Running head: LGBTQ YOUNG ADULTS

LGBTQ Young Adults: Connecting the Occupational Dots Rachel M. Booth and Estee K. Woods Saginaw Valley State University

LGBTQ YOUNG ADULTS LGBTQ Young Adults: Connecting the Occupational Dots

Over the last twenty years, there have been significant changes within the United States in regards to culture, societal norms, and diversity (Black, 2002). Merriam-Webster online dictionary defines diversity as being composed of distinct element or differing from one another: unlike (2012). Factors relating to population diversity include ethnicity, gender, age, sexual orientation and social class, among others. Sexual identity has been an expanding topic in diversity due to the growing number of young adults classifying their sexuality as lesbian, gay, bisexual, transgender, or queer/questioning (LGBTQ) sexual orientation (Nolan, 2006). Members of the LGBTQ population frequently face both psychological and social issues as a result of rejection from family and friends, as well as discrimination among the community (Bedell, 2000). Lack of acceptance from family members can contribute to the high numbers of LGBTQ young adults running away or being forced out of their homes (Nolan, 2006). It is estimated that there are 750,000 Americans who are homeless each night. Approximately 575,000 of those are adolescent through young adult; 11-35% of homeless young adults are thought to be LGBTQ (Van Yu, 2010). Young adults whom identify as LGBTQ and are homeless face additional risks on the streets due to homophobia, discrimination, and hate crimes (Nolan, 2006). Furthermore, homeless young adults of the LGBTQ community are at higher risk for survival crimes committed out of desire for specific needs. Examples of these crimes include robbery, or selling drugs and/or sexual services (Nolan, 2006). Diversity and cultural competence are important components in the practice of occupational therapy. As described by the American Occupational Therapy Association (AOTA) Ethics Commission, cultural competence is the process of developing and practicing appropriate, relevant, and sensitive strategies and skills in interacting with culturally different

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persons. Cultural competence is also mentioned in the Guidelines to the Code of Ethics which states, Occupational therapy personnel shall develop an understanding and appreciation for different cultures in order to be able to provide culturally competent service (Wells, 2005). The National Center for Cultural Competence defines culture as "the integrated pattern of human behavior that includes thoughts, communication, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups" (Peterson and Coltrane, 2003). Occupational therapists have a need and a duty to become familiar with persons from all cultural groups, thus including the LGBTQ community. Understanding the relationship between culture and the common occupational patterns of clients will enhance their therapeutic relationship and client-centered practice. To recognize if LGBTQ young adults are in need of occupational therapy services, the authors completed a review of the literature on homeless LGBTQ young adults including AJOT, CINAHL, Medline, AMA, Science Direct, and PsycInfo databases with the following combination of search terms: LGBTQ young adult, LGBTQ adolescent, adolescent sexual orientation, motivation, goals, values, interests, occupational therapy, lesbian adolescent homelessness, gay homelessness, bisexual, and homelessness. Despite an extensive search, the authors did not find any information or articles on the LGBTQ homeless populations that addressed areas such as motivation, goals, values, and interests. Very little is identified concerning the occupational patterns within this group. This becomes important when assessing a clients cultural context. Cultural context often influences accessibility to resources, quality of care and satisfaction with occupational performance (Wells, 2011). The lack of information about the expanding LGBTQ population conveys the need for additional research to allow occupational therapists to better understand their LGBTQ clients and facilitate meaningful

LGBTQ YOUNG ADULTS treatment. Statement of Research Problem

There is limited research focused on the vocational and personal needs of LGBTQ young adults, particularly those that are homeless. Much of the research on this population focuses on the common stigmas related to mental health statistics, and percentiles for the contraction of HIV/AIDS. The American Occupational Therapy Associations Centennial Vision states By the year 2017, we envision that occupational therapy is a powerful, widely recognized, sciencedriven, and evidence-based profession with a globally connected and diverse workforce meeting societys occupational needs (AOTA, 2006). The vision and need are apparent; however, the research regarding occupational performance patterns within this culture is scarce. Without further research, including evidenced-based information on the LGBTQ community, the Centennial Vision will not be achieved for this population. Purpose of the Study The purpose of this phenomenological study was to learn about the patterns of participation in occupation among the LGBTQ homeless population within the context of the Ruth Ellis Center (REC) located in Detroit, Michigan. The REC serves as a drop-in center for LGBTQ youth, providing meals, clothing, toiletries, counseling and leadership opportunities, among other services. The authors asked young adults of the LGBTQ population questions in regards to motivation, goals and values, interests related to vocation and leisure, as well as independent living skills. This research provides a foundation for future development of occupational interventions/treatment for LGBTQ young adults. It is the duty of the occupational therapist to adhere to ethical protocols and assist underserved populations. In addition, it is important that occupational therapy practitioners

LGBTQ YOUNG ADULTS practice cultural competence (Black & Wells, 2007). According to Wells (2005), cultural

competency can be defined as understanding the importance of social and cultural influences on patients health beliefs and behaviors; considering how these factors interact at multiple levels of the health care delivery system; and finally, devising interventions that take these issues into account to assure quality health care delivery to diverse patient populations (Wells, 2005). By integrating cultural competence into practice, therapists can provide a more client-centered approach to treatment, by further understanding common occupational patterns of the homeless LGBTQ population. Research Questions This qualitative study gathered data regarding motivation, goals, values, and interests among the homeless young adult LGBTQ population, within the context of the Ruth Ellis Center in Detroit, MI. The research questions were as follows: 1. How does identifying as LGBTQ impact participation in valued occupations? 2. How have community-based programs served the LGBTQ young adult population? 3. What occupational therapy services and resources would be beneficial to increase participation in specific occupations? Theoretical Perspective This study was guided by the Model of Human Occupation (MOHO), which was developed in 1980 to identifying the importance of culture and its influence on a clients occupational choice (Black and Wells, 2007). MOHO is the most frequently used frame of reference in occupational therapy practice. This theory states the importance of understanding a clients physical and social environments to better address occupational set-backs. MOHO is focused on engaging clients in meaningful and client-centered treatment to help clients reach

