Working ethically with sexual and gender minority clients requires cultural competence. While this column attempts to address some specific ethical issues, clinicians are advised to seek training and supervision and to develop relationships with LGBTQ people outside of the office to continue to develop cultural competence.
It is also important to recognize that there are significant clinical differences between working with LGBTQ kids, teens, adults and seniors.
Most importantly, while LGBTQ is often used as an umbrella term, bisexual and transgender or gender nonconforming (TGNC) individuals often experience stigma from within the lesbian and gay community, which can be especially painful and further isolating.
Lastly, despite the LGBTQ acronym, working with TGNC individuals requires separate training and competence than simply working with gay, lesbian, bisexual or queer clients.
By now, everyone should know that sexual orientation change efforts are considered harmful and ineffective. A number of states have bans on such “treatment,” and most mental health organizations have made strong statements that same-sex feelings, attractions and behaviors are normal and that there is insufficient evidence to support the use of interventions to change a person’s sexual orientation.
Many clinicians working with sexual orientation and gender identity make the mistake of assuming sexuality and gender are binary constructs. These clinicians may assume that “coming out” means someone is on the path to becoming gay or lesbian, and they fail to recognize bisexuality or pansexuality (an attraction and interest to partners along the gender spectrum) as valid, lasting orientations.
Similarly, clinicians may assume someone seeking help with gender identity issues is transitioning from male to female or vice versa, instead of possibly landing in a non-binary place of identifying as genderfluid or genderqueer, equally valid gender identities. It is easy to see how a clinician working from a binary model could unwittingly complicate someone’s treatment, particularly if the client is just beginning to explore these themes and also shares the assumption that they must land on only either end of the spectrum.
Monitoring countertransference about sexual content, fantasies and behaviors is another way to practice ethically with sexual and gender minority clients. People seeking help for sexual or gender identity issues need safe spaces to talk about their bodies, their attractions and sometimes their sexual experiences with others, which may feel confusing, frightening or affirming and exciting.
Clinicians who feel strong judgment or repulsion or arousal should have a place to consult with others about such reactions so that they do not interfere with the therapy. Some clients may present with other sexual interests that are foreign to a clinician, and if the topic of sexuality is already on the table, these clients may be more likely to share information about multiple partners, using sex toys or engaging in BDSM play with partners.
Developing a working knowledge and seeking consultation on such issues may be an essential part of doing ethical work with a client. Of course, not all LGBTQ clients have these interests, and some may also present with low sex drives or low sexual interest.
Understanding a client’s stage of coming out and recognizing their resources is essential. Who are they out to? And who are their allies? What are their relationships like with friends, family, romantic partners, work colleagues and the broader community?
An important piece of work can be helping a client to connect to online and offline LGBTQ communities for support. Groups like COLAGE can be helpful for children of lesbian and gay individuals, and other groups like PFLAG may help kids come out to their parents. The Straight Spouse network can also help when a husband or wife comes out within a marriage.
Other important factors to consider are other cultural variables and whether the client also has support about intersecting identities (race, ethnicity, religion, disability etc.) A strong awareness of minority stress and the microaggressions clients face and not enacting them in treatment is crucial.
Those seeking more information should note that APA offers guidelines for working with gay, lesbian and bi-sexual clients (http://www.apa.org/pi/lgbt/
Those seeking further information on working with TGNC individuals also may find the World Professionals Association for Transgender Health to be an extremely valuable resource. (http://wpath.org/)
Keely Kolmes, Psy.D., is a licensed psychologist with a practice in the San Francisco area. She is co-author with Edward L. Zuckerman, Ph.D., of The Paper Office for the Digital Age. Her email is firstname.lastname@example.org.