Working with LGBTQI+ Clients

1. Working with LGBTQI+ Clients Jessica M. Kilgore, M.Ed., LPC, NCC, CCMHC, ALPSICEEFT Certified Emotionally Focused Therapist

2. Objectives Following this workshop participants will be able to the following in reference to the LGBTQI+ community: • Use accurate terminology • Have an understanding of healthy norms and development • Identify challenges and concerns • Have an introductory understanding of culturally competent and LGBTQIA Affirmative Counseling

3. Multicultural Competence • The ACA Code of Ethics requires counselors to be developmentally and culturally sensitive in all stages of counseling with all clients as well as in counselor education and supervision (Standards A.2.c., B.1.a., E.5.b., E.8., F.2.b., F.11.c., H.5.d.). • The ACA Code of Ethics also requires counselors to be aware of historical prejudices in diagnosis (Standard E.5.c.); this directly applies to work with LGBTQI+ persons, as they were pathologized as mentally ill through much of history.

4. Multicultural Competence • Standard A.4.b. requires counselors to be aware of personal values; counselors working with LGBTQI+ clients must be aware of their own values related to gender and affectional orientation in order not to impose these attitudes in their work with clients.

5. Multicultural Competence • Standard A.11.b. maintains that counselors cannot refer clients based on value conflicts. • Standard C.2.a. specifically requires counselors to develop multicultural counseling competence in order to work appropriately with diverse clients; counselors should receive continuing education to improve their multicultural competence (Standard C.2.f.)

6. Intersectionality • Every person carries a series of complex identities and backgrounds that form multiple perspectives of both privilege and marginalization. • The complex intersection of social identities is called intersectionality (Harper et al, 2013).

8. Privilege and Marginalization • As counselors we are tasked to understand the impact of discrimination, power, stereotypes, privilege, and oppression in any population. • We must also understand our own privilege and marginalization.

10. LGBTQIA+ • There are currently 11 recognized identities under the affectional orientation and gender minority umbrella (LGBTQQIAAP-2S): • Lesbian • Gay • Bisexual • Transgender • Queer • Questioning • Intersex • Asexual • Ally • Pansexual / polysexual • Two spirited

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12. Terminology • Affectional Orientation – the direction an individual is predisposed to bond with and share affection emotionally, physically, spiritually, and/or mentally (Harper et al, 2013, p. 38) • Ally – a person who supports, and respects members of the LGBTQIA+ community.

13. Terminology • Cisgender– a person whose gender identity and biological sex assigned at birth align • Gender Identity – the internal perception of one’s gender, and how they label themselves • Queer – an umbrella term to describe individuals who do not identify as straight • Questioning – exploring one’s own affectional orientation or gender identity.

14. Terminology • Intersex – someone whose combination of chromosomes, gonads, hormones, internal sex organs, and genitals differ from the two expected patterns of male or female • Asexual – having a lack of (or low level of) sexual attraction to others and/or a lack of interest or desire for sexual partners. Another term used is “ace”.

15. Terminology • Pansexual / Polysexual– a person who experiences sexual, romantic, physical, and/or spiritual attraction for members of all gender identities/expressions • Two-spirited – individuals who have an indigenous heritage and who identify with traditional Native concepts of variant gender and affectional orientation as having spiritual and social value (Jacobs, Thomas, & Lang, 1997).

16. Terminology • FtM / F2M; MtF / M2F – abbreviation for female to male transgender person or male to female transgender person • Gender Nonconforming –an umbrella term that indicates a child who at a young age does not exhibit gender-stereotyped play or interests. Heterosexual individuals can be gender nonconforming.

17. Terminology • Gender Binary – the idea that there are only two genders, male or female • Gender fluid – a gender identity best described as a dynamic mix of boy and girl. • Genderqueer– someone who experiences a blending of genders – includes those who consider themselves both genders – or neither

18. Terminology • Heteronormativity– people’s assigned sex, gender identity, gender roles, and affectional identity are immutable, binary, and heterosexual in nature (VandenBos, 2015). • Heterosexism – prejudice against any individuals who do not meet heteronormative expectations, which include binary male versus female gender expression and identity, as well as heterosexual attractions (VandenBos, 2015).