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their personal goals (Kielhofner, 2008). This model is particularly supportive when researching persons within this cultural group, whom have been exposed to homelessness. This study was also influenced by the Occupational Adaptation Model (OA) (Scaffa, 2001). This theory was developed by Schkade and Schultz as a tool for research to study how occupation and adaption are woven together to describe an innate human process, focused on environmental enrichment to enhance performance patterns of occupation. This theory suggests that the demands of an ever-changing environment will affect an individual, causing the individual to adapt to the environment. Based upon this theory, it is expected that environmental demands, such as homelessness, impact the needs of the individual and how one is forced to adapt given their current living situation. Definitions LGBTQ. A group of individuals who identify as Lesbian, Gay, Bi-sexual, Transgender or questioning (Mayer et al., 2008). Lesbian. Women primarily sexually oriented to other women (Mayer et al., 2008). Gay. Men primarily sexually oriented to other men (Mayer et al., 2008). Bi-sexual. Individuals that are sexually oriented towards both male and female (Mayer et al., 2008). Transgender. A group of individuals who have difficulty identifying with a specific gender, expressions, or behaviors untraditionally associated with the gender they were born with (Mayer et al., 2008, p. 6). Young Adult. For the purposes of this study, male and females between the ages of 1823, as 23 years of age is the upper age limit of the Ruth Ellis Center. (Ruth Ellis Center, 2012) ADL. Activities of daily living are activities that involve taking care of ones own body

LGBTQ YOUNG ADULTS (AOTA, 2002). Areas of occupation. Activities that one engages in throughout their life, ADLs,

IADLs, rest and sleep, education, work, play, leisure, and social participation (AOTA, 2002). Homeless. An individual without a fixed nighttime residence (Cochran, Stewart, Ginzler, & Cauce, 2002). Intervention. The actions taken by the health professional to plan, treat and review the plan of care for an individual (AOTA, 2002). Transitional Living. A program that provides housing for youth under the age of 21, who are actively homeless or facing homelessness (Nolan, 2006). Significance of the Study Little is known about the homeless LGBTQ population. The authors did not find any information or articles on the LGBTQ homeless populations that addressed areas such as motivation, goals, values, and interests. In order for occupational therapists to best serve the LGBTQ population, it is essential that one has a firm base of knowledge about the individuals they are serving. Therefore, it is important that these areas within occupational therapy are explored in order to provide preliminary knowledge to provide better interventions for clients of the LGBTQ community. Limitations of the Study A few limitations of the study must be noted. With qualitative research, a small number of participants are studied. Due to the small size this limits generalizability. The population interviewed for this study was likely to be transient and mobile, which has posed a problem for future follow up. The participants of the Ruth Ellis Center are predominately males of AfricanAmerican descent, residing in urban inner-city Detroit, MI. This decreases the generalizability

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of findings in relation to other LGBTQ young adults that are of different ethnicity, social status or located in rural areas. Additionally, participants may have withheld helpful information from the authors, due to difficulties of trust with personal information. Also, the authors own personal experiences such as bias, family values, friendships within the LGBTQ culture, among others, could have had an influence on the study. Review of the Literature The known published literature about the homeless population of lesbian, gay, bisexual, transgender, and questioning young adult is scarce regarding valued occupations and occupational performance patterns. As mentioned above, culture is defined as a combination of ones own thoughts, actions, customs, beliefs, and values (Wells, 2011). It is important for clinicians to access as much information as possible when working with clients from a specific cultural group, such as the LGBTQ population, to better attend to and help understand their clients needs during treatment. The literature review will first explore how cultural competency and ethics relate to the field of occupational therapy. It will then highlight general research that has been collected on the LGBTQ community. Health needs such as substance abuse and mental health disorders, as well as other health needs discovered among the LGBTQ population will also be examined. Finally, the review of the literature will highlight programs of support within the United States that are available resources for this cultural group. Cultural Competency and Ethics Relating to Occupational Therapy Practice Many professions are required to take ethical and moral principles into greater consideration, rather than basing decisions on medical knowledge alone (Wells, 2011). Ethical principles including autonomy, beneficence, and justice are listed in the Occupational Therapy Code of Ethics (Wells, 2005). To appropriately make ethical decisions, one must have an

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understanding of cultural competency. Learning new patterns of behaviors and applying them to a setting is known as competence within a practice (Wells, 2011). It is important for clinicians such as occupational therapists, to be conscious of how clients sexual orientation affects the context of their social environment. It is also important for the clinician to be able to identify with ones own culture, as well as being aware of possible cultural biases. Cultural competency is necessary because it will promote a client-centered approach to treatment. Client-centered care provides more meaningful activities to a client resulting in improved recovery (Wells, 2005). Under beneficence, within the context of the Occupational Therapy Code of Ethics it is stated that occupational therapy personnel shall recognize and appreciate the cultural components of economics, geography, race, ethnicity, religious and political factors, marital status, age, sexual orientation, gender identity, and disability of all recipients of their service. The Occupational Therapy Code of Ethics also states that a persons culture can guide individuals on how they cope and interact with others. Establishing and maintaining effective communication between a therapist and client will help determine the success of an intervention (Wells, 2005). The central purpose of occupational therapy practice is identifying client-centered activities that can be used in treatment to help clients meet their maximum potential. Sexual orientation is a defining characteristic of the LGBTQ culture, thus it should be recognized as part of the culture and integrated into treatment. When sexual orientation is expressed as a theme that is meaningful to the clients occupational activities, it then becomes important to occupational performance (Jackson, 1995). One of the influential theories of this study, as stated previously, is the Model of Human Occupation (MOHO). This model states the importance of culture and its

LGBTQ YOUNG ADULTS influence on a clients occupational choice (Black and Wells, 2007). Through engagement in

