burke, executive director of Dignity/USA, the largest national lay movement of LGBTQ Catholics, their families, and friends. Sadly, many of the Latino families of the Pulse shooting victims are Spanish-speaking only and reportedly had difficulty finding someone to explain what had happened.

Family considerations of being LGBTQ+.

Some families may know privately that they have an LGBTQ member but do not publicly acknowledge the fact. Family members may say things like “being married is maybe not for you, and that’s OK,” or “People should be allowed to be whoever they are.” This communication, while masked, is supportive and illustrates “an understanding” in the family. It may be some time before a family can say “we support our child, regardless” or “I know you are gay, and that’s OK.”

Gender identity can, therefore, be communicated nonverbally and behaviorally. For example, gay Puerto Rican and gay Dominican men in New York City discussed how they disclosed their gender identity by bringing their same-sex partner to family functions without the direct verbalization of a romantic relationship. This strategy, by which gay identity is implied and unspoken, is known as “tacit subjectivity,” or “tacitness.” The authors of this study postulated that for gay Latino men, their relationships in the family and Latino community are more important than the acknowledgment of individual difference and the expression of authenticity.

This perspective is consistent with the importance of community and family identity, a common aspect of non-Western cultures. At the extreme, some communities are very hostile to LGBTQ+ individuals, including in the United States. After sending “thoughts and prayers” to Orlando, the GOP House chair blocked legislation aimed at making sure that federal contractors cannot discriminate based on gender identity or sexual orientation.

Meanwhile, in Pakistani Muslim families, an LGBTQ+ member threatens the marriage prospects of the girls and may place the family in danger of being killed. Yet, 50 top Pakistani clerics recently issued a religious decree, or fatwa, declaring that transgender people have full marriage, inheritance, and funeral rights under Islamic law. The fatwa stated that a female-born transgender person having “visible signs of being a male” may marry a woman or a male-born transgender with “visible signs of being a female,” and vice versa. However, it ruled that a transgender person carrying “visible signs of both genders” – or intersex – may not marry anyone.

Currently in Pakistan, gay marriage is punishable by life imprisonment. The new fatwa also declared that any act intended to “humiliate, insult, or tease” the community was “haraam” (forbidden). The fatwa also states that transgender people should not be deprived of family inheritances, nor the right to be buried in Muslim ceremonies and that parents who deprived their transgender sons or daughters of inheritances were “inviting the wrath of God.”

Complexity of grieving after Pulse

The unique cultural and family aspects of the Pulse shooting makes the process of grieving complex. The cultural aspects of LGBTQ+ identity, both within that community and within Latino culture, bring new variables to the grieving process. Many of the previously held truths about grieving may turn out to be unimportant in this tragedy, and new factors may emerge.

Previously held findings on complex grief include:

• The importance of personal risk factors, such as female gender and preexisting psychiatric difficulties, in increasing the probability for mental distress.

• Interpersonal risk factors, such as kinship and social support, especially the loss of a child.

• Low perceived social support associated with depression after disaster-related bereavement.

• Social isolation related to difficulties in adjustment after the sudden and violent loss of a child.

• Finding meaning in the loss is related to lower mental distress and grief after violent losses.

• Social support has shown nonconclusive results in the general bereavement literature. Still, some studies suggest that social support may exert a protective effect on mental health adversities after sudden and violent losses.

After the Pulse shooting, these variables need to be reanalyzed. Specific personal risk factors are likely to emerge, such as a victim’s comfort with LGBTQ+ identity and their feelings of connection with the victims. Interpersonal factors will relate to the acceptance of their families and the presence of other safe places. The social status of LGBTQ+ community vis-à-vis the mainstream culture also will have an impact. Meaning-finding is a universal need that may be more difficult to reach for the LGBTQ+ community.

An assumption that likely will be upheld is that sudden, unexpected, and violent losses, compared with losses from natural deaths, are followed by a more difficult grieving process. This has been confirmed in several empirical studies that show a heightened risk for prolonged grief disorder (PGD), major depressive disorder, and posttraumatic stress disorder (PTSD) after violent losses.

In a study measuring PGD in 1,723 college students who had experienced either sudden and violent or natural losses, Joseph Currier, PhD, and his colleagues found that the violence of the loss, not the suddenness, predicted the increased PGD risk (Death Stud. 2006;30:403-28).

Also, it was more difficult to make sense of violent losses, and those students spent more time talking about the loss. In line with studies of PGD, the violence of the loss – not the suddenness – has been shown to account for the increased PTSD risk in the bereaved (J Anxiety Disord. 2003; 17[2]131-47).

DSM-5 diagnosis of persistent complex bereavement disorder

How to make a diagnosis? There is controversy surrounding the accuracy of DSM-5 proposed criteria for persistent complex bereavement disorder (PCBD). In a study of family members of U.S. military service members who died of any cause since Sept. 11, 2001 (n = 1,732), the DSM-5 PCBD criteria accurately excluded nonclinical, normative grief, but also excluded nearly half of clinical cases (Am J Psychiatry. 2016 May 24. [doi: 10.1176/appi.ajp.2016.15111442]).

PCBD previously has been referred to in the literature as complicated grief and prolonged grief disorder. However, those three labels refer to the same syndrome of clinically impairing grief, which affects approximately 7%-15% of bereaved individuals. This syndrome is diagnosed when persistent and severe grief symptoms continue beyond 6-12 months after the death of a loved one and are associated with functional impairment.

Typical symptoms include difficulty accepting the death or a strong sense of disbelief about the death, intense yearning and longing for the deceased, anger and bitterness, distressing and intrusive thoughts related to the death, and excessive avoidance of reminders of the painful loss. In recognition of their lack of validation, PCBD criteria were included in section 3 of DSM-5 Conditions for Further Study.

In summary, the Pulse shooting highlights the importance of assessing grief from a variety of new perspectives. First, assess the patient’s own personal sense of identity and how much she identifies with the victims. Second, assess the cultural and family aspects pertinent to the patient’s expression of gender identity. Third, assess the degree of acceptance the person feels and her ability to access a safe community. Assess the degree of persecution she feels in society at large. This assessment includes identifying where the patient experiences a true sense of belonging. Lastly, the path forward is always a meaning-making endeavor.

Summary of proposed PCBD in DSM-5

• Criterion A requires that the individual has experienced the death of a loved one.

• Criterion B requires the presence of 1 of 4 symptoms related to yearning, longing, and sorrow.

• Criterion C requires 6 of 12 symptoms demonstrating reactive distress to the death or social/identity disruption.

• Criterion D requires clinically significant distress or functional impairment.

• Criterion E requires that distress or impairment is outside of sociocultural norms.

Symptoms present for at least 12 months and that are not better accounted for by major depressive disorder, generalized anxiety disorder, or posttraumatic stress disorder.

Source: Dr. Heru

Thank you to Shiona Heru, JD, for her comments.

References

1. Gender-inclusive version is to use either Latinx (the x symbol represents the absence of o/a) or Latin@ (using the @ symbol mixes the o and @).

2. For more on “The Singular Experience of the Queer Latin Nightclub”: http://www.theatlantic.com/entertainment/archive/2016/06/orlando-shooting-pulse-latin-queer-gay-nightclub-ramon-rivera-servera-intrerview/487442/

Dr. Heru is with the department of psychiatry at the University of Colorado Denver, Aurora. She is editor of “Working With Families in Medical Settings: A Multidisciplinary Guide for Psychiatrists and Other Health Professionals (New York: Routledge, 2013). She has no conflicts of interest to disclose. .