19. Terminology • Homophobia / Biphobia / Transphobia– fear, hatred and/or disgust toward people who have feelings or love for member’s of one’s own gender • Internalized Homophobia / Biphobia / Transphobia – one who cannot accept his homosexual/bisexual/transsexual feelings due to his own internalization of homophobia/biphobia/transphobia • Microaggressions– brief and commonplace daily verbal, behavioral, or environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative slights or insults toward a person of a certain cultural background

20. History of Oppression & Bias • Same-sex relations have been recorded throughout ancient history. • There is also evidence of transgender & third-gender persons in nearly every civilization across recorded history (Greenberg, 1988). • Starting in the fourth century, these relationships began to be viewed as immoral (Fone, 2000).

21. History of Oppression & Bias • The Roman Catholic church originally accepted same-sex relationships and at some point gender roles became associated with natural law. • In 390, sodomy was made illegal by Christian emperors and became punishable by death (Ginicola, Smith, & Filmore, 2017). • From the 5th to the 17th century these laws spread.

22. History of Oppression & Bias • The field of psychiatry helped to decriminalize same-sex sexual activity; theorists and psychiatrists coined the term homosexual and argued it was a clinical disorder (Bayer, 1987; Drescher & Merlino, 2007; Krajeski, 1996) • April 27, 2016 Tennessee’s governor signed into law a bill that gives counselors the right to refuse service to anyone based on the counselor’s sincerely held principles (Tennessee Senate Bill 1556, 2016).

23. History of Oppression & Bias • Sexual Orientation Change Efforts (SOCE) • Popularity of SOCE grew in the 1980s & 1990s • In 2003 Robert Spitzer, MD, published a study claiming 200 highly motivated individuals changed their sexual orientation from “homosexual” to heterosexual. • It has been determined SOCE is unfit and unethical to carry out with clients.

24. Science of Gender & Affectional Orientation • Gender orientation involves the experience of being feminine or masculine in the mind (Harper et al., 2013; VandenBos, 2015). • Affectional Orientation involves the biological and physiological impulse of attraction or arousal and the psychological impulse for romantic and emotional attraction (Harper et al., 2013; VandenBos, 2015).

25. Science of Gender & Affectional Orientation • Sex hormones play a role in the development of sexual attraction and orientation (Ellis & Ames, 1987). • Disruptions in androgens in the fetal period have been linked to gender-differentiated behavior in children (Auyeng et al., 2009; Berenbaum, 1999). • These hormones are responsible for creating structural and functional differences in the brain that is measurable in adults and children.

26. Science of Gender & Affectional Orientation • Heterosexual, cisgender males & females typically differ in brain anatomy and circuitry. • A region of the hypothalmus is larger in males than females. • There are also differences between the sexes in the amygdala and striaterminalis; neurochemical patterns, hormone expression, and activity patterns in the brain. • Researchers call this phenomenon the gendered brain (LeVay, 2011).

27. Science of Gender & Affectional Orientation • A significant amount of research shows: • There is a biological foundation for the gender appearance of the brain; • The genetic and intrauterine environment impacts hormones; • The brains of LGBTQI+ individuals have been found to indicate significant difference from their heterosexual and cisgender counterparts in terms of cross-gender similarities & increased variance • Mountains of evidence point to a physiological cause for these affectional orientation & gender orientation differences (LeVay, 2011).

28. Growing Up LGBTQI+ • LGBTQI+ students reported verbal (74.1%) and physical (36.2%) harassment as well as assault (16.5%) due to their affectional orientation • LGBTQI+ students reported verbal (55.2%) and physical (22.7%) harassment and assault (11.4%) due to their gender expression. • Most students (56.7%) claimed they did not report incidents to school staff because they doubted the school would respond. • Out of those who did report, 61.6% stated the school staff did nothing in response. Goodrich & Luke, 2015

29. Growing up LGBTQI+ • A study of 2,255 lesbian, gay, and bisexual participants noted more than 50% reported suicidal ideation, and a little fewer than 40% reported at least one attempt. • This makes LGBTQI+ youth more than 4 times likely than heterosexuals to attempt suicide (Eisenberg & Resnick, 2006). • One study showed around a 50% prevalence rate for suicidal ideation among transgender youth, and approximately 1/3 of transgender youth reported at least one suicide attempt (Ginicola, Smith & Filmore, 2017).