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meaningful and client-centered ac tivities, MOHO provides support to address difficulties with occupational performance (Kielhofner, 2008). Overview of Research on LGBTQ Populations The field of psychology and counseling has been historically focused on collecting statistical data among the lesbian, gay, bisexual, transgender, or questioning populations. Qualitative research explaining occupational patterns among the LGBTQ population continues to be rare due to accessibility (Singh, 2011). Difficulties accessing this population are likely attributed to the risks for the LGBTQ individual, including potential job loss, hate crimes, and disengagements of social supports (Singh, 2011). Studies have shown that LGBTQ populations have a need for mental health services two to four times greater than the heterosexual population (Singh, 2011). This statistic supports the need for further research within the LGBTQ population in regards to occupational performance patterns to help address these issues. Singh conducted a content analysis that examined the limited amount of qualitative studies published over the last ten years, regarding the LGBTQ population. Only 12 empirical qualitative articles involving LGBTQ populations were published between the years 1998 and 2008. The most commonly found research related to the health factors and needs associated with this group. Sample sizes ranged from 10-50 participants, equaling a total of 220 subjects (Singh, 2011). Specifics on the sexual identities of each participant are unknown, due to lack of information within the studies. Seventy percent of the participants identified as European American, Caucasian, or White, making it difficult to generalize to other racial or ethnic groups. The studies over the last ten years have focused more on gay men and women, while discounting transgender and bisexual men and women (Singh, 2011).

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Health care needs amongst the LGBTQ homeless youth population. A review of the literature has found commonalities of concern amongst the LGBTQ homeless youth population in regards to health care. The most significant area of concern is that of mental health disorders (Mayer et al., 2008). Though a mental health disorder is not a direct result of being a sexual minority, it has been shown that stressors attributed to sexual identity increase the risk of developing disorders including depression and anxiety (Dowshen & Garofalo, 2009). Recent studies have found that suicide has been on the rise within the LGBTQ youth population, as compared to non-LGBTQ youth (Nolan, 2006). Body image and eating disorders have also shown to be more prevalent among gay and bisexual males, as compared to their heterosexual peers (Mayer et al., 2008). These studies are important in regards to uncovering the need of future research in occupational performance patterns among this group. Another area of concern with this population is substance abuse; several studies have found an increase in substance abuse and alcohol amongst LGBTQ youth (Dowshen & Garofalo, 2009). These youth will often self-medicate or use substances as coping mechanisms to deal with life stressors (Mayer et al., 2008). Furthermore, as alcohol and drug use increase, researchers have found increased unsafe sexual practices, leading to health issues related to sexually transmitted infections (Mayer et al., 2008). Recent studies have suggested that the increase in substance abuse, alcoholism, and unsafe sex practices, as well as increased mental health disorders, are due to life stressors experienced by the LGBTQ young adult population (Nolan, 2006). The cause of these life stressors may originate from family rejection, bullying, social stigmas, the stress of hiding ones own sexual identity, as well as verbal and/or physical abuse by peers and family members (Finlayson, Baker, Rodman, & Herzberg, 2002).

LGBTQ YOUNG ADULTS Transitional housing and homeless shelters for homeless LGBTQ youth. Studies

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have estimated that 40% of 1.7 million homeless or displaced youth are sexual minorities (Ruth Ellis Center, 2012). Sometimes, housing for runaway youth and the homeless is available. These facilities can help to provide things like guidance, goals, and support for transitional living. Research has shown that transitional living programs can decrease repeat cases of homelessness (Nolan, 2006). It is important for occupational therapy clinicians to understand and recognize the increased health risks faced by homeless LGBTQ young adults, along with the increased need for assistance in regards to meaningful occupations within this population. Homeless LGBTQ young adults are frequently without family, educational or peer support (Cochran et al., 2002). Basic needs such as adequate nutrition, safe housing, sufficient education and suitable employment are negatively impacted by lack of permanent residency, which can lead to serious mental disorders and substance abuse. Services currently available do not match the needs of the homeless population. This substantiates the need for client-centered therapy when facilitating treatment, as this will ensure appropriate services to match their needs (Finlayson et al., 2002). Currently, there are only four organizations available in the United States that specifically serve the needs of homeless LGBTQ youth. The Ruth Ellis Center in Detroit, Michigan is one of those four organizations. It is the only shelter located in the Midwest United States that provides residential and drop-in programs specifically tailored to the needs of the LGBTQ homeless youth population (Ruth Ellis Center, 2012). A review of the literature suggests that one common goal of the staff at transitional housing programs is the development of life skills for the LGBTQ community. Key life skills include money management, interpersonal skills, independence regarding suitable housing and

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sustainable income, in addition to responsibility related to everyday commitments (Nolan, 2006). Studies have pointed out the importance of learning these life skills in order for homeless youth to manage the change from transitional living programs to living out in the community with friends or family, or by living independently (Nolan, 2006). It is clear that there have been significant changes over the past twenty years within the United States in regards to culture, diversity, and societal norms (Black, 2002). In particular, the LGBTQ population has become more visible to the public eye; consequently, this population has experienced more discrimination and hate crimes from within their own communities (Nolan, 2006). The LGBTQ population represents 40% of 1.7 million homeless youth in the United States (Ruth Ellis Center, 2012). Family rejection, verbal, and physical abuse, as well as substance abuse are some of the reasons LGBTQ youth to leave home in search of a more accepting environment (Nolan, 2006). In addition, these kinds of stressors will frequently cause psychological and social issues for the LGBTQ youth, leading to an increase in mental health disorders within this population (Mayer et al., 2008). Due to this increased utilization of mental health services by the LGBTQ population, it is suggested that there is a need for further qualitative inquiry about this underserved population (Singh, 2011). There is little research available in regards to activities of daily living of homeless LGBTQ youth. A review of the literature did not reveal data on the LGBTQ population in regards to financial management, employment interests and pursuits, leisure activities, average education level, facilitators and barriers to overcoming homelessness, and personal values found amongst the LGBTQ population. This shows the evident need for further research in these areas. Methods

LGBTQ YOUNG ADULTS Research Design

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This study utilized a qualitative phenomenological design which allowed the researchers to gather in-depth information about occupational performance patterns of LGBTQ young adults living in a major metropolitan area, within the United States. These patterns were studied in the areas of motivation, goals, values and interests associated with vocation, leisure and independent living skills. This design allowed the researchers to identify common themes among individuals within this particular group, as well as allowing the researchers to carefully select participants that would provide a firm understanding of their experiences. Phenomenological research provides thorough, narrative examination of participants thoughts, feelings and experiences. When conducting qualitative research, the depth of exposure and knowledge of the participants is more important than a large sample size (Kielhofner, 2006). Each participant was eager to share their story of homelessness, while identifying with LGBTQ. Participants A total of four African-American young adults participated in this study; 3 males and 1 female. Two of the three males identified themselves as gay. The other male identified as bisexual and the female as lesbian. The participants ranged in age from 22 to 25 years old. All participants were members of the Ruth Ellis Center in Detroit, MI and had experienced homelessness for at least four weeks. Instrumentation The researchers collected data by conducting interviews. The interviews were designed to collect information concerning occupational performance specifically in regards to motivation, goals, values and interests related to vocation, leisure and independent living skills of LGBTQ

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young adults living in a major metropolitan area in the United States. Interview questions were peer-reviewed by the board members of the Ruth Ellis Center to decrease the risk that the questions would cause emotional distress for the participants of the study. The questions were reviewed and revised in accordance to the feedback received from the Ruth Ellis Center board members. The researchers collected data by conducting interviews on a one-on-one, face-to-face basis. Participants volunteered for a time that worked well for them on the day of the interviews. The researchers developed a list of open-ended questions to encourage participants to express their thoughts, feelings and life experiences. The interviews focused on gathering information regarding occupational performance in the areas of motivation, goals, values and interests related to vocation, leisure and independent living skills of the LGBTQ young adults included in the study. Apparatus An audio recorder was used to record the interviews. A computer was used in conjunction with ExpressScribe software to transcribe the interviews into a word document format. Procedures Study site. Interviews were conducted in a private room at the Ruth Ellis Center, a nonprofit LGBTQ homeless shelter located in a Metropolitan area of Detroit, Michigan. The center serves 70-100 homeless LGBTQ young adults on average each night by providing a drop-in center, safety-net services and resources for stable housing for 13 to 21 year olds (Ruth Ellis Center, 2012). Transcription and data analysis took place on the campus of Saginaw Valley State University in Saginaw, Michigan.

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Data collection. Data was collected through individual, in-person interviews, each lasted between 45-60 minutes, in a private room at the Ruth Ellis Center. Each participant volunteered their time to participate in the study. An audio-recording device was used to record each interview. Additional notes were taken with a paper and pencil. All participants were asked ten formal open-ended questions. Those interviewed were asked additional questions if appropriate. The participants were notified of their right to refuse to answer a question. The interviewer complied and moved onto the next question, if needed. Data analysis procedures. Once the interview process was complete, the authors transcribed the audio recordings, with the help of ExpressScribe software, into a word document. The recordings, notes and transcriptions of the interviews were kept in a locked cabinet. Once the transcription process was complete, an overview of the data was performed to identify common themes of occupational patterns and performance (open coding). Next, the authors performed axial coding by condensing those ideas into 5-7 common ideas among the responses. Finally, the authors used selective coding to yield an overarching idea or theme. Results There were four participants in total that were interviewed at the Ruth Ellis Center in Detroit, MI. All of the participants were of African American descent, one female and three males. The female is a 22 year old who identified her sexual orientation as lesbian. Two of the males, ages 23 and 25, identified as being gay. The third male, age 23, identified as homo flexible. Unlike bisexual orientation, homo flexible is attracted to both sexes; however they are more attracted to one sex over the other. Impact onon Participation in Valued Occupations

LGBTQ YOUNG ADULTS All of the participants noted that their involvement in valued occupations have been

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impacted due to internal and external societal views of their sexual orientation. Internal societal views pertain to family and friends of the participants. Where as external societal views deals with social stigmas involving their resources, culture, and personal values linked to the LGBTQ community. All participants expressed fear of being judged or facing rejection when trying new things, such as applying for a new job or attending college. Participant D states, when I was working at [a local restaurant], I mean, I didn't have too many people judge my sexuality, but I had people that I had associated with that would come back and be like 'such n such did this, such and such did that but me personally, I was just like 'okay this is me and I'd brush it off, I'm still gonna be gay, gay faggit, and you know just do what I gotta do. Im not gonna stop bein me. I'm here to make money. I'm not here to prove to y'all or make yall feel a type of way cuz I'm gay and your straight. Participants voiced the need to feel happy, motivated and understood in order to engage in meaningful activities. When asked what their typical day consists of responses included watching TV, caring for family or pets, socializing with friends and family, completing household chores, reading a book, listening to music and engaging in social media. However, there was little to no mention of current employment or active vocational pursuits. Although the participants have established long-term vocational goals most of them have not set short-term goals due to other barriers including lack of adequate housing, consistent employment history, and social hardships such as rejection from family and friends and fear of rejection involving the employment process. All participants reported that they are receiving income subsidized from the government and seem to be content with their current socioeconomic status. When asked

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where participant C gets his income, he states, Well probably the government, food stampsit pays the bills for now. When also asked about income participant A states, Um, anywhere, anything possible, as long as it's legal. [laughs] like it could be everything from like little side jobs, temporary jobs, summer jobs, or one of those medical studies. Thats what I'm doing most. Living Situation. A common theme among two of the participants was the ambition to move out of their current living situation with relatives, or living on their own. These participants were not currently living with their immediate family members (i.e. mother, father). Although two of the participants expressed the need to move out, there is a lack of motivation to seek the necessary resources and employment in order to live independently. Participant A states, I want to be out of my grandmothers house by 25 Im not living with my grandmamma at 25. To me, just thats just depressing. I know a lot of people are in their 30's and live with their family and thats fine for them, but you know, I feel that I need I know I WANT to move on. I dont' like saying need and I like saying 'want because to me need is needing something, like giving your power away to whatever. Wanting is taking that power back. However, there are not many resources available to them in order to apply for jobs, nor is there protection in the legal system. Participant D currently has her own apartment but still has a fear of ending up back on the streets due to financial concerns. Education. All four participants stated that they plan on going back to school eventually and owning their own businesses. Participant D attended one year of college but was forced to quit when she was unable to find a steady place to stay. She stated, The reason why I am not doing it [school] because right now Im on a struggle, which Im fighting to keep my apartment, so thats mostly the main reason why I am not in school again. I need to have time to maintain and find a stable job to help me keep my apartment. Once I get back on that, hopefully, pray to