30. Growing up LGBTQI+ • Research with transgender youth has identified several resilience strategies that they may use in response to transgender oppression: • The ability to self-define and theorize one’s gender, • Proactive agency and access to supportive educational systems, • Connection to a transgender-affirming community, • Reframing of mental health challenges, and • Navigation of relationships with family and friends (Singh, Meng, & Hansen, 2014).

31. Growing up LGBTQI+ • Family support is a key indicator of LGBTQI+ resilience • Supporting family acceptance and resilience often entails being able to engage in grief work with families, helping families to let go of the image of what they intended for their LGBTQI+ child and process the fear and anxiety they may have for their child.

32. LGBTQI+ Persons in Adulthood • Experiences in adolescence predict the difficulty of development in early adulthood (D’Augelli, 2006). • Understanding one’s affectional orientation and coming out can also interfere with other important developmental tasks. • Rankin (2003) noted that roughly 30% of LGBTQI+ college students reported experiencing harassment due to their affectional orientation or gender identity; 51% stated they chose not to disclose due to fear of harassment.

33. LGBTQI+ Persons in Adulthood • LGBTQI+ couples who seek therapy primarily view their committed relationships as similar to those of heterosexual couples. • LGBTQI+ couples face additional stressors related to external, sociocultural, and familial.

34. Identity Development • Vivian Cass (1979, 1984) was the first to present a model explaining the identity development in gay males and lesbian women. • It is a stage model that is not meant to be linear. • Stage I – Identity Confusion • Stage II Identity Comparison • Stage III Identity Tolerance • Stage IV Identity Acceptance • Stage V Identity Pride • Stage VI Identity Synthesis

35. Cass Model • Stage I Identity Confusion • Recognizes thoughts / behaviors as gay, usually finds this unacceptable • Redefine meaning of gay behavior as kinky, enjoying dirty sex, etc. • Seeks information on being gay

36. Cass Model • Stage II – Identity Comparison • Accepts the possibility he/she “might” be gay • Feels positive about being different, exhibits this in ways beyond orientation • Accepts behavior as gay • Accepts sexual identity but inhibits sexual behavior

37. Cass Model • Stage III – Identity Tolerance • Accepts probability of being gay, recognizes sexual / social / emotional needs of being gay • Seeks out meeting other LGBTQI+ people through groups, social media, bars, etc. • Personal experience builds sense of community, positively and negatively

38. Cass Model • Stage IV – Identity Acceptance • Accepts (vs. tolerates) gay self-image and has increased contact with LGBTQI+ subculture and less with heterosexuals • Increased anger toward anti-gay society • Greater self-acceptance as LGBTQI+

39. Cass Model • Stage V – Identity Pride • Immersed in LGBTQI+ subculture, less interaction with heterosexuals. • Views world as divided “gay” or “not gay” • Confrontation with heterosexual establishment • Disclosure to family, co-workers • Gay adolesence

40. Cass Model • Stage VI – Identity Synthesis • LGBTQI+ identity integrated with other aspects • Recognizes supportive heterosexual others • Sexual identity still important but not primary factor in relationships with others

41. Benefits and Challenges of Coming Out • Disclosure is a process that occurs over the course, and in different contexts, of a person’s life • Potential benefits of disclosure include self-integration, self-growth, and empowerment for the LGBTQI+ identified person (Corrigan & Matthews, 2003). • Potential challenges include familial and social rejection, emotional, physical & financial consequences, increased risk of verbal or physical abuse, homelessness and alienation / isolation from others.

42. Benefits and Challenges of Coming Out • Research suggests LGBTQI+ persons typically disclose their identities to one or more friends prior to family; often disclose to siblings prior to parents. • Developing a positive identity surrounding affectional orientation and gender variance is crucial for positive mental health and well-being. • Counselors should never push clients to move too quickly or to disclose their identity before they are ready.