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God and everything I love that before classes start I will be able to have a job where I can go to school, because that is what my plans are. Her dream is to open a daycare. Participant B, originally from a large city, moved to Detroit several years ago to take care of his grandmother, who was in poor health. Before moving to Detroit, he completed three years of college, majoring in vocal performance and minoring in business. When asked about uprooting his life and moving back to Detroit he states, Its everyday life and you gotta do what you gotta do, and she took care of me. Thats who raised me. Family values were more important than completing his degree. Participant C completed high school and will be starting college in the Fall of 2013. He has ambitions to open his own bakery or restaurant. Participant A is not currently enrolled in school but has plans to attend in the near future. He would like to major in the creative arts, specializing in films, photography and foreign language. The participants expressed a desire to further their education, however, external barriers such as financial hardship, lack of permanent housing and family values took priority over educational pursuits. It is because of these barriers that these participants had to put their education on hold. Some of the participants were living on the streets since age 15 or in foster care, disowned by family members and friends. Social and Familial Interactions. Social participation is also negatively impacted in the LGBTQ community as they experience rejection, and or exploitation by family, friends and peers. One participant states, In the gay lifestyle you have to be very careful of who you let in your circle, because they may only be using you for something that is beneficial to them. A lot of grimy things happen in this life style so I feel you just have to be careful. You really have to use that saying, as your mom sayin, dont talk to strangers. A different participant had this to say

LGBTQ YOUNG ADULTS when asked about building friendships and trust, The only friends that I made, were like, I would study people before I make friends with them, you know. Its, like, friends who I could come out to that wouldnt A) run away from me or B) fight me. All four participants shared their coming out story, fears, and feelings of rejection.

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Participant C talked about how he felt he had to hide his sexual identity. He stated, At the time, I was with people who dont believe in it, so you gotta hide yo sexuality to make them happy. Participant A reflects back on what she told her mother, I cannot keep coming home from school having you, like, verbally abuse me and make me feel like Im nothing because Im gay. All of the participants have faced rejection from one or more family members due to their sexual orientation. Participants generally stated that mothers were less accepting and that fathers and grandmothers were most accepting. Three out of four participants mentioned that AfricanAmerican culture is not accepting of the LGBTQ lifestyle, often resulting in families asking their LGBTQ children to leave the home. During one of the interviews, participant B expressed his response to his mother kicking him out of his home, I am the same person that I was yesterday, that I was 2 years ago, that I was 6 years ago. What do you mean you didnt raise a faggot? I am the same man regardless. I walked out with 2 suitcases and I was gone. They never heard from me again, until I was in my sophomore year of college. Participant A reflects on her past regarding her absent mother, I want to be able to birth my child, be able to take care of my child as a mother and not someone who gives birth and gave it [baby] away. Interests. Participants reported engaging in a broad spectrum of activities, mostly of the creative arts realm. Participants state that the creative arts are a way that they can further express themselves. Participant B enthusiastically states, Um, singing, I love singing, because I always singing songs since I was 4. LOVE dancing of course! What else do I like to do? I like running. I

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enjoyed cross country in college and H.S. Current interests of the participants include cooking, cleaning, dancing, singing, writing, traveling, backpacking, watching television, and reading. Athletic interests included swimming, running and tennis. All of the participants enjoy spending time with friends and family. An interesting subject uncovered during interviews, is the ballroom scene. Participant D explained that people from all around, even out of state, come to Detroit to watch or participate. The competitors compete in modeling or dancing classifications (i.e. runway, beauty, vogue dancing). Participant C explained the ballroom scene as, It consists of different areas/categories, sponsored by members with money. Its an underground thing for LGBTQ, promoting non-violence, like catwalk, runway, voguing, advertised with Facebook and flyers at local gay bars. The ballroom scene forms a sense of community and togetherness, while allowing members of the LGBTQ population to express themselves without feeling discrimination. The participants listed a variety of activities that they currently enjoy, as well as activities that they are interested in pursuing. Reoccurring responses included going back to school, starting their own business and traveling. Participant B expressed the interest in starting his own Kiki scene. A Kiki scene is similar to the ballroom scene but is a place for the younger generation for ages 6 and above to compete in specific talent areas (Vogue, runway, gorgeous girls, etc). Participant B shares that he likes the kiki scene better because, It pulls people out of the ballroom atmosphere which can be negative because of drugs. Participant C stated that he would like to be an advocate and educator for LGBTQ population for safe sex, AIDS/HIV, and sexually transmitted diseases. He also emphasized the lack of sexual education courses tailored specifically to the LGBTQ population provided in

LGBTQ YOUNG ADULTS grade school. He would like to become a leader in the community who isnt afraid to say he is HIV positive, Yeah, I might look good but I tell you, you dont want no parts of this. Im all about informing and letting people know what it [HIV/AIDS] is, not keeping it a secret, thats what I want to start. Positive Effects of Community-Based Programs Each participant expresses the feelings of rejection and lack of social support from

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family and friends. Community-based programs, like the Ruth Ellis Center, offer LGBTQ young adults a safe place full of acceptance and social support. When asked about the impact of the Ruth Ellis Center participant C responded, I am lovin it here. I love it. Ruth Ellis is my second home. When I am not home, this is my second home because they help me a lot. I can always come here for therapy or anything that I just need to talk about and need to get away. This is where I come to release everything cuz they always love and carin about people and thats what people need in this world, who loves and understands them. Not only do community-based programs help with social and emotional support, but they also provide basic needs such as housing, food, toiletries, showers, internet access, clothing, counseling, leadership opportunities, as well as AIDS/HIV counseling, education and testing. Participant B described the benefits of the Ruth Ellis Center in particular by saying, I didnt know anything about their services, like the mental health services, group services, Ruth housing-like getting youth off the street to live, eat, sleep and a place to work, and like the resources they dont have in the streets. The Ruth Ellis Center also offers extracurricular activities to keep its youth off the street. The most popular activity is Vogue dancing. Vogue dancing gives members the opportunity to dance to African-inspired music and beats, while expressing their sexuality in a safe place.

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Another component contributing to the social support is the idea of family trees. A family tree is a mural painted on the wall of the common area where participants of the Ruth Ellis Center can put their name with a group of others to create their own family. Family trees are developed in community-based LGBTQ centers to establish a sense of community and camaraderie. Participant C explains A mother is someone who councils a person that is just coming out. A father figure, [can be] same age or older, get advice from mother and father that they couldnt get from biological mom and dad regarding LGBTQ concerns. This provides a positive family-like dynamic for the youth to turn to when they need that motherly or fatherly relationship, such as seeking advice or emotional and social support. The importance of the family tree helps fill that void created from rejection by their biological families. The community supports within the LGBTQ population enable individual to feel worthwhile and accepted by a large group of people. Acceptance by others, or lack there of, seems to be a common expressed by the participants. The participants expressed the desire to reach within their own community to help and educate those who are still learning to navigate their own acceptance of their sexual orientation. They would like to educate other LGBTQ youth ways to deal with rejection from family, friends and peers once they come out. Discussion The purpose of this study was to provide occupational therapy clinicians with knowledge about the homeless LGBTQ population in regards to participation of valued occupations, available community-based programs, and how occupational therapy could be beneficial to this population. Occupational therapy practitioners, are expected to be culturally competent, nonjudgmental, and client-centered (AOTA, 2006). The findings of this study include common themes of displacement of trust, as well as factors and barriers that impact level of engagement

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in everyday occupations. These findings will help practitioners better serve clients that identify as LGBTQ. Current research states that members of the LGBTQ community frequently face family rejection, social stigma, and feelings of disengagement (Cochran et. al., 2002). Throughout all four interviews, there was a consistent undertone of a distrust of others. It was very difficult to get people at the center to volunteer to be interviewed. The researchers had volunteered there in the past, hoping to make people at the center more comfortable. Both researchers have been warned about trust being an obstacle to our research, so we wanted them to at least be familiar with our faces. However, it is difficult to establish a presence at a drop-in center, where people come and go as they please. Participants at the center seemed to trust each other the most. This was exemplified by our initial participant going to other members and encouraging them to be interviewed. She let them know that we were cool, which was interpreted as non-threatening, non-judgmental, and friendly. OT practitioners should be aware of the hesitancy to trust others, when treating this cultural group. Once the researchers gained trust from the participants, the participants seemed to be very open and responsive to questions asked. Lack of trust started at a young age for all participants. They were afraid to come out to their family in fear of rejection. It may be that the parents or family members of an LGBTQ youth have a difficult time seeing past the label [gay, etc] and are more willing to let their child walk out of their lives than to accept their sexual orientation (Nolan, 2006). This could be due to the social stigma, as well as the African-American view of the LGBTQ population (Lewis, 2003). Experiencing rejection by a parent or family member can make it difficult to form effective relationships in the future (Nolan, 2006).

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The participants of this study expressed a sense of caution and hesitancy when it came to creating new relationships. This could be assumed from their past experiences of feeling rejection from family, friends and/or peers. Absence of trust, in regards to the knowledge of their sexual orientation can be assumed to be learned behavior overtime, due to the fear of negative implications. Social participation within any given environment could be compromised and lead the participant to feel alienated, cautious, or feelings of repressing their own individuality (Nolan, 2006). Members of the LGBTQ community may hesitate to establish new relationships, or to seek out new opportunities such as jobs, or a new education setting such as college (Finlayson, Baker, Rodman, & Herzberg, 2002). All participants expressed fear of being judged or facing rejection when trying new things, such as applying for a new job or attending college. In Michigan, specifically as well as other states it is legal to fire an employee who identifies as LGBTQ. Although the Elliott-Larsen Civil Rights Act (ELCR) states that employers cannot discriminate based on race, religion, color, national origin, sex, age, marital status, height, weight, or arrest record, it does not currently protect the LGBTQ population. Due to the fact that sexual orientation, and gender identity/expression are not included in the current ELCR it allows employers to refuse hire or fire current employees based on sexual orientation. This also allows for landlords to refuse housing, and restaurant owners to deny patronage without being legally reprimanded (Michigan Department of Civil Rights, 2013). This could be attributed to the current employment and housing laws, mentioned above, as this may contribute to fear of rejection and discrimination. Facing rejection in an unfamiliar area, such as a new school or job, making new friends, and establishing trust worthy relationships can be stressful and difficult, particularly if they have experienced it in the past

LGBTQ YOUNG ADULTS (Nolan, 2006). Not having a core foundational support system of steady housing and family support may contribute to feelings of low self-worth. A lack of self-worth can make it difficult for any individual to better themselves, thus creating a sense of shortsightedness, as they had lack of parental guidance and safety net to fall back on (Nolan, 2006). With the lack of legal protection for the LGBTQ population contributing to the

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possibility of being fired based on sexual orientation, or asked to leave a facility; it is no wonder that their participation in valued occupations, both extracurricular and vocational would be negatively affected. Knowing that discrimination against LGBTQ in the form of denial of jobs, housing and eating at restaurants is an approved pattern of behavior by society in general could be discouraging for this population (Michigan Department of Civil Rights, 2013). Society is essentially denying rights to community resources and making it difficult to access daily needs of income and housing. This would be difficult for any population to have to overcome in order to move forward in life (ESRC Global Poverty Research Group, 2004). Occupational therapy practitioners could be an advocate for the LGBTQ youth by offering support, motivation and vocational skills training. Current research states that homeless young adults within the LGBTQ community have issues with education, family, and peer support (Cochran et. al., 2002). The research also states that without permanent residency, negative effects such as substance abuse can take root. Known stressors resulting from homelessness can cause social and psychological dysfunction (Cochran et. al., 2002). All of the participants were homeless at least once, and experienced the fear of living on the streets. During interviews, there was some mention of substance abuse within the community, but it was not a major theme. Negative effects of homelessness on education were discussed. Some of the participants did not finish school or further their education due to

LGBTQ YOUNG ADULTS homelessness. This is a good opportunity for occupational therapist practitioners to help LGBTQ youth with resources for housing, mental health and substance abuse.