43. Benefits and Challenges to Coming Out • Disclosing identity has potential to bring out unresolved childhood issues with Family of Origin and socialization. • LGBTQI+ persons do not always feel better after coming out and are surprised.

44. Our Role as Therapists • The ACA Code of Ethics (ACA, 2014) designates knowledge of culturally competent, strengths-based approaches developed from both quantitative and qualitative as critical to developing evidenced-based, ethical practices. • The Code addresses the core values of the counseling profession: • Enhancing human development throughout the life span • Honoring diversity and embracing multiculturalism in support of the worth, dignity, potential, and uniqueness of people within their social and cultural contexts • Promoting social justice • Safeguarding the integrity of the counselor-client relationship • Practicing in a competent and ethical manner (p. 3)

45. Our Role as Therapists • Studies have shown clients who identify has LGBTQI+ indicate: • Warm and intimate environments were important therapeutic qualities and enhanced their sense of trust • Sensitive, kind, warm, and caring counselors who expressed openness; expressed nonjudgmental and accepting attitudes; and could demonstrate an active, attentive, and fully present stance with their clients provided the best experience • Counselor’s use of a holistic approach to counseling through conceptualizing and treating clients as whole people with other concerns not related to their affectional orientation added to the therapeutic experience.

46. Our Role as Therapists • Affirmative therapy is: • an approach to therapy that embraces a positive view of LGBTQI+ identities and relationships and addresses the negative influences that homophobia, transphobia, and heterosexism have on the lives of LGBTQ clients.

47. Our Role as Therapists • Being an affirmative therapist involves: • Self-reflection – reflect on your own upbringing, attitudes and beliefs; acknowledge areas of privilege; recognize bias stemming from living in a heteronormative and gender-binaristic society. • Get involved – live an affirmative life; become familiar with the issues; strive for social justice and social change. • Create an affirmative setting – provide LGBTQI+ friendly reading material, literature and resources; include affirming language on all paperwork; use client’s preferred name; don’t resort to heteronormative assumptions , instead ask about a client’s partner • Be open about your commitment to providing affirmative therapy with all clients, regardless of sexual orientation or gender identity. • With heterosexual and/or cisgender clients, act as an advocate by challenging heterosexism and the gender binary.

48. Our Role as Therapists • Therapists strive for certain qualities: • Espouse supportive, nonpathological framework for viewing the client • Have knowledge and skills relevant to working with this population • Have increased self-awareness of how their experience of privilege and oppression may impact the client • Therapists should affirm the client’s identity, providing a warm, accepting space for healing. • Empower the client by taking a collaborative approach to treatment

49. References American Counseling Association. (2014). ACA Code of ethics. Alexandria, VA: Author Auyeng, B., Baron-Cohen, S., Ashwin, E., Knickmeyer,R., Taylor, K., Hackett, G., & Hines, M. (2009). Fetal testosterone predicts sexually differentiated childhood behavior in girls and in boys. Psychological Science, 20(2), 144–148. Bayer, R. (1987). Homosexuality and American psychiatry: The politics of diagnosis. Princeton, NJ: Princeton University Press Berembaum, S. A. (1999). Effects of early androgens on sex-typed activities and interests in adolecents with congenital adrenal hyperplasia. Hormones and Behavior, 35(1), 102–110. Cass, V. C. (1979). Homosexual identity formation: A theoretical model. Journal of Homosexuality, 4(3), 219–235.

50. References Cass, V. C. (1984). Homosexual identify formation: Testing a theoretical model. Journal of Sex Research, 20(2), 143–167. Corrigan, P. W., & Matthews, A. K. (2003). Stigma and disclosure: Implications for coming out of the closet. Journal of Mental Health, 12, 235–248. D’Augelli, A. R. (2006). Developmental and contextual factors and mental health among lesbian, gay, and bisexual clients. The Career Development Quarterly, 50, 33–44. Drescher, J., & Merlino, J. P. (Eds.). (2007). American psychiatry and homosexuality: An oral history. New York, NY: Harrington Park Press