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Depression and anxiety are two recurring themes throughout previous LGBTQ literature (Dowshen & Garofalo, 2009). Yet, during the interview process, the interviewees seemed hopeful, enthusiastic, and happy about their current lives. There was a lot of conversation regarding past and current obstacles. However, the interviewees remained optimistic. It is hard to say whether that is how these young adults are really feeling, or if it is a defense/coping mechanism. It is common for those who identify as LGBTQ to have to hide their feelings and thoughts from others, to appear as though everything is okay (Finlayson, Baker, Rodman, & Herzberg, 2002). This may stem from a distrust of others discussed previously. Many, if not most, have had to hide their sexual identity at some point in their lives, so it may be natural to hide negative feelings, such as anxiety and depression, as well (Cochran et al., 2002). The participants enjoy a broad spectrum of interests that most of society enjoys engaging in. However, referring back to the topic of social participation and fear of rejection from others, these interests may be impacted due to that fear. Perhaps in a way, these interests are muted for that very reason, and are limited to the safety of their inner circle of trusted friends, or at home, constraining social participation and growth of those interests and hobbies (Finlayson, Baker, Rodman, & Herzberg, 2002). Resources available to the LGBTQ youth are few and far between. Drop-in centers, like the Ruth Ellis Center, provide a safe environment, a sense of community and amenities. The Ruth Ellis Center offers HIV/AIDS education, testing, and counseling. Counselors are available for the youth to discuss problems or situations in a judgment-free and confidential setting. Clothing, showers, toiletries, and meals are provided on a daily basis at no charge to members of

LGBTQ YOUNG ADULTS the center. Participants may also seek employment and leadership opportunities through resources provided by the social worker. The Ruth Ellis Center also provides computers with internet access that is available for the participants use. The Ruth Ellis Center also offers residential housing for members who are homeless. Many young adults that attend the center

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have basic needs that the center can provide for. Without those needs met, a member can have a harder time fostering improvement in many areas of their life (ESRC Global Poverty Research Group, 2004). These centers provide another, much needed, resource for this population. The Ruth Ellis Center delivers a safe environment where members can express themselves without fear of rejection or discrimination. The members form strong and unique bonds with each other through workshops, group therapy and leadership activities. The center focuses on self-respect, self-expression and self-worth. In one group activity, the members wrote down social stigmas and discriminatory acts that they have felt in the past. Members had the opportunity to talk about their past and present hardships, while leaning on others for support. Two nights a week members can partake in vogue dancing. Members are encouraged to bring their own music and dance with expression. This offers the young adults an opportunity for leisure and social engagement. Because the LGBTQ youth experience rejection and discrimination it is difficult for them to find community resources (Noland, 2006). The Ruth Ellis Center provides the necessary assets to enable the youth to move forward in life. Resources are free so those who have little to no income have a place to turn to when in need. The participants expressed the importance of the Ruth Ellis Center as it gave them the resources to find social support, meet basic needs such as clothing, food, shelter, free counseling services, and HIV/AIDS testing and education. This enables them to move forward in life and to re-establish themselves after experiencing rejection

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from family, friends or homelessness. It is important for occupational therapy practitioners to be aware of drop-in centers, like the Ruth Ellis Center, offered to LGBTQ youth. These centers provide the foundational basic needs found under the theory of Maslows hierarchy of needs. The theory states that the physiological needs including food, water, warmth, shelter, sleep and clothing must be met in order to fulfill the next tier of needs. The centers provide these physiological needs along with security and safety such as health, employment, family (family trees mentioned above) and social stability. If the basic foundational needs are not met, these unmet needs will distract therapeutic intervention. It is important that the occupational therapist set goals for obtaining basic needs first, rather than social interaction or self-esteem (Weinberg, 2005). When comparing the findings of this study to previous research available, similarities were found. Research on LGBTQ youth has focused on AIDS and HIV statistics. In this study, the topic of AIDS and HIV surfaced more than expected. One of the interviewees disclosed that he was HIV positive, while another alluded to the fact but did not specifically state it. Both of these participants were very interested in the existing research on these topics. They seemed to want to be more informed, and to want to use that knowledge to help others. They also feel that HIV and AIDS education should be integrated into schools at an earlier age. This is a good opportunity for practitioners to help educate the youth on the prevention, cause and effect, as well as resources available regarding HIV and AIDS. The kiki scene would have a positive impact on the younger generation of LGBTQ youth. It would provide a safe space where the youth could connect with older individuals who would provide guidance and support while the younger generation learns to accept their sexuality and learn how to embrace it. It would also provide opportunities for the youth to build their

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confidence through competitive events (Larson, 2000). A safe space would be available for them to express their sexual orientation without implications from others such as bullying or alienation. The lack of current spaces and events would make the kiki scene a valuable resource to those who lack social or familial support, therefore allowing the youth to feel accepted and worthwhile in an otherwise unsupportive community (Nolan, 2006). Currently, occupational therapy services are not provided at the Ruth Ellis Center. Although the center would benefit greatly from having skilled services that the profession can provide, however the financial resources are not available at this time. Occupational therapists can help clients by discovering new leisure pursuits, offering vocational training, and helping to overcome barriers within the environment. As stated above, LGBTQ young adults have difficulty setting short-term goals related to schooling, resources to apply for jobs, training and skills required to secure a vocation. This could be partially due to lack of community resources, rejection by others and establishments such as employers, peers within schools, churches etc. LGBTQ youth are like any other young adult, where they need guidance and assistance from adults to help them navigate through their young adult life. Occupational therapists are skilled in regards to goal writing. An OT can help this community uncover new interests, goals and selfworth. While listening to these young adults recap their moments of strength, pain and insecurities, there is an overarching theme of displaced trust. Through therapeutic-use-of-self and OT, a safe place with a relationship of respect and trust can be provided (AOTA, 2002). A study was conducted in 2008 to gage the occupational therapy practitioners comfort level and preparedness in working with clients who are lesbian, gay or bisexual. The study found many of the practitioners felt that they were prepared and comfortable to work with clients who identify as being lesbian, gay or bisexual. However, only 14% of the practitioners reported that

LGBTQ YOUNG ADULTS they have resource and support for this particular community. In regards to the LGBTQ population, there is still much need for future research. This study was conducted to gather common themes to provide a foundation for future research.

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There is still much to discover regarding specifics about the lack of short term goals within this population. The profession has a need and a duty to uncover treatments specifically geared toward the distrust found among those in this community. Occupational therapists would benefit from becoming aware of the current resources available to this group and to provide meaningful engagement in occupations, as well as client-centered care (Black & Wells, 2007).

LGBTQ YOUNG ADULTS References American Occcupational Therapy Association. (2002). Occupational therapy practice

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framework: Domain and process. American Journal of Occupational Therapy, 56, 609639. American Occupational Therapy Association. (2006). AOTA's centennial vision. Retrieved from http://www.aota.org/News/Centennial/Background/36516.aspx?FT=.pdf Bedell, G. (2000). Daily life for eight urban gay men with HIV/AIDS. The American Journal of Occupational Therapy, 54(2), 197-206. Black, R. M. (2002). Occupational therapys dance with diversity. The American Journal of Occupational Therapy, 56(2), 140-147. Black, R. M., & Wells, S. A. (2007). Culture and occupation: A model of empowerment in occupational therapy. Bethesda, MD: AOTA Press. Cochran, B. N., Stewart, A. J., Ginzler, J. A., & Cauce, A. M. (2002). Challenges faced by homeless sexual minorities: Comparison of gay, lesbian, bisexual, and transgender homeless young adult with their heterosexual counterparts. American Journal of Public Health, 92, 773-777. Diversity. (2012). In Merriam-Webster. Retrieved June 26, 2012, from http://www.merriamwebster.com/dictionary/diversity Dowshen, N., & Garofalo, R. (2009). Optimizing care for LGBTQ youth. Contemporary Pediatrics, 26(10), 59-64. ESRC Global Poverty Research Group. (2004). Subjective well-being poverty versus income poverty and capabilities poverty. Retried from http://www.gprg.org/pubs/workingpapers/pdfs/gprg-wps-003.pdf

LGBTQ YOUNG ADULTS Finlayson, M., Baker, M., Rodman, L., & Herzberg, G. (2002). The process and outcomes of a

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multimethod needs assessment at a homeless shelter. American Journal of Occupational Therapy, 56(3), 313-321. Jackson, J. (1995). Sexual Orientation: Its relevance to occupational science and the practice of occupational therapy. The American Journal of Occupational Therapy, 49(7), 669-679. Kielhofner, G. (2006). Research in occupational therapy: Methods of inquiry for enhancing practice (pp. 353-354). Philadelphia, PA: F.A. Davis Company. Kielhofner, G. (2008). Model of human occupation : theory and application. Baltimore, MD: Lippincott Williams & Wilkins Larson, R. (200). Toward a psychology of positive youth development. American psychologist, 55(1), 170-183. Lewis, G. (2003). Black-white differences in attitudes toward homosexuality and gay rights. American Association for Public Opinion Research, 67(1), 59-78. Mayer, K. H., Bradford, J. B., Makadon, H. J., Stall, R., Goldhammer, H., & Landers, S. (2008). Sexual and gender minority health: What we know and what needs to be done. American Journal of Public Health, 98(6), 989-995. Michigan Department of Civil Rights. (2013). LGBT Inclusion under Michigan Law with Recommendations for Action. Retrieved from http://www.michigan.gov/documents/mdcr/MDCR_Report_on_LGBT_Inclusion_409727 _7.pdf Nolan, T. C. (2006). Outcomes for a transitional living program serving LGBTQ youth in New York City. Child Welfare, 85(2), 385-406. Patten, M. L. (2009). Understanding research methods: Ground theory for data analysis (7th ed.,

LGBTQ YOUNG ADULTS p. 159). Glendale, AZ: Pyrczak Publishing. Peterson, E., & Coltrane, B. (2003). Culture in second language teaching. Retrieved from http://www.cal.org/resources/Digest/0309peterson.html Ruth Ellis | Ruth Ellis Center. (n.d.). Ruth Ellis | Ruth Ellis Center. Retrieved June 10, 2012, from http://www.ruthelliscenter.org/ Scaffa, M. (2001). Occupational therapy in community-based settings. Philadelphia: Margaret Biblis. Singh, A. A., & Shelton, K. (2011). A content analysis of LGBTQ qualitative research in counseling: A ten-year review. Journal of Counseling and Development, 89, 217-226.
Weinberg, H. (2005). THE EFFECTIVE TIME-BINDER AND MASLOW'S "SELF-ACTUALIZING PERSON". Et Cetera, 62(3), 313-317. Retrieved from http://search.proquest.com/docview/204090566?accountid=960

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Wells, Shirley A. (2005). On cultural competency and ethical practice. Retrieved from http://www.aota.org/Practitioners/Ethics/Advisory/36525.aspx Wells, Shirley A. (2011). Cultural competency and ethical practice. Retrieved from http://www.aota.org/-/media/Corporate/Files/Practice/Ethics/Advisory/CulturalCompetency.pdf Yu, V. (2010). Shelter and transitional housing for transgender youth. Journal of Gay and Lesbian Mental Health, 14, 340-